**9. Depression in terminally ill patients**

The incidence of major depression in terminally ill patients is between 25 and 77% [33]. Treatment should be started as soon as possible, since a lapse of time is needed for the treatment to begin to take effect, and in terminally ill patients we do not have time, we must be able to early recognize the signs and symptoms of depression that allow us to start the most appropriate treatment for each patient [34].

The sign that can help physicians in diagnosing the presence of depression is when there is a poor response to pain management, despite using different treatments. In these cases, as Robert L. Fine MD points out in his article "Depression, anxiety and delirium in terminally ill patient" [33], revising the dose of analgesics and increasing it, as well as adding antidepressant treatment, has very good results.

## **10. Consequences of depression in cancer patients**

Cancer by itself produces enough physical and emotional discomfort in those who suffer from it, as part of its own clinical picture and as a consequence of treatments.

However, the sum of psychosocial stressors and physical alterations can trigger a depressive disorder. The association between cancer and depression worsens the suffering and quality of life of patients [34].

The association between cancer and depression also reduces therapeutic adherence and increases mortality and morbidity [35]. Depression also decreases the patient's ability to cope with the disease and exacerbates the number and intensity of physical symptoms. In this way, the hospitalization time is prolonged, it can lead to suicide and the psychological burden on the family increases [34].

In a systematic review of patients with breast, lung, brain, skin, and blood cancer, mortality was 25% higher in patients with depressive symptoms and 39% higher in patients with major or minor depression, even when the known survival clinical prognostic factors are controlled [36].

It is common to find cancer patients with suicidal ideation. People with cancer are about 2 to 3 times more likely to commit suicide than the general population. This can be caused by the specific situations of each case, such as the location of the tumor, an advanced stage, the prognosis of the disease and obviously the presence of a depressive disorder that is not identified and treated in time [37].

For this reason, it is important to diagnose depression and other psychiatric disorders in oncological patients, since not treating them can seriously complicate the prognosis of the patient [37].
