Terminal cancer care should do more to treat depression

Depression could be clouding the last 24 hours of life for a significant number of people with advanced cancer, pointing to a need for better – and earlier - psychological help, according to a large study from Norway.

Although it’s challenging to tease apart depression symptoms from the pain, fatigue and cognitive problems associated with end-stage cancer, more can be done to alleviate depression and anxiety, researchers said.

“Health care providers may think this is a normal part of the dying process,” said lead author Dr. Elene Janberidze from the European Palliative Care Research Center at the Norwegian University of Science and Technology in Trondheim.

“However, some patients experiencing depressive symptoms and/or depression can be treated and thus both the patients and their families may have a better quality of life,” Janberidze told Reuters Health in an email.

Previous studies have estimated the rates of depression in patients with advanced cancer at anywhere from 2 percent to 56 percent, she and her colleagues write in the journal BMJ Supportive and Palliative Care.

Janberidze said that her team chose to focus on patients in their last 24 hours of life because this group had not been well investigated.

They used data from a 2005 nationwide survey of doctors who had signed the death certificates of patients that died within the past two months. The researchers examined data on 1,363 cancer patients during their last 24 hours of life, assessing the symptoms reported by their attending physicians and rating their level of depression.

After accounting for symptoms of the individuals’ illness, the researchers found that overall 37 percent of patients were depressed. More women than men were severely or very severely depressed, and patients aged 17 to 65 were more likely to be moderately depressed than those 80 years or older.

Geriatricians were four times more likely than other doctors to assess their patients as seriously or severely depressed. Pain specialists, palliative care consultants, psychiatrists and psychologists were also more often tending to patients with symptoms of serious depression than to those with mild or moderate depression.

Mild or moderately depressed patients were more likely to feel tired, anxious and confused than those without depression symptoms. Individuals who were severely or very severely depressed also tended to feel anxious.

Holly Prigerson, who directs the Center for Research on End-of-Life Care at Cornell University, said she admired the authors for trying to gauge depression in cancer patients who were so close to death.

“The study is novel in that it evaluates retrospectively the depressive symptom severity of patients within 24 hours of death,” Prigerson said in an e-mail to Reuters Health. “I’m unaware of any other study that has attempted this."

But Prigerson also noted some of the study’s limitations, such as trying to assess patients who could be unconscious or delirious, have multiple organ failure and difficulty communicating their emotions.

Physicians also need to distinguish physical and psychological symptoms and might not always have enough information on a patient’s psychological state when they are dying or might not have enough training to diagnose their “psychological distress,” she said.

“It is also difficult to draw conclusions regarding the clinical implications of the study,” Prigerson said. “Given patients are actively dying, it is doubtful that a psychosocial intervention or administration of an antidepressant will effectively improve the patients’ quality of death.

“Psychosocial interventions and care in the months and weeks leading up to the death can have a profound impact on patients’ quality of life prior to death, however,” Prigerson said.

Janberidze said doctors should be checking cancer patients for physical and psychological pain and integrating palliative care with their cancer management earlier in their disease. She also said family members could help monitor the patient’s pain.

“In general it is important for family members with loved ones who have advanced stage cancer to pay attention to the signs and symptoms of depression and inform healthcare providers immediately. Doctors should investigate the patient further and recommend psychological interventions as needed,” Janberidze said.