Medical concepts of depression in the palliative care setting: perspectives from palliative medicine specialists and psychiatrists.

Abstract

Depression is one of the focus areas within the scope of palliative care, but its conceptual ambiguity poses many challenges for clinicians. This ambiguity is arguably more pronounced in the palliative care setting, given the confluence of advanced illness and potential psychosocial, existential and spiritual ramifications at the end-of-life. The existing literature indicates that clinicians hold various notions about depression, which could impact on the diagnosis and treatment of depression. Similarly, conceptual diversity is evident in the palliative care research literature on depression and precludes meaningful meta-synthesis of their findings. This core problem of concept forms the topic of this thesis, which reports on research that explored medical concepts of depression in the palliative care setting. This thesis is comprised of three studies and is presented in publication format. Study 1 was an exploratory study and a prelude to the other studies. Through the use of a questionnaire, it explored broad concepts of depression that were held by medical practitioners practising in palliative care. In addition to demonstrating conceptual variations, it identified some areas of conceptual differences specific to depression in the palliative care setting, which contributed to the design of Studies 2 and 3. These two studies sought to understand and characterise the conceptualisations of depression from the respective perspectives of palliative medicine specialists and psychiatrists working in the Australian palliative care setting. These medical specialist groups were chosen for their recognised expertise and authority on end-of-life medical care and depression. The two qualitative studies used purposive sampling, a semi-structured, in-depth interviewing technique, and the theoretical framework of Kleinman’s Explanatory Model. Thematic analysis was performed on verbatim transcripts. The findings of the three studies are presented in the form of five papers. Paper 1 reports on the questionnaire study, while the other four papers report on selected aspects of Studies 2 and 3, as determined by the chief thematic domains that were identified through data analysis. The contents are organised in the following manner: Paper 2 focuses on palliative medicine specialists’ concepts of depression; Paper 3 on palliative medicine specialists’ causal explanations for depression; Paper 4 on palliative medicine specialists’ treatment approaches for depression; and Paper 5 on psychiatrists’ concepts of depression. In this thesis, it is demonstrated that depression was not a unitary concept among medical practitioners in the studies, but varied within and between medical disciplines. For palliative medicine specialists, depression involved divergent ontological perspectives that called for an absolute judgement on normality versus pathology on the one hand, and contextual understanding on the other. These perspectives were difficult to unite and gave rise to anxiety over diagnostic boundaries and errors. In comparison, psychiatrists more overtly articulated the heterogeneity of depression and accommodated its multifarious natures using different conceptual models. Specific challenges were highlighted for depression in the palliative care setting, relating to its conceptualisation, diagnosis and treatment. A direct link was also supported between the concept of depression, its causal explanation and treatment approach. The findings of this thesis have implications for future research on depression in the area of palliative care, developments in treatment guidelines for depression in this area, medical education and professional development for palliative care clinicians, service models for the interfacing of palliative care and psychiatry, and developments in psychiatric nosology and causal explanation frameworks. Furthermore, the central relevance of conceptualisation to clinical practice is illustrated.