Depression in Terminally ill patients

1. Depression in Terminally ill patients “what have I got to live for?.......there is no one to live with me” Dr Nicky Rourke November 2013

2. Depression in the Terminally ill patient. • Case presentation – psychological issues • Depression in cancer patients • Why its important? • Barriers recognising depression/psychological distress • Risk factors of depression • Learning points

3. Case presentation • 103yr old retired engineering worker admitted from home 22/10/13. • Diagnosed June 2013 lung cancer. • Background hx– Heart failure NYHA Class IV. • Fast track referral from GP in March following 2/12 hx of haemoptysis and SOB. Suspicious CXR – pleural effusion.

4. June ‘13 - CT thorax showed LLL malignancy with local node involvement. • Review by Dr Lawless - no active treatment • DTU referral

5. DTU • Retired engineering worker • Ukrainian, lived in UK for over 50yrs • Widowed, wife died 5years ago was in NH. Son died last year. • Lives in own home. • Independent with ADLs, main issues fatigue, SOB. • Deterioration over next 3/12 leading to admission.

6. BIOPSYCHOSOCIAL BACKGROUND PRIOR TO ADMISSION

7. Physical issues • Haemoptysis • Breathlessness • Oedema • 24/8 Memory problems • 24/9 Chest pain • 30/9 Chest infection • 8/10 General deterioration, started oramorph for pain

8. Social • Support – HF nurse, OT, GP, DTU, friends, befriender, nephew • Residential care ? Option • Difficulty in taking medication dosset box • Memory problems • Stopped medications • Declined HF nurse visit • Cancelled MOW • Declined carer assistance • Unkempt appearance at DTU

9. Psychological • 6/8 “feels lonely” • 13/8 - does not like living alone, likes company. Wishes to explore residential care. “ Philosophical about dying” • 2/9“ worried about finishing at Manorlands...what will I do after?”

10. 11/9 self neglect - appearance at DTU • 22/10 home visit by HF nurse found to be drowsy ?oramorph OD. • Admission to Manorlands ?LRTI

11. Current admission • 22/10 Confused but reported by ward nurses to be “bright” • 29/10 “ don’t be upset but I’m going to die”denied any worries, declined any assistance with cares • 31/10 discussion with medical team re: discharge plans ? To NH. Appears confused about what will happen to his home

12. 1/11 patient found by nurse with dressing gown cord around neck “ I am trying to hang myself” • “horrible things go though my mind..... Feel frightened”...patient points to heaven, “I’m the last one alive” • Later same day denied any serious intent of ending life, impulsive decision.

13. 3/11 – appears to be more confused • 4/11 not eating/drinking. Poor sleep at night • “waiting for my funeral” • 5/11 “ I'm not well” Commenced 30mg mirtazepine, then reduced to 15mg • Pt reported to be low in mood, curtains drawn in room, lying on bed all day. Persuaded to change room nearer to nurses station.

14. 12/11 worried about future, sees no future, “no family ” wishes life was over • 13/11 problems sleeping, zopiclone, denies any suicidal tendencies • 19/11 analgesia reviewed, commenced oxycodone 5mg. • 20/11 remains low in mood “what have I got to live for?....no one to live with me”

15. Currently less well in self but stable • Plan – for discharge to NH, pt agreeable.

16. Depression • Affects approx 15%-25% of cancer patients (NCI 2013) • Associated with intense suffering and a cause of intense suffering • Treatable in many cases, early intervention more effective • Specific illnesses have been linked with depression, pancreatic ca. • Identifying pre-existing risk factors can help to highlight depression

17. Looking for depression clues • Previous hx of depression • Prior suicide attempts • Social stresses • Hx of substance abuse • FH depression

18. Advanced disease increases likelihood of depression • Differentiating between normal grief and clinical depression sometimes difficult. • Important to exclude any medical causes of symptoms.

19. Possible medical causes of depressive symptoms • Uncontrolled pain • Advanced disease • Metabolic abnormalities- hypercalcaemia, electrolyte imbalance • Anaemia • Vit B12/folate deficiency • Endocrine abnormalities – hyperthyroidism/hypothyroidism • Medications – steroids, methyldopa, propanolol, some chemo agents/antibiotics

20. Why is it important to recognise depression/psychological distress?

21. Impairs pts capacity for pleasure, meaning and connection • Affects quality of life • Amplifies pain/symptoms • Reduces pts ability to do emotional work of separating/saying good bye • Anguish and worry in family/friends • Major risk factor for suicide (Mc Cartney et al)

22. Barriers to recognition/treatment of depression

23. Block, SD (2005) • Belief that psychological distress normal feature of dying process fail to differentiate natural distress from clinical depression • Clinical skills in diagnosing depression, delirium, anxiety. (junior doctors – acute setting) • Patients and physicians often avoid discussion – time constraints • Reluctance to prescribe psychotropic agents • Physicians feel a sense of hopelessness-therapeutic nihilism.

24. At least 50% of all people diagnosed with cancer will adapt – 5 stages of grief. • May experience spectrum depressive symptoms, -sleep and appetite disturbances, anxiety, ruminative thoughts, fears for the future.

25. Sadness, grief or depression?

26. Grief • Pts experience somatic distress, agitation, sleep, appetite disturbances, social withdrawal, decreased concentration Depression • Pts experience similar symptoms + hopelessness, helplessness, worthlessness, guilt and suicidal ideation

27. Grief • Able to retain capacity for pleasure • Grief comes in waves • Pts express a wish for death to come quickly • Able to look forward to the future. Depression • Pts enjoy nothing • Depression is constant, unremitting • Pts express intense and suicidal ideation • No sense of a positive future

28. Indicators of depression in terminally ill patients ( Block 2005) • Dysphoria • Depressed mood • Sadness • Tearfulness • Anhedonia • Hopelessness • Worthlessness • Social withdrawal • Guilt • Suicidal ideation • Intractable pain • Excessive somatic preoccupation • Disproportionate disability • Poor cooperation/refusal of treatment • Personal FH mental health issues • Pancreatic cancer

29. Assessment Screening tools • Asking the question During the past month have you often been bothered by … feeling down, depressed, or hopeless? little interest or pleasure in doing things? Arroll et al BMJ  2003;327:1144-1146 • HAD • PHQ-9

30. Diagnosis • Symptoms lasted >2 weeks and present on most days • Cognitive symptoms such as guilt, worthlessness, hopelessness, thoughts of suicide and anhedonia – most useful in diagnosing depression in people with cancer. (National Cancer Institute 2013)

31. First step – pain control. • Pain is a major risk factor for depression and suicide among patients with cancer. • Psychotherapy/pharmacological interventions.

32. Psychopharmacology - psychostimulants, SSRIs TCA’s. • psychostimulants- (dextroamphetamine) take effect quickly, can be considered in treating depression near the end of life. • best used in patients who have weeks/months not for those with relatively long life spans. Some reluctance with use, concerns re side effects.

33. Learning points • Collateral information, premorbid personality. Look back at entries from other HCP • Can highlight potential issues and risk factors. • Important to explore mental health of patient and family, asking those questions on admission, not avoiding. • Equally as important as physical symptom, low threshold for treatment. • Involvement of the multidisciplinary team paramount.