Cambridgeshire Palliative Care Guidelines Group Review Date: February 2016

FACTSHEET 15 ON PALLIATIVE CARE

ANXIETY AND DEPRESSION

Anxiety and depression remain under diagnosed and under treated in palliative care
patients. Estimates of the incidence of depression in palliative care vary but are of the
order of 20-40%. Often the symptoms will be accepted by the patient, family, or physician
as a “normal” reaction to incurable illness.

30% of patients will experience “adjustment reactions” at the time of diagnosis or of

relapse, but these will usually resolve within a few weeks, with appropriate support.

20% of patients will develop psychiatric disorders that require specific management
and treatment in addition to support.

Risk Factors for Anxiety and Depression

Poorly controlled physical symptoms

Past history of mood disorder or alcohol/drug misuse
Difficult relationships and communications
Social isolation and lack of social support

ASSESSMENT

It may be necessary to assess patients on more than one occasion – in order to

differentiate between an adjustment process and a depressive disorder or anxiety state.

Observations and comments from family members may be helpful

Poor response of physical symptoms to medical treatment may indicate underlying
psychological disturbance.
If appropriate consider use of an assessment tool

Where the symptoms attributable to physical disease and symptoms attributable to

psychological disturbance overlap (e.g. loss of weight, poor sleep, lack of energy, poor
appetite) a trial of treatment may be acceptable.

MANAGEMENT

Dedicate time for discussion to clarify areas of concern, and allow expression of
patient’s feelings.
Explore the patient’s preferred method of treatment and involve them in decisions
and plans.
Explain their disorder in terms of reaction to their illness and situation, emphasising
that it does not indicate “spread of disease to the brain” nor that the patient is
“going mad”.
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Cambridgeshire Palliative Care Guidelines Group Review Date: February 2016

Explore support mechanisms.

Offer information to the patient e.g. information prescription.
Consider referral for additional support e.g. Macmillan nurse.
Explain potential role for a variety of therapies e.g. relaxation therapies, creative
therapies etc.
Consider discussion with palliative care specialist.
Consider referral to psychiatrist if patient expresses suicidal thoughts and plans,
has previous psychiatric history or if condition resistant to treatment.
Consider referral for psychological therapies e.g. Cognitive Behavioural Therapy
(CBT) via Improving Access to Psychological Therapies service (IAPT).

PHARMACOLOGICAL TREATMENT

Anxiety
Short term - either lorazepam 0.5 to 1mg four times daily as required sublingual or
oral or diazepam 2 to 5mg three times daily as required.

Longer term - consider trial of SSRI antidepressant.

Acute anxiety state

Sedate with lorazepam 1mg, may need up to 2.5mg sublingual or oral, max 5mg
daily.
If available midazolam 10mg subcutaneously (half this dose in the elderly), up to
60mg in 24 hours, reassess and review need for further doses.

Agitation
Haloperidol 3 to 5mg subcutaneously, as bolus – can be repeated after 30
minutes to a maximum of 20mg in 24 hours. Regular reassessment is required –
look for a precipitating cause e.g. acute physical or psychological change (contact
specialist if problems persisting).

Depression
Consider the burden of additional medication.
Preferably choose a once daily formulation.

Where treatment is aimed solely at “depression” use SSRI e.g. sertraline 50 -

200mg daily. Where the patient has other symptoms e.g. poor sleep, poor appetite
which may respond to the side effects of an alternative antidepressant consider
e.g. mirtazapine 15mg – 45mg at night.

Explain antidepressant will take several weeks to achieve maximum effect.

Plan to increase to full therapeutic dose over three weeks but reassess at each
increment.
Ensure ongoing reassessment once treatment is established.

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IF PROBLEMS PERSIST, PLEASE SEEK SPECIALIST ADVICE

General palliative care references include:

‘Palliative Care Formulary’, Fourth Edition (PCF4)
Edits: Robert Twycross and Andrew Wilcock available via Palliativedrugs.com

Palliative Adult Network Guidelines Third Edition (also available as an App)

Edits: Max Watson, Caroline Lucas, Andrew Hoy, Ian Back, Peter Armstrong

NICE Guidance – Anxiety and Depression

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