Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 15.1 About Depression

Depression is sometimes described as the “common cold” of mental illness, affecting more than 11 million Americans each year (NAMI 1996). However, unlike the usual cold, depression is a serious illness, one that takes a physical, mental, emotional, and economic toll on its victims and those who love them.

Depression can be fatal. It is the strongest risk factor for suicide, and experts suggest that of the approximately 30,000 people who commit suicide each year, more than 90 percent have a mental illness or addiction (Moscicki, 1997). It can kill in less direct ways, too, by causing patients not to comply with other medical treatments and by disrupting sleep and eating patterns, further compromising the health of already vulnerable people.

The good news is that such suffering can be alleviated: Medication and psychotherapy, usually in combination, relieve depression for almost 80 percent of those who seek treatment.

Common symptoms include:

Depressed people often lack the insight they might ordinarily have - insight that would otherwise help them cope with their problems. Depressed people usually withdraw from others; for dying patients, who may already feel isolated, this additional isolation can be devastating. Life can, indeed, feel bleak and hopeless.

Certain medical illnesses, such as cancer and heart disease, can cause symptoms similar to those of depression - decreased appetite, loss of energy and sex drive, loss of sleep, and fatigue. Doctors should be encouraged to look at these symptoms as signs of depression and to question patients about their mood. Family members can sometimes describe changes in the patient’s well-being, mood, or usual coping ability.

The following factors can predispose people for depression:

Source: AHCPR, 1994

Depression, overlooked in most adults, is virtually ignored in elderly patients. In part, this is because providers do not screen patients for depression; in part, it results from misinformation and misunderstanding about depression. Some older patients who are depressed may simply believe that this is just how life is, that they should simply bear their unhappiness. Others may feel too ashamed to discuss feelings of depression, believing depression to be a character flaw, or blaming themselves for their symptoms. Some may be concerned about the cost of treatment, which some insurance policies do not cover. Others may not realize that medications commonly prescribed to older people or to those with heart disease can cause depression. Still others view it as part of the normal aging process.

Doctors and others may mistake depression for early symptoms of dementia, or, like their elderly patients themselves, may view depression as a normal part of aging. However, because suicide rates increase with age - and the highest rates occur in white men over the age of 65 (Moscicki, 1997) - depression among the elderly is truly a risk factor for suicide.

Although depression increases the risk of suicide for all people, among terminally ill patients, hopelessness appears to be an important predictor of suicidal thoughts (Chochinov et al., 1998). Patients may look at their illnesses realistically - they may know their prognosis, their treatment, and so on - and yet still remain hopeful. Hopeless patients, on the other hand, have no desire to continue living. Among the hopeless, there is an absence even of anger - one typical reaction to illness - as well as an inability to engage in life. In a study of almost 200 terminally ill patients, the degree of hopelessness was correlated more highly with suicidal thoughts than was the level of depression.

Depression is best treated through a combination of psychotherapy and antidepressant medications. The newest generation of antidepressants - including Prozac, Zoloft, and Effexor - have fewer side effects than do earlier generations of antidepressants. Medications commonly prescribed for depression are the tricyclics, selective serotonin reuptake inhibitors (SSRIs), and norepinephrine and serotonin reuptake inhibitors (NSRIs). Doctors should be aware that cancer patients and old or frail patients may require lower doses of antidepressants to achieve results.

Should teams decide to screen more dying patients for depression, they must know how to provide appropriate treatment or make referrals. Teams of providers, including mental health professionals, can provide “depression consults,” much as pain experts consult for pain, to educate colleagues and families.

Providers can recommend a treatment trial to patients. For example, a physician might prescribe an antidepressant for six weeks. Other drugs can be effective in patients for whom six weeks is too long to wait, or those for whom a quick improvement is essential to well-being. Psychostimulants often work within 24 to 48 hours.

The accompanying chart indicates which antidepressants are most effective for relieving specific symptoms. Because tricyclics are often used as adjuvant therapies, and not in therapeutic doses, they are not included in this list.

Table 15.1 Physical Symptom and Distress-Driven Approach to
Choosing an Antidepressant in Adult Cancer Patients
Distressing SymptomSSRIStimulant
Fatigue+++++
Insomnia ----
Pain+++
GI upset--+
Opioid side effects++++
Constipation++ ++
Loss of appetite+/-+
Akathisia----
Anxiety++
Dry mouth++++
---no effect or avoid
+least effect
+++greatest effect
+/-mixed results
Adapted from Passick et al, Depression in Cancer Patients: Recognition and Treatment, 1997

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].

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