Third Annual Compassionate Care Conference
N. Gregory Hamilton, M.D.
October 2, 1999
SOME NOTES ON TREATING DEPRESSION AND ANXIETY IN THE SERIOUSLY
Use tact and timing in delivering the diagnosis and prognosis for
patients with serious illnesses to help prevent depression and anxiety.
Some suggested approaches include:
Speak with clear, honest directness without fearing the truth.
Listen and watch for the patient's reaction.
Respect the patient's style of coping, as well as their own strength
and ability to deal with adversity (Zerbe, 1999a, p. 209).
Honestly acknowledge that nothing is known with 100% certainty in
medicine. "Anyone who has practiced medicine very long has seen surprising
Help the patient "prepare for the worst and hope for the best." Reassure
the patient that you will be with them; this is an acknowledgment
of your commitment to them as a human being and to the fact that
you provide twenty-four-hour-a-day medical coverage through your
practice or clinic. Your reassurance will not be misinterpreted as
a promise to personally remain in day and night personal attendance. "Most
fundamentally, clinicians can serve the dying person by being present"
(Byock, 1996, p. 250)
Empathize when appropriate. Remember, the patient's talking and
the clinician's listening has been repeatedly documented to be associated
with more functional and meaningful days, less pain, fewer physical
symptoms, less depression and anxiety, and even longer life (Spiegel,
1993, 1999; Spiegel et al., 1989).
Tolerate whatever feelings of helplessness or loss you may have
without needing to take abrupt or definitive action (Hamilton, 1996;
Hamilton & Hamilton, 1999).
Always remember that simply listening and understanding is a clinical
Respect and encourage the patient's healthy defenses. The most healthy
defenses (Vaillant and Vaillant, 1990; Soldz and Vaillant, 1998)
are: suppression, sublimation, humor, altruism, and anticipation.
Suppression is the ability to recall and focus on adversity while
also being able to set it aside temporarily to attend on other things
(i.e.. sources of satisfaction, meaning, joy, and love). Suppression
is more adaptive than other forms of putting something out of mind,
because it is more flexible and does not deny reality.
Denial is the sweeping, emergency psychological defense of recognizing
a fact while simultaneously denying its very existence. "I do not
have this cancer and I am not going to die from it."
Repression does not deny the existence of something but unconsciously
and automatically relegates it to the realm of the forgotten. "I
can't remember our ever talking about the likely outcome of this
illness." Suppression is the healthy setting aside of difficulty
in order to get on with life. "Yes, my daughter and I have talked
about the fact that I may not be with her very much longer, and we
have shed our tears and will again. But I am not there yet. For now,
we would rather talk about how my granddaughter is doing at her figure
skating. Did I tell you she ... "
Supportive psychotherapy is not confined to the offices of psychiatrists;
it is a common, if often unnoticed part of everyday clinical practice.
It encourages healthy defenses (Gabbard, 1994), such as suppression,
humor, anticipation (realistic, hopeful planning for the future),
sublimation (work, creative activity, spiritual endeavors), and altruism
(helping others), while helping patients overcome anxieties and fears
which may lead to maladaptive defenses.
Support and, when appropriate, encourage religious devotion. While
it should not be imposed, clinicians should recognize that religious
devotion has been empirically demonstrated to be associated with
improved recovery from depression and with numerous other health
benefits (Koening et al, 1998. Mitka, 1998).
Encourage self-help efforts in the areas of healthy behaviors (Zerbe,
1999b). Many of these behaviors are the very ones people find difficult
to do when they are depressed, anxious, or medically ill. It is best
to refrain from admonishing the patient to do these things; just
remind them that if they can bring themselves to do these things,
they are likely to help.
Some behaviors which clinical experience has shown to help include:
Eating regular, small, healthy meals whether or not you are hungry.
Going to bed and getting up at the same time daily whether you sleep
well or not. Light, regular exercising, such as walking, or even
physical therapy for those restricted to bed. Working, even a very
reduced amount. Engaging in social activities, even if they are superficial
and brief. Pursuing creative activities such as painting, drawing,
writing, crafts or hobbies. Engaging in prayer or organized religious
services. And helping others, even if only through a telephone call
or word of encouragement.
When helping a patient look for meaningful interests and activities
as they adjust to diminished capacities, consider looking at their
previous interests with an eye to changing their scale in time and
space. A potted plant can be as beautiful as a terraced garden. An
inspired moment can provide a window to eternity. A still, small
moment can make all the difference. Ask your patient for what they
have discovered. What have they learned to find meaningful in their
new circumstances? What goals have they set for themselves in considering
their new limitation of physical ability and perhaps of time?
A diagnostic evaluation is the foundation for good treatment. Consider
depression or anxiety early and often. Treatable depression and anxiety
of clinical relevance is dramatically under diagnosed in the elderly
and medically ill (Lebowitz et al., 1997). Consider despondency or
anxiousness symptoms requiring diagnosis, as you would with a non-medically
While common, depression and anxiety are not inevitable concomitants
of serious illness. Many patients adjust to this life circumstance
while finding hope and meaning to the last moment. And many patients
who temporarily lose hope regain it when their anxiety or depression
lifts (Chochinov et al., 1999). Take a thorough history of the symptoms
including onset and course of illness, concomitant symptoms, previous
episodes of similar symptoms, family history, history of alcohol
or drug abuse, and physical illnesses or medicines which can cause
psychiatric symptoms. Take a history of current and past losses and
the patient's reactions to those losses, including their successful
coping strategies. Obtain appropriate laboratory studies, including
complete blood count, chemistry screen, and thyroid profile, as well
as other appropriate tests.
When symptoms of depression or anxiety might be caused either by
psychiatric illness or physical illness or its treatment, make both
diagnoses. An either/or approach to diagnosing physical or psychiatric
illness can lead to overlooking important diagnoses of therapeutic
relevance. When in doubt about whether you are treating an anxiety
disorder or a mood disorder with anxiety as one of its symptoms,
error on the side of placing mood disorder ahead of anxiety disorder
in your differential diagnosis. Anxiety is often a symptom of depression.
Inquire about suicidal ideation or feelings and take any such symptoms
seriously. These symptoms should be diagnosed and treated in seriously
ill individuals with the same care that they are addressed in other
individuals. Do not hesitate to obtain psychiatric consultation about
diagnosis even if you intend to treat the patient yourself. Most
patients experience referral for psychiatric consultation a sign
of competent and thorough medical care.
Treatment takes place within a confidant and compassionate doctor-patient
relationship (Hamilton, 1996; Hamilton et al., 1998). Consider the
patient's depression or anxiety disorder within an overarching biopsychosocialspiritual
model of human functioning to avoid overlooking important areas of
treatment. Reassure your patient that treatment is likely to be helpful.
The triad of "empathy, psychotherapy, and medication" can usually
alleviate even the most serious symptoms of depression and anxiety,
such as the wish to die (Hendin, 1998, p. 158).
Most primary care clinicians prefer to begin treatment with careful
listening and empathy combined with psychotropic medication, because
of time considerations and their training. Only a few minutes of
respectful and careful listening by the doctor, nurse, or social
worker can help the patient feel valued and cared about enough to
alleviate their depression or anxiety to a significant extent. Caring
about the patient and valuing them as a human being can have a beneficial
effect in itself (Hamilton et al., 1998; Zerbe, 1999b). When social
factors such as family discord, social isolation or economic distress
complicate the treatment, attend to these difficulties with as much
vigor as to physical causes of distress.
When necessary, obtain consultation and assistance from experts
in this area. When in doubt as to whether symptoms arise from physical
illness or medication or from primary depression or anxiety, most
clinicians treat both the psychiatric disturbance and the potential
physical causes simultaneously. When in doubt as to whether the primary
diagnosis is of a depressive disorder or an anxiety disorder, most
clinicians prefer to begin a trial of treating the depression, since
antidepressants can alleviate many kinds of anxiety disorders, but
some treatments of anxiety (such as higher doses of benzodiazepines
over an extended period of time) can at times exacerbate depression.
When using antidepressants or antianxiety medications, pay careful
attention to potential dangerous interactions with other medications
in these medically vulnerable patients. Pay careful attention to
any side effects. If a new symptom arises shortly after beginning
a new psychotropic medication in a medically ill patient, it may
be best to consider the new symptom to be caused by the medication,
instead of attributing that symptom to physical illness which may
also cause such symptoms. There are enough available antidepressants
with differing side effects that there should be low tolerance for
uncomfortable side effects. Most depressions or anxiety disorders
rapidly respond to listening, empathy and medication. If the patient
is not improving in six weeks, or if the patient is getting worse,
do not hesitate to refer to a psychiatrist for re- evaluation and
possible combined pharmacotherapy and psychotherapy.
Remember the caregiver. Caregivers can be the key to the well being
of the patient, yet they often feel neglected (McSkimming et al.,
1999). Maintaining hope in the caregiver can be as crucial to the
caregiver as it is for the patient (Zerbe, 1999b).
Take care of yourself. Remember that discouragement and anxiety
are to some extent contagious. When faced with discouraged or anxious
feelings about a depressed or anxious patient, consider the possibility
that the patient may have communicated with you in such a way that
you have empathized with and identified with their plight. Such feelings
can be used in the service of empathic understanding (Hamilton, 1996).
If you are tempted to base decisions or take action on feelings of
discouragement or anxiety instead of containing (Hamilton, 1996;
Hamilton and Hamilton, 1999) those feelings and using them clinically
to help the patient improve, seek consultation with a trusted colleague
and postpone decision making until you can regain your clinical balance.
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Hamilton, N.G. (1996). The Self and the Ego in Psychotherapy. Northvale,
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