Depression

KEYPOINTS

  • Every individual’s experiences with depression are different
  • Depression can occur in both patients and caregivers
  • Depression often goes under-recognized
  • Depression is sometimes difficult to diagnose given the changes of the disease process which may mimic signs and symptoms of depression (loss of appetite, energy, etc)
  • Important to ask about history and current experiences of depression for patients and family/caregivers
  • Depression screening and assessment tools exist but often are not specific to a palliative care population
  • Non-pharmacological and pharmacological approaches exist – every individual is different
  • Choosing an approach may vary depending on the time and resources available, the patient’s prognosis, and the patient’s desire for support
  • Side effects of medication may limit treatment options

CONSIDERATIONS

Signs and symptoms of depression can be difficult to diagnose. The following provides examples of psychological, social, and spiritual factors that may be indicators of depression. A thorough assessment of all factors is important when evaluating for depression.

Possible Risk Factors

  • Prolonged grief
  • Un-controlled pain
  • Unrelieved emotional and spiritual distress
  • Overwhelming financial distress
  • Overwhelming family distress
  • Isolation and abandonment from family, community and spiritual connections
  • Pre-existing mental health issues in patient and/or family/caregivers

Possible Indicators

  • Excessive feelings of worthlessness, guilt, shame, hopelessness, helplessness
  • Recurrent thoughts of death and suicide
  • Loss of interest/pleasure in almost all activities
  • NOTE: Physiological symptoms such as fatigue, loss of energy, anorexia, or insomnia are not as reliable since the illness itself can produce these

STRATEGIES

Non-Pharmacological

  • Interdisciplinary assessment (identifying and attending to range of physical/psychological/social/spiritual factors)
  • Counselling support (social worker, psychologist, psychiatrist, spiritual advisor, etc.)
    • Cognitive behavioural therapy (CBT)

Pharmacological

  • Tricyclic antidepressants
    • More side effects, especially in higher doses
    • Starting dose should be low and increase slowly
    • If anxiety or insomnia present may choose a sedating TCA at bedtime
    • May also help with neuropathic pain
    • Often less expensive
  • SSRIs
    • Less side effects
    • Temporary nausea and anxiety common as side effects
    • May be more expensive
  • Psychostimulants (e.g. methylphenidate)
    • Often a rapid onset of action
    • Potential side effects include agitation, anxiety and insomnia

Questions to stimulate investigation of depression

  • “Tell me about how your mood has been recently?”
  • “How often have you been experiencing these feelings and emotions?” (e.g., how many times per week, at what times of the day, under what circumstances, etc.)
  • “Do you think you are depressed? How do you know when you are depressed?” (e.g., physiological and emotional symptoms)
  • “Have you ever been depressed? What did you do in those situations? Was it helpful?”
  • “What do you notice about the situations and moments that you are not depressed? ”What is helping in these times?”
  • “What would be helpful now in supporting you with how you are feeling?”

SOURCES/REFERENCES

  1. Haig RA. Management of depression in patients with advanced cancer. Medical J Aust 1992;156(7):499-503. http://www.ncbi.nlm.nih.gov/pubmed/1556979
  2. Librach L, Gifford-Jones W. Ian Anderson continuing education program in end-of-life care. Module 6: psychological symptoms. [Online]. Available from: URL:http://www.cme.utoronto.ca/ENDOFLIFE/Modules/PSYCHOLOGICAL%20SYMPTOMS%20MODULE.pdf
  3. Segal Z. Mindfulness-based cognitive therapy for depression. New York: Guilford Publications; 2001.
  4. Storey P, Knight C. Pocket guide to hospice/palliative medicine. Gainesville (FL): American Academy of Hospice and Palliative Medicine; 2003
  5. Storey P, Knight CF. UNIPAC Two: Alleviating psychological and spiritual pain in the terminally ill. Gainesville (FL): American Academy of Hospice and Palliative Medicine; 1997.
  6. Watson M, Lucas C, Hoy A, Back I. Oxford handbook of palliative care. Oxford: Oxford University Press; 2005.
  7. Werth J, Blevins D, editors. Psychosocial issues near the end of life: a resource for professional care providers. Washington (DC); American Psychological Association; 2006.

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