Physical symptoms commonly associated with depression can be caused by physical illness or treatments so may be less helpful in establishing a diagnosis. These can include:

• weight/appetite change
• insomnia
• loss of energy
• fatigue
• psychomotor slowing
• loss of libido.

Depressive symptoms in palliative care patients include:

• greater severity of dysphoric mood
• excessive feelings of guilt, worthlessness, hopelessness
• social withdrawal and loss of pleasure in daily activities
• a wish for earlier death (or suicidal ideation)
• a positive response to the question “Do you feel depressed?”

Risk factors for depression in palliative care can include:

• personal or family history of depression
• concurrent life stresses
• multiple losses
• unfulfilled life aspirations
• absence of social support
• history of substance misuse/dependence
• oropharyngeal, pancreatic, breast and lung cancers (more common).

Additional barriers to diagnosis exist and include:

• patient/family feeling that a “fighting spirit” is needed to maximise active treatment/ support from health professionals
• difficulty deciding whether depression is a primary problem or reflects suboptimal symptom control
• concerns about polypharmacy and drug interactions
• other physical/ psychological conditions mimicking depression:
• exclude hypoactive delirium
• exclude hypothyroidism
• screen for dementia
• review medication (QThaloperidol can cause motor retardation).
• complex care packages; many staff involved and lack of continuity.

A number of assessment tools are available. In primary care, the PHQ-9 can be used as a screening tool. The brief Edinburgh Depression Scale is suited to palliative care patients. The Hospital Anxiety and Depression questionnaire is widely available, has a focus on physical symptoms, and is widely used.