Depression

Introduction and Definition

Risk factors

Appropriate assessment to identify cause and severity of symptoms

Explanation to patient and family

Correct reversible factors

Institute non-pharmacological interventions by involvement of the interdisciplinary team

Pharmacological interventions

Consider adjuvant/second line treatment

Referral to appropriate service/more experienced clinician

Introduction  

Definition

Depression is defined by the World Health Organisation as a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration. 

All Palliative Care patients should be assessed for depression as it is strongly and consistently associated with poor quality of life. It causes more reduction in role and social functioning than could be attributed to the physical illness alone. Depression reduces physical functioning and is often associated with symptoms that are difficult to control. Depression also has a major impact on the patient’s family and carers. 

Estimates of the prevalence of depression in patients vary but at least 25% may develop a significant mood disorder when suffering from advanced cancer. 

Certain types of cancers are associated with an increased incidence of depression. A spectrum ranging from sadness to adjustment disorder to depressive illness is recognised. There is concern that depression may be under-diagnosed as patient, family members and clinicians may attribute the emotional signs and symptoms of depression to natural sadness and the physical features to the progressive illness. Other confounding factors may be the patient’s presentation with overriding anxiety or a slow worsening of personality traits, such as attention seeking, which may go unnoticed. 

Depression in HIV/AIDS patients – the diagnosis and treatment of mood disorders is essential to the well-being of a patient infected with HIV. Depression is very common and often under-diagnosed and under-treated in HIV/ AIDS. Depression often increases over the course of the illness, especially after the onset of AIDS. 

Risk factors for depression

• Personal or family history of depression
• Concurrent life stresses
• Absence of social support
• Depression is more common in oropharyngeal, pancreatic, breast and lung cancers

Appropriate assessment to identify cause and severity of symptoms 

Physical symptoms commonly associated with depression are also features of physical illness or treatment so are less helpful in making a diagnosis such as: 

• Weight/appetite change 
• Insomnia 
• Loss of energy 
• Fatigue 
• Psycho-motor slowing 
• Loss of libido 

These biological features are not reliable as features of depression in patients with late stage illness and greater emphasis must be placed on psychological and behavioural features. 

Depressive symptoms in palliative care patients include: 

• Greater severity of dysphoric mood
• Excessive feelings of hopelessness, guilt, worthlessness
• Social withdrawal; loss of pleasure in daily activities
• A wish for earlier death (or suicidal thoughts)
• A positive response to the question “Do you feel depressed?” 

Atypical presentation of depression (More common in the Palliative Care setting) 

• Irritability 
• Agitation 
• Anxiety 
• Histrionic behaviour 
• Hypochondriasis 
• Psychotic features (delusions, paranoia) with depressed mood 

Assessment tools: 

• In primary care, the PHQ-9 is used as a screening tool. (Patient Health Questionnaire) 
• The HADS (The Hospital Anxiety and Depression scale) and the BECKS Depression Inventory have been used most commonly in Palliative Care but have not been altogether satisfactory as they rely on physical symptoms
• The Brief Edinburgh Depression Scale is more suited to palliative care patients

Explanation to patient and family 

As always in the Palliative Care setting it is essential to take time to explain the signs, symptoms and causes of depression, as well to discuss treatment options with both patient and family/carers. Witnessing a loved one becoming depressed can result in considerable stress and burden on the family and they should be offered counselling and supportive care. Patients and families need to understand that depression in patients with serious illness is still treatable and should not be accepted as “normal”. It is never appropriate to assume that a psychiatric symptom is simply an ‘understandable’ reaction to the situation. 

Correct reversible factors 

• Ensure that any reversible causative factors such as distressing physical symptoms are eliminated
• Adequate pain control may improve depressive symptoms significantly

Institute non-pharmacological interventions by involvement of the interdisciplinary team 

• Ensure adequate emotional support and counselling is available so that fears and concerns can be explored and channelled appropriately. In mild depression, psychological support can be as effective as medication
• Spiritual distress may be a component of depression, or distinct from it
• Recommend supportive psychotherapy or cognitive behavioural therapy as appropriate

Pharmacological interventions 

• There is little difference in efficacy between antidepressants
• Consider side effects and any co-morbid illnesses. Check for drug interactions
• A current or previously effective antidepressant should be used unless contra-indicated
• Treatment of depression can significantly improve quality of life and is as effective in palliative care as in other situations

Antidepressants – there is little information concerning the effectiveness of antidepressant medication in terminally ill patients. There is, however, a body of evidence showing that under-treatment of depression is common and that patients are often not prescribed antidepressants within the final six weeks of life. Further, psycho-stimulants are very rarely used in this terminal situation despite some evidence of benefit. 

Tricyclics e.g. 

• Amitriptyline 10-150 mg nocte 
• Imipramine 10-150 mg per day 
• Lofepramine 70-210 mg per day 

Tricyclic antidepressants may take several weeks to lift depression. Amitriptyline has a greater sedative effect in comparison with imipramine and lofepramine. They all have antimuscarinic properties to greater or lesser degrees, and therefore may be associated with symptoms such as hypotension, dry mouth and difficulty in micturition. Doses should gradually be increased to avoid unnecessary side effects. 

Selective serotonin re-uptake inhibitors (SSRIs), e.g. 

• Paroxetine 20 mg mane 
• Fluoxetine 20 mg mane 
• Citalopram 20 mg mane 

These drugs are less sedative than tricyclic antidepressants and have few antimuscarinic effects, low cardio-toxicity and may have a faster onset of action than the tricyclics. Gastrointestinal side effects such as nausea are dose-related. Fluoxetine in particular may cause restlessness and anxiety and should be used with caution. There is some evidence of an increased incidence of gastrointestinal bleeding in combination with NSAIDS or aspirin. 

Serotonin and noradrenaline re-uptake inhibitors (SNRIs)  e.g. 

• Venlafaxine 37.5 mg b.d. increased to 75 mg b.d 
• These have fewer adverse effects than SSRIs. Slow release capsules are preferable. (75mg and 150 mg given once daily) 

Noradrenergic and specific serotonergic agents (NaSSA)  e.g 

• Mirtazapine 15-45 mg nocte 

Consider adjuvant/second line treatment 

Other agents 

• Cortiocosteriods e.g. Dexamethasone 2-4 mg daily 
• Psychostimulants e.g. Methyphenidate (Ritalin) from 10 mg daily 
• Sulpiride (Eglonyl®) 150-300 mg tds 

At the end-of-life stage, when a patient has a prognosis of only a few weeks, it may be more appropriate to try a low dose of psycho-stimulant or corticosteroid to increase cognitive function and to lift a patient’s mood. Sulpiride does not have a delayed effect like other antidepressants so can be useful when prognosis is limited. 

These agents can also be used for a few weeks when waiting for the antidepressant medication to set in. 

Key notes to remember when prescribing antidepressants 

“Start low, go slow” 

Antidepressants should not be stopped abruptly if at all possible but withdrawn gradually. 

Referral to appropriate service/more experienced clinician 

Patients with severe, prolonged or resistant depression and/or suicidal ideation are uncommon, but should be referred to a psychiatrist for assessment and medication.