Depression is a significant comorbidity in palliative care settings, particularly for individuals facing very short prognoses, often measured in days or weeks. A recent survey highlighted the commonality of encountering depression among palliative physicians treating these patients. Despite the high prevalence of depression, reaching up to 50% in this vulnerable population, and frequent clinical interactions, a concerningly low 40% of clinicians reported routinely screening for depression. Furthermore, all surveyed clinicians acknowledged experiencing uncertainty in determining the underlying causes of depression in this specific context. This uncertainty underscores the complex nature of Palliative Care Depression Diagnosis and management in end-of-life scenarios.
The complexity of providing adequate depression care in patients with extremely limited prognoses stems from a confluence of factors. These challenges can be categorized into several key domains that impact both the accuracy of diagnosis and the effectiveness of treatment strategies.
One significant domain is patient-related challenges. Patients at the end of life are often characterized by frailty, a significant burden of co-existing symptoms, and the typical issues associated with the dying process. When the window for therapeutic intervention is severely restricted, these factors complicate both assessment and treatment. The very nature of terminal illnesses can mimic or mask symptoms of depression, making differential diagnosis particularly difficult.
Another critical area of challenge lies within clinician-related factors. Palliative care physicians often report feeling limited by their own psychiatric skills within the specialized palliative care environment. Many express a lack of confidence in their ability to accurately differentiate depression from other conditions presenting similar symptoms in terminally ill patients. This perceived incompetence in diagnostic differentiation is a significant barrier to effective palliative care depression diagnosis.
Systemic issues within healthcare also contribute to the problem. Inadequate resources and limited access to specialized mental health services within local health systems represent a major impediment. The lack of readily available mental health support for palliative care teams further complicates the process of diagnosing and managing depression in this setting.
Adding to the complexity is the very concept of depression itself. The heterogeneity of depression and the lack of specific, evidence-based guidelines tailored to patients with extremely poor prognoses create a significant challenge. Clinical practice is often guided by research and literature that may not directly address the unique circumstances of end-of-life care, leading to uncertainty in the most appropriate diagnostic and treatment approaches.
Finally, societal attitudes play a role in hindering optimal depression care in palliative settings. The stigma associated with mental illness in general, coupled with a societal tendency to “normalize” or “accept” depression as an inevitable part of the end-of-life process, can prevent patients from receiving the necessary care. This normalization can lead to under-recognition and under-treatment of clinically significant depression.
Palliative physicians have reported being less inclined to screen for depression and express ambivalence regarding depression assessment methods, particularly concerning somatic symptoms, when dealing with patients with very poor prognoses compared to those with better prognoses. Diagnosing depression in this context is further complicated because symptoms of terminal illnesses, such as fatigue and weight loss, can overlap with and obscure somatic symptoms of depression.
Despite the perception that somatic symptoms might be less reliable for palliative care depression diagnosis in this population, it’s crucial to recognize their continued relevance in the overall assessment. Somatic symptoms can significantly influence the suitability and choice of interventions. Training clinicians in various approaches to evaluating somatic symptoms, such as the Endicott Criteria, could enhance diagnostic accuracy and improve depression assessment in palliative care.
While clinicians may generally opt for less aggressive interventions in patients with very short prognoses, the survey revealed a bimodal distribution in the use of non-typical pharmacological interventions. Some clinicians were more inclined to use psychostimulants, atypical antipsychotics, benzodiazepines, and novel medications like ketamine. These medications are known for their rapid-onset potential and ability to augment traditional antidepressants. This bimodal distribution suggests that clinicians who are knowledgeable and trained in leveraging the benefits of these non-typical treatments while managing potential side effects are more likely to employ them. Conversely, clinicians lacking such training or access to these resources tend to avoid them.
Similar findings in primary care and palliative settings in the United Kingdom indicate that inadequately prepared clinicians may develop a nihilistic attitude and uncertainty towards depression screening and assessment. The infrequent use of electroconvulsive therapy (ECT) in palliative care is likely due to the perception that it is overly burdensome for patients with very limited prognoses.
To improve depression care for patients at the end of life, it is essential to equip palliative physicians and their multidisciplinary teams with the necessary skills to effectively screen, assess, and administer rapid-acting, first-line depression interventions in a manner that minimizes patient burden. This can be facilitated through improved integration of psychiatric services into palliative care settings.
Consistent with findings among palliative physicians in the United States, approximately 70% of respondents in the current survey expressed a desire for enhanced collaboration with psychiatric services. Strategies to foster better collaboration between palliative care and psychiatry at both clinical and health service levels include:
- Integrative multidisciplinary teams: Creating teams that formally incorporate psychiatric expertise into palliative care.
- Joint development of tiered-referral models: Establishing structured referral pathways tailored to the specific needs of local health services to ensure timely access to psychiatric consultation.
- Integrated clinician training: Implementing joint training initiatives, such as workshops and experiential learning opportunities, to enhance the skills of both palliative care and psychiatry professionals in addressing depression in palliative care.
For future research, collaboration between palliative care and psychiatry researchers is vital to expand the limited evidence base. Beyond the identified barriers to depression care processes, research challenges include the impact of depression and terminal illness on patients’ capacity to consent and participate in research, as well as ethical considerations related to trial participants receiving potentially ineffective treatments.
There is a pressing need for integrated palliative care and psychiatry research focused on identifying appropriate depression screening and assessment methods and exploring potentially rapid-acting interventions using practical and inclusive trial designs suitable for patients with very poor prognoses. Examples of such designs include n-of-1 trials, Bayesian response-adaptive randomization, and well-designed prospective case-controlled studies. Furthermore, developing consensus-based approaches between palliative care and psychiatry, potentially through Delphi methods, and updating existing guidelines based on the current evidence to specifically guide depression care for patients with very short prognoses are critical next steps.
Ultimately, enhanced collaboration between palliative care and psychiatry is urgently needed to optimize timely access to necessary interventions, address the limitations of both disciplines individually, and significantly improve the quality of care for patients experiencing depression in palliative care settings.
Limitations
This study was limited by low response rates, particularly from psychiatrists. These low rates were likely exacerbated by the COVID-19 pandemic, which understandably shifted clinicians’ focus towards pandemic-related activities over non-COVID-19 research. It is also possible that psychiatrists perceived the topic as less relevant due to limited engagement with palliative care. The small sample size restricted the statistical power for detailed subgroup analyses. The survey did not include non-physician palliative care professionals, such as nurses, pastoral care providers, or psychologists. Additionally, the respondents were exclusively from the Australasian region, potentially limiting the generalizability of the findings to other geographical contexts. As inherent in survey-based methodologies, there is a risk of reporting bias, where reported practices may not fully reflect actual clinical practices. Regarding depression interventions, the study did not individually examine various non-pharmacological approaches, such as supportive psychotherapy versus cognitive therapy. A technical issue also resulted in the survey question about psychostimulant use being initially unavailable to the first 28 ANZSPM respondents. Despite these limitations, the collected data provides valuable insights into the current practices and perceptions of palliative physicians in Australasia. Finally, while the prevalence data regarding perceived barriers to depression care in very poor prognosis settings offers valuable information, it does not necessarily indicate the relative importance or influence of specific subcategories in optimizing depression care. Less frequently reported subcategories, such as the heterogeneity of depression concept and unsupportive societal attitudes, may actually reflect a lack of awareness among clinicians, highlighting the need for increased education and awareness in these areas.
