Assessing and Treating Depression in Palliative Care Patients: Antidepressants, Psychotherapy Can Improve Dying Patients' Quality of Life

By Marks, Sean; Heinrich, Thomas | Current Psychiatry, August 2013 | Go to article overview

Assessing and Treating Depression in Palliative Care Patients: Antidepressants, Psychotherapy Can Improve Dying Patients' Quality of Life


Marks, Sean, Heinrich, Thomas, Current Psychiatry


Depression is highly prevalent in hospice and palliative care settings--especially among cancer patients, in whom the prevalence of depression may be 4 times that of the general population. (1) Furthermore, suicide is a relatively common, unwanted consequence of depression among cancer patients. (2) Whereas the risk of suicide among advanced cancer patients may be twice that of the general population, (3) in specific cancer populations (male patients with pancreatic adenocarcinoma) the risk of suicide may be 11 times that of the general population. (4)

Mental health professionals often are consulted when treating depressed patients with advanced illness, especially when suicidal thoughts or wishes for a hastened death are expressed to oncologists or primary care physicians. To mitigate the effects of depression among seriously ill patients (Box, page 36), (5), (6) mental health professionals must be able to assess and manage depression in patients with progressive, incurable illnesses such as advanced malignancy.

Box

Don't underestimate the impact of depression in this setting

Left untreated, depression in seriously ill patients can be associated with increased physical symptoms, suicidal thoughts, worsened quality of life, and emotional distress. (5) Moreover, depression can impair the patient's interaction with family during a pivotal time in which patients may be saying goodbye, thank you, or planning for their death. Depressive symptoms even can erode the construct of patient autonomy by interfering with one's ability to engage in medical decisions and attain a sense of meaning from their illness. (6)

Diagnostic challenges

Assessing depression in seriously ill patients can be a challenge for mental health professionals. Cardinal neurovegetative symptoms of depression, such as anergia, anorexia, impaired concentration, and sleep disturbances, also are common manifestations of advanced medical illness. (7) Furthermore, it can be difficult to gauge the significance of psychological distress among cancer patients. Although depressive thoughts and symptoms may be present in 15% to 50% of cancer patients, only 5% to 20% will meet diagnostic criteria for major depressive disorder (MDD). (8), (9) You may find it challenging to determine whether to use pharmacotherapy for depressive symptoms or whether engaging in reflective listening and exploring the patient's concerns is the appropriate therapeutic intervention.

Side effects from commonly used therapeutics for cancer patients--chemotherapeutic agents, opioids, benzodiazepines, glucocorticoids--can mimic depressive symptoms. Clinicians should include hypoactive delirium in the differential diagnosis of depressive symptoms in cancer patients. Delirium is an important consideration in the final days of life because the condition has been shown to occur in as many as 90% of these patients. (10) A mistaken diagnosis of depression in a patient who has hypoactive delirium (see "Hospitalized, elderly, and delirious: What should you do for these patients?" page 10) might lead to a prescription for an antidepressant or a psychostimulant, which can exacerbate delirium rather than alleviate depressive symptoms.

Significant attitudinal barriers from both clinicians and patients can lead to under-recognition and undertreatment of depression. Clinicians may believe the patient's depression is an appropriate response to the dying process; indeed, feeling sad or depressed may be an appropriate response to bad news or a medical setback, but meeting MDD criteria should be viewed as a pathologic process that has adverse medical, psychological, and social consequences. Time constraints or personal discomfort with existential concerns may prevent a clinician from exploring a patient's distress out of fear that such discussions may cause the patient to become more depressed. (11) Patients may underreport or consciously disguise depressive symptoms in their final weeks of life. …

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