People with terminal illnesses tend to be prone to anxiety and depression. After examining 46 studies on the topic, Gotopf and co-authors found that about 15% of patients with advanced stages of cancer suffer from major depressive disorder diagnosed by psychiatrists. At the same time, according to estimates of the incidence of depression on the Hospital Anxiety and Depression Scale (HADS), the average prevalence of severe depression in the last stage of cancer is 29%.
Treating depression is important not only because depression increases the patient’s mental distress,
but also because it aggravates pain and other symptoms. Studies in Canada, Australia and the United Kingdom show that these countries have a lower percentage of patients with fatal illnesses who suffer from anxiety and depression. Given the limited life expectancy of patients with incurable diseases, it is important to identify depression early, as it reduces the patient’s quality of life and worsens symptoms. In addition, depression treatment takes time to be effective.
So how can you help a patient suffering from anxiety and depression?
The causes of depression and anxiety can be different.
The causes of anxiety and depression can be normal and understandable, or they can be pathological. Anxiety and depression can be associated with an incurable illness of the patient or with one of the aspects that are also directly related to the disease. On the other hand, they may have nothing to do with cancer at all.
If the patient has ever had symptoms of depression, one should inquire about the previous
treatment, whether it was effective, and what, in the patient’s opinion, may be effective this time.
Depression and anxiety can be associated with difficulties in relationships with other people, or it is a personality trait of the patient, or a recurrent mental problem. Perhaps the patient is more sad than depressed, he gets used to the idea that he has an incurable disease and that his life will be shorter than he imagined.
The only way to find out the cause is to talk to the patient. Knowing the cause of anxiety and depression can help guide appropriate treatment.
We need to talk to the patient first, and then perhaps to his family and friends. We need to understand how the patient is feeling and why he is feeling it. This will allow us to find out if he suffers from depression and anxiety or not. The only way to identify these disorders is to screen for depression at the first screening and use the following questions as screening tools: “Are you feeling depressed?” or “Do you feel interested in your daily activities?”
“Communication is only part of the problem.”Doctor Anna Sonkina on how to teach doctors to communicate with patients on an equal footing and convince an anti-vaccine to deliver a vaccine
If you think that anxiety and depression may be present, ask the patient some or all of the
following questions: How did the anxiety and depression begin? was there any event that triggered this? what are the facilitating and exacerbating factors? how does the patient sleep? are there any significant physical symptoms? Has the patient previously had depression and anxiety? does his family support him? perhaps someone died recently in the family? Does the patient believe in God? if so, how and how much does it help him?
Treatment for anxiety and depression
1. To begin with, we must turn to factors that can be leveled: pain, insomnia and difficulties in communication.
2. We need to support the patient emotionally and give him time to cope with the sadness. We
need to find out what is behind his anxiety and help sort out the reasons.
3. Consideration should also be given to non-drug treatment. In the case of an anxiety disorder, this can include relaxation techniques and meditation. For depression, this can include psychological counseling, cognitive behavioral therapy, and self-help books.
4. Drug therapy.
Treatment for anxiety
First-line drugs are symptomatic treatment, for example, beta-blockers, if this is not enough, then you need to add SSRIs, if that is not enough, you can try benzodiazepines.
Treatment for depression
SSRIs, mirtazepine, and tricyclic antidepressants can help, but we must remember ourselves and warn the patient and family members that the effects of these drugs are not immediate. After 2 weeks, the dose of the antidepressant will need to be adjusted if the effect is insufficient, and after 4 weeks, a second drug may need to be added.
5. If the patient does not improve, or is suicidal, or responded poorly to therapy in a previous episode of depression, psychiatric advice should be sought.
Some features of dosage and interaction with other antidepressant drugs when prescribing them to patients with incurable diseases
At a late stage of an incurable disease, especially in elderly patients who are losing weight, with multiple organ failure, the recommended doses of drugs should be reduced, and possibly even discontinued, since there is a high risk of side effects.
With incurable diseases, especially in old age and when the patient is losing weight, his organs do not work as well as before, and the dose of medication must be reduced. If side effects appear, the medication should be stopped if possible.
The five stages of experiencing illnessHow to support a loved one with cancer and help him cope with experiences
A hospice patient in his 70s is depressed and does not sleep well. After talking with him, the doctor recommended taking antidepressants. Unfortunately, the doctor started with the normal adult dose of amitriptyline – 75 mg at bedtime – and the patient soon became disoriented and drowsy. The next day, the head of the department conducted an examination. On his recommendation, the patient did not take this drug at all for several days, and then resumed taking it at very low doses. He did not have any side effects, and after about a week, his sleep improved, he felt an improvement in his mood.
It should be remembered that antidepressants and phenothiazine major tranquilizers interact poorly, sometimes very seriously, with tramadol and cause serotonin intoxication, which can be fatal.
Once we have assessed the patient’s condition and mapped out a treatment regimen, we need to draw up a treatment plan with the patient.
It is necessary to discuss with the patient:
1) our impression of his symptoms of anxiety and depression;
2) treatment options. You should listen to the patient’s opinion, find out his fears and doubts about the treatment. Draw up a treatment plan together. Set a date for the next inspection to assess if the scheme is working; if not, start over.
Such an approach, when we first of all discuss everything with the patient and carefully listen to his opinion, asserts his autonomy, focuses on the fact that the patient always has a choice, and even if he poses a danger to himself or others, we cannot insist so that he sticks to what we think is most appropriate in the given situation. The doctor and patient should discuss and agree on treatment.
Refractory depression and anxiety
Depressive disorders and anxiety cause mental and physical distress. Treating a patient with the methods described above can alleviate his condition. However, some types of depression and anxiety cannot be treated by either a general practitioner or a psychiatrist.
If the patient has a long-term life prognosis – from several months to several years – it is necessary to continue treatment for depression, as we would do with a healthy person, seeking advice from a specialist psychiatrist.
However, if the patient’s condition does not offer hope for a long life prognosis and further interventions will only exacerbate suffering, depression, and anxiety, it may be worth discussing sedation as a way to combat psychological discomfort. The regimen may include sedation for a short period (for a couple of days) or episodes of sedation throughout the day. For example: sleeping in the morning and waking up for dinner, sleeping in the afternoon, waking up in the evening for the arrival of family members. The patient may prefer drug sedation to persistent anxiety.
If you have opted for sedation, it is important to discuss all issues with the patient and colleagues, as this
period is always ethically and emotionally difficult for everyone.
If a decision is made to use sedatives, the patient’s approval must be obtained and the strategy must be explained to the family. Some patients decide to say their last words to relatives before falling asleep.
Depression and anxiety can be difficult to cope with, but dealing with these symptoms
can help the patient and their family. You will improve the quality of his life in the last days, and therefore, soften memories and help relatives cope with the loss.
1. Hotopf M. et al. Depression in advanced disease: a systematic review. Part 1. Prevalence and case finding // Palliative Medicine. 2002. Vol. 16.P. 81–97.
2. Rayner et al. Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis // Palliative Medicine. 2011. Vol. 25 (1). R. 36-51.
3. Wilson KG et al. Depression and anxiety disorders in palliative cancer care // Pain Symptom Management. 2007. Feb. Vol. 33 (2). R. 118-129.
4. O’Connor M. et al. The prevalence of anxiety and depression in palliative care patients with cancer in Western Australia and New South Wales // Medical Journal of Australia. 2010. Sep. Vol. 6. No. 193 (5 Suppl). R. 44–47.
5. Mitchell.AJ et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies – Lancet – Published Online. 2011.19 Jan.