Depression

Key messages

Definition and prevalence

Depression in palliative care is a mood disorder that can manifest as persistent sadness, lack of interest or pleasure in activities, and feelings of hopelessness, potentially affecting a patient's quality of life and emotional well-being. [1] Unlike typical emotional responses to the stress of illness, depression in this context may involve a more sustained psychological burden that can influence the patient’s engagement with care and decision-making processes. [2]

The reported prevalence of depression in palliative care varies considerably, with estimates ranging from 24% to 70%, depending on factors such as patient population, diagnostic criteria, and assessment methods used. [3,4] This variability suggests challenges in distinguishing depressive symptoms from other common manifestations of serious illness, such as fatigue, pain, and cognitive decline. [5] These overlapping symptoms might complicate accurate diagnosis, highlighting the importance of careful assessment.

Research indicates that existential distress—characterised by a deep sense of meaninglessness, fear of mortality, and concerns about one’s legacy—is a significant factor in the development and experience of depression in palliative care. Addressing these existential issues is important, as they appear to amplify the psychological burden faced by patients nearing the end of life, contributing to the complexity of their emotional experience. [6,7] Interventions that target these existential concerns, such as meaning-centred therapies, may be vital in alleviating depressive symptoms and improving patients' overall sense of well-being.

Assessment

Assessing depression in palliative care involves using a combination of initial screening tools and comprehensive evaluations to gain a thorough understanding of the patient's psychological state. Screening tools like the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ-9) are frequently utilised for their practicality in identifying depressive symptoms in palliative care settings. [1] These tools offer a structured way to detect potential depression, although they may not fully capture the existential distress that often accompanies advanced illness, which is a significant psychological factor influencing patients at this stage. [6]

A more detailed assessment often follows initial screenings to understand the broader impact of depression on a patient’s quality of life. This involves a mix of self-reported measures, such as mood and cognitive evaluations, alongside clinician observations. This comprehensive approach helps to differentiate depressive symptoms from those that may arise due to the physical effects of serious illnesses, such as fatigue, sleep disturbances, or pain. [8] The inclusion of clinician-led observational assessments allows for a nuanced understanding of the patient's emotional and psychological needs, facilitating a more personalised care strategy.

The role of interdisciplinary collaboration is essential in these assessments, particularly in complex cases where the patient’s emotional, spiritual, and psychological distress intersects with physical symptoms. Involving specialists like psychologists, social workers, and spiritual care providers in the assessment process ensures that all dimensions of the patient’s condition are considered, leading to a more comprehensive evaluation. [2] Early involvement of these professionals supports timely interventions, tailored specifically to the individual needs of the patient, which is important in delivering holistic palliative care. [5]

Non-pharmacological treatment

Non-pharmacological interventions play a significant role in managing depression in palliative care by addressing both psychological and existential aspects of distress. Cognitive Behavioural Therapy (CBT) is commonly adapted to focus on acceptance and coping strategies rather than solely targeting negative thought patterns. Studies suggest that CBT, when tailored to the context of terminal illness, can reduce depressive symptoms and enhance emotional resilience, allowing patients to better cope with their condition. [5,9] The adaptability of CBT to address existential concerns, such as fear of death and loss of meaning, is important in making it a suitable approach for palliative care. [2,4]

Managing Cancer and Living Meaningfully (CALM) therapy has been recognised as an effective intervention for addressing existential distress in palliative care settings. This therapy facilitates structured discussions on themes such as mortality, meaning, and legacy, helping patients to confront their fears and engage more deeply with their emotional experiences. [6,8] Evidence suggests that CALM therapy can significantly reduce depressive symptoms by fostering a sense of purpose and enhancing patients’ psychological well-being as they navigate the challenges of advanced illness. [2,5]

Mindfulness-based interventions, including mindfulness-based stress reduction (MBSR), have been employed to promote present-moment awareness and acceptance in patients experiencing depression. These approaches have shown potential in alleviating distress by reducing rumination on past regrets and anxieties about the future. [7] However, the effectiveness of mindfulness strategies may vary depending on the patient's level of engagement and openness to these techniques, highlighting the need for a personalised approach to their implementation. [1,8]

Dignity therapy is another non-pharmacological intervention that supports patients in reflecting on meaningful aspects of their lives, reinforcing their sense of self-worth and connection to loved ones. Research indicates that dignity therapy can significantly alleviate depressive symptoms by helping patients create a sense of legacy, affirm their life's value, and strengthen their bonds with family and friends. [4,5,8] This therapeutic approach is particularly beneficial for individuals nearing the end of life, as it addresses both their emotional and existential needs.

Integrating these non-pharmacological approaches into patient care requires consideration of each individual's cultural background, personal values, and specific psychological challenges. Engaging interdisciplinary teams that include psychologists, counsellors, and spiritual care providers is essential for tailoring these interventions to resonate with the patient's values and beliefs. [1,2] Such a collaborative approach helps ensure that care is both empathetic and attuned to the complex dimensions of depression in palliative care.

Pharmacological treatment

Pharmacological interventions are a fundamental component in managing depression within palliative care, often used alongside non-pharmacological approaches to provide comprehensive symptom relief. Selective serotonin reuptake inhibitors (SSRIs), such as sertraline and fluoxetine, are frequently considered first-line treatments for depression due to their established efficacy and relatively favourable side-effect profile. [1] SSRIs are well-tolerated, which is crucial in palliative care, where patients often present with multiple comorbidities and are at risk for adverse effects. [4]

Serotonin-norepinephrine reuptake inhibitors (SNRIs), including venlafaxine and duloxetine, are also utilised when SSRIs prove inadequate or unsuitable. SNRIs are beneficial not only for their antidepressant properties but also for their role in alleviating neuropathic pain, a common symptom in palliative care, which enhances their therapeutic value. [2,8] However, close monitoring is necessary due to potential side effects like increased blood pressure and gastrointestinal issues. [2]

Mirtazapine, an atypical antidepressant, is often favoured in palliative care due to its dual benefit in addressing depressive symptoms while also managing issues like insomnia and poor appetite. Studies suggest that mirtazapine can significantly improve sleep quality and nutritional intake, which are essential for maintaining comfort in palliative patients. [5,9] Nevertheless, its sedative properties require careful management, especially in older or frail individuals. [10]

Ketamine has emerged as a promising option for treatment-resistant depression in palliative care due to its rapid onset of action. Research indicates that ketamine can provide quick and effective relief from depressive symptoms, which is valuable for patients with limited life expectancy who require immediate symptom management. [11] Despite its potential, ketamine's use is limited by the risk of dissociative effects and hallucinations, necessitating careful patient selection and monitoring. [1]

Electroconvulsive Therapy (ECT) is typically reserved for severe cases of treatment-resistant depression in palliative care, where rapid symptom relief is necessary. While ECT has demonstrated substantial improvements in mood for some patients, its use in palliative settings is limited due to logistical challenges and the invasiveness of the procedure. [12]

The choice of pharmacological treatment in palliative care must be individualised, taking into account the patient’s symptom profile, overall health status, drug tolerability, and personal goals of care. Involving a multidisciplinary team in decision-making helps ensure that the chosen interventions align with the patient's values and provide the best possible quality of life. [1,2]

Equity and access

Equity in access to depression treatment in palliative care is heavily influenced by cultural, socio-economic, and geographic disparities. Aboriginal and Torres Strait Islander peoples and Culturally and Linguistically Diverse (CALD) populations often face significant barriers due to a lack of culturally sensitive care and integration of traditional healing practices into mainstream mental health services. For these groups, language barriers, cultural beliefs, and healthcare systems that do not align with their values can lead to under-diagnosis and inadequate treatment for depression. [13,14] Bridging these gaps requires culturally competent care models that incorporate traditional practices alongside conventional treatments.

Geographic and socio-economic factors further limit access to depression care, particularly for those in rural and remote areas, where specialised mental health services are scarce. The reliance on telehealth solutions to address these geographic disparities has been mixed, with challenges such as inconsistent digital access and low patient engagement. [15,16] Additionally, individuals from lower socio-economic backgrounds face financial barriers that restrict their ability to afford medications and psychological support, exacerbating the mental and emotional burden for both patients and their families. [17,18]

Stigma and discrimination also play a significant role in preventing groups like LGBTQI+ individuals, those with substance use histories, and incarcerated populations from seeking mental health care. Fear of prejudice from healthcare providers often results in untreated depression, particularly in settings where judgment or bias is prevalent. [19,20] Addressing these challenges requires training healthcare professionals in cultural competence and inclusivity, alongside policy reforms that prioritise equitable mental health support for all individuals, regardless of their background or circumstances. [21,22]

Care context

The care context for managing depression in palliative care is influenced by the environment in which patients receive their care, including home-based care, residential aged care homes, hospitals, and community-based settings. Each setting presents distinct challenges and opportunities that impact how depression is recognised, managed, and supported.

Home-based care is often preferred because it provides a familiar and supportive environment, which can help alleviate depressive symptoms. Studies indicate that patients receiving palliative care at home benefit from the emotional and social support of family members, positively impacting their mental well-being. [23,24] However, without professional mental health support, the burden on caregivers can be overwhelming, leading to increased stress and potential burnout. [20]

Residential aged care homes frequently face barriers to effective depression management due to a focus on physical health needs and limited mental health resources. Depression in these environments is often under-recognised and under-treated, which exacerbates distress for residents coping with advanced illness. [21,22] Improving mental health care in these settings requires training staff to recognise depressive symptoms and enhancing access to specialised mental health professionals. [25]

Hospitals and specialist palliative care units typically have better access to multidisciplinary teams, including psychologists, social workers, and spiritual care providers, facilitating comprehensive depression management. Despite their resources, these clinical settings can feel impersonal and overly focused on symptom control, potentially neglecting patients' emotional and existential needs. [18] Addressing these gaps requires integrating psychological and spiritual support into routine care. [13]

Community-based care models and telehealth services extend mental health support to individuals in rural or underserved areas, where access to specialised services is limited. Telehealth has shown promise for monitoring depressive symptoms and providing psychological interventions, although its effectiveness depends on digital literacy and connectivity. [26] To make these models inclusive, they must address both technological barriers and cultural sensitivities, especially for CALD populations. [14]

Implications for families and carers

Families and friends of individuals with depression in palliative care are often profoundly impacted by the emotional and psychological demands of caregiving. Evidence indicates that caregivers frequently experience heightened levels of stress, anticipatory grief, and emotional exhaustion, which can be exacerbated by the complexity of supporting a loved one through both physical and mental health challenges. [6,23] Depression in patients can amplify these difficulties, leading to a significant emotional toll on caregivers, who may struggle to balance their own mental health needs with the demands of caregiving. [9]

A primary challenge for families is the lack of adequate support and resources to manage the psychological aspects of depression in their loved ones. Research highlights that caregivers often feel unprepared to address the multifaceted nature of depression, particularly when their roles extend beyond emotional support to include coordination of care and medical decision-making. [1,24] Structured interventions that provide psychoeducation, counselling, and support for family members have been shown to reduce caregiver burden and enhance their capacity to provide empathetic, effective care. [7,15]

Practical implications also play a significant role in shaping the caregiver experience. Families are often tasked with navigating complex healthcare systems, advocating for appropriate mental health services, and ensuring that treatment decisions align with the patient’s values and preferences. Studies suggest that empowering caregivers through involvement in shared decision-making and equipping them with clear communication strategies can lead to better patient outcomes and reduced stress levels for the family. [21] Providing access to culturally competent support that acknowledges the diverse backgrounds and beliefs of families can further enhance their engagement in the caregiving process. [13,19]