Abstract
Dear Editor:
The incidence and mortality of hematologic malignancies have steadily increased, and most patients with advanced disease eventually face physical, psychiatric, and psychological symptoms, treatments, or comorbidities.
The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families. Patients with advanced, irreversible disease need palliative care in every country of the world. Palliative care was not considered a priority even in developed countries for a long time. Terminally ill patients have been sent home with a limited amount of medication, with no assured follow-up. Palliative care is a culturally sensitive issue and requires a specific approach that reflects diverse realities, including those at the local health system level. The challenges to the implementation of palliative and hospice care in low-income countries are significant.
Depression is common among patients with hematologic malignancies and particularly those receiving palliative care. It is one of the most common psychiatric diseases seen in patients with advanced cancer. Due to the lack of recognized criteria, prevalence estimates vary widely from 5% to 26% for major depression and from 7.2% to 25.7% for minor depression in those patients with advanced cancer. 1 Reported rates of depression varied from 1% among patients with acute leukemia to over 40% of patients with other malignant diseases.2,3 The diagnosis of depression depends on the presence of cognitive/psychological symptoms (e.g., hopelessness, suicidal ideation, guilt, worthlessness). Diagnosing depression in a palliative-care population is fraught with difficulty for reasons that include the significant overlap between the somatic symptoms of depression and symptoms of end-stage disease or its treatment. It is important to recognize and treat depression during the course of cancer, especially in palliative stages where particular emphasis is on quality of life. 4
Factors associated with depression in this population include increased frequency and intensity of physical symptoms, lower general well-being, increased mortality, and a hastened desire to die. There is a growing body of evidence linking various measures of psychological distress, including diagnosed depression and anxiety disorders, with such problems as pain, weakness or fatigue, and low functional status. Despite clear evidence that depression is an important symptom in advanced disease, depression is rarely formally assessed.
In countries with limited resources, emphasis on symptom control, especially depression, should be of highest priority, and should be integrated into the health care system. A range of policy options and technical options must exist to enable governments to ensure that medicines are consistently available and affordable. In resource-poor settings where there is little to treat depression, inexpensive interventions might be more acceptable. Conditions include poor availability, a lack of affordability, and poor prescribing practices. Although many medicines for chronic diseases are theoretically provided free or at low cost in the public sector, their availability is poor.
It has been noted that patients are not usually offered access to adequate psychological services in hematologic malignancies treatment. Lower levels of depression can contribute to the preservation of immunity capacities and to therapeutic adherence. It's important to recognize depressive disorders because, if untreated, they add to patients' suffering and hamper their ability to come to terms with their disease. When cure is not possible, the therapeutic approach of psychological signs and symptoms is often forgotten. Clinical depression is a serious psychiatric complication that can affect many such patients, causing significant additional suffering. It is well known that depression is frequently missed and therefore goes untreated. Doctors may attribute somatic symptoms of depression to the cancer illness, highlighting their tendency to separate mental from physical health. These conditions cause significant distress for not only the patient, but also the family and care team. Many palliative care staff are insufficiently trained in detecting depressive symptoms, communicating about emotional issues, or providing psychological care.
Despite such a difficult scenario, important initiatives have been taken and are in progress in several developing countries. The most effective approach to the management of these conditions is often a combination of nonpharmacologic and pharmacologic treatments. Psychological therapy is a recommended treatment for depression, but questions surround its feasibility, acceptability, and availability in palliative care. 5 Psychiatric consultation service should assess the psychiatric problems in cancer patients, as one of the strategies to improve the psychosocial care of patients. Antidepressant medication can mitigate symptoms of depression even in the final days and weeks of life. Amphetamines or neuroleptics can be used in patients with a very limited survival time. Family members play an integral role in symptom assessment, monitoring, and delivery of complex therapeutic interventions. Caring for a palliative cancer patient in the home forces the family to reorganize as they learn the intricacies of caring for the dying. Although many medicines for chronic diseases are theoretically provided free or at low cost in the public sector, their availability is poor. Allocations of resources to address this burden remain very low in low-income countries.
The provision of simple psychological support by members of the hospice care team can often be extremely effective. Training and educating health professionals is necessary. This, combined with pain management and easing of some of the social and financial burdens, can improve the patient's mood. Palliative care that will provide maximum quality and duration of life for such patients presents a challenge.