How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients

We would like to thank the readers for their positive comments on our article. There seems to be agreement on the importance of using a holistic model of palliative care to address the different dimensions of physical, psychological, social and spiritual care. Within this model, however, there is still the individual patient to attend to. Whatever dimension we are addressing, a key element seems to be to connect to the individual patient and his or her context. This is essential in the communal process that we go through together with our patient, navigating through the complexity of physical, psychological, social and spiritual issues that can all be interrelated. The model of different dimensions of palliative care can be our nautical chart, and a very helpful one, but the actual sailing we have to do together with our patient. The same may be true when addressing symptoms of depression in a palliative care context. Some of the FPs in our study explicitly reported using models, guidelines and screening tools for depression. They also recognize however that these instruments are limited when it comes to making an assessment in the individual context of the patient. Sometimes they feel it is appropriate, based on their 'cumulative knowledge' and their actual connection with the patient, to classify symptoms of mood as 'normal sadness' (for which they will also provide care and attention). Assessing depression in palliative care remains a challenge, but being aware of the available models and screening tools and interpret them in the context of the individual patient may do justice to the high-quality patient-centered care that we are aiming for. Finally, working in a multidisciplinary team, in which each professional brings his expertise, it is important that we communicate about the way we navigate as a team, together with the patient. If we all can bring our expertise and orient our care as a team within the context of the individual, the patient might benefit the most. The challenge of health care and health care education is to allow models, protocols and frameworks to help us orient theoretically and, when bringing this knowledge into the context of the patient, to remain aware that the patient is the true reference point of our care.

Competing interests:   None declared

Dear Editors

I read with interest the interesting paper by Warmenhoven and colleagues of their qualitative study of 22 family physicians exploring issues in diagnosis and assessment of depression in palliative care patients. The authors state that the difficulties perceived by family physicians in their study may reflect the relative lack of training in palliative care and possible lack of co-ordinated care between family physicians and family physicians working in the Netherlands. Warmenhoven's findings however are very similar to a study carried out of UK senior Palliative care Physicians some ten years ago (1) which also reported difficulties with the assessment and on distinguishing symptoms of depression from sadness and whether it was appropriate to treat patients when life expectancy was short. Interestingly this study also identified difficulties in accessing psychosocial support and particularly psychiatric input. It appears that the issues of assessment and management of depression in palliative care patients are perennial , common, multi-national and across all specialities. The very essence of palliative care is to provide a team based holistic model of care with equal attention being paid to the psychological, social , spiritual and physical components of distress and suffering. Whilst all would acknowledge that sadness as death approaches is inevitable, depression is not universal in palliative care patients. Are we in danger as physicians of being so careful not to treat "sadness " in patients approaching death ,that we shy away and sometimes ignore the symptoms of depression ? Depression in palliative care patients requires the same assessment , management and collaborative care approach as any other patient family physician would treat. The recently published European Collaborative guidelines (2) already provide many of the recommendations made in the conclusions of this paper . Validated brief patient-friendly psychometric tools are available (3) and if incorporated into clinical practice can guide the family physician as to which patients are " appropriately sad" and which patients are exhibiting symptoms of depression . The guidelines also include the management of depression. Good palliative care seeks to care for the patient holistically - a true holistic approach addresses all symptoms the patient may exhibit . As physicians we only serve to increase the sense of total isolation and abandonment that many depressed patients feel, if we do not feel comfortable or have the confidence to assess and manage depression effectively in our palliative care patients .

References

1) Lawrie I, Lloyd-Williams M, Taylor F How do palliative medicine physicians assess and manage depression. Palliat Med. 2004 Apr;18(3):234-8

2) Rayner L, Price A, Hotopf M, Higginson IJ The development of evidence -based European guidelines on the management of depression in palliative cancer care. Eur J Cancer. 2011 Mar;47(5):702-12.

3) Lloyd-Williams M, Shiels C, Dowrick C. The development of the Brief Edinburgh Depression Scale (BEDS) to screen for depression in patients with advanced cancer. J Affect Disord. 2007 Apr;99(1-3):259-64..

Competing interests:   None declared

This excellent paper from Holland focuses on the role of general practitioners in diagnosing and managing depression in patients with palliative care needs. (1) It rightly highlights the difficulty of differentiating between normal sadness and clinical depression. However, I was surprised that no reference was made in this article to existential or spiritual distress that palliative care patients may suffer at the end of life, and which can sometimes be difficult to differentiate from depression. It is recognised in palliative care that people who face life-threatening illnesses have four dimensions of need: physical, psychological, social and spiritual. To discuss depression without acknowledging that there is a great overlap between depression and existential distress at the end of life is not complying with the holistic paradigm that is palliative care, and indeed family medicine. Research in Scotland has shown that it is possible to differentiate and characterise psychological and existential distress at the end of life in people with cancer and non-malignant disease.(2) We have also found that just as family physicians can help depressed people at the end of life, they can also help people who have existential distress at the end of life by simply being with them and witnessing their distress.(3) I look forward to further holistic research taking forward these key areas of psychological and spiritual distress together.

Scott A Murray

1. Warmenhoven F, van Rijswijk E, van Hoogstraten E, van Spaendonck K, Lucassen P, Prins J, et al. How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients. The Annals of Family Medicine. 2012 July/August 2012;10(4):330-6.

2. Murray SA, Kendall M, Grant E, Boyd K, Barclay S, Sheikh A. Patterns of Social, Psychological, and Spiritual Decline Toward the End of Life in Lung Cancer and Heart Failure. Journal of Pain and Symptom Management. 2007;34(4):393-402.

3. Murray SA, Kendall M, Boyd K, Worth A, Benton TF. General practitioners and their possible role in providing spiritual care: a qualitative study. The British journal of general practice : the journal of the Royal College of General Practitioners. 2003;53(497):957-9.

Competing interests:   None declared