Blogs to Boards: Question 13

A 54 yo man with a 7 month history of metastatic bladder cancer presents to the cancer center’s palliative care clinic. He complains of low mood, anhedonia, feelings of guilt, shame, and worthlessness most days for the last 2 months.  He says, “Of course I’m depressed – who wouldn’t be? I’ve got a cancer that the doctors tell me is terminal. What good am I to my family? They’d be better off without me.”

The best next step would be to:

  1. Tell the patient that he is depressed and recommend a treatment plan for it.
  2. Ask your team’s social worker to see the patient for grief counseling.
  3. Provide emotional support and counseling with the patient that what he is experiencing is part of the expected adjustment to having a terminal illness.
  4. Refer the patient to psychiatry for complicated depression.

Discussion: Correct answer is (a)

  1. Psychiatric disorders including depression and anxiety disorders occur in only a minority of patients at the end of life. Published numbers have ranged from 10-40%; while higher than the general population, they are not the norm. Persistent low mood, feelings of worthlessness, guilt, and shame are highly suggestive of depression. The patient should be counseled about this and offered treatment.
  2. While this may end up being appropriate for this patient, his symptomotology is most c/w depression and a) is the better answer.
  3. See (a).  This is not ‘normal.’
  4. Complicated depression is not a diagnosis. He has untreated depression, and HPM specialists should be able to initiate appropriate therapy!