Assessing depressive symptoms in palliative care

Kelly, 2009

Depressed mood, along with other low mood states (eg sadness, grief, demoralisation) is frequently encountered in patients with palliative care needsRobinson, 2015. Although sadness is understandable in patients with a life-limiting illness, depressive disorders are treatable.

The Psychotropic guidelines provide advice on assessment of depressive symptoms—see Assessing a person with depressive symptoms and Disorders that can cause depressive symptoms. However, assessing depressive symptoms can be challenging in patients with palliative care needs because of the considerable overlap with somatic symptoms of life-limiting illnesses (eg anorexia, weight loss, fatigue, insomnia). Collateral history from carers or family members can aid assessment. Evaluation of depressive symptoms in patients with palliative care needs requires:

exploring the patient’s emotional and coping responses to their life-limiting illness and circumstances
taking a history of current symptoms—including asking about the presence of symptoms in Features suggestive of major depression in patients with a life-limiting illness , the onset (including potential triggers) and duration of the symptoms, and their impact on functioning
asking about a personal or family history of depression
assessing factors that can contribute to depressed mood—see Factors that can contribute to depressed mood in palliative care
assessing and monitoring for risk of suicide.

A variety of assessment methods and tools can help identify, assess and monitor treatment when used as an adjunct to the clinical interview; they should not replace the need for a clinical interview. For examples of assessment tools, see Rating scales for depressive symptoms in the Psychotropic guidelines.

Hypoactive delirium can be mistaken for depression. Assess for delirium, and manage if present—see Delirium in palliative care.

If depressive symptoms impact on function or relationships, and contribute to a decline in health that is disproportionate to disease burden, consider the development of a depressive disorder (eg major depression, adjustment disorder with depressed mood)—see Disorders that can cause depressive symptoms in the Psychotropic guidelines.

Figure 1. Features suggestive of major depression in patients with a life-limiting illness

depressed mood that cannot be lightened

loss of pleasure or interest, even within the limitations of the illness

loss of interest or inability to derive enjoyment from previous activities and past times

an excessive feeling of being a burden to others, accompanied by a sense of worthlessness or low self-esteem

fearfulness or anxiety

withdrawal or avoidance of others

ruminations

excessive guilt or remorse

a pervasive sense of hopelessness or helplessness

a persistent desire for death, or suicidal ideation

prominent and persistent insomnia

excessive irritability or restlessness

difficulty concentrating

feelings of loss of control

Figure 2. Factors that can contribute to depressed mood in palliative care

decline in health and function

difficult to manage symptoms (eg pain)

physiological changes

inadequate nutrition

inadequate sleep

loss and grief

social stressors

social, family, cultural and spiritual matters

drug adverse effects (eg corticosteroids, antineoplastic drugs) [NB1]

medical conditions (eg central nervous system diseases)

radiotherapy to the brain

metabolic abnormalities (eg hypercalcaemia, hypothyroidism)

Note: NB1: See Some substances and drugs associated with development of depressive symptoms in the Psychotropic guidelines for a list of drugs that are associated with development of depressive symptoms.