Many children with life-limiting illnesses die in the hospital setting. Some studies suggest that up to 49% of children who have terminal cancer die in the hospital (Wolfe et al. 2000). Differentiating the sadness and dysphoria that appropriately occur when a young person with terminal illness faces death from the symptoms of a primary depressive disorder can be difficult (see Table 6-6). Increased somatic symptoms, worries, fears, hopelessness and helplessness, depressed mood, and irritability may be manifestations of emotional distress rather than a primary depression (Freyer et al. 2006).

Depressive disorders, however, are still common among those facing the end of their lives, and these disorders remain underdiagnosed and undertreated. Suicidal ideation or thoughts for hastened death, although commonly believed to accompany terminal illness, generally suggest the presence of a depres-

Table 6-6. Comparison of grief with major depression in terminally ill patients

Grief characteristics

Depression characteristics

Patients experience feelings, emotions, and behaviors that result from a loss.

Almost all terminally ill patients experience grief, but only a minority develop a mood disorder requiring treatment.

Patients usually cope with distress on their own.

Patients experience somatic distress, loss of usual patterns of behavior, agitation, sleep and appetite disturbance, decreased concentration, and social withdrawal.

Grief is associated with disease progression.

Patients retain the capacity for pleasure. Grief comes in waves.

Patients express passive wishes for death to come quickly.

Patients are able to look forward to the future.

Patients experience feelings, emotions, and behaviors that fulfill criteria for major depression that is generalized in all facets of life.

Major depression occurs in 1%-5% of terminally ill patients.

Medical or psychiatric intervention is usually necessary.

Patients experience similar symptoms, plus hopelessness, helplessness, worthlessness, guilt, and suicidal ideation.

Depression has increased prevalence in patients with advanced disease; pain is a major risk factor.

Patients enjoy nothing.

Depression is constant and unremitting.

Patients express intense and persistent suicidal ideation.

Patients have no sense of a positive future.

Source. Reprinted from Block S: "Assessing and Managing Depression in the Terminally Ill Patient." Annals of Internal Medicine 132:209-218, 2000. Copyright 2000, American College of Physicians. Used with permission.

sive disorder. Findings from some studies among terminally ill adults suggest that the presence of depression is an important precipitant for suicidal ideation and desire for hastened death (Breitbart et al. 2000).

Mental health clinicians are often asked to assess mood symptoms and to make recommendations for psychopharmacological treatments in the palliative care setting. Often, the consultation is motivated by the medical team's distress about their inability to help the child and family. Although psychopharma-cological interventions may prove helpful for some children, the clinician should make an effort to help the patient, family, and medical team work through their feelings of loss and to interpret the symptoms of depression as a normal and important part of the grieving process.

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