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The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
E
P
E
C
EPEC – Oncology
Education in Palliative and End-of-life Care – Oncology
O
Module 3h
Symptoms –
Depression
Depression . . .



Depressed mood
Anhedonia – loss of interest or
pleasure
> 2 weeks
. . . Depression . . .

Irritability

Changes in
Appetite or weight
Sleep
Psychomotor activity

Decreased energy

Worthlessness, helplessness,
hopelessness

Guilt
. . . Depression

Difficulty thinking, concentrating,
making decisions

Suicidal ideation or wishes to hasten
death

Somatic symptoms often not helpful
in this population
Risk factors . . .

Poorly controlled pain

Progressive physical impairment

Advanced disease

Medications
Steroids
Chemotherapeutics
. . . Risk factors

Particular diseases
Pancreatic, breast, lung, mets to
nervous system

Younger age

Spiritual pain

Risk factors in general population
Prior Hx, family Hx, social stress
Suicide attempts, substance use
Prevalence

Up to 58 % of cancer patients
Prognosis

Untreated, associated with poor
prognosis

Knowledge of true extent of disease
and prognosis do no lead to
depression or adverse outcomes
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology

Involved neurotransmitters
Norepinephrine
Serotonin
Dopamine

Genetics

Environmental influences
Assessment . . .

Assess for signs and symptoms
noted above
Do you feel depressed most of the time?

Family observations

Screening tools
. . . Assessment

Differentiate between
Grief reactions
Adjustment disorders
Delirium, particularly hypoactive
Dementia

Consult with mental health
professionals
Suicide

Suicidal thoughts are a sign of
depression

Discussion may reduce the risk

Assess all depressed patients for risk
Have you ever thought of committing
suicide?
Do you have a plan?

High risk if recurrent thoughts, plans
Management

Counseling

Complementary therapies

Pharmacotherapy

Combinations are best

Lack of improvement within weeks
suggests more aggressive therapy or
psychiatry consult needed
Counseling

Weave into routine interventions
Include family when possible

Improve patient understanding

Create a different perspective

Identify strengths, coping strategies

New coping strategies
Complementary therapies

Relaxation

Exercise

Distraction

Sunlight

Guided imagery

Meditation

Massage therapy

Aromatherapy

Self-hypnosis
Pharmacotherapy . . .

Tricyclic antidepressants

SSRIs
Preferred as less adverse effects

Psychostimulants

Other antidepressants
. . . Pharmacotherapy

Choose by time to effect
Days – psychostimulants
Weeks / months – SSRIs, other
antidepressants

Start dosing low, titrate slowly

Consider consultation
Tricyclic antidepressants

Not first-line therapy when SSRIs
available, unless looking for
Analgesic or sleep altering effects

Latency 3 – 6 weeks

Adverse effects are common
Anticholinergic, cardiac
Nortriptyline, desipramine have fewer
adverse effects
SSRIs

Latency 2 – 4 weeks

Highly effective

Well tolerated

Once-daily dosing

Lower doses may be effective in
advanced illness

Check for drug-drug interactions
Psychostimulants . . .

Rapid effect in hours to days

Minimal adverse effects

Alone or in combination with SSRIs

Can continue indefinitely

Tolerance may not be a factor

Diminish opioid induced sedation
. . . Psychostimulants

May exacerbate

Choose
Tremulousness
Methylphenidate
Anxiety
Dextroamphetamine
Anorexia
Pemoline
Insomnia
Modafinil
Other antidepressants

May be particularly helpful for:
Sedation (mirtazapine, trazodone)
Energy (bupropion, venlafaxine)
Appetite stimulation (mirtazapine)

Still being studied in this population
Summary . . .

Very common

Intense suffering

Not inevitable

Treatable in most cases, with
multiple approaches

Early treatment is better
E
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. . . Summary
O
Use comprehensive
assessment and
pathophysiology-based therapy
to treat the cause and improve
the cancer experience