Evidence-based, but practical..and comes out against routine screening for distress unless system in place to offer treatment

1. Chronology of Distress,
Anxiety, and Depression in
Older Cancer Patients
International Workshop on Palliative
Care to the Geriatric Oncology Patient
Muscat, Sultanate of Oman,
February 10-13, 2013
James C. Coyne, Ph.D.
Department of Psychiatry, University of Pennsylvania
Health Psychology Program, University of Groningen

2. Do older cancer patients experience fewer
psychological symptoms- anxiety and
depression?
Previously answered “of course,” but becoming
controversial idea.

3. Major depression 15%
Anxiety disorders 10%
Dysthymia 3%

5. • Cancer is less disruptive of social roles such as
parenting and employment
• Greater acceptance of mortality, inevitability of
end-of-life
• Diagnosis and experience of cancer interpreted
in the context of larger physical co-morbidities

6. Different themes for older
cancer patients:
•Patients’ perception of effects
on family members: family
burden
•Lost opportunity to witness
family transitions
•Widowhood and social
isolation (important predictors
of non-remission of clinical
depression)

7. In general, major depression in the context of a
general medical condition has longer episodes
and a greater likelihood of relapse and
recurrence.
In the case of cancer, attention to depression is
often sacrificed to the competing priority of
dealing with the cancer, despite the reduction in
morbidity that would be achieved by effective
treatment of depression.

8. Depression among cancer patients is
associated with:
•Negative impact on patient’s quality of life
•Reduced acceptance of and compliance with
treatment plans
•Prolonged hospitalizations
•Reduced effective coping
•Desire for early death or suicide

9. Trajectory of adaptation to a
diagnosis of cancer and its
treatment

10. Normal response to diagnosis
of cancer is upset, sadness,
fright, and worry about the
future.
It is difficult to immediately
establish whether response is
abnormal and when formal
psychiatric diagnosis and
treatment are appropriate.

11. Much of initial response to cancer diagnosis is
self-limiting or responsive to attention and
support and better information.
By six months, residual distress tends to have
existed before diagnosis, be tied to non-cancer
factors, or reflect neuroticism or psychiatric
comorbidity.

12. Different Patterns of Adjustment
65
60
55
Cut Point
50 Never Disressed
45 Resolved Distress
Chronic Distress
40
35
30
Diagnosis 3 Months 6 Months
Never Distressed  52% of sample; No Elevations over time
Resolved Distress  36% of sample; Elevated distress at diagnosis
that resolves by 3 months
Chronic Distress  12% of sample; Elevated distress at all times

14. Deferred diagnosis of mild mental
disorder, supportive action
(stepped diagnosis, stepped care)

15. On the other hand, be alert to the early
emergence of psychiatric disorder,
particularly among patients with a past
history
•Vegetative symptoms such as psychomotor
retardation, extreme insomnia
•Pathological guilt and excessive self-blame

16. It is controversial whether cancer is associated
with psychiatric co-morbidity more than with other
physical health conditions.
The challenge is making a diagnosis and
ensuring adequate follow up within the competing
demands of dealing with a life-threatening
condition.

17. In general, major depression in the context
of a general medical condition has longer
episodes and a greater likelihood of relapse
and recurrence.
In the case of cancer, attention
to depression is often
sacrificed to the competing
priority of dealing with the
cancer, despite the reduction
in morbidity that would be
achieved by effective
treatment of depression.

18. • 25 studies
• Antidepressants more efficacious than placebo
at 4-5, 6-8, and 9-18
• Superiority over placebo is apparent within 4-5
weeks and increases with continued use.

19. Detecting psychiatric morbidity:
The argument against routine
screening of cancer patients for
depression and anxiety

20. Effective care for depression requires accurate
diagnosis and follow up.
Routine care for depression in general medical
settings typically no better than receiving
placebo in a clinical trial.
Estimated that 40% of general medical patients
receiving treatment for depression achieve no
benefit over remaining on waiting list.

21. Rather than routinely screening
patients for depression and placing
them in inadequate routine care
without follow-up:
•Concentrate on ensuring better follow-up
care for known cases of
depression
•Concentrate on patients
at high risk for depression

22. Be aware of the limitations of common self-
report screening instruments:
•Cut points may not hold in another language
and culture unless cross validated
•Do not reliably distinguish between anxiety and
depression symptoms
•Do not translate well (ex.- butterflies in the
stomach)

23. The Hospital Anxiety and
Depression Scale (HADS)
should not be used
Coyne JC, van Sonderen E:
The Hospital Anxiety and
Depression Scale (HADS) is
dead, but like Elvis, there will
still be citings. Journal of
Psychosomatic Research.
73:77-78.

25. Importance of history
psychiatric disorder

26. Psychiatric disorders tend to be recurrent and
episodic, with onset the late teens or early 20s.
Most psychiatric disorders in cancer patients will
be recurrences, so past history a good predictor.
Late onset depression is treatable, but less
responsive than a recurrence.

27. • Anhedonia
• Apathy
• Pain, fatigue masquerading
as depressive symptoms

28. Many depressed patients
do not renew prescriptions.
About half require dosage
adjustment, medication
changes, or education
about adherence at five
weeks to achieve benefits.

29. Don't neglect needs of informal caregivers.
Initial symptomatology of women is higher than
men, regardless of whether they are patients or
spouses.

30. A key issue in the management of depression
among elderly cancer patients is not the
availability of efficacious treatments, but
ensuring their effective delivery and follow-up.

31. Collaborative care for depression:
• At least 79 evaluations, 4 with the elderly, 3
with cancer patients
• Interdisciplinary team approach
• Key element is a depression care manager,
usually a nurse
• Effect sizes in the range of => .30-.40

32. Is there an app for this?
Challenge of collaborative care is
sustainability, cost of care
manager
App decision aids for providers
Cell phone support, reminders
for patients

33. Thank you!
jcoynester@gmail.com
Follow me on Twitter
@CoyneoftheRealm