The RCPsych Article of the Month for February is ‘Delivering mental healthcare to patients with a depressive disorder alongside a life-limiting illness’ and the blog is written by author, Daniel Hughes and the article is published in BJPsych Bulletin.

Our article titled ‘Delivering mental healthcare to patients with a depressive disorder alongside a life-limiting illness’, published in BJPsych Bulletin, was based on my experience of being a psychiatric trainee working within a community palliative care team for one day a week. This gave me an opportunity to understand the unique challenges faced when treating mental illness at the end of life. I also came to realise how such patients often ‘fall between the gaps’, and it can be difficult to work out who is going to deliver mental healthcare or psychological support to such patients.

The article starts with a fictionalised case study regarding a gentleman called Jeremy with bowel cancer that has spread to his lungs, who then develops depression. After review, an antidepressant was started resulting in Jeremy’s sleep and mood both improving. He was able to access some talking therapy and felt supported by his palliative care team, with regards to both his physical and mental health.

Depression in people receiving palliative care is common, with around 25% of such patients meeting the diagnostic criteria for ‘major depressive disorder’. As well as various psychiatric symptoms, having depression alongside a palliative diagnosis may further reduce life expectancy. Feeling low in mood can be due to many things in this population – normal sadness or grief responses following being given a palliative diagnosis, or an adjustment disorder. It is however also important to recognise and treat depressive disorders at the end of life. Unfortunately, at the moment, we know that this is not happening as often as it should be.

When patients such as Jeremy express a wish to hasten death at the end of life this needs a thorough assessment. This can feel uncomfortable for clinicians, particularly if done without support of mental health teams. Managing suicidal risks needs to consider patient access to (potentially dangerous) medications, developing appropriate crisis plans and involvement of crisis supports, such as mental health crisis teams. This approach can be even more difficult when a patient is, for example, admitted to a hospice.

Evidence suggests antidepressants are effective in this population, however prescribing is complicated by the patient’s physical health diagnosis, physical frailty and other drugs that are commonly used in palliative care. Psychological approaches, such as dignity therapy and group therapy, have been demonstrated to work well, although access is variable.

It is our hope that this article prompts mental health clinicians and palliative care clinicians to think about mental illness in those at the end of life, consider the treatment options available and encourage working between specialties to better patient outcomes. Ultimately, only through more integrative service design (encouraging those from different specialities to approach patient care together) can such joint up working be made possible.

Delivering mental healthcare to patients with a depressive disorder alongside a life-limiting illness by Hughes and colleagues is an important clinical paper that reminds us to review and consider psychiatric conditions in this group. Although it is not easy to differentiate between different possible reasons for low mood amongst people with life-limiting illnesses, it is important not to discount treatable depression where it exists. Therefore, full assessments are required, often including physical health assessments, along with liaison with other teams such as palliative care teams when required. Treatments should, of course, be patient-centred, often following joint reviews. The authors highlight the key need to prevent under-diagnosis and treatment, and therefore unnecessary suffering, amongst people with life-limiting illness, and their article provides important education and advice for cross-specialty working in this complex area.   

Andrew Forrester

Editor-in-Chief, BJPsych Bulletin