normal sadness relating to declining health and fear of death. Patients who are sad usually retain some hope for the future and still derive satisfaction from relationships. Sadness tends to fluctuate, whereas depression is more constant and char acterised by self-loathing and a sense of permanence (see Table 3) Patients who do not meet criteria for major depression may still benefit from psychological support and referral to specialist palliative care. If there is uncertainty about the diagnosis, or if the patient is severely depressed or suicidal they should be referred to a mental health specialist. clini cians should ask patients directly about suicidal ideation and intent and be particularly vigilant during high risk peri ods such as initiation of antidepressant treatment