ABC of palliative care: Depression, anxiety, and confusionBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7119.1365 (Published 22 November 1997) Cite this as: BMJ 1997;315:1365
- 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 of support from family and friends
Emotional distress and psychiatric disorder also affect some relatives and staff.
Depression and anxiety are usually reactions to the losses and threats of the medical illness. Other risk factors often contribute.
Confusion usually reflects an organic mental disorder from one or more causes, often worsened by bewilderment and distress, discomfort or pain, and being in strange surroundings with strange carers. Elderly patients with impaired memory, hearing, or sight are especially at risk. Unfortunately, reversible causes of confusion are underdiagnosed, and this causes unnecessary distress in patients and families.
Common causes of organic mental disorders
Prescribed drugs—Opioids, psychotropic drugs, corticosteroids, some cytotoxic drugs
Infection—Respiratory or urinary infection, septicaemia
Macroscopic brain pathology—Primary or secondary tumour, Alzheimer's disease, cerebrovascular disease, HIV dementia
Metabolic—Dehydration, electrolyte disturbance, hypercalcaemia, organ failure
Drug withdrawal—Benzodiazepines, opioids, alcohol
Depression and anxiety
These are broad terms that cover a continuum of emotional states. It is not always possible on the basis of a single interview to distinguish self limiting distress, which forms a natural part of the adjustment process, from the psychiatric syndromes of depressive illness and anxiety state, which need specific treatment. Borderline cases are common, and both the somatic and psychological symptoms of depression and anxiety can make diagnosis difficult.
Symptoms and signs of depression
Reduced energy, fatigue
Disturbed sleep, especially early morning waking
Psychomotor agitation or retardation
Low mood present most of the time, characteristically worse in the morning
Loss of interest and pleasure
Reduced concentration and attention
Feelings of guilt or worthlessness
Pessimistic or hopeless ideas about the future
Suicidal thoughts or acts
Somatic symptoms—These are often the presenting symptoms, and they overlap with symptoms of the physical illness. For example, depression may manifest as intractable pain, while anxiety can manifest as nausea or dyspnoea. Such symptoms may seem disproportionate to the medical pathology and respond poorly to medical treatments
Psychological symptoms—Although these might seem understandable, they differ in severity, duration, and quality from “normal” distress. Depressed patients seem to loathe themselves, over and above loathing their disease. This manifests through guilt about being ill and a burden to others, pervasive loss of interest and pleasure, and hopelessness about the future. Suicide attempts or requests for euthanasia, however rational they might seem, often indicate clinical depression.
Symptoms and signs of anxiety
Apprehension, worry, inability to relax
Difficulty in concentrating, irritability
Difficulty falling asleep, unrefreshing sleep, nightmares
Muscular aches and fatigue
Restlessness, trembling, jumpiness
Shortness of breath, palpitations, lightheadedness, dizziness
Sweating, dry mouth, “lump in throat”
Nausea, diarrhoea, urinary frequency
This may present as forgetfulness, disorientation in time and place, and changes in mood or behaviour. The two main clinical syndromes are dementia (chronic brain syndrome), which is usually permanent, and delirium (acute brain syndrome), which is potentially reversible.
Symptoms and signs of delirium
Clouding of consciousness (reduced awareness of environment)
Impaired memory, especially recent memory
Impaired abstract thinking and comprehension
Disorientation in time, place, or person
Perceptual distortions—Illusions and hallucinations, usually visual or tactile
Transient delusions, usually paranoid
Psychomotor disturbance—Agitation or underactivity
Disturbed cycle of sleeping and waking, nightmares
Emotional disturbance—Depression, anxiety, fear, irritability, euphoria, apathy, perplexity
Delirium, which is more relevant to palliative care, comprises clouding of consciousness with various other abnormalities of mental function from an organic cause. Severity often fluctuates, worsening after dark. Paranoid ideas can be exacerbated by the mental mechanisms of “projection” and “denial”—for example, attributing symptoms to poisoned food rather than a progressive illness. Dehydration, neglect of personal hygiene, and accidental self injury may hasten physical and mental decline. Noisy, demanding, or aggressive behaviour may upset or harm other people. So called “terminal anguish” is a combination of delirium and overwhelming anxiety in the last few days of life.
Underrecognition of psychiatric disorders
Patients reluctant to voice emotional complaints—Fear of seeming weak or ungrateful; stigma
Professionals reluctant to inquire—Lack of time, lack of skill, emotional self protection
Attributing somatic symptoms to medical illness
Assuming emotional distress is inevitable and untreatable
Various misconceptions about psychiatric disorders in medical patients contribute to their widespread underrecognition and undertreatment. Education and training in communication skills, for both patients and staff, could help to remedy this.
Standardised screening instruments include the hospital anxiety and depression (HAD) scale for mood disorder and the mini mental state (MMS) or mental status schedule (MSS) for cognitive impairment. Though not sensitive or specific enough to substitute for assessment by interview, they can help to detect unsuspected cases, contribute to diagnostic assessment of probable cases, and provide a baseline for monitoring progress.
Knowledge of previous personality and psychological state is helpful in identifying high risk patients or those with evolving symptoms, and relatives' observations of any recent change should be heeded.
References for screening instruments
Hospital anxiety and depression scale—Zigmond AS, Snaith RP. The hospital anxiety and depression (HAD) scale. Acta Psychiatr Scand 1983;67:361-70
Mini mental state—Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”—a practical method of grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98
Mental status schedule—Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8
Prevention and management
Principles of psychological management
Sensitive breaking of bad news
Providing information in accord with individual wishes
Permitting expression of emotion
Clarification of concerns and problems
Patient involved in making decisions about treatment
Setting realistic goals
Appropriate package of medical, psychological, and social care
Continuity of care from named staff
General guidelines for both prevention and management include providing an explanation about the illness, in the context of ongoing supportive relationships with known and trusted professionals. Patients should have the opportunity to express their feelings without fear of censure or abandonment. This facilitates the process of adjustment, helping patients to move on towards accepting their situation and making the most of their remaining life.
Visits from a specialised palliative care nurse (such as a Macmillan nurse) or attendance at a palliative care day centre, combined with follow up by the primary healthcare team, often benefit both patients and families. Religious or spiritual counselling may be relevant. Psychiatric referral is indicated when emotional disturbances are severe, atypical, or resistant to treatment; when there is concern about suicidality; and on the rare occasions when compulsory measures under the Mental Health Act 1983 seem to be indicated.
Non-drug therapies, both “mainstream” and “complementary,” share the common features of increasing patients' sense of participation and control, providing interest and occupation when jobs or hobbies have had to be discontinued, and offering a supportive personal relationship. Usually delivered in regular planned sessions, they can also help in acute situations—for example, deep breathing, relaxation techniques, or massage for acute anxiety or panic attacks.
For bedridden patients who are anxious or confused as well as very sick, it is important to provide nursing care from a few trusted people; a quiet, familiar, safe, and comfortable environment; explanation of any practical procedure in advance; and an opportunity to discuss underlying fears.
Some psychological and practical therapies
Brief psychotherapy—Cognitive-behavioural, cognitive-analyti problem solving
Group discussions for information and support
Practical activity—Such as craft work, swimming
Relatives also need explanation and support.
For more severe cases, drug treatment is indicated in addition to, not instead of, the general measures described above.
Drugs should be prescribed if a definite depressive syndrome is present or if a depressive adjustment reaction fails to resolve within a few weeks. The antidepressant effect of all these drugs may be delayed for several weeks after starting therapy.
Tricyclic antidepressants produce a worthwhile response in about 80% of patients, and their sedative, anxiolytic, and analgesic properties may bring added benefits. However, they have considerable anticholinergic side effects, and they are toxic in overdose. Amitriptyline is the standard compound; dothiepin is similar but is sometimes better tolerated. For both drugs, low doses in the range 25–50 mg at night are sometimes effective, but many patients need 75–150 mg or more. Lofepramine, at doses of 70–210 mg daily, has lower toxicity.
Specific serotonin reuptake inhibitors such as sertraline (50 mg daily) or paroxetine (20 mg daily) have few anticholinergic effects, are non-sedative, and are safe in overdose. However, they may cause nausea, diarrhoea, headache, or anxiety. Several newer related antidepressants have recently become available.
Other treatments—Many alternative compounds are also available, and the less widely used ones—including monoamine oxidase inhibitors, psychostimulants, lithium, and various combinations of antidepressants—may be tried on psychiatric advice with due regard to their interactions with other drugs. For severe depression only, electroconvulsive therapy is safe and rapidly effective. Organic mental disorders do not necessarily contraindicate the use of antidepressant drugs or electroconvulsive therapy.
Benzodiazepines are best limited to short term or intermittent use; prolonged administration may lead to a decline in anxiolytic effect, and cumulative psychomotor impairment. Low dose neuroleptic drugs such as haloperidol 1.5-5 mg daily are an alternative. blockers are useful for autonomic overactivity. Chronic anxiety is often better treated with a course of antidepressant drugs, especially if depression coexists.
Acute severe anxiety can present as an emergency. It may mask a medical problem—such as pain, pulmonary embolism, internal haemorrhage, or drug or alcohol withdrawal—or it may have been provoked by psychological trauma such as seeing another patient die. Whether or not the underlying cause is amenable to specific treatment, sedation is usually required. Lorazepam, a short acting benzodiazepine, can be given as 1 mg or 2.5 mg tablets orally or sublingually, or intravenously as 25–30 g/kg. Alternatively, midazolam 5–10 mg can be given intravenously or subcutaneously. An antipsychotic such as haloperidol 5–10 mg may be better if the patient is also psychotic or confused. Medical assessment needs to be repeated every few hours, and the continued presence of a skilled and sympathetic companion is helpful.
It is best to identify any treatable medical causes before prescribing further drugs, which may make the confusion worse. In practice, however, sedation is often required. For mild nocturnal confusion, an antipsychotic such as thioridazine 25–50 mg or haloperidol 1.5-5 mg at bedtime is often sufficient. For severe delirium, a single dose of haloperidol 5–10 mg may be offered in tablet or liquid form or by injection. This may be repeated hourly until a calming effect is achieved, with the dose increasing to 20 mg if necessary. If it does not work a benzodiazepine or a barbiturate can be added.
“Lifting the heart” A week ago nothing mattered I didn't want to do anything I just wanted to die. Today something lifted my heart up Somebody had built some flowers The newness of new crocuses.
These words were written by a man who had been both confused and suicidally depressed after diagnosis of a brain tumour, but whose mental state improved after prescription of amitriptyline
It may be possible to withdraw the drugs after one or two days if reversible factors such as infection or dehydration have been dealt with. Otherwise, sedation may need to be continued until death, preferably by continuous subcutaneous infusion, for which a suitable regimen might be as much as haloperidol 10–30 mg with midazolam 30–60 mg per 24 hours. These drugs can be mixed in the same syringe.
Emotional disorders in patients with incurable disease should never be dismissed as inevitable or untreatable. Worthwhile improvements in psychological state can often be achieved even though the physical illness continues to advance. We must be wary of projecting any sense of hopelessness onto our patients and avoid dismissing anxiety and depression as understandable, thereby denying appropriate treatment in many cases.
Jennifer Barraclough is consultant in psychological medicine, Churchill Hospital, Oxford Radcliffe NHS Trust.
The ABC of palliative care is edited by Marie Fallon, Marie Curie senior lecturer in palliative medicine, Beatson Oncology Centre, Western Infirmary, Glasgow, and Bill O'Neill, science and research adviser, British Medical Association, BMA House, London. It will be published as a book in June 1998.