The term “depression” can be used to describe an emotional state that may be as simple as minor mood alterations or as major as a pathological inability to function or cope with life (Breitbart, Dickerson, Shuster et al., 2002). Reactive, or situational, depression is a common and expected response to a life-threatening disease. Reactive depression is generally self-limiting and resolves as the individual uses education, support, and other coping resources to face the threat against well-being.

A depressed mood becomes a problem for patients when it is prolonged or severe and interferes with daily functioning. Depressed mood related to an identifiable psychosocial stressor that exceeds what would be normally expected or that impairs social or occupational functioning may fit the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for an Adjustment Disorder with Depressed Mood (Strain, 1998). Although less specific than the criteria for Major Depressive Disorder, this diagnosis does allow for identification of early or temporary depressed states and can assist in obtaining appropriate treatment.

Major Depressive Disorder is a serious medical condition that disrupts an individual’s mood, behavior, thought processes, and physical health (American Psychiatric Association, 2000a). The DSM-IV criteria for this diagnosis are listed in Box 25-1.

Many studies document the prevalence of depression in various populations. However, these studies are somewhat difficult to compare since the researchers do not always differentiate among reactive depression, adjustment disorders, and major depressive disorders. The incidence of depressive symptoms in cancer patients varies among studies, but it is thought to be as high as 25% for significant mood disturbance (Goy & Ganzini, 2003). Depression is seen in equal proportions in patients without cancer who have terminal diagnoses (Waller & Caroline, 2000).

The data on incidence of major depressive episodes in persons with advanced cancer show less variability than do the preceding studies, probably because the criteria for major depression are well defined. Approximately 5% to 15% of patients with advanced cancer have a major depressive disorder (Hinshaw, Carnahan, & Johnson, 2002).

Recent research into the etiology of depression has found what appears to be complex bidirectional relationships among neural, endocrine, and immune systems (Illman, Corringham, Robinson et al., 2005). These data lend support for a theory of cytokine-mediated depression. Interleukin-6 has been specifically identified as higher in individuals with acute depressive conditions (Illman et al., 2005). Overactivity of the hypothalamic-pituitary-adrenal axis has also been implicated in the development of depression. This combination is believed to have an overall immunosuppressive effect on the patient (Hinshaw et al., 2002).

There are a number of risk factors associated with a diagnosis of depression (Goldberg, 2004; Hinshaw et al., 2002; Paice, 2002):

As individuals face end-of-life, the emotions that accompany the dying process can be overwhelming. The terminally ill experience multiple losses and naturally grieve these losses. Although reactive depression is normal, it is nonetheless distressing and should not be ignored. It is extremely important that the clinician assess for signs of a depressed mood and determine the severity of the patient’s depression—from mood change to adjustment disorder to major depression—and provide for the appropriate management for all levels of depression.

The patient’s feelings of hopelessness, worthlessness, or suicidal ideation must be fully explored along with a thorough physical assessment of the somatic responses to depression (Breitbart et al., 2002; Goldberg, 2004; Hinshaw et al., 2002; Mystakidou, Rosenfeld, Parpa et al., 2005). Changes in heart rate and respiratory rate may indicate anxiety, which often accompanies depression.

The clinician must identify other potential causes for the patient’s somatic complaints, as well as disease-, symptom-, or medication-related causes of the depressive symptoms. A thorough assessment includes identification of uncontrolled symptoms, metabolic abnormalities, endocrine abnormalities, and medications associated with depressive symptoms.

The clinician must utilize the entire team when caring for persons with depressive symptoms. The supportive care of the nurse, social worker, spiritual counselor, and primary care physician may be sufficient to address the distress associated with a depressed mood. However, a clinical psychiatrist should be consulted when caring for the individual with major depression (American Psychiatric Association, 2000b).

Optimal therapy for major depression is often a combination of supportive psychotherapy, cognitive-behavioral techniques, and pharmaceutical management. For mild major depression, psychotherapy alone, antidepressant medication alone, or a combination of the two may be used. Moderate and severe major depressions often require the combination of psychotherapy and antidepressant medications. Short-term interventions for mild depression include active listening, offering verbal support, providing information to assist the individual in coping with the situation, identifying past strengths, and supporting previously successful ways of coping. The importance of incorporating spiritual support when appropriate should not be underrated. For the individual at risk for suicide, it is essential to consult a skilled psychiatrist, maintain a supportive relationship, and focus on improved quality of living (Goldberg, 2004; Goy & Ganzini, 2003; Hinshaw et al., 2002; Nelson, 2002; American Psychiatric Association, 2000b).

For individuals with a high risk of suicide, the clinician must take steps to ensure safety. Supervision, either in the patient’s residence or in a facility, may be required 24 hours a day. Objects or medications that may be used for self-harm must also be removed from the environment.

Antidepressant medications are effective in the treatment of depression. There are several different classes of antidepressant medications, whose effectiveness is comparable among and within classes. Medication selection is based on anticipated side effects, patient preference, quantity and quality of clinical trial data, and medication costs. Based on these considerations, the following medications can be considered: selective serotonin reuptake inhibitors (SSRIs), desipramine, nortriptyline, bupropion, and venlafaxine (American Psychiatric Association, 2000b). The elderly are particularly prone to the orthostatic hypotensive and anticholinergic side effects of tricyclic antidepressants and tend to have fewer side effects if one of the antidepressants listed is used (Goldberg, 2004). The axiom “start low and go slow” is certainly appropriate when titrating antidepressants in the elderly. Table 25-1 lists some of the more frequently used antidepressants by class and indicates the prevalence of various side effects. In June 2005, the Food and Drug Administration (FDA) issued a Public Health Advisory regarding the potential suicidality in adults taking antidepressant medications. It is clear that clinicians must use sound clinical judgment in placing individuals on any medication and that in situations such as this, where an increased risk of suicide may exist, patients must be followed carefully for clinical changes suggestive of worsening symptoms. This includes closer monitoring when doses are increased or agents changed as well as when first initiated (FDA, 2005).

Psychostimulants are another class of medications used for the treatment of depression in the terminally ill. These medications enhance mood, decrease fatigue, and stimulate appetite, leading to an overall improved sense of well-being. Unlike the antidepressants, which tend to require several days to weeks to achieve therapeutic effect, the psychostimulants generally have a more immediate onset of action. Potential adverse side effects include tremor, tachycardia, insomnia, nightmares, and psychosis (Breitbart et al., 2002; Hinshaw et al., 2002; Rozans, Dreisbach, Lertora et al, 2002; Waller & Caroline, 2000). These medications are generally started at low doses and titrated upward for desired effect or until untoward side effects occur. Dextroamphetamine is usually started at 2.5 to 5 mg orally daily. The starting dose for methylphenidate is 5 mg orally in the morning and 2.5 mg orally at noon.

Anxiety often accompanies depression. Cognitive-behavioral interventions, active listening, and psychosocial support, alone or in combination with administration of benzodiazepines, are helpful in managing this symptom. See Chapter 17 for a more detailed discussion.

Complementary interventions also play a role in the treatment of depression. These interventions can improve mood and outlook, decrease feelings of hopelessness and helplessness, and decrease anxiety (Goldberg, 2004; Hinshaw et al., 2002). Chapter 32 addresses the use and benefits of complementary therapies in end-of-life care. The clinician should consider the following for patients who have depressed mood states:

Depression, like many psychiatric illnesses, is often perceived as an embarrassment or a disgrace. Patients and families need support and education about the diagnosis of depression, with emphasis that it is not a sign of weakness or a character flaw. Some persons find written information helpful, such as the Major Depressive Disorder: A Patient and Family Guide (American Psychiatric Association, 2000a).

The following information must be included in the teaching plan for the patient and family:

Early detection and ongoing assessment of depression are important considerations for the clinician caring for patients at end-of-life. Timely interventions are not always possible, and thoughtful consideration should be given to the appropriate medications that can be used to improve patient outcomes.