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:
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During the last month have you often been bothered by feeling down, depressed or hopeless?
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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
- Insomnia
- 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
Past history of depression
Uncontrolled physical symptoms e.g. 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
Key features to assess
Screen for organic causes of low mood (e.g. 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
Management
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.
Medication options
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 which may be useful in insomnia (even at low doses)
Duloxetine helps neuropathic pain in some people
Citalopram or Escitalopram is often used for a more activating effect
Take care with SSRIs - watch out for low sodium and risk of GI bleeding