Assessing and Managing Depression in the Terminally Ill Patient

Physicians who care for terminally ill patients confront a range of complex medical and psychosocial challenges, and treating patients who are experiencing psychosocial distress is often a particularly troublesome clinical task. Although it is difficult to imagine any patient facing the end of life without emotional distress, physicians may not immediately be able to differentiate between normal, appropriate, inevitable distress and more severe disturbances. In this paper, I use three cases to illustrate assessment and management of normal distress and grieving, clinical depression, and the wish to hasten death in the presence of psychological distress. Why Should Physicians Treat Psychological Distress in Terminally Ill Patients? Psychological distress impairs the patient's capacity for pleasure, meaning, and connection; erodes quality of life; amplifies pain and other symptoms (1-3); reduces the patient's ability to do the emotional work of separating and saying good-bye; and causes anguish and worry in family members and friends. Finally, psychological distress, particularly depression, is a major risk factor for suicide and for requests to hasten death (4). What Are the Barriers to the Recognition and Treatment of Psychological Distress in Terminally Ill Patients? Although psychological distress is well documented in dying patients (5), it tends to be underrecognized and undertreated (6). Numerous factors act as barriers to recognition and treatment of psychological symptoms. First, both patients and clinicians frequently believe that psychological distress is a normal feature of the dying process and fail to differentiate natural, existential distress from clinical depression. Second, physicians may lack the clinical knowledge and skills to identify such problems as depression, anxiety, and delirium; this may be especially true for the challenging clinical context of terminal illness, in which many of the usual diagnostic clues are confounded by coexisting medical illness and appropriate sadness (7). Third, many patients and physicians are reluctant to consider psychiatric causes of distress because of the stigma associated with such diagnoses. Fourth, patients and clinicians often avoid exploration of psychological issues because of time constraints and concerns that such exploration will cause further distress (8, 9). Fifth, physicians are sometimes reluctant to prescribe psychotropic agents, which can cause additional adverse effects, and therefore may hesitate to diagnose a condition that they do not feel they can treat successfully. Finally, when caring for dying patients, physicians may feel a sense of hopelessness that can lead to therapeutic nihilism (10). These factors are reflected in the fact that antidepressants account for only 1% to 5% of all psychotropic agents prescribed for patients with cancer (11, 12). How Prevalent Is Psychological Distress in Terminally Ill Patients? Psychological distress is a major cause of suffering among terminally ill patients and is highly correlated with poor quality of life (13). More than 60% of patients with cancer report experiencing distress. Differentiating the distress associated with normal grieving from that associated with psychiatric disorders requires an appreciation of the clinical characteristics and prevalence of these entities. Derogatis and colleagues (14) found that 47% of patients with varying stages of cancer fulfilled diagnostic criteria for psychiatric disorders. Of this 47%, 68% had adjustment disorders with depressed or anxious mood, 13% had major depression, and 8% had organic mental disorders (for example, delirium). Research has shown that patients with other terminal illnesses also have a greater incidence of psychiatric disorders than healthy persons (15). Case One: Sadness, Grief, or Depression? Mr. Roberts, a 53-year-old man with end-stage pulmonary disease, is cared for at home by his wife and the local hospice program. He receives long-term oxygen therapy, is bedridden, and has been hospitalized twice in the past year for respiratory failure that required ventilatory support. Mr. Roberts is concerned about becoming a burden to his wife and children. The family's income is barely enough to meet their needs. Recently, the hospice nurse has expressed concern about Mr. Roberts's mental state because he has been asking repeatedly why he has to wait around to die. When directly questioned, he states that he has no intention of ending his life but that he is distressed by his helplessness and dependence. He says he feels like a time bomb ticking. He spends his time watching television and trying to complete two woodworking projects, one for each of his two sons. The physician who hears this report must assess the severity of and the possible interventions for Mr. Roberts's distress. Is he depressed, or is he experiencing normal grieving that is part of the dying process? What is the appropriate threshold for diagnosing depression? In addition, the physician must confront the challenge of bearing with the patient's distress and remaining present as a witness and an ally while the patient traverses this difficult passage. The clinical features of grief and depression are contrasted in Table 1. Table 1. Grief Compared with Depression in Terminally Ill Patients Our knowledge of psychological disorders in terminally ill patients is derived predominantly from patients with AIDS and cancer and from geriatric patients. Relatively little published literature is available about psychological issues affecting patients with end-stage pulmonary, cardiac, renal, and neurologic disease. Therefore, the recommendations in this paper represent extrapolations from existing literature and expert opinion but lack specific evidence of efficacy in some patient populations. How Is Depression Diagnosed in Terminally Ill Patients? The physician makes a house call to further assess Mr. Roberts's condition. Throughout the visit, Mr. Roberts makes cheerful jokes about his conditionHey, Doc, not dead yet!and repeatedly refers to his death in a joking manner. Through questioning, the physician learns that Mr. Roberts is not sleeping well because he is short of breath and anxious about not waking up, that his appetite is poor, and that he has little energy. He reports that he does not want to see anyone except his family and that he lacks the concentration and focus to read. When asked whether he is depressed, Mr. Roberts replies, Depressed? That word holds no meaning for me. Angry, yes. Fed up, yes. Worried about my family, yes. But depression? Never. He remarks on how much he enjoys his woodworking projects and how he worries that he will not have time to complete them. He speaks about his pleasure in visiting with his sons. Then he says, This dying thing can't be over quick enough or last long enough for me. Mr. Roberts reports that he is realistic about his prognosis, hopes for a few more good months, is trying to do as much as possible for himself, and is not suicidal. He says that joking has always been his way of coping with difficult situations. Mr. Roberts's case presents many of the common challenges in diagnosing depression (32). He has several of the neurovegetative symptoms of depression (difficulty sleeping, poor appetite, loss of energy, and diminished concentration). However, these symptoms may be caused or exacerbated by underlying disease. Mr. Roberts is also grieving as he anticipates his death. His withdrawal from persons other than his family is probably part of the normal grieving process, particularly because he continues to enjoy his visits with his children. Like other terminally ill patients, he expresses ambivalence about the prospect of death, simultaneously accepting and denying it (33). The clinical interview is the gold standard for the diagnosis of depression (34, 35). Chochinov and coworkers (36) found that the single question Are you depressed? provides a sensitive and specific assessment of depression in terminally ill patients. A patient who responds affirmatively to such an inquiry is likely to receive a diagnosis of depression after a comprehensive diagnostic interview. The busy physician can use this question as a screening tool; for example, Mr. Roberts's negative response is important evidence against a diagnosis of depression. Table 2 summarizes the indicators of depression that are most useful in the diagnosis of patients with terminal illness. The criteria in Table 2 differ from the traditional criteria outlined in Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (41), because the usual diagnostic features of depression do not specifically apply to patients with terminal illness. Table 2. Indicators of Depression in Terminally III Patients When assessing these psychological symptoms, physicians must put the patient's responses in context. For example, the patient's illness may be grounds for realistic hopelessness. The patient may be helpless because of his or her physical condition. His or her role in life may have changed drastically because of illness and may result in a loss of self-esteem. A patient whose illness is related to behavior (for example, smoking) may feel a sense of guilt for causing the illness. However, when these symptoms are out of proportion to the patient's actual situation, they are useful indicators of major depression. The physician can also use his or her own emotional responses to patients as a diagnostic clue. Patients with depression often engender feelings of boredom, hopelessness, aversion, and lack of interest in their caregivers, mirroring the dysphoria, hopelessness, and self-criticism that are hallmarks of the patient's experience of depression (42). Mr. Roberts's physician notes that he enjoys his patient's mordant sense of humor and is amused by his delight in shocking the hospice nurse with his jokes (further evidence that Mr. Roberts is not depressed). Mr.