The clinical epidemiology and management of depression in palliative care

Student thesis: Doctoral ThesisDoctor of Philosophy


ACKGROUND: The management of depression in palliative care is impeded by inadequate understanding of the nature of depression in this context. Estimates of the prevalence of depression in palliative care vary widely and very few studies have assessed remission. Further, there is concern that somatic symptoms common in advanced disease may confound diagnosis. Whilst antidepressants are the mainstay of treatment in the general population, their efficacy and acceptability in palliative care are unclear. -- AIM: To provide new knowledge on the clinical epidemiology and pharmacological treatment of depression in palliative care, and consolidate this evidence in a clinical guideline to inform and improve future practice. -- METHODS: A cross-sectional survey with 4-week follow-up was conducted to determine the prevalence and remission of depression in patients newly referred to specialist palliative care. Presence of depression was assessed using the PRIME-MD PHQ-9. The predictive value of somatic symptoms was assessed by calculating the PPV and NPV of EORTC-QLQ-30 items on sleep disturbance, poor appetite and fatigue. A systematic review and meta-analysis was undertaken to determine whether antidepressants are appropriate for palliative patients. Due to the dearth of data in advanced disease, the efficacy and acceptability of antidepressants and placebo were compared in RCTs of patients with any physical illness. In addition a subgroup analysis of patients with life-threatening illness was performed. Outcomes were assessed at 4 time-points (4-5, 6-8, 9-18 and >18 weeks). Data from the survey and meta-analysis informed the development of a clinical guideline on the management of depression in palliative care, and a Delphi study was conducted to elicit expert opinion where evidence was absent. The GRADE system was used to indicate the quality of evidence and strength of recommendations.
Date of Award2012
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorMatthew Hotopf (Supervisor) & Irene Higginson (Supervisor)

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