Depression and anxiety

These are broad terms that cover a continuum of emotional states. It is not always possible on the basis of a single interview to distinguish self limiting distress, which forms a natural part of the adjustment process, from the psychiatric syndromes of depressive illness and anxiety state, which need specific treatment. Borderline cases are common, and both the somatic and psychological symptoms of depression and anxiety can make diagnosis difficult.

Somatic symptoms—Depression may manifest itself as intractable pain, while anxiety can manifest itself as nausea or dyspnoea. Such symptoms may seem disproportionate to the medical pathology and respond poorly to medical treatments.

Psychological symptoms—Although these might seem understandable, they differ in severity, duration, and quality from “normal” distress. Depressed patients seem to loathe themselves, over and above loathing their disease. A useful analogy is that the patient who is sad blames the illness for how they feel, whereas a patient who is depressed blames themselves for their illness. This expresses itself through guilt about being ill and a burden to others, pervasive loss of interest and pleasure, and hopelessness about the future. Attempted suicide or requests for euthanasia, however rational they might seem, invariably indicate clinical depression. It is important that such thoughts are elicited—for example, by asking “have you ever felt so bad that you wanted to harm or kill yourself?”

Confusion

This may present as forgetfulness, disorientation in time and place, and changes in mood or behaviour. The two main clinical syndromes are dementia (chronic brain syndrome), which is usually permanent, and delirium (acute brain syndrome), which is potentially reversible.

Delirium, which is more relevant to palliative care, comprises clouding of consciousness with various other abnormalities of mental function from an organic cause. Severity often fluctuates, worsening at night. Dehydration, neglect of personal hygiene, and accidental self injury may hasten physical and mental decline. Noisy, demanding, or aggressive behaviour may upset or harm other people. So called “terminal anguish” is a combination of delirium and overwhelming anxiety in the last few days of life. A physical cause usually contributes to “terminal anguish.”

Various misconceptions about psychiatric disorders in medical patients contribute to their widespread under-recognition and undertreatment. Education and training in communication skills, for both patients and staff, could help to remedy this.

Standardised screening instruments that have been validated for use in palliative care patients include the Edinburgh depression scale and the minimental state (MMS) or mental status schedule (MSS) for cognitive impairment. Though not sensitive or specific enough to substitute for assessment by interview, they can help to detect unsuspected cases, contribute to diagnostic assessment of probable cases, and provide a baseline for monitoring progress.

Knowledge of previous personality and psychological state is helpful in identifying high risk patients or those with evolving symptoms, and relatives’ observations of any recent change should be obtained.

General guidelines for both prevention and management include providing an explanation about the illness in the context of ongoing supportive relationships with known and trusted professionals. Patients should have the opportunity to express their feelings without fear of censure or abandonment. This facilitates the process of adjustment, helping patients to move on towards accepting their situation and making the most of their remaining life.

Visits from a specialist palliative care nurse or attendance at a palliative care day centre, combined with follow-up by the primary healthcare team, often benefit both patients and families. An opportunity to explore and express spiritual concerns is often helpful for all those patients, including those with no specific religious belief. Psychiatric referral is indicated when emotional disturbances are severe, atypical, or resistant to treatment; when there is concern about suicide; and on the rare occasions when compulsory measures under the Mental Health Act 1983 seem to be indicated.

Non-pharmacological therapies increase a patient’s sense of participation and control. Usually delivered in regular planned sessions, they can also help in acute situations—for example, deep breathing, relaxation techniques, or massage for acute anxiety or panic attacks.