Depression, Anxiety, and Delirium in the Terminally Ill Patient

Abstract

Learning objectives: 1. Identify depression, anxiety, and delirium near the end of life. 2. Describe management plans for depression, anxiety, and delirium near the end of life. I n this article, I discuss depression, anxiety, and delirium in the context of terminal illness. These highly prevalent disorders are frequently underdiagnosed in this setting. The failure to diagnose and treat them may subsequently prevent "quality dying." Death is not a good thing, to say the least, but sooner or later it comes to us all; when it comes to our patients, we need to do a better job of providing the highest quality of care. Provision of a "good death" is one of the major goals of the Educating Physicians on End-of-Life Care (EPEC) curriculum and is perceived as more and more important by the public and the medical community. Although many physicians are comfortable dealing with depression and anxiety in a routine ambulatory setting, the context of a terminal illness requires different approaches to assessment and management of these disorders, as shown in the following summary of a patient encounter. CASE STUDY A 35-year-old man with AIDS met with his primary care physician. She shared with him the results of his blood tests, which revealed a high viral load. This didn't surprise the patient; he indicated that he had been both tired and anorexic (neither of which would be surprising in a patient with a serious illness like AIDS). His partner was present during the office visit and added that the patient had just been lying around in his paja-mas, didn't seem to be interested in anything, and wasn't taking his medications on schedule. "What's the point?" the patient asked. He said that he didn't care anymore, that he was going to die regardless of what he did. Through further questioning, the physician then determined that he had sadness, loss of energy, sleep disturbance, and recurrent thoughts about death. The patient said that although he had been thinking about death, he hadn't seriously contemplated suicide. On the basis of this discussion , the physician told the patient that it wasn't entirely the HIV making him feel this way, but clinical depression was also likely playing a major role. She encouraged him to take some antidepressant medications so that he could be back to his old self again-the person who wanted to fight the HIV disease. The patient agreed to give the medications a try. Teasing apart the symptoms of depression from the symptoms of terminal disease can be difficult. This encounter could have been much less effective if the physician had not considered that many of the patient's physical symptoms-impaired sleep, lack of appetite, lack of energy-might be signs of depression. When those symptoms were combined with psychological symptoms such as lack of motivation, isolation, sadness, and suicidal ide-ation, depression became the most likely cause of the patient's decline. In this case, the patient's viral load was rising because he wasn't taking his medicine, and he wasn't taking his medicine because he was depressed. Treating the depression became an essential part of caring for this patient. DEPRESSION The medical literature suggests that the incidence of major depression in terminally ill patients ranges from 25% to 77%. Depression is both associated with intense suffering and a cause of intense suffering. Yet, it is not inevitable. It is treatable in many cases, and early treatment is more effective than late treatment. Early treatment is, of course, dependent on early recognition of the problem; all too often, physicians wait until the last weeks of a dying patient's life to decide to address the depression. By this point, it is generally too late.