|Ahead of print publication
Prevalence of anxiety and depression in cancer patients during radiotherapy: A rural Indian perspective
Neelam Sharma1, Abhishek Purkayastha2
1 Department of Radiation Oncology, Army Hospital (Research and Referral), New Delhi, India
2 Department of Radiation Oncology, Command Hospital (Southern Command), Pune, Maharashtra, India
|Date of Submission||21-Apr-2019|
|Date of Decision||22-Nov-2019|
|Date of Acceptance||19-Dec-2019|
|Date of Web Publication||06-Oct-2020|
Department of Radiation Oncology, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: This cross-sectional, quantitative epidemiological study was aimed at finding the prevalence of depression in cancer patients and correlation of anxiety and depression with various factors such as age, sex, and type of malignancy while coming for treatment to the radiotherapy department of a tertiary cancer hospital, at the onset, midway, and at the end of radiotherapy treatment using the Hospital Anxiety and Depression Scale (HADS).
Materials and Methods: A total of 100 consecutive cancer patients referred for definitive radiotherapy were included. All patients were administered the HADS. The percentage of respondents with anxiety increased significantly after initiating RT and maximum scores were recorded at the end of treatment. The association between anxiety scores and various factors such as age, site, and sex during various phases of RT was found using Chi-square test.
Results: At the beginning of Radiotherapy (RT), 61% of our patients reported abnormal scores while this percentage increased to almost 89% at the end of treatment, the comparison between the scores at the beginning and at the end reach a statistical significance (P < 0.0005) while the comparison between the scores at the start and midway led to (P < 0.011). According to the subsite, maximum prevalence of anxiety and depression was seen in patients having head and neck malignancies while older age again was a significant factor leading to the symptoms of anxiety and depression.
Conclusion: The diagnosis of cancer carries with it a significant amount of psychological morbidity, both subjectively experienced and objectively observed. Cancer treatments such as chemotherapy and radiotherapy further aggravate anxiety by becoming additional stressors.
Keywords: Anxiety, cancer, depression, treatment
| > Introduction|| |
Cancer is a series of traumatic stresses and events. Cancer patients and their families face multiple challenges in the areas of resuming and maintaining life activities, coping with treatment and side-effects, managing the emotional impact and stresses and adjusting to significant long-term losses and changes. Depression and anxiety are not uncommon among people diagnosed with cancer. Patients with untreated depression or anxiety are less likely to take their cancer treatment positively and continue good health habits because of fatigue or lack of motivation. They may also withdraw from family or other social support systems, which means they will not ask for the needed emotional and financial support to cope with cancer. This in turn may result in increasing stress and feelings of despair. Routine screening for distress is internationally recommended as a necessary standard for good cancer care.
Patients have common fears, which have been called six Ds: death, dependency on family, spouse and physician; disfigurement and change in early appearance and self-image, sometimes resulting in loss or changes in sexual functioning; disability interfering with achievement of age appropriate tasks in work, school or leisure roles; disruption of interpersonal relationships; and finally, discomfort or pain in later stages of illness. Many researchers have reported that six mental disorders occur more frequently in cancer patients to warrant a detailed assessment and clinical intervention. Three represent direct reaction to illness: adjustment disorders with depression and/or anxiety, major depression and delirium. Others (primarily anxiety disorders, personality disorders and major depressive disorders) are preexisting conditions often exacerbated by the illness.,
Links between psychological and physiological domains of relevance to cancer risk and survival are being actively explored through psychoneuroimmunology. Research in these areas will occupy the research agenda for the first quarter of the new century. At the start of the third millennium, psycho oncology has come of age as one of the youngest subspecialties of oncology, as one of the most clearly defined subspecialties of consultation liaison psychiatry.,, Depression in cancer patients may result from (a) situational stress related to the cancer diagnosis and treatment, (b) medications (steroids, interferon, or other chemotherapeutic agents), (c) a biologically determined depression (endogenous or major depression), which is not related to a precipitating event, or (d) recurrence of a bipolar mood disorder. The first two are the most common. Although the exact etiology of depression in cancer is unknown, several factors have been suggested including the emotional impact of a cancer diagnosis, side effects of treatment, progression of cancer with associated disability, and symptoms and cerebral dysfunction associated with carcinomatosis, disruption of key relationship, dependence, disability, disfigurement and approaching death.
After extensive literature search very few studies were found where prevalence of anxiety and depression during various phases of RT has been studied. This study was planned especially to quantify effect of RT as a treatment modality in already anxious and depressed cancer patients.
| > Materials and Methods|| |
It is a cross-sectional, quantitative, epidemiological study conducted in a tertiary cancer center over a period of 6 months in the year 2017–2018. Study population comprised of a total of 100 consecutive cancer patients referred for definitive radiotherapy to our department. All the patients consented for the study. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Data collection technique
On their first arrival at our department the patients were given a short self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS), constructed for use in clinical practice. They were instructed by the same oncology nurse how to complete the questionnaire. There was no communication between the nurse and the patient on the specific items. No patient refused to participate. Patients were given this questionnaire twice more, at the middle of treatment and at the end of treatment, respectively.
HADS is a useful instrument for screening depression and anxiety in clinical settings. It was developed by Zigmond and Snaith in 1983. Its purpose is to provide clinicians with an acceptable, reliable, valid and easy to use practical tool for identifying and quantifying depression and anxiety.
Seven questions in the Hospital Anxiety and Depression (HAD) deal with anxiety and seven with depression. The answers to every question are scored on a scale of 0–3. The highest amount of points is thus 21. Scores higher than 10 are considered to indicate morbidity, scores between 8 and 10 are interpreted as borderline levels of anxiety or depression, and scores below 8 are considered normal. The questionnaire has been validated against psychiatric ratings., and has been used in nonpsychiatric settings to identify subjects with symptoms of anxiety or depression., According to factor analysis, HAD produces two distinct though correlated factors corresponding to anxiety and depression. The scale has been considered a practical instrument for identifying and monitoring the psychological status of patients under treatment for cancer.,,,,
Most factor analyses demonstrated a two-factor solution in good accordance with the HADS subscales for Anxiety (HADS-A) and Depression (HADS-D), respectively. The correlations between the two subscales varied from 0.40 to 0.74 (mean. 56). Cronbach's alpha for HADS-A varied from 0.68 to 0.93 (mean 0.83) and for HADS-D from 0.67 to 0.90 (mean 0.82). In most studies an optimal balance between sensitivity and specificity was achieved when case was defined by a score of 8 or above on both HADS-A and HADS-D. Further validation studies of the English and of foreign language translations of the HADS were undertaken in a variety of settings and centers. Since 98% patients in our study were from a rural background, Hindi version of this scale was used by us.
All analysis was performed with SPSS by Windows, version 17.0, SPSS Inc., Chicago, USA. Student's paired t-test and Chi-square test were used to compare scores during various phases of RT and to find the association between various factors and anxiety and depression scores during various phases of RT, respectively.
| > Results|| |
The basic demographics are shown in [Table 1]. In our study 96% patients belonged to a rural background and 80%–85% of them presented in locally advanced stages of disease in relation to various sites. Maximum number of respondents, i.e., 34% were from 50 to 60 years of age group while 75% of them were legally married. Majority 62% were females and all of them were housewives. In males majority 65.8% comprised farmers while 34.2% were serving army personnel. A majority, i.e., 78% were staying in joint families and 88% of patients expressed satisfaction with their family environment. There was no comorbid condition in 92% of patients. At the beginning of treatment, 61% our patients reported to have abnormal scores while these percentages were 68% and 89%, respectively, at midway and end of treatment. A comparison between RT0 (scores at beginning of treatment) and RT1 (scores midway of treatment) had mean values of 10.98 ± 4.77 and 12.22 ± 4.82, respectively, with a statistical significant (P < 0.001) while a comparison between RT1 and RT2 (scores at the end of treatment) led to mean values of 12.22 ± 4.82 and 15.61 ± 4.15 respectively leading to a significant (P < 0.001). The comparison between RT0 and RT2 group led to a significant (P < 0.001). Hence, we concluded that radiotherapy itself increases anxiety and depression in cancer patients significantly [Table 2] and [Table 3]. [Figure 1] demonstrates the variation in scores during different phases of radiotherapy.
|Table 2: Percentage of patients with various scores during different phases of radiotherapy|
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|Table 3: A comparative statistical analysis of mean scores of patients during different phases of radiotherapy|
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|Figure 1: Pictorial representation of depression scores of patients during various pH|
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Out of 100 patients carcinoma (Ca) breast was the most common malignancy in 32% females while majority of the male patients had head and neck malignancy, of which oral cavity was the most common subsite with a percentage of 13%. 62.5% of Ca breast patients had abnormal scores at RT0 while these scores increased to 93.8% at the end of treatment at RT2. While in Ca cervix, 60% of patients had abnormal scores at RT0 while 80% patients responded abnormal scores at RT2. While 100% patients of head and neck malignancy reported abnormal scores at the beginning and end of treatment, however comparative analysis of depression scores among patients of Ca in breast, cervix, and head and neck did not reach a statistical significance during any phase of RT (P = 0.98, 0.76, 0.17) [Table 4].
|Table 4: Scores in relation to various factors during various phases of radiotherapy|
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The most affected age group was 60–70 years at RT0 with almost 81.8% having abnormal scores while at RT1 this percentage was almost 100% in 70–80 years age group. In both these age groups the scores remained persistently high even at the end of treatment with a percentage of about 95.5%. However, age did not affect the depression scores in a significant manner during any phase of treatment (P = 0.06, 0.23, 0.11) [Table 4].
Of males and females, 62.9% of females versus 57.9% of males reported abnormal scores. However at the end of treatment these scores were 69.4% and 65.8%, respectively. We did not find any statistically significant difference in the levels of depression between males and females at any point of time (P = 0.36, 0.66, 0.96) [Table 4].
Occupation wise the worst affected group was farmers with almost 72% having abnormal scores which increased to 96.0% at the end of treatment. While the least affected group occupation wise was serving army personnel with only 30.8% having abnormal scores at beginning of treatment [Table 4]. We did not find much difference between married and unmarried groups, during any stage of treatment (P = 0.98, 0.58, 0.68) [Table 5].
|Table 5: scores in relation to various family related factors during various phases of radiotherapy|
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Surprisingly in our study 91% of patients of joint families reported abnormal scores while this percentage was 81.8% in nuclear families reported abnormal scores. We find a statistical significant difference (P = 0.02) between two groups midway during RT [Table 5].
Presence of a comorbidity resulted in higher number 87.5% of patients having abnormal scores while only 58.7% of patients without comorbidities reported abnormal scores at presentation but we did not find any statistically significant difference at any point of time (P = 0.12, 0.92, 0.09) [Table 5].
A comparison between rural and urban background led to 88.5% and 100% patients respectively reporting abnormal scores at the beginning of treatment. On comparison between these two groups we found a statistical significant difference at the middle of RT (P = 0.05) [Table 5].
| > Discussion|| |
Current treatment of cancer involves surgery, chemotherapy, and radiotherapy. Approximately 4 of 10 patients (40%) with cancer receive radiotherapy at some point of their treatment. Radiation treatment (RT) is associated with highly unpleasant side effects. The side effects include nausea, vomiting, and increasing fatigue. The unpleasant fatigue usually seen in radiotherapy patients had a high correlation with psychiatric morbidity.
In a prospective study by Chaturvedi in an Indian hospital on levels of anxiety and depression in patients receiving radiation, treatment anxiety and depressive disorders were detected frequently both before treatment and later during follow-up. Frequency of anxiety increased significantly after initiating RT, but later reduced during follow-up assessments after a few months. Similarly, subjective wellbeing changed as the radiation treatment progressed. In a review by Astrup et al. from the past 15 years, 12 longitudinal studies it was found that depressive symptoms in head neck cancer patients who underwent radiotherapy (RT) levels of depressive symptoms increased during RT, peaked at the completion of treatment, and then decreased over time. In our study also, we found that both the anxiety and depressive symptoms were maximum at the end of the treatment with a significant P < 0.005.
In a study by Nikbakhsh et al. in Iran, they found that breast and stomach cancer patients had the highest prevalence of anxiety and depression. In breast cancer patients, the importance of body image and the influence of mastectomy on it, self-image, and its effect on sex drive can justify the higher frequency of anxiety and depression in this group. In gastrointestinal tract cancer patients, the high frequency of anxiety and depression can be related to the changes due to the disease itself or the effect of different treatments on the patient's appearance. While in our study maximum scores were reported by head and neck patients in males and in breast patients in females but the difference did not reach a statistical significant difference. The difference in the pattern of prevalence of anxiety and depression according to subsite can vary according to the prevalence of cancer subsites in a particular country or institute.
In our study, the most affected age group was 60–70 years at RT0 with almost 81.8% having abnormal scores while at RT1 this percentage was almost 100% in 70–80 years age group. In both these age groups the scores remained persistently high even at the end of treatment with a percentage of about 95.5%.
The same observation has been made by other authors in past research suggesting that psychological responses to cancers vary by age.,,,, In these studies also, higher frequencies in older ages were observed as old age increases the duration of disease, high probability of cancer metastasis and more disability and these conditions increase anxiety and depression in older patients.
In our study we did not find much difference in prevalence of depression in males and females (P = 0.36, 0.66, 0.96). However in a study by Pandey et al. males were found to more depressed than their female counterparts. However, the results of Keller and Henrich were found to be contradictory; female cancer patients were more depressed than the males. Inconsistent gender difference may be due to multicultural nature of the studies.
In a study by Kapur, they found that education and monthly family income indirectly reflect their standard of living and the capacity to afford treatment. However, in a study by Akin Odanye et al., both higher education and higher socioeconomic status were found to be predictors of depression. In our study, we found that farmers were worst affected with almost 72% having abnormal scores which increased to 96.0% at the end of treatment. While the least affected group occupation wise was serving army personnel with only 30.8% having abnormal scores at beginning of treatment. This can be explained by the nature of study setting, where most of the patients come from academically and financially deprived households and rural background. A comparison of depression scores between patients from urban and rural background led to a statistical significant P = 0.05, midway during RT. On extensive literature search, we did not find any study which has compared cancer patients from rural and urban backgrounds during RT. However, there are studies which have compared mental health of cancer survivors from rural and urban backgrounds. In one of such studies by Burris and Andrykowski, they found that mental health of patients from rural background was worse than patients from an urban background with a statistical significant difference.
In our study, the presence of a comorbidity resulted in higher number, i.e., 87.5% of patients having abnormal scores while only 58.7% of patients without comorbidities reported abnormal scores at presentation. However, we did not find any statistical significance (P = 0.12, 0.92, 0.09). As per studies by Pasquini and Biondi and Purohit et al. also, having a coexistent illness is one of the strongest risk factors for having depression in cancer patients.
The weakness of our research was the absence of clinical structural interview with patients, which caused the probable diagnosis of anxiety and depression according to HADS. If structural interview had been performed, definite diagnosis could have been made.
| > Conclusion|| |
Depression remains an underrecognized comorbidity in cancer patients, with major implications on patient suffering, mortality, and healthcare expenditure. Depression in cancer is markedly different from depression in healthy individuals and involves a unique symptomatology. The results in our study give a perspective of prevalence of depression in cancer patients from rural India where education and resources are still lacking to handle this important issue. Positive patient–physician relationships and communication at the first physician patient contact can markedly reduce levels of distress in these patients. In addition patients may benefit from a range of approaches, including relaxation strategies, meditation and progressive muscle relaxation, enable patients to relieve mental and physical tension, thereby reducing stress, and have been observed to improve depression. Psychoeducation may be used to build knowledge and coping strategies with regard to cancer, reducing uncertainty and anxiety, especially in patients from rural background. In our institute, a group has been formed by cancer survivors and other volunteers who are actively involved in counseling of these patients, and we have seen a marked improvement in patients' attitude and coping strategies toward this dreaded disease.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]