for cancer survivorship research?

Anxiety and depression – appropriate terms for cancer survivorship research?

Jon Håvard Loge

Regional Centre for Excellence in Palliative Care, Dept. of Oncol., Oslo University Hospital/

Dept. of Behavioural Sciences in Medicine, University of Oslo

Outline – reflect on practice including own

 Terminology

 Prevalence of anxiety and depression

 Assessment methods – HADS as is mostly used

 Distress

 Conclusions

Depression and anxiety

 Symptoms - continuous

 Syndromes – categorical

 Psychiatric disorders – diagnostic systems (ICD10 / DSMV)

 Depression Disorder (subtypes)

 Anxiety disorders: PTSD, GAD, PD…

 Adjustment disorders

 Depression and anxiety symptoms co-occur

 Anxiety - common symptom among depressed (Brenne 2013)

 In adjustment disorders

 As emotional distress

Depression & anxiety prevalence ca. survivors

 Meta-analysis 2013 – case control studies

 16 studies on depression (N=51 300 vs 217 600)

 11.6% vs 10.2

 Diversity of assessment methods – HADS scored differently

 4 used diagnostic criteria – i.e. disorder

 12 studies on anxiety (N=48 900 vs 226 400)

 17.9 vs 13.9

 Anxiety disorders – not specified

 Cut-offs on self-report instruments (HADS)

 Same phenomena studied?

Mitchell AJ. LancOn 2013

Does terminology matter?

Not distinguishing symptoms & syndromes

 Imprecise

 Health problems intermixed - grief vs. depression, temporary distress vs disorder

 Specific problems can be overlooked – PTSD

 Limits clinical value of findings

 Planning, setting up services

 Informing our patients

 Selection for treatment

 Negative effect on our impact?

Depression

Depression – symptom & disorder

 Most studied psychiatric problem in oncology

 > 16 000 hits PubMed

 Anxiety: 9 600 hits

 Prevalence estimates: 1-53% - explained by:

 Assessment method

 Sample characteristics

 Most commonly assessed by patients’ report on questionnaires

 > 100 instruments (Wasteson, 2009)

 I.e. studies of different depression symptoms – not disorder

What is depression?

 Lowered mood – melancholy (black gall)

 Term depression

 Assigned different meanings

 Psychiatrist vs. health professional vs. lay-man

 Categorical disorder vs. spectrum condition - discussed

 Categorical = a distinct entity different from other

 Spectrum = continuous phenomenon, i.e. mood in distress

DSMV-criteria depression disorder:

symptom-threshold + duration + functional decline

Criterion ¹ Symptom type

1. Lowered mood ² Psycological

2. Anhedonia ² Psychological (?)

3. Anorexia / weight loss Somatic 4. Insomnia / hypersomnia Somatic 5. Psykomotor agitation / retardation Somatic

6. Fatigue Somatic

7. Selfblame Psychological

8. Lowered concentration Psychological 9. Thoughts dead / suicide Psychological

1: Five or more present for more than 14 days and a change from previously

2: One must be present

Assessment methods

Principle of psychiatric diagnostic systems

- same symptom across severity levels

 Normal reactions – emotions including:

 Irritability, anxiousness, lowered mood, sadness, grief..

 Acute reactions:

 Strong normal reactions of short duration

 Adjustment disorders:

 More than anticipated… i.e. > normal reactions

 Longer duration > 14 days

 Major Depressive Disorder

”Normal”

”Pathological”

Are we “blinded” by wording of the instruments?

 Hospital Anxiety and Depression Scale

 Beck’s Depression Inventory

 CES-D (Centre Epidemiologic Studies Depression scale

 …….

 Not taking face validity, construct validity &

psychometric properties into account?

 Often more or less arbitrary cut-points

 Cheap & easy to administer

 Tradition?

Anhedonia – a major depression criterion

 Anhedonia (+ mood + fatigue (ICD))

 Inability to feel pleasure from stimuli that usually give pleasure

 5 items on anhedonia in HADS (7 items anxiety and depression subscales) – i.e. HADS-D is a measure of anhedonia

 Still enjoy things that used to enjoy

 Can laugh and see the funny side of things (+mood)

 Have lost interest in appearance

 Look forward with enjoyment to things (+mood)

 Can enjoy a book or radio or TV programme

 HADS: 2 other items

 Mood & retardation (=fatigue)

Anhedonia – a valid depression criterion in (severely?) somatically ill?

EORTC item 24:

Did you feel depressed

What can HADS be used for?

 HADS popular from 1980’s:

 Shortness, postulated robust towards disease (anhedonia)

 Not duration or functional consequences – measure state

 Psychometrics - conflicting findings

 Factor structure inconsistent: 1,2,3

 Best used as a unidimensional measure of distress?

 Depression disorder in palliative cancer patients

 HADS-D performed poorer than total sum-score and anxiety-score in detecting depression (Le Fevre 1999, LLoyd-Williams 2001)

 HADS not recommended for case-finding (Mitchell 2010)

 Total sum-score for distress screening

A «new» term - distress

N

C

C

N

Guidelines (1998-2008)

 Chose the term distress because:

 Acceptable and not stigmatizing (i.e. political)

 Sounds normal (i.e. political)

 Can be defined and measured by self-report

 NCCN defined distress as:

Distress is a multifactorial unpleasant emotional experience of a

psychological (cognitive, behavioral, emotional), social, and/or spiritual

nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic,

social isolation, and existential and spiritual crisis.

 A wide definition

 Not followed by specific actions – opposed to a diagnosis

Distress – the original model

Distress – used to screen for disorders!

Reviews on instruments:

 Vodermaier A, J Natl Canc Inst 2009

Ability to accurately detect adjustment, depression and anxiety disorders

 Thekkumpurath P, J Pain Sympt Mange 2008 Ability to detect depression

 The concept also used more broadly, i.e. including delirium

Of high relevance in itself - clinical encounters!

Conclusions

 Symptoms and disorders different constructs

 As in clinical practice

 Distress – umbrella term launched for political reasons

 First generation self-report instruments still dominating

 Newer instruments available (PHQ-9 for depression), others for specific anxiety disorders

 Which disorders underlie the increased levels of anxiety?

 A common assessment and classification system?

 Based upon psychiatric diagnostic systems

 Reachable?

Thank you for your attention