Distinguishing between sadness and depression at the end of life.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

Professor Gregory Crawford

The Australian Palliative Care Association published an insightful interview by Heather Wiseman with Professor Gregory Crawford titled - Distinguishing between sadness and depression at the end of life: a significant challenge tackled by a leader in palliative care.

Depression is an important issue knowing that a study from Oregon indicated that 26% of the people who had asked for assisted suicide were depressed while a Netherlands study found that depressed people were 4.1 times more likely to request euthanasia.

Professor Crawford who is the president-elect of the Australasian Chapter of Palliative Medicine for the Royal Australian College of Physicians did his doctoral thesis on ‘Depression in palliative care in Australia: identification and assessment.’

In the interview, Crawford responds to the question of distinguishing between sadness and depression. He states:

There has been a large amount of research in this area, but it is still very difficult to really determine what is a normal reaction to what is happening, like sadness, and what is an abnormal reaction, like a major depressive illness. 

Not everybody at the end of life is depressed and you wouldn’t want to make a diagnosis that isn’t there. Equally, there is still a large stigma in our society associated with being diagnosed with a mental illness, and another challenge is that the treatments are not necessarily simple. Most are oral medications that have interactions and side effects and they are slow to make a difference. 

The bottom line, however, is that this isn’t easy. I am confident that I can make a significant difference to 90% of people who turn up to me with pain, but I don’t have the same confidence with depression or other psychological issues. They are harder to treat and there are fewer treatment options.

Crawford commented on the importance of treating depression:

The implications of not diagnosing are that patients have increasing suffering and may not be getting the best treatment. They may be losing an opportunity to have more time or meaningful interaction with people around them. For their families, this can be a very large trauma; to not understand why somebody has turned their back on them or why they might be rejecting relationships, being overwhelmingly sad, or wanting to die precipitously. When triggered by depression, those responses can be quite challenging.

Professor Crawford focus on depression and palliative care based on his personal experience:

One of the motivators was that I looked after a 15-year-old girl who had a malignancy who looked like she was dying. I was working as the clinical head of palliative care at a hospital in Adelaide, and she was referred to us on the basis that she only had weeks to live. She had difficult pain to manage and other symptoms that led to her becoming more and more withdrawn. 

I was slow to recognise that she was depressed and I found it hard to find advice and support about to manage it. 

I looked in the literature and talked to psychiatrists and other colleagues. I ended up changing her antidepressants and she made a miraculous improvement, both physically and psychologically. She improved and lived for another 12 months. She had serious, progressive disease but her physical function and her ability to interact and live improved. She went off on a holiday, achieved some other things on her wish list and made lots of other nice memories for her family.
She died at home, supported by our palliative care service and her GP, and we had support from the paediatric palliative care service. 

It showed me that sometimes the symptoms of impending death and the symptoms of advanced depression can look very much the same. I felt a bit like I had failed, having taken so long to recognise her depression and then act on it, which made me determined to learn more about depression in this context. It drove me to try and understand more about psychological illness.

The comments by Professor Crawford are particularly important considering that the Netherlands and Belgium permit euthanasia for psychiatric reasons while Canada is debating expanding the euthanasia law to permit euthanasia for psychiatric reasons.

Professor Crawford is chairman of Palliative Care SA, a senior consultant in palliative medicine and the director of research and education at the Northern Adelaide Palliative Service, and president-elect of the Australasian Chapter of Palliative Medicine for the Royal Australian College of Physicians.