Research report
Depression, psychosocial variables and occurrence of life events among patients with cancer

https://doi.org/10.1016/S0165-0327(97)01445-6Get rights and content

Abstract

Depressive disorders and psychosocial related factors were investigated in 113 patients one year after the diagnosis of cancer. Patients with an ICD-10 diagnosis of depression (31% of the sample) showed higher external locus of control, poorer social support, higher incidence of undesirable and/or uncontrollable events than non-depressed patients. They also differed in reporting more frequently a life-time history of emotional disorders, inability to adjust to the diagnosis of cancer and in having a lower score on the performance status. Of these factors, past psychiatric history, early maladjustment to cancer, poor social support and low performance status were predictors of depressive symptoms. However, because of the cross-sectional nature of the study, no conclusion regarding a causal relationship between depression and psychosocial variables is possible.

Introduction

Considerable evidence exists about the prevalence of affective disorders in patients with cancer. A number of studies have shown that depression represents the most common disturbance secondary to cancer, affecting 30–40% of the patients (see Mermelstein and Lesko, 1992, McDaniels et al., 1995for reviews). In one of the main studies employing reliable psychiatric criteria, a diagnosis of mood disorders according to the DSM-III was made in 38% of 215 out-patients with cancer (Derogatis et al., 1983). Subsequent research reported that adjustment disorders may affect 30–35% of cancer patients (Razavi et al., 1990), dysthymia up to 40% (Bayle et al., 1992) and major depression a percentage ranging from 5–8% (Lansky et al., 1985, Razavi et al., 1990, Harrison et al., 1994) to almost 30% (Bukberg et al., 1984, Evans et al., 1986, Kathol et al., 1990). Although the prevalence of psychological disturbances tend to decrease over time (Morris et al., 1977), 20% of cancer patients remain depressed or worse psychologically (Ell et al., 1989, Kornblith et al., 1992) and about 30% develop an affective disorder in the two years following the diagnosis (Meyer and Aspegren, 1989, Parle et al., 1996).

Of the several variables examined, a history of depression (Maunsell et al., 1992), poor social support (Wortman and Dunkel-Schetter, 1979), inadequate coping mechanisms (Weisman, 1989, Classen et al., 1996), external locus of control (Marks et al., 1984, Taylor et al., 1984, Grassi et al., 1993) and advanced stage of illness (Bukberg et al., 1984Cella et al., 1987) have been the most frequently related to depressive symptoms secondary to cancer. Less data are available on the association between stressful life events and depression among cancer patients. Bukberg et al. (1984)showed that the number of negative life events in the previous six months was related to depression in hospitalised cancer patients with high levels of functioning, but not in patients with high disability. In a study of long-term survivors of cancer, a higher incidence of stressful life events in the six years following the diagnosis was found in patients with a DSM-III-R psychiatric diagnosis than those psychologically healthy (Grassi and Rosti, 1996). These findings seem to confirm investigations which have strengthened the role of life stressful events, low social support and external locus of control in favouring depression in the general population not affected by physical illness (Husaini and Neff, 1981, Tennant, 1983, Lefcourt et al., 1984, Brown and Harris, 1986, Holahan and Moos, 1991, Vilhjalmsson, 1993, Dalgard et al., 1995, Cui and Vaillant, 1996). Research carried out in community and primary care settings has demonstrated that depression is a major medical problem which deserves extreme attention by health providers (Kathol et al., 1994, Nemeroff, 1994). Similarly, depression and its consequences in patients affected by medical illness, especially cancer, should be correctly evaluated and treated (Rodin and Voshart, 1986, Fava et al., 1988, Cassem, 1995, Cavanaugh, 1995). In fact, depressed cancer patients show worsening of quality of life (Godding et al., 1995, Koller et al., 1996, Grassi et al., 1996), difficulties in family functioning (Kissane et al., 1994), maladaptive response to illness (Grassi et al., 1989, Watson et al., 1991) and high suicidal rate (Henriksson et al., 1995). It has also been suggested that depression may be associated with a more rapid progression of cancer (see Watson and Ramirez, 1991for review). For these reasons, correct assessment of depressive symptoms and their evolution over time and identification of risk factors need to be addressed for warranting early and appropriate psychiatric treatment in cancer patients (Maguire, 1995).

On these bases, the present study was conducted to explore in more detail the prevalence of depressive disorders and its association with individual psychological characteristics, social support and stressful life events occurred in the previous year, in patients with cancer.

Section snippets

Subjects

Participants were a consecutive series of out-patients who had been diagnosed as having cancer 12–14 months previously and who were followed by the Division of Medical Oncology, St. Anna Hospital in Ferrara (Northern Italy). Patients aged between 18 and 70 years and no or minor difficulty in carrying on their daily life, as indicated by a score >80 at the Karnofsky performance status scale (KPS) (Karnofsky and Burchenal, 1949) were recruited for the study.

The patients were fully informed of the

Patients' characteristics.

One-hundred and twenty-five patients were recruited for the study. Five patients refused to participate (refusal rate=0.4%). Of the remaining 120, 8 patients (6.6%) with an ICD-10 psychiatric diagnosis other than mood disorders (F06 organic mental disorder n=1, F40 phobic disorder n=3, F41 other anxiety disorders n=2, F60 personality disorder n=1) were excluded from analysis, leaving 113 patients as the study group. Twenty-two were males (19.5%) and 91 females (80.5%). They ranged in age from

Discussion

In this study we examined the relationship between depression and psychosocial variables in patients with cancer about one year after the diagnosis.

A first result of the study is that nearly one-third of patients presented symptoms indicating a mood disorder according to the ICD-10. More specifically, a diagnosis of depressive episode was made in about 8% of the patients (25% of all the diagnoses of mood disorders), a persistent depressive disorder in 9% and an adjustment disorder in 14%.

Acknowledgements

The authors wish to thank the patients and the staff for their co-operation, and Dr. Lawrence Robert Jr. Jones for his assistance in the preparation of the manuscript. The study was supported by funds from the Italian Ministry of the University and Scientific and Technological Research (MURST).

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