Terminal Illness

When facing death, terminally ill patients must deal with extreme psychological distress.

Undiagnosed mental illness and mood disorders such as depression often contribute to a person’s discomfort and pain at the end of life. However, patients will often disregard depressive symptoms as “normal” and hide them from physicians.

Also, doctors may not be properly trained to diagnose depression. Or, they may be reluctant to acknowledge a patient’s depression because they feel that treatments such as antidepressants may have unintended side effects.

Unfortunately, underdiagnosis and undertreatment of depression can degrade the quality of life and hasten death for a terminally ill patient.

When Symptoms May Be Normal Sadness

Grief is a normal part of the dying process. Feelings that are common among terminally ill patients may include:

  • deep sadness and regret (this may include crying or sobbing)
  • anger
  • difficulty sleeping or changes in appetite
  • fatigue
  • restlessness
  • disbelief
  • disengagement or apathy

When normal feelings of grief become excessive and start to interfere with every aspect of a person’s life, they may indicate a more serious problem.

When Symptoms May Be Depression

The symptoms of depression in terminally ill patients often correspond with symptoms of their disease, making it all the more difficult to diagnose. Symptoms to watch for include:

  • severe mood swings or other mood disturbances           
  • prolonged difficulty sleeping
  • prolonged difficulty eating
  • loss of interest in once pleasurable activities or hobbies
  • feelings of helplessness
  • feelings of guilt
  • persistent worrying
  • suicidal ideation

Older patients are more likely to seek general medical care rather than mental health care for their symptoms. They also tend to focus on the physical manifestations of their symptoms (such as sleeplessness) rather than on their depressed mood.

When Symptoms May Be Side Effects of Medication

Many medications may cause symptoms that might be mistaken for depression. They include:

  • changes in appetite and weight gain or loss
  • dry mouth (“cotton mouth”)
  • disturbance in sleep patterns
  • fatigue or a decrease in energy

Risk Factors for Depression in the Elderly

Since elderly people are most likely to be diagnosed with a terminal illness, it’s important to recognize risk factors for depression specific to them. Risk factors include: 

  • a history of chronic illness
  • a personal or family history of depression
  • substance abuse
  • poorly controlled pain
  • lack of social support system
  • recent bereavement
  • difficulty adjusting to stressful situations
  • brain disease
  • decreased mobility
  • certain medications
  • physical and cognitive decline 

Diagnosing Depression

The American College of Physicians strongly recommends that clinicians regularly assess patients for depression and to focus on signs of guilt, hopelessness, worthlessness, helplessness, and suicidal ideation. This is because screening for depression can optimize the physical comfort of patients and help them prepare for death. In fact asking, “Are you depressed?”is the single most effective question to ask seriously ill patients. An affirmative response should then be followed by other screening measures.

Treatments for Depression in Terminally Ill Patients

Once a diagnosis of depression is made, doctors should establish a “low threshold for treating depression” in the terminally ill, according to the American College of Physicians.

Treatment options may include counseling, psychotherapy, or psychoactive medications.

Due to the limited life expectancy of patients, psychostimulants are recommended as the “first-line agents” for treating depression in the terminally ill. They’re fast-acting and may help a patient cope better than slower-acting medications such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (which may also not be as well-tolerated by older patients).

Other Considerations

A caregiver will often undergo similar feelings of grief and stress as a terminally ill patient. Therefore, they may not be in a position to properly assess feelings of depression or suicidal ideation.

Research has shown that discussions of suicide or a patient’s requests to hasten death don’t result in further distress. However, left untreated, depression itself may put a patient—especially older men—at greater risk of suicide.