How to Manage Anxiety and Depression in Patients with Serious Illness

Terms like anxiety and depression are thrown around casually in our culture, but what they actually mean are very different for different people. These conditions are quite common in patients with serious illness, and it’s our job as palliative care clinicians to accurately identify, diagnose, and consider treatment or referral when a mental health issue goes beyond our experience and expertise.

To ensure correct diagnoses, we need to rely on DSM V TR criteria. For example, depression symptoms can include poor sleep, disinterest, guilt, feelings of worthlessness, fatigue, and change of appetite. When it comes to anxiety, we may only consider panic attacks without recognizing generalized anxiety or “the walking worried” individuals who have a non-pathologic nervous temperament.

So, step one in addressing depression or anxiety is making sure we are screening using the appropriate standards rather than just loosely throwing these words around.

Based on research, it’s critical to know one's family history. Are a patient’s parents or siblings anxious or depressed? Have they been officially diagnosed? What therapies have worked well or have not worked for them? One must use caution when considering medications for anyone with a family history of bipolar disorder.

Often, patients with bipolar disorder can present in a depressive episode which, observed at a moment in time, is indistinguishable from a unipolar depression. If the patient does have bipolar disorder, the patient will need different types of medications for mood stabilization, and SSRIs could even cause a manic episode. Therefore it is important to take a comprehensive history to understand the patterns of your patients’ mental health issues over time.

An additional possibility to consider is a diagnosis of bereavement. As clinicians, we see patients in a singular moment in time, thus missing potential movement through the natural arc of shock, anger, sadness, remorse, and anxiety. In palliative care, we need to be alert to a prolonged grief disorder, which is defined by symptoms such as identity disruption and avoidance of reminders of a person’s death over a year period of time. (See DSM V TR.)

After initial diagnosis, many patients with cancer have a new onset of depression or anxiety that has been catalyzed through the traumatic awareness of their loss of health. Data has supported this concept as mental health disorders are viewed through an epigenetic lens. Patients with other serious illnesses, like end-stage renal disease or CHF, may have mental health issues because of their ongoing morbidity and loss of function, especially as they become sicker.

There is also the concept of psychosomatic or somatic illnesses, which are presentations of psychiatric issues in medical form. It can be difficult to tell whether worsening physical symptoms are due to the psychological effects of a diagnosis of serious illness, have biological causes, or both. Some of the medications we prescribe can also contribute to mental health issues—for example, steroids can cause anxiety—so we need to question whether mental health symptoms are iatrogenic. Regardless of the etiology, we should validate our patient’s experience when appropriate.

Many times, it is “normal” to have a panic attack upon learning your cancer has metastasized. It can be typical for someone to feel sad or blue when having multiple admissions to the hospital for a COPD exacerbation. The key is to ask questions about a patient’s symptoms and reflect back on your past clinical experience to assess whether a patient’s response is within the bell curve of a human response to an event. Of note, patients with mental health issues are often affected in multiple ways (sleep, appetite, mood, etc.) in all spheres of life (work, home, relationships), and issues do not improve over a few days.

Unfortunately, mental health can be a taboo topic, depending on generation and culture. Thus, a stigmatized mindset can exist, leading to resistance to disclose anxiety and depression. It is imperative to ask general questions and follow up around any comments such as “feeling down” or “overwhelmed” as part of a complete palliative symptom evaluation. You may want to include a palliative care social worker or a psychologist to help you when unsure if there is an issue. They are experts in mental health, assess for anxiety and depression, and refer to psychiatry.

A shortage of psychiatrists means a majority of those prescribing medications like selective serotonin reuptake inhibitors (SSRIs) are not primarily trained in mental health. With this in mind, I recommend that providers become familiar with two SSRIs and one SNRI. This will help establish comfort with specific agents, including potential side effects, and likely be effective for a majority of patients. As with pain, providers should define specific targets for treatment with medications, such as a change in mood, hours of sleep, and number of panic attacks.

After prescribing, it is important to teach patients that the pill they take today (or on the first day) will help them in two to six weeks. I share with them that the response will not be like a light switch but consistent with a sunrise—gradual with difficulty determining when it starts helping. As a general rule, one-third of patients will have a positive response, one-third of patients will have no major benefit, and one-third may have side effects. In the non-seriously ill population, women often complain of weight gain and men an inability to ejaculate.

If you have attempted your familiar agents with no positive outcome, then it is very reasonable to refer them to a psychiatrist.

People are social creatures. We’re pack animals. When someone has a serious illness like cancer, there's a feeling of isolation that may cause people to pull away from their ‘packs.’ Add to that depression and anxiety, which are isolating conditions, and people tend to pull back even more from activities and social environments and develop rather rigid thinking patterns.

As palliative care clinicians, we should be checking for isolation and not be afraid to ask some hard questions: “Are you getting out?” “What have you been up to?”

Use solid psychological criteria, and don’t be afraid to probe further to make sure you know whether you’re managing depression, anxiety, or something else. Connect patients to support groups. Get a mental health professional involved, starting with your palliative care social worker.

For additional information about anxiety and depression, visit the below organizations' websites:

• National Alliance of Mental Health (NAMI)
• Substance Abuse and Mental Health Services Administration (SAMSA)
• Anxiety & Depression Association of American (ADAA)

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.