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

Abstract

PURPOSE Depression is highly prevalent in palliative care patients. In clinical practice, there is concern about both insuffi cient and excessive diagnosis and treatment of depression. In the Netherlands, family physicians have a central role in delivering palliative care. We explored variation in family physicians' opinions regarding the recognition, diagnosis, and management of depression in palliative care patients. METHODSWe conducted a focus group study in a sample of family physicians with varied practice locations and varying expertise in palliative care. Transcripts were analyzed independently by 2 researchers using constant comparative analysis in ATLAS.ti. RESULTSIn 4 focus group discussions with 22 family physicians, the physicians described the diagnostic and therapeutic process for depression in palliative care patients as a continuous and overlapping process. Differentiating between normal and abnormal sadness was viewed as challenging. The physicians did not strictly apply criteria of depressive disorder but rather relied on their clinical judgment and strongly considered patients' context and background factors. They indicated that managing depression in palliative care patients is mainly supportive and nonspecifi c. Antidepressant drugs were seldom prescribed. The physicians described diffi culties in diagnosing and treating depression in palliative care, and gave suggestions to improve management of depression in palliative care patients in primary care.CONCLUSIONS Family physicians perceive the diagnosis and management of depression in palliative care patients as challenging. They rely on open communication and a long-standing physician-patient relationship in which the patient's context is of great importance. This approach fi ts with the patient-centered care that is promoted in primary care. INTRODUCTIONM ood disturbances are common in palliative care patients. When confronted with a patient on a palliative trajectory who reports feeling sad, it can be challenging to differentiate depression from normal sadness. The prevalence of major depression and adjustment disorder in patients with advanced cancer is 6.7% and 16.3%, respectively.1 Depression in palliative care is associated with poor treatment adherence, increased diffi culties in relieving physical symptoms, disability, poor prognosis, higher mortality, longer inpatient stays, and elevated health care costs. [2][3][4][5][6] Consequently, recognition, diagnosis, and treatment of depression are important. Health care professionals face the dilemma that active screening for and treatment of mood symptoms are encouraged, but may lead to overtreatment and medicalization of normal sadness. [7][8][9] In palliative care, this 10,11 Family physicians fi nd it diffi cult to achieve balance between supporting and empowering patients with depressive symptoms, and actively treating patients with a depressive disorder. 9,12,13 This diffi culty could be even more prominent in palliative care, where physical symptoms and grief may hamper the...

Palliative Medicine Practitioners' Views on the Concept of Depression in the Palliative Care Setting

“…15,16 Health professionals have reported difficulties with assessing and managing depression in the palliative care setting. [17][18][19][20] In particular, the distinction between depression and sadness or grief has been reported as challenging by family physicians, 20 palliative medicine physicians, 17 nurses, 18 and professional carers. 19 In a U.K. survey, palliative medicine physicians reported using an assortment of screening methods to assess for depression and endorsed different symptoms as useful for this purpose, 17 whereas general practitioners in the Netherlands emphasized clinical judgement of contextual factors in their assessment.…”

Depressive disorder in the last phase of life in patients with cardiovascular disease, cancer, and COPD: data from a 20-year follow-up period in general practice

“…In general, this is assumed to be small because criteria for diagnosis are discussed in monthly meetings, where the application of diagnostic criteria is monitored. However, GPs may have different views or different ways of assessing depressive disorder in the last phase of life 15 that has not been monitored specifically. Furthermore, in interpreting the findings of this study, it must be considered that depressive disorder throughout the 20 years of data that were included in this study may not have been a stable concept.…”

“…Indeed, a recent focus group study showed that while GPs are sometimes reluctant to classify sadness as depression in a palliative care context, they frequently attend to normal sadness in palliative care patients. 15 GPs can attend to emotional issues in a palliative care context without dichotomising the complex pattern of complaints into normal or disorder and with a explicit focus on the context of the depressive complaints that the patient experiences.…”

“…15 Therefore, it is recommended studying the last phase of life with a broader concept of depression to gain more insight in the actual situation in clinical practice.…”

“…[13][14][15] Hence, GPs also have a major role in recognising depression in patients in the last phase of their life. In primary care, patients who are diagnosed with a depressive disorder by GPs meet diagnostic criteria of depression using standardised psychiatric interviews, Composite International Diagnostic Interview (CIDI) and Schedules for Clinical Assessment in Neuropsychiatry (SCAN).…”