Treatment of Depression at the End of Life: Clinical and Ethical Issues

The issue of "treatable depression" in terminally ill patients has been raised in discussions of physician-assisted suicide. However, the role of psychiatry in palliative care remains largely undefined. Studies have documented a major depression prevalence in hospitalized patients with acquired immunodeficiency syndrome (AIDS) and cancer of 17% to 36% and in terminally ill patients from 9% to 17%. No randomized, controlled trials of depression treatment in the terminally ill have been completed. Tricyclic antidepressants and selective-sertonin reuptake inhibitors (SSRIs) have been proven effective in randomized trials for major depression in patients with cancer or human immunodeficiency virus (HIV) infection. Psychostimulants have shown effectiveness by randomized trial in medical inpatients, but only by case series in the terminally ill. Randomized trials have shown the effectiveness of psychotherapies for depression in cancer (ie, cognitive behavioral) and HIV-infected patients (ie, interpersonal). An open trial suggests effectiveness for problem-solving therapy for terminally ill patients. In summary, the treatability of depression in the terminally ill remains to be proven by randomized trials.