Depression in patients nearing end of life

Overview

Depression near the end of life is common but frequently under-recognised and under-treated, partly because its symptoms (fatigue, reduced appetite, sleep disturbance, low mood) overlap substantially with the expected somatic effects of advanced physical illness itself
A significant proportion of patients with advanced illness experience clinically significant depression, though estimates vary depending on diagnostic criteria used and the overlap with disease-related symptoms

Distinguishing depression from an appropriate, expected sadness/grief response to a terminal diagnosis (which does not itself require pharmacological treatment) from a clinical depressive disorder (which does) is a genuine diagnostic challenge, since both involve low mood in the context of serious illness

Cognitive and affective symptoms (hopelessness, worthlessness, pervasive anhedonia, persistent suicidal ideation) are more specific for depression than somatic symptoms (fatigue, appetite/sleep change) in this population, since the somatic symptoms alone are poorly discriminating given their overlap with the underlying illness
Ask directly about suicidal ideation and, specifically, about a wish for hastened death - a persistent, pervasive wish for death (distinct from an understandable, situational acceptance of approaching death) warrants active assessment and treatment, not dismissal as an inevitable part of dying

Both pharmacological (antidepressants, chosen with attention to interactions, time-to-effect versus expected prognosis, and side-effect profile) and non-pharmacological (psychotherapy, counselling, psychosocial support) treatment are effective and should be offered when depression is identified, even in patients with a limited prognosis
Address reversible contributing factors where present (uncontrolled physical symptoms, particularly pain, can both mimic and worsen depression) alongside specific depression treatment

Anticipatory grief (a distinct, expected process not requiring treatment in itself), demoralisation syndrome, desire for hastened death/requests related to voluntary assisted dying (where legally available - requires careful distinction from untreated depression)

Depression in advanced illness is treatable and treatment can meaningfully improve quality of life even with a short remaining prognosis - "of course they're depressed, they're dying" is a common but clinically inaccurate framing that leads to under-treatment of a genuinely treatable condition

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