Depression in Palliative Care Patients

Background

• Depression or depressive symptoms are characterized by persistent low mood, loss of interest or pleasure in daily activities, hopelessness, and/or suicidal ideation and are experienced by approximately half of patients who receive palliative care.
• Palliative care is interdisciplinary care (including medicine, nursing, social work, chaplaincy, and other specialties) that seeks to improve quality of life in patients with serious, primarily incurable illness and in their families.
• Risk factors for depression in patients receiving palliative care include a personal or family history of psychological conditions, social problems, problems resulting from underlying or concurrent medical conditions, advanced stage of illness, use of medications, and younger age.
• Risk factors for suicide in patients receiving palliative care include a history of previous/prior suicide attempts, psychiatric disorders associated with impulsive behavior (such as borderline personality disorder), a family history of suicide, advanced stage of disease and poor prognosis, inadequately controlled pain, confusion/delirium, and deficit symptoms such as loss of mobility and the inability to eat and to swallow.

Evaluation

• Inquire about depression and anxiety in all patients receiving palliative care. Questions should assess the patient's mood, intensity and duration of depressive symptoms, and risk for suicide.
• When assessing for depression focus on and prioritize cognitive/affective symptoms; physical symptoms such as weight loss and fatigue may be sequelae of the underlying condition (Strong Recommendation).
• Exclude other causes for depressive symptoms.
• Attempt to differentiate between clinical depression and normal sadness.
• In assessing risk of suicide vigilance is especially important during periods of high risk, including when starting or changing treatments or in other periods of high stress.
• Regularly assess for depressive symptoms as the psychological state of patients receiving palliative care is unstable (Strong Recommendation).
• Use a validated scale to screen for depression and assess severity.
• Consider making a clinical diagnosis of depression based on Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) or ICD-10 criteria.
• Obtain a detailed medication history to assess for medications which might:
  • produce or exacerbate depression
  • interact with other medications leading to symptoms
  • be inadequately dosed for symptom control

Management

• Communicate with the patient in a way that is open, nonjudgmental, and centered on the patient while actively inquiring about their concerns and feelings (Strong Recommendation).
• For all patients in palliative care with depressive symptoms, offer psychological therapy such as cognitive behavioral therapy and problem-solving therapy as well as psychosocial interventions such as dignity therapy (Strong Recommendation).
• For moderate-to-severe depression or for mild depression not responsive to psychological therapy, consider more intense therapy and/or medications such as antidepressants (Weak Recommendation).
• When selecting medications to treat depression or depressive symptoms consider:
  • patient's ability to comply with protocol and route of administration
  • possible interactions and contraindications including underlying condition, concurrent medical conditions and symptoms, or other medications
  • expected survival of patient (relative to time to effect of medication)
  • some adverse events which may be clinically beneficial (such as increased appetite) or may exacerbate symptoms, depending on clinical situation
• Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication in patients with depression.
• Other classes of medications may be considered, but they are associated with more adverse events:
  • tricyclic antidepressants (TCAs) (consider avoiding in patients with cardiac conditions or risk of suicide)
  • atypical antidepressants
  • monoamine oxidase inhibitors (MAOIs) (but many contraindications and adverse events including increased hypertension)
• If a beneficial response is achieved, consider continuing medication for at least 4 months after resolution of depression before considering taper.
• Refer to a specialist in palliative care to improve symptom control and psychosocial support (Strong Recommendation).
• For patients at risk of suicide:
  • assess for immediate needs and make an urgent referral to a mental health specialist if necessary
  • provide frequent reassessment, support, and aggressive symptom management
  • initiate crisis-intervention psychotherapeutic approach involving the patient's support system
• Advise patient that most treatment takes several weeks until improvement in mood is noted.