Caring for depression in the dying is complex and challenging – survey of palliative physicians

Abstract

Background Depression is prevalent in people with very poor prognoses (days to weeks). Clinical practices and perceptions of palliative physicians towards depression care have not been characterised in this setting. The objective of this study was to characterise current palliative clinicians’ reported practices and perceptions in depression screening, assessment and management in the very poor prognosis setting. Methods In this cross-sectional cohort study, 72 palliative physicians and 32 psychiatrists were recruited from Australian and New Zealand Society of Palliative Medicine and Royal Australian and New Zealand College of Psychiatrists between February and July 2020 using a 23-item anonymous online survey. Results Only palliative physicians results were reported due to poor psychiatry representation. Palliative physicians perceived depression care in this setting to be complex and challenging. 40.0% reported screening for depression. All experienced uncertainty when assessing depression aetiology. Approaches to somatic symptom assessment varied. Physicians were generally less likely to intervene for depression than in the better prognosis setting. Most reported barriers to care included the perceived lack of rapidly effective therapeutic options (77.3%), concerns of patient burden and intolerance (71.2%), and the complexity in diagnostic differentiation (53.0%). 66.7% desired better collaboration between palliative care and psychiatry. Conclusions Palliative physicians perceived depression care in patients with very poor prognoses to be complex and challenging. The lack of screening, variations in assessment approaches, and the reduced likelihood of intervening in comparison to the better prognosis setting necessitate better collaboration between palliative care and psychiatry in service delivery, training and research.

A Focus Group Study of Palliative Physician and Consultation-Liaison Psychiatrist Perceptions of Dealing with Depression in the Dying

“… 11 Less than 25% of participants reported more likely to intervene for major depressive disorder with non-pharmacological and/or typical antidepresants when life-expentancy is short. 11 A sense of “ therapeutic nihilism ” was described: “ Why assess it if there is little I can do about it? ”; “ Pointless if interventions (including psychosocial) will not be practical/acceptable.…”

“… 2 – 8 In the general palliative care population, assessment and management of such can be challenging due to co-existing symptom burdens, associated complications from physical illnesses, and often complex psychosocial dynamics. 2 , 9 – 11 Within this cohort, there is a subgroup with very poor prognoses measured in days-to-weeks. This subgroup may pose extra clinical challenges as they usually have poorer functional status and higher symptom burden than others while the usual interventions for depressive symptoms may not benefit in-time nor be tolerated.…”

“…The authors undertook a survey of Australasian (Australia and New Zealand) palliative care physicians and psychiatrists to address such. 11 The survey identified low rates (40%) of depression screening with all participants having experienced diagnostic uncertainty, reporting assessment and management variations. 11 Less than 25% of participants reported more likely to intervene for major depressive disorder with non-pharmacological and/or typical antidepresants when life-expentancy is short.…”

“… 11 The survey identified low rates (40%) of depression screening with all participants having experienced diagnostic uncertainty, reporting assessment and management variations. 11 Less than 25% of participants reported more likely to intervene for major depressive disorder with non-pharmacological and/or typical antidepresants when life-expentancy is short. 11 A sense of “ therapeutic nihilism ” was described: “ Why assess it if there is little I can do about it?…”

Exercising Hope in Palliative Care Is Celebrating Spirituality: Lessons and Challenges in Times of Pandemic

“…This is the case of terminal illnesses that are both desperate and intrusive. When faced with such situations, many people give in to despair and disillusionment, as evidenced by the increase in suicidality (Salamanca-Balen et al, 2021 ), and experience anxiety and depression (Lee et al, 2022 ), while others continue to nourish the hope that better days will come, even invoking divine protection, thus, envisioning improvements in health or family life.…”