Virtually all patients experience 'preparatory grief' (Kubler-Ross, 1997) when faced with the prospect of impending death. These feelings are usually present for a variable period of time and then often diminish in intensity over time. In some patients the dysphoria persists in great intensity and may be associated with a sense of hopelessness, helplessness, worthlessness, negative self-image and an active desire for an early death. Such patients are thought to be clinically depressed. Depression is one of the most common psychiatric illnesses affecting terminally ill patients with an estimated prevalence varying between 3% and 45 % (McDaniel et al., 1995 ;Minagawa et al., 1997;Plumb and Holland, 1997;Hotopf 2002). Depression significantly decreases terminally patients' quality of life (Hotopf 2002) and also complicates the optimal palliation of other physical symptoms present secondary to the terminal illness. If diagnosed and treated appropriately, depression can be significantly alleviated even in terminally ill patients.
Challenges exist in the diagnosis of depression at the end of life for the following reasons:
โขt he vegetative signs of depression including weight changes, sleep problems, loss of libido etc. are often present secondary to the patients' advanced illness; and