Download Depression and psychological distress

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Depression and psychological
distress - how are they related?
National Resource Centre for Long-term
Studies after Cancer, Norwegian Radium
Hospital &
Dept. of Behavioral Sciences in Medicine,
University of Oslo
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Folie 1
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Outline
General issues
Stress and distress
Use of the term in palliative care
Distress
Some general aspects
Depression
Classification of psychological phenomena
- a crash course
In relation to cancer and palliative care
Distress and depression
In recent publications
How is it modeled?
Some viewpoints – for discussion
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How do you conceptualize?
- each concept and the relation
Distress
Dep.
Distress
Dep.
Dep.
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Distress
Distress and depression
Complicated and often poorly defined terms
Distress
Broad range of meanings
Different subtypes
Depression
Inconsistent use of both
Narrower term – 2 major meanings:
An affect – lowered mood (depressio mentis) – a symptom
A psychiatric disorder – Major Depressive Disorder
The relation varies:
Depression included in the concept of distress
Other psychiatric conditions also counted as distress
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Principles of psych. classification
Man-made – not God-made (C. von Linné)
Purpose of psychiatric classifications
Communication – between professionals
Control – i.e. select candidates who probably will benefit treatment
Understanding – quality control & research
Most psych. symptoms occur in many conditions
Also in normal reactions such as depr. mood in sadness
Some central criteria for counting as disorders:
Symptom load – how much of each symptom - i.e. intensity
Duration
Functional consequences
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Principles of psych. class. II
DSM & ICD - non-hierarchical systems
Jaspers 1913 created a hierarchical diagnostic system:
organic / schizophrenia / mood disorder / personality disorder /
neurosis
DSM & ICD - non-aetiological
Based upon symptoms & behaviors
Exception to non-aetiological: PTSD with a specific cause
Psych. diagnosis = certain constellation of symptoms
That is symptom clustering!
The diagnoses = the clusters
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The upper excluded the lower
Distress – the concept
Stress – hard to define & hard to research
In physics – leading to strain – old term
As many perceptions as people?
Never reached an agreed-upon definition
Form of the Middle English destresse, derived via old French
from the Latin stringere – to draw tight (Wikepedia)
H Selye 1930’s – as a ”psychophysiological concept”
The reactions of the organism to external events
Stressor = the perceived threat
Renewed interest 1970’s – life events & biological
mechanisms
Individualized response – appraisal (Lazarus)
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Distress – the concept II
Distress – introduced by H Selye 1975
Persistent stress - not resolved through coping or adaptation
May lead to anxiety or withdrawal (=depression) behavior
Failure to deal with stress - i.e. a response to external events
Opposed to eustress – the good stress
Different types of distress
(Wikepedia)
Fetal distress
Respiratory distress
Emotional distress
Psychological distress
Suffering
……....
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Distress – the original model
Depression
Depression used as a term for:
Depressed mood – a symptom
Loss of pleasure (anhedonia) – a symptom
A disorder of affect
– a syndrome as defined by the DSMIV / ICD-10
Partly a colloquial term – feeling down, blue,…
What is measured by different assessment tools
Depressed mood observed in different diagnoses
Depressive episode
Adjustment disorders
Personality disorder (dystymia)
Important to distinguish Depression as a disorder (the diagnosis
of depression) from depression as a symptom
In this context = the disorder
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A disorder of affect:
- DSMIV-criteria for depression
Criteria 1
Type of symptom
1. Lowered mood 2
Psychological
2. Anhedonia * 2
Psychological (?)
3. Anorexia / weight loss
Somatic
4. Insomnia / hypersomnia
Somatic
5. Psychomotor agitation / retardation
Psychological?
6. Fatigue
Somatic
7. Feeling of guilt
Psychological
8. Lowered concentration
Somatic?
9. Recurrent thoughts of death / suicide
Psychological
1
:
5 or more criteria present for last 14 days and a change from previous
2
Major criteria - one must be present
*:
Anhedonia = lacking ability to feel pleasure of stimuli that usually gives
pleasure
:
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functioning
Assessment of depression in pall.care
- A systematic literature review
198 papers included
105 different assessment methods
64 used only once
Usage not based upon definition of depression
Few studies classified depression
Traditional rather than quality reasons
Regional differences, e.g. HADS most common in Europe
while seldom employed in the USA or Canada
Majority of classifications were cut-off scores (77%)
Less than one third took duration into account
18% assessed consequences and impact upon functioning
Depression: different phenomena across studies
Depression = transient lowered mood = sadness = ..…
Wasteson L et al..Subm 2009
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Distress in pall./cancer care
National Comprehensive Cancer Network guidelines
Distress Management 1997-2008 - expert consensus
Referring to emotional and psychological problems
The term distress chosen for political reasons
More acceptable / less stigmatizing than psycho…
Sounds normal and less embarrassing
Can be defined and measured by self-report
NCCN definition of distress in cancer:
.. is a multifactorial unpleasant emotional experience of a
psychological (cognitive, behavioral, emotional), social,
and/or spiritual nature that may interfere with the ability to
cope effectively with cancer, its physical symptoms and its
treatment. Distress extends along a continuum, ranging
from common normal feelings of vulnerability, sadness and
fear to problems that can become disabling, such as
depression, anxiety, panic, social isolation, and existential
and spiritual crisis
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Distress in pall./cancer care II
How much distress during last week?
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- the Distress Thermometer
The Distress Thermometer II
Additional content:
Indicate problematic areas the past week (Yes / No)
Practical problems (5 items)
Family problems (2 items)
Emotional problems (6 items)
Spiritual / religious concerns
Physical problems (21 items)
Anyone seen similar content in other contexts?
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Bodily functioning
Mobility
Different symptoms
The Distress Thermometer III
Published 1998 – in relation to NCCN guidelines
“The benchmark for measuring the distress level of
patients with cancer” (JC Holland 2001)
Validated for evaluation of distress
It is an assessment method – comparison to others
And anxiety and depression
Cut-off was 4v5 – revised in 2007: 3v4
Rationale?
Introduced as a screening tool
Psychometric properties for psychiatric case detection: 50%
Compared to other screening tools?
Further developed into Emotion Thermometers (distress,
anxiety, depression & anger)
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Distress and depression
“NCCI guidelines (2008)” - algorithm
Brief screening tool – risk score
Assessment of risk factors
Referral to
Evaluation for
Mental health, social or pastoral services
Dementia
Delirium
Mood disorder - depression
Adjustment disorder
Anxiety disorder
Substance-related or personality disorder
Interpretation of conceptualization
Depression = subcategory in distress
Depression = a major cause of distress?
NCCN Guidelines 2008, www.nccn.org
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Distress and depression II
“Measurement of psychological distress”
Different brief screening tools
More comprehensive screening tools
Incl. HRQOL-instruments
Different psychiatric disorders and assess. methods
Disorders
Incl. the distress thermometer
Depression
Anxiety
Delirium
Interpretation of conceptualization
Distress = poor (HR)QOL
Depression = subcategory in distress
Kelly B et al. Pall Med 2006; 20:779-789
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Distress and depression III
“Screening for psychological distress”
Points to a need for broader assessment
Distress includes
Psychological problems in pall. care
Normal reactions
Screening tools
Psychological problems in pall care do not fit traditional
psychiatric classifications
Adjustment disorders common – an example
Unidimensional scales – i.e. single items / distr. thermometer
Multidimensional scales – HADS, EDS ..
Capacity for identifying depression correctly
Interpretation of conceptualization
Depression = subcategory in distress
Distress does not include other psychiatric conditions
Thekkumpurath P et al. J Pain Sympt Manage 2008
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Distress and depression IV
“Clinical practice guidelines for the management
of psychosocial distress at the end of life”
Adaptation of NCCN guidelines to end of life care
Chosen distress to avoid stigma
Distress along a continuum
Expert opinions
From normal reactions to depression, anxiety & delirium
Interpretation of conceptualization
Depression = subcategory in distress
Depression = a major cause of distress?
Murillo M, Holland JC, Pall Supp Care 2004; 2: 65.-77
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Distress: the assessment model
Screening
Screening
Distress
Psychiatric disorders
- Depression, delirium, anxiety...
Traditional screening vs. NCCN guideline model
Which model is optimal?
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Psychiatric disorders
- Depression, delirium, anxiety...
Distress & depression
– some comments
Hospital Anxiety and depression Scale (HADS)
Does depression cause distress or
Depression = extreme distress?
Distress: another broad term
Introduced for political reasons
Alternative: Suffering – good face validity
Distress = poor HRQOL
Most commonly used tool for assessment of depression
Also recommended as screening tool for distress!
From content of the Distress thermometer
Some challenges
Does avoiding psycho… reduce stigma?
Does a new term influence practice – an empirical question
Does it help in identifying treatable disorders
Clinical usefulness:
State vs trait / treatable or self-limitating?
Duration – stability – consequences
Does screening improve care?
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Do you conceptualize differently?
Distress
Dep.
Distress
Dep.
Dep.
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Distress
Conclusions
Distress
Depression
Assessed quite differently
Very few studies use the diagnostic criteria
Distress and depression
A modern term from stress research
Often assessed as HRQOL and depression
NCCN Guidelines recommend unidimensional assessment
Most authors:
Depression: a subcategory of distress
Cited commonly as underlying distress
A cause of distress? Does distress cause depression?
What improves care, treatment and research?
A broad concept or focus on treatable disorders?
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