Depression prevalence in cancer patients: a cross sectional study

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Introduction Major depression is a leading cause of disability worldwide and when comorbid with a chronic disease it is associated with reduced quality of life and increased healthcare costs [1]. Depression is a major cause of concern in cancer patients. Clinical depression is a common and more often unrecognized source of suffering in cancer patients [2]. It is an important factor leading to drop out before the start of cancerdirected treatment. Depression also contributes to suicidal tendencies in cancer patients. The prevalence of depression varies depending upon the type and sites of cancer with reported rates of 1 % in acute leukemia to 40 % in other cancers [3, 4]. There are two core symptoms of depression namely depressed mood and a marked loss of interest or pleasure in most or all activities [5]. This study aimed to estimate the prevalence of depression and its relationship with sociodemographic factors among cancer patients. Materials and methods A samplings were collected from all cancer patients who were admitted at Dr. Vithalrao Vikhe Patil Foundation’s Medical College Hospital from December 2015 to December 2016. All subjects gave informed consent to participate in the investigation and personal data processing. Baseline interviews were conducted in person by a trained physician. This study has been approved by the Institutional Ethics Committee. This study included all stages and types of cancer patients, who were admitted for investigation or treatment of cancer such as surgery, chemotherapy, radiotherapy on the inpatient ward of the hospital. The inclusion criteria were aged 18-60 years old, can give informed consent, awareness of the diagnosis of cancer, and could communicate with the physician. The exclusion criteria were severe confusion or having assessable brain pathology. All subjects gave informed consent. Baseline interviews were conducted by a trained person. Demographic data: age, sex, educational level, marital status, support systems, employment status, income, and debt were recorded. Duration of cancer, primary organs site, stage of cancer, and oncology treatments were viewed from medical records. The mini international neuropsychiatric interview (MINI) questionnaire version 5.0.0 was used for screening and processing the symptoms of depression [6]. Hamilton’s depression rating scale (HDRS) was used for grading of depression (0-7: No depression; 8-13: Mild; 14-18: Moderate; 19-22: Severe; ≥24: Very severe) [7]. Results and discussion In this cross-sectional study, 128 cancer patients were screened for depression. Demographic and other details like type of cancer, stage of cancer, and number of treatment are displayed in table 1. Table 1 Characteristics All (N= 128) Age (years) ≤ 50 68(53.1 %) >50 60 (46.8 %) Sex Male 70 (54.6 %) Female 58 (45.3 %) Characteristics of patients Table 1 continuation MINI. Out of 44 patients, 28 (63.6 %) patients were males and 16 (36.3 %) patients were females. Based on Hamilton’s depression rating scale (table 2), 41.8 % of patients were suffering from mild depression, 18.6 % of patients with moderate depression, 16.2 % were suffering from severe depression and 23.2 % of patients were having very severe depression. Characteristics All (N= 128) Education level Uneducated 32 (25 %) 10th standard 43(33.5 %) Degree 53 (41.4 %) Residential status Rural 47 (36.7 %) Urban 81(63.2 %) Marital status Married 88 (68.7 %) Single 15 (11.7 %) Divorced 15 (11.7 %) Widow 10 (7.8 %) Social Support system No support 39 (30.4 %) With social support 89 (69.5 %) Employment status Unemployment 31 (24.2 %) Labourer 33 (25.7 %) Agriculturist 25 (19.5 %) Business 21 (16.4 %) Private job 12 (9.3 %) Government job 6 (4.6 %) Level of income (INR) ≤ 10,000 69(53.9 %) >10,000 59(46 %) Primary organs of cancer Head and neck 27 (21 %) Breast 15 (11.7 %) Lungs 9 (7 %) GIT 17 (13.2 %) Genitourinary 12 (9.3 %) Gynaecological 35 (27.3 %) Musculoskeletal 3 (2.3 %) Hematological 10 (7.8 %) Time since cancer diagnosis (years) Median (IQR) 1·0 (0·4-3·3) Stages of cancer 1 21 (16.4 %) 2 23 (17.9 %) 3 39 (30.4 %) 4 34 (26.5 %) Leukemia 11 (8.5 %) Number of treatment One method or less 56 (43.7 %) Two method or more 72 (56.2 %) Hamilton’s depression rating scale of depression Table 2 Scaling of depression Number (percentage) Mild depression 18 (41.8 %) Moderate depression 8 (18.6 %) Severe depression 7 (16.2 %) Very severe depression 10 (23.2 %) 53.1 % of patients were below 50 years of age and 1. % of patients were above 50 years of age. 54.6 % of patients were males and females were 45.3 % patients. 44 patients were identified with depression using the Around 15 % of depressed patients were using antidepressants. The two most commonly used antidepressant medications were sertraline (10 %) and citalopram (5 %). Further analysis showed that the married group showed mild depression in in 11 (50 %) patients, moderate depression was seen in 5 (22.7 %) patients, severe depression in 3 (13.6 %) patients, and very severe depression was seen in 3 (13.6 %) patients. In the unmarried and divorced females (4 patients), 3 had very severe depression and 1 had moderate depression. In the widowed females, 1 (25 %) patients had mild depression and 3 (75 %) patients had moderate depression. In patients with monthly income more than INR 10000 group, mild depression was seen in 9 (45 %) patients, moderate depression in 6 (30 %) patients, severe depression in 4 (20 %), and very severe depression in 1 (5 %) patients. In patients with monthly income less than INR 10000 group, mild depression was seen in 10 (41 %) of patients, moderate depression in 7 (29 %) patients, severe depression in 4 (16 %), and very severe depression in 3 (12 %) patients. In the literate group (10th standard and degree) patients, mild depression was seen in 46 % (13) of patients, 28 % (8) patients were having moderate depression, 14 % (4) patients were having severe, and very severe depression was seen in 10.7 %(3) patients. In the illiterate group of patients, 43.7 % (7) had mild depression, 18.7 % (3) patients had moderate depression, severe depression was seen in 12.5 % (2) and very severe depression was seen in 25 % (4). In unemployed patients, 3 patients (10 %) were suffering from mild depression, moderate depression were seen in 2 patients (20 %), severe depression seen in 2 patients (20 %) and 3 patients (30 %) with very severe depression. Depressive disorder is the most common problem in cancer patients. Amongst the different psychiatric disorders in cancer patients the prevalence of depression is high [5]. From this study, the prevalence of major depressive disorder in cancer patients was 24 %. Recent study showed that the prevalence of depressive symptomatology among cancer patients was 23.4 %. Increased likelihood of depressive symptoms was detected among patients in the inpatient setting (37.1 %) [8]. The mean prevalence of depression based on previous study was around 13 % and using all assessment methods it varies from approximately 4 to 49 % [9]. However, another recent study showed the prevalence of depression among cancer patients on chemotherapy was 70.86 % [10]. This wide variation is due to several factors including the treatment setting, type of cancer included and method used to screen for symptoms (e. g. interview by trained psychiatrist or self-report instrument) [11]. The rates were dependant on how severe diagnostic system was applied and in what way the physical symptoms were considered. In this study, all the patients had received and completed the cancer treatment in spite of their depression. This study explains the signifi of understanding the psychological distress by treating oncologists and referral of these patients to clinical psychiatrist for psychological and pharmacological treatment. Sociodemographic differences in a same and established society can signifi contribute to different out comes in the cancer survival, [9] and in a developing country like India with substantial inequalities among different groups may needs extra care in the management of cancer patients suffering from depression. In analysis, depression of varying degrees was seen both in patients with subjective financial limitations and those with financial suffi . There were several reports on the impact of marital relationships on the occurrence of emotional symptoms in patients with cancer. Earlier studies demonstrated that patients with cancer were more likely to report depression or depressive symptoms if they were unmarried or widowed [13, 14]. Even present study also exhibited that 8 cancer patients who were unmarried, divorced and widowed females had varying degree of depression ranging from mild to severe depression. This attributes to lack of inter-relationship among family members, absence of family support, and poor social support leading to a significant likelihood of patients with cancer developing emotional symptoms. Several studies captured higher rates of depressive and anxiety symptoms were found among patients with cancer of a lower educational level [15-17]. However, a single study reported higher rates of depression in patients with cancer of middle or high socioeconomic status or a higher level of education [18]. A study in 2016 demonstrated that agricultural workers suffering from cancer to experience higher levels of depressive symptoms compared with office workers with cancer [19]. Our study too concurred with previous reports that irrespective of socioeconomic or educational status, there is a wide range of mild, moderate and severe depression present in cancer patients with either low or middle or high socioeconomic status or a lower or higher educational status. The failure to detect and treat elevated levels of psychological distress might jeopardize the result of cancer therapies, decrease patient’s quality of life and increase health care cost [20]. In this study because of early recognition of psychiatric distress there was outstanding compliance to cancer directed treatment. Our study has the following limitations. Number of patients included in our study is not enough, and the effectiveness of the testing may not be sufficient; in future studies, we need a larger sample size without selection bias will reveal the incidence of depression in cancer patients and no signifi relationship of degrees of depression with sociodemographic parameters could be established in this study. Early recognition of psychiatric distress for the identification of depression is an integral part in the wide-ranging management of cancer patients. Conclusion The psychological impact of cancer is significant. The lack of recognizable risk factors makes the task of diagnosing psychiatric conditions in cancer patients a problematic one. Early detection of psychiatric illness will help for identification of depression which could the complete management of cancer patients.

About the authors

Rohan Jahagirdar

Author for correspondence.
Email: drjahagirdarrohan@gmail.com
ORCID iD: 0000-0001-8287-9562
Dahod, Gujarat, India

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