1. Depression in the Veteran Hospice Patient Courtney Butler, MSW, MPH Director of Clinical Support Services December 17 th, 2013

2. What is Depression? The act of feeling sad or blue is experienced by almost everyone. These feelings are typically short in duration and are temporary. Depression, however, interferes with a person’s ability to function on a daily basis and often requires treatment to manage symptoms. (National Institute of Mental Health, 2013)

3. What is Depression? Major depressive disorder, or major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. Some people may experience only a single episode within their lifetime, but more often a person may have multiple episodes (National Institute of Mental Health, 2013)

4. Signs and Symptoms of Depression Social withdrawal Increases/ decreases in sleep Changes in appetite Fatigue or decreased energy Difficulty concentrating, problems with memory Loss of interest in activities/ hobbies that were once pleasurable Irritability, restlessness

5. Depression in the Veteran Traumatic events and/ or stressful situations that occur in military life can be associated with depression in Veterans and Service members. This includes: Death of a friend or family member Traumatic events such as combat, injury, natural disasters, or physical/ sexual abuse Health problems or disabilities Retirement (U.S. Department of Veteran Affairs, 2011)

6. Depression in a Terminal Patient Virtually all patients who are faced with dying experience episodes of sadness. These sad feelings are usually very intense for a variable period of time and then often gradually diminish in intensity. Depression, however, is not inevitable and should not be considered a normal part of the dying process. (Periyakoil, V. & Hallenbeck, J., 2002)

7. Signs and Symptoms of Depression in a Terminal Patient Sadness, tearfulness Hopelessness, helplessness, worthlessness Social withdrawal, Lack of pleasure Guilt Suicidal ideation Intractable pain or other symptoms Excessive somatic preoccupation Disproportionate disability Poor cooperation or refusal of treatment of symptoms

8. Grief in Terminal Patients Persons who are dying prepare for their death by mourning the losses implicit in death. The anticipated separation from loved ones is an obvious one. Simple pleasures of living may be grieved. People may reflect on their past and relive great moments and disappointments, and mourn for missed opportunities. Looking to the future, they may grieve the loss of much-anticipated experiences such as a child’s graduation or the birth of a grandchild. (Rando, T.A., 2000)

9. Grief or Depression? Grief and depression have similar symptoms, including sadness, changes in appetite, changes in sleeping patterns, tearfulness, and decreased interest in activities that once brought pleasure (Sadock, B. & Sadock, A., 2003)

10. Grief versus Depression in the Terminally-Ill Patient G RIEF Patients experience feelings, emotions, and behaviors that result from a particular loss that comes in waves, but diminishes over time Patients who are grieving maintain a normal self-image Patients express passive wishes for death to come quickly D EPRESSION Patients experience feelings, emotions, and behaviors that fulfill criteria for a major psychiatric disorder that is persistent over time Patients who are depressed can display a sense of worthlessness and maintain a poor self-image Patients express intense and persistent suicidal ideation (Block, 2000; Periyakoil, V. & Hallenbeck, J., 2002)

11. Grief versus Depression in the Terminally-Ill Patient G RIEF A person that is grieving maintains a sense of hope; hope may shift focus Patients that are grieving typically need social interaction to help process the grief Patients retain the capacity for pleasure D EPRESSION Pervasive hopelessness Patients who are depressed do not derive pleasure from social interactions; typically socially isolated Patients enjoy nothing ((Block, 2000; Periyakoil, V. & Hallenbeck, J., 2002)

12. Treatment Medication Introduction of anti-depressant medication Changes to medication regimen Counseling Education Increase social supports Skill development

13. Treatment-Grief RELIEVER R eflect E mpathize L ead I mprovise E ducate V alidate the E xperience R ecall (Periyakoil, V. & Hallenbeck, J., 2002)

14. Treatment-Depression Medication Treatment How long is the patient likely to live? What side effects do you want to avoid? What side effects might enhance quality of life? Counseling Explore fears surrounding abandonment, fear of the unknown death, fear for loved ones, and fear of the afterlife/ future

15. QUESTIONS