Anxiety and Depression

Question 1

Prevalence and risk factors for depression and anxiety and palliative care

Answer 1

• 14% anxiety in advaned disease
• 20% depression
• Risk factors:
  
  • degree of disability
  • physical symptoms
  • proximity to death
  • lower self esteem
  • less spiritual well being
  • prior depression
  • percevied lack of social support
  • higher disease burden
  • younger age

Question 2

Clinical significance of untreated anxiety and depression

Answer 2

• Anxiety:
  
  • more physical distress : fatigue, pain, dyspnea, anorexia, poor well being
  • poor confidence in medical team
  • less likely to ask questions and understand information
• Depression:
  
  • limit participation in EOL care
  • poorer QOL
  • desire for hastened death
  • suicide
  • increased pain
  • 2x health care utilization
  • lower survival in advanced cancers

Question 3

Major Depressive Episode

Answer 3

DSMIV:

• 1 of Core symptoms (most important and pathognomic):
  
  • Depressed mood
  • Anhedonia
  • every day, almost all day x 2 weeks
• > 5 other symptoms:
  
  • change in weight
  • loss of appetite
  • insomnia
  • hypersomnia
  • psychomotor agitation or retardation
  • decreased energy
  • worthlessness
  • guilt
  • concentration
  • SI or attempt
• Not a result of medical condition:
  
  • very difficult in advanced cancer

Question 4

Other categories of depression

Answer 4

• Dysthymia
  
  • chronic low mood over 2 years
  • 2/6 neurovegetative symptoms
• Adjustment disorder
  
  • excessive emotional reaction causes impairment in function
• Mood disorder due to general medical condition
• Substance induced mood disorder
• Mood disorder NOS
  
  • minor depression < 2 weeks, etc

Question 5

Biological causes of depression

Answer 5

• hypothyroidism
• anemia
• malnutrtion
• medication use and withdrawal
• substance use and withdrawal

Question 6

Sadness as part of dying process

Answer 6

• Normal
• Kubler Ross: denial, anger, bargaining, depression, acceptance
• facing our own mortality –> search for meaning –> post traumatic grwoth
• pathologize normal sadness
• but if sadness persistent and pervasive and interfering with function, consider MDE
• treatment can improve QOL

Question 7

Desire for hastened death in depression

Answer 7

• 45% advanced illness resport occasional desire for hastened death
• higher rates of depression
• suicide thoughts vs plan
• interprofessional team
• listen and validate patient’s concerns
• risk factors:
  
  • delirium
  • meaninglessness
  • hopelessness
  • functional limitations
  • history of psych disorder
  • alcohol / substance use

Question 8

Suicidality assessment

Answer 8

• 2x incidence in cancer patients than in general population

RISK FACTORS:

• male
• white
• older age
• lung, stomach, head and neck cancers
• concern about lack of autonomy
• dependence on others

Question 9

Biological factors contributing to anxiety and depression

Answer 9

• Physical symptoms
  
  • pain
  • nausea
  • dyspnea
  • fatigue, insomnia
• Medical conditions
  
  • delirium
  • thyroid
  • B12
  • electrolytes
  • glucose
  • hypercalcemia
• Medications
  
  • steroids
  • cytokines (interfern-alpha, interluekin1, GnRH)
  • alcohol, nicotine, street drugs

Question 10

Psychosocial factors contributing to anxiety and depression

Answer 10

• psychological factors
• attachment security
• existential concerns
• coping
• fear about future
• loss of identity
• dignity
• dependence on others
• previous trauma
• losses
• disease progression
• communication with treatment team
• role changes
• unresolved conflict
• caregiver burnout
• financial burdens
• day to day support
• future planning

Question 11

Pharmacological treatment of depression

Answer 11

Canadian Network for Mood and Anxiety Treatments : EB guidelines for treatment of depression in terminal illness

• First line: SSRI / SNRI
• Sertraline, citalopram, escitalopram 9(lowest drug-drug interactions)
• SE: headache, sedation, activation, hyponatremia, GI upset, withdrawal sx, increased SI
• Buproprion : activating, helpful with fatigue, hypersomnia, pyschomotor retardation
• Mirtazapine : sedating, appetite stimulation
• Atypical antipsychotics : bipolar disorder, adjunct in depression. Not first line.
• Psychostimulants (methyphenidate, dexamphetamine) : rapid onset, no RCT. May worsen anxiety

Question 12

Psychosocial treatments for depression

Answer 12

• empathic listening
• helping to navigate health care system
• evidence poor:
  
  • relaxation
  • psychoeducation
  • CBT
  • psychotherapy

Question 13

Anxiety definition

Answer 13

DSM IV

• Panic disorder:
  
  • panic attacks + 1 month of worry about panic attack, change in behaviour
  • Panic attack:
    
    • episode of intense anxiety x minutes
    • chills, diaphoresis, depersonalization, fear of loss of control, fear of dying, shaing, paresthesias, lightheadedness, nausea, chest tightness, dyspnea, choking, palpitations
• Phobias
• GAD
  
  • excessive worry that is difficult to control
  • restless, irritbale, fatgued, concentration, muscular tension, sleep disturbance
  • catastrophize
• PTSD / Acute stress disorder
  
  • experienced or witnessed serious threat risk of harm, injury, death
  • fear, helplessness, horror
  • flashbacks
  • hyperarousal, dissociation
  • 6 months
  • hematological malignancies (sudden in onset, dramatic clinical status changes)
• Anxiety disorder NOS
  
  • anticipatory nausea/vx

Question 14

Anxiety treatment

Answer 14

• consider general medical causes and drug effects
• optimize symptom control (pain etc)

Benzodiazepines:

• short term situational anxiety, panic attacks
• risk respiratory depression, falls, delirium
• Lorazepam, oxazepam, temazepam : hepatic failure
  
  • metabolism by phase 2 glucuronidation

SSRI (first line)

• half dose intiation to minimize side effects that make anxiety worse, treatment discontinuation

TCAs/ SNRIS (all reasonable choices)

Buspirone (non benzo anxiolytic)

• non sedating

Atypical neuroleptics

• adjuncts PTSD, anxiety
• not first line in palliative care for anxiety

Question 15

Non Pharmacological treatment of anxiety

Answer 15

• Attention to physical situation
  
  • PT/OT/lifeline
  • support groups, volunteers
• Breathing, visual imagery
• Box breathing
• CBT
• mindfulness based stress reduction

Question 16

Adjustment disorder

Answer 16

• Lacks specificity
• Most common psychiatric diagnosisin medically ill people
• clinical utility :
  
  • prodromal / transient distress
  • not as stigmatizing
• Treatment:
  
  • psychological interventions first line
  • medications if not responding to first line
  • treat insomnia, anxiety, depression, physical symptoms
  • supportive relationships with clinicians

Question 17

SIGECAPS for Depression (5/9 x 2 weeks)

Answer 17

• Suicidal thoughts
• Interests decreased
• Guilt
• Energy low
• Concentration low
• Appetite disturbance
• Psychomotor changes
• Sleep changes

Question 18

Serotonin Discontinuation Syndrome

Answer 18

HANGMAN

• Headache
• Anxiety
• Nausea
• Gait instability
• Malaise
• Asthenia / fatigue
• Numbness

Question 19

Panic disorder : Diagnosis

Answer 19

• Students fear 3 Cs
• Sweating
• Trembling
• Unsteadiness, dizziness
• Depersonalization
• Excessive heart rate
• Nausea
• TIngling
• Shortness of breath
• Fear of dying, losing control or going crazy
• Cs: chest pain, chills, choking
• at least 1 attack and 1 month of behaviour avoidance, concern about additional panic attck
• No attributable to effects of a substance or other medical disorder

Question 20

Acute Stress Disorder

Answer 20

• Traumatic event
• Re-experience intrusive symptoms:
  
  • memories, flashbacks, psychological distress, physiological sx
• avoidance of memories, thoughts of traumatic event
• alterations in mood, detachment, anhedonia
• Arousal and reactivity:
  
  • hypervigilace, irritability, startling, concentration
• shorter than PTSD : lasts about a month
• hematologic malignancy recurrence is common trigger:
  
  • sudden onset and dramatic changes in clinical status

Question 21

PTSD

Answer 21

• Traumatic event or exposure repeatedly to trauma
• Symptoms the same as acute stress reaction, but last > 1 month
• unable to function
• Not attributed to medical or other psychiatric condition

Question 22

Demoralization syndrome

Answer 22

• not an official DSMIV diagnosis
• Symptoms:
  
  • loss of meaning
  • loss of hope
  • sense of being trapped
  • feels like giving up
  • socially isolated
  • desire to die
  • lasts for more than 2 weeks

Question 23

Dysthymia

Answer 23

• 2 years depressed mood
• 2/6 neurovegetative symptoms
• no more than 2 months without symptoms

SIGECHAL

• Suicidal thoughts
• Interests decreased
• Guilt
• Energy dereased
• Concentration decreased
• Hopelessness
• Appetite
• Low self esteem

Question 24

Why is younger age associated with increased risk of depression?

Answer 24

• Greater sense of loss
• less prior experience of coping with adversity
• greater capacity of older people to find meaning and experience secure attachment in relationships