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The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

TM. The EPEC-O Project Education in Palliative and End-of-life Care - Oncology. The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

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The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

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  1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  2. EPEC– Oncology Education in Palliative and End-of-life Care – Oncology Module 3h: Symptoms - Depression

  3. Depression . . . • Depressed mood • Anhedonia – loss of interest or pleasure • Lasting longer than 2 weeks

  4. . . . Depression . . . • Irritability • Changes in: • Appetite or weight • Sleep • Psychomotor activity • Decreased energy • Worthlessness, helplessness, hopelessness • Guilt

  5. . . . Depression • Difficulty thinking, concentrating, making decisions • Suicidal ideation or wishes to hasten death • Somatic symptoms often not helpful in this population

  6. Risk factors . . . • Poorly controlled pain • Progressive physical impairment • Advanced disease • Medications • Steroids • Chemotherapeutics

  7. . . . Risk factors • Particular cancers • Pancreatic • Breast • Lung • Metastases to nervous system • Younger age • Presence of spiritual pain • Risk factors in general population: • Prior personal history • Family history • Presence of social stress • History of suicide attempts • substance use

  8. Prevalence • Up to 58% of cancer patients

  9. Prognosis • Untreated, associated with poor prognosis • Knowledge of true extent of disease and prognosis do not lead to depression or adverse outcomes

  10. Key points • Pathophysiology • Assessment • Management

  11. Pathophysiology • Involved neurotransmitters • Norepinephrine • Serotonin • Dopamine • Genetics • Environmental influences

  12. Assessment . . . • Assess for signs and symptoms noted mentioned previously • Family observations • Screening tools • Single question: “Do you feel depressed most of the time?” • Numerous other validated tools

  13. . . . Assessment • Differentiate between: • Grief reactions • Adjustment disorders • Delirium, particularly hypoactive • Dementia • Consult with mental health professionals

  14. 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

  15. Management • Counseling • Complementary therapies • Pharmacotherapy • Combinations are best • Lack of improvement within weeks suggests more aggressive therapy or psychiatry consult needed

  16. Counseling • Weave into routine interventions • Include family when possible • Improve patient understanding • Create a different perspective • Identify strengths, coping strategies • Develop new coping strategies

  17. Relaxation Distraction Guided imagery Meditation Massage therapy Aromatherapy Self-hypnosis Exercise Sunlight Complementary therapies

  18. Pharmacotherapy . . . • Tricyclic antidepressants • Selective Serotonin Reuptake Inhibitors (SSRIs) • Preferred: less adverse effects • Psychostimulants • Other antidepressants

  19. . . . Pharmacotherapy • Choose by time to effect: • Days: psychostimulants • Weeks to months: SSRIs, other antidepressants • Start dosing low, titrate slowly • Consider consultation

  20. 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

  21. 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

  22. 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

  23. May exacerbate: Tremulousness Anxiety Anorexia Insomnia Choose: Methylphenidate Dextroamphetamine Pemoline Modafinil . . . Psychostimulants

  24. Other antidepressants • May be particularly helpful for: • Sedation (mirtazapine, trazodone) • Energy (bupropion, venlafaxine) • Appetite stimulation (mirtazapine) • Still being studied in this population

  25. Summary . . . • Very common • Intense suffering • Not inevitable • Treatable in most cases, with multiple approaches • Early treatment is better

  26. . . . Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.

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