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Overview
Depression is common, but easily overlooked in the palliative care setting. [1,2] It has been identified as one of 11 common symptoms in a review of end-stage patient symptoms across five diseases. [3] Twenty nine percent of palliative care patients are likely to suffer from depression and around 15% could experience a major depressive disorder. [2]

Depressive symptoms are present in several psychiatric disorders. In cancer patients the most common are major depressive disorder, adjustment disorder and depression secondary to a medical condition. [4] Assessing depression is more difficult in advanced palliative disease because constitutional symptoms are very similar to depression.

The distinction between normal and appropriate sadness and depression requiring some active intervention may be difficult to make in palliative care. [5] However, the intrapsychic elements are a useful guide, eg, hopelessness, inability to experience pleasure. Family perceived change in patient behaviour is often a good indicator.

Depression: the palliative context

• Life-limiting illness 
• Transition from active or curative to palliative care 
• Uncontrolled pain or other symptoms 
• Late onset dementia 
• Medication effects eg, steroids 
• Deteriorating performance status

Important contributing factors

• Past history of depression 
• History of substance misuse / dependence 
• Social isolation 
• Family distress or dysfunction 
• Multiple losses or unfilled life aspirations

Key messages

• Identifying depression in people at the end of life can be difficult due to biological changes [6,7]
• Depression and mood disorders can have a significantly negative impact on patient and family quality of life [8,9]
• Depression can sometimes be associated with patient requests for assistance with early death [10,9]
• There are too few studies to draw clear conclusions about management of depression in a palliative care setting. [4,11,2]

Active research areas / controversies

• Management of depression in palliative populations has not been extensively studied. As yet, there are too few adequate studies to draw clear conclusions. [6]
• Substantial research studies in this area are lacking. Available research is limited, based on small samples or patients with very high non-participation rates. Use of antidepressant medications has not been well studied in hospice and palliative care. [12,13 10, 2,14] 
• Some antidepressants can also be used as adjuvant therapy in pain management. [4]
• The overlap between depression, demoralisation and request for hastened death is currently being examined within the literature. [15,16]
• There are studies developing screening instruments specifically for palliative care populations. [17,18,19,20].

Finding out more

• Clinical practice guidelines Australian and New Zealand College of Psychiatry 
• Rodin G, Katz M, Lloyd N, Green E, Mackay JA, Wong RK. Treatment of depression in cancer patients. Current Oncology 2007 Oct;14(5):180-8.

Related CareSearch pages
Anxiety

References

1. Payne S.  Symptom management.  Depression in palliative care patients: a literature review. International Journal of Palliative Nursing 1998 Jul-Aug;4(4):184-91. 
2. Hotopf M, Chidgey J, Addington-Hall J, Ly K L. Depression in advanced disease: a systematic review Part 1. Prevalence and case finding. Palliative Medicine 2002 Mar;16(2): 81-97.   
3. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. Journal of Pain and Symptom Management 2006 Jan;31(1):58-69. 
4. Carr D, Goudas L, Lawrence D, Pirl W, Lau J, DeVine D et al. Management of Cancer Symptoms: Pain, Depression, and Fatigue. Agency for Healthcare Research and Quality Evidence Report / Technology Assessment 2002 July;61:1-5.   
5. Block SD. Psychological issues in end-of-life care. Journal of Palliative Medicine 2006 Jun;9(3):751-72.  
6. Rodin G, Katz M, Lloyd N, Green E, Mackay JA, Wong RK. Treatment of depression in cancer patients. Current Oncology 2007 Oct;14(5):180-8.
7. Chochinov HM, Breitbart W. Handbook of Psychiatry in Palliative Medicine. Oxford: Oxford University Press; 2000. 
8. Wilson KG, Chochinov HM, Skirko MG, Allard P, Chary S, Gagnon PR, et al. Depression and anxiety disorders in palliative cancer care. Journal of Pain and Symptom Management 2007 Feb;33(2):118-29.  
9. Breitbart W, Rosenfeld B, Pessin H, Kaim M, Funesti-Esch J, Galietta M, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA. 2000 Dec 13;284(22):2907-11  
10. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitude and experiences of oncology patients, oncologists and the public. Lancet 1996 Jun 29;347(9018):1805-10 
11. Ly K L, Chidgey J, Addington-Hall J, Hotopf M. Depression in palliative care: a systematic review. Part 2. Treatment. Palliative Medicine 2002 Jul;16(4):279-84. 
12. Miovic M, Block S. Psychiatric disorders in advanced cancer. Cancer 2007 Oct 15;110(8):1665-76.  
13. Patrick DL, Ferketich SL, Frame PS, Harris JJ, Hendricks CB, Levin B, et al. National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002. Journal of the National Cancer Institute 2003 Aug 6;95(15):1110-7. 
14. Potash M, Breitbart W. Affective disorders in advanced cancer. Hematology / Oncology Clinics of North America 2002 Jun;16(3):671-700. 
15. Kissane DW, Kelly BJ. Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill. Australian and New Zealand Journal of Psychiatry 2000 Apr;34(2):325-33 
16. Hudson PL, Kristjanson LJ, Ashby M, Kelly B, Schofield P, Hudson R, et al.  Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systematic review. Palliative Medicine 2006 Oct;20(7):693-701 
17. Robinson JA, Crawford GB.Identifying palliative care patients with symptoms of depression: an algorithm. Palliative Medicine. 2005 Jun;19(4):278-87. 
18. Lloyd-Williams M, Dennis M, Taylor F.A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer. Palliative Medicine. 2004 Sep;18(6):558-63.
19. Lloyd-Williams M, Spiller J, Ward J.Which depression screening tools should be used in palliative care?Palliative Medicine. 2003 Jan;17(1):40-3. Review.
20. Meyer HA, Sinnott C, Seed PT.Depressive symptoms in advanced cancer. Part 1. Assessing depression: the Mood Evaluation Questionnaire. Palliative Medicine. 2003 Oct;17(7):596-603.

This page was created on 14 May 2008 and will be reviewed in May 2010