The development of evidence-based European guidelines on the management of depression in palliative cancer care
Introduction
Depression is common among patients with cancer and particularly those receiving palliative care. A systematic review by Hotopf et al. in 2002 found a median prevalence of 15% for major depression in advanced disease.1 Depression compounds the physical consequences of advanced disease. It is associated with disability, pain and fatigue,2, 3, 4 and there is evidence that depressed patients have poorer prognosis and higher mortality in a range of physical illnesses.5, 6, 7 Detecting depression in palliative care is difficult as somatic symptoms (e.g. poor appetite, sleep disturbance and fatigue) may be due to depression, advanced disease or medical treatment.8 Also, depression is difficult to distinguish from normal fear and distress,9 which often accompany terminal illness. In patients with advanced disease, the coexistence of multiple symptoms makes drug interactions more likely and treatment more complicated. Though antidepressants have been shown to ease depression in physically healthy people, there is doubt about whether they are appropriate for terminally ill patients.10 Psychological therapy is the other recommended treatment for depression,11, 12 but questions surround its feasibility, acceptability and availability in palliative care.13, 14
In 2009, the UK National Institute for Health and Clinical Excellence (NICE) published recommendations for the management of depression in people with a chronic health problem. This guideline covered primary, secondary and tertiary care but specified that palliative care was outside its remit.11 Depression in palliative care poses particular challenges and clinicians need clear guidance on improving outcomes at the end of life. A pragmatic report from the European Association of Palliative Care (EAPC) in 2001 highlighted the problem of under-detection and under-treatment of depression in palliative care. This report called for collaboration between palliative care and mental health professionals and integration of clinical experience and scientific evidence in order to establish best practice.15
The European Palliative Care Research Collaborative (EPCRC) was established through the EAPC Research Network in 2006, with funding from the European Commission.16, 17 The collaborative brought together 11 centres in six European countries, with the aim of improving the management of cachexia, pain and depression through translational research. The scientific work within the EPCRC spans three main strands: (1) genomics, (2) symptom assessment and classification, and (3) guideline development and dissemination. Clinical practice guidelines were developed to assist palliative care professionals in managing each of the three symptoms – pain, cachexia and depression. This paper outlines the development of the EPCRC depression guideline and provides a summary of its key recommendations.
Section snippets
Materials and methods
The guideline was developed in accordance with the methods of the National Institute for Clinical Excellence (NICE).18 Recommendations were devised using the best available evidence. Where evidence was absent or equivocal, Delphi consensus methods were implemented to elicit and refine expert opinion. The quality of evidence and the strength of recommendations were determined using the GRADE system.19
Guideline content
The following section briefly summarises the guideline’s key recommendations.
Discussion
The translation of research findings into systematically developed guidelines has been found to improve patient outcomes by bringing evidence-based knowledge into clinical practice.93, 94, 95 The EPCRC depression guideline was developed to address the lack of guidance on managing depression in patients receiving palliative care. It draws together the most current and important evidence in the field, enabling clinicians to access and implement new knowledge quickly and easily.
This is the first
Contributions
L.R.: coordinating guideline development – including expert group meetings, Delphi study, Cochrane review, guideline consultation, literature review, writing recommendations, grading evidence. A.P.: identifying clinical priorities, conducting Cochrane review. M.H.: winning peer review funding for project; supervision of guideline development – including expert group meetings, Delphi study, Cochrane review, guideline consultation, literature review, writing recommendations, grading evidence.
Role of funding source
This work was performed on behalf of the European Palliative Care Research Collaborative. The European Palliative Care Research Collaborative is funded by the European Commission’s Sixth Framework Programme (Contract No. LSHC-CT-2006-037777, EPCRC) with the overall aim to improve treatment of pain, depression and fatigue through translation research. Core scientific group/work package leaders: Stein Kaasa (Project Coordinator), Frank Skorpen, Marianne Jensen Hjermstad, and Jon Håvard Loge,
Conflict of interest statement
M.H. is an independent expert witness (instructed by the claimants’ solicitor) in a group litigation on the potential for paroxetine to cause adverse events on withdrawal of treatment. L.R., A.P. and I.J.H. do not have any competing interests. No competing interests were declared by the members of the expert group.
Acknowledgements
The funders of the study had no role in study design, data collection, data analysis, data interpretation or the writing of the paper.
We thank Marjolein Bannink, Stephen Barclay, Augusto Caraceni, Trudie Chalder, Harvey Chochinov, Marilène Filbet, Pam Firth, Luigi Grassi, Jane Hutton, Jenny Kieldsen, David Kissane, Nigel Konzon, Iain Lawrie, Sally List, Mari Lloyd Williams, Jon Håvard Loge, Kathryn Mannix, Stirling Moorey, Maria Nabal, Mike Philpot, Holly Prigerson, Lukas Radbruch, Peter
References (99)
- et al.
Depression – an independent predictor of early death in patients with advanced cancer
J Affect Disord
(2009) - et al.
Helping cancer patients disclose their concerns
Eur J Cancer
(1996) - et al.
Patient-clinician information engagement increases treatment decision satisfaction among cancer patients through feeling of being informed
Patient Educ Couns
(2009) - et al.
Changes in symptoms and pain intensity of cancer patients after enrollment in palliative care at home
J Pain Symptom Manage
(2007) - et al.
An analysis of the validity of the Hospital Anxiety and Depression Scale as a screening tool in patients with advanced metastatic cancer
J Pain Symptom Manage
(2001) - et al.
Screening for depression in terminally ill cancer patients in Japan
J Pain Symptom Manage
(2006) - et al.
Validity of the beck depression inventory, hospital anxiety and depression scale, SCL-90, and Hamilton depression rating scale as screening instruments for depression in stroke patients
Psychosomatics
(2002) - et al.
The development of the Brief Edinburgh Depression Scale (BEDS) to screen for depression in patients with advanced cancer
J Affect Disord
(2007) - et al.
Evaluation of a one-question interview for depression in a Radiation Oncology Department in Japan
Gen Hosp Psychiatry
(2006) - et al.
Gradations of clinical severity and sensitivity to change assessed with the Beck Depression Inventory-II in Japanese patients with depression
Psychiatry Res
(2005)
Symptoms of depression and delirium assessed serially in palliative-care inpatients
Psychosomatics
Problem solving therapies for depression: a meta-analysis
Eur Psychiatry
Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis
Lancet
Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations
Lancet
Depression in advanced disease: a systematic review: part 1. Prevalence and case finding
Palliat Med
Temporal relationships between physical symptoms and psychiatric disorder. Results from a national birth cohort
Br J Psychiatry
The functioning and well-being of depressed patients. Results from the Medical Outcomes Study
JAMA
Ascribed meaning: a critical factor in coping and pain attenuation in patients with cancer-related pain
J Palliat Care
Depression following myocardial infarction. Impact on 6-month survival
JAMA
Mortality at 12 and 24 months after stroke may be associated with depressive symptoms at 1 month
Stroke
Measurement of depression in patients with cancer
Cancer
The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder
A survey of antidepressant prescribing in the terminally ill
Palliat Med
Assessing the feasibility, acceptability and potential effectiveness of Dignity Therapy for people with advanced cancer referred to a hospital-based palliative care team: Study protocol
BMC Palliat Care
Psychological services in hospices in the UK and Republic of Ireland
J R Soc Med
Depression in palliative care: a pragmatic report from the Expert Working Group of the European Association for Palliative Care
Support Care Cancer
Symptom assessment in palliative care: a need for international collaboration
J Clin Oncol
Palliative cancer care research
Palliat Med
Depression: management of depression in primary and secondary care
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
BMJ
Applying the Delphi process to palliative care tool development: lessons learned
Support Care Cancer
Early palliative care for patients with metastatic non-small-cell lung cancer
N Engl J Med
Cicely Saunders: selected writings 1958–2004
Physician characteristics and the recognition of depression and anxiety in primary care
Med Care
How to recognize and manage psychological distress in cancer patients
Eur J Cancer Care (Engl)
Desire for information and involvement in treatment decisions: elderly cancer patients’ preferences and their physicians’ perceptions
J Clin Oncol
Patient satisfaction with treatment decisions for clinically localized prostate carcinoma. Results from the Prostate Cancer Outcomes Study
Cancer
The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies
Oncol Nurs Forum
Why is self-help neglected in the treatment of emotional disorders? A meta-analysis
Psychol Med
Association between pain and depression among older adults in Europe: results from the Aged in Home Care (AdHOC) project: a cross-sectional study
J Clin Psychiatry
Pain, depression, and fatigue in cancer
Integr Cancer Ther
Cited by (100)
Depressive Symptoms and Palliative Care Concerns Among Patients With Non-communicable Diseases in Two Southern African Countries
2023, Journal of Pain and Symptom ManagementA systematic review of pharmacologic treatment efficacy for depression in older patients with cancer
2022, Brain, Behavior, and Immunity - HealthPsychiatric conditions in palliative medicine
2020, Medicine (United Kingdom)Citation Excerpt :Antidepressants should be considered when treating depression in palliative care. Selective serotonin reuptake inhibitors (SSRIs),5 serotonin–noradrenaline reuptake inhibitors (e.g. duloxetine) and α2-adrenoceptor antagonists (e.g. mirtazapine) are the antidepressants most commonly used towards the end of life. Efficacy, tolerance and prognosis play an important role in determining the appropriate pharmacotherapy because these drugs take 2–4 weeks to improve symptoms.1,3
Integration of oncology and palliative care: a Lancet Oncology Commission
2018, The Lancet OncologyThe use of antidepressants in oncology: A review and practical tips for oncologists
2018, Annals of OncologyValidation of the Brief Edinburgh Depression Scale (BEDS) in a Mexican population with advanced cancer in a palliative care service
2019, Palliative and Supportive Care