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Jane FletcherPsychologist / Director
Melbourne Psycho-oncology Service – Cabrini Health
Cabrini Monash Psycho-oncology Research Unit
Monash University
St Vincent’s Hospital Melbourne
[email protected]© Jane Fletcher 2009
© Jane Fletcher 2009
Reactions to breast cancer
Vary from person to person
Problem Challenge
Life saving Devastating
Process of
Adaptation
Adjustment
Acceptance
© Jane Fletcher 2009
Reactions to breast cancer
Adaptation, adjustment and acceptance
In own time
In own way
Unique experience
Depends on persons previous life challenges, coping and personality styles, social support etc
© Jane Fletcher 2009
Issues after breast cancer
Physical issues
Social issues
Spiritual / existential issues
Health care / system issue
Emotional and psychological issues
© Jane Fletcher 2009
Emotional and psychological issues
Anger / resentment
Uncertainty
Loss of control
Hopelessness
Helplessness
Loneliness
Anxiety
Depression
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
What is depression? A deep persistent sadness and pessimism
Can affect anyone at any age
Extremely common
One in five (20%) people affected by depression at some time in their lives
One million Australian adults and 100,000 young people live with depression each year
More common in women than men
One in four females and one in six malesBeyond Blue, 2009
Edvard Munch, Despair, 1892
Edvard Munch, Despair, 1893-4
© Jane Fletcher 2009
What is anxiety?
Feelings of persistent worry and fear
Some anxiety is good and motivates us to perform at our best
Excessive anxiety result in fight or flight reaction
‘Fighter’ ready for perceived aggression and unable to relax
‘Escaper’ (flight response) freezes with anxiety and may avoid upsetting situations or dissociate from the experience
Pedersen (2008)
Edvard Munch, Anxiety, 1894
Edvard Munch, Scream, 1893
© Jane Fletcher 2009
Why is identifying and treating depression and anxiety important? Unmanaged depression and anxiety can result in
Significant reduction in quality life
Increased suicide risk
Treatment delays
Compliance issues
Increased complications
Increased health care costsAmerican Psychosocial Oncology Society (2006)
© Jane Fletcher 2009
Depression and breast cancer
© Jane Fletcher 2009
Depression and breast cancer Depression prevalent in 20-50% people with breast
cancer
At diagnosis – 20%-28%
Recurrent disease ~ 50%
Advanced disease – 20%-40%
Palliative care ~ 27%-77%
Depression can be associated with an increased desire for death and increased suicide rate
Population rates 5-20% - gender differences
(Breitbart et al 2000)
© Jane Fletcher 2009
Depression and breast cancer Distinguish between ‘upset’ and clinically
significant distress
Periods of low mood and grief are ‘normal’ reactions to cancer
Level of ‘appropriate sadness’
Reaction is transient
Question depressive disorder when
Persistent
Impact on individual’s life and functioning
© Jane Fletcher 2009
Types of depression
Major depression
Depressed mood > two weeks
Also called clinical depression or unipolar depression
Range of subtypes
Dysthymia
Less severe depressed mood that lasts for years
© Jane Fletcher 2009
Types of depression
Mixed depression and anxiety
Combination of symptoms of depression and anxiety
Bipolar disorder
Periods depression and mania
Adjustment disorder
© Jane Fletcher 2009
What causes depression? Biological - monoamine hypothesis
Deficiency of the neurotransmitters serotonin, norepinephrine and dopamine in the synaptic cleft between neurons in the brain
Psychological factors
Significant life events – breast cancer
Social
Familial predisposition
Unknown
© Jane Fletcher 2009
Relationship between cancer and depression The relationship is complex
Depression after breast cancer may be triggered by
Diagnosis
Other issues related to the breast cancer and its treatment
Impact of the cancer person's life
May be related to other difficult life events (past or present)
© Jane Fletcher 2009
Who is most likely to develop depression?
Pre morbid depression
Socially isolated
Other significant life events
Co-morbidities
Drug interactions and side effects
Steroids
Opioids
Benzodiazepines
© Jane Fletcher 2009
Who is most likely to develop depression?
Pain
Significant cause of depression in cancer patients
Depression may change perceptions of the meaning and severity of pain
Pain or fear of unrelieved pain critical variable in requests of physician assisted suicide
© Jane Fletcher 2009
Diagnosing depression?
DSM – IV TR Criteria: Major Depressive Episode
Depressed mood
Diminished interest or pleasure in activities
Significant weight loss/gain or decrease/increase in appetite
Insomnia or hypersomnia
© Jane Fletcher 2009
Diagnosing depression?
DSM – IV TR Criteria: Major Depressive Episode
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Diminished ability to think or concentrate or indecisiveness
Recurrent thoughts of death or suicidal ideation
© Jane Fletcher 2009
Criteria for major depression One or both of main emotional symptoms of
depression
Dysphoria (sadness)
Anhedonia (lack of pleasure)
Plus at least five of the somatic symptoms
DSM-IV TR criteria also require
Presence of vegetative and/or somatic symptoms with psychological symptoms and must be present for two weeks and present a significant change from prior functioning
© Jane Fletcher 2009
Psychological symptoms of depression
Dysphoria (sadness)
Anhedonia (lack of pleasure)
Hopelessness
Feelings of guilt
Worthlessness
© Jane Fletcher 2009
DEPRESSION
Alteration in mood (anxiety/depression)
Fatigue
Low energy
Loss of appetite
Loss of sleep
Psychomotor retardation
CANCER AND ITS TREATMENT
Pain and other symptoms
Fatigue
Low energy
Loss of appetite
Loss of sleep
Psychomotor retardation
Vegetative and somatic symptoms
© Jane Fletcher 2009
Mnemonic for depression diagnostic criteria SIGECAPS
Sleep (increase/decrease)
Interest (diminished)
Guilt/low self esteem
Energy (poor/low)
Concentration (poor)
Appetite (increased/decreased)
Psychomotor (agitation/retardation)
Suicidal ideation
© Jane Fletcher 2009
Major depression
Depressed mood for 2 or more weeks plus 4 SIGECAPS
Dysthymia
Depressed mood, plus three SIGECAPS for 2 years, most days
Unipolar - not bipolar disorder with depressed mood
If patient who is prescribed antidepressants begin to show manic symptoms may be bipolar
© Jane Fletcher 2009
Be alert to reports that patients are:
Having a very low mood for most of the time
Not being able to be lifted out of low mood
Not feeling usual self
Not being able to enjoy anything
Loss of interest in favourite activities
Feeling worse in the mornings
Problems getting off to sleep or waking early
Poor sleeping patterns or sleeplessness
© Jane Fletcher 2009
Be alert to reports that patients are:
Poor concentration and forgetfulness
Feelings of guilt/burden/blame
Feeling helpless or hopeless
Feeling vulnerable or oversensitive
Feeling close to tears
Irritability
Loss of motivation, unable to start or complete jobs
© Jane Fletcher 2009
Be alert to reports that patients are:
Physical hyperactivity or inactivity
Loss of interest in sex
Thoughts of suicide or death
Slow speech; slow movements
Drug or alcohol abuse
© Jane Fletcher 2009
Adjustment disorders
Often called minor depression or reactive depression
Abnormal and excessive reaction to a life stress
Most common mood disorder in cancer patients
Symptoms typically begin within 3 months of the stressor, and do not last longer than 6 months after stressor stops
Ongoing stressors-breast cancer?
© Jane Fletcher 2009
Adjustment disorders
Diagnostic criteria
The symptoms clearly follow stressor
The symptoms are more severe than would be expected
There do not appear to be other underlying disorders
© Jane Fletcher 2009
Adjustment disorders
Diagnosis requires
Sadness or inability to find pleasure in life as a response to stressor like cancer
Temporally related to onset of symptoms
Symptoms sufficiently severe to cause impairment in social and occupational functioning
© Jane Fletcher 2009
Treatment for depression
If patient depressed refer them to the appropriate health professional/s
GP
Psychologist
Psychiatrist
Social worker
Counsellor
© Jane Fletcher 2009
Treatment for depression Pharmacological
Antidepressants
Psychological
Psychotherapy /psychotherapeutic interventions
Lifestyle factors
Exercise
Sleep
© Jane Fletcher 2009
Pharmacological – antidepressants Prescribed medical doctor
Best when combined with psychological / psychotherapeutic interventions
Use for major depression or when symptoms are severe - patient dependent
Mechanisms differ depending of class
Norepinephrine
Serotonin
© Jane Fletcher 2009
Pharmacological – antidepressants
Between 2-4 weeks to take effect
Monitor side effects and symptom response
© Jane Fletcher 2009
Pharmacological – antidepressants
Side effects are usually mild and resolve within first few weeks
Dry mouth
Drowsiness
Nausea
Sleeplessness
Sexual problems
Headaches
© Jane Fletcher 2009
Pharmacological – antidepressantsClasses commonly used in cancer patients
Tricyclic antidepressants (TCAs)
More side-effects than newer drugs
Monoamine oxidase inhibitors (MAOIs)
Difficult to use due to drug-drug and drug-food interactions
© Jane Fletcher 2009
Pharmacological – antidepressantsClasses commonly used in cancer patients
Selective serotonin reuptake inhibitors (SSRIs) eg Sertraline – Zoloft, Fluoxetine – Prozac/Lovan
Highly effective
Reduced side effect profile
Generally non sedating
© Jane Fletcher 2009
Pharmacological – antidepressantsClasses commonly used in cancer patients
Serotonin and noradrenaline reuptake inhibitors (SNRIs) eg Venlafaxine – Effexor
Fewer side effects
Effective in severe depression
May assist with hot flushes and neuropathic pain
© Jane Fletcher 2009
Pharmacological – antidepressantsClasses commonly used in cancer patients
Noradrenaline-serotonin specific antidepressants (NaSSAs) eg Mirtazapine– Remeron
Relatively new antidepressants
Particularly helpful when there are problems with anxiety or sleep
Generally low in sexual side-effects
© Jane Fletcher 2009
Psychological interventions
Provided by
Psychologist
Psychiatrist
Social Worker
Counsellors / Psychotherapist
Some GPs
Check qualifications and experience in dealing with cancer patients
© Jane Fletcher 2009
Psychological interventions
Types of therapies include
Cognitive Behavioural Therapy (CBT)
Supportive or existential psychotherapy
Acceptance and Commitment Therapy (ACT)
Therapy is usually individualised and will differ for each person
Many therapists will use a range of techniques
© Jane Fletcher 2009
Psychological interventions
Cognitive Behavioural Therapy
Present based
Teaches problem solving
Reframing attitudes
Challenges ‘black and white thinking’
Relaxation skills
Guided imagery
© Jane Fletcher 2009
Psychological interventions
Supportive or existential psychotherapy
Encourages expression of emotion
Validates individual experience
Support through empathic listening and encouragement
Utilises information provision
Highlights strengths of individual
Encourages use of adaptive coping
© Jane Fletcher 2009
Psychological interventions Acceptance and Commitment Therapy
Acceptance of what is out of your personal control, while committing to do whatever is in your personal control
Teaches psychological skills to deal with painful thoughts and feelings effectively – mindfulness skills
Helps to clarify what is truly important and meaningful i.e. values - then use that knowledge to guide, inspire and motivate person to change life for the better
© Jane Fletcher 2009
Lifestyle factors
Exercise
Evidence exercise improves mood
Diet
Sleep
Getting enough sleep
Good sleep hygiene
Natural therapies
St John’s Wort
© Jane Fletcher 2009
Anxiety and breast cancer
© Jane Fletcher 2009
Anxiety and breast cancer
Anxiety ~ 35% of patients with cancer diagnosis
Range of disorders with different rates(Zabora et al, 2000)
© Jane Fletcher 2009
Anxiety and breast cancer? Feelings of anxiety increase or decrease at different
times
Most patients are able to reduce their anxiety by learning more about their cancer
For some, particularly those who have experienced episodes of intense anxiety before their cancer diagnosis, feelings of anxiety may become overwhelming
Most patients who have not had an anxiety condition before their cancer diagnosis will not develop an anxiety disorder associated with cancer
© Jane Fletcher 2009
Anxiety and breast cancer Some level of anxiety is a normal reaction to breast
cancer
Difficult to distinguish between normal fears associated with cancer and abnormally severe fears that can be classified as an anxiety disorder
Anxiety associated with cancer may increase
Feelings of pain
Interfere with sleep
Nausea and vomiting
Reduce quality of life
© Jane Fletcher 2009
What is anxiety?
Primary psychiatric disorders
Generalized anxiety disorder (GAD)
Pervasive feeling of dread or apprehension
Panic disorder +/- agoraphobia (avoidance of places that may result in panic)
Obsessive-compulsive disorder
Post traumatic stress disorder
© Jane Fletcher 2009
What is anxiety?Cancer related anxiety
Psychological anxiety can be interpreted as a reaction to a threat
Anxiety increases in certain situations
Initial diagnosis
Treatment
Lead up to follow up appointments
Waiting for test results
Recurrence
© Jane Fletcher 2009
What is anxiety?Phobic reactions
Anxiety that may lead to full blown panic
Claustrophobic patients and MRI/CT scans
Needle phobia
White coat syndrome
© Jane Fletcher 2009
What is anxiety?Conditioned response
Anticipatory nausea
Often associated with anxiety
PTSD
Survivors
Undergo additional treatment
© Jane Fletcher 2009
Anxiety related to breast cancer Some persons may have already experienced
intense anxiety in their life because of situations unrelated to their cancer
These anxiety conditions may recur or become aggravated by the stress of a cancer diagnosis
Patients may experience extreme fear, be unable to absorb information given to them by health professionals, or be unable to follow through with treatment
© Jane Fletcher 2009
Signs and symptoms of anxiety
Psychological
Worry, apprehension, fear and sadness
Patients may be able identify focus or source of these symptoms
Often non-specific and ‘free floating’
Crying spells, ruminations
Inability to ‘turn off’ – especially at night
© Jane Fletcher 2009
Signs and symptoms of anxiety
Physical
Tachycardia and tachypnea
Tremor
Diaphoresis
Nausea
Dry mouth
Insomnia
Anorexia
© Jane Fletcher 2009
Signs and symptoms of anxiety May be intermittent – increasing over hours or days
Occurs in response to stressor - anticipation of upcoming diagnostic test and passes once stressor over
May be persistent and pervasive through day
Typical of primary anxiety disorders
Co-morbid depressive symptoms
Reactions to chronic stressors (eg fear of recurrence, family and financial problems)
Side effects of regular medication
© Jane Fletcher 2009
Signs and symptoms of anxiety
Panic attacks present with acute anxiety
Severe palpitations, perspiration and nausea
Great fear of catastrophic event
Feeling of impending doom
Usually last for several minutes
Multiple events can occur in one day
© Jane Fletcher 2009
Be alert to reports that patients are: Feeling shaky, jittery, or nervous
Tense, fearful, or apprehensive
Having to avoid certain places or activities because of fear
Palpitations
Trouble catching breath when nervous
Unjustified sweating or trembling
Knot in stomach
Lump in throat
© Jane Fletcher 2009
Be alert to reports that patients are: Pacing
Afraid to close eyes at night for fear that may die in sleep
Worry about the next diagnostic test, or the results of it, weeks in advance
Sudden fear of losing control or going crazy
Sudden fear of dying
Intense worry about pain or other physical issues
Confusion or disorientation
© Jane Fletcher 2009
Who is most likely to develop anxiety disorder? History of anxiety disorders
Experiencing anxiety at the time of diagnosis
Severe pain
Socially isolated
Non responsive cancer
History of severe physical or emotional trauma
Cancer medications and treatments
© Jane Fletcher 2009
Treatment for anxiety disorders
If patient anxious refer them to the appropriate health professional/s
GP
Psychologist
Psychiatrist
Social worker
Counsellor
© Jane Fletcher 2009
Types of treatment for anxiety disorder
Depends on how the anxiety is affecting daily life
Treat the cause of anxiety if possible
Pain or another medical condition
Medication side effect
All treatment begins with adequate information and support
Medications may be used alone or in combination with psychological therapies or strategies
© Jane Fletcher 2009
Treatment for anxiety disorder Pharmacological
Anti-anxiety
Antidepressants
Psychological
Psychotherapy /psychotherapeutic interventions
Lifestyle factors
Exercise
Sleep
© Jane Fletcher 2009
Pharmacological therapies
Anti-anxiety medication
Benzodiazepine
Short acting such as lorazepam (Ativan) and alprazolam (Xanax)
Rapid action
Useful for intermittent acute anxiety or panic
Pre meds
Preferred in seriously ill
© Jane Fletcher 2009
Pharmacological therapies
Anti-anxiety medication
Benzodiazepine
Longer acting such as diazepam (Valium) and clonazepam (Klonopin)
Useful for more persistent anxiety
Less tolerance
Fear of addiction vs. symptom control
© Jane Fletcher 2009
Pharmacological therapies
Anti-anxiety medication
Antipsychotic drugs
Haloperidol (Haldol)
Use in low doses for anxiety
Especially if agitation and tremor present
© Jane Fletcher 2009
Pharmacological therapies
Anti-anxiety medication
Opioid analgesics
Morphine
Effective in terminally ill
© Jane Fletcher 2009
Pharmacological therapies
Anti-anxiety medication
Antidepressants
Patients with pre existing anxiety
No used on an ‘as needed’ basis
SSRIs
© Jane Fletcher 2009
Psychological interventions Types of psychological therapies include
Psycho-education
Active problem solving
Cognitive Behavioural Therapy (CBT)
Supportive or existential psychotherapy
Acceptance and Commitment Therapy (ACT)
Mindfulness Based Stress Reduction (MBSR) techniques
© Jane Fletcher 2009
What else is helpful?
© Jane Fletcher 2009
Helpful psychological strategies
Expressive therapies
Journaling
Music
Art
Self-help groups
Peer support
© Jane Fletcher 2009
Helpful psychological strategies
Stress reduction techniques
Mindfulness based stress reduction - meditation
Relaxation techniques
Guided imagery
Biofeedback
Hypnosis
© Jane Fletcher 2009
Helpful psychological strategies
Mindfulness exercise
Yoga
Tai Chi
Qigong
© Jane Fletcher 2009
Relaxation techniques
1 – 10
Deep breaths
Relax, relax, relax………………
Metronome / clock
Progressive muscle relaxation
Mindful focus on the breath
Special place
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
Screening for distress
Goal
Early detection
Early assessment / referral
Early treatment / intervention
Early detection = screening on a routine basis
Embedded in routine care at multiple time intervals
© Jane Fletcher 2009
Screening for distress
Distress Thermometer
0–10 visual analogue scale - indicate level of distress on the scale
"No Distress" at 0
"Moderate Distress" at the midpoint
"Extreme Distress" at 10
Supplementary questions covering various areas of distress (e.g. family problems, physical problems)
© Jane Fletcher 2009
Screening for distress
Distress Thermometer
Cut off for referral generally 4
Referral to appropriate source given results of problem list
Re screen on a regular basis
Evaluate outcome of intervention and referral
© Jane Fletcher 2009
Other measures to screen for distress
K10
10 items measuring anxiety and depression symptoms
Used by GPs as part of MHCP assessment
Scores 20 or above indicative of disorder and need referral for assessment and treatment
© Jane Fletcher 2009
© Jane Fletcher 2009
© Jane Fletcher 2009
Simple questions to assess mood Three questions used in primary care to detect
depression
During the past month, have you been bothered by feeling down, depressed, or hopeless?
During the past month, have you been bothered by little interest or pleasure in doing things?
Is this something with which you would like help?
Arroll et al 2005
© Jane Fletcher 2009
Simple questions to assess mood Other questions that may be useful
‘Anxiety is understandably common in people who have been treated for cancer. Would you say that anxiety is an issue for you?’
‘Coping with cancer isn’t just about physical issues, the emotional impact is important too.’‘Could you tell me what the cancer has meant emotionally?’‘Would say that you have ever felt really sad or depressed?’
NBOCC & NCCI, 2003
© Jane Fletcher 2009
Cancer Helpline 13 11 20 Speak to GP or health professional
Medicare rebateable psychological assistance under the Better Outcomes in Mental Health Care program is available – discuss with GP
Those who need help are not alone