Tackling depression in the dying

It is common for people with advanced life-limiting illnesses to suffer from clinically significant depressive symptoms, particularly towards the end of life. These symptoms can exacerbate physical and psycho-existential suffering, worsen the quality of life for families and individuals, and deprive people of meaningful social interactions for good closures.

In a recent survey of palliative care physicians and psychiatrists in Australia and New Zealand undertaken by PaCCSC researchers, it was found that dealing with depressive symptoms in these people can be challenging for clinicians. Clinicians reported a lack of routine depression screening in the palliative care setting. 

Symptoms of the underlying disease processes can mimic that of pathological depressive disorders. And, the co-existing symptom burden and frailty of these individuals reduces the tolerability of various depression interventions, which also might not work in time. Importantly, clinicians reported a sense of “therapeutic nihilism” with fewer than 25% of participants reporting they were more likely to intervene for major depressive disorder with non-pharmacological and/or typical antidepressants when life expectancy is short.

Following the survey, a focus group study was undertaken to ascertain in greater depth the perceptions of Australasian palliative physicians and psychiatrists. Participants were asked about depression screening, assessment, and management when life expectancy is extremely short (days to weeks), exploring reasons for practices, key barriers to care, and potential solutions. Three one-hour online focus groups (2 palliative medicine and 1 consultation liaison psychiatry) were conducted between November and December 2020. Participants included eleven fellows and trainees from the Australia and New Zealand Society of Palliative Medicine and four from the Royal Australian and New Zealand College of Psychiatrists. Data underwent conventional qualitative content analysis.

Overall, both palliative medicine and psychiatry participants perceived depression care to be complex and challenging. Participants said that clinicians lacked the required training and uniformity in approaches to depression care in people with very poor prognoses.  Participants reported concerns about causing harm to patients and key relationships through the depression care processes, for example, adverse effects of interventions, or “robbing people of appropriate drivers [to bring people together]”. 

Participants from both specialties perceived a general lack of access to required liaison psychiatry and psychology services, especially those with palliative care expertise. Linkages between existing palliative care and psychiatry services were often perceived to be suboptimal with negative clinician perceptions towards the other discipline. There was also a perceived lack of research evidence to support various assessment methods and interventions in people with very poor prognoses. This was complicated by a reluctance to enrol these individuals into clinical trials and ethical concerns around patients possibly receiving ineffective interventions. 

Lastly, the stigma of mental health issues was reported as a barrier to care. Initiating patient discussion around psychological needs and having liaison psychiatry or psychology input was not observed by patients to be the norm, contributing to patients’ resistance to depression care.

Participants suggested potential solutions to improve depression care in people with very poor prognoses. Overall, these solutions centred around integrating care processes between palliative care and psychiatry. These included:

• introducing psycho-existential distress screening to existing generic symptom screening
• developing a consensus approach to depression care and its associated clinician training
• advocating for funding to improve resourcing of both disciplines
• utilising community resources (e.g., volunteers) and strategies that optimise existing palliative care and psychiatry service linkages (e.g., regular integrative multidisciplinary team meetings and ward rounds)
• establishing referral systems that better meet individual service needs by having a tiered referral model for psychiatry services and deformalising psychiatry referral thresholds
• having integrative palliative care psychiatry research using innovative clinical trial designs to address feasibility and ethical concerns (e.g., Pre-consent/N-of-1), and
• rebranding psychiatric services as part of routine clinical care in the palliative care setting. 

Overall, this study provides insights into the perceived complexities and challenges of depression care in the very poor prognoses setting by palliative physicians and psychiatrists, elaborating key perceived barriers to care and postulating potential solutions. Developing clinician training, supportive health systems, and innovative research strategies centering on integrating palliative care and psychiatry care processes may be integral to optimising depression care when providing care to people with very poor prognoses.

Improving depression care for those who are dying is everyone’s business. You can read the full text of this article in BMC Palliative Care.

Dr Wei Lee is a palliative care physician based in the northern districts of Sydney. He is passionate about palliative care research and symptom management. He is a PhD candidate at University of Technology Sydney, exploring depression in end of life.