**1. Introduction**

Depression is thought to be one of the most serious and common mental disorders that could arise in palliative care settings. The term depressed is widely misunderstood among a large section of people. Often depressed is misused by the word "feeling sad". Many physical symptoms like fatigue, weight loss, sleep cycle, weakness, lack of interest are common in advanced illness. There should be proper monitoring of symptoms in depression. A survey was done by Lauren Rayner and team [1] that determined the pervasiveness of depression in patients receiving palliative care, after the initial assessment by clinicals, nurses 300 patients were interviewed. According to the survey, 58 patients met the criteria for MDD (major depressive disorder) while 109 met the criteria for any depressive disorder. Males were more prone to MDD. Depression could not be only identified by somatic symptoms, but a proper psychological assessment and support are also needed. A study done by Franca Warmenhoven and team suggested that [2] many physicians failed to distinguish between the normal and abnormal sadness, patients receiving palliative care, the therapeutic and diagnostic processes for depression is a continuous

and overlapping process. There is high non-specificity in diagnostic methods for depression in palliative care settings. The occurrence of depression also depends upon the past life of the patients and their relationship with their family members. A study conducted by Moira o Connor, Kate white RN and team upon patients with cancer in Western Australia and new south wales [3], has shown that depression is more prevalent in patients with a family history of anxiety. Many patients battling life-threatening illnesses have gone through a lot of pain, trauma, diagnostic measures by the time they approach palliative care. Each of the phases they have gone through has a psychological impact on the patient. Depending upon the diagnostic criteria used the rates of depression could range from 3–69% [4]. Gender, age, demographics widely influence the personality and mental status of patients. Participants diagnosed with mental disorders were significantly younger than the other participants and have a smaller social network. Women are significantly likely to be more depressed than men (P = 0.082) [5]. Patients receiving palliative care with moderate to severe depression could be benefited from an intense narrative intervention as the score reduced on PHQ-9 [patient health questionnaire, it is a multiple-choice questionnaire that is used for screening for depression]. Healthcare workers who understand the background of patients thoroughly with practitioners could deliver the intervention. Intervention is a partially structured narrative that is performed by experienced scientists with research trainers who had background knowledge of patients with advanced illness [6]. Patients are more prone to depression in advanced stages of illness (**Figure 1**). Helping patients with support groups in the initial stages of disease could prove effective. Taking care of patients suffering from idiopathic pulmonary fibrosis is very challenging because at that time no medication could prove its efficacy that could improve the quality of patient's life, but many therapies could reduce symptoms in patients. However, a placebo effect could have improved the outcome, when introduced to the support groups and palliative care have increased the quality of life [7]. A comorbid condition for the patient in palliative care could be very challenging to treat. A study suggested that psychotherapy when given to patients with advanced and serious illness in palliative care can reduce symptoms of depression and tends to improve the quality of life [8]. Cognitive-behavioral therapy helps the patients to accept the condition and treat emotional distress, intervention narrated by health professionals also has significant effects [8]. Detection of depression in palliative care screening could be an effective way as it excludes the non-depressed patients from the depressed ones, but one disadvantage is that it could not detect the degree to which a diagnostic criterion is applied to the patient. Comprehensive clinical evaluation should not be substituted by screening but supplement it. Mostly the detected cases rarely take into account the duration of symptoms. The ability to detect and treat depressive symptoms should be an initial priority to treat depression in palliative care [9, 10]. To achieve quality palliative care, an acceptable or good amount of psychological care is a must.

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

distress that also require medical help [14].

**2. Assessment and diagnosis**

Most patients face a stigma from seeking help from medical professionals, thus it should be dealt with and solved. Members of the medical and research team should arm themselves with interactive communication skills. Unconsciously or unknowingly the healthcare workers should be very vigilant not to portray hopelessness or any negative thought in respect to the disease diagnosis or treatment to the patient. They should be compassionate and empathetic towards the patient. In the advanced stages of the disease, the intensity and frequency of physical symptoms can vary. Screening for mood disorders and depression should be done in patients expressing the significantly high intensity of physical symptoms to provide treatment to the condition [11]. Lack of support system from friends and family at the time of palliative care is certainly a risk factor for non-remission. A strong correlation was found between remission of depression and improvement of physical symptoms [12]. An additional amount of psychological care could benefit depressed patients in palliative care with low support groups for their treatment [12]. Psychological therapies including cognitive behavior therapy showed some positive results in the treatment procedure. Some interventions like antidepressants and psychostimulants remain challenging, requiring a wide level of clinical trials. Pharma logical approach when combined with psychotherapy, support group therapy, an aromatherapy massage could be proven very effective in treating depression [13]. A study performed in cancer patients to detect depression states that no method has been completely accurate for definitive screening. Detailed tests combined with simple questions could be considered as a method. Work carried out in future generation should be beyond screening for psychopathy alone, there is a wide variety of psychological

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].

**Figure 1.**

*Factors responsible for depression in patients.*

#### *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*

and overlapping process. There is high non-specificity in diagnostic methods for depression in palliative care settings. The occurrence of depression also depends upon the past life of the patients and their relationship with their family members. A study conducted by Moira o Connor, Kate white RN and team upon patients with cancer in Western Australia and new south wales [3], has shown that depression is more prevalent in patients with a family history of anxiety. Many patients battling life-threatening illnesses have gone through a lot of pain, trauma, diagnostic measures by the time they approach palliative care. Each of the phases they have gone through has a psychological impact on the patient. Depending upon the diagnostic criteria used the rates of depression could range from 3–69% [4]. Gender, age, demographics widely influence the personality and mental status of patients. Participants diagnosed with mental disorders were significantly younger than the other participants and have a smaller social network. Women are significantly likely to be more depressed than men (P = 0.082) [5]. Patients receiving palliative care with moderate to severe depression could be benefited from an intense narrative intervention as the score reduced on PHQ-9 [patient health questionnaire, it is a multiple-choice questionnaire that is used for screening for depression]. Healthcare workers who understand the background of patients thoroughly with practitioners could deliver the intervention. Intervention is a partially structured narrative that is performed by experienced scientists with research trainers who had background knowledge of patients with advanced illness [6]. Patients are more prone to depression in advanced stages of illness (**Figure 1**). Helping patients with support groups in the initial stages of disease could prove effective. Taking care of patients suffering from idiopathic pulmonary fibrosis is very challenging because at that time no medication could prove its efficacy that could improve the quality of patient's life, but many therapies could reduce symptoms in patients. However, a placebo effect could have improved the outcome, when introduced to the support groups and palliative care have increased the quality of life [7]. A comorbid condition for the patient in palliative care could be very challenging to treat. A study suggested that psychotherapy when given to patients with advanced and serious illness in palliative care can reduce symptoms of depression and tends to improve the quality of life [8]. Cognitive-behavioral therapy helps the patients to accept the condition and treat emotional distress, intervention narrated by health professionals also has significant effects [8]. Detection of depression in palliative care screening could be an effective way as it excludes the non-depressed patients from the depressed ones, but one disadvantage is that it could not detect the degree to which a diagnostic criterion is applied to the patient. Comprehensive clinical evaluation should not be substituted by screening but supplement it. Mostly the detected cases rarely take into account the duration of symptoms. The ability to detect and treat depressive symptoms should be an initial priority to treat depression in palliative care [9, 10]. To achieve quality palliative care, an acceptable or good amount of psychological care is a must.

**208**

**Figure 1.**

*Factors responsible for depression in patients.*

Most patients face a stigma from seeking help from medical professionals, thus it should be dealt with and solved. Members of the medical and research team should arm themselves with interactive communication skills. Unconsciously or unknowingly the healthcare workers should be very vigilant not to portray hopelessness or any negative thought in respect to the disease diagnosis or treatment to the patient. They should be compassionate and empathetic towards the patient. In the advanced stages of the disease, the intensity and frequency of physical symptoms can vary. Screening for mood disorders and depression should be done in patients expressing the significantly high intensity of physical symptoms to provide treatment to the condition [11]. Lack of support system from friends and family at the time of palliative care is certainly a risk factor for non-remission. A strong correlation was found between remission of depression and improvement of physical symptoms [12]. An additional amount of psychological care could benefit depressed patients in palliative care with low support groups for their treatment [12]. Psychological therapies including cognitive behavior therapy showed some positive results in the treatment procedure. Some interventions like antidepressants and psychostimulants remain challenging, requiring a wide level of clinical trials. Pharma logical approach when combined with psychotherapy, support group therapy, an aromatherapy massage could be proven very effective in treating depression [13]. A study performed in cancer patients to detect depression states that no method has been completely accurate for definitive screening. Detailed tests combined with simple questions could be considered as a method. Work carried out in future generation should be beyond screening for psychopathy alone, there is a wide variety of psychological distress that also require medical help [14].
