Depression and Medical Co-Morbidities .

and Interventions

Gary Rodin MD FRCPcProfessor of Psychiatry , University of Toronto

Head, Department of Psychosocial Oncology and Palliative CarePrincess Margaret Cancer Centre

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

Medical and Demographic FactorsAge and Gender

Living situation Medical diagnosis and treatment

Personal/family history of psych illness Psychiatric co-morbidity

depression/psychiatric illnessDisease-Related

FactorsBiological Mechanisms

Physical suffering & disability

Stage of diseaseProximity to death

Psychosocial Factors

Social supportAttachment security

Self-esteemSpiritual well-beingEconomic hardshipCaregiving burden

Non-pathological sadness Adjustment disorder Major depression Mild Moderate Severe

Fitzgerald et al 2013

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

Detection of Psychological Distress in Medical Settings

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

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

Proportion of Patients with Metastatic Cancer with Elevated Symptoms of Depression,

Hopelessness and the Desire for Hastened Death

BDI>15 BHS>8 SAHD>905

10152025303540

patientsspouse

Braun et al JCO 2007Rodin et al: SSM 2009 Lo et al JCO 2010l

% ofsample

Depression Hopelessness Desire for Hastened Death

BDI<9 BDI 9-15 BDI 16-21 BDI 22-30 BDI>300

5

10

15

20

25

30

35

40

45

50 46.9

30.9

13.2

7.6

1.4

%Sample

Miller et al Soc Psy Epidemiology 2011

The Distribution of Depressive Symptoms in Patients with Metastatic Cancer

Predicted Depressive Symptoms for Individuals Differing in Physical Burden and

Psychosocial Vulnerability over the last year of life.

Lo C et al. JCO 2010;28:3084-3089Lo et al 2010

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

System

Distress Screening Results

Depression Anxiety0

5

10

15

20

25

30

35

Column1Severe

% sample

N- 1215

Bagha ..Li 2012

High sensitivity and specificity of• ESAS-A > 3 for anxiety • ESAS-D>2 for depression

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 your life ?”

▪ 7.1% endorsed this item

Leung, Li .. Rodin et al, 2014

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

Depression & the Disease Specificity Hypothesis

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

Evidence Regarding Depression and Medical Disease Specificity

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

Depression,Disease Progression

&Mortality 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

Does Treatment of Depression in Medical Patients improve Survival?

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

Treatment of Depression:

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

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

Treatment of Depression in Medical Populations

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

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

Antidepressant Medication

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

Psychotherapeutic Approaches in Medical Populations

Cognitive-behavioral approaches Relaxation therapy Biofeedback Guided imagery and hypnosis Cognitive Reframing

Supportive-Expressive (psychodynamic) approaches emotional expression, self-understanding, psychological support

The Predictable Problems and Crises of Metastatic

Cancer :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

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

Symptom management& communication with healthcare providers

Thinking of the future, hope, and mortality

Spirituality &sense of meaning/purpose

Changes in self & relations with close others

The Domains of CALMfrom the practical to the profound

Qualitative Outcomes 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

Phase II Quantitative Outcomes

Phase II Study Significant reductions in symptoms of :

▪ Depression▪ Distress about death and dying

Significant improvement in spiritual wellbeing

Lo… Rodin, Pall Med 2013

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!”

Plato428 -367 BCE