Depression

Description

General Measures

Medicine Treatment

Referral

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F32.0-3/F32.8-9/F33.0-3/F33.8-9/F34.1 + (Z51.5)

See: Depressive Disorders

DESCRIPTION

Depression might be difficult to diagnose in palliative care patients as some symptoms of depression are similar to disease manifestations such as anorexia and insomnia. The key indicators of depression in palliative care patients are persistent feelings of hopelessness and worthlessness and/or suicidal ideation. Young children may present with somatic complaints e.g. abdominal pain or headaches, or may have restlessness.

GENERAL MEASURES

Refer to a social worker to assist with concerns of future care of patient, family, and finances.

MEDICINE TREATMENT

Adults

• Fluoxetine, oral.
  • Initiate at 20 mg alternate days for 2 weeks.
  • Increase to 20 mg daily after 2–4 weeks.
  • Delay dosage increase if increased agitation/panicky feelings occur.

LoE:IIb¹⁶

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CAUTION FLUOXETINE

Fluoxetine is contraindicated if eGFR < 10 mL/min

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OR

If fluoxetine is poorly tolerated: 

• Alternative SSRI e.g.: 
• Citalopram, oral.
  • Initiate at 10 mg daily for 2 weeks.
  • Then increase to 20 mg daily.

LoE:IIb¹⁷

OR

If a sedating antidepressant is required:

• Tricyclic antidepressants (Doctor prescribed), e.g.: 
• Amitriptyline, oral, at bedtime.
  • Initial dose: 25 mg per day.
  • Increase by 25 mg per day at 3–5 day intervals.
  • Maximum dose: 150 mg per day.

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Note:

Tricyclic antidepressants may cause dry mouth, constipation, urinary retention, and confusion, which might be especially problematic in palliative care patients.

Use the lowest dose possible, and titrate slowly

LoE:IVb¹⁸

Effects of SSRIs are only apparent after 2–3 weeks of treatment, so they should be reserved for patients where end-of-life is not imminent.

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REFERRAL

• All children and adolescents.
• All patients to a psychologist and social worker if available.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024

Chapter 22: Medicines Used in Palliative Care_22.2 Neuropsychiatric Conditions_22.2.3 Depression