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Research ArticleOriginal Research

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

Franca Warmenhoven, Eric van Rijswijk, Elise van Hoogstraten, Karel van Spaendonck, Peter Lucassen, Judith Prins, Kris Vissers and Chris van Weel
The Annals of Family Medicine July 2012, 10 (4) 330-336; DOI: https://doi.org/10.1370/afm.1373
Franca Warmenhoven
MD
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  • For correspondence: f.warmenhoven@anes.umcn.nl
Eric van Rijswijk
PhD
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Elise van Hoogstraten
MD
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Karel van Spaendonck
PhD
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Peter Lucassen
PhD
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Judith Prins
PhD
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Kris Vissers
MD, PhD
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Chris van Weel
MD, PhD
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  • Re:The patient within the model of care
    Mieke Vermandere
    Published on: 09 August 2012
  • The patient within the model of care
    Franca Warmenhoven
    Published on: 03 August 2012
  • Are physicians so careful not to treat "sadness" that they ignore the symptoms of depression ?
    Mari Lloyd-Williams
    Published on: 28 July 2012
  • Depression and Spiritual Distress at the end of life
    Scott A Murray
    Published on: 26 July 2012
  • Re:How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
    Roderick D MacLeod
    Published on: 25 July 2012
  • Published on: (9 August 2012)
    Page navigation anchor for Re:The patient within the model of care
    Re:The patient within the model of care
    • Mieke Vermandere, Research fellow, GP

    Dear authors,

    Congratulations with this valuable piece of qualitative research, which explores the twilight zone between 'normal' and 'abnormal' sadness in palliative patients. As my colleague Scott Murray properly noticed, I would also like to add some insights from a spiritual point of view. Victor Frankl introduced the term "noogenic neurosis" in 1979, as a mental illness rooted in a basic lack of meaning in...

    Show More

    Dear authors,

    Congratulations with this valuable piece of qualitative research, which explores the twilight zone between 'normal' and 'abnormal' sadness in palliative patients. As my colleague Scott Murray properly noticed, I would also like to add some insights from a spiritual point of view. Victor Frankl introduced the term "noogenic neurosis" in 1979, as a mental illness rooted in a basic lack of meaning in one's life. (1) By doing this, he was a pioneer in describing "spiritual distress", as we call it nowadays. (2) The Dutch guideline for spiritual care in palliative care takes it even further, and uses the term "spiritual crisis". (3) Their description of a spiritual crisis is very interesting in the light of this study: "Sometimes the spiritual process goes less natural because the confrontation with the end of life becomes that forceful, that a patient experiences fear or panic attacks, or symptoms of depression. [...] Feelings of fear, panic, impotence, and loss of meaning are characteristic for this crisis." (3)

    I will not decide on the difference between a depression and a spiritual crisis, but I believe that their genesis may be very similar, and I would like to illustrate this with a metaphor. Every human being carries a balance inside, with his/her inner resources on one side, and his/her spiritual distress on the other side. It is the unconscious reflex of everyone to keep that balance on an even keel: e.g. when we feel distressed because of the loss of a loved one (more spiritual distress), we try to strengthen our inner resources by calling a friend, by making a long walk at the seaside, by prayer, etc. Throughout life, we mostly manage to keep that balance on an even keel. However, at the end of life, the spiritual distress may be that heavy, that the balance inclines on this side. The patient doesn't find enough inner resources, and experiences spiritual distress or a clinical depression.

    This may seem a bit simplistic, but I think it's worthwhile considering it as a point of view from which prevention, diagnosis, and treatment of depression/spiritual crisis at the end of life can be seen. In prevention, care givers should encourage palliative patients to strengthen their inner resources, and to use them. In diagnosis, we should not only assess the stressors, but also the inner resources of our patients. And finally, I believe that treatment should not only focus on managing the depressive symptoms, but also, and perhaps even more, on strengthening our patients' resources, e.g. by music, by art, by meditation or prayer, by the proximity of loved ones, ... I look forward to discuss this further. I wish Franca and her colleagues all the best for their future research projects!

    Mieke Vermandere

    References:

    (1) Frankl, V.E. (1979) Der Mensch vor der Frage nach dem Sinn. M?nchen: Piper Verlag.

    (2) Puchalski C, Ferrell B, Virani R et al. Improving the quality of spiritual care as a dimension of palliative care: the report of the consensus conference. J Palliat Med 2009;12(10):885-904.

    (3) Leget C, Staps T, van de Geer J, Mur-Arnoldi C, Wulp M, Jochemsen H. Spirituele Zorg. Landelijke Richtlijn: Versie: 1.0. 2010.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (3 August 2012)
    Page navigation anchor for The patient within the model of care
    The patient within the model of care
    • Franca Warmenhoven, M.D.

    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 ind...

    Show More

    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

    Show Less
    Competing Interests: None declared.
  • Published on: (28 July 2012)
    Page navigation anchor for Are physicians so careful not to treat "sadness" that they ignore the symptoms of depression ?
    Are physicians so careful not to treat "sadness" that they ignore the symptoms of depression ?
    • Mari Lloyd-Williams, Professor and Director of Academic Palliative and Supportive Care

    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 b...

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    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

    Show Less
    Competing Interests: None declared.
  • Published on: (26 July 2012)
    Page navigation anchor for Depression and Spiritual Distress at the end of life
    Depression and Spiritual Distress at the end of life
    • Scott A Murray, St. Columba's Hospice Professor Primary Care

    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...

    Show More

    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

    Show Less
    Competing Interests: None declared.
  • Published on: (25 July 2012)
    Page navigation anchor for Re:How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
    Re:How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
    • Roderick D MacLeod, Professor

    I congratulate the authors of this study on bringing light to a sometime murky area. The study is significant on many counts. Firstly, it is an acknowledgment of the challenges of diagnosing depression in people near the end of life. The literature has many examples of the confusion which can surround this area and some clarity is provided here. Secondly, and perhaps most importantly, the paper emphasises the key role of...

    Show More

    I congratulate the authors of this study on bringing light to a sometime murky area. The study is significant on many counts. Firstly, it is an acknowledgment of the challenges of diagnosing depression in people near the end of life. The literature has many examples of the confusion which can surround this area and some clarity is provided here. Secondly, and perhaps most importantly, the paper emphasises the key role of family physicians in recognising and managing depression in this group of vulnerable people. Knowing a person is a key element of any medical practice but is of vital importance in primary care. Palliative care physicians rely on family physicians to provide backgound information on not just physical but also psychological, social, and spiritual apsects of a person's health and illness. Relying on 'cumulative knowledge' is vital and helps all who are tasked with the care of people approaching death. This is an encouraging paper that should be offered to all who are training to be family physicians to help them understand one of many key roles in this essential part of the multidisciplinary team of care at the end of life.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
Franca Warmenhoven, Eric van Rijswijk, Elise van Hoogstraten, Karel van Spaendonck, Peter Lucassen, Judith Prins, Kris Vissers, Chris van Weel
The Annals of Family Medicine Jul 2012, 10 (4) 330-336; DOI: 10.1370/afm.1373

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How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients
Franca Warmenhoven, Eric van Rijswijk, Elise van Hoogstraten, Karel van Spaendonck, Peter Lucassen, Judith Prins, Kris Vissers, Chris van Weel
The Annals of Family Medicine Jul 2012, 10 (4) 330-336; DOI: 10.1370/afm.1373
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