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Depression in advanced disease

Depression prevalence
Results
Comment

Depression in advanced disease is common, but might be easily overlooked. With an emphasis on improving the quality of life, it should not be. What we need is good evidence about how to spot it, and good evidence about how to treat it. Two systematic reviews from London and Stanford [1,2] make a start.

Depression prevalence


This systematic review [1] set out to find all studies examining the prevalence of depression in advanced disease. The problems were two: defining depression and defining advanced disease. For the first, the aim was to examine different methods of detecting depression, from clinical recognition to using different depression scales. For the second, reviewers had a target population of patients in palliative care settings, excluding studies focusing on non-cancer conditions like heart failure or AIDS. At least 50% of patients had to have cancer, and oncology studies were included if expected or real survival was less than six months.

A very extensive search strategy was used, examining many electronic databases, the St. Christopher's Hospice database, the Cochrane Library, and with handsearching selected journals.

Results


The review performs no meta-analysis to give an overall figure for depression, because there was real clinical heterogeneity between studies. The six main diagnostic criteria were clinical recognition, single-item scales, the Hospital Anxiety and Depression Scale (HADS), other questionnaires, use of diagnostic criteria and case-finding studies.

Figure 1 shows an abacus plot of the prevalence rates found for the first five of these methods in just under 6,700 patients in which the overall rate of depression was about 30%. For HADS and others reporting degrees of depression, only severe depression was included for Figure 1. Many studies were very small, and this also contributed to the wide variation, which was from under 10% to over 60%.

Figure 1: Prevalence of depression in patients with advanced disease according to different diagnostic methods



Comment


It is not possible to say that any particular method finds more depression than another, or which is correct. What is clear is that it is relatively common. A sister review on treatments [2] found no reports for psychosocial interventions, and only three randomised trials with antidepressants with a total of 163 patients. Two showed antidepressants to be better than placebo, and one showed fluoxetine to be as effective, but with lower discontinuations, than desipramine. The authors also comment on literature showing that antidepressants may be underused in a palliative care setting.

Palliative care has few randomised trials and even fewer systematic reviews. These constitute a significant addition to the knowledge, as opposed to the experience, base. Experience in palliative care is good, and has enabled great advances to be made. Knowledge will cement and improve that.

References:

  1. M Hotopf et al. Depression in advanced disease: a systematic review part 1. Prevalence and case finding. Palliative Medicine 2002 16: 81-97.
  2. KL Ly et al. Depression in advanced disease: a systematic review part 2. Treatment. Palliative Medicine 2002 16: 279-284.
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