Assessment of Depression among Cancer Patients

Dr. Vijayalakshmi K

Professor and HOD of Department of Psychiatric Nursing Apollo College of Nursing,Vanagaram to Ambattur Road Ayanambakkam, Chennai, India

*Corresponding Author Email: k.vijayalakshmi2000@gmail.com

ABSTRACT:

Depression among cancer patients is highly prevalent and common comorbidity. This study was aimed at assessing the depression among cancer patients.

Methods and Materials: This study was conducted using cross sectional, descriptive research design, at B. P. Koirala Memorial Cancer hospital and B. P. Koirala Institute of Health Sciences in Nepal. Purposive sampling technique was used to select the samples - 50 cancer patients ( Cases), 100 controls. The tools used for the data collection were, 1. Semi structured proforma to collect information on socio demographic characteristics of cases and controls 2. 18 items Standardized depression Screening Quiz developed by Goldberg. Data was collected using the pretested and predetermined tools using the interview method after obtaining the informed written consent from the participants. Collected data was analyzed through appropriate descriptive statistics (Frequency, %, Mean and SD) and inferential statistics ( t test) using SPSS version 16.

Results:

Regarding level of Depression among Cancer Patients 72% of the cancer patients had some form of depression which varied in degrees. Depression scores was also higher (M 18/90, SD 4.2) in cases than controls (M 9/90, SD 2.32) which was statistically significant (p<0.001).

Conclusion: Depression is common comorbidity among cancer patients, which can be identified and treated effectively.

KEYWORDS: Assessment, Depression, Cancer Patients

INTRODUCTION:

Depression is a common mental disorder. Globally, more than 350 million people of all ages suffer from depression. Depression affects all people regardless of age, geographic location, demographic, or social position. The World Health Organization estimates that depression will be the 2nd highest medical cause of disability by the year 2030, second only to HIV/AIDS.¹ In the southeast Asian region, 11% of DALYs and 27% of YLDs are attributed to neuropsychiatric disease including depression. A review of eight epidemiological studies on depression in South Asia shows that the prevalence in primary care was 26.3%. ²

Depression is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. Especially when long-lasting and with moderate or severe intensity, depression may become a serious health condition.³Even though no one is immuned to mental illness including depression, there are certain factors which makes the individual more vulnerable to depression. It is known fact that there is interrelationships between depression and physical health. ⁴For example, diseases such as cancer, cardiovascular disease, HIV/AIDS can lead to depression and vice versa. Among these diseases depression is more common among cancer patients.

Cancer is a life-threatening and feared diagnosis, and is a source of great distress in patients. A cancer diagnosis generates a higher sense of distress.⁵ High levels of mental distress for sustained periods of time in cancer patients may lead to anxiety, depression or both.⁶ This mixed symptomatology is very common, with two thirds of cancer patients with depression also expressing clinically significant levels of anxiety.⁷Depression leads to a poorer quality of life (QOL) and compromises patient outcomes, with depression resulting in higher rates of mortality in cancer.^8,9

A meta-analysis revealed that minor or major depression increases mortality rates in cancer patients by up to 39%, and that patients displaying even few depressive symptoms may be at a 25% increased risk of mortality.^10-12The impact of mood and mental wellbeing on cancer progression is considered important by doctors and patients, with >70% of oncologists and 85% of patients believing that mood affects the progression of cancer.¹³The symptoms of depression may appear shortly after diagnosis or anytime during or after treatment.Depression may make it harder to cope with cancer treatment. It may also interfere with one’s ability to make choices about care. Therefore, identifying and managing depression are important parts of cancer treatment. These symptoms range from mild to severe. Severe depression interferes with a person's relationships and day-to-day activities and responsibilities.

Even though depression in cancer patients is prevalent and can significantly affect quality of life, yet it is often unrecognized and underdiagnosed. There is also paucity of research in this area especially in Countries like Nepal and India. Hence this study was undertaken by the researcher to assess the depression among cancer patients. Assessment and early diagnosis of Depression will be helpful in initiating appropriate treatment and counselling based on the severity of the illness. It will further facilitate the patients in coping with cancer, improve quality of life and prognosis.

METHODS AND MATERIALS:

This study was conducted using cross sectional, descriptive research design, after obtaining ethical clearance from Institutional Review board of the Institution, at B. P. Koirala Memorial Cancer hospital and B. P. Koirala Institute of Health Sciences in Nepal. These Institutes are tertiary level health care centers. Purposive sampling technique was used to select the150 samples (Cases 50, controls-100). All the available sample who fulfilled the criteria during the study period were included in the study. Inclusion criteria included – Cases (Cancer patients): All diagnosed cancer patients aged above 15 years, able to cooperate and willing to participate in the study and taking treatment in the cancer Hospital. Controls: Family members (Spouses, parents, siblings and children) who were accompanying the patients taking treatment in B. P. Koirala Institute of Health Sciences with other minor physical illness. Exclusion criteria included- 1. Cases and controls who are notwilling to participate in the study. The tools used for the data collection were, 1. Semi structured proforma to collect information on socio demographic and clinical characteristics of cases and controls 2. Standardised depression Screening Quiz developed by Goldberg.¹⁴It consists of 18 items with six options for each item. Scoring for each item ranged from 0-5. Hence obtainable score was 0-90. Obtained score was interpreted as follows. 0-9- No Depression, 10-17- Possible mild depression, 18-21- Borderline Depression, 22-35- Mild to Moderate depression, 36-53-Moderate to severe depression, 54-90- severe Depression. Individual item scores were totaled and level of depression assessed accordingly. Data was collected after conducting pilot study with 10% of sample size, using the pretested and predetermined tools using the interview method after obtaining the informed written consent from the participants. Personal interview with participants was conducted in private room. Collected data was analyzed through appropriate descriptive statistics (Frequency, %, Mean and SD) and inferential statistics ( t test) using SPSS version 16.

RESULTS:

Tab 1 shows that, more than half of them were females (56%, 60%), 34 and 35 % of them were aged between 46-60 years, housewives ( 40, 30), around half of them were illiterates ( 52%, 48%), their family monthly income was more than 10000, (66%, 65%), belonged to nuclear family(74%, 75%) and urban area (56%, 52%) among cases and controls respectively.

With regard to clinical characteristics, Fig 1, indicates that, cancer in reproductive system was the common site of the cancer (32%) followed by digestive system (24%). Equal number of patients received treatment in OPD and Inpatient department( 50%, 50%).

Regarding level of Depression among Cancer Patients Tab 2 indicate that, 30% of them had possible mild depression followed by no depression (28%). Overall 72% of them had some form of depression which varied in degrees. Tab 3 indicates that, depression scores was higher (M 18 SD 4.2) in cases than controls (M 9, SD 2.32) which was statistically significant ( p<0.001).

Tab1: Demographic Characteristics of cancer patients (Cases and Controls) (N=150)

Characteristics

Cases ( n=50) n ( %)

Controls( n=100) n and %

Gender

Male

Female

22( 44)

28 ( 56)

Age in Years

16-30

31-45

46-60

>60

8 (16)

16( 32)

17( 34)

9 (18)

Educational Status

Illiterate

Primary

Secondary

Hr Secondary and above

26 (52)

10 (20)

4 (8)

Occupational status

Farmer

House wife

Laborer

Retired

Business

Government service

Others

17 (34)

20 (40)

2 (4)

3 (6)

2 (4)

4 (8)

2 (4)

Family income per month in Nepali Rs

≤ 10000/

>10000

17 (34)

33 (66)

Marrital Status

Married

Single

Widow/ widower/separated

46 (92)

3 (6)

1 ( 2)

Family type

Joint

Nuclear

13 (26)

37 (74)

Habitat

Rural

Urban

22 (44)

28 (56)

Figure 1: Percentage distribution of Site of the cancer among patients

Figure 2: Percentage distribution of type of treatment received by cancer Patients

Tab 2: Level of Depression among Cancer Patients ( N=50)

Level of Depression	Depressive Scores	n	%
No depression	0-9	14	28
Possible milddepression	10-17	15	30
Borderline depression	18-21	5	10
Mild to Moderate depression	22-35	11	22
Moderate to severe depression	36-53	5	10
Severe Depression 54-90	54-90	0	0

Tab 3: Comparison of Depressive Scores Between Cases and Controls (N=150)

Group

Mean ( SD)

Independentt value

P value

Cases ( n=50)

18 ( 4.20)

P<0.001

Controls ( n-100)

9 ( 2.32)

DISCUSSION:

This study was aimed at assessing the depression among cancer patients. Regarding level of Depression among Cancer Patients Tab 2 indicate that, 30% of them had possible mild depression followed by no depression (28%). Overall 72 % of them had some form of depression even though it varied in its severity. It reflects the fact that depression is highly prevalent among cancer patients. There was also significant difference in depressive scores between cases and controls. i.e depression scores was higher (M 18, SD 4.2) in cases than controls (M 9, SD 2.32) which was statistically significant ( p<0.001).

These findings are consistent with various other studies conducted in different parts of the world. It is true that, the rate of depression in cancer patients is thought to be up to three times higher than in the general population.^15, Studies using Diagnostic for Statistical Manual of Mental Disorders (DSM) criteria⁶ for major depressive disorder (MDD) have identified a variety of prevalences ranging from 2.0–43.5%.^{13,
14. 16}A study by Linden et al⁷, and a comprehensive literature review by Ng et al ¹⁷ detailing rates of depression in >9,000 patients, each in a variety of settings and ages, calculated the prevalence as 10.8% and 12.9%, respectively. In addition, a further 16% of patients are reported to have subclinical, yet still damaging, depression⁹

Depression causes a greatly diminished QOL in cancer patients by worsening physical symptoms, and increases the negative impact on patients and their families throughout the course of the disease. Depression in cancer patients increases the length of hospital stay and resource use, increasing health expenditure. Depressed cancer patients are also at a higher risk of suicide compared with the general public.

These facts clearly indicatethe requirement to effectively identify, diagnose and treat depression in cancer patients in order to improve Quality of life, psychological wellbeing, prognosis and survival rates. Both psychosocial interventions and pharmacotherapy are effective in treating depression in cancer depending upon the severity of the illness. The management of depression is likely to be different in each patient.

CONCLUSION:

Depression remains an under-recognised comorbidity in cancer patients, with major implications on patient suffering, quality of life, mortality, prognosis and healthcare expenditure. Depression in cancer is most of the time unrecognized as many of the symptoms of cancer and depression overlaps, which makes it difficult to diagnose. However, depression in cancer is markedly different from depression in healthy individuals, and involves a unique symptomatology and a strong biological etiology. Findings of the present study clearly indicates the magnitude of the problem which underscores the need for health professionals for planning effective screening programs to identify depression among cancer patients. Early diagnosis and treatment for depression will improve the quality of life, wellbeing, and survival rate among cancer patients.

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