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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 6: Anxiety, Delirium, Depression
    Assessment and Management of Depression

    Assessment of Depression Management of Depression

    Assessment of Depression in Advanced Illness

    What Symptoms to Look for and How to Assess

    • Somatic symptoms (e.g., changes in appetite, weight, energy level, libido, or sleeping) are almost invariably present in patients with advanced illness. Because of this, such symptoms are less reliable diagnostic indicators of depression in this population than they are in the general population
    • Psychological and cognitive symptoms of depression should therefore be the focus in assessment of depression in patients with advanced illness. The most reliable criteria include:
      • Persistent dysphoria
      • Anhedonia (loss of pleasure or interest)
      • Feelings of helplessness, hopelessness, and worthlessness
      • Loss of self-esteem
      • Feelings of excessive guilt
      • Pervasive despair
      • Bothersome ruminations about death
      • Pain not responding as expected
      • Sad mood with flat affect
      • Anxiety, irritability, or unpleasant mood
    • The screening question, "Do you feel depressed most of the time?" is a highly sensitive and specific question in this population
    • Where possible, include the observations of family, friends and other members of the health care team as they may provide considerable information to add to the history
    • More specific screening tools (such as the Beck inventory for depression) for the identification of depression are available
    • If you are having difficulty determining the presence or extent of a patient's depression, use colleagues as resources. For instance:
      • You may need the assistance of a child psychologist, child life specialist, or social worker if the patient is a child or adolescent

      • Ask an experienced psychiatrist for assistance as appropriate


    Assessment of Suicidality - Common Questions and Answers

    • Who should be assessed for risk of suicide?
      • All patients with depressive symptoms should be assessed for their risk of suicide
    • Why should I be so concerned about suicidal thoughts? Aren't these normal in patients with advanced illness?
      • Suicidal thoughts are an important sign of depression, even in patients with advanced life-threatening illness
    • Won't talking about suicide put the idea in my patients' minds?
      • No, in fact, open discussion of suicide may reduce the risk. It is a myth that asking about suicide will "put the idea into someone’s head." To the contrary, allowing patients to discuss the thoughts they are having may reduce the likelihood they will actually commit suicide. This is particularly true when the physician acknowledges their feelings and desires, and addresses the root causes of their distress (see Module 5: Physician-Assisted Suicide)
    • What should I do if I think my patient is suicidal?
      • Patients with recurrent thoughts of suicide or serious plans should be considered at high risk. Immediate consultation with a mental health specialist with experienced in this area is indicated


    Management of Depression in Advanced Illness

    Techniques for Treating Depression: An Overview

    To treat depressed patients who are living with life-threatening illness, use a combination of supportive psychotherapy, cognitive approaches, behavioral techniques and antidepressant medication

      Psychotherapeutic Interventions: Individual or group counseling have both been shown to reduce depressive symptoms. In addition to formal sessions with psychiatrist, psychologists, or other mental health professionals, nurses, social workers, and chaplains may also be able to conduct both formal and informal sessions, depending on their training
      Cognitive Approaches: Time spent talking with patients about their feelings and reframing their ideas may be very helpful. These approaches can be used by the primary physician, as well as other colleagues
      Behavioral Interventions: Relaxation therapy, distraction therapy with pleasant imagery, etc. have been shown to reduce depressive symptoms in patients with mild to moderate levels of depression. Complementary and alternative medical approaches may be useful adjuncts
      Antidepressant Medications: A variety of medications that will be discussed below work with all severities of depression. They work better than psychotherapy alone in severe depression


    Goals of Supportive Counseling

    • General Tips for Supportive Counseling:
      • Look for opportunities to weave supportive counseling that uses aspects of brief supportive psychotherapy into routine interventions

      • Include family members whenever possible

      • Refer seriously depressed or anxious patients for formal psychotherapy

    • Improve patient understanding
      • During the discussions, to provide the patient with an improved understanding of his or her:
        • Prognosis
        • Potential treatments
        • Outcomes
      • In this way, the interaction itself may be therapeutic
    • Encourage new perspectives
      • Giving patients information and helping them to gain an improved understanding of the situation they face may help them to develop different perspectives on their:
        • Perceptions
        • Expectations
        • Needs
        • Fears and fantasies about illness and death
    • Help establish/re-establish patient's sense of self-worth and meaning
      • Discuss short-term goals
      • Identify and reinforce the patient’s previously demonstrated:
        • Strengths
        • Successful coping techniques
    • Introduce new coping techniques
      • Inform patients about techniques such as:
        • Relaxation
        • Meditation
        • Guided imagery
        • Self-hypnosis
      • Educate the patient and family members about modifiable factors that contribute to anxiety and depression


    Pharmacological Management of Depression

    General Considerations in the Pharmacologic Treatment of Depression

    • The time available for treatment will strongly influence the choice of medication for initial therapy
      • When reversal of depression is an immediate short-term goal, a rapid-acting psychostimulant is the best choice
      • If a response in 2 to 4 weeks is acceptable, an atypical antidepressant or SSRI may be an appropriate choice
    • With all antidepressant medications, dosing should "start low and go slow"
      • Titrate the dose to effect and tolerability
      • Warn patients about possible adverse effects and assure them that these will usually ameliorate within a few days
    • If patients are not responding as expected, seek consultation with an experienced colleague, such as a psychiatrist



    • Basic Information and Examples of Drugs in this Class
      • The psychostimulants are often underappreciated for their antidepressant qualities

      • Drugs in this class include:

        • Methylphenidate
          • Usually started at 5 mg in the morning and at noon, and then titrated to effect

          • An extended-release formulation taken once in the morning may improve tolerability

        • Dextroamphetamine
        • Dextroamphetamine
    • Advantages of Psychostimulants
      • Act quickly (within days). Some patients report increased energy and an improved sense of well-being within 24 hours

      • Produce minimal adverse effects

      • Can be used alone or in combination with other antidepressants

      • May be continued indefinitely as their antidepressant effect persists over time

      • Tolerance to the antidepressant effect does not appear to develop

      • May also be used to diminish opioid-induced sedation

      • Their potential as adjuvant analgesics has been reported
    • Disadvantages of Psychostimulants

      • May produce:
        • Tremulousness
        • Anxiety
        • Anorexia
        • Insomnia

      • These adverse effects should be monitored

      • If discontinued, psychostimulants should be tapered off slowly


    Selective Serotonin Reuptake Inhibitors

    • Examples of Drugs in this Class
      • fluoxetine
      • paroxetine
      • sertraline
      • citalopram
    • Advantages of SSRIs
      • Highly effective (70% of patients report a significant response)
      • Low doses may be sufficient in advanced illness
      • Once-daily dosing is possible
      • Cause less constipation, sedation, and dry mouth than the tricyclic antidepressants
    • Disadvantages of SSRIs
      • Latency (require 2-4 weeks to take effect)
      • Nausea may be worse than with tricyclics


    Tricyclic Antidepressants

    • Examples of Drugs in this Class
      • amitriptyline
      • clomipramine
      • desipramine
      • doxepin
      • imipramine
      • nortriptyline
      • protriptyline
      • trimipramine
    • Issues to Consider before Using Tricyclics
      • Not recommended as first first-line therapy to manage depression unless they are being used as adjuvants to control neuropathic pain
      • Titration to achieve an adequate dosage may take 3 to 6 weeks, delaying the onset of therapeutic action
      • Anticholinergic adverse effects (e.g., dry mouth, constipation, orthostatic hypotension, blurred vision, urinary retention, delirium) and cardiac conduction delays (proarrhythmic) are all seen with some frequency
      • If a tricyclic antidepressant is to be used, the secondary amines nortriptyline and desipramine are preferable as they tend to have fewer side effects


    Atypical Antidepressants

    • This diverse group of older and newer medication is growing quickly
    • Examples include:
      • mirtazapine
      • bupropion
      • nefazodone
      • trazodone
      • venlafaxine
    • Their precise role in patients with advanced disease is being studied


    Non-Pharmacologic Management

    • Although this module focuses on equipping physicians with the medical knowledge, attitudes, and skills to manage depression, this does not exclude the role of non-pharmacological management of depression
    • Use appropriate colleagues and team members to help address the emotional and spiritual issues that overlap and influence clinical depression
    • Complementary and alternative methods may be useful adjuncts for some patients. It is beyond the scope of this module to discuss these in detail
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