Depression can have a profound impact on quality of life and its treatment is as important in advancing illness as control of physical symptoms. Diagnosis is difficult as the physical symptoms mimic those of advanced illness.
These two simple questions may help:
During the last month have you often been bothered by feeling down, depressed or hopeless?
Do you have little interest or pleasure in doing things?
Depression also needs to be differentiated from appropriate sadness and demoralisation (bleak perpectives about the future but can still enjoy the present moment)
Symptoms common to depression AND serious illness include:
- Anorexia and weight loss
- Loss of energy and fatigue
In patients with advanced illness, depressive features can also include:
- Excessive feelings of guilt, worthlessness, hopelessness
- Social withdrawal and loss of pleasure in activities (anhedonia)
- Wish for an earlier death or overt suicidal ideation
Risk factors for depression in palliative care:
- Personal or family history of depression
- Uncontrolled physical symptoms eg severe pain or breathlessness
- Concurrent life stressors - such as isolation, financial worries and recent bereavement
- Tense family relationships and unfinished business
- History of substance/ alcohol abuse.
- Certain types of cancers – eg depression is very common in pancreatic cancer
it is important to:
- Screen for organic causes of low mood (eg hypothyroidism, hypomanic delirium)
- Consider spiritual and existential distress
- Optimise symptom control i.e. good pain relief
- You may find using an assessment tool such as PHQ-9 helpful - it is brief and validated.
In many cases of mild mood disturbance, directing patients to self-help resources , often CBT or mindfulness based can be enough.
Social interventions to improve connection and self-esteem are really crucial.
Consider referral or self-referral to the Talking Therapies Service (IAPT) or to local Clinical Psychology Service.
In cases of severe depression or suicidal ideation, patients should be referred via local mental health Single Point of Access.
Depression is often missed in older people with frailty or advancing illness - the video below is helpful.
- SSRI’s are often well tolerated and safer in overdose. They may cause nausea initially - take care if nausea is already a symptom.
- Sertraline is often first line
- Mirtazapine has appetite-stimulating and sedative properties (even at low doses). It may also be of value in breathless patients.
- Duloxetine helps neuropathic pain in some people
- Citalopram is often used for a more activating effect
- Take care with SSRIs - watch out for low sodium and risk of GI bleeding