Clinically Significant Depressive Symptoms Are Prevalent in People With Extremely Short Prognoses—A Systematic Review

Abstract

Context. Currently, systematic evidence of the prevalence of clinically significant depressive symptoms in people with extremely short prognoses is not available to inform its global burden, assessment, and management. Objectives. To determine the prevalence of clinically significant depressive symptoms in people with advanced life-limiting illnesses and extremely short prognoses (range of days to weeks). Methods. A systematic review and meta-analysis (random-effects model) were performed (PROSPERO: CRD42019125119). MEDLINE, Embase, PsycINFO, CINAHL, and CareSearch were searched for studies (1994e2019). Data were screened for the prevalence of clinically significant depressive symptoms (assessed using validated depression-specific screening tools or diagnostic criteria) of adults with advanced life-limiting illnesses and extremely short prognoses (defined by survival or functional status). Quality assessment was performed using the Joanna Briggs Institute Systematic Reviews Checklist for Prevalence Studies for individual studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) across studies. Results. Thirteen studies were included. The overall pooled prevalence of clinically significant depressive symptoms in adults with extremely short prognoses (n ¼ 10 studies; extremely short prognoses: N ¼ 905) using depression-specific screening tools was 50% (95% CI: 29%e70%; I 2 ¼ 97.6%). Prevalence of major and minor depression was 10% (95% CI: 4% e16%) and 5% (95% CI: 2%e8%), respectively. Major limitations included high heterogeneity, selection bias, and small sample sizes in individual studies. Conclusions. Clinically, significant depressive symptoms were prevalent in people with advanced life-limiting illnesses and extremely short prognoses. Clinicians need to be proactive in the recognition and assessment of these symptoms to allow for timely intervention.

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

“…As demonstrated by the survey, encountering depression in patients with very poor prognoses was common to palliative physician. However, despite the high prevalence of depression (up to 50%) in this population and the frequency of clinical encounters, only 40% of clinicians reported to screen for depression, with all clinicians reported to have experienced uncertainty when assessing the cause of depression [ 26 ]. This is reflected by the current study finding of the perceived challenging complexity of depression care in the very poor prognosis setting by clinicians.…”

“…According to the literature, this complexity may be contributed to by the interplay of various domains of challenges reported in Table 4 : 1) Patients’ frailty, co-existing symptom burden and associated end-of-life issues when time for intervention effects is poor [ 9 , 14 ]; 2) Clinicians’ self-perceived limitations of psychiatry skills in the palliative care setting and incompetence in diagnostic differentiation [ 9 , 27 ]; 3) Health system’s inadequacy of resources and access to required interventions in the local health services (e.g. mental health services) [ 8 , 9 ]; 4) Heterogeneity of depression concept and the lack of evidence to guide practice in the literature for this context [ 26 , 28 ]; and 5) Unsupportive societal attitudes that prevents the optimisation of depression care (e.g. stigma of mental illnesses, the “normalisation” or “acceptance” of depression at the end-of-life) [ 29 , 30 ].…”

“…There is a need for integrated palliative care and psychiatry research that explores appropriate depression screening and assessment strategies and potentially rapidly effective interventions using feasible and inclusive trial designs in the very poor prognosis setting (e.g. n-of-1, Bayesian response-adaptive-randomisation, or well-designed prospective case-controlled studies) [ 26 , 35 , 42 ]. Developing consensus approaches between palliative care and psychiatry via Delphi and updating the existing guideline based on the currently limited evidence to guide depression care specifically for people with very poor prognoses need to be considered [ 16 , 17 ].…”

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

“…Clinically significant depressive symptoms are prevalent in people with advanced life-limiting illnesses. 1 , 2 These can exacerbate physical and psycho-existential sufferings, worsen the quality-of-life for families and individuals, and deprive people from having meaningful social interactions for good closures at the end-of-life. 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.…”

Study protocol for SKIPMDD: subcutaneous ketamine infusion in palliative care patients with advanced life limiting illnesses for major depressive disorder (phase II pilot feasibility study)

“…It affects approximately 10%-15% of individuals in the palliative care setting. [1][2][3] MDD can significantly impact the quality-of-life of those affected and may be associated with a sense of worthlessness and the desire for hastened death. [4][5][6][7] The assessment and management of MDD can be challenging in the palliative care setting, particularly in the presence of substantial medical comorbidities when the prognosis is limited to only days to weeks.…”