9th January 2024

Depression

The prevalence of depressive disorder in the UK general population is around 7.5%, but around 15% of palliative patients meet the diagnostic criteria for major depressive disorder, and many others exhibit depressive symptoms. For a diagnosis of depression, at least one of the core symptoms must be present for at least two weeks. Other associated symptoms, as shown below, should also be considered.

Palliative patients have additional risk factors for depression. This is especially true for those who are young, have advanced disease at diagnosis, are socially isolated, have poor symptom control, have had a decline in performance status, have a previous personal or family history of depression, and those with additional life stresses such as a recent bereavement or relationship breakdown.

The associated symptoms used to diagnose depression, as shown above, can be less useful in palliative patients who may have fatigue, appetite changes or sleep disturbances because of their disease or treatment.

Screening tools to help diagnose depression includes the PHQ-9, which is used in primary care. The Hospital Anxiety and Depression (HAD) questionnaire is largely focused on physical symptoms, so it may not be useful in a palliative setting, whilst the Brief Edinburgh Depression Scale (BEDS) has been shown to be more valuable in a palliative context.

Differentials for Depression in Palliative Patients

• Dementia
• Poorly controlled physical symptoms
• Medication side-effects, e.g., steroids, methyldopa, propranolol
• Brain metastases
• Metabolic – hypothyroidism, hypercalcaemia, B12/ folate deficiency

Management of Depression

Non-Pharmacological:

• Adequate symptom control and referral to palliative services if necessary
• Guided self-help programmes
• Cognitive Behavioural Therapy (CBT)
• Counselling

Pharmacological:

There is currently insufficient evidence to recommend one antidepressant over another, so choice should be based on the patient’s previous experience with antidepressants, likelihood of interactions with other medications and consideration of side effects. It is important to remember that antidepressants can take several weeks to work, so if someone is approaching end-of-life, there will be insufficient time for the medication to work.

• SSRIs e.g., sertraline, fluoxetine, citalopram
  • Side effects include nausea, vomiting, anorexia, diarrhoea, increased risk of gastrointestinal (GI) bleeding, insomnia, agitation and increased risk of serotonin syndrome if used with other serotonergic medications
  • Serotonin syndrome is a group of symptoms that can happen with use of serotonergic medications, e.g. SSRIs, MAOIs, St John’s Wort, ecstasy, and amphetamines. Symptoms include confusion, sweating, hyperthermia, hyperreflexia, myoclonus and rigidity. Management is supportive, including IV fluids and benzodiazepines may be used. In more severe cases, serotonin antagonists such as cyproheptadine or chlorpromazine may be necessary
• Mirtazapine
  • Generally, well tolerated and can have beneficial effects on appetite, weight gain and management of insomnia
• Tricyclics, e.g., amitriptyline
  • Antimuscarinics can cause dry mouth, constipation, blurred vision and urinary retention. It can have a role in palliative patients with neuropathic pain but would generally not be started as first line for depression