A 75-year-old woman with stage 4 breast cancer with brain metastases is admitted to hospice with a life expectancy of 2-4 weeks. She responded poorly to her last chemotherapy treatment and decided with her family that palliative care was best. Although her pain is fairly well controlled, the patient has very poor appetite, little energy, and sleeps for most of the day. She often does not get up for meals and has lost 3.6 kg (8 lb) in the past week. During a family visit, the daughter notices that the patient is quieter than usual and appears very depressed; she says, "She barely responds to us anymore and just cries softly."
Physical examination is unchanged. The patient is alert and oriented. When the physician asks the patient about her mood she says, "Of course I am depressed given my situation. I'm just so hopeless and tired."
In addition to providing support, which of the following is the most appropriate next step in management of this patient?

Question

A 75-year-old woman with stage 4 breast cancer with brain metastases is admitted to hospice with a life expectancy of 2-4 weeks.  She responded poorly to her last chemotherapy treatment and decided with her family that palliative care was best.  Although her pain is fairly well controlled, the patient has very poor appetite, little energy, and sleeps for most of the day.  She often does not get up for meals and has lost 3.6 kg (8 lb) in the past week.  During a family visit, the daughter notices that the patient is quieter than usual and appears very depressed; she says, "She barely responds to us anymore and just cries softly."
Physical examination is unchanged.  The patient is alert and oriented.  When the physician asks the patient about her mood she says, "Of course I am depressed given my situation.  I'm just so hopeless and tired."
In addition to providing support, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Major depression in terminally ill patients is under-recognized and undertreated as physicians may assume that depression is a normal part of the grieving process. After ensuring adequate pain control and providing support, physicians should have a low threshold for pharmacological treatment with the goal of alleviating patient and family distress and facilitating emotional connection in the last weeks of life. The patient's anticipated life expectancy should guide medication selection. First-line treatments for depression such as selective serotonin reuptake inhibitors (eg, escitalopram) typically require several weeks to take effect and would be appropriate for patients with a life expectancy of several months (Choice B). In patients whose life expectancy is only 2-4 weeks, psychostimulants (eg, methylphenidate, dextroamphetamine, modafinil) are preferred due to their faster onset of antidepressant action. Stimulants may also be useful in counteracting general fatigue and opioid-related sedation. They are generally well tolerated, and improvement in mood and energy can be seen within 1-2 days. (Choice A) Electroconvulsive therapy (ECT) can achieve a more rapid response in severely depressed patients compared to medication. However, this patient's brain metastases are a relative contraindication to ECT, and its use would be inconsistent with palliative care's goal of providing nonintrusive comfort care. (Choice D) Mirtazapine is a first-line antidepressant that is particularly helpful in patients with anorexia and insomnia due to its appetite-stimulating and sedating properties. However, like other antidepressants, it typically requires weeks to take effect. (Choice E) Although it can be difficult to differentiate grief from major depression in terminal illness, this patient's severely depressed mood, withdrawal from family, and despondency are concerning for depression. A rapid antidepressant response could alleviate her suffering and improve quality of life in the weeks she has left. Patients, families, and physicians should not underestimate the impact of depression under the assumption that anyone in the same situation would be depressed. Educational objective: Depression in terminally ill patients is undertreated. Due to their rapid onset of action, psychostimulants should be considered for treating depressed palliative care patients with a life expectancy of days to weeks. __________ References: Managing grief and depression at the end of life. (http://www.ncbi.nlm.nih.gov/pubmed/22962989) Effects of methylphenidate on fatigue and depression: a randomized, double-blind, placebo-controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/22208450)

A 75-Year-Old Woman with Stage 4 Breast Cancer with Brain