Download 17. Depression and Anxiety

Palliative Care:
Depression and Anxiety
Hong-Phuc Tran, M.D,
Learning Objectives
• Identify signs and symptoms of depression
• Discuss risk factors for depression
• Understand differential diagnoses of depression
• Learn management of depression
• Explain signs and symptoms of anxiety
• Understand management of anxiety
Depression: Introduction
• Depression is often under-recognized and undertreated in terminally ill patients
• Persistent depression is not normal for patients near
end-of-life or with terminal conditions and should
be treated
• Prevalence of depression is 1-40% in palliative care
settings
• Up to 58% of patients with cancer have depression
Signs and Symptoms of Depression
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Sad or depressed mood
Insomnia or sleeping too much
Anhedonia
Guilt or hopelessness
Low energy
Difficulty thinking or concentrating
Anorexia or eating too much
Psychomotor retardation
Recurrent suicidal ideations, plans or attempts
When the above symptoms occur for 2+ weeks, then
diagnosis of major depression is made
Examples of Risk Factors for Depression in
Terminally Ill Patients
• Poorly controlled pain
• Progressive physical impairments
• Medication side effect
– Steroids, benzodiazepines, some chemotherapy agents
• Malignancy
– Patients with breast, lung or pancreatic cancer have
higher incidence of depression
• Age
– Younger patients with cancer are more likely to be
depressed than older patients
• Prior personal or family history of depression
• Lack of social support
Differential Diagnoses of Depression
• Adjustment disorder
• Bereavement
• Dementia
• Delirium (hypoactive)
Examples of Tools to Screen for
Depression
• “Do you feel depressed most of the time?”
▫ Sensitive and specific screening question
• Patient Health Questionnaire-9 (PHQ-9)
• Beck Depression Inventory
Management of Depression (1)
• Standard antidepressants effective but delayed onset of
2-6 weeks
• Selective serotonin reuptake inhibitors (SSRIs) have less
side effects than tricyclic antidepressants (TCAs)
– TCAs have anti-cholinergic side effects
• Psycho stimulants can be used if need rapid effect
– Can be started at same time as SSRIs, which take longer to
work
– Beneficial effect on energy, mood, appetite, mental
alertness
– Trial of methylphenidate 2.5mg in early morning hours, up
titrate if needed
Management of Depression (2)
• Electric Convulsive Therapy (ECT)
– Induces seizures, releasing more epinephrine,
serotonin, dopamine
– Benefits: Effective, safe for rapid treatment of
severe depression
– Contraindications: CNS space occupying lesions
• Psychotherapy
– Psychiatrist, psychologist, chaplain, social worker
Management of Depression (3)
• Complementary Therapies
– Sunlight exposure
– Aromatherapy
– Relaxation therapy
– Distraction therapy with pleasant imagery
– Meditation
– Guided imagery
– Music therapy
– Massage therapy
Anxiety: Introduction
• Anxiety is a state of feeling apprehension
– Can lead to functional impairment & poor quality
of life when excessive or persistent
• Present in up to 21% of cancer patients
– Only a small % had any symptoms of anxiety prior
to cancer diagnosis or treatment
• Often overlooked & not treated aggressively
Anxiety: Introduction (2)
• Generalized anxiety disorder (GAD) is diagnosed
when excessive anxiety or worry lasts 6+ months
& impacts day-to-day activities.
• Often co-occurs with adjustment disorders &
depression
• Cancer patients may develop hyper arousal &
nightmares and meet criteria for Posttraumatic
Stress Disorder (PTSD)
Signs and Symptoms of Anxiety
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Excessive worry, apprehension, foreboding
Irritability, tension
Agitation, restlessness, hyper arousal
Insomnia
Sweating, tachycardia
Hyperventilation, shortness of breath
Gastrointestinal distress, nausea
Screening for Anxiety
• Screening questions
▫ “Do you find yourself worrying a lot?”
▫ “Are you often fearful?”
▫ “Do often feel anxious?”
• Obtain collateral information
Examples of Some Reversible
Causes of Anxiety
• Alcohol
• Caffeine
• Medication side effect
– Levothyroxine, antipsychotics, psycho stimulants,
steroids, beta-agonists
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Pulmonary embolus
Uncontrolled pain
Hypoxia
Abnormal metabolic status
Withdrawal from nicotine, alcohol, opioids
Cardiac arrhythmias
Management of Anxiety
• Treat reversible causes
• Complementary or alternative therapy
▫ Guided imagery, meditation, music,
aromatherapy, massage therapy
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Supportive counseling
Coping techniques
Limit caffeine, alcohol
Pharmacologic management
Benzodiazepines (BZs)
• Can be used when immediate relief is desired
▫ Choose based on desired half-life
▫ Examples of common BZs
 Clonazepam (half-life: 30-40 hrs)
 Example dosing: 0.5-2mg po daily to BID prn
 Lorazepam (half-life: 12 hrs)
 Example dosing: 0.25mg-2mg po / SL q 6h PRN
▫ Taper slowly when discontinuing
 (e.g. reduce dose by 25-50% each day)
Gapabentin & Trazodone
• Alternative options with BZs contraindicated or
when primary hypnotic effect desired
▫ Gabapentin 300mg po qHS
 Increase dose every 3-5 days if ineffective, first to
300mg po q12h, then 300mg po q8h, then by
increments of 100mg q 8h
 Max dose is 3,600mg/day (use with caution in
elderly)
▫ Trazodone 12.5mg po q2hr prn anxiety/agitation
▫ Trazodone 25-100mg po qHS for insomnia
Selective Serotonin Reuptake
Inhibitors (SSRIs)
• Can be used for chronic anxiety
• Higher doses may be needed to manage chronic
anxiety
• Example: paroxetine, citalopram, escitalopram
Paroxetine
• Often chosen due to sedating, calming effect
• Initial starting dose 10-20mg po daily
• Target is 20-40mg daily
• Max 50mg/day
• Use extended release formulation to reduce risk
of adverse events
Citalopram (Celexa)
• Starting dose 10-20mg daily
• Increase weekly by 10-20mg daily
• In elderly, max dose is 20mg daily
• In patients < 65, usual target is 40mg daily. Max is
60mg/day
• Black box warning: Prolonged QTc interval,
increased risk of mortality in elderly
Escitalopram (Lexapro)
• Starting dose: 5-10mg daily
• Maintenance & maximum dose: 10-20mg daily
• For severe anxiety, consider starting both
benzodiazepine and SSRI together
▫ Once SSRI becomes effective in 4-6 weeks, then
benzodiazepine can be tapered off
• Consult psychiatrist when benzodiazepine
discontinuation is complicated
References & Suggested Readings
• EPEC (Education for Physicians on End-of-Life Care): Anxiety at
http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/modul
e-3/module-3c-pdf
• EPEC (Education for Physicians on End-of-Life Care): Depression at
http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/modul
e-3/module-3h-pdf
• Morrison RS, Meier DE. Clinical Practice: Palliative Care. N Engl J Med.
2004 Jun 17;350(25):2582-90