|Ahead of print publication
Psychological impact of COVID-19 pandemic on cancer patients: A cross-sectional study
Deepak Abrol1, Rajesh Kumar Chandel2, Mustafa Ali2, Shaveta Bhagat2, Vimal Kumar Sharma1
1 Department of Radiation Oncology, Government Medical College, Kathua, Jammu and Kashmir, India
2 Department of Psychiatry, Government Medical College, Kathua, Jammu and Kashmir, India
|Date of Submission||11-Aug-2021|
|Date of Acceptance||27-Aug-2021|
|Date of Web Publication||23-Feb-2022|
Government Medical College Kathua, House No: 49-F, New Plot, Jammu- Jammu & Kashmir (UT)
Source of Support: None, Conflict of Interest: None
Background: Coronavirus disease 2019 (COVID-19) has globally impacted not only physical wellbeing but also the mental aspects in a far more extensive manner. The prevalence of psychological issues in cancer patients is much higher than in the general population, and the same has been impacted more during the COVID-19 pandemic. The purpose of this study was to estimate the psychological impact of COVID-19 on the mental health of cancer patients with no prior history of any form of mental disease.
Methodology: A cross-sectional study of both inpatients and outpatients undergoing treatment and follow-up for different forms of cancer was conducted, and patients were assessed for perceived risk, anxiety, and depression.
Results: Among the total of 150 participants, 31.8% of patients reported fear and concern. The major concern was regarding fear of treatment delay and fear of getting lonely. Over the prevalence of anxiety disorder with a cut-off score of ≥10 based on Generalized Anxiety Disorder-7 and Patient Depression Health Questionnaire-9 were 34% and 24%, respectively. Patient with female gender, married, being treated for ovarian cancer and who does not have metastatic changes were more anxious. Depressive symptoms were more in female patients, those who are married, and in the group with treatment delay due to COVID-19.
Conclusion: There is urgent need for psychological intervention among cancer patients as there is an increase in mental health problems in this special group due to COVID-19 pandemic.
Keywords: COVID-19, depression, fear, generalized anxiety, mental disorder, perceived risk, psychological impact
| > Introduction|| |
Coronavirus disease 2019 (COVID-19) Pandemic has changed our lifestyles and brought about major changes in perception about various Issues. COVID-19 caused by severe acute respiratory syndrome coronavirus 2 is responsible for the ongoing global health crisis. The World Health Organisation acknowledged it as a global pandemic on March 11, 2020, roughly after 4 months of its initial reporting in Wuhan province of China. The magnitude of this virus has not only affected physical health but also had a great impact on mental wellbeing along with severe negative influences on social and economic wellbeing around the world. Governments throughout the world were forced to implement lockdowns for months together to combat the virus resulting in psychological distress, worsening and relapse of preexisting medical and mental illness, treatment delay along with significant financial burden and social isolation in all sections of the population. Depression, anxiety along with the number of psychological distress in the form of anger, fear of dying, disgust, uncertainty, and feeling of helplessness as a result of COVID-19 has been well documented.,,,,, This forms the basis for our study to focus on these problems in a subset of patients, i.e., cancer patients who are already suffering from cancer. Cancer patients form a unique group because of several reasons such as the need for a frequent visit to hospitals to get treatments, being at higher risk of mental health problems in comparison to the general population, being immunocompromised, and greater chances of contracting COVID-19 along with poor outcome; social isolation from caregivers who are the main social support in terms of treatment and care. There was quite a frequent delay in cancer treatment directly as a result of the COVID-19 pandemic., This study aimed to understand the Psychological adverse effect of COVID-19 pandemic in terms of experiencing symptoms suggestive of depression, on cancer patients conducted in a tertiary hospital.
| > Methodology|| |
In the present study, a total of 150 participants who had a diagnosis of cancer and undergoing treatment and follow-ups at Government Medical College, Associated hospital between the periods of (April-2019 and May-2021) were recruited. The recruitment was strictly based on the fulfillment of inclusion and exclusion criteria.
- Patients had a confirmed diagnosis of cancer and undergoing treatment between April-2019 and May-2021
- Both inpatients and outpatients
- Age between 18 and 90 years
- Both genders
- Enable to understand and provide both oral and written consent for participation.
- Prior history of any mental issues, including substance dependence except nicotine
- Prior treatment with any form of psychotropic substance based on medical records
- Prior history of neurological or developmental conditions, head injuries, dementia, or seizure.
All the participants were recruited after taking written consent which included access to their old medical records and current medical status.
Socio-demographic and clinical characteristics
Socio-demographic variables include age, sex, education level, marital status, employment status, and complete medical history related to cancer regarding the type of cancer, duration of treatment, type of on-going treatment, which is either chemotherapy or radiotherapy (taking either in private or government hospital/institute other than the current study hospital), treatment status, remission status, and also details of COVID impact/COVID lockdown impact on the on-going cancer treatment in any form.
Questionnaires for the present study have been divided into three domains; perceived risk, anxiety, and depression. Qualitative data gathering technique were applied after understanding the themes which emerged during regular interactions with patients. These interviews were open-ended and were purposive conversation between the researchers and patients. Perceived risks were assessed initially by ruling out any kind of risks experienced by the patients during the pre-COVID-19 as well as COVID-19 period. In the current study, the focus was on the changes or fear which patients do experience during COVID-19 pandemic and the effect due to lockdown was assessed. Fear of getting an infection on visiting the hospital and the change in the same perception after the initiation of COVID-19 pandemic; fear of going to the hospital in seeking cancer treatment and concerns regarding how the pandemic has affected the treatment and extent to which it caused delay in duration, frequency or timing of treatment which the patient used to get before COVID which the author has summarized in delayed or not delayed based on the patient responses the amount of time which cancer patients used to spend at home versus the amount of time he or she used to spend talking to friends, praying at religious places or spending time with his or her relative which are more of the basis for his social and spiritual supports and how much that has been affected by COVID; and the introduction of mask and sanitizers which he or she was not used to before the pandemic and how much fear or uncertainty has created by the same has been elaborated in the interview. The interview was open-ended, and all patients have been allowed to speak elaborately. Based on the above-mentioned interview, the themes were designed. These themes have been rated between (0 and 5), 0 being the lowest perceived risk and 5 the highest on the scale. Anxiety was assessed using Generalized Anxiety Disorder (GAD-7), which is a 7-item self-administered questionnaire to assess the presence and severity of GAD. Each item is further divided into four items and graded (0–3), 0 indicates “not at all” and 4 indicated “nearly every day." A cut of the score of GAD-7 ≥10 was considered for anxiety disorder. Depression was assessed using a Patient Health Questionnaire-9 (PHQ-9). PHQ-9 is 9-items self-administered validated four-point Likert questionnaire and a cut-off score of PHQ-9 ≥10 was considered to have depressive symptoms.
Statistical analyses for the study were done using the statistical program SPSS 26.0 (IBM SPSS Statistics for Windows Version 26.0. Armonk, NY: IBM Corp.), Socio-demographic and clinical variables in the study based on categorical and continuous were assessed by percentage and mean with standard deviation (SD), respectively. Participants rated ≥60% on perceived risk were only being considered in the statistical analyses, and individual themes had been analyzed among cancer groups. Independent-sample t-test and ANOVA were used to compare all the inter-group parametric data. The association of participant variables with anxiety and depression was assessed by using multivariate regression analyses. A P ≤ 0.05 was taken as statistically significant.
| > Results|| |
Socio-demographic and clinical characteristics
Among the 150 participants, 59.3% were female and 40.6% were male, and the majority of the patient were married (86%) with a mean age of 67.25 (SD 9.4) years. The majority of participants were from urban areas (65.3%). Breast (30.6%) and lung (21.3%) cancer followed by stomach (20%) cancer were the predominant types in the current study group with 59.3% of metastasis and 28% of the patients were reported in remission. Being Peripheral Medical Institute, such type of data with more metastatic patients are expected. The detailed socio-demographic and clinical characteristics of patients are summarized in [Table 1].
The overall percentage of risk perceived by all groups of cancer patients during the time of the COVID pandemic was 31.8%. The top concern of all the themes was “Delay in cancer treatment due to COVID-19” and “Feeling of loneliness secondary to COVID-19 restriction” reported by 52.6% and 39.3% of the participants, respectively. Twenty percentage and 22.6% of the participants reported using the mask while they are alone and usage of hand sensitizers despite not being in contact with any individual or infected objects, respectively, because of fear of the highly contagious nature of the COVID-19 virus [Table 2]. The percentage of individual themes among 6 different cancer groups is summarized in [Table 3]. “Fear of getting COVID” (P = 0.007, ⴄ2 = 0.308); “Feeling of loneliness” (P = 0.025, ⴄ2 = 0.209); “Fear about delay in cancer treatment” (P ≤ 0.001, ⴄ2 = 0.245); and “Hand sanitizer usage” (P ≤ 0.001, ⴄ2 = 0.719) were responded affirmatively with statistical significance among the 6 cancer group [Table 4].
|Table 3: Percentage of perceived risk themes reported among cancer groups|
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The prevalence of anxiety in the current cancer study population based on GAD-7 severity score of GAD ≥10 was 34%; [Figure 1]. The prevalence of anxiety was statistically significant among females; widows; patients with metastasis and those in whom cancer treatment was delayed due to COVID-19 based on independent t-test and ANOVA [Table 5]. In the multivariate regression analyses, the prevalence of anxiety was higher in patients whose ages are ≥65 years (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.04–0.86; P = 0.003); females population in comparison to males (OR, 0.009; 95% CI, 0.001–0.0.16; P = 0.001), in married (OR, 27.69; 95% CI; 5.17–148.38, P < 0.001); patients with ovary cancer as compared to other group of cancer (OR, 70.72; 95% CI, 2.18–2294.37; P = 0.02) and patients who does not have metastatic changes (OR, 10.57;95% CI, 1.50–74.26; P = 0.02) [Table 6]. There was no association with other parameters.
|Table 5: Comparison of anxiety (GAD-7) with socio-demographic and clinical variables (N=150)|
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|Table 6: Multivariate regression analyses in understanding the factors associated with anxiety in total patients (n=150)|
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The prevalence of depression based on PHQ-9 ≥ 10 was 24%; [Figure 2]. The prevalence of depression was statistically significant among females; widows; patients with metastasis, and those in whom cancer treatment was delayed due to COVID-19 based on independent t-test and ANOVA [Table 7]. In the multivariate analysis, the prevalence was noted to be higher in female population in comparison to males (OR, 0.02; 95% CI, 0.002– 0.0.25; P = 0.003); patients who were married (OR, 6.98; 95% CI; 2.20–22.08, P < 0.001) and inpatient whose treatment has been delayed due to COVID-19 (OR, 3.75; 95% CI, 0.96–14.61; P = 0.05) [Table 8]. There was no association with other parameters.
|Figure 2: Prevalence of depression among cancer patients based on severity|
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|Table 7: Comparison of depression (PHQ-9) with socio-demographic and clinical variables among various groups|
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|Table 8: Multivariate regression analyses in understanding the factors associated with depression in total patients (n=150)|
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| > Discussion|| |
This study was an effort to understand the impact of the COVID-19 pandemic on the mental and psychological wellbeing of various types of cancer patients. To our best knowledge, it is the first of its kind study conducted in the union territory of Jammu and Kashmir. The prevalence of perceived risk/fear was between (27.3% and 39.3%), anxiety (34%), and depression (24%). Lifetime and current morbidity of mental health based on the National Mental Health Survey-2016 were 13.9% and 10.5%, respectively, and the prevalence of neurotic and stress-related disorder for both current and lifetime were (female: 3.0%; male: 2.4%) and (female: 5.7%; male: 4.8%), respectively. Another study conducted by Gopalan et al. before the COVID-19 pandemic reported the prevalence of adjustment disorder and major depressive disorder in 22.6% and 10.6%, respectively, in cancer patients. Similar result was reported by Wang et al in a study conducted among cancer patients in China. They found prevalence rate of depression of 23.4% which is almost similar to 24% of the current study. Prevalence of anxiety on the other hand were 34% in the current study as compared to 17.7% among the Chinese population. Another Chinese study has reported 22.5% of cancer patients suffering from anxiety disorder based on GAD ≥ 10, similar to the scale used in the present study. Alexander reported an increase from 9.3% to 16.7% before and after the outbreak of COVID-19 in major depressive symptoms, an increase from 8.0% to 27% in generalized anxiety symptoms, and increased distress level by 16.7% in German cancer patients. Apart from depression and anxiety, cancer patients perceived a high level of fear/risk. The major concern was the delay in cancer treatment secondary to the lockdown imposed due to COVID-19 and the fear of going to the hospital to get the treatment as they perceived the virus highly contagious. The lung cancer group was noted to be affected more than the rest of the other group. The reason could be related to the direct relation of the COVID-19 virus to the respiratory system resulting in more fear and anxiety in this particular group. In a Chinese study, the prevalence of anxiety and depression in lung cancer patients was reported at 35.71% and 51.43%, respectively. The increased rate in the prevalence of fear, anxiety, and depression among cancer patients particularly during the pandemic, could be due to preexisting nature and prognosis of cancer itself which was further complicated by the COVID-19 pandemic; not able to go to the hospital for necessary or scheduled treatment further cemented the fear and anxiety and social isolation from peer and relatives minimizes the psychological support to deal with cancer. There is a need to address the psychological impact of uncertainty, fear, distress, anxiety, and depression, particularly in cancer patients, to minimize the deterioration of physical distress due to preexisting conditions as well as to avoid severe mental conditions, including suicides., Psychological interventions not only improve the quality of life (QOL) but also provide mental strength, reassurance, social support, and hope toward life.
| > Conclusion|| |
An increase in mental health disorders and psychological impact during the COVID-19 pandemic on cancer patients enrolled in the present study has helped us in understanding the effect of COVID-19 and the utmost need for psychological interventions in this special group of patients with predisposing risk for psychiatric disorders. There is a need to engage the available resource in addressing these concerns, need for psychoeducation regarding both COVID and mental disorder, and prompt intervention for the same to improve the QOL.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]