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狩泉禄
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2 PSYCHO-ONCOLOGY Multidisciplinary subspecialty of oncology concerned with the emotional responses of patients at all stages of disease, their families and staff. First goal is quality of life. Second goal is to understand the psychological, social and behavioral risks that influence cancer incidence & survival.

3 psychooncology?

4 7 / 52 / / 32 / 2008; 2010 Fallowfield & Jenkins 2004

5 PSA

6 Emotional Distress The Sixth Vital Sign ( Vital signs: temperature, respiration, heart rate, blood pressure, and pain. To recognize emotional distress as a core indicator of a patient's health and wellbeing. Bultz BD, Carlson LE. Journal of Clinical Oncology, 2005:23;

7 1983 DSM-III 47% (adjustment disorder) 68% 13% ( Derogatis, Morrow, Fetting, et al, 1983) (anxiety)

8 53.7% 28% (dementia)(10.7%) (7.5%) (3.2%) (3.2%) (generalized anxiety disorder) (1.1%) (Minagawa, Uchitomi, Yamawaki, Ishitani, 1996)

9 (Biological factor) (1) (2) (medical condition) (Psychological factor) (Social factor) (1) (2)

10 (Assessment) (Mental Status Examination, M.S.E.)

11 lifetime prevalence 5% 12% 10% 25% 23% sadness

12 Berard 15% 20% (Berard, 2001) Potash Breitbart later stage (depressive disorders) 23% 58 % (Potash & Breitbart, 2002)

14 Massachusetts General hsopital Lisa F. Price (Price, 2004)

15 1994 DSM-IV depressive episode 1 2

16 > 5/9 5%

18 (neurotransmitter) serotonin; 5-HT norepinephrine; NE (dopamine; DA) introjection

20 5-HT

33 somatization

34 Beck depression Inventory BDI Zung self-rating depression scale Zung-SDS PHQ-9 Hamilton Rating Scale for Depression HAM-D

35 ANXIETY

36 A.N.S. (1) (2) (1) (2) (3)

37 A.N.S.

39 Night terror

40 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD

41 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD

42 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD

43 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD Subsyndromal anxiety

44 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD Subsyndromal anxiety MDD

45 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD Subsyndromal anxiety MDD Anxious dysthymia

46 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD Subsyndromal anxiety MDD Anxious dysthymia

47 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD Subsyndromal anxiety MDD Anxious dysthymia GAD

48 Combinations of Syndromes Anxiety and depression can be combined in a wide variety of syndromes. GAD(generalized anxiety disorder), MDD GAD MAD MDD Subsyndromal anxiety MDD Anxious dysthymia GAD Dysthymia

50 胰

51 絕沉絕

52 4% 13% Kugaya et al., % 5% Uchitomi et al., % 14% Akechi et al., % 18% Akechi et al., % 35% Okamura et al., % 20% Okamura et al., % 16% Akechi 2004., et al

Demoralization Demoralization has been commonly observed in the medically and psychiatrically ill and is experienced as existential despair, hopelessness, helplessness, and loss of meaning

53 Demoralization Demoralization has been commonly observed in the medically and psychiatrically ill and is experienced as existential despair, hopelessness, helplessness, and loss of meaning and purpose in life. Demoralization can occur in people who are depressed, cancer patients who are not depressed and those with Clarke DM, Kissane DW. Aust N Z J Psychiatry. 2002;36:

54 Demoralization [dictionary] 1. To undermine the confidence or morale of; dishearten: an inconsistent policy that demoralized the staff. 2. To put into disorder; confuse. 3. To debase the morals of; corrupt. [Free Dictionary],, [ ] [Dr. eye]

56 DEMORALIZATION SCALE 5 Factor Structure: 24 items 1. Loss of meaning [5 items] 2. Dysphoria [5 items] 3. Disheartenment [6 items] 4. Helplessness [4 items] 5. Sense of failure [4 items] 5 factor solution accounts for 67.1% of variance; alpha coefficients Kissane

57 Cronbach s alpha of demoralization scale DS (n=100): mean: 30.82; SD:17.73 (Kissane et al. 2004) DS-MV (n=214): mean: 30.27; SD:15.62 (Hung et al. 2010) Alpha Alpha (DS) (DS- Total scale (24 items) MV) Loss of meaning (5) Dysphoria (5) Disheartenment (6;5*) Helplessness (4) Sense of failure (4) *

58 Distinguishing Demoralization from DSM-IV Depression among cancer patients in Australia (Kissane, 2004) PHQ >10 used to define DSM- IV Major Depression Total demoralization scale score split at median (n=100) Low DS High DS Not depressed n = Depressed n =

59 Distinguishing Demoralization from DSM-IV Depression among cancer patients in Taiwan (Hung, 2010) PHQ-9 >10 Total demoralization scale used to define score split at median (n=214) DSM-IV Major Depression Low DS High DS Not depressed n = 149 Depressed n = (46.3%) 16 (7.5%) 50 (23.4%) 49 (22.9%)

61 (/ 100,000) 2003 Levi et al ( ) 4.6 ( ) (/ 100,000) SMR* 2008 Misono et al Robinson et al MacFarla ne et al ( ) 1.45 ( ) 1.19( ) Ahn et al ( ) 3.45( 1 ) 2010 Chung et al (3 ) (2002) (2003) 15.31(2004)

62 95%Cl Tanaka et al., 1999

63 % Lin HC, Wu CH, & Lee HC (2009). Risk factors for suicide following hospital discharge among cancer patients. Psychooncology

64 Suicide among cancer patients in Taiwan , /100,000 ( ) (Chung & Lin, 2010) Chung, K. H., & Lin, H. C. (2010). Methods of suicide among cancer patients: a nationwide population-based study. Suicide & Life-Threatening Behavior, 40(2),

Suicide among cancer patients in Taiwan 2002-2004 1,065 288.90/100,000 ( ) (Chung & Lin, 2010) Chung, K. H., & Lin, H. C. (2010).

65 Suicide among cancer patients in Taiwan , /100,000 ( ) (Chung & Lin, 2010) Chung, K. H., & Lin, H. C. (2010). Methods of suicide among cancer patients: a nationwide population-based study. Suicide & Life-Threatening Behavior, 40(2),

66 2011年7月1日星期五

69 * 2010;21: Mandarin version of Demoralization scale (DS-MV) had been evaluated for reliability and validity.

73 夠呢

74 溫溫

75 產產

Development of antidepressant treatment MAOI mono-amine oxidase inhibitor NaSSA noradrenergic and specific serotonergic antidepressant 1950 1960

76 Development of antidepressant treatment MAOI mono-amine oxidase inhibitor NaSSA noradrenergic and specific serotonergic antidepressant non-selective tricyclic AD TCA selective serotonin re-uptake inhibitor SSRI serotonin noradrenaline re-uptake inhibitor SNRI

77 The development of main antidepressants Tricyclic antidepressants (TCAs) Imipramine (Tofranil) late 1950s Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine (Prozac) 1986 Citalopram (Cipram) 1989 Sertraline (Zoloft) 1991 Paroxetine (Seroxat) 1992 Fluvoxamine (Luvox) 1994 Escitalopram (Lexapro) 2002

78 Serotonin-norepinephrine reuptake inhibitors (SNRIs) Venlafaxine (Effexor) 1993 Milnacipran (Ixel) 1998 Duloxetine (Cymbalta) 2002 Dopamine reuptake inhibitor (DRI) Bupropion (Wellbutrin) 1985 [for fatigue syndrome]

79 Noradrenergic and specific serotonergic antidepressant (NaSSA) Mirtazapine (Remeron) 1994 [only one drug] Alpha 2 antagonism Increase release and concentration of 5- HT & NE Enhanced 5-HT1 mediated neurotransmission Improve mood Block 5HT2A, 5HT2B, 5HT3 receptors Anti-emetic, anxiolytic, Antihistaminergic effect at low dose Somnolence, weight gain

80 Mechanism of NaSSA

81 NaSSA = Remeron Noradrenergic neurotransmission Serotonergic neurotransmission NA - antidepressant effect 5-HT 1 - antidepressant effect - anxiolytic effect Pinder RM, J Clin Psychiatry 1997; 58(11): HT 2 blockade 5-HT 3 blockade Prevents: - nausea - anxiolytic effect - vomiting - sleep improvement Prevents: - agitation - restlessness - sexual dysfunction

82 Pharmacokinetics of Antidepressants Richelson E. Pharmacokinetic Drug Interactions of New Antidepressants: A Review of the Effects on the Metabolism of Other Drugs. Mayo Clin Proc 1997;72:

83 Richelson E. Mayo Clin Proc 1997;72:

84 Tamoxifen s protection against breast cancer recurrence is not reduced by concurrent use of the SSRI citalopram. British Journal of Cancer (2008) 99, Concurrent use of citalopram does not reduce tamoxifen's prevention of breast cancer recurrence.

85 Conclusion 1 6 vital sign 1/10 (demoralization)

86 Conclusion 2 NaSSA ( Mirtazapine) SNRI ( Venlafaxine) DRI ( Buspirone)

勞工保險殘廢給付「精神障害」等級及審查標準之研究

勞工保險殘廢給付「精神障害」等級及審查標準之研究計劃編號 :BLI95-02 行政院勞工委員會勞保局委託研究報告勞工保險殘廢給付精神障害等級及審查標準之研究研究主持人 : 邱偉哲醫師計劃主辦單位 : 行政院勞工委員會勞工保險局研究期間 : 中華民國九十五年五月十八日至中華民