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Depression

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] For those patients living with cancer the prevalence rates for depression are reported to be as high as 25-35%. [4]

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. [5] Assessing depression is more difficult in advanced palliative disease because symptoms of other conditions, such as advancing or co morbid disease, may appear similar to symptoms of depression.

Also, the distinction between the sadness one may feel towards the end of life and depression requiring some active intervention may be difficult to make in palliative care. [6] While assessment tools are available these are not diagnostic – a complete clinical assessment is required.

Symptoms associated with Depression: the palliative context [7]

  • Depressed mood and an inability for this to be lightened
  • Loss of pleasure or interest (even within the limitations of the illness)
  • A sense of worthlessness or low self-esteem (eg feeling a burden to others)
  • Fearfulness / anxiety
  • Avoiding others or withdrawal
  • Brooding or excessive guilt / remorse
  • A pervasive sense of hopelessness or helplessness
  • Suicidal ideation
  • Prominent insomnia
  • Excessive irritability
  • Indecisiveness.

(Taken from Therapeutic Guidelines Palliative Care 3rd edition, 2010)

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 of advancing disease. [8-9]
  • Depression and mood disorders can have a significantly negative impact on patient and family quality of life. [10-11]
  • Depression can sometimes be associated with patient requests for assistance with early death. [11-12]
  • The evidence is divergent regarding the effective use of pharmacological and non-pharmacological therapies in people with cancer, advanced cancer and at the end of life.
  • Based on evidence from the general population a combination of therapeutic approaches to treat depression is the most effective. [13]
  • While medication has been found to be effective in treating depression – there is no evidence for the efficacy of one antidepressant over another. Each individual case needs to be assessed in terms of benefits and burden of treatment and the individual patient's condition. [14]
  • Antidepressant medication can require more than 6 weeks to induce a therapeutic effect. [15] 

Active research areas / controversies

  • There are too few studies to draw clear conclusions or consensus about the conceptualisation, assessment and management of depression in a palliative care setting. [2,5,16-17]
  • Screening tools for depression and distress in the palliative population are still being tested. [18-23]
  • The cultural influence on the expression of depression at the end of life is not clearly understood. [24]
  • Evidence reported in the literature ranges from ‘limited’ [13] to ‘strong’ [15] regarding the effectiveness of psycho educational therapies in people with cancer, HIV [25] and at the end of life.
  • The overlap between depression, demoralisation and request for hastened death is being examined within the literature. [26-27]
PubMed Searches
Depression
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Review Collection
  1. Payne S. Symptom management. Depression in palliative care patients: a literature review. Int J Palliat Nurs. 1998 Jul-Aug;4(4):184-91. No Abstract Available.
  2. Hotopf M, Chidgey J, Addington-Hall J, Ly KL. Depression in advanced disease: a systematic review Part 1. Prevalence and case finding. Palliat Med. 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. J Pain Symptom Manage. 2006 Jan;31(1):58-69.
  4. National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown, NSW: National Breast Cancer Centre; 2003. (838kb pdf)
  5. Carr D, Goudas L, Lawrence D, Pirl W, Lau J, DeVine D, et al. Management of cancer symptoms: pain, depression, and fatigue. Evid Rep Technol Assess (Summ). 2002 Jul;(61):1-5.
  6. Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006 Jun;9(3):751-72.
  7. Palliative care Expert Group. Therapeutic guidelines: palliative care. Version 3. Melbourne: Therapeutic Guidelines Limited; 2010.
  8. Rodin G, Katz M, Lloyd N, Green E, Mackay JA, Wong RK. Treatment of depression in cancer patients. Curr Oncol. 2007 Oct;14(5):180-8.
  9. Chochinov HM, Breitbart W. Handbook of psychiatry in palliative medicine. Oxford: Oxford University Press; 2000.
  10. Wilson KG, Chochinov HM, Skirko MG, Allard P, Chary S, Gagnon PR, et al. Depression and anxiety disorders in palliative cancer care. J Pain Symptom Manage. 2007 Feb;33(2):118-29.
  11. 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.
  12. 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.
  13. Rodin G, Lloyd N, Katz M, Green E, Mackay JA, Wong RK, et al. The treatment of depression in cancer patients: a systematic review. Support Care Cancer. 2007 Feb;15(2):123-36.
  14. Fulcher CD, Badger T, Gunter AK, Marrs JA, Reese JM. Putting evidence into practice: interventions for depression. Clin J Oncol Nurs. 2008 Feb;12(1):131-40.
  15. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med. 2008 Jan 15;148(2):147-59.
  16. Ly KL, Chidgey J, Addington-Hall J, Hotopf M. Depression in palliative care: a systematic review. Part 2. Treatment. Palliat Med. 2002 Jul;16(4):279-84.
  17. Wasteson E, Brenne E, Higginson IJ, Hotopf M, Lloyd-Williams M, Kaasa S, et al. Depression assessment and classification in palliative cancer patients: a systematic literature review. Palliat Med. 2009 Dec;23(8):739-53. Epub 2009 Oct 13.
  18. Robinson JA, Crawford GB. Identifying palliative care patients with symptoms of depression: an algorithm. Palliat Med. 2005 Jun;19(4):278-87. 
  19. Lloyd-Williams M, Dennis M, Taylor F. A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer. Palliat Med. 2004 Sep;18(6):558-63.
  20. Lloyd-Williams M, Spiller J, Ward J. Which depression screening tools should be used in palliative care? Palliat Med. 2003 Jan;17(1):40-3.
  21. Meyer HA, Sinnott C, Seed PT. Depressive symptoms in advanced cancer. Part 1. Assessing depression: the Mood Evaluation Questionnaire. Palliat Med. 2003 Oct;17(7):596-603.
  22. Thekkumpurath P, Venkateswaran C, Kumar M, Bennett MI. Screening for psychological distress in palliative care: a systematic review. J Pain Symptom Manage. 2008 Nov;36(5):520-8. Epub 2008 May 20.
  23. Mitchell AJ. Are one or two simple questions sufficient to detect depression in cancer and palliative care? A Bayesian meta-analysis. Br J Cancer. 2008 Jun 17;98(12):1934-43. Epub 2008 May 27.
  24. Pasquini M, Biondi M. Depression in cancer patients: a critical review. Clin Pract Epidemiol Ment Health. 2007 Feb 8;3:2.
  25. Himelhoch S, Medoff DR, Oyeniyi G. Efficacy of group psychotherapy to reduce depressive symptoms among HIV-infected individuals: A systematic review and meta-analysis. AIDS Patient Care STDS. 2007 Oct;21(10):732-9. 
  26. Kissane DW, Kelly BJ. Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill. Aust N Z J Psychiatry. 2000 Apr;34(2):325-33. 
  27. 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. Palliat Med. 2006 Oct;20(7):693-701.
Last updated 18 January 2017