Depression

F32-3/F32.8-9/F33.0-4/F33.8-9/F34.1 + (Z51.5)

See: Depressive disorders.

DESCRIPTION

Depression might be difficult to diagnose in palliative care patients as some symptoms of depression are similar to disease manifestations such as anorexia and insomnia. The key indicators of depression in palliative care patients are persistent feelings of hopelessness and worthlessness and/or suicidal ideation. Young children may present with somatic complaints e.g. abdominal pain or headaches, or may have restlessness.

GENERAL MEASURES

Refer to a social worker to assist with concerns of future care of patient, family, and finances.

MEDICINE TREATMENT

Adults

  • Fluoxetine, oral.
    • Initiate at 20 mg alternate days for 2 weeks.
    • Increase to 20 mg daily after 2–4 weeks.
    • Delay dosage increase if increased agitation/panicky feelings occur.

LoEI [13]

OR

If fluoxetine is poorly tolerated:

  • Alternative SSRI e.g.:
  • Citalopram, oral.
    • Initiate at 10 mg daily for 2 weeks.
    • Then increase to 20 mg daily.

LoEI [14]

OR

If a sedating antidepressant is required:

  • Tricyclic antidepressants, e.g.:
  • Amitriptyline, oral, at bedtime.
    • Initial dose: 25 mg per day.
    • Increase by 25 mg per day at 3–5 day intervals.
    • Maximum dose: 150 mg per day.

Note: Tricyclic antidepressants may cause dry mouth, constipation, urinary retention, and confusion, which might be especially problematic in palliative care patients. Use the lowest dose possible, and titrate slowly.

LoEIII [15]

REFERRAL

  • All children and adolescents.
  • All patients to a psychologist and social worker if available.