|Year : 2016 | Volume
| Issue : 3 | Page : 432-434
Prevalence of depression and anxiety disorder in cancer patients: An institutional experience
A Shankar1, C Dracham1, S Ghoshal1, S Grover2
1 Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||24-Feb-2017|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
AIM: This study aimed to screen the patients with various malignancies for the presence of depressive disorders and anxiety disorder using standardized rating scales. MATERIALS AND METHODS: Five hundred and thirty-four (n = 534) patients attending the radiotherapy outpatient services completed the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 (GAD-7) Questionnaire. RESULTS: About half (n = 248; 46.4%) of the patients had psychiatric morbidity either in the form of depressive disorder or in the form of GAD. Higher stage of malignancy (from early, advanced to metastasis) was associated with higher prevalence of depressive disorder and GAD. The presence of psychiatric morbidity, especially anxiety disorder, was associated with being from low socioeconomic status. CONCLUSION: The present study suggests that psychiatric morbidity in the form of depressive and anxiety disorders is very common among patients with malignancies. Accordingly, there is a need for close liaison between oncologists and mental health professionals to improve the outcome of patients with various malignancies.
Keywords: Anxiety, cancer, depression, malignancy
|How to cite this article:|
Shankar A, Dracham C, Ghoshal S, Grover S. Prevalence of depression and anxiety disorder in cancer patients: An institutional experience. Indian J Cancer 2016;53:432-4
|How to cite this URL:|
Shankar A, Dracham C, Ghoshal S, Grover S. Prevalence of depression and anxiety disorder in cancer patients: An institutional experience. Indian J Cancer [serial online] 2016 [cited 2017 May 1];53:432-4. Available from: http://www.indianjcancer.com/text.asp?2016/53/3/432/200651
| » Introduction|| |
The diagnosis of cancer is associated with a lot of psychological distress. Untreated psychiatric morbidities among patients with cancer can significantly impact morbidity, lead to poor adherence to treatment, longer and more frequent hospitalizations, contribute to poor prognosis, poor quality of life, and lead to increased mortality., The psychiatric comorbidities in the cancer patients are often underdiagnosed. Data regarding the prevalence of psychiatric disorders in cancer patients are sparse., Most of the data are from developed countries where the sociodemographic scenarios are different from developing countries. Although there are some studies from India, these are limited by small sample sizes. In this background, the present study aimed to screen the patients with various malignancies for the presence of depressive disorders and anxiety disorder using standardized rating scales.
| » Materials and Methods|| |
The study was approved by the Ethics Committee of the Institute, and all the patients were recruited after obtaining written informed consent. Patients were recruited among patients attending the oncology outpatient services of a tertiary care hospital. To be included in the study, the patients were required to be aged >18 years and have a biopsy proven malignancy. Patients those known to have diagnosed psychiatric illness before be diagnosed with malignancy, patients with preexisting severe cognitive impairment, and patients too sick to participate in an interview or complete the questionnaire themselves were excluded from the study.
The participants were recruited from the outdoor services. Participants completed the questionnaires themselves, and if they required any clarification, an oncology resident was available for assistance.
Patient Health Questionnaire-9
Hindi version of the Patient health Questionnaire-9 (PHQ-9) was used to assess depression. It is a self-report questionnaire, which comprises nine items, each evaluating the nine Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria of depression, rated as “0” (not at all) to “3” (nearly every day). PHQ-9 has been shown to be a valid instrument to diagnose depression, having high sensitivity (61%) and specificity (94%) for diagnosing depression in adults. PHQ-9 score ≥10 has a sensitivity of 88% and a specificity of 88% for the diagnosis of major depression made by a mental health profession. In the present study, we used the cutoff of ten for making the diagnosis of depression.
Generalized Anxiety Disorder-7 Scale
It is a seven-item scale to assess anxiety. It has been shown to have good reliability as well as criterion, construct, factorial, and procedural validity. Cutoff points of 5, 10, and 15 are interpreted as representing mild, moderate, and severe levels of anxiety on the Generalized Anxiety Disorder-7 (GAD-7). However, the diagnostic threshold has been reported to be a cutoff score of 8 or more. There is good agreement between self-report and interviewer-administered versions of the scale. In the present study, a cutoff score of 8 or more was used to make the diagnosis of GAD.
Data were analyzed using Statistical Package for Social Sciences version 14 (SPSS Inc., Chicago). Mean, standard deviation (SD), frequency, and percentages were used to describe the data. Parametric statistics (e.g., Student's t-test, Chi-square, and Pearson correlation test) were used to study the association of demographic and clinical variables with psychiatric morbidity.
| » Results|| |
Five hundred and thirty-four (n = 534) patients attending the radiotherapy outpatient services completed the questionnaires. The mean age of the patients was 51.78 years (SD = 14.13). Majority of the patients (n = 293; 54.9%) were more than 50 years of age at the time of assessment. Males (n = 293; 54.9%) outnumbered the females (n = 241; 45.1%). Similarly, patients those from nuclear families (n = 287; 53.7%) outnumbered those from joint families (n = 247; 46.3%). In terms of socioeconomic status, majority of the patients belonged to the lower socioeconomic status (n = 362; 67.8%) and this was followed by middle socioeconomic status (N = 163; 31.5%) and very few patients (n = 9; 1.7%) belonged to high socioeconomic status as per the modified Kuppuswamy scale 2014. Substance use in the form of tobacco and/or alcohol use was present in about two-fifth (n = 210; 39%) of the patients. Most commonly involved malignancy site was that of head and neck (n = 124; 23.2%), followed by gastrointestinal (n = 108; 20.2%), breast (n = 79; 14.6%), and gynecological (n = 71; 13.3%) malignancies. In other patients (n = 153; 28.6%), the malignancies involved other organs of the body. In 13.5% (n = 72), the malignancy was in the early stage and majority of patients had locally advanced disease (n = 368; 68.9%). Metastatic disease was seen in 17.6% (n = 94) of cases.
Psychiatric morbidity in the study sample
Slightly less than half (n = 248; 46.4%) of the patients had psychiatric morbidity either in the form of depressive disorder or in the form of GAD. Depression was slightly more prevalent (n = 200; 37.5%) than in GAD (n = 191; 35.8%). In most cases, depression was of moderate severity (n = 182; 34.1%) and very few patients had severe depression (n = 18; 3.4%). Further, it was seen that in more than half of the patients who had psychiatric morbidity (143 out of 248), they fulfilled the diagnosis of both depressive disorders and GAD.
Factors associated with psychiatric morbidity
In terms of prevalence of psychiatric morbidity, it was noted that depression was most common among patients with endocrine malignancies (100%), followed by malignancies of thoracic region (46.7%), multiple myeloma (50%), gastrointestinal (41.7%), unknown primary (41.7%), genitourinary (40.7%), bone and soft tissue (39.3%), gynecological (38%), breast (35.9%), brain (33.3%), head and neck (32.3%), lymphoma (23.1%), and hematological (16.7%) malignancies. GAD was most common among patients with genitourinary malignancies (55.6%), followed by multiple myeloma (50%), unknown primary (50%), malignancies of thoracic region (43.3%), gastrointestinal (40.7%), brain (37%), endocrine (33.3%), head and neck (32.3%), breast (32.1%), gynecological (32.4%), bone and soft tissue (28.6%), hematological malignancies (6.7%), and lymphoma (15.4%). When the prevalence of either one of the psychiatric morbidities was evaluated, psychiatric morbidity was most prevalent among those with malignancies of endocrine glands (33.3%), followed by genitourinary (55.6%), gastrointestinal (50.9%), multiple myeloma (50%), thoracic region (50%), unknown primary (50%), gynecological (49.3%), breast (44.9%), bone and soft tissue (42.9%), head and neck (42.7%), brain (40.7%), lymphoma (30.8%), and hematological malignancies (16.7%).
In terms of demographic and clinical correlates, there was no significant difference in the prevalence of depressive disorders, GAD, presence of at least one psychiatric morbidity, and presence of both the disorders among patients of either gender, those aged <50 years and those aged ≥50 years, and those using or not using any substance. When psychiatric morbidity was compared based on the site by considering the sample size of at least seventy cases for each malignancy site, no significant difference was seen in the prevalence of psychiatric morbidity in patients with different malignancies. Compared to those belonging to nuclear families, patients from joint family had higher prevalence of GAD (40.5% vs. 31.7%; χ2 = 4.45; P = 0.04*) or presence of both the disorder (30.4% vs. 23.7%; χ2 = 9.1; P = 0.03*). Compared to those belonging to middle socioeconomic status family, anxiety was more common among those belonging to low socioeconomic status families (40.1% vs. 26.7%; χ2 = 12.28; P =0.02*). However, a consistent finding was seen for all types of psychiatric morbidities and stages of malignancy. Prevalence of all psychiatric morbidity increased significantly with increase in stage of malignancy from early, advanced, or those with metastasis.
| » Discussion|| |
In this study, about half of the patients were found to have a psychiatric diagnosis. The presence of psychiatric disorders in about half of the patients reflects the negative impact of the illness on the patients. Further, this finding suggests that there is a need for close liaison between oncologists and mental health professionals. In India, most of the oncology centers do not have full-time mental health professionals such as psychiatrists, psychologists, or psychiatric social workers who could identify and manage the psychological aspects associated with malignancy. This finding calls for having full-time mental health professionals attached to all the oncology units.
An important finding of the present study includes increase in the prevalence of psychiatric morbidity with increase in stage of the malignancy. This finding suggests that if sufficient manpower is not available to screen all patients with malignancy for psychiatric disorders, then the resources should be diverted to those with higher stage of malignancy.
The present study has certain limitations. First, number of patients in different oncology groups was too small to draw any concrete conclusion. Second, the psychiatric indicators were evaluated using screening instruments and the psychiatric diagnoses were not confirmed by a trained mental health professional. Further, in the present study, no attempt was made to study various psychosocial factors such as social support, coping, and life stage, which can influence the prevalence of psychiatric disorders. The study also did not take into account various clinical variables such as time since diagnosis, level of disability due to illness and treatment, and cost of treatment which could also influence the prevalence of psychiatric morbidity. The study also did not evaluate the impact of psychiatric morbidity on the course and outcome of malignancy.
| » Conclusion|| |
The present study suggests that about half of the patients with various malignancies have psychiatric morbidity in the form of depressive disorders or anxiety disorders or both. These findings call for close liaison between oncologists and mental health professionals to improve the outcome of patients with various malignancies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Pinquart M, Duberstein PR. Depression and cancer mortality: A meta-analysis. Psychol Med 2010;40:1797-810.
Chaturvedi SK. Psychiatric oncology: Cancer in mind. Indian J Psychiatry 2012;54:111-8.
Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. Oncologists' recognition of depression in their patients with cancer. J Clin Oncol 1998;16:1594-600.
Walker J, Holm Hansen C, Martin P, Sawhney A, Thekkumpurath P, Beale C, et al.
Prevalence of depression in adults with cancer: A systematic review. Ann Oncol 2013;24:895-900.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.