From: Caring for depression in the dying is complex and challenging – survey of palliative physicians
DOMAINS/SUBCATEGORIES | PREVALENCE OF REPORTING OF SUBCATEGORIES AMONG RESPONDENTS (N = 66) (%) | EXAMPLE QUOTES |
---|---|---|
Patient - frailty, co-existing symptom burden and competing priorities of associated end-of-life issues when time for intervention effects is poor | ||
• Frailty, Burden & Intolerance* | 71.2% | • “Fatigue, nausea, pain” (Participant 72) and “declining cognition” (Participant 27) • “Even when good psychology, psychiatry and/or pastoral care are available these patients are often too fatigued to participate in talking therapies” (Participant 25) • “Lack of effective medication which will make a difference without causing unnecessary side effects” (Participant 6) |
• Therapeutic Efficacy - Lack of therapeutic options that are rapidly effective in the context of very poor prognoses* | 77.3% | • “Time frame required for effect of pharmacologic and non pharmacologic interventions” (Participant 5) • “Timing and the poor prognosis which impedes any intervention to be effective.” (Participant 2) |
• Competing priorities - Prioritisation of physical or other psychosocial & spiritual co-existing issues, symptoms or goals | 21.2% | • “Competing priorities - physical symptoms and planning for end-of-life are often more pressing “(Participant 25) • “Other symptoms take priority and are focused on much more than mood disorders” (Participant 44) |
Clinician - self-perceived limitations in psychiatry skills in the palliative care setting with incompetence in diagnostic differentiation | ||
Challenging diagnostic differentiation | ||
o Depression vs terminal illness symptoms* | 53.0% | • “Challenges differentiating somatic symptoms from depression vs physical illness” (Participant 5) • “Usually hard to teese out how much is depression and how much is part of dying process” (Participant 13) |
o Between depressed-mood syndromes or differentials (e.g. existential distress, demoralisation, adjustment disorder, organic brain syndrome) | 19.7% | • “Challenges differentiating demoralisation from major depression” (Participant 5) • “Distinguishing between adjustment and depression” (Participant 8) • “Misattribution – e.g. depression with psychotic symptoms being attributed to delirium” (Participant 4) |
o Normal vs Pathological | 16.7% | • “Hard to distinguish from normal grief” (Participant 19) • “Difficulty assessing the difference between normal reactive mood changes [versus] pathological level of mood changes” (Participant 68) |
• Limited Skills & Training | 24.2% | • “Limited skills in psychiatric assessment - my last psychiatry placement was as a 3rd year medical student” (Participant 60) • “Limited knowledge of what works to improve mood in limited time frame” (Participant 41) |
System – Inadequate health system resources and access to required interventions in the local health services | ||
• Suboptimal access and delivery of palliative care and mental health services | 37.9% | • “High patient numbers for a small number of clinicians; Lack of allied health staff in [palliative care] MDT to deliver interventions” (Participant 31) • “Poor access to psychology/psychiatric services” (Participant 44) |
• Lack of access to desired depression interventions | 13.6% | • “Lack of access to resources for non-pharmacological management e.g. psychology, music therapy” (Participant 71) • “Access to rapid-acting medications like modafinil” (Participant 42) |
• External Environment | 1.5% | • “[Lack of] control of clinical envirmnment” (Participant 31) |
• Language & Cultural issues | 1.5% | • “Language / cultural barriers” (Participant 64) |
Literature - Heterogeneity of depression concept and the lack of evidence to guide practice in the very poor prognosis setting | ||
• Lack of evidence & guidelines | 15.2% | • “Uncertainty regarding the best treatment for this population/limited evidence base” (Participant 56) |
• Heterogeneity of the concept and definition of depression in very poor prognosis setting | 1.5% | • “Lack of defined criteria for diagnosis of depression in this group of patients” (Participant 48) |
Society – Unsupportive attitudes and beliefs of patients, family and clinicians that prevents optimisation of depression care | ||
• Nihilism / Futility | 10.6% | • “A sense of futility - Why assess it if there’s little I can do about it? “(Participant 25) • “Therapeutic nihilism” (Participant 21) |
• Acceptance / Normalisation | 12.1% | • “Acceptance that this [depression] is a normal part of end of life” (Participant 21) • “Normalisation” (Participant 40) • “Of course he/she is depressed, he/she is dying” (Participant 4) |
• Resistance / Disinclination of patients, public, family or clinicians/staff | 4.5% | • “Stigma” (Participant 65) • “Pressure from other health care professionals not to treat patients as they are dying” (Participant 34) • “Family not willing to engage non-pharm [interventions]” (Participant 64) |