Psychosocial adaptation and quality of life among Brazilian patients with different hematological malignancies

Abstract

This study aims to investigate the prevalence of posttraumatic stress disorder (PTSD) symptoms, anxiety, and depression in patients with hematological malignancies, and to investigate the possible relationship between these symptoms and variables such as demographic data, social support, and quality of life (QOL). We studied 107 patients: 54 with non-Hodgkin's lymphoma (NHL), 18 acute myelogenous leukaemia (AML), 10 acute lymphoblastic leukaemia (ALL), and 25 multiple myeloma (MM). Demographic data were collected, and three standardized instruments were applied to this group of patients: Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire of QOL. The results showed a significant percentage of patients presenting with symptoms: 13% had high levels of intrusive thoughts, 20.5% had high levels of anxiety, and 16.8% had high levels of depression. Patients with MM had the lowest QOL scores in the EORTC physical functioning subscale. Patients under intravenous chemotherapy treatment had a higher level of anxiety than the monitoring patients. Patients with recent diagnosis had a level of intrusion symptoms (IES) relevantly higher than the others. The unemployed patients and those with lower social support had levels of stress, anxiety, and depression significantly higher than the others. Our results confirm the high incidence of intrusion, avoidance, anxiety, and depression in patients with hematological malignancies and highlight the importance of a multidisciplinary staff to complement the treatment of these patients, including psychosocial assistance.

Introduction

The advances in cancer diagnosis and treatment have allowed patients to have a longer life span than in the past. However, there is evidence that oncologic patients may present with difficulties in their psychological adaptation and a worsening in quality of life (QOL) [1]. The diagnosis itself, the invasive treatments, and surviving while keeping the disease under control may lead some patients to experience a posttraumatic stress disorder (PTSD).

According to the Diagnostic and Statistical Manual of Mental Disorders IV-R (DSM-IV-R) [2], some of the criteria for PTSD diagnosis are the exposition to a traumatic event; intrusive memories and feelings about the event; thoughts and avoidance feelings; hypervigilance, irritability, or insomnia. Also, in DSM-IV-R [2], the diagnosis of chronic diseases that could represent a risk of death was included as a stress traumatic event.

Horowitz et al. [3] created the Impact of Event Scale (IES) in order to measure the symptoms of intrusion and avoidance in response to potentially stressful life events. Many studies have used this instrument to evaluate the levels of these symptoms in oncologic patients. The results have shown that the levels of intrusion and avoidance symptoms are relevantly higher in oncologic patients than in the general population [1], [4]. However, these symptoms decrease as time goes by [5], [6], [7] and positively correlate with the anxiety level, as measured by the Hospital Anxiety and Depression Scale (HADS) [8].

Anxiety and depression are also common symptoms in oncologic patients [9]. The Hospital Anxiety and Depression Scale was created by Zigmond and Saith [10] to evaluate anxiety and depression symptoms in patients with physical diseases. It has been widely used in cancer patients [6], [7], [8]. Moreover, in recent years, great importance has been given to the QOL. It corresponds to a multidimensional concept in which its typical definitions involve the physical, psychological, social, and environmental well-being. With regard to the cancer patient's QOL, several studies have used the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire [7], [8], [9], [11], [12]. They found a relevant correlation between emotional function, as measured by EORTC QLQ-C30, and anxiety, as measured by HADS [9], and also between these scales and the IES subscale of intrusion [7].

Another important factor affecting patient's psychosocial adaptation to cancer treatment is social support. Low levels of social and family support are positively related to anxiety and intrusive thoughts [7], [13]. In a study with Hodgkin's disease patients, Kornblith et al. [5] found that patients who have a high risk of bad psychosocial adaptation are those with a lower income, low educational level, are unemployed or single.

In reference to studies of patients with hematological malignancies, Cella and Tross [4] have also conducted a study with Hodgkin's disease patients showing that the high level of distress is associated with return-to-work obstacles. Montgomery et al. [14], in one study with leukaemia and lymphomas patients, showed that 14% of them scored high in the HADS scale, and also there was a significant association between patients who scored high on the HADS and dissatisfaction with the information provided; the researchers did not find any significantly different scores among different diagnoses. Gulbrandsen et al. [12], in one study that evaluates the QOL of patients with multiple myeloma (MM), using the EORTC QLQ-C30 questionnaire, found that the most stressing problems the patients should deal with are their pain, fatigue, and a reduced level of physical function.

Considering the importance of this issue for cancer patients, the aims of this study were (1) to investigate the prevalence of intrusion, avoidance, anxiety, and depression in patients with hematological malignancies; (2) to correlate these symptoms with demographic data and QOL; (3) to determine whether there is a difference in the incidence of these symptoms among acute lymphoblastic leukaemia (ALL), acute myelogenous leukaemia (AML), indolent non-Hodgkin's lymphoma (iNHL), aggressive non-Hodgkin's lymphoma (aNHL), and MM patients.

The relevance of this study can be justified by the inexistence of published data that criteriously evaluate the psychosocial adaptation and QOL of patients with ALL, AML, NHL, and MM, especially from studies conducted among a Brazilian population sample.