Depression at the end of life: Podcast with Elissa Kozlov and Claire Ankuda

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Anne: And this is Anne Kelly.

Eric: Alex. We have some people on Skype.

Alex: From the Skype line joining us from the Garden State in New Jersey. We have Elissa Kozlov who is a clinical psychologist, researcher instructor at Rutgers university. Welcome to the GeriPal podcast, Elissa.

Elissa: Thank you.

Alex: And we have Claire Ankuda. Did I say that right? Did I get the emphasis on the right syllable?

Claire: Ankuda.

Alex: Ankuda, okay. Claire Ankuda, who is a palliative care physician researcher at Mount Sinai. Welcome to the GeriPal podcast Claire Ankuda.

Eric: Alex is struggling today. That’s because all he had for breakfast was an Apple, which he’s still eating right now. Well, Claire and Elissa, we’re going to be talking about depressive symptoms in the last year of life. You just had a great article published in JAGS on this particular subject. But before we talk about depression at the end of life, we always start off with a song request. Do you have a song for Alex?

Elissa: Yeah, we do. We would like to hear Hurt, but not the Nine Inch Nails version, the Johnny Cash version.

Eric: I was hoping Alex would break out all of like the synthesizer stuff for the Nine Inch Nails version.

Elissa: Or maybe merge them together.

Anne: Oh, there’s a challenge.

Eric: Okay. Trent, you’re ready?

Alex: (singing).

Eric: I love that song.

Elissa: You nailed it.

Eric: Elissa and Claire, why did you pick that song?

Claire: We pick this song because we both thought it really captures depression and many elements of depression, including the terrible social isolation and how cut off from other people folks feel when they’re depressed. I think it’s this experience in this that we see in our patients that really drove us to do this study.

Eric: And it’s an awesome song.

Claire: And it’s an awesome sone.

Eric: Let’s dive into the kind of article and we always start off with like, how did you get interested this in as a subject?

Elissa: Well, so as a psychologist, I’m always thinking about the mental health care of those around me. I trained in geriatrics and palliative care and just saw a lot of mental health symptoms that don’t always get addressed at end of life, which we understand there’s a lot of competing demands and sometimes a pain crisis might trump a mental health crisis, I get that. But we really wanted to explore what the depression trajectory looked like in that last year of life. And Claire had the methodological expertise to help me do that. So it was a great opportunity for us to work together.

Eric: And you guys are at different institutions, like how did you actually do that? Like where did this meeting of the minds come from?

Claire: Elissa wrote an amazing paper about screening for palliative care needs and community senior housing in New York city that I was really impressed by. And I just moved to New York and we had coffee and really hit it off. One thing we talked about is as researchers in palliative care, there is often just a few of us in each department or institution and we’re so siloed from each other. Like in New York, I mean I am 30 blocks uptown from where Elissa was at Cornell and yet no idea what she was doing. So we actually, we started an early researcher network in New York to get together to get to know each other, to get to know each other’s work. We found that our interests really complemented each other and our skills really complimented each other. So like in geriatrics and healthcare we think about multidisciplinary clinical teams, I think we saw an opportunity to build a multidisciplinary research team.

Alex: This is great. And most of our listeners are clinicians, but some of our listeners are budding researchers are interested in getting into research, but they may not be at institutions where they have a mentoring to nurture them through the early stages of research. Do you have any advice for folks who may be at such institutions about how to connect with mentors outside of their own institution?

Elissa: Definitely. I think that that is a huge barrier to a lot of folks, especially not in major metropolises like New York or San Francisco. There are some interesting networks for them to join. For example, there are triple networks which focus on late life pain that really …

Claire: Through HPM, there’s an early investigator forum that has a lot going on.

Elissa: There’s also…

Alex: GSA, Gerontological society of America.

Elissa: Thank you. Yeah, they have a great palliative care and hospice and geriatrics research groups, special interest groups. I found that when I was in graduate school, those special interest groups had mentors from nursing and social work that I didn’t have access to at my graduate institution who were incredibly helpful connecting me to people and resources that I just wouldn’t have known about otherwise.

Claire: I think one tip we have, one thing that worked really well in terms of working together is we’re both early investigators. I think that can be challenging in some ways because it’s not the structure of a mentor advising an early investigator. And what we found was the two of us have similar interests but very different skills. So I do a lot of work with data and surveys and quantitative methods. Elissa is a psychologist and brings a lot of clinical expertise in terms of depression and interventions around depression. So we found that because we have sort of complimentary skill sets, it was very natural to write papers together.

Eric: Then going to specifically this paper, like why did you think about doing this paper? Like what’s the gap here as far as knowledge?

Elissa: Sure. So I’ve been looking at mental health symptoms at end of life in my own research area for quite some time. And it’s actually incredibly challenging to get good data on this topic because Claire and I were just talking about how you can’t really predict when someone’s going to die with great precision. So doing longitudinal studies to try to figure out what the symptomatology is throughout those last few years is pretty hard to do in a prospective study. I was reading an article that looked at this dataset and how it pertained to pain epidemiology. And I messaged Claire, I said, “Can we do this with depression?” And she said, “There’s absolutely no reason why not.” So this is the first paper that really looked at the epidemiology of depression in that last year of life. And we learned a lot about how people spend the last year of their life suffering with a lot of depressive symptoms that are not being addressed by our current healthcare system necessarily.

Alex: That’s great. And I love that you just referenced the paper that Eric and I wrote about pain at the end of the life. That’s awesome.

Elissa: You’re welcome [laughing].

Alex: Good. I wonder if you could talk a little bit about sort of the clinical context. You mentioned earlier on Elissa about how you’ve seen patients who are nearing the end of life who have depression. I’m wondering if we could take a moment and talk about…do people feel that those who are closer to death experience more depression and more depressive symptoms?

Eric: I think specifically too, I think there is also a myth out there like, “Oh my gosh, everybody who’s dying, they’re depressed. Like how can you not be depressed if you’re dying?”

Alex: Right. And how do you even assess depression near the end of life, given that there’s tremendous overlap between depressive symptoms and terminal illness.

Elissa: Or grief.

Eric: You got a lot of answers, you’ve got…

Alex: We asked like 10 questions there, so you can answer whatever you want.

Claire: These are some big questions and maybe just to speak to from my motivation for doing this work is as a palliative care clinician, I certainly see depressive symptoms as common and grief as common. That being said, I see a portion of patients who really, it feels like mental illness to where it is not coming in waves like grief. They are unable to experience joy, they are unable to connect to their families. They’re utterly overwhelmed by psychological distress. I think as a palliative care clinician with a robust interdisciplinary team, I had some tools in terms of a chaplain and social worker who are, they’re amazing. But meeting Elissa, I’m thinking more about what psychology brings to bear. It’s striking and I think anyone who’s worked in a hospital knows this. There are some people you just leave the room saying, “I think they need counseling.”

Claire: I think it’s striking the lack of evidence based psychological treatments for people with serious illness and especially in the hospital. I think my interest is clinically seeing, yes, there’s normal grief, there’s normal bereavement, processes that we observe. There’s something more in some portion of patients and I’m not sure we have the tools that we need to fully address that.

Elissa: I’ll just add, you asked some measurement questions, which I want to touch on briefly because the psychological sciences had made really great strides in trying to differentiate what is depression, what is grief, what is anxiety, what is normal and what is abnormal in general. So there’s some really good measures and tools out there to help us differentiate that. But what we do with that information doesn’t always come naturally. So I had the benefit of training in a hospice setting at a VA hospital, actually in the Bay Area while I was on internship. We had the benefit of having social work and chaplaincy and doctors and nursing all working collaboratively. And there’s room for everyone because there’s a lot of support that’s needed, but what often doesn’t get deployed outside of like those kinds of very robust teams is evidence-based brief psychotherapy, which does work.

Elissa: I trained in that throughout graduate school in internship and it’s just not available to the majority of patients. I think what we’re trying to do with this study is build the case that we need to start thinking more innovatively about how to deliver mental health care to people who are really vulnerable and in need of these services.

Alex: That’s a terrific point. I think so many palliative care teams out there either don’t have access to a psychologist or they may have access, but it’s just very part time and it’s hard for the psychologist to carve out the time to do the brief psychotherapy or perhaps they’re not trained in it. So incredibly important that we utilize these nonpharmacologic interventions. Because though we do have medications that are effective in treating depression, even near the end of life, all of these medications have side effects and that we have to be cautious about, especially when we’re layering them on top of potentially opioids, benzodiazepines, et cetera.

Eric: Maybe we can start off and kind of structuring this. Maybe we can talk about kind of what you found as far as how common depressive symptoms are and then afterwards we can talk a little bit about kind of more specifics about what we can do pharmacologically and non-pharmacologically when we think somebody has depression and how we separate that from other disorders, including just anticipatory grief. So let’s go to the paper. Like how common is this? First, what did you do in this paper? Kind of if you had to summarize it in a sentence or two. See, I know that’s hard.

Claire: Sure. So there’s actually a lot of data that shows that depressive symptoms, which is actually what we look at in this paper. I want to be clear on that. It’s not clinical depression. We weren’t diagnosing depression. We were looking at depressive symptoms. There’s been other work that shows that depressive symptoms are common at the end of life. But there’s been very little work showing how they change the trajectories of these symptoms as people approach death and how these trajectories might vary based on what clinical condition you have, based on demographics, based on other factors. So in this paper we tried to measure what those trajectories were of depressive symptoms and what factors and how the trajectories might look different for different people. So we found that overall, depressive symptoms stay stable until about three months before death and then they increase for the overall population.

Claire: And they increased pretty dramatically to where about 60% of people in our study had depressive symptoms in the last month of life. Now just going back to that point of how we found this, we took advantage of a survey that is done on a large population of older events called the HRS, the health and retirement study. So that survey is done every other year on a group of older adults as they age and some of them die. So the survey happens at the same time. The time between when the survey is done and death is random. So over time it allows us to estimate what’s happening to people who are one month before death, two month before death, three months before death just by the chance of where the survey catches them. So that allowed us to track this without having to know in advance where someone was at in terms of the predicted time to death.

Eric: What did you use to kind of measure depressive symptoms?

Claire: Yeah, so we used a scale called the CES-D, the center for epidemiologic studies, depression scale. So it’s an eight item scale that asks about things like feeling sad, feeling lonely, not enjoying life as well as measures like fatigue. The reason why we liked that scale is because in this paper it allows us to look at each question individually to say, “Okay, is it just fatigue that’s going up at the end of life, which we might expect from people getting sicker? Or is it some of these other more psychological symptoms that are also going up at the end of life.”

Elissa: We should note it’s a screener, not a diagnostic. So that 60% in the last month are people who would have screened positive for further assessment based off of their scores on the CES-D. One another kind of number that I think is important to know. So Claire mentioned that the numbers stay fairly stable and then skyrocket in the last three months, but that stable number is still about a third. So in the last year of life, about a third of the population would screen positive for further screening, for depression. And that’s significant, that’s a lot of people who are suffering for the entire year before they die. Then a majority, almost two thirds who are meeting those criteria in the last month. That’s in my opinion, a public health issue that needs further research and further strategies to address.

Anne: Does that surprise you or was that something you kind of had a hunch you might find out?

Claire: It did surprise us, especially because I think we are, I know we are vastly underestimating the rate of depression from this survey. Because what we’re doing is we’re looking at people who answered this survey and we know the sickest people weren’t able to do that screening question. We also know those are most likely had the highest risk of depression. So I think that is a very low estimate. I think the reality is much higher and it surprised me to see that it’s not just things like fatigue that it… 40% of people in the last month of life report that they’re lonely. I think some of these numbers are just heartbreaking that we’re seeing in terms of what people are saying their experience is like.

Eric: So when we think about let’s say the screening tool, it does include things like fatigue, which could be related to their underlying disease and it includes other things that may be related to depression. When I usually think about depression and correct me if I’m wrong, depression at the end of life, hopelessness, worthlessness, suicidal ideation, like those are the things that I really start worrying about and thinking about separating depression at the end of life versus depression at any other time. Are we worried here that this, because they includes these other things that could be related to the disease, that the incidents actually have real depression maybe lower. Because like we’ve turned up our sensitivity because we’re also looking at these symptoms that are just common with end of life diseases.

Elissa: So these are important questions about measurement. And the CES-D is a fairly robust scale in geriatric population. So there’s been other papers written that essentially validate the use of this scale with this particular population. I think you bring up a good point, but I think it almost speaks a little bit to the idea of some symptoms might be expected at end of life. I think we need to kind of scale back that stigma about mental health symptoms as people have illness and age. One thing that I often think about in terms of suicidality and hopelessness is most people don’t want to die. Most people who have serious illness do not commit suicide and most people who commit suicide do not have serious illness.

Elissa: So this idea that it’s expected to have these kinds of clusters of symptoms as we age and as we get closer to death is something that we really need to challenge and also to better understand. Part of our goal with this paper is to better understand what is the normal experience as people get closer to death. And two thirds is a lot, but I think that there’s a lot to learn from those numbers too. It’s not everyone. So I think we still need to understand what’s happening that’s causing so many people to have these symptoms. In the paper we did differentiate between the physical symptoms and the emotional symptoms to make sure that it wasn’t these declining health states that were driving the CES-D elevated scores.

Alex: Did you see similar kind of trajectories?

Claire: We did, yeah. We actually saw some of the strongest trajectories were in things like feeling sad and loneliness, which I would say cannot be explained by some of the physical manifestations of people’s illness.

Alex: That’s a really strong point. Here’s a question though. For the clinicians out there, how would you recommend that they screen for depression near the end of life? What questions should they be asking? I was taught by Susan Block that it’s like the hopelessness, helplessness end of the spectrum. It sounds like you’re challenging that approach.

Elissa: Not necessarily, I think screening is so important, but I think it’s also important to make sure that you have the resources to do something if someone screens positive. Because I think a lot of healthcare systems do all these great screens and then people just sort of fall away because there isn’t necessarily a followup care plan. There are built in measures so it depends on what the style of the clinician is. There are questions you can ask. You can do a clinical interview surrounding the major symptoms of depression. So you can look at the PHQ-9 for those major symptoms of depression. If you have more time, there are specific scales that are more tailored to an older, sicker population. For example, the hospital anxiety and depression scale HAD, as it’s called or the geriatric depression scale can be a little bit more precise with these populations.

Elissa: But I really think that asking questions about it, it’s just a really important first step, especially for clinicians who maybe don’t have all the scales available to them. Ask, have you been able to connect with your family? Are you feeling isolated? Are there things that have been on your mind that you don’t feel like you can talk? Have you felt sad or down or blue most of the day, nearly every day for the last two weeks? These sort of bread and butter questions to kind of get at what is your patient’s emotional state and how can we improve it?

Alex: That’s great. Anything you’d add to that Claire or Anne or Eric about how you ask about depression?

Claire: So I think one thing that’s really important in this is also, I believe coming from work that Susan Block has done on distinguishing depression from what’s expected is the trajectory of the symptoms and people’s day to day life. Is this something that is coming and going or is this sort of depressive symptoms that are just not going away? And that are not something that is coming in waves. That’s something that I think is very important to ask about.

Eric: A while back actually, I read an article of Susan on depression and grief. One of the things we looked at was the two item screener. Are you depressed? And have you experienced loss of interest in things or activities that you would normally enjoy? That’s actually a pretty good sensitivity in cancer patients, people with severe cancer. So I always stick because my memory is bad. I always stick to a two item screener when I ask about depression. Anne, do you do anything different?

Anne: No, I agree. And I just wanted to highlight something I think Elissa was talking about earlier asking about kind of are they able to feel connected to their family or to talk about things. I think about some folks that we’ve cared for who might have from the outside looking in a really robust network of support and people who love them and yet they themselves are feeling very disconnected or socially isolated in some way. And so not to assume that just because someone is surrounded by well meaning loving people, that they’re able to actually kind of benefit from that support if there’s depression on board.

Alex: Right. You can be lonely in a crowd, you can feel disconnected even when you’re married or isolated. I often ask about are there things that you hope for, because that’s sort of a standard question that we ask anyway, we’re trying to figure out what somebody’s goals and values are. But sometimes when they say no, if they say no, that should sort of trigger, oh, if there’s nothing you hope for, that’s a sense of hopelessness right there and should lead you down the avenue of further questioning about depression.

Elissa: I do just want to add. I think in the context of end of life, sometimes it can be okay to not have a ton of hope because you might actually have a pretty grim prognosis. So it can be difficult to have hope in the face of a grim prognosis. But one of the things I always look for are the symptoms of distress and dysfunction. Are they interfering with your life? I can be hopeless about my future but still really enjoy my present. I can still be able to engage with my family and enjoy my hobbies while knowing full well that my illness is incurable. And I’ve seen that clinically quite a lot. So a lot of times those symptoms might be present and might be kind of okay-ish. But if they’re interfering with someone’s ability to engage in their lives and engage in what’s currently happening around them, that’s when I start to get really worried about depression.

Alex: That’s great. And that gets back at one of the points you made early on about what are symptoms that are disabling or that have negative consequences versus symptoms that may be are tolerable and don’t have such negative impact on a person’s life and experience.

Eric: So like can we go into some of the practical parts? So it sounds like this is really common if we screened for it depressive symptoms, that there are potentially things that we could look at that makes us think, “Yeah, this is looking like depression.” For the diagnosis of depression that near the end of life, we’re still looking to like the DSM-5, two weeks of depressive symptoms, anhedonia, SIG-E-CAPS stuff.

Elissa: I mean, let’s remember the DSM-5 was not created with this population in mind. So I think that this is where clinicians have to think about how do I make my patient’s life better? So I’m a little less tied to the DSM-5 for geriatrics and end of life patients because it just doesn’t always fit perfectly well because it’s not who these criteria were made for. There’s very limited research on how those criteria fit into this population. So really it’s your patient’s suffering and can we do something about it?

Eric: So, and what can we do?

Claire: I think one thing before we dive into what we can do. I think depression is not, depression is not depression and this population and one thing that we are really interested in was how does people’s experience differ? Because yes, everyone in our study died, but they had very different clinical conditions and courses and life circumstances. One of the really interesting things we found is that in the cancer population, we found that these depressive symptoms really dramatically spike in the last couple months of life. I think that’s actually pretty typical to how we imagine depression. Looking at the end of life from a palliative care perspective. But as especially as palliative care sort of expands and moves most upstream to a broader population, I think it’s important to understand that when we looked at people, for example with lung disease, we actually found rates of depressive symptoms that were as high as the cancer population, but that persisted the entire last year of life.

Claire: Similarly, people with functional disabilities, so people identified not through any particular condition, but who had on their the last survey that they did before death who reported they had difficulties with activities of daily living, like bathing and eating and getting in and out of bed. Those people had very high levels of depressive symptoms as high as cancer. So I think part of this is changing the framework. We’re thinking about it and I think different forces are at play in those different populations. And it’s important to understand what forces are at play to understand what we can do about it.

Alex: So let’s go to somebody who may have like many weeks to months to live. Like, is that for nonpharmacological therapies, are we thinking like how long does like CBT take? And like what are our options for non-pharmacological treating this person?

Elissa: So we have options. I think is an important thing to know whether it’s traditional. So the research says that most CBT is eight to 12 weeks and sometimes in clinical practice we can shorten that. It’s really hard to do these prospective really brief right before death research studies. But I think that when there’s skilled clinicians who know the different techniques that are evidence-based in other populations, there isn’t really a reason why we can’t start to apply those techniques to this population. So for example when I was training on hospice, I didn’t have a lot of time with my patients. So depending on what the constellation of symptoms and resources and supports that were available, I would try some CBT. I would try some reminiscence therapy from time to time. Mindfulness-based therapy works really well in a short term situation, if you can get someone to engage in it sort of fully and intentionally. Bringing in the family to help with some of these things, getting them… I mean, even behavioral activation, which is sort of the bread and butter, first-line depression treatment.

Elissa: It’s hard to think about how do you get someone to do more. The behavioral activation is essentially do more, feel better. That’s how I sum it up. So what does do more feel better look like in a extremely disabled or bedbound patient with weeks, a month left to live. While it might mean more visitors, it might mean more books on tape, just something to make them pass the time in a meaningful way for them. But I think this is an area that needs a lot more research and this is a really hard area to do research and because of all of the logistical constraints.

Alex: And when would you consider pharmacological therapy?

Claire: So I think one of the third… First things I’d consider is pharmacological therapy for other symptoms. So for example, one thing I found really interesting about our results of depression being so high in people with lung disease is that because of untreated dyspnea. And we also know that there’s higher rates of depression, people with untreated pain. So I think the first line of pharmacotherapy I think about is actually for those symptoms for which pharmacotherapy is absolutely indicated and making sure that that’s not contributing.

Eric: And for those who want a little bit more about dyspnea listen to last week’s episode with David Cairo. We just did a whole episode on dyspnea treatment and opioids. All right. What about specifically treating the depression?

Alex: Methylphenidate.

Eric: Alex is bringing up methylphenidate or Ritalin.

Claire: Yeah. I think I would say these decisions, so there’s the ideal situation. The reality is if you can access, if your patient can access a psychotherapist who can provide these kinds of evidence-based treatments, I would say that’s part of the shared decision making of whether you try that first, if you have that resource or whether you jump to something like Ritalin. Again, I think that’s going to be a highly resource dependent situation and highly patient preference dependent.

Elissa: But we can also think a little bit about prevention strategies. Like so if we know that there are certain populations and certain clinical presentations that are at higher risk, which our paper found as Claire discussed, lung disease, ADL impairment. But we also know that women, people of color, people from lower SES backgrounds and younger people with terminal illnesses, all of these people are at higher risk for developing depression, in the last year of life. So maybe thinking a little bit more about screening early and often and trying to nip some of these symptoms in the bud while there are more resources and more time available. I’m not saying start everyone on a prophylactic anti-depressant by any means, but if you know that there’s a spike in a lot of people’s symptoms and they’re already trending towards that, let’s get proactive about it. Let’s do more feel better sooner before and maybe for a major depressive episode if we can.

Eric: Yeah, I mean I think that’s really helpful because like when I looked at the literature on methylphenidate, it was kind of a little bit meh, like it’s not super great evidence for it at the end of life. We usually think about it for people who have less than four to six weeks to live, which is usually the amount of time it takes for antidepressant, SSRI, SNRI or TCAs to actually start kicking in. But pretty good evidence for those drugs and people with advanced diseases near the end of life with advanced illnesses. It’s also interesting, kind of more research and we probably should do a podcast on this is ketamine too for treatment resistant depression, especially for people with advanced illness too.

Claire: Absolutely. I think that’s very interesting. That is not something I personally have clinical experience with, but I think is extremely interesting and promising. And yet I’ll go back to you. Ideally we would have psychology supports for people who you’re considering those medications. And concurrent with things like Ritalin, that would be the idea of the world. I know that is not the reality.

Eric: Well, that’s kind of the best evidence. That the combination of both psychological and pharmacological therapies for people with major depression. Is that right?

Claire: Absolutely. Yes.

Alex: One question I have that can’t be addressed by these data is, is hospice doing this better? Are they doing a better job of assessing screening, treating depression? Or are patients who enroll in hospice more depressed? I could see it going either way. I could see for example because they have their major focuses on symptoms near the end of life and these persons are recognized as dying that they assessed for depression routinely and maybe treat it. On the other hand, I could also see that many of the medications that persons in hospice are often start on opioids, benzodiazepines in particular might have side effects that lead people or exacerbate depressive symptoms near the end of life. I’m just throwing a… there’s not really a question in there, but any thoughts about that issue?

Elissa: I have a paper that looked at depressive symptoms for patients on hospice in the last week of life and it showed similarly high rates in that last week of life. But again, methodologically, it’s a very different snapshot of what’s happening. I think the main challenge with hospice right now is that we’re not getting patients enrolled in hospice early enough to have maximal impact. So I’d like to think that hospice is this better but I also know that the reality is that most people are not on hospice long enough to make that substantial quality of life improving impact throughout that, I mean, ideally six months. That’s the hospice cutoff. But how many people are actually on hospice for the entire last six months of life? We know it’s more like last couple of weeks or last month or two of life. And that’s just not a lot of time to make a huge impact on a host of symptoms, let alone mental health care.

Anne: I think going back to something you said earlier around wanting to really bolster the argument around the need for resources to be dedicated to mental health care for people who are approaching the end of life. I can think of a number of cases where in which depending on the hospice agency that someone is enrolled with, they may not have staff who are dedicated to provide expert mental health care, also combined with someone who might be less able to leave the house to seek that kind of support for themselves. And just wanted to acknowledge, it sounds like that in of itself could be a useful role for additional resources too.

Alex: Yes psychologist is not the traditional core member of the hospice team. Right? Like for Medicare hospice, you have to have certain members, professions represented social worker, nursing, physician, et cetera.

Anne: And there may be social workers who are trained in providing mental health care and or that doesn’t mean that their job description really allows them to allocate their time in that same way.

Elissa: Yeah. I always want to give a big shout out to the work that social workers do. They are a mental healthcare provider and they are on a lot of these interdisciplinary teams. And they’re not necessarily protected to do the mental health care that they know how to because there’s so many competing demands on their time.

Eric: Well said. So before we end, if you had a magic wand, you can make three changes that providers do for patients near the end of life. What are those three things?

Claire: That providers do for patients?

Eric: It could be like add a psychologist to the team.

Claire: Yeah, that one.

Eric: All right. One, you got two more now.

Claire: Sharon’s policy payment issue is paying therapists to provide care, especially in the hospital setting.

Alex: Great. It comes back to money again?

Claire: It’s back to money.

Alex: You got one more.

Claire: I think the other broader point is I think the one of the interesting experience I’ve had in talking about this work is a common reaction is, “Well, of course they’re depressed, they’re dying.” I just think we need to reframe that and that depressive symptoms are common, but I think untreated depression, we need to take really seriously as serious as we do pain or dyspnea and really think about what an evidence-based interventions we have or need to build to address that aspect of suffering in our population.

Eric: Wonderful. And it sounds like another really important thing that I got out of this article is it’s really important to screen our palliative care populations and our older adults for depression because it’s actually really common. So if we’re not screening for it then we’re missing a lot of folks. So with that, I just want to thank you for joining us on this podcast.

Alex: Thank you Elissa. Thank you Claire.

Eric: But before we leave, Alex, can you give us a little bit more of Hurt?

Alex: (singing).

Eric: I love that song.

Alex: It’s such a fun song.

Claire: Great song.

Alex: Great choice.

Eric: Well, I want to thank both of you again for joining us today and for all of our listeners for your continued support. If you haven’t done so already, please rate us on your favorite podcasting app.

Alex: And thank you to Archstone Foundation. Thank you, Elissa. Thank you, Claire.

Claire: Thank you.

Elissa: Thank you.

Eric: Bye everyone.

Anne: Bye.

Alex: Bye folks.