Nursing Center - Journal Issue

Keywords: depression, palliative care, terminal illness

Abstract

Depression is an underrecognized condition experienced by a significant number of palliative care patients. It contributes to considerable distress in patients and families and can become yet another terminal illness for the patient to endure. This article outlines evidence-based approaches to the diagnostic assessment and treatment of depression using an actual case (with fictional names) to illustrate the challenges pertinent to palliative care patients. Special attention is given to the nurse's role in screening and providing support for the depressed patient who is also facing life-threatening illness.

DEPRESSION IN TERMINAL ILLNESS: THE CHALLENGES

"Well, if I knew I was dying, I would be depressed, too!" The frowning oncology resident was obviously uncomfortable as he responded to the nurse who had approached him with concerns about her patient, Anna Adkin. Mrs Adkin, a 57-year old woman diagnosed with stage IV non-small cell lung cancer 2 months ago, was admitted for pneumonia as well as anorexia coupled with a weight loss of 15 lb over the past 2 months. The nurse reported to the resident that the patient slept most of the day and, if awake, closed her eyes when staff entered the room. She answered questions with "yes" or "no" only and appeared emotionally aloof when her oncologist talked with her about her illness. Despite obvious labored breathing, Mrs Adkin had no symptom complaints.

The nurse worried that her patient was depressed and therefore suggested the resident consult a mental health specialist. After some hesitation, he agreed and asked the hospital psychologist to talk with the patient saying, "I am not sure what you can really do for Mrs Adkin-she does not seem willing to talk to anyone, and I don't think she wants to take any more pills[horizontal ellipsis]."

This prototypical communication exemplifies the discomfort and uncertainty experienced when the possibility of depression in terminally ill patients is broached. The resident's response reflects two of the main challenges faced when dealing with depression in a palliative care population.

First, there is a diagnostic challenge. Significant life-changing situations lead to cognitive, emotional, and behavioral adjustment responses. If one did not initiate the changes, there are many unknown variables in the process, and perceived control is limited.1 Adjustment challenges and intensely emotional acute grief responses over perceived losses are common and not necessarily a sign of psychopathology. Because the diagnosis of a terminal illness leads to change in all areas of life and raises questions about the very basis of existence, difficult adjustment responses are expected. Therefore, it is not surprising that the oncology resident's first reaction is to explain Mrs Adkin's unusual behavior and lack of emotional expression as being a normal adjustment response. However, further assessment is indicated. Adequate screening requires knowledge of the criteria for diagnosing a clinically significant depression and differentiating the condition from a normal adjustment response to terminal illness.

The second challenge revealed in the resident's comments is that of depression treatment at the end of life. Is pharmacological treatment indicated knowing it will increase the medication burden, risk for adverse effects, and stress on the liver and kidneys in patients already debilitated by their illness? How much help can antidepressants be if they require weeks to take effect? How much psychotherapy and supportive therapy can a patient tolerate while dealing with physical and cognitive limitations?

Uncertainty about how to answer these questions can contribute to avoiding the issues. Therefore, it is not surprising that the current literature 2,3 concludes that depression is underdiagnosed and undertreated in the palliative care population, and the majority of these patients still do not have access to specialized mental health services.4

This article explores the rationale for adequate diagnosis and treatment of depression in palliative care. Evidence-based methods for screening, diagnostic criteria, and intervention options are presented with emphasis on the role of the palliative care nurse.

DEPRESSION: ITS RELEVANCE IN PALLIATIVE CARE

Prevalence of Depression in Terminally Ill Patients

Over the past 20 years, the reported incidence of depression in serious illness has varied. For example, the review of Solano et al 5 of 64 relevant articles concluded that the prevalence of depression ranges from 3% to 77% in cancer, 10% to 82% in AIDS, 9% to 26% in heart disease, 37% to 71% in chronic obstructive pulmonary disease, and 5% to 50% in renal disease. This wide range of prevalence is largely a result of differences in diagnostic criteria and the assessment procedures used6,7 as well as differences in setting and clinical populations included in the respective studies. Mitchell et al8 included 24 studies and data from more than 4000 patients in a recent meta-analysis and found that 24.6% of palliative care patients fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major or minor depressive disorders. The Canadian National Palliative Care Survey9 used semistructured interviews with 381 palliative cancer patients and diagnosed 13.1% with major depression and 20.7% with at least one anxiety or depressive disorder based on the current DSM.10 Factors correlating with depression included younger age, smaller social networks, less participation in organized religion, lower performance status, increased physical symptoms and social concerns, and existential issues.

Based on these recent studies, approximately one-third of all palliative care patients can be expected to have depression. Depressive disorders are the most common mental health problem in palliative care 11 and a cause of serious ramifications if untreated.

When the psychologist visited Mrs Adkin, she told her she was "not up for talking" and that the psychiatrist who visited her earlier asked "too many questions." However, she agreed that her husband could talk to the psychologist outside the room "if he feels it might help him."

Mr Adkin shared that he was very concerned about his wife's indifference. Married for almost 35 years, the couple managed their inherited rural farm together while raising two sons. One son has a 5-year-old who Mrs Adkin helped raise since the boy's mother died unexpectedly 3 years ago.

Mr Adkin described his wife as a high-energy person actively engaged in life prior to her illness. Since her recent diagnosis, she had become more and more withdrawn, did not want to eat or cook, was no longer active in the community, and spents most of her day staring out the window or sleeping.

Mr Adkin described the emotional rollercoaster and drastic changes in the family's life: anxiety associated with delayed diagnosis, the shock of hearing the diagnoses, uncertainty about treatment options, and adverse effects of chemotherapy and radiation. Now they faced the challenge of being far away from home in the hospital without support from family and their church.

He was concerned that his wife recently stated, "I hope I die soon so I won't be a burden to you and the kids. I feel so useless." He believed she blamed herself for having cancer attributing it to smoking as a young woman growing up on her parent's tobacco farm.

Mr Adkin could not understand her random thought processes and admitted he became frustrated with her because of her unusual behaviors and the suffering this causes for his family. Moreover, he felt completely unprepared to take over decision making and paperwork for their farm and caregiving for his wife. He had desperately tried to get input from his wife about all these topics, but she only withdrew further, adding to his frustration. He looked at the psychologist tearfully and said, "As if the cancer wasn't bad enough[horizontal ellipsis]."

Consequences of Depression for Patients and Families

Patients experience depressive symptoms to be as debilitating as significant physical symptoms.12,13 Lloyd-Williams et al14 found depression to be an independent predictor of poor survival in patients with end-stage cancer. Moreover, untreated depression has dramatic repercussions for patients' and family's quality of life, decreases immune response, and impairs the patient's ability to adhere to treatment.15

Major depressive disorders impair the capacity to experience pleasure, meaning, and connection,16 and depressed patients avoid making important healthcare decisions or plans for personal or family affairs at this crucial time in life.17 These factors cause significant distress and worry among family and friends and can contribute to complicated grief. Depression has been shown to amplify the experience of pain and other physical symptoms,18,19 resulting in increased frequencies of physician visits and hospital stays. Finally, clinically significant depression increases the risk for suicide and requests for hastened death so that depression in itself can become yet another terminal illness the patient is facing. Such negative consequences contribute to a general consensus that depression must be recognized and treated in the palliative care population.20,21 To do so, nurses must be knowledgeable regarding diagnostic criteria and screening methods.

DIAGNOSIS OF DEPRESSION IN PALLIATIVE CARE PATIENTS

Diagnostic Criteria

Mrs Adkin clearly demonstrated emotional and behavioral deviations from her normal self as described by her husband and observed by her nurse. But, do these changes justify a diagnosis of a clinically significant depression?

To answer this question, established diagnostic criteria for depression should be applied. In the United States, the DSM in its current version 10 is the standard classification system establishing criteria for such diagnosis. The DSM-IV, Text Revision (DSM-IV-TR) lists depression under mood disorders-syndromes with mood disturbance as the cardinal symptom. In order to diagnose a major depressive disorder, the criteria outlined in Table 1 must be fulfilled.

Table 1 - Click to enlarge in new window

TABLE 1 Diagnostic Criteria

Mrs Adkin refused to engage with the psychologist or psychiatrist. Therefore, no comprehensive interview to diagnose depression was possible at this time. However, based on the interview with Mr Adkin and the nurse's observations, the psychiatrist and psychologist were able to verify many of the symptoms mentioned in the DSM-IV-TR.

Mrs Adkin confirmed with the psychiatrist that she has felt depressed most of the time since her cancer diagnosis (Criterion 1). Her husband described a significant reduction in his wife's interest in previously enjoyable activities (Criterion 2). Mrs Adkin has had significant weight loss, reduced appetite, and decreased interest in eating for several months (Criterion 3). A drastic change in sleeping patterns with hypersomnia is described by the husband and the nurse (Criterion 4) as well as psychomotor retardation evidenced by her sitting in a chair or being in bed most of the time (5). Moreover, the husband observed that his wife seems to "always be tired" (Criterion 6). Feelings of worthlessness or excessive or inappropriate guilt are not accessible to direct observation and would have to be clarified with Mrs Adkin. However, her statements of feeling "useless" as well as her husband's suspicion that she feels responsible for having cancer suggest the existence of cognitions that would fulfill this criterion. We have no indication for diminished ability to think or concentrate, but, contrary to her normal personality, Mrs Atkins refuses to think about important topics and make decisions. She has denied any suicidal ideations, stating that her religious beliefs would not allow her to think about this at all. However, death and dying are clearly on her mind as she wishes for death to come quickly.

This assessment of Mrs Adkin identifies more than five symptoms and both cardinal symptoms of depression (Criterion 1 and 2). However, some of the symptoms mentioned as Criterion for depression are somatic in nature (Criterion 3-6) and are commonly found in palliative care patients as a result of disease progression or treatment adverse effects. The interpretation of such somatic symptoms has been described as the most common problem in diagnosing depression in palliative care patients.17 Because of patients' medical circumstances, somatic symptoms have been deemed to be poor predictors of depression in palliative care settings.

According to the psychologist's progress note: "Mrs Adkin's anorexia and weight loss can be a common symptom in advanced cancer. Her hypersomnia, psychomotor retardation, and fatigue can all be caused by her cancer and/or her current pneumonia diagnosis. Some of her medications can also be sedating or sleep inducing (eg, nausea medication). Her indecisiveness and unwillingness to talk about various topics could be due to cognitive problems resulting from the cancer's affect on brain functions or general exhaustion. At this time, particularly with limited participation from Mrs Adkin in the diagnostic process, it will be difficult to decide if the origin of these symptoms is psychological, physical, or both."

Different strategies have been suggested to deal with the risk for an inflated rate of depression diagnoses in palliative care patients and include suggesting the exclusion of all physical symptoms, attempting to clinically evaluate the symptoms' origin (illness, treatment, or mood disorder), increasing the number of symptoms needed for diagnosis from five to seven, or replacing somatic with nonsomatic symptoms.22 In the end, it is left to the clinician to decide which approach to choose. The most commonly discussed strategy is to focus on cognitive and affective symptoms rather than somatic symptoms. Passik et al23 emphasize that cognitive symptoms of depression are the most accurate index of severity of depression in patients with medical illness. Table 2 shows four symptoms and assessment questions recommended by the American Psychological Association for assessing depression near the end of life.24

Table 2 - Click to enlarge in new window

Anhedonia is defined as the inability to gain pleasure from usually pleasurable experiences. When assessing this symptom in a palliative care patient, one must again take into account changes in physical and cognitive abilities due to the illness progression. A reduced functional status decreases options for continuing many activities previously enjoyed, leading to acute grief and adjustment responses that should not be mistaken as depressive symptoms. Wilson et al 9 have shown that nondepressed patients may refocus their interest on those activities that are less physically or mentally demanding activities without losing interest in activities altogether. Responding to family visits or showing interest in specific TV shows or therapeutic interventions may indicate that the hospitalized patient still experiences activities as pleasurable.

Pervasive hopelessness has been described as the hallmark criterion for depression 25 and is negatively associated with survival in cancer patients. Nondepressed individuals normally retain hopes and aspirations throughout the dying process, although hopes and goals often change as illness progresses. Typical hopes center around physical comfort during the dying process, meaningful interactions with family and friends, resolving interpersonal conflicts, and being remembered. Assessing hopelessness is crucial as it is the strongest predictor of suicidal ideation17,23 and the desire for hastened death.26,27 A description of a comprehensive suicide assessment is beyond the scope of this article, but patients who report such thoughts of self-harm or suicide need prompt assessment and evaluation from a mental health specialist. Although persistent suicidal ideations or suicide attempts are clearly not expected, recurrent thoughts of death and dying can be a normal part of adjusting to functional limitation or the anticipated dying process, complicating the assessment of suicide potential. Chochinov et al28 report that 44.5% of 200 terminally ill patients acknowledged an occasional wish for death to come soon, but only 8.5% of these patients reported a serious and pervasive desire to die. Therefore, careful assessment of thoughts of death and dying versus suicidal ideations by specially trained healthcare providers is paramount.

Worthlessness is oftentimes expressed by patients' statement that their lives have amounted to nothing or their anticipation that no one will remember them or mourn after their passing. Patients tend to describe their current functional limitations and grief about their new challenges when asked about if they feel worthless, but assessment should focus on the patient's entire life, his/her value as a person, and changes in perceptions in recent weeks.

Guilt is another cardinal symptom for depression. Some degree of guilt is quite common when approaching the end of life 29 and is seen as a normal part of the life review process. Pathological guilt, however, emphasizes past mistakes now seen as overwhelming or focuses on pervasive feelings of being a burden to others despite minimal demands on family. Patients may blame themselves for their illness despite unknown etiology. In depressed patients, guilt can become the center of their attention, leading to difficulties focusing on anything else in their lives.

Mrs Adkin's cognitive and affective symptoms support the diagnosis of a major depressive disorder, regardless of her physical symptoms.

Diagnostic Assessment Tools

Clinical Interview

The gold standard method to assess symptoms of depression is a specialized clinical interview conducted by a mental health specialist.15 These interviews focus on the personal and family history of mental health problems as well as current stressors and symptoms and may take an hour or more. Further compounding the lack of mental health specialists and their time to conduct such intensive interviews is the fact that patients have reduced attention span or get exhausted easily. Significant depression in itself can lead to reduced capacity to participate in long interviews; patients may not perceive such interviews to be of value because of their feelings of hopelessness and despair. The depression may also contribute to cognitive problems, which impair the interview process.

Mrs Adkin participated in her initial interview with the hospital psychiatrist for 10 minutes, answering questions with yes/no only before she decided she was too tired and did not see "how this questioning will help anyone."

Self-report Measures: Questionnaires and Screening Tools

In the last years, several standard depression questionnaires have been assessed for their use in palliative care or physically ill patients.30-33 Although it is unquestionably a worthwhile endeavor to find objective, reliable, and valid self-report measures for depression in palliative care patients, there are some restrictions to their use in this patient population. Like interviews, even short questionnaires can pose an overwhelming burden to patients because of their restricted energy level and attention span. Reading and writing can be difficult because of functional limitations. Moreover, these measures do not take into account the patient's specific situation and challenges, which can impact reliability and validity of these instruments. This is particularly true for patients in inpatient settings.

With this in mind, efforts have been made to develop short screening tools to identify depressed patients in palliative care settings needing an in-depth evaluation (for review, see Thekkumpurath et al 34 and Lloyd-Williams et al35). Most notably, Chochinov and his colleagues36 found that the single question "Are you depressed?" can provide a sensitive and specific assessment of depression in terminally ill patients. They demonstrated that patients giving an affirmative response to this question would often be diagnosed with depression after a comprehensive interview. This study attracted palliative care providers, and using this simple question has become the most preferred method of screening for depression in palliative care patients.37,38 In a meta-analysis including 17 studies (13 of them in late-stage palliative settings), Mitchell37 found that asking the question "Are you depressed?" and inquiring about loss of interest delivered the best predictive value of a depressive disorder. When combining these screening questions with the wealth of information nurses gain from close contact with patients, the nurse becomes the ideal person to detect depression early and advocate for appropriate assessment and treatment. Our case exemplifies how Mrs Adkin's nurse accurately identified the need for an in-depth depression assessment by relying on her own observations. With more training, she would have been able to use targeted questions to further justify a mental health consultation.

Grief and Adjustment Responses Versus Clinically Significant Depression

Symptoms of depression can be observed in seriously ill patients adjusting to the continued loss of functions and independence as well as patients experiencing anticipatory grief related to their reduced life span. While patients with adjustment or grief responses can also benefit from counseling, only depressed patients should be treated with antidepressants. Therefore, it is important to distinguish these conditions.

There are some distinctive characteristics that differentiate grief from clinically significant depression. Most notably, depressed mood and other symptoms of adjustment and grief tend to come in waves triggered by specific stimuli such as significant changes in functional status (eg, becoming bedbound) or events (eg, birthdays). On the other hand, positive triggers (eg, visit from grandchildren) can improve the mood in the same way. In contrast to this, episodes of major depression are characterized by negative affectivity, which is maintained most of the time regardless of specific events or triggers.16,25 Pervasive anhedonia, hopelessness, worthlessness, and suicidal ideations, as mentioned earlier, are symptoms typically seen in clinical depression but not in adjustment responses. Periyakoil and Hallenbeck25 describe a useful algorithm for differentiating between preparatory grief and depression. For patients with sufficient attention span and stamina, the 42-item Terminally Ill Grief or Depression Scale39 can be used to clarify between both conditions.

Treatment

Although many clinicians are still pessimistic about treating depression in patients with only weeks or months to live, a fact discussed as "therapeutic nihilism,"40 growing evidence shows that interventions can alleviate some or all symptoms of depression and despair.16 As interventions are usually not burdensome, it has been recommended that clinicians have a low threshold for starting treatments.16 A combination of supportive techniques, psychotherapy, and antidepressant medication has been recommended repeatedly to treat depression in palliative care patients.11,25,41

Pharmacological Treatments

With only a few notable exceptions, pharmacological interventions for depression and anxiety in the terminally ill are largely the same as interventions for physically healthy populations. Patients with prognoses of several months or more can benefit from use of the most common antidepressants, while those with short prognoses or waiting for an antidepressant to reach a therapeutic level often benefit from psychostimulants.

Historically, tricyclic antidepressants (TCAs), such as amitriptyline and nortriptyline, were the mainstay in treating depression. However, the adverse effect profiles of these drugs can be troublesome in the terminally ill. Their anticholinergic adverse effects include constipation, dry mouth, urinary retention, serious tachycardia, and arrhythmias; other adverse effects include postural hypotension and dizziness, which can contribute to falls. However, a TCA can be helpful in relieving neuropathic pain offering dual benefit to patients with such pain.42

Newer antidepressants, such as the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, have simpler dosing regimens and fewer adverse effects.43 While as effective as the TCAs, these medications do not carry the same anticholinergic and cardiac risks and have become first-line therapy.15 Potential adverse effects include increased intestinal motility, nausea, insomnia, headaches, anxiety, and restlessness.44 Within this group, fluoxetine and norfluoxetine require 5 to 6 weeks to reach a steady state in the body compared with 4 to 14 days for paroxetine, fluvoxamine, and sertraline.43

Bupropion may be used for patients with a poor response to other antidepressants. This medication has energizing effects similar to the stimulant drugs and therefore may be beneficial for the patient with psychomotor-retarded depression.43

For depressed patients with limited prognosis (weeks), short-acting psychostimulants such as methylphenidate, dextroamphetamine, pemoline, and modafinil have proven efficacious.15,16,40,45,46 These medications can also combat the fatigue of terminal illness and/or the sedation of opioid analgesia. Additional benefits include augmentation of analgesia and enhancement of appetite in cachexia.45 Common adverse effects include insomnia, nervousness/anxiety, dry mouth, constipation, and tachycardia.44

For a summary listing of the most frequently recommended antidepressants, dosage ranges, and nursing implications, see Table 3.

Table 3 - Click to enlarge in new window

TABLE 3 Frequently Used Medications for Treatment of Depression in Terminal Illness

Mrs Adkin was not initially excited about the psychiatrist's suggestion of antidepressant medication. As she told him, "I don't need more medicine, and it won't help me now anyway." However, she admitted that she had felt "slightly off for a few weeks" about 10 years ago, and her primary care physician prescribed Zoloft (sertraline), which did help her get "up and going" again. Not remembering any significant adverse effects, she agreed to take it again. "What harm can it do to me now?" She was started on a daily dose of 50 mg Zoloft.

Psychotherapy

Treatment for major depression in terminally ill patients has been shown to be less effective if psychotherapeutic support is not provided.11 The Task Force on Promotion and Dissemination of Psychological Procedures of the American Psychological Association has developed criteria for the treatment of late-life depression, and the following interventions met the established criteria: cognitive behavioral therapy (CBT), behavioral therapy, problem-solving therapy, bibliotherapy, brief psychodynamic therapy, life review, and reminiscence therapy.47

Recent research addressing treatment of depression in palliative care patients has paid particular attention to psychological interventions, with CBT approaches being most evaluated and showing encouraging results.48 The National Comprehensive Cancer Network recommends CBT as an effective treatment option to reduce both depression and physical symptoms in patients with cancer.49 Encouraging research shows that after a brief training in CBT, palliative care professionals from different disciplines were able to successfully apply CBT techniques to hospice patients with mild-to-moderate depression.24,50

Cognitive behavioral therapy is an active, directive, time-limited, and structured approach to psychotherapy,51 focusing on changes in thoughts and thought patterns (cognitive changes) and/or actions (behavioral changes).

Cognitive Changes

When depressed, cognitions tend to focus on negative information, and information processing is distorted in unrealistic ways. Cognitive techniques are used to identify and challenge these thoughts or thought patterns and replace them with more realistic ones. Topics particularly burdensome for palliative care patients, such as fear of the dying process and afterlife or concerns about being a burden to their family, can be addressed.

Behavioral Changes

Being depressed reduces interest in continuing daily activities, thereby eliminating rewarding experiences. Reestablishing meaningful as well as "fun" activities is an important step to improve the patient's mood. For patients with advanced physical illness, learning to cope with physical symptoms can be another CBT goal. Inadequate factual or perceived social support has been shown to impact both the onset and ability to recover from clinical depression,52 and physically ill persons have a greater need for social support than the general population.11 Therefore, teaching and facilitating communication among patients, their families, and friends to improve social support are important goals addressed with CBT.

Two recent innovative treatments that utilize the principles of life review have shown promise in their ability to combat distress in the terminally ill. Meaning-centered group psychotherapy, piloted by Breitbart and colleagues,53 is an 8-week intervention combining psychoeducation, life storytelling, and experiential exercises with the goal of helping participants develop and/or maintain a sense of meaning in life. Dignity psychotherapy, developed by Chochinov and colleagues,54 has similar goals but uses the development of a written legacy to be shared with family and friends as the mechanism for enhancing meaning and purpose.

Despite all the advantages psychotherapeutic interventions can offer to palliative care patients, there are limitations when used with seriously ill patients. Even short therapy sessions can be physically and cognitively challenging or even overwhelming. Therefore, supportive treatment options and environmental changes play an important role in treating these patients.

Mrs Adkin refused counseling with the psychologist, but psychopharmacological treatments and environmental changes (see below) were started. The psychologist continued to visit daily inquiring about the patient's needs or concerns. After a few days, Mrs Adkin asked for some coffee, stating that she felt cold. After providing coffee for her, she started to talk about feeling depressed and being a burden to her family. With the help of the psychologist, she was able to acknowledge the dramatic changes the illness caused in her life and accept this fact as a challenge similar to dramatic life changes she had experienced earlier in her life. Eventually, she was able to focus on supporting her family at this time (help husband with decisions, explain procedures for farm management, help with grandchild), even from her hospital bed away from home. Meaningful activities (eg, preparing a will and living will, working with the physical therapist) were discussed as well as fun activities like calling her grandchildren and listening to their stories. Cognitive strategies were used to address unhelpful cognitions like being out of control or being a burden to her family. Moreover, plans incorporating the patient's organizational strength helped her to feel more in control and important to her family again. Her family brought in her laptop which allowed her to communicate with friends and organize banking and insurance business away from home.

Mrs Adkin had stable family support, but her husband struggled with addressing the "elephants in the room," as Mrs Adkin put it. So the psychologist worked with the couple to facilitate communication about difficult topics like her illness and death/dying. Mr Adkin stated that "just talking with her again" was a big relief and gave him strength in this difficult time.

Encouraged by the psychologist, the son set up daily phone calls from church and community friends at a time convenient for Anna, considering her energy level and treatments. The patient's pastor suggested congregation members write to Mrs Adkin thanking her for her influence and reminding her of her ongoing impact in their lives. The other son decided to get psychological support for himself to improve his coping with multiple challenges in his life (job loss, loss of mother, previous loss of wife), and this relieved Mrs Adkin's worries about the future for him and her grandson.

The oncologist addressed treatment options, and Mrs Adkin chose some palliative chemotherapy aimed at alleviating symptoms. She decided not to get hospice involved at this time as she felt that she had all the needed resources, but she wrote down the contact information for her local hospice in case "something comes up and I will need them later on."

Supportive/Complimentary Interventions

Outside of nurses (RNs and NPs) specializing in mental health, most nurses are not trained or qualified to offer intensive psychotherapy. The nurse should facilitate patient referrals to the team psychologist or social worker when such treatment is indicated. However, there are many supportive interventions the nurse at the bedside can provide to the depressed patient. Examples of such interventions are listed in Table 4. Attending to expert symptom management will build trust and enable the patient to address psychosocial issues. The nurse should use discretion in determining what supportive interventions are most appropriate for a patient and family. Timing and patient response are also important in deciding how and when to intervene.

Table 4 - Click to enlarge in new window

TABLE 4 Supportive Nursing Interventions

As stated above, Mrs Adkin was not interested in talking with the psychologist or anyone else at first. While waiting for the antidepressants to take effect, some environmental changes were implemented based on family input and patient's preferences. The patient's bed was moved closer to the window, and family photographs were brought in and displayed. Quiet church music from the patient's collection was brought by the family to be played. Silk flowers arranged by a church friend were used to decorate the window sill. The nurse increased Mrs Adkin's level of control by asking her if it is OK to enter the room and allowing her choices in treatment options (injection in left/right arm, medicine now or after lunch, etc). Within the next days, Mrs Adkin started to talk more with her healthcare providers. She explored options for managing her pain and shortness of breath and was more approachable.

CONCLUSION

Major depression is a treatable condition, a fact unchanged by a terminal prognosis. As illustrated by Mrs Adkin's story, adequate treatment of depression can significantly improve quality of life for terminally ill patients and their families. Both pharmacological and nonpharmacological treatments have an important role and should be tailored to individual needs.

For terminally ill patients with depression, ongoing social contacts and trustful relationships coupled with the assurance that care will be provided throughout the illness and dying process are of critical importance.14 However, there are significant barriers to this goal. Neither terminal illness nor psychiatric illnesses like depression are comfortable topics to address as they stimulate anxieties and insecurities.16 Many healthcare providers feel unprepared to deal with either of these topics. In doing so, the practitioner must face personal frustration with the patient's condition and feelings of helplessness. Healthcare providers are often afraid such discussions might increase the patient's depressive mood,55 or they, themselves, may have to deal with intense emotions for which they are unprepared.56 Patients oftentimes do not volunteer information about their depressed mood.9 They may fear worrying their families, or they may view their emotional response as normal in the light of their "hopeless" situation. They are afraid of the stigma of the diagnosis or treatment57 or may deem themselves unworthy of help. Finally, patients may perceive staff as not willing or not having the time to discuss their emotional problems.58

Unfortunately, mental health professionals are still not readily available in all settings, increasing the need for other healthcare providers to educate themselves about assessment and treatment of depression. Nurses in particular can play an important role in providing helpful interventions.19 Because of their constant presence in day-to-day care for their patients, nurses are ideally situated to recognize patients with depression and help them get the treatment they need.2 Recognizing this opportunity, Canada recently adopted emotional distress as the sixth vital sign49 to be checked routinely by nurses. As our case example shows, the nurse can be key to identifying a depressive disorder in a palliative care patient and initiating diagnostic and treatment efforts. Although the nurse's schedule may not allow him/her to provide specialized psychotherapeutic interventions, he/she can play a vital role by creating a conducive environment and supporting the depressed patient. Specialized training to increase nurses' comfort level when working with depressed patients is recommended.2

After her discharge, Mrs Adkin did well for 3 weeks at home, after which she developed recurrent infections and postobstructive pneumonia. She came back for one last 2-day hospital stay. She was less awake and alert, was more withdrawn, and had a short attention span. Realizing she was dying, her family decided to stop cancer treatments while providing aggressive comfort care. In a short meeting with the hospital psychologist and her nurse, Anna reported gratitude for the opportunity to spend "so much precious time" with her grandchildren. She became tearful thinking of leaving them but smiled when contemplating aloud, "I will see them all again one day in heaven." A hospital chaplain stopped by and provided support and prayer for Mrs Adkin.

Mrs Adkin went home with home hospice care and died 10 days later with her husband and sons at her bedside. In a follow-up phone call with the psychologist, her husband reflected on her short but intense time with a terminal illness. He said the time when his wife was depressed was hardest for his family because "although she was still alive, she was not really here." He felt that treating the depression gave him his wife back, and now he can remember her as "the wonderful person she had always been." He ended the conversation saying, "I don't even want to imagine how it would have been to live with the memories if she had continued to be so depressed until her death."