**8. Social support and support groups**

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 for breast cancer [61].

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

certain limitation that it could identify only major depressive disorders [22]. For the assessment to be smooth and functioning, there should be well-equipped hospitals with improvised mechanisms and techniques and well-trained staff. When patients were openly asked about feeling depressed the responses recorded from most of the patients were less sensitive and showed false results because the patients tend to hide their illness because of them being stigmatized. The stigma of depression should be eradicated as it hampers the testing problem. To eradicate this stigmatization one must preach to everyone in the family and hospital staff, should organize some seminars and conduct workshops. Many of the medical staff and even doctors treating patients are not well aware of depression as a psychological illness. For the patients to be comfortable with the doctors and staff, there should be good interpersonal communication skills between both doctors and the patients, which could be established by a non-judgemental and emphatic behavior of doctors towards patients [31]. The mental and emotional support from friends and family to the patient at the time of illness could also help the patient to recover more likely than those who do not have it. In the hospital where nurses play a vital role and act as a bridge between doctors and patients, they need to be well trained and highly professional. Untrained staff and nurses in the hospital could be a major reason for prolonged and untreated depression in the patients. Once the depression is assessed, treatment methods could be both psychological and pharmacological. The major limitation of pharmacological drugs is it has certain side effects in some patients apart from treating depression [35, 47, 49, 51]. Patients who experience side effects from antidepressants or psychostimulants should be treated in combination with psychotherapy, yoga and meditation are also effective in the treatment process which helps the patient to achieve peace of mind.
