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.

psychooncology?

7 / 52 / 47 300 4 / 32 / 2008; 2010 Fallowfield & Jenkins 2004

PSA 0.22 1.22

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; 6440-1

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

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

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

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

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

Berard 15% 20% (Berard, 2001) Potash Breitbart 1983 1995 later stage (depressive disorders) 23% 58 % (Potash & Breitbart, 2002)

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

1994 DSM-IV depressive episode 1 2

> 5/9 5%

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

5-HT

somatization

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

ANXIETY

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

A.N.S.

Night terror

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

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

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

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

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

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

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

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

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

胰

絕 沉 絕

4% 13% Kugaya et al., 2000 4% 5% Uchitomi et al., 2000 1 5% 14% Akechi et al., 2001 5% 18% Akechi et al., 2001 18 7% 35% Okamura et al., 2000 3 2% 20% Okamura et al., 2005 7% 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 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;36:733-42.

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]

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 0.79-0.89 Kissane

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) 0.94 0.92 MV) Loss of meaning (5) 0.87 0.84 Dysphoria (5) 0.85 0.69 Disheartenment 0.89 0.88 (6;5*) Helplessness (4) 0.84 0.72 Sense of failure (4) 0.71 0.63 *

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 = 61 47 14 Depressed n = 39 6 33

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 = 65 99 (46.3%) 16 (7.5%) 50 (23.4%) 49 (22.9%)

(/ 100,000) 2003 Levi et al. 1995-1998 14.4 ( ) 4.6 ( ) (/ 100,000) SMR* 2008 Misono et al. 2009 Robinson et al. 2009 MacFarla ne et al. 1973-2002 31.4 16.7 1996-2005 ( ) 1.45 ( ) 1.19( ) 1983-2002 1.78 2010 Ahn et al. 1993-2005 2.00( ) 3.45( 1 ) 2010 Chung et al. 2002-2004 288.9 (3 ) 13.59 (2002) 14.16 (2003) 15.31(2004)

95%Cl 3-5 4.35 1.87-8.58 5 1.62 1.03-2.43 2.13 1.22-3.47 50 1.93 1.19-2.95 4.66 2.12-8.84 3.58 1.54-7.06 5.86 1.58-15.05 Tanaka et al., 1999

2002-2004 1866 40 46% Lin HC, Wu CH, & Lee HC (2009). Risk factors for suicide following hospital discharge among cancer patients. Psychooncology

Suicide among cancer patients in Taiwan 2002-2004 1,065 288.90/100,000 ( ) (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), 107-114

Suicide among cancer patients in Taiwan 2002-2004 1,065 288.90/100,000 ( ) (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), 107-114

2011年7月1日星期五

* 2010;21:427-435. Mandarin version of Demoralization scale (DS-MV) had been evaluated for reliability and validity.

夠 呢

溫 溫

產 產

Development of antidepressant treatment MAOI mono-amine oxidase inhibitor NaSSA noradrenergic and specific serotonergic antidepressant 1950 1960 1970 1980 1990 2000 non-selective tricyclic AD TCA selective serotonin re-uptake inhibitor SSRI serotonin noradrenaline re-uptake inhibitor SNRI

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

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

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

Mechanism of NaSSA www.cnsforum.com

NaSSA = Remeron Noradrenergic neurotransmission Serotonergic neurotransmission NA - antidepressant effect 5-HT 1 - antidepressant effect - anxiolytic effect Pinder RM, J Clin Psychiatry 1997; 58(11): 501-508 5-HT 2 blockade 5-HT 3 blockade Prevents: - nausea - anxiolytic effect - vomiting - sleep improvement Prevents: - agitation - restlessness - sexual dysfunction

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;72:835-47.

Richelson E. Mayo Clin Proc 1997;72:835-47.

Tamoxifen s protection against breast cancer recurrence is not reduced by concurrent use of the SSRI citalopram. British Journal of Cancer (2008) 99, 616 621 Concurrent use of citalopram does not reduce tamoxifen's prevention of breast cancer recurrence.

Conclusion 1 6 vital sign 1/10 (demoralization)

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