DEPRESSION

«  Sadness is natural in dying patients.

Reactive depression often responds to good symptom control and improved family communications. Endogenous depression is not common, and can be difficult to diagnose in terminally ill patients. The usual indicators of depression (disturbed sleep, anorexia, weariness, constipation, reduced libido, emotional lability) are also seen in advanced illness.

The best clues to true depression are:

• Past history of depression

• Expressionless face (unable to greet family)

• Unable to enjoy favorite things

• Low self-esteem

• Persistent guilty feelings

• Delusions (“My cancer is contagious.”)

Comments about suicide are not necessarily depressive. They may be the patient’s way of saying "I want to stay in control", or "I want you to understand what I am going through." Chronic pain for months on end (associated particularly with carcinomas of the rectum and tail of the pancreas) can cause depression.

Anti-depressants usually take 2 to 3 weeks to take effect, although a response can occur in 7 to 10 days. They should be started at low dosage and increased quickly to a maximum tolerated dose (usually the dry mouth is the limiting factor). Even in very ill patients large doses can be well tolerated, and it is important to use as high a dose as possible. In frail elderly patients tricyclics may cause confusion. 20% of patients will not respond to tricyclics. Amitriptyline 25mg to 150mg at bedtime also has sedative properties. Imipramine 25mg to 150mg at bedtime is less sedating. (see Anti-depressants)

A useful guide to the speed of increase in daily doses is:

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.