Med/Psych Update PALLIATIVE CARE Assessing and treating depression in palliative care patients Antidepressants, psychotherapy can improve dying patients’ quality of life epression is highly prevalent in hospice and pallia- tive care settings—especially among cancer patients, in whom the prevalence of depression may be 4 D 1 times that of the general population. Furthermore, suicide is a relatively common, unwanted consequence of depres- sion among cancer patients.2 Whereas the risk of suicide among advanced cancer patients may be twice that of the general population,3 in specific cancer populations (male patients with pancreatic adenocarcinoma) the risk of sui- cide may be 11 times that of the general population.4 Mental health professionals often are consulted when treating depressed patients with advanced illness, especial- ly when suicidal thoughts or wishes for a hastened death © PALETTE7/SHUTTERSTOCK, INC are expressed to oncologists or primary care physicians. To mitigate the effects of depression among seriously ill pa- Sean Marks, MD tients (Box, page 36),5,6 mental health professionals must be Assistant Professor of Medicine Division of Hematology and Oncology able to assess and manage depression in patients with pro- gressive, incurable illnesses such as advanced malignancy. Thomas Heinrich, MD Associate Professor and Director Division of Psychosomatic Medicine Department of Psychiatry and Behavioral Medicine Diagnostic challenges • • • • Assessing depression in seriously ill patients can be a challenge Medical College of Wisconsin for mental health professionals. Cardinal neurovegetative Milwaukee, Wisconsin symptoms of depression, such as anergia, anorexia, impaired Disclosure concentration, and sleep disturbances, also are common man- The authors report no financial relationship with any company whose ifestations of advanced medical illness.7 Furthermore, it can products are mentioned in this article or with manufacturers of competing products. be difficult to gauge the significance of psychological distress among cancer patients. Although depressive thoughts and symptoms may be present in 15% to 50% of cancer patients, only 5% to 20% will meet diagnostic criteria for major depres- Current Psychiatry sive disorder (MDD).8,9 You may find it challenging to deter- Vol. 12, No. 8 35 Box for an antidepressant or a psychostimulant, which can exacerbate delirium rather than Don’t underestimate the impact alleviate depressive symptoms. of depression in this setting Significant attitudinal barriers from both eft untreated, depression in seriously ill clinicians and patients can lead to under- Lpatients can be associated with increased recognition and undertreatment of depres- physical symptoms, suicidal thoughts, sion. Clinicians may believe the patient’s Palliative worsened quality of life, and emotional depression is an appropriate response to distress.5 Moreover, depression can impair care the patient’s interaction with family during the dying process; indeed, feeling sad or de- a pivotal time in which patients may be pressed may be an appropriate response to saying goodbye, thank you, or planning for bad news or a medical setback, but meeting their death. Depressive symptoms even can erode the construct of patient autonomy MDD criteria should be viewed as a patho- by interfering with one’s ability to engage logic process that has adverse medical, psy- in medical decisions and attain a sense of chological, and social consequences. Time meaning from their illness.6 constraints or personal discomfort with exis- tential concerns may prevent a clinician from Clinical Point Table 1 exploring a patient’s distress out of fear that Side effects from Questions included in Robinson’s such discussions may cause the patient to 4-point algorithm become more depressed.11 Patients may un- commonly used derreport or consciously disguise depressive 1. In the past 2 weeks, have you been worn therapeutics for 12 out or had too little energy, even when you symptoms in their final weeks of life. cancer patients can haven’t been doing a lot? mimic depressive 2. During the past 2 weeks, have you often been bothered by a lack of interest or Responding to these challenges symptoms pleasure in doing things? The Science Committee of the Association 3. In the past 2 weeks, have you been feeling of Palliative Medicine performed a thor- depressed or sad at all? ough assessment of available screening 4. In the past 2 weeks, have you talked or moved more slowly than is normal for you? tools and rating scales for depressive symp- Were you so restless that you couldn’t sit toms in palliative care. Although the com- still? mittee found that commonly used tools Source: Reference 15 such as the Edinburgh Depression Scale and the Hospital Anxiety and Depression Scale have validated cutoff thresholds for pallia- mine whether to use pharmacotherapy for tive care patients, the depression screening depressive symptoms or whether engaging tool with the highest sensitivity, specificity, in reflective listening and exploring the pa- and positive predictive value was the ques- tient’s concerns is the appropriate therapeu- tion: “Are you feeling down, depressed, or hope- tic intervention. less most of the time over the last 2 weeks?”13,14 Side effects from commonly used thera- Other short screening algorithms have peutics for cancer patients—chemothera- been validated among palliative care patients peutic agents, opioids, benzodiazepines, (Table 1).15 Endicott proposed a structured glucocorticoids—can mimic depressive approach to help clinicians differentiate symptoms. Clinicians should include hypo- MDD from common physical ailments of active delirium in the differential diagnosis progressive cancer in which physical criteria of depressive symptoms in cancer patients. for an MDD diagnosis are substituted by af- Discuss this article at Delirium is an important consideration in fective symptoms (Table 2).16 The improved www.facebook.com/ the final days of life because the condition risk-benefit ratio of selective serotonin CurrentPsychiatry has been shown to occur in as many as 90% reuptake inhibitors (SSRIs) and serotonin- of these patients.10 A mistaken diagnosis of norepinephrine reuptake inhibitors (SNRIs), depression in a patient who has hypoactive coupled with the potential significant delirium (see “Hospitalized, elderly, and morbidity associated with MDD and sub- delirious: What should you do for these pa- syndromal depressive symptoms, makes it Current Psychiatry 36 August 2013 tients?” page 10) might lead to a prescription necessary to recognize and treat those symp- toms even when the cause of the depressive Table 2 symptoms is unclear. Physical depressive symptoms vs replacement psychological Psychotherapy in palliative care symptoms Psychotherapeutic interventions such as dig- Physical symptoms… nity therapy, which invites patients to utilize Change in appetite a meaning-centered life review to address his Sleep disturbance (her) existential concerns, may help depressed Fatigue 17 palliative care patients. Evidence suggests a Diminished ability to think or concentrate strong association between diminished digni- …are replaced by psychological symptoms ty and depression in patients with advanced Tearfulness, depressed appearance illness.18 Individualized psychotherapeutic in- Social withdrawal, decreased talkativeness terventions that provide a framework for ad- Brooding, self-pity, pessimism dressing dignity-related issues and existential Lack of reactivity, blunting distress among terminally ill patients could Source: Reference 16 help preserve a sense of purpose throughout Clinical Point the dying process. Surveys of dignity therapy Placebo-controlled have been encouraging: 91% of participants reported being satisfied with dignity therapy ness on the patient or family, or reduced need trials of SSRIs and and more than two-thirds reported an im- for hospitalization. Therefore, mental health SNRIs have yielded proved sense of meaning.18 professionals should consider palliative care mixed results in Other promising psychotherapeutic in- consultation for advanced cancer patients cancer patients; terventions include supportive-expressed with signs of psychological distress. differences in efficacy group therapy, in which a group of ad- vanced cancer patients meets with a mental may not be significant health professional and discusses goals of Pharmacotherapy options building bonds, refining life’s priorities, and Antidepressants. Patients with excessive “detoxifying” the experience of death and guilt, anhedonia, hopelessness, or rumina- dying.19 A primary purpose of this therapy tive thinking along with a related impair- is not just to foster improved relationships ment in quality of life may benefit from within a group of cancer patients, but also pharmacotherapy regardless of whether within their family and oncology team, they meet diagnostic criteria for MDD. with the aim of improving compliance with Although SSRIs and SNRIs have become a anti cancer therapies. Nurse-delivered, one- mainstay in managing depression, placebo- on-one sessions focusing on depression edu- controlled trials have yielded mixed results cation, problem-solving, coping techniques, in depressed cancer patients. Furthermore, and telecare management of pain and de- differences in efficacy among these antide- pression also improves outcomes among de- pressants may not be significant, according pressed cancer patients.20 to a recent meta-analysis.22 Hospital-based inpatient and