Is it true that depression is invariably present and can be considered normal in patients with advancing illnesses, such as cancer, neurodegenerative diseases, or end-stage organ failure?

Depression in Advanced Illness: False

The statement is FALSE—depression is NOT invariably present in advancing illnesses and should never be considered normal or an expected consequence of serious disease. 1

Prevalence Data Contradicts "Invariable" Presence

While psychological distress is common in advanced illness, actual clinical depression affects only a minority of patients:

• Approximately 15-18% of patients with advanced illness meet diagnostic criteria for major or minor depression 2, 1
• Using diagnostic interviews (the gold standard), depression prevalence is only 15% (range 6-32%) in cancer-predominant palliative care populations 1
• This rate is two to three times higher than the general population (15%), but far from universal 3
• The yearly incidence of new depressive symptoms ranges from only 1.8% to 17% 1

Depression is a Treatable Medical Condition, Not a Normal Response

Depression must be distinguished from normal grief and sadness, which ARE expected responses to advancing illness. 1 The critical clinical error is conflating these distinct entities:

• Depression is a treatable emotional disorder that requires evaluation and intervention 1
• The American Thoracic Society explicitly recommends mental health consultation to assess whether depression is "the root cause of intractable suffering" before considering interventions like palliative sedation 1
• Both antidepressants and psychotherapy are effective in treating depression in patients with advanced cancer and other serious illnesses 2, 3

Clinical Consequences of Untreating Depression

Failing to recognize and treat depression as abnormal has severe consequences for morbidity, mortality, and quality of life:

• Depression is an independent predictor of poor survival in advanced cancer and increases mortality risk 4, 5
• Depression is associated with four-fold higher rates of euthanasia requests and significantly increases desire for hastened death 1
• Depression preferences to limit life-sustaining therapy may change after successful treatment, requiring reevaluation of end-of-life preferences after adequate treatment time 1
• Depression reduces quality of life, decreases treatment compliance, prolongs hospitalization, and reduces functional capacity 2, 6, 4

Screening and Assessment Requirements

Guidelines mandate routine screening for depression in patients with advanced disease, explicitly because it is NOT normal: 1

• Advanced disease and worsening symptoms are risk factors for depression, not guarantees of its presence 1
• Prevalence increases as patients become sicker, but depression remains frequently underdiagnosed and undertreated 2, 4
• The American College of Physicians recommends screening at initial visits for patients with cancer affecting oropharynx/GI tract or advanced cancer 1

Common Pitfall to Avoid

The most dangerous clinical error is dismissing depression as "understandable" or "normal" given the circumstances. This therapeutic nihilism leads to:

• Failure to screen and diagnose a treatable condition 2, 4
• Unnecessary suffering that compromises quality of life 1
• Potentially shortened survival that could be extended with treatment 5
• Distorted end-of-life decision-making that may not reflect the patient's true values 1