**3. Diagnostic challenges**

Patients with severely ill conditions receiving palliative care are prone to depression and other psychiatric illnesses but assessing these psychiatric conditions could be very challenging by the medical staff. Multiple somatic symptoms are expressed in the patients with advanced cancer which could overlap with symptoms of depression, thus depression assessment could be very challenging. The study found out the occurrence of depression was significantly related to poor performance status and more pain. One could not exclude somatic symptoms in the assessment of depression which could have a direct or indirect relation with it. Comorbid depression characterization was increasing pain, poorer physical condition than expected normally [23]. There should be no omission of somatic symptoms when as they remain influential in the diagnosis of depression. All somatic symptoms were present in any depressive disorder (ADD) like insomnia or sleeping too much, poor appetite, lack of concentration, etc., whereas major depressive disorder includes both somatic and non-somatic symptoms. Defining depression with HADS score the symptoms were psychologically followed up by somatic symptoms. Thus, in a palliative care setting symptoms like poor appetite, feeling tired overpowered symptoms like feeling bad or speaking slowly. There should be proper symptom diagnosis to determine the broad or narrow concept of depression [24]. Many clinical find these steps challenging as to differentiate between the symptoms (**Figure 2**). Mood disorders symptoms can be the effect of physiological impairment in the body. Pancreatic cancer is highly malignant, and it is very hard to treat. Patients are often feared for it because of its deadly reputation. Patients that develop psychological conditions like mood disorders, depression is likely the outcome of disruptive physiological conditions of the pancreas like impaired secretion of hormones, digestive enzymes or neurotransmitters. Thus, here the reason for psychological symptoms was impaired physiological processes of the patients [25]. Depression prevalent among cancer patients could range from 3.8–58%. 25% patients suffer from depression who have

**Figure 2.**

*Differentiating between symptoms of depressions.*

been hospitalized with a significant level of physical impairment [26]. Barriers in assessment could form if there arises confusion about depression with some different sources of sadness among cancer patients. The consequence of depression could lead to suicidal or self-harm tendencies if not assessed properly. It is unclear that patients having a comorbid condition like having cancer with depression could be worse than patients only having depression without underlying disease. There is an uncertainty in identifying symptoms of depression in patients with severe diseases because the symptoms tend to overlap with the disease. The cases of depression are often missed. Physicians and nurses were capable of identifying only half of the cases and half of the cases were left undetected [27, 28]. A study was conducted that determined the accuracy of physicians to detect depressive symptoms among patients. A survey was performed on 1,109 subjects who were treated by 12 oncologists by 25 ambulatory oncology clinics that were affiliated with community cancer care Indiana [29]. Subjects had to complete ZSDS (Zung Self-Rating Depression Scale) and physicians rated their patients based on depressive symptoms, pain, anxiety. To detect depression physicians, tend to rate their patients based on how the patient endorses on the ZSDS scale (**Figure 3**). The rating of the physician was also influenced by the medical correlation of the patient. The patient's mood symptoms like sadness, hopelessness also affected the rating. Physicians tend to be affected by symptoms like crying mood, depressive mood, but this could not be labeled as the reliable indicator of depression [29]. In the UK, a study was done to assess the ability of 143 doctors in 34 cancer centers and hospitals [31]. It was found out that the misclassification of psychiatric morbidity in 34.7% of 797 patients and wrong assessment was made. There was a lack of proper communication skills between doctors and the patients. There should be a need in the improvement of skills during the consultation [31]. Many patients from rural background who are not economically capable of affording a psychiatrist are often left undetected. In physically ill patients, the diagnosis of depression is often complicated because of pervasive somatic symptoms that could be or could not be due to primary disease. In confounding somatic symptoms many options have been proposed. Symptoms that are directly caused by medical conditions are excluded according to DSM IV. The distinction between the symptoms practically could be very challenging.


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*Depression: A Challenge during Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.96563*

**4. Treatment and therapies**

**5. Psychotherapy**

[15, 34].

For the diagnosis of major depressive disorder, 5 out of 9 symptoms should be present when all the symptoms were excluded. This is highly standardized that could only identify severely depressed patients [32, 33]. When the false-negative results are greater, there is a failure to treat depression, or false-positive results the risk of initiating unnecessary therapy. Cassem suggests that clinicals should include on the side of caution the somatic symptoms in diagnosing medically ill patients [34]. However, when the approach suggested by Cassem is used there could be a possibility of prevalence of an exaggerated number of patients with the depressive disorder

When depression is identified in patients with terminal illness requires various measures to treat it. Treatment procedures could include pharmacological treatment, psychological treatment or the combination of both of these. A study was conducted to prove the efficacy of antidepressants in patients with depression in palliative care. It was found out the administration of antidepressants in these patients was found to be more effective than the placebo effect, and it was more apparent within 4–5 weeks and increased with its continuous use [35]. Patients showing depressive symptoms or depressed anxiety mixed symptoms were daily given oral doses of ketamine hydrochloride. In this 28-day trial, there was found to be a significant improvement in both depressive and anxiety symptoms in patients, the improvement was significant and gradual for 28 days with some rare side effects like diarrhea, insomnia, trouble sitting [36]. There is a slight misconception that the psychotherapeutic approach is not beneficial in severely depressed patients but in a study done by Driessen, et al., it was found that psycho-therapeutic approaches

could be beneficial in both mild and severe depression [37].

training, there is deterioration in clinical empathy [40].

Depressive symptoms that diminish with psychological interventions can also be provided by medical caregivers apart from the specialist in psychological oncology. When the relation of health care workers with the patients is perceived as supportive then the patients with cancer tend to show less traumatic stress. Patients with leukemia significantly show stress symptoms which are associated with physical symptoms, psychological intervention could prevent traumatic stress in the patients. A study of breast cancer patients identified that women who don't have emotional support from family and friends have difficulty in interacting with nurses and physicians [38, 39]. For both undergraduate and postgraduate medical

Several types of psychological therapies are being performed depending upon the severity of depressive symptoms (**Figure 4**) stage of the disease, the interest of the patient and motivation to participate in psychological therapy. Cancer patients who were diagnosed with mild to moderate depression could be benefitted from cognitive behavioral therapy, methods of relaxation, approaches to problem-solving [40–42]. Supportive expressive therapy could be beneficial for the patients who have more advanced disease that targets the fear related with death and existential concerns. Many psychotherapies have been developed like meaning-centred group therapy which is beneficial spiritual and emotional wellbeing [43], dignity therapy which empowers meaning to life [44], mindfulness-based meditation therapy, effective in cancer patients [45], and managing cancer and living peacefully [46].

**Figure 3.** *Zung self rating depression scale (ZSDS standard scale) [30].* *Depression: A Challenge during Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.96563*

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

been hospitalized with a significant level of physical impairment [26]. Barriers in assessment could form if there arises confusion about depression with some different sources of sadness among cancer patients. The consequence of depression could lead to suicidal or self-harm tendencies if not assessed properly. It is unclear that patients having a comorbid condition like having cancer with depression could be worse than patients only having depression without underlying disease. There is an uncertainty in identifying symptoms of depression in patients with severe diseases because the symptoms tend to overlap with the disease. The cases of depression are often missed. Physicians and nurses were capable of identifying only half of the cases and half of the cases were left undetected [27, 28]. A study was conducted that determined the accuracy of physicians to detect depressive symptoms among patients. A survey was performed on 1,109 subjects who were treated by 12 oncologists by 25 ambulatory oncology clinics that were affiliated with community cancer care Indiana [29]. Subjects had to complete ZSDS (Zung Self-Rating Depression Scale) and physicians rated their patients based on depressive symptoms, pain, anxiety. To detect depression physicians, tend to rate their patients based on how the patient endorses on the ZSDS scale (**Figure 3**). The rating of the physician was also influenced by the medical correlation of the patient. The patient's mood symptoms like sadness, hopelessness also affected the rating. Physicians tend to be affected by symptoms like crying mood, depressive mood, but this could not be labeled as the reliable indicator of depression [29]. In the UK, a study was done to assess the ability of 143 doctors in 34 cancer centers and hospitals [31]. It was found out that the misclassification of psychiatric morbidity in 34.7% of 797 patients and wrong assessment was made. There was a lack of proper communication skills between doctors and the patients. There should be a need in the improvement of skills during the consultation [31]. Many patients from rural background who are not economically capable of affording a psychiatrist are often left undetected. In physically ill patients, the diagnosis of depression is often complicated because of pervasive somatic symptoms that could be or could not be due to primary disease. In confounding somatic symptoms many options have been proposed. Symptoms that are directly caused by medical conditions are excluded according to DSM IV. The distinction between the symptoms practically could be very challenging.

**212**

**Figure 3.**

*Zung self rating depression scale (ZSDS standard scale) [30].*

**Figure 2.**

*Differentiating between symptoms of depressions.*

For the diagnosis of major depressive disorder, 5 out of 9 symptoms should be present when all the symptoms were excluded. This is highly standardized that could only identify severely depressed patients [32, 33]. When the false-negative results are greater, there is a failure to treat depression, or false-positive results the risk of initiating unnecessary therapy. Cassem suggests that clinicals should include on the side of caution the somatic symptoms in diagnosing medically ill patients [34]. However, when the approach suggested by Cassem is used there could be a possibility of prevalence of an exaggerated number of patients with the depressive disorder [15, 34].
