Intended for healthcare professionals

Clinical Review

ABC of palliative care: Depression, anxiety, and confusion

BMJ 1997; 315 doi: (Published 22 November 1997) Cite this as: BMJ 1997;315:1365
  1. Jennifer Barraclough


    A common mistake is to assume that depression and anxiety represent nothing more than natural and understandable reactions to incurable illness. When cure is not possible, the analytical approach we adopt to physical and psychological signs and symptoms is often forgotten. Excuse is found in the overlap of symptoms due to physical disease, depression, and anxiety. This error of approach and the lack of diagnostic importance given to major and minor symptoms of depression result in underdiagnosis and treatment of psychiatric disorder

    Losses and threats of major illness

    • Knowledge of a life threatening diagnosis, prognostic uncertainty, fears about dying and death

    • Physical symptoms such as pain and nausea

    • Unwanted effects of medical and surgical treatments

    • Loss of functional capacity, loss of independence, enforced changes in role

    • Practical issues such as finance, work, housing

    • Changes in relationships, concern for dependants

    • Changes in body image, sexual dysfunction, infertility

    The emotional and cognitive changes in patients with advanced disease reflect both psychological and biological effects of the medical condition and its treatment. Psychological adjustment reactions after diagnosis or relapse often include fear, sadness, perplexity, and anger. These usually resolve within a few weeks with the help of the patients' own personal resources, family support, and professional care. A minority of patients, about 10-20%, develop formal psychiatric disorders that require specific evaluation and management in addition to general support. It is important to recognise psychiatric disorders because, if untreated, they add to patients' suffering and hamper their ability to come to terms with their illness, put their affairs in order, and communicate with others.

    Risk factors for anxiety and depression

    • Organic mental disorders

    • Poorly controlled physical symptoms

    • Poor relationships and communication between staff and patient

    • Past history of mood disorder or misuse of alcohol or drugs

    • Personality traits hindering adjustment—Such as rigidity, pessimism, extreme need for independence and control

    • Concurrent life events or social difficulties

    • Lack …

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