**2. Assessment and diagnosis**

The first step is the assessment and is one of the most important and crucial steps in the diagnosis of depression. This step could itself be very challenging in the environment. In a study, a structured interview was constructed for assessing the symptoms of patients in the advanced cancer stage receiving palliative care. Visual analogue scales (VAS) were also completed by the participants along with the interview. Impressive interrater reliability was shown by interview items (interclass correlations were > 0.9). Structured interview for symptoms and concerns was found to be sensitive between each participant of the subgroup. Thus, a structured interview method of assessment could be proven reliable and valid way in determining depression during palliative care [15]. To treat a disease, the first step is to identify it. Undetected depression in patients receiving palliative care could lead to severe consequences. Often physicians find it difficult to distinguish between sadness and depression in patients with advanced illness at the end of their life so there should be a different diagnostic mechanism for determining depression in terminally ill patients. Correlation between subscale of depression and HADS (hospital anxiety and depression scale) of the 25 patients that were admitted to a hospice correlated with 100 mm linear Visual analogue scale (VAS). VAS thus was thought to be an effective screening tool for patients who were suffering from depression in advanced disease [16]. Hospital anxiety and depression scale (HADS) could be used in yielding numerical scores and is quite acceptable to the patients. The person who deals with this scale should have proper knowledge and time to deal with psychological and emotional stress generated by its use. There comes a time when patients tend to have consistent high HADS scores, a proper review should be maintained in that situation. Earlier detection could be made possible by regular screening from the referral time and thus could be followed by treatment protocols [17].

Psychological distress comes in many ways and forms. Its proper assessment makes it a big task. Psychiatric questionnaires when routinely assessed by the clinical staff could produce proper results. Awareness could be raised in non-psychiatric staff by educational programs, screening for the disease could be most effective when it coupled with informative and educational seminars in the presence of responsible psychiatric input. The attention of psychologists and researchers is often attracted by unidimensional scales like distress thermometers because they are easy to use, but there is always a question on their validity in complex psychological constructs. The scale with a length of 6–30 items is multidimensional scales that focuses on a wide variety of distress like somatic, behavioral. The large size of the questionnaire poses one disadvantage. Identifying the causes of depression, distressing symptoms, mood swings that co-exist with other illnesses in the patient could be detected through the HADS anxiety subscale. To improve the clinical issue, screening for psychological issues should be the priority. To gain as many benefits as possible from screening it should be accompanied by validation of treatment. There is a minute difference between assessment and screening for a disorder that is assessment is a more complex process that involves various steps like identification of the problem, a good therapeutic relationship followed by management strategies, whereas screening involves only identification of the psychological distress that eventually leads to assessment in the identified patients [18]. Patients suffering from advanced stages of cancer often face mood disorders and various psychiatric problems which are often underdiagnosed or overlapped with the symptoms of the disease. This may be led to severe difficulties and the patient could lead to poor quality of life. A comparison was bought in the screening procedure between Edmonton Symptom Assessment System (ESAS) for depression with Hospital Anxiety and Depression Scale (HADS). The study suggested that a sample of 216 patients were analyzed using ESAS and the score for depression was found to be 2(0–10) and 6(0–16) using HADS. The sensitivity using ESAS was found out to be 77% and 83% and specificity was found out to be 55% and 47% for moderate to severe depression. The cut-off point that was analyzed using ESAS for the screening of depression in palliative care was 2 out of 10 [19]. Interviewing for psychiatric illness in the palliative care setting is very important. There was a comparison between formal psychiatric interview compared with two-item screening interview which determined the specificity and sensitivity of two item screening interview was the main objective in the study to identify the depressed patients in palliative care study. The sensitivity and specificity of the two-item questionnaire were found out to be 90.7% and 67.7%. The false-positive and false-negative results were 32.3% and 9.3%. The study concluded that the two-question screening tool has high sensitivity and low false-negative results. There was also an easy detection and the patients tend to respond positively to the two-item questionnaire who previously had some experience of depression in the earlier stage than the patients with no prior history of depression [20]. One in four palliative care patients tends to show symptoms of depression, so the screening tool therefore must be very accurate. A comparison was drawn out between three screening tools. The initial was the verbally rating mood on the scale of 0–10, responding to the question that was asked to the patients "Are you Depressed?" in either yes or no format, and last was the completion of the Edinburg depression scale. Using DSM IV criteria, a semistructured interview was also performed. When determined the sensitivity and specificity of the "yes" answer it was found to be 55% and 74%. The sensitivity and specificity of verbally rating mood on the scale were found to be 80% and 43% and at last, the Edinburg depression scale was found to be highly accurate with the sensitivity of 70% and specificity of 80%. In comparison to these three scales, the Edinburg depression scale was found to be highly reliable in detecting depression in

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practices [22].

**3. Diagnostic challenges**

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

patients in palliative care [21]. In medical oncology and palliative care settings patients are prone to depression. The rapid screening for depression could be validated by BCD (Brief Case find for Depression). A comparison was drawn out to carry the validation of BCD in a palliative care setting with Primary Care Evaluation of Medical Disorders (PRIME -MD), HADS and beck depression inventory (BDI). Validity was constructed by comparing depressed patients and non-depressed patients relating to symptoms, pain, performance status by using these methods the prevalence of depression was found to be 34%, 12%, 19% and 14% respectively of BCD, PRIME MD, BDI and HADS. BCD was found to be much sensitive than other instruments as it detected a higher rate of depression as compared to other methods. BCD when compared to PRIME MD could recognize both major and minor depression whereas PRIME MD could be used for detection for major depression among patients. The validity of BCD could also be proved by patients having a high BDI score, HADS depression score with probable depression on BCD compared to those without probable depression. A comparison was also drawn between depressed patients according to BCD and non-depressed patients significantly showed scores on the higher side on PRIME MD. The administration of BCD is not very complicated, could be a part of a routine clinical interview. The results could be obtained immediately. Depression and anxiety are often thought to be the same, distinction was obtained between these two by using BCD that supports its discriminatory validity. Thus, BCD could be introduced in standard clinical

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

*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*

Psychological distress comes in many ways and forms. Its proper assessment makes it a big task. Psychiatric questionnaires when routinely assessed by the clinical staff could produce proper results. Awareness could be raised in non-psychiatric staff by educational programs, screening for the disease could be most effective when it coupled with informative and educational seminars in the presence of responsible psychiatric input. The attention of psychologists and researchers is often attracted by unidimensional scales like distress thermometers because they are easy to use, but there is always a question on their validity in complex psychological constructs. The scale with a length of 6–30 items is multidimensional scales that focuses on a wide variety of distress like somatic, behavioral. The large size of the questionnaire poses one disadvantage. Identifying the causes of depression, distressing symptoms, mood swings that co-exist with other illnesses in the patient could be detected through the HADS anxiety subscale. To improve the clinical issue, screening for psychological issues should be the priority. To gain as many benefits as possible from screening it should be accompanied by validation of treatment. There is a minute difference between assessment and screening for a disorder that is assessment is a more complex process that involves various steps like identification of the problem, a good therapeutic relationship followed by management strategies, whereas screening involves only identification of the psychological distress that eventually leads to assessment in the identified patients [18]. Patients suffering from advanced stages of cancer often face mood disorders and various psychiatric problems which are often underdiagnosed or overlapped with the symptoms of the disease. This may be led to severe difficulties and the patient could lead to poor quality of life. A comparison was bought in the screening procedure between Edmonton Symptom Assessment System (ESAS) for depression with Hospital Anxiety and Depression Scale (HADS). The study suggested that a sample of 216 patients were analyzed using ESAS and the score for depression was found to be 2(0–10) and 6(0–16) using HADS. The sensitivity using ESAS was found out to be 77% and 83% and specificity was found out to be 55% and 47% for moderate to severe depression. The cut-off point that was analyzed using ESAS for the screening of depression in palliative care was 2 out of 10 [19]. Interviewing for psychiatric illness in the palliative care setting is very important. There was a comparison between formal psychiatric interview compared with two-item screening interview which determined the specificity and sensitivity of two item screening interview was the main objective in the study to identify the depressed patients in palliative care study. The sensitivity and specificity of the two-item questionnaire were found out to be 90.7% and 67.7%. The false-positive and false-negative results were 32.3% and 9.3%. The study concluded that the two-question screening tool has high sensitivity and low false-negative results. There was also an easy detection and the patients tend to respond positively to the two-item questionnaire who previously had some experience of depression in the earlier stage than the patients with no prior history of depression [20]. One in four palliative care patients tends to show symptoms of depression, so the screening tool therefore must be very accurate. A comparison was drawn out between three screening tools. The initial was the verbally rating mood on the scale of 0–10, responding to the question that was asked to the patients "Are you Depressed?" in either yes or no format, and last was the completion of the Edinburg depression scale. Using DSM IV criteria, a semistructured interview was also performed. When determined the sensitivity and specificity of the "yes" answer it was found to be 55% and 74%. The sensitivity and specificity of verbally rating mood on the scale were found to be 80% and 43% and at last, the Edinburg depression scale was found to be highly accurate with the sensitivity of 70% and specificity of 80%. In comparison to these three scales, the Edinburg depression scale was found to be highly reliable in detecting depression in

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patients in palliative care [21]. In medical oncology and palliative care settings patients are prone to depression. The rapid screening for depression could be validated by BCD (Brief Case find for Depression). A comparison was drawn out to carry the validation of BCD in a palliative care setting with Primary Care Evaluation of Medical Disorders (PRIME -MD), HADS and beck depression inventory (BDI). Validity was constructed by comparing depressed patients and non-depressed patients relating to symptoms, pain, performance status by using these methods the prevalence of depression was found to be 34%, 12%, 19% and 14% respectively of BCD, PRIME MD, BDI and HADS. BCD was found to be much sensitive than other instruments as it detected a higher rate of depression as compared to other methods. BCD when compared to PRIME MD could recognize both major and minor depression whereas PRIME MD could be used for detection for major depression among patients. The validity of BCD could also be proved by patients having a high BDI score, HADS depression score with probable depression on BCD compared to those without probable depression. A comparison was also drawn between depressed patients according to BCD and non-depressed patients significantly showed scores on the higher side on PRIME MD. The administration of BCD is not very complicated, could be a part of a routine clinical interview. The results could be obtained immediately. Depression and anxiety are often thought to be the same, distinction was obtained between these two by using BCD that supports its discriminatory validity. Thus, BCD could be introduced in standard clinical practices [22].
