Palliative Care Guidelines - NHS Lanarkshire

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Depression in Palliative CareIntroductionPalliative Care Guidelines: Depression• All patients should be assessed for depression.• Depressiono is strongly and consistently associated with a poor quality of life.o causes more reduction in role and social functioning than would be due to the physicalillness alone.o reduces physical functioning.o is often associated with symptoms that are difficult to control.o has a major impact on the patient’s family.• Treatment of depression can significantly improve quality of life and is as effective in palliativecare as in other situations.Assessment• Physical symptoms commonly associated with depression may be due to physical illness ortreatment so are less helpful in making a diagnosis.o Weight/appetite changeo Insomniao Loss of energyo Fatigueo Psychomotor slowingo Loss of libido• Depressive symptoms in palliative care patients include:o Greater severity of dysphoric mood.o Excessive feelings of hopelessness, guilt, worthlessness.o Social withdrawal; loss of pleasure in daily activities.o A wish for earlier death (or suicidal thoughts).o A positive response to the question “Do you feel depressed?”• Risk factors:o Personal or family history of depression.o Concurrent life stresses.o Absence of social support.o Oropharyngeal, pancreatic, breast and lung cancers (more common).• Additional barriers to diagnosis:o Patient/family feeling that a “fighting spirit” is needed to maximise active treatment/ supportfrom health professionals.o Difficulty deciding if depression is a primary problem or whether improving other symptomswould improve mood.o Concerns about polypharmacy and drug interactions.o Other physical/ psychological conditions mimicking depression.• Exclude hypoactive delirium (see: Delirium).• Review medication (haloperidol can cause motor retardation).o Complex care packages; many staff involved and lack of continuity.Assessment tools:• In primary care, the PHQ-9 is used as a screening tool.• The Brief Edinburgh Depression Scale is suited to palliative care patients.• The Hospital Anxiety and Depression questionnaire is widely available but relies on physicalsymptoms so may be less helpful.© NHS Lothian Issue date: January 2009 Review date: March 20121
Palliative Care Guidelines: DepressionManagementGeneral• In mild depression, psychological support can be as effective as medication.• Adequate pain control may improve depressive symptoms significantly.• Spiritual distress may be a component of depression, or distinct from it.• Consider supportive psychotherapy or cognitive behavioural therapy.• Patients with severe depression and/or suicidal ideation are uncommon but should be referredto psychological medicine / psychiatry for assessment.Medication• 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 contraindicated.Selective serotonin reuptake inhibitors (SSRI)o Sertraline:• 1st choice if recent cardiac event; normal dose in renal failure.o Citalopram: tablet and oral suspension• few drug interactions; useful for agitated depression/ anxiety; relatively safe if patient isat risk of seizures.o Fluoxetine:• long acting so low withdrawal risk; many drug interactions so may not be suitable inpalliative care patients.Side effects:• nausea, vomiting, anorexia, dyspepsia, diarrhoea.• risk of gastrointestinal bleeding – avoid or use with caution if history of GI bleeding,patient over 80 or taking NSAID/ aspirin.• insomnia, sweating, impaired sexual function.• vivid dreams, agitation, hyponatraemia.Mirtazapine• tablet and oro-dispersible tablet.• sedative, particularly at lower doses; appetite stimulant.• well tolerated in the elderly and patients with heart failure or diabetes.Tricyclic antidepressantso Amitriptyline: also treats nerve pain.o Lofepramine: better tolerated than other tricyclics.Side effects:• avoid if cardiac disease or risk of seizures.• dry mouth, hypotension and confusion limit dose.• sedative/ anxiolytic action may be helpful.Practice pointAntidepressants should be withdrawn gradually, if possible.ResourcesProfessionalhttp://www.depression-primarycare.org/clinicians/toolkits/materials/Patienthttp://www.patient.co.uk/Key reference1. Lloyd-Williams M. Diagnosis and treatment of depression in palliative care. European J Pall Care 2002; 9(5): 186-8Further reading: http://www.palliativecareguidelines.scot.nhs.uk2 Issue date: January 2009 Review date: March 2012 © NHS Lothian
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