The development of evidence-based European guidelines on the management of depression in palliative cancer care

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Abstract

Depression is common in cancer patients, particularly those with advanced disease. It is associated with adverse outcomes such as increased pain, disability and poorer prognosis. Our aim was to produce a European evidence-based clinical guideline on the management of depression in patients receiving palliative care to inform practice, establish policy, promote European consensus and ultimately improve patient outcomes. Recommendations were devised using the best available evidence. Where evidence was absent or equivocal, Delphi consensus methods were implemented to elicit and refine expert opinion. Evidence was graded according to the process proposed by GRADE. The resulting guideline has three main sections: (1) prevention; (2) detection, diagnosis and assessment; and (3) treatment. The prevention section outlines strategies such as optimal palliative care and support, effective communication and information-giving. The detection section provides recommendations on symptoms, screening, diagnosis and severity assessment. The treatment section gives guidance on treatment decisions including choice of psychological therapy and antidepressant medication. This is the first comprehensive, evidence-based guideline on managing depression in palliative care. It has the potential to improve patient outcomes by enabling clinicians to access and implement evidence-based knowledge quickly and easily.

Introduction

Depression is common among patients with cancer and particularly those receiving palliative care. A systematic review by Hotopf et al. in 2002 found a median prevalence of 15% for major depression in advanced disease.1 Depression compounds the physical consequences of advanced disease. It is associated with disability, pain and fatigue,2, 3, 4 and there is evidence that depressed patients have poorer prognosis and higher mortality in a range of physical illnesses.5, 6, 7 Detecting depression in palliative care is difficult as somatic symptoms (e.g. poor appetite, sleep disturbance and fatigue) may be due to depression, advanced disease or medical treatment.8 Also, depression is difficult to distinguish from normal fear and distress,9 which often accompany terminal illness. In patients with advanced disease, the coexistence of multiple symptoms makes drug interactions more likely and treatment more complicated. Though antidepressants have been shown to ease depression in physically healthy people, there is doubt about whether they are appropriate for terminally ill patients.10 Psychological therapy is the other recommended treatment for depression,11, 12 but questions surround its feasibility, acceptability and availability in palliative care.13, 14

In 2009, the UK National Institute for Health and Clinical Excellence (NICE) published recommendations for the management of depression in people with a chronic health problem. This guideline covered primary, secondary and tertiary care but specified that palliative care was outside its remit.11 Depression in palliative care poses particular challenges and clinicians need clear guidance on improving outcomes at the end of life. A pragmatic report from the European Association of Palliative Care (EAPC) in 2001 highlighted the problem of under-detection and under-treatment of depression in palliative care. This report called for collaboration between palliative care and mental health professionals and integration of clinical experience and scientific evidence in order to establish best practice.15

The European Palliative Care Research Collaborative (EPCRC) was established through the EAPC Research Network in 2006, with funding from the European Commission.16, 17 The collaborative brought together 11 centres in six European countries, with the aim of improving the management of cachexia, pain and depression through translational research. The scientific work within the EPCRC spans three main strands: (1) genomics, (2) symptom assessment and classification, and (3) guideline development and dissemination. Clinical practice guidelines were developed to assist palliative care professionals in managing each of the three symptoms – pain, cachexia and depression. This paper outlines the development of the EPCRC depression guideline and provides a summary of its key recommendations.

Section snippets

Materials and methods

The guideline was developed in accordance with the methods of the National Institute for Clinical Excellence (NICE).18 Recommendations were devised using the best available evidence. Where evidence was absent or equivocal, Delphi consensus methods were implemented to elicit and refine expert opinion. The quality of evidence and the strength of recommendations were determined using the GRADE system.19

Guideline content

The following section briefly summarises the guideline’s key recommendations.

Discussion

The translation of research findings into systematically developed guidelines has been found to improve patient outcomes by bringing evidence-based knowledge into clinical practice.93, 94, 95 The EPCRC depression guideline was developed to address the lack of guidance on managing depression in patients receiving palliative care. It draws together the most current and important evidence in the field, enabling clinicians to access and implement new knowledge quickly and easily.

This is the first

Contributions

L.R.: coordinating guideline development – including expert group meetings, Delphi study, Cochrane review, guideline consultation, literature review, writing recommendations, grading evidence. A.P.: identifying clinical priorities, conducting Cochrane review. M.H.: winning peer review funding for project; supervision of guideline development – including expert group meetings, Delphi study, Cochrane review, guideline consultation, literature review, writing recommendations, grading evidence.

Role of funding source

This work was performed on behalf of the European Palliative Care Research Collaborative. The European Palliative Care Research Collaborative is funded by the European Commission’s Sixth Framework Programme (Contract No. LSHC-CT-2006-037777, EPCRC) with the overall aim to improve treatment of pain, depression and fatigue through translation research. Core scientific group/work package leaders: Stein Kaasa (Project Coordinator), Frank Skorpen, Marianne Jensen Hjermstad, and Jon Håvard Loge,

Conflict of interest statement

M.H. is an independent expert witness (instructed by the claimants’ solicitor) in a group litigation on the potential for paroxetine to cause adverse events on withdrawal of treatment. L.R., A.P. and I.J.H. do not have any competing interests. No competing interests were declared by the members of the expert group.

Acknowledgements

The funders of the study had no role in study design, data collection, data analysis, data interpretation or the writing of the paper.

We thank Marjolein Bannink, Stephen Barclay, Augusto Caraceni, Trudie Chalder, Harvey Chochinov, Marilène Filbet, Pam Firth, Luigi Grassi, Jane Hutton, Jenny Kieldsen, David Kissane, Nigel Konzon, Iain Lawrie, Sally List, Mari Lloyd Williams, Jon Håvard Loge, Kathryn Mannix, Stirling Moorey, Maria Nabal, Mike Philpot, Holly Prigerson, Lukas Radbruch, Peter

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