Depression and Medical Co-Morbidities .

1. and Interventions Depression and Medical Co-Morbidities . Gary Rodin MD FRCPc Professor of Psychiatry , University of Toronto Head, Department of Psychosocial Oncology and Palliative Care Princess Margaret Cancer Centre

2. What is Depression? • An experience • A symptom complex • A continuum of distress disorder • a final common pathway of distress • A disorder • A neurobiological state Rodin et al 2009

3. Medical and Demographic Factors Age and Gender Living situation Medical diagnosis and treatment Personal/family history of psych illness Psychiatric co-morbidity depression/psychiatric illness Disease-Related Factors Biological Mechanisms Physical suffering & disability Stage of disease Proximity to death Psychosocial Factors Social support Attachment security Self-esteem Spiritual well-being Economic hardship Caregiving burden Non-pathological sadness Adjustment disorder Major depression Mild Moderate Severe Fitzgerald et al 2013

4. Why is Depression Clinical Important in Medical Populations • Adversely affects: • Quality of life • Grassi et al, 1996 • Severity of Physical symptoms • Fitzgerald et al 2013 • Treatment compliance • Colleoni et al, 1996 • Will to live • Rodin et al, 2007 • Family distress • Braun et al, 2007 • Health care utilization • Prieto et al, 2002 • Lo et al, 2011

5. Detection by physicians of self-reported distress: • 2642 patients in cancer aftercare program in Germany • Mild to severe distress on psychosocial questionnaire detected by physicians in 10% of cases • Werner et al 2010 • 2,325 primary healthcare recipients completed the General Health Questionnaire (GHQ) • Physicians (n=67) identified GHQ-distress in 42 % of cases • Rabinowitz et al 2005 Detection of Psychological Distress in Medical Settings

6. Reason for Low Detection Rate of Depression in Medical Settings • Systemic factors • Case volumes • Lack of privacy • Lack of psychosocial treatment resources • Medical staff factors • Lack of training in emotional enquiry • Lack of time • Discomfort with emotions • Patient Factors • Perceived stigma/ lack of interest of medical staff • Fear of emotions • Lack of awareness • Diagnostic Uncertainty • Confounding Symptoms of depression and medical illness • e.g. anorexia, weight loss, fatigue, sleep disturbance

7. Proportion of Patients with Metastatic Cancer with Elevated Symptoms ofDepression, Hopelessness and the Desire for Hastened Death % of sample Braun et al JCO 2007 Rodin et al: SSM 2009 Lo et al JCO 2010l Desire for Hastened Death Hopelessness Depression

8. The Distribution of Depressive Symptoms in Patients with Metastatic Cancer % Sample Miller et al Soc Psy Epidemiology 2011

9. Predicted Depressive Symptoms for Individuals Differing in Physical Burden and Psychosocial Vulnerability over the last year of life. Lo C et al. JCO 2010;28:3084-3089 Lo et al 2010

10. Distress Assessment and Response Tool(DART) • Goal: • Administered electronically to cancer outpatients q 2-3 months: • Edmonton Symptom Assessment System (ESAS) for physical symptoms (each visit) • Social Difficulties Inventory (SDI-21) for practical concerns • Patient Health Questionnaire (PHQ-9) for depression • Generalized Anxiety Subscale (GAD-7) for anxiety • Desire for support • Suicidal intention • Print-out of summary scores for patient and clinic staff • Response Algorithm • Download into electronic record

11. System

12. Distress Screening Results • High sensitivity and specificity of • ESAS-A > 3 for anxiety • ESAS-D>2 for depression Bagha ..Li 2012

13. Suicidality in 4822 Ambulatory Patients • Ideation: • Thoughts that you would be better off dead, or of hurting yourself in some way • 5.8% endorsed this item • Intent (in those with ideation) • “Is there a chance you would do something to end yourlife ?” • 7.1% endorsed this item • Leung, Li .. Rodin et al, 2014

14. Risk Factors for Suicidal Ideation & Intention • Suicidal ideation • more recent cancer dx • personal or family hx depression • more difficulty making treatment decisions • more social difficulties • Symptoms of , anxiety, depression and physical distress • Suicidal intention • male sex • difficulty with treatment decisions and self-care -Leung, Li .. Rodin et al, 2014

15. Depression has been postulated to be more common in such diseases as : • Cancer, especially pancreatic cancer • Cardiac disease • Parkinson’s disease • Right sided strokes • Multiple sclerosis Depression & the Disease Specificity Hypothesis

16. Neurobiological and physical aspects of specific diseases may contribute to depression • BUT-differences in the prevalence of depression across different diseases tend to disappear after controlling for: • Stage of disease • Severity of physical disability and distress • Location of treatment (inpatient vs outpatient) • Past personal and psychiatric history • Social support Evidence Regarding Depression and Medical Disease Specificity

17. Cardiac Disease • Increased disease progression and both cardiac and all-cause mortality • Allosaimi & Baker 2012 • Van Melles et al 2004 • Diabetes • Increased all-cause mortality • Zhang et al 2005 • Katon et al 2005 • Lin et al 2009 • Cancer • increased mortality in lung cancer • Nakaya, N et al 2008 • Hamer, M et al 2009 • Pinquart et al 2010 • Temel et al 2012 Depression,Disease Progression &Mortality

18. No evidence that treatment of depression with antidepressant medication in cardiac patients reduces mortality in patients with cardiac disease, diabetes or cancer • Mechanisms that contribute to the association of depression and mortality are not clear Does Treatment of Depression in Medical Patients improve Survival?

19. Positive outcomes and sustained improvement are most likely to occur when treatment is directed at etiological and pathogenic factors, rather than solely at symptoms . • Luytens et al, 2006 • Psychiatric interventions should address subsystems of variables that are relevant in specific contexts • Kendler et al 2008 Treatment of Depression:

20. Preferences Effectiveness of Treatment for Depression in Cancer Patients • Systematic Reviews • Psychotherapy as effective as pharmacotherapy • Williams and Dale, 2006 • Rodin et al , 2007 • Psychotherapy preferred to pharmacotherapy with advanced disease • Akechi et, 2008 • Individual therapy may be more effective than group therapy (not specific to cancer) • Cuijpers, 2008

21. Tailored psychological interventions are the mainstay of treatment for all patients • Pharmacotherapy should be reserved for patients meeting criteria for psychiatric disorders • Outcomes are improved with collaborative care Treatment of Depression in Medical Populations

22. Efficacy of Antidepressants in Minor Depression • Based on systematic review & meta-analysis • No clinically important difference between antidepressants and placebo in Rx of minor depression. • Shifting from drugs to psychological interventions requires investment in human resources for training and supervision and delivery of interventions • In systems with no or low resources doctors should still shift away from drug intervention for minor depression as resources may be better spent elsewhere in the health system. . Barbui et al Brit J Psychiatry 2011

23. Sertraline, citalopram, escitalopram are relatively well-tolerated and have the fewest drug-drug interactions • Dual effects may be beneficial e.g. • Mirtazepine-weight gain • Duloxetine-neuropathic pain relief • Venlafaxine-hot flashes • Li, Fitzgerald and Rodin JCO 2013 • Psychostimulants have not been shown to relieve depression though they may have an effect on fatigue Antidepressant Medication

24. Cognitive-behavioral approaches • Relaxation therapy • Biofeedback • Guided imagery and hypnosis • Cognitive Reframing • Supportive-Expressive (psychodynamic) approaches • emotional expression, • self-understanding, • psychological support Psychotherapeutic Approaches in Medical Populations

25. :Progressive physical disability • Complex treatment decisions • Disruption in self-concept • Fear of dependency • Crisis of meaning • Fear of death and dying • Pressure of time • Planning for the end The Predictable Problems and Crises of Metastatic Cancer

26. Managing Cancer and Living Meaningfully (CALM) • Brief semi-structured intervention • 3-6 individual sessions • 45-60 minutes in length • Primary caregiver attends one or more sessions • Delivered over 6 months • Semi-structured, with attention to four domains • Delivered by specially trained mental health professionals • Ongoing weekly supervision seminars

27. The Domains of CALMfrom the practical to the profound Symptom management & communication with healthcare providers Changes in self & relations with close others Spirituality & sense of meaning/purpose Thinking of the future, hope, and mortality

28. This (CALM) has been the only opportunity for us to be looked at as people by the medical system. I think that is really important because you are more than the sum of your parts… • I have been able to grow as a person…it makes me feel like I will be able to handle death in a peaceful way. • Nissim et al, Palliative Medicine 2011 Qualitative Outcomes

29. Phase II Study • Significant reductions in symptoms of : • Depression • Distress about death and dying • Significant improvement in spiritual wellbeing Lo… Rodin, Pall Med 2013 Phase II Quantitative Outcomes

31. Integrating Mind and Body in Psychiatric Medical Care . • “The greatest mistake physicians make is that they attempt to cure the body without attempting to cure the mind; yet the mind and the body are one and should not be treated separately!” Plato 428 -367 BCE