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.  For those patients living with cancer the prevalence rates for depression are reported to be as high as 25-35%. 
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.  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.  While assessment tools are available these are not diagnostic – a complete clinical assessment is required.
Symptoms associated with Depression: the palliative context 
- 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
(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.
- 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. 
- 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. 
- Antidepressant medication can require more than 6 weeks to induce a therapeutic effect. 
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. 
- Evidence reported in the literature ranges from ‘limited’  to ‘strong’  regarding the effectiveness of psycho educational therapies in people with cancer, HIV  and at the end of life.
- The overlap between depression, demoralisation and request for hastened death is being examined within the literature. [26-27]