**6. Pharmacological approaches**

Administration of antidepressants in physically healthy patients has shown improvement in treating depression, but when it comes to treating physically ill patients there has been a serious doubt in using it. Tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRI) are two classes of antidepressants that showed effective results than the placebo effect. But patients stopped taking them after 6–8 weeks of treatment because they experienced serious side effects like sexual dysfunction and dry mouth [47]. There is an inhibition of cytochrome P450 by SSRI drug–drug interaction. Citalopram is well tolerated as it has the fewest drug interaction compared to fluvoxamine which is a potent inhibitor of CYP1A2 and CYP2C19. The assessment of SSRI drug combination should be administered on an individual basis [48]. Drugs such as quetiapine and olanzapine are some antipsychotic medications that have been proposed for symptom palliation because they are thought to improve insomnia, appetite changes, nausea related to chemotherapy with some additional effects on depression, but rather than cancer population its efficacy is derived from general psychiatric [49]. Fatigue and symptoms of depression are very common in terminally ill older patients with advanced illnesses. Administration of methylphenidate showed possible effectiveness towards depressive symptoms and fatigue because of its rapid onset of action [50]. Patients that develop depression in palliative care were restricted and not allowed to use psychostimulants according to European guidelines [51]. Physicians prescribing drugs should be well aware of their toxicity and interactions with other drugs. When antidepressants were administered to the patient's suicidal tendencies increased mostly between young adults and adolescents [52]. It is important to study drug interaction because patients with cancer when administered antidepressants can alter the pharmacokinetics of the other drugs that were prescribed to the patient for its illness. For example, women who received tamoxifen for the treatment of breast cancer when administered with antidepressants can significantly decrease the survival chances. Paroxetine which is a potent irreversible inhibitor of CYP2D6 which is an antidepressant when administered with tamoxifen increases the risk of death in breast cancer patients [53]. Antidepressants to the patient should be provided following its symptoms of depression and physical illness. In a study done by Mehmet et al., it was found that when low doses of mirtazapine were administered for the treatment of depression in cancer patients, it was significantly safe until 24 weeks period of time, which reduced depressive symptoms [54].

#### **7. Age, demographics gender**

Depression is common in patients with serious illness in palliative care. Age factor could also contribute to its prevalence. A study was conducted in determining the prevalence of depression in heart failure patients [55]. In the total of patients, it

**215**

for breast cancer [61].

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

*Prevalence of depression in different age groups [55].*

depressed than men (44%) [55].

**Figure 5.**

**8. Social support and support groups**

was found out 48% of the patients were depressed [55]. Younger patients tend to be more depressed when compared to non-depressed patients. The age group between 19 and 29 had a 5% depression rate, 30–44 years had a 7.5% prevalence of depression and those over 65 years had the least depression rate that is 1.4% (**Figure 5**). When compared between men and women (64%) of women are likely to be more

Support groups for the patients suffering from depression in palliative care could be beneficial as it is associated with the gradual improvement of depressive symptoms and helps in improving the patient's emotional stress and quality of life of the patient. Cancer patients when participated in these support groups had a positive impact [56]. Patients with ostomy when participated in ostomy support group functioned at much more advanced levels than they were in any other previous support group. They experience a willingness to live and tried making new friends [57]. The efficiency of support groups increases when there is additional social support provided by friends and family members. A study done on breast cancer patients analyzed that how women cope with stress and anxiety [58]. It was found out that women who received social support from family showed an effective way of coping with stress. For effective stress management, it was determined that social support was very necessary [58]. Apart from family and friends nurses also play a crucial role in providing social support to the patients. In the medical staff nurses are the ones that are closest to the patient when they need anything. The connection between patients and healthcare is built by nurses themselves, so they need to understand the whole social support system and the nurses should be trained in providing counseling to the patients who are unable to get social support. In a study done on breast cancer patients, there was found to be a direct relationship between psychiatric morbidity and social [59]. For patients suffering from different types of cancer, one year after diagnosis for psychological disorder it was found out that 31.8% of the patients were diagnosed with depression who had low social support scores [59, 60]. A study conducted on different types of cancer, breast cancer, other cancer and mixed cancer by Bina Nausheen and team, results collectively suggested that there is a relationship between cancer progression and social support is strong

Depression is treatable in palliative care patients if one identifies it at the right time. Delayed diagnosis will always lead to delayed treatment which in order will worsen the situation. In the assessment procedure VAS (Visual analogue scale) is very effective for screening depression that correlated well with HADS [16]. Another sensitive diagnostic method is BCD (Brief Case find for Depression) which is very simple to administer which could detect both major and minor depression. PRIME MD (Primary Care Evaluation of Medical Disorders) has a

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


#### **Figure 5.**

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

period of time, which reduced depressive symptoms [54].

Depression is common in patients with serious illness in palliative care. Age factor could also contribute to its prevalence. A study was conducted in determining the prevalence of depression in heart failure patients [55]. In the total of patients, it

**7. Age, demographics gender**

Administration of antidepressants in physically healthy patients has shown improvement in treating depression, but when it comes to treating physically ill patients there has been a serious doubt in using it. Tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRI) are two classes of antidepressants that showed effective results than the placebo effect. But patients stopped taking them after 6–8 weeks of treatment because they experienced serious side effects like sexual dysfunction and dry mouth [47]. There is an inhibition of cytochrome P450 by SSRI drug–drug interaction. Citalopram is well tolerated as it has the fewest drug interaction compared to fluvoxamine which is a potent inhibitor of CYP1A2 and CYP2C19. The assessment of SSRI drug combination should be administered on an individual basis [48]. Drugs such as quetiapine and olanzapine are some antipsychotic medications that have been proposed for symptom palliation because they are thought to improve insomnia, appetite changes, nausea related to chemotherapy with some additional effects on depression, but rather than cancer population its efficacy is derived from general psychiatric [49]. Fatigue and symptoms of depression are very common in terminally ill older patients with advanced illnesses. Administration of methylphenidate showed possible effectiveness towards depressive symptoms and fatigue because of its rapid onset of action [50]. Patients that develop depression in palliative care were restricted and not allowed to use psychostimulants according to European guidelines [51]. Physicians prescribing drugs should be well aware of their toxicity and interactions with other drugs. When antidepressants were administered to the patient's suicidal tendencies increased mostly between young adults and adolescents [52]. It is important to study drug interaction because patients with cancer when administered antidepressants can alter the pharmacokinetics of the other drugs that were prescribed to the patient for its illness. For example, women who received tamoxifen for the treatment of breast cancer when administered with antidepressants can significantly decrease the survival chances. Paroxetine which is a potent irreversible inhibitor of CYP2D6 which is an antidepressant when administered with tamoxifen increases the risk of death in breast cancer patients [53]. Antidepressants to the patient should be provided following its symptoms of depression and physical illness. In a study done by Mehmet et al., it was found that when low doses of mirtazapine were administered for the treatment of depression in cancer patients, it was significantly safe until 24 weeks

**6. Pharmacological approaches**

*Therapies performed to treat depression.*

**Figure 4.**

**214**

*Prevalence of depression in different age groups [55].*

was found out 48% of the patients were depressed [55]. Younger patients tend to be more depressed when compared to non-depressed patients. The age group between 19 and 29 had a 5% depression rate, 30–44 years had a 7.5% prevalence of depression and those over 65 years had the least depression rate that is 1.4% (**Figure 5**). When compared between men and women (64%) of women are likely to be more depressed than men (44%) [55].
