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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 162-165
 

Effect of radiotherapy on psychiatric disorder in patients with head and neck cancer


1 Department of Radiation Oncology, Erciyes University Medical School, Kayseri, Turkey
2 Department of Psychiatry, Erciyes University Medical School, Kayseri, Turkey

Date of Web Publication28-Apr-2016

Correspondence Address:
D Unal
Department of Radiation Oncology, Erciyes University Medical School, Kayseri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.180816

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 » Abstract 

Purpose: The aim of this prospective study was to evaluate the effects of radiotherapy (RT) on psychiatric disorder in patients undergoing RT for head and neck cancer. Materials and Methods: The prospective study included 51 patients with head and neck cancer. The diagnosis of psychiatric disorder was made by Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria. Severity of psychopathology was assessed by the Hamilton Depression Rating Scale (HAM-D). Results: Although HAM-D score increased after RT (from 4 [0-26] to 7 [0-24]), this increase was not significant (P = 0.108). Fourteen (27.5%) of 51 patients had a psychiatric disorder before RT treatment; adjustment disorder in 6, depression in 4, sleep disorder in 3, anxiety disorder in 1 patient. On the other hand, 16 (31.4%) of 51 patients had a psychiatric disorder after RT treatment; adjustment disorder in 6, depression in 5, sleep disorder in 4, anxiety disorder in 1 patient. There was no significant difference between two periods in terms of the prevalence of psychiatric disorder (P = 0.721). Conclusions: The presence of psychiatric disorder was high in patients with head and neck cancer even before RT. Similarly, its high rate continued after RT. However, there is no significant effect of RT on development of psychiatric disorder.


Keywords: Head and neck cancer, psychiatric disorder, radiotherapy


How to cite this article:
Unal D, Orhan O, Ozsoy S D, Besirli A, Eroglu C, Kaplan B. Effect of radiotherapy on psychiatric disorder in patients with head and neck cancer. Indian J Cancer 2016;53:162-5

How to cite this URL:
Unal D, Orhan O, Ozsoy S D, Besirli A, Eroglu C, Kaplan B. Effect of radiotherapy on psychiatric disorder in patients with head and neck cancer. Indian J Cancer [serial online] 2016 [cited 2019 Dec 16];53:162-5. Available from: http://www.indianjcancer.com/text.asp?2016/53/1/162/180816



 » Introduction Top


Currently, in patients with cancer, a very important topic is quality-of-life as well as survival. There may be potential unfavorable effects of diagnosis and treatment of head and neck cancer on psychosocial state. Really, this effect has been revealed by high suicide risk found for patients with head and neck cancer.[1]

Although physical adverse effects of radiotherapy (RT) for the treatment of head and neck cancer have been shown in numerous studies, effects of RT on psychosocial function have been evaluated in only a few studies.[2] This has special clinical significance because psychiatric disorders such as depression and anxiety affect negatively quality-of-life and survival in patients with cancer.[3] Furthermore, the psychiatric disorders respond well to treatment. In addition, Chen et al. have shown that an alarming number of patients undergoing RT for head and neck cancer have symptoms suggestive of psychosocial distress even before beginning treatment. This proportion increases significantly during RT.[2]

Several factors including change the timings of meals, an increased number of meals, a limited selection of food and the need for special cooking methods of the foods result in that patients with head and neck cancer do not eat in a social environment. Furthermore, changes in facial view may contribute to social isolation and psychological disorders.[4]

The aim of this prospective study was to evaluate effects of RT on psychiatric disorder in patients undergoing RT for head and neck cancer.


 » Materials and Methods Top


This prospective study was performed in Department of Radiation Oncology in Erciyes University Medical School between December 2008 and December 2009. This prospective study was performed in 56 patients with non-metastatic head and neck cancer. Three patients were excluded from this study because of a history of psychiatric disorder. Two of the 56 patients could not complete RT. Finally, 51 patients were included in this study. The study protocol was approved by the local ethics committee. Informed consent was obtained from all patients subjected to study procedures. Patients were excluded if they were <18 years old, had severe disease such as heart failure and renal failure, had a history of any other cancer, were not suitable for RT, had a history of any psychiatric disorder and/or received antidepressant drug or if they refused to give consent.

Psychiatric examination and psychometric tests

All psychiatric interviews and psychometric tests were performed by the same experienced psychiatrist both before and after RT. The diagnosis of psychiatric disorder was made by Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria.[5] Severity of depressive symptoms was assessed by the Hamilton Depression Rating Scale (HAM-D), which was developed by Hamilton and adapted for the Turkish population by Akdemir et al.[6],[7] In the first psychiatric examination before RT, appropriate psychotropic medication was started to patients with a psychiatric disorder. Unfortunately, none of the patients use the medications regularly. Therefore, effects of anti-psychiatric medication were not evaluated in patients with a psychiatric disorder.

RT and chemotherapy

Patients irradiated by using 6 MV linear accelerator beams (varian CDX 2300). RT was curative for the majority of the patients; curative RT in 32 (62.8%) patients and adjuvant RT 19 (37.2%) patients. RT was given through two parallel opposite lateral fields to the cervical lymph nodes as well as the primary tumor sites and/or through anterior field to the inferior cervical and the supraclavicular lymph nodes. It was given in 1.8-2.0 Gy/day doses 5 days a week by conventional fractionation (total 60-70 Gy by spinal cord protection at 46 Gy). Cisplatin 50 mg/week was concomitantly given to the majority of patients.

The eastern cooperative oncology group performance status

The Eastern Cooperative Oncology Group (ECOG) score were described as following:

0: Asymptomatic

1: Symptomatic, but completely ambulatory

2: Symptomatic, <50% in bed during the day

3: Symptomatic, >% in bed, but not bedbound

4: Bedbound

5: Death.

Statistical analysis

SPSS 15.0 software was used for the statistical analysis. Continuous variables with normal distribution were presented as mean ± standard deviation. Median value was used where normal distribution was absent. Qualitative variables were given as percent. Statistical analysis for the parametric variables was performed using the Student's t-test between two groups. The Mann-Whitney U test was used to compare non-parametric variables between two groups. The Chi-square test was used to compare qualitative data between two groups. The significance between periods was assessed by the Wilcoxon signed-rank test for nonparametric variables and the McNemar test for qualitative variables. A P value of 0.05 was considered to be statistically significant.


 » Results Top


[Table 1] shows demographic and clinical characteristics of patients. The localization of cancer was larynx in 27 (52.9%), pharynx in 13 (25.5%), parotid gland 5 (9.8%), lip 2 (3.9%), oral cavity 1 (2.0%), maxillary sinus 1 (2.0%), skin cancer + neck metastasis 1 (2.0%) and unknown primary cancer 1 (2.0%) patient.
Table 1: Demographic and clinical characteristics of patients

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Although HAM-D score increased after RT (from 4 (0-2) to 7 (0-24), this increase was not significant (P = 0.108).

[Figure 1] and [Figure 2] shows psychiatric disorders in patients before and after RT, respectively. Fourteen (27.5%) of 51 patients had a psychiatric disorder before RT treatment; adjustment disorder in 6, depression in 4, sleep disorder in 3, anxiety disorder in 1 patient. On the other hand, 16 (31.4%) of 51 patients had a psychiatric disorder after RT treatment; adjustment disorder in 6, depression in 5, sleep disorder in 4, anxiety disorder in 1 patient. There was no significant difference between two periods in terms of the prevalence of psychiatric disorder (P = 0.721).
Figure 1: Psychiatric disorders in patients before radiotherapy

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Figure 2: Psychiatric disorders in patients after radiotherapy

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Comparison of clinical parameters in patients with and without psychiatric disorder is expressed in [Table 2]. HAM-D score was significantly higher in patients with a psychiatric disorder than in those without psychiatric disorder both before RT and after RT. ECOG score was significantly worse in patients with a psychiatric disorder than in those without psychiatric disorder before RT while there was no significant difference between two groups after RT. On the other hand, there was no significant difference between two groups in terms of other demographic and clinical parameters including age, gender, smoking, drinking, family history of cancer, use of concomitant chemotherapy, RT dose, cancer localization, stage of cancer and comorbid diseases both before RT and after RT (P > 0.05).
Table 2: Comparison of clinical parameters in patients with and without psychiatric disorder

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 » Discussion Top


Currently, in patients with cancer, a very important topic is quality-of-life as well as survival. A significant proportion of these patients develop a depressive disorder. As defined in DSM-IV,[5] one side of the spectrum is slightly depressed mood while major depression is on the other side of the spectrum. On the other hand, the making a distinction between sadness, which is caused by cancer and is understandable to some extent and clinical depression is of great importance because major depression, which reduces significantly compliance with treatment and the quality-of-life, should be recognize and treat. Furthermore, depression reduces survival in patients with cancer.[3]

The results of the prospective study evaluating psychosocial functions in patients undergoing RT for head and neck cancer are notable in several ways. Firstly, a significant proportion (27.4%) of patients with head and neck cancer had a psychiatric disorder before beginning of RT course. This finding reveal that psychiatric disorders are likely overlooked and are not usually treated in this patient population and is consistent with those found in several studies made earlier.[2],[8] Secondly, none of these patients who experienced psychiatric disorder had a prior history of mental illness. This shows that a new diagnosis of cancer is likely the cause of psychiatric disorder. Thirdly, the high frequency of psychiatric disorder remained after the end of RT.

Fourteen (27.5%) of 51 patients had a psychiatric disorder before beginning of RT course. Adjustment disorder and depression were the most frequent psychiatric disorders. In a manner very similar to the period prior to RT, 16 (31.4%) patients had a psychiatric disorder after the end of RT. Adjustment disorder and depression were still the most frequent psychiatric disorders. These findings show also that the frequency of psychiatric disorder did not increase during RT course in patients undergoing RT for head and neck cancer.The findings of our study did not resemble those in a previous study performed by Chen et al. in 40 patients with head and neck cancer.[2] In their study, the frequency of depression before beginning of RT course was found 45% and 58% by using the Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory-II (BDI-II), respectively. The frequency of depression after the end of RT course was found 75% and 60%, respectively and a difference between two periods in terms of frequency of depression was statistically significant.[2] There may be several reasons for the difference between our study and their study. Firstly, they used HADS and BDI-II without a psychiatric interview (examination), which performs by a psychiatrist, to assess psychiatric disorder. In our study, although HAM-D, a test asking questions in the style of the survey, was used, psychiatric disorder was investigated a full psychiatric examination by a psychiatrist. As is known, psychiatric examination is required for diagnosis of a psychiatric disorder such as depression. Secondly, they observed that both HADS and BDI-II score were lower significantly in patients with married life and found that being single or divorced had a negative impact on the development of psychosocial disorder compared to being married. In our study, although not shown in the results section, all patients except one, whose wife had died, but he lived with his children, were married and lived with their family. The pattern of life of patients appears to an important reason why prevalence of psychiatric disorder in our study was lower than in their study and why there was no negative change in frequency of psychosocial disorder during RT course. Social support could associate with a better emotional adaptation to cancer.[9] It is critical to both adaptation to the disease and successful rehabilitation in patients with head and neck cancer.[10],[11] Furthermore, it has been reported that living alone increases significantly the risk of psychological illness in patients with newly diagnosed head and neck cancer.[12] All this information also supports our opinion mentioned above.

Even only the fear of cancer often leads to think that depression is an understandable reaction against this life-threatening illness. However, the frequency of psychiatric disorders in cancer patients is similar to those in patients with an inflammation-associated disease such as rheumatoid arthritis and coronary artery disease.[13],[14],[15]

Kugaya et al. found that 18 (16.8%) of 107 in Japan patients with head and neck cancer had an adjustment disorder or major depression.[12] In a study performed by Lloyd-Williams, the prevalence of major depression was found to be 27% in patients with advanced cancer.[16] Brintzenhofe-Szoc et al. found that approximately 30% of 8265 patients with cancer had anxiety and/or depression.[17] Derogatis et al. reported that the prevalence of psychiatric disorder (which was diagnosed by DSM-III criteria) among cancer patients was 44% and approximately 68% of the psychiatric diagnoses consisted of adjustment disorders, with 13% representing depression.[18] Akechi et al. found that the proportions of terminally ill cancer patients diagnosed with adjustment disorders and major depression at baseline were 16.3% and 6.7% respectively, whereas at follow-up, 10.6% were diagnosed with adjustment disorders and 11.8% with major depression.[19]

There may be many causes of the differences in the frequency of psychiatric disorder. One of the causes is the sample size and patient characteristics of the studies. Many factors including number of patients, cancer localization, histopathology of cancer (squamous or non-squamous) and stage of cancer may affect results. Type of psychiatric disorder also appears to affect significantly the results because some studies investigated only depression, whereas the other studies examined psychiatric disorders such as adjustment disorders, anxiety as well as depression. Diagnostic methods used to identify psychiatric disorders can affect the results because they are not homogeneous. For example, psychiatric disorder was investigated performing psychiatric examination by a psychiatrist in this study whereas such a psychiatric examination was not performed in most studies. On the other hand, racial and geographic differences and the factors such as ethnicity may affect meaningfully the results.


 » Conclusion Top


Prevalence of psychiatric disorder was very high in patients with head and neck cancer even before beginning of RT course. Similarly, this high rate remained after the end of RT. On the other hand, there was no significant negative effect of RT treatment on the development of psychiatric disorder.

 
 » References Top

1.
Zeller JL. High suicide risk found for patients with head and neck cancer. JAMA 2006;296:1716-7.  Back to cited text no. 1
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2.
Chen AM, Jennelle RL, Grady V, Tovar A, Bowen K, Simonin P, et al. Prospective study of psychosocial distress among patients undergoing radiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 2009;73:187-93.  Back to cited text no. 2
    
3.
Suthahar A, Gurpreet K, Ambigga D, Dhachayani S, Fuad I, Maniam T, et al. Psychological distress, quality of life and coping in cancer patients: A prospective study. Med J Malaysia 2008;63:362-8.  Back to cited text no. 3
    
4.
Breitbart W, Holland J. Psychosocial aspects of head and neck cancer. Semin Oncol 1988;15:61-9.  Back to cited text no. 4
    
5.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision. Washington, DC: American Psychiatric Association; 2000.  Back to cited text no. 5
    
6.
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 6
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7.
Akdemir A, Türkçapar MH, Orsel SD, Demirergi N, Dag I, Ozbay MH. Reliability and validity of the Turkish version of the Hamilton Depression Rating Scale. Compr Psychiatry 2001;42:161-5.  Back to cited text no. 7
    
8.
Fritzsche K, Liptai C, Henke M. Psychosocial distress and need for psychotherapeutic treatment in cancer patients undergoing radiotherapy. Radiother Oncol 2004;72:183-9.  Back to cited text no. 8
    
9.
Maunsell E, Brisson J, Deschênes L. Social support and survival among women with breast cancer. Cancer 1995;76:631-7.  Back to cited text no. 9
    
10.
Rapoport Y, Kreitler S, Chaitchik S, Algor R, Weissler K. Psychosocial problems in head-and-neck cancer patients and their change with time since diagnosis. Ann Oncol 1993;4:69-73.  Back to cited text no. 10
    
11.
Pruyn JF, de Jong PC, Bosman LJ, van Poppel JW, van Den Borne HW, Ryckman RM, et al. Psychosocial aspects of head and neck cancer: A review of the literature. Clin Otolaryngol Allied Sci 1986;11:469-74.  Back to cited text no. 11
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12.
Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, et al. Prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 2000;88:2817-23.  Back to cited text no. 12
    
13.
Lespérance F, Frasure-Smith N. Depression in patients with cardiac disease: A practical review. J Psychosom Res 2000;48:379-91.  Back to cited text no. 13
    
14.
Creed F. Psychological disorders in rheumatoid arthritis: A growing consensus? Ann Rheum Dis 1990;49:808-12.  Back to cited text no. 14
    
15.
Dickens C, McGowan L, Clark-Carter D, Creed F. Depression in rheumatoid arthritis: A systematic review of the literature with meta-analysis. Psychosom Med 2002;64:52-60.  Back to cited text no. 15
    
16.
Lloyd-Williams M, Dennis M, Taylor F. A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer. Palliat Med 2004;18:558-63.  Back to cited text no. 16
    
17.
Brintzenhofe-Szoc KM, Levin TT, Li Y, Kissane DW, Zabora JR. Mixed anxiety/depression symptoms in a large cancer cohort: Prevalence by cancer type. Psychosomatics 2009;50:383-91.  Back to cited text no. 17
    
18.
Derogatis LR, Morrow GR, Fetting J, Penman D, Piasetsky S, Schmale AM, et al. The prevalence of psychiatric disorders among cancer patients. JAMA 1983;249:751-7.  Back to cited text no. 18
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19.
Akechi T, Okuyama T, Sugawara Y, Nakano T, Shima Y, Uchitomi Y. Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: Associated and predictive factors. J Clin Oncol 2004;22:1957-65.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]

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