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Assessing and Managing Depression in the Terminally Ill Patient

Susan D. Block, MD, ACP-ASIM End-of-Life Care Consensus Panel
[+] Article, Author, and Disclosure Information

This paper was written by Susan D. Block, MD, and was developed for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel. Members of the ACP-ASIM End-of-Life Care Consensus Panel were Bernard Lo, MD (Chair); Janet Abrahm, MD; Susan D. Block, MD; William Breitbart, MD; Ira R. Byock, MD; Kathy Faber-Langendoen, MD; Lloyd W. Kitchens Jr., MD; Paul Lanken, MD; Joanne Lynn, MD; Diane Meier, MD; Timothy E. Quill, MD; George Thibault, MD; and James Tulsky, MD. Primary staff to the Panel were Lois Snyder, JD (Project Director), and Jason Karlawish, MD. This paper was reviewed and approved by the Ethics and Human Rights Committee, although it does not represent official ACP-ASIM policy. Members of the Ethics and Human Rights Committee were Risa Lavizzo-Mourey, MD (Chair); Joanne Lynn, MD; Richard J. Carroll, MD; David A. Fleming, MD; Steven H. Miles, MD; Gail J. Povar, MD; James A. Tulsky, MD; Alan L. Gordon, MD; Siang Y. Tan, MD; Vincent Herrin, MD; and Lee J. Dunn Jr., LLM.

Acknowledgments: The author thanks Cheryl Adamick for secretarial support.

Grant Support: By National Institutes of Health grant CA66818-05, the Project on Death in America, the Robert Wood Johnson Foundation, and the Nathan Cummings Foundation. The Greenwall Foundation provided support to the End-of-Life Care Consensus Panel.

Requests for Reprints: Lois Snyder, JD, Center for Ethics and Professionalism, American College of Physicians-American Society of Internal Medicine, 190 North Independence Mall West, Philadelphia, PA 19106.

Current Author Address: Susan D. Block, MD, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115.

Ann Intern Med. 2000;132(3):209-218. doi:10.7326/0003-4819-132-3-200002010-00007
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Psychological distress often causes suffering in terminally ill patients and their families and poses challenges in diagnosis and treatment. Increased attention to diagnosis and treatment of depression can improve the coping mechanisms of patients and families. This paper reviews the clinical characteristics of normal grief and clinical depression and explains strategies for differential diagnosis.

Although some literature discusses the psychological issues facing elderly patients and terminally ill patients with cancer, less is known about patients with end-stage pulmonary, cardiac, renal, and neurologic disease. Data on the effectiveness of interventions in terminally ill patients are lacking. Treatment recommendations in this paper represent extrapolations from existing literature and expert opinion.

Diagnosing and treating depression in terminally ill patients involve unique challenges. Evidence of hopelessness, helplessness, worthlessness, guilt, and suicidal ideation are better indicators of depression in this context than neurovegetative symptoms. Although terminally ill patients often have suicidal thoughts, they are usually fleeting. Sustained suicidal ideation should prompt a comprehensive evaluation.

Clinicians should have a low threshold for treating depression in terminally ill patients. Psychostimulants, because of their rapid onset of action, are useful agents and are generally well tolerated. Selective serotonin reuptake inhibitors and tricyclic antidepressants may also be used. Psychological interventions—including eliciting concerns and conveying the potential for connection, meaning, reconciliation, and closure in the dying process—can also facilitate coping.





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