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Slide 1: Erminia Gabello BSN, RN
Slide 2:  Depression in terminally ill patients is prevalent, difficult to assess, under recognized, and undertreated in the hospice setting Associated with significant morbidity and mortality Depression is a significant symptom for approximately 25% of palliative care patients   (Lawrie, 2004)
Slide 3:  Describe common barriers to the recognition and treatment of psychological symptoms of depression in palliative care patients Differentiate between normal grief associated with dying and clinical depression in palliative care patients Discuss the use of screening tools used in the literature to identify symptoms of depression in palliative care patients Evaluate interventions for the treatment of depression in palliative care patients   
Slide 4:  The research that was reviewed involving depression in palliative care patients took place both in the home hospice and inpatient hospice setting
Slide 5:       Impairs capacity for pleasure, meaning, and connection Erodes quality of life Amplifies pain and other symptoms Reduces ability to do the emotional work of separating and saying goodbye Causes anguish and worry in family members and friends Major risk factor for suicide/desire to hasten death (Block, 2000)
Slide 6:       Failure to distinguish natural, existential distress from clinical depression Lack of clinical knowledge and skills Stigma associated with diagnosis of depression Time constraints Physician reluctance to prescribe psychotropic agents Physician hopelessness/therapeutic nihilism (Block, 2000)
Slide 7:         Diminished interest or pleasure in all or almost all activities Psychomotor retardation or agitation Feelings of worthlessness or excessive and inappropriate guilt Diminished ability to concentrate and think Recurrent thoughts of death and suicide Fatigue and loss of energy Significant weight loss or gain Insomnia or hypersomnia (Lawrie, 2004)
Slide 8:       Hopelessness Helplessness Worthlessness Guilt Social withdrawal Suicidal ideation       Dysphoria Depressed mood Sadness Tearfulness Lack of pleasure Intractable pain (Block, 2000)
Slide 9:     Patients retain the capacity for pleasure Grief comes in waves Patients express passive wishes for death to come quickly Patients are able to look forward to the future     Patients enjoy nothing Depression is constant and unremitting Patients express intense and persistent suicidal ideation Patients have no sense of a positive future (Block, 2000)
Slide 10:  “Are You Depressed?” a single-item interview assessing depressed mood (Chochinov, 1997). The Hospital Anxiety and Depression (HAD) Scale (Snaith, 2003). The Geriatric Depression Scale (GDS) (Kurlowicz, 2007)  
Slide 11:  Pain control Psychopharmacology Psychotherapy and counseling Psychiatric referral   
Slide 12:  Psychostimulants: methylphenidate, dextroamphetamine, and pemoline Selective serotonin reuptake inhibitors (SSRIs): sertraline, fluoxetine, and paraxetine Tricyclics: amitriptyline, imipramine, doxepin, desipramine, and nortriptyline (Block, 2000)  
Slide 13:  Psychological tasks of dying include:         Grieving Saying goodbye Constructing a meaningful context to one’s life Letting go Leaving a legacy Completing relationships Grappling with spiritual and religious issues Attending to family (Cohen, 2004)
Slide 14:  Indications for psychiatric referral        Clinician is uncertain about psychiatric diagnosis Patient has history of major psychiatric disorder Patient is suicidal Patient requesting assisted suicide or euthanasia Patient is psychotic or confused Patient is unresponsive to first-line antidepressants Patient’s family is dysfunctional (Block, 2000)
Slide 15:       Examine a patient’s reasons for wanting to end life now Assess pain and symptom control Review patient’s social supports Assess cognitive status Assess psychological condition Explore religious, spiritual, and existential concerns (Block, 2000)
Slide 16:  Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer (Breitbart, 2000) Objective: To assess the prevalence of desire for hastened death among terminally ill cancer patients and to identify factors corresponding to desire for hastened death 
Slide 17:  Design: Prospective survey conducted in a 200-bed palliative care hospital in New York, NY. Patients: 92 terminally ill cancer patients (60% female; 70% white; mean age 65.9 years) admitted between June 1998 and January 1999 for end of life care and passed a cognitive screening test Main Outcome Measure: Scores on the Schedule of Attitudes Toward Hastened Death (SAHD)  
Slide 18:    Results: 17% of patients had a high desire for hastened death based on the SAHD; 16% of 89 patients met criteria for a current major depressive episode. Desire for hastened death was significantly associated with a clinical diagnosis of depression (P=.001) Depression (P=.003) and hopelessness (P<.001) provided independent and unique contributions to the prediction of desire for hastened death
Slide 19:  Conclusion: Depression and hopelessness are the strongest predictors of desire for hastened death in this population, and provide independent and unique contributions Limitations: Can the SAHD differentiate individuals who have accepted death from those who desire a hastened death? Generalizability: Sample was recruited from a state-of –the-art palliative care facility  
Slide 20:  A qualitative study of clinical nurse specialists’ views on depression in palliative care patients (Lloyd-Williams, 2003) Objective: To examine how palliative care nurse specialists, working both in the community and within a hospital, perceive, assess, and manage depression in their patients 
Slide 21:  Sample selection: Using a purposive sample, palliative care nurse specialists were recruited from a large hospital and a community palliative care team in central England Data collection: Semi-structured interviews were carried out over a 3 month period 
Slide 22:  Results: 4 underlying themes were identified  Depression as a symptom compared with other symptoms Lack of training Stigmatization of mental illness Treatment issues   
Slide 23: Mrs. R. is a 75 year old woman diagnosed with Stage III ovarian cancer last year. Her cancer did not respond to chemotherapy, and she and her husband came to live with her daughter to pursue treatment at a major academic center. Her cancer progressed causing a small bowel obstruction that led to her hospitalization. She required opioids to keep her pain free, but these caused sedation which was distressing to both the patient and her husband. A psychiatry consult was requested when she started showing signs of depression and expressed a wish to die.
Slide 24:  Physical suffering:  treatment with methylphenidate for opioid-induced sedation  Grieving and depression:   ensuring a safe, nonjudgmental place to talk not becoming overwhelmed by the affect expressed
Slide 25:  Life review:  The therapist becomes a witness to the patients existence, contributions, and connections  Addressing fears:  Role of the therapist is to provide reassurance that the patient will not be abandoned as death approaches
Slide 26:  Spiritual and religious issues:  The therapist can provide a nonjudgmental ear and help the patient to overcome feelings that are blocking reliance on their faith as a comfort and support  Relationship completion:  The therapist can model some of these tasks such as saying goodbye, expressing appreciation, or by role playing in the context of the therapeutic relationship
Slide 27:  Legacy:   The therapist plays a critical role by asking openended questions, remaining nonjudgmental, and helping patients recognize previously unacknowledged contributions The therapist also helps the patient create new legacies
Slide 28:  Early recognition of clinical indicators for depression in terminally ill patients Enhanced training and education in all interdisciplinary areas in the assessment and management of depression in terminally ill patients Transfer of psychological and psychiatric assessment skills to clinical nurse specialists in managing care of terminally ill patients Further research exploring the development of universal criteria for the diagnosis of depression in terminally ill patients   
Slide 29: Block, S.D. (2000). Assessing and managing depression in the terminally ill patient. Annals of Internal Medicine, 132(3), 209-218. Breitbart, W., Rosenfeld, B., Pessin, H., Kaim, M., Funesti – Esch, J., Galietta, M., et al. (2000). Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. Journal of the American Medical Association, 284(22), 2907-2911. Chochinov, H.M., Wilson, K.G., Enns, M., & Lander, S. (1997). “Are you depressed?” Screening for depression in the terminally ill. American Journal of Psychiatry, 154(5), 674-676.
Slide 30: Cohen, S.T., & Block, S.D. (2004). Issues in psychotherapy with terminally ill patients. Palliative and Supportive Care, 2, 181-189. Lawrie, I., Lloyd-Williams, M., & Taylor, F. (2004). How do palliative medicine physicians assess and manage depression. Palliative Medicine, 18, 234-238. Lloyd-Williams M., & Payne, S. (2003). A qualitative study of clinical nurse specialists’ views on depression in palliative care patients. Palliative Medicine, 17, 334-338.