Depression in Palliative Care

Depression is common in terminal illness, affecting an estimated 13–26% of patients. It is associated with increased pain, suicidal ideation, and desire for a hastened death. These associations make persistent depressive symptoms a safety issue, not merely an emotional response to serious illness. Sadness, grief, fear, and existential distress may occur as a person approaches death. The clinical question is whether the patient also has a sustained depressive pattern: depressed mood most of the time, accompanied by hopelessness, helplessness, worthlessness, guilt, reduced ability to experience emotional improvement, or suicidal thinking. A patient may have both understandable grief and a depressive disorder. Advanced illness obscures the picture. Fatigue, appetite loss, poor sleep, reduced mobility, and weight change may result from the illness, treatment, pain, or medication. These “vegetative” symptoms therefore carry less diagnostic weight by themselves than the patient’s mood, thoughts, emotional reactivity, and safety. Pain and depression can reinforce one another. A patient who is depressed may experience pain as more overwhelming, while uncontrolled pain can deepen hopelessness and withdrawal. Assess both rather than assuming that one explains the other....