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Assessment and management of depression in palliative care

Authors
William Breitbart, MD
Anna L Dickerman, MD
Section Editors
Peter P Roy-Byrne, MD
Susan D Block, MD
Deputy Editors
Diane MF Savarese, MD
David Solomon, MD

INTRODUCTION

Patients with advanced illness often experience psychological distress. While emotional distress is natural and expected in individuals experiencing serious illness and confronting the end of their lives, the differentiation between a normal and appropriate reaction to dying versus a more serious psychiatric disorder such as major depression can be clinically challenging.

This topic reviews assessment and management of depression in patients receiving palliative care for serious illness. The basic principles of palliative care, assessment and management of other symptoms that are prevalent among patients with advanced illness, as well as psychosocial, existential, and spiritual issues in palliative care are discussed separately. (See "Benefits, services, and models of subspecialty palliative care" and "Overview of comprehensive patient assessment in palliative care" and "Approach to symptom assessment in palliative care" and "Overview of managing common non-pain symptoms in palliative care" and "Psychosocial issues in advanced illness" and "Overview of spirituality in palliative care".)

SCOPE OF THE PROBLEM

Depressive syndromes are a common mental health problem in palliative medicine, yet are widely misunderstood, underdiagnosed, and undertreated [1-5]. Data on the prevalence of moderate to severe depression in the last six months of life for patients with terminal cancer were provided by a unique observational cohort study of all cancer decedents in Ontario Canada between 2007 and 2009 (figure 1) [6].

Clinicians often fail to recognize the extent of a patient's depression until too late in the course of the disease. As an example, in a survey of 1046 consecutive hospice patients, only 10 percent were prescribed antidepressants at some point during hospice care [3]. Patients prescribed tricyclic antidepressants were nearly always underdosed, and three-fourths of those started on antidepressants died within two weeks.

Among the many barriers to the recognition and treatment of psychological symptoms in patients with advanced illness are the following:

                                     

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