Dr.

Richard Lim Boon Leong MBBS(UM), MRCP(UK) Consultant Palliative Medicine Physician Hospital Selayang

Depression and anxiety are common psychiatric conditions in patients with advanced illness particularly cancer.
In incurable cancer patients of 37 symptoms:
Prevalence of depressed mood 39% (9th) Prevalence of anxiety 30% (15th) Constipation ranked 10th Dyspnoea ranked 16th
Teunissen et al 2007

Prevalence of depression and anxiety in other non-cancerous conditions:

Condition
Cardiac failure End stage renal ds

Depression
10-60% 19-52%

Anxiety
11-45% 69-87%

COPD

8-80%

6-74%

WHO definition of palliative care:

. prevention and relief of suffering by means of

early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Physical Psychological

Total Pain
Social

Spiritual

We are probably better at fixing the physical symptoms than psychological and spiritual Perception of physical symptoms are amplified by anxiety and depression leading to more suffering

ANXIETY

In palliative care, it is recognised that a having a terminal illness is indeed a frightening reality. Symptoms of fear and anxiety may occur for a variety of reasons.

Tension Restlessness Jitteriness Autonomic hyperactivity Dyspnoea Numbness Nausea, abdominal discomfort

Vigilance Insomnia Distractability Apprehension Worry Rumination

Psychological Adjustment disorder Agitated depression Anxiety disorder Panic disorder

Organic Delirium Hypoxia Sepsis Cardiac ds Poorly controlled pain Drug reactions Drug withdrawal Substance withdrawal

Anxiety Subscale (0-7 / 8-10 / 11-21) 1. I feel tense or wound up 2. I get a sort of frightened feeling as if something awful is about to happen 3. Worrying thoughts go through my mind 4. I can sit at ease and feel relaxed 5. I get a sort of frightened feeling like 'butterflies' in the stomach 6. I feel restless as I have to be on the move 7. I get sudden feelings of panic

Rule out and treat underlying organic causes (pain, respiratory distress, drug reactions etc) Pharmacological
Benzodiazepines
Mainstay of pharmaco mx of anxiety

Neuroleptics (haloperidol , olanzepine)

Delirium associated with anxiety

Sedating antihistamines (hydroxyzine)

Useful in patients with pain and anxiety

Antidepressants (TCA , SSRI

Anxiety assoc with depression

Drug

Dose range 10-60mg / day

Route SC / IV

Very short acting Midazolam

Short acting Lorazepam Alprazolam Oxazepam

0.5-2mg tds/qid 0.25-2mg tds/qid 10-15mg qid

PO/SL PO/SL PO

Intermediate acting Diazepam 5-10mg bd-qid Clonazepam 0.5-2mg bd -qid

PO PO

Short acting benzodiazepines are the choice drug for anxiety in palliative care. Midazolam commonly used in crisis settings parenterally as continuous infusion and prn in terminal phase. Long acting useful in patients with seizure disorders and organic brain syndromes. Caution in liver impaired patients.

DEPRESSION

Depressed mood and sadness is common in patients with terminal illness and can often be deemed as an appropriate response.
Major depression is reported to have a median prevalence of 15% in advanced cancer. (Hotopf et al 2002) Studies consistently report under-treatment and under-diagnosis of depression in palliative care settings.

Challenge in palliative care is to differentiate depression from sadness. Classical DSM-IV criteria of somatic symptoms may be due to underlying organic problem:

weight loss decreased appetite Insomnia/ hypersomnia fatigue diminished ability to concentrate

Diagnosis is therefore more reliant on psychological or cognitive symptoms rather than somatic criteria.
Anhedonia Feelings of worthlessness Hopelessness

Excessive guilt
Suicidal ideation

1.
2. 3.

Inclusive approach

Exclusive approach Substitutive approach

Exclude the somatic criteria Endicott Substitution Criteria (somatic for other cognitive criteria) Clinician determines cause of physical symptoms. 7 instead of 5

Follow DSM-IV

4.
5.

Aetiologic approach

Higher threshold criteria

DSM-IV Criteria Poor appetite or weight changes Loss of energy and fatigue or psychomotor retardation or agitation Insomnia and hypersomnia

Endicotts Substitution Tearfulness or depressed appearance Brooding, self-pity, pessimism Social withdrawal

Feeling of worthlessness or Lack of reactivity, cannot be excessive guilt or diminished cheered up ability to think or concentrate

Typical presentations: Persistent low mood, tearfulness and distress Loss of interest or pleasure in daily activities, social withdrawal Feelings of hopelessness, helplessness, worthlessness or guilt Suicidal thoughts, plans or actions, including requests for physician assisted suicide/ euthanasia

Screening Tool

Sensitivity

Specificity

Single-item Are you depressed?

Two-item During the last month, have you been bothered by feeling down, depressed or hopeless? During the last month, have you been bothered by having little interest or pleasure in doing things? Hospital anxiety and depression scale (HADS)

0.42-0.86

0.74-0.92

0.91-1.00

0.57-0.86

0.68-0.92

0.65-0.90

If depression is suspected, a diagnostic interview should be performed. Clinician should further assess the details and context of patients symptoms. Understanding the social circumstances, past experiences, belief systems allows clearer interpretation of feelings to differentiate normal grief from depression.

Depresion Feels outcast and alone Feeling of permanence Regretful, rumination on irredeemable mistakes Extreme self-depreciation / self-loathing Constant and unremitting No hope/interest in future Enjoys few activities Suicidal thoughts/behaviour

Sadness Able to feel intimately connected with others Feeling that some day this will end Able to enjoy happy memories Sense of self worth Comes in waves Looks forward to things Retains capacity for pleasure Will to live
EPCRC guidelines on Mx of depression in palliative care 2011

Treatment modalities include:

Optimal physical symptom management and

psychosocial support Pharmacotherapy (TCA, SSRI, SNRI, NaSSA, psychostimulants) Supportive psychotherapy Cognitive behavioural interventions
Relaxation and distraction Guided imagery

Severity of depression
Mild, moderate or severe

Performance status of the patient Co-morbidities and concurrent symptoms Prognosis / Estimated survival

MILD
Characterised by a small number of symptoms with limited impact on the patients everyday life

MODERATE
Characterised by a larger number of symptoms which makes it difficult for the patient to function as they would normally

SEVERE
Characterised by a large number of symptoms which make it very difficult to carry out everyday activities. There may be psychotic symptoms, food and/or fluid refusal and persistent suicidal ideation

EPCRC guidelines on Mx of depression in palliative care 2011

Refer to Pall Care for symptom control and psychosocial support Assess quality of relationships with significant others; facilitate communication consider guided selfhelp programme Consider brief psychological intervention (brief CBT, problem solving) MILD

Use recommendations as for mild depression Initiate antidepressant meds and/or psychological therapy Escalate dose or switch agent for persistent symptoms after 4 weeks MODERATE

Use recommendations as for mild and moderate depression Consider hypnotic or sedative in sleep disturbed or very distressed patients Refer to mental health specialist

Lithium, ECT, anti-psychotics

SEVERE

EPCRC guidelines on Mx of depression in palliative care 2011

Drug

Usual daily dose range (mg)

Tricyclic anti-depressants Amitriptyline

10-150 20-160 50-200 10-60

SSRI Fluoxetine Sertraline Citalopram

SNRI Venlafaxine NaSSA Mirtazepine

75-225 15-60

Patients on TCA for neuropathic pain should consider increasing dose for depression rather than adding another agent if TCA is well tolerated. TCA should be avoided in cardiac failure, recent MI or conduction defects. Also avoid in prostatism, glaucoma and epilepsy

Fluoxetine has active metabolite norfluoxetine with long halflife and may cause anxiety and appetite suppression. Not so useful in terminally ill. Sertraline and citalopram cause less induction of P450 isoenzymes and are safer in palliative care. Sertraline is SSRI of choice for recent cardiac events. Citalopram is safe in patients at risk of seizures

Mirtazepine has specific benefits that may be useful in palliative care patients:
May increase appetite May reduce nausea Has a sedative effect Early onset of action may be useful in short

prognosis

As most anti-depressants take up to several weeks for onset of response, patients with short life-expectancy and depression require an alternative approach to pharmacotherapy.
Less than 3 weeks consider psychostimulant
Methylphenidate 2.5-15mg (at 8am and 12pm)

Short days with terminal delirium and agitation

Infusion with benzodiazepines and haloperidol

Suicidal ideation is relatively infrequent in cancer patients and often only occurs in the significantly depressed patient.
Allowing patients to discuss suicidal thoughts often decreases risk of suicide.

Desire for hastened death increased 4-7x in depressed patients and associated with pessimistic cognitive style rather than symptoms of pain.

Demoralization syndrome
Hopelessness Loss of meaning Existential distress Distinct from depression

Active listening
Life review Group psychotherapy Dignity Conserving Care

A Attitude
Healthcare providers examine their own attitudes and

assumptions towards patient

B-Behaviour
Healthcare providers behaviour towards patient with

kindness and respect in simple things.

C- Compassion
Compassion refers to a deep awareness of the suffering of

another coupled with the wish to relieve it.

D- Dialogue
Dialogue must acknowledge personhood beyond the

illness itself and recognise the emotional impact that accompanies illness

Anxiety and depression are common symptoms in palliative care.

These symptoms can amplify the perception of physical symptoms and increase suffering. Clinicians should understand the basic assessment and management of these conditions to provide holistic palliative care.