**12. Treatment of depressive symptoms in cancer patients**

The treatment of depressive symptoms in cancer patients is not different from that of patients with depression. The recommendation is always a multidisciplinary intervention that includes the medical treatment of the underlying disease and mental health interventions (psychiatry and psychology), social work, physical therapy, and others that speed up the recovery process or delay patient deterioration [34].

Regarding mental health, pharmacological treatment is as important as individual, group, and family psychological interventions.

It is interesting to point out that in the systematic review carried out by Dwin Gayatri et al., on "Quality of life of cancer patients at palliative care units in developing countries" [43], they find that in developing countries, patients in palliative care

over 65 years of age, married or ever married, with a high level of education, users of complementary or alternative medicine, who practice religious or spiritual activities, are more likely to obtain high levels of quality of life scores.

Also, they mention that spirituality and religiosity positively affect the ability of cancer patients to cope with this situation, among other things because it gives the patient greater social support and a belief system, offering a coping mechanism and influencing neuroendocrine and neuroimmunology mechanisms.

From the medical point of view, the main way of approaching depression from the somatic area is pharmacological management. There must be coordination between the medical oncologist and the psychiatrist to choose the appropriate medication based on the patient's symptom profile, tolerability and risk-benefit, with the aim of designing a strategy for each patient [34].

Selective serotonin reuptake inhibitors (SSRIs) are effective in treating depression in cancer patients. However, it is important to consider the pharmacological interactions with antineoplastic agents that can reduce their efficacy or increase their toxicity. Fluoxetine, sertraline, paroxetine, and fluvoxamine inhibit transformation through CYP450 3A4 [44].

Other drugs like citalopram, and escitalopram, are weak inhibitors, which makes them a safer choice. Dual antidepressants have also shown efficacy due to their speed of action and their usefulness in collateral symptoms, such as vasomotor symptoms and pain. Mirtazapine is very useful in symptoms such as pain, nausea, insomnia, and anxiety [34].

Regarding the psychological approach, an intervention is important from the moment the patient is diagnosed with cancer. It should not be expected that the cancer patient manifests a psychological disorder. Primary prevention helps prevent the occurrence of subsequent clinical psychopathological conditions, such as depression [44].

Individual cognitive-behavioral psychotherapy is the one that has been more studied, proving its effectiveness. Its help is based on the restructuring of the exaggerated negative beliefs that the patient has about himself, the world and the future. The objective is that the patient can have a more realistic vision, which helps him to face life in general in a healthier way [45].

On the other hand, strategies such as mindfulness, or full attention, have become highly relevant in recent years for managing stress and somatic pain. Other strategies, such as relaxation and other imagery-based therapies, have been used in successful interventions, reported in numerous publications. Music therapy has also been shown to relieve patients' pain and psychological symptoms [46].

Among the beneficial effects of these psychological interventions is the reduction of the stress impact on the body, reduction of fear of the illness, activation of the immune system, increased motivation for lifestyle changes, strengthening the "desire to live", coping with despair and evaluation and modification of the patient's beliefs regarding the disease [44].

Another important point to keep in mind is the role of family and friends as a source of social, personal, emotional, and financial support. For this reason, it is extremely important to carry out an adequate family/or social psychological approach, addressing the concerns and difficulties that arise in the family or social support group of the cancer patient [47].

Many times, family conflicts, the sadness of losing a loved one and feelings of guilt can worsen the course of the disease, while mutual supportive relationships, unity, and family skills in caring for the sick are important protective factors [47].
