Prevalence of anxiety and depression among cancer patients attending tertiary care hospital in Puducherry – A cross-sectional study

INTRODUCTION

Cancer overall affects the body as well as the mind. It is the second most leading cause of death in the world. A diagnosis of cancer begins a long journey that can affect physical health, mental well-being, and relationships with loved ones.^[1] In addition to coping with the worry and stress brought about by their diagnosis, patients with cancer and their families must cope with the stresses induced by intensive treatments for the illness and the permanent health impairment and disability, fatigue, and pain that can result, even when there are no longer any signs of the disease. These effects contribute to emotional distress and mental health problems among cancer patients.^[2] Most commonly presenting psychiatric conditions are depression, anxiety (panic disorder, post-traumatic stress disorder, and phobias), adjustment disorder, and delirium. Depression is a comorbid disabling syndrome that affects approximately 15–25% of cancer patients.^[3]

According to the American psychological association, psycho-oncology refers to the study of psychological, behavioral, and psychosocial factors involved in the risk, detection, course, treatment, and outcome (in terms of survival) of cancer. The field examines responses to cancer on the part of patients, families, and caregivers at all stages of the disease.^[4] A very minimum people have knowledge on psychiatric conditions and seek necessary medical attention for it. Often the symptoms may remain overlapped, where even medical professionals find it difficult to diagnose it. It was believed that one-third of the people diagnosed with cancer were having depression.^[5-7] The fear begins from the question of survival, intensive treatments, economic instability, bodily disfigurements, physical limitations, fear of losing jobs, and being burden to the family, it persists even after the treatment and present as fear of recurrence. Some may even show somatic symptoms.^[8,9] Not every patient was counseled after their diagnosis or treatment. The efficacy of the several forms of specialized psychotherapeutic interventions and psychosocial rehabilitation, especially if in the form of collaborative care, indicates a general benefit in reducing the severity of psychiatric symptoms, as well as somatic symptoms (e.g., pain) and in improving quality of life (QOL), well-being, and return to work and illness behavior. The interventions with the most empirical support for treating distress in cancer patients include supportive-expressive group psychotherapy, cognitive-behavioral and cognitive-existential therapy, and meaning centered psychotherapy.^[5]

Medical knowledge enhances the sense of control and mastery a person has over his or her disease, and educational interventions generally yield positive outcomes. Interventions for medical patients are usually more effective when they provide patients with cues for using the knowledge related to their disease and daily management or with some emotion focused components, which helps them to adjust and live through the different phases of the illness.^[10,11]

This study mainly focuses on the outpatients and in patients of oncology ward and captures the level of anxiety and depression among them using depression anxiety stress scale 21 (DASS-21) and their QOL using the World Health Organization (WHO) QOL BREF. The primary objective of the study is to find prevalence of anxiety and depression among the cancer patients and secondary objective is to assess the QOL and its association with sociodemographic variables.

MATERIAL AND METHODS

RESULTS

It was found out of 226 cancer patients, majority of them 151 (66.8%) were in the age group of 30–59 years and 148 (66.5%) were female. Most of the participants were educated at least up to high school level and nearly half of them were not employed at present. About three-fourth of the participants belonged to class IV socioeconomic status. Majority of the participants belonged to Hindu religion and were married. Of 226, 35 (15.5%) did not have any other comorbidities and had no addictions.

From Figure 1, it was found among 226 cancer patients, 62 (27.4%) had stress, 178 (78.8%) had anxiety, and 154 (68.1%) were in depression. Among 62 cancer patients who were in stress, majority, 41.9% had mild stress and of 178 cancer patients who had anxiety, 87 (48.9%) had moderate anxiety. Out of 154 patients in depression, about half of them were in mild depression and 13 (8.4%) had very severe depression [Table 1].

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Figure 1:

Prevalence of stress, anxiety, and depression among cancer patients.

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From Table 2, it was found. The mean raw score in overall QOL is 3.27 ± 0.94 standard deviation (SD) and in general health is 3.46 ± 0.81) (SD). Out of all the domains, environmental domain had highest score in QOL, particularly in items related to freedom, safety and security, and transport.

The mean QOL was higher for environmental and social domains, whereas it was lowest in physical domain. There was statistically significant difference in the QOL perceived by the cancer patients in various domains (P < 0.001). Out of 226 participants, 22.6%, 26.1%, 47.8%, and 76.1% of them had good QOL in physical, psychological, social, and environmental domains, respectively. There was statistically significant difference between good and poor QOL of cancer patients in various domains (P < 0.001) [Table 3].

It was found among cancer patients, except their marital status, none of the variables were statistically associated with overall QOL of patients (P = 0.01). Marital status (P = 0.001) and duration since the diagnosis of cancer (P = 0.005) had significant association with environmental domain of the QOL of patients [Table 4].

DISCUSSION

In the present study, the prevalence of anxiety and depression among cancer patients was found to be 78.8% and 68.1%. The mean QOL was higher for the environmental and social domains, whereas it was lowest in the physical domain which clearly states stigma rendered by society making them negligent and unwanted, due to cancer plays a key role in influencing their confidence pushing them to depression. Gonzalez-Saenz de Tejada et al. study shows, the location of cancer, divorced or widowed, and non-functionally independent cancer patients are more prone for anxiety and depression, while higher baseline scores, higher social support, and improvements in physical functioning, cognitive functioning, and social functioning were associated with improvements in anxiety and depression.^[13] In this study, the low physical domain is due to physical impairment and bodily disfigurement after surgery and need for assistance in daily activities. Kumar et al. study states poor outcomes after operations that do not focus on aesthetic correction and QOL could be another reason for psychological distress.^[14] Study shows alterations in appearance, and problems with speech, chewing, and swallowing affect social function and QOL and also lead to depression.^[14] The present study shows that there are high environmental and social domains, which is attributed to good family support, freedom, and safety of the patient and nearby hospital facilities. Among cancer patients, marital status was statistically associated with overall QOL of patients (P = 0.01). This study also states that people with low income, low educational background, and lesser knowledge about the disease and its treatment have more anxiety and depression. There is low QOL after 2 years of diagnosis of cancer (55.2 ± 7.2) among the study population. Gender plays an important role, based on study by Linden et al., females diagnosed with cancer are more prone for depression.^[15] This study had maximum number of breast cancer patients, those who underwent mastectomy showed high level of depression. Studies shows that loss of job and income, anxiolytics and antidepressants, cancer-related neuropathic pain, and mastectomy were associated with higher odds of anxiety and/or depression.^[16] Studies by Pinquart and Duberstein show that depression leads to a poorer QOL and compromises patient outcomes, with depression resulting in higher rates of mortality in cancer.^[17]

Age group plays an important role in psychological involvement, this study shows people between 30 and 60 years are more prone for depression and anxiety. Jacob et al. study on 29 366 women initially diagnosed with breast cancer or genital organ cancer, women in the age groups of 41–50, 51–60, and 61–70 years were at a higher risk of depression/anxiety than women in the age group of 71–80 years (odds ratios equal to 1.50, 1.38, and 1.22).^[18] The prevalence of depression and anxiety also involves the treatment plan. Most of the patient in this study were undergoing chemotherapy and more incidence of depression and anxiety are seen among the patient suffering from the adverse effect of chemotherapy. Study shows wide range of side effects (e.g., nausea, vomiting, constipation, anemia, hair loss, or even secondary neoplasm) induced by chemotherapy may further deteriorate the emotional, cognitive and social functions of cancer patients, and consequently lead to the occurrence of mental disorders.^[19]

As this study focuses on QOL, the physical factors causing depression and anxiety are insomnia, nausea, fatigue, and reduced appetite, while the other factor includes financial difficulties, loss of job, less family support, and divorce. Studies shows that the two important factors that related to major depressive disease were insomnia and financial difficulties among cancer patient.^[20] The treatment of depressive and anxious cancer patient involves psychoanalysis and pharmacotherapy. Studies show that patient may likely to benefit from psychoeducation, cognitive behavioral therapy, problem-solving therapy, and acceptance and commitment therapy. Pharmacotherapy involves prescribing strong analgesics for pain, benzodiazepine for anxiety, and Selective serotonin reuptake inhibitors (SSRI) and Tricyclic antidepressants (TCA) for depression.^[21] Clinical guidelines for physician might help in early diagnosis of depression and providing comprehensive management. The National Comprehensive Cancer Network from United States has established specific tool for the routine assessment of psychosocial morbidity and an algorithm for the management of psychological disorders (e.g., adjustment disorders, depression, suicide and suicide risk, and cognitive disorders) in cancer patients.^[22]

It is hospital-based cross-sectional study that temporarily cannot be maintained. Smaller sample size hence the findings cannot be generalized.

CONCLUSION

Depression and anxiety remain underdiagnosed among the cancer patient. This study emphasizes the need for combined oncologist and psychiatrist workup for depression and anxiety patients for necessary psychological interventions to improve healing effects. All the patients have to be linked to palliative care for psychosocial support and comprehensive management for cancer patients by providing patient patient-friendly environment and developing guidelines for counseling.