Anxiety and Depression Flashcards
1
Q
Prevalence and risk factors for depression and anxiety and palliative care
A
- 14% anxiety in advaned disease
- 20% depression
- Risk factors:
- degree of disability
- physical symptoms
- proximity to death
- lower self esteem
- less spiritual well being
- prior depression
- percevied lack of social support
- higher disease burden
- younger age
2
Q
Clinical significance of untreated anxiety and depression
A
- Anxiety:
- more physical distress : fatigue, pain, dyspnea, anorexia, poor well being
- poor confidence in medical team
- less likely to ask questions and understand information
- Depression:
- limit participation in EOL care
- poorer QOL
- desire for hastened death
- suicide
- increased pain
- 2x health care utilization
- lower survival in advanced cancers
3
Q
Major Depressive Episode
A
DSMIV:
- 1 of Core symptoms (most important and pathognomic):
- Depressed mood
- Anhedonia
- every day, almost all day x 2 weeks
- > 5 other symptoms:
- change in weight
- loss of appetite
- insomnia
- hypersomnia
- psychomotor agitation or retardation
- decreased energy
- worthlessness
- guilt
- concentration
- SI or attempt
- Not a result of medical condition:
- very difficult in advanced cancer
4
Q
Other categories of depression
A
- Dysthymia
- chronic low mood over 2 years
- 2/6 neurovegetative symptoms
- Adjustment disorder
- excessive emotional reaction causes impairment in function
- Mood disorder due to general medical condition
- Substance induced mood disorder
- Mood disorder NOS
- minor depression < 2 weeks, etc
5
Q
Biological causes of depression
A
- hypothyroidism
- anemia
- malnutrtion
- medication use and withdrawal
- substance use and withdrawal
6
Q
Sadness as part of dying process
A
- Normal
- Kubler Ross: denial, anger, bargaining, depression, acceptance
- facing our own mortality –> search for meaning –> post traumatic grwoth
- pathologize normal sadness
- but if sadness persistent and pervasive and interfering with function, consider MDE
- treatment can improve QOL
7
Q
Desire for hastened death in depression
A
- 45% advanced illness resport occasional desire for hastened death
- higher rates of depression
- suicide thoughts vs plan
- interprofessional team
- listen and validate patient’s concerns
- risk factors:
- delirium
- meaninglessness
- hopelessness
- functional limitations
- history of psych disorder
- alcohol / substance use
8
Q
Suicidality assessment
A
- 2x incidence in cancer patients than in general population
RISK FACTORS:
- male
- white
- older age
- lung, stomach, head and neck cancers
- concern about lack of autonomy
- dependence on others
9
Q
Biological factors contributing to anxiety and depression
A
-
Physical symptoms
- pain
- nausea
- dyspnea
- fatigue, insomnia
-
Medical conditions
- delirium
- thyroid
- B12
- electrolytes
- glucose
- hypercalcemia
-
Medications
- steroids
- cytokines (interfern-alpha, interluekin1, GnRH)
- alcohol, nicotine, street drugs
10
Q
Psychosocial factors contributing to anxiety and depression
A
- psychological factors
- attachment security
- existential concerns
- coping
- fear about future
- loss of identity
- dignity
- dependence on others
- previous trauma
- losses
- disease progression
- communication with treatment team
- role changes
- unresolved conflict
- caregiver burnout
- financial burdens
- day to day support
- future planning
11
Q
Pharmacological treatment of depression
A
Canadian Network for Mood and Anxiety Treatments : EB guidelines for treatment of depression in terminal illness
- First line: SSRI / SNRI
- Sertraline, citalopram, escitalopram 9(lowest drug-drug interactions)
- SE: headache, sedation, activation, hyponatremia, GI upset, withdrawal sx, increased SI
- Buproprion : activating, helpful with fatigue, hypersomnia, pyschomotor retardation
- Mirtazapine : sedating, appetite stimulation
- Atypical antipsychotics : bipolar disorder, adjunct in depression. Not first line.
- Psychostimulants (methyphenidate, dexamphetamine) : rapid onset, no RCT. May worsen anxiety
12
Q
Psychosocial treatments for depression
A
- empathic listening
- helping to navigate health care system
- evidence poor:
- relaxation
- psychoeducation
- CBT
- psychotherapy
13
Q
Anxiety definition
A
DSM IV
- Panic disorder:
- panic attacks + 1 month of worry about panic attack, change in behaviour
- Panic attack:
- episode of intense anxiety x minutes
- chills, diaphoresis, depersonalization, fear of loss of control, fear of dying, shaing, paresthesias, lightheadedness, nausea, chest tightness, dyspnea, choking, palpitations
- Phobias
- GAD
- excessive worry that is difficult to control
- restless, irritbale, fatgued, concentration, muscular tension, sleep disturbance
- catastrophize
- PTSD / Acute stress disorder
- experienced or witnessed serious threat risk of harm, injury, death
- fear, helplessness, horror
- flashbacks
- hyperarousal, dissociation
- 6 months
- hematological malignancies (sudden in onset, dramatic clinical status changes)
- Anxiety disorder NOS
- anticipatory nausea/vx
14
Q
Anxiety treatment
A
- consider general medical causes and drug effects
- optimize symptom control (pain etc)
Benzodiazepines:
- short term situational anxiety, panic attacks
- risk respiratory depression, falls, delirium
- Lorazepam, oxazepam, temazepam : hepatic failure
- metabolism by phase 2 glucuronidation
SSRI (first line)
- half dose intiation to minimize side effects that make anxiety worse, treatment discontinuation
TCAs/ SNRIS (all reasonable choices)
Buspirone (non benzo anxiolytic)
- non sedating
Atypical neuroleptics
- adjuncts PTSD, anxiety
- not first line in palliative care for anxiety
15
Q
Non Pharmacological treatment of anxiety
A
- Attention to physical situation
- PT/OT/lifeline
- support groups, volunteers
- Breathing, visual imagery
- Box breathing
- CBT
- mindfulness based stress reduction
