Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 2, Num. 3, 2006, pp. 136-139

Journal of Cancer Research and Therapeutics, Vol. 2, No. 3, July-September, 2006, pp. 136-139

Original Article

Prevalence of psychiatric disorder in asymptomatic or minimally symptomatic cancer patients on treatment

Mishra SanjibKumar, Mohapatra PrashantKumar, Bhattacharya Kausik, Gupta Tejpal, Agarwal JaiPrakash

Department of Radiotherapy, A.H.R.C.C, Cuttack, Orissa and Department of Radiation Oncology, Tata Memorial Hospital, Mumbai
Correspondence Address:Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai - 400 012 Email: sanjib_debu2000 @yahoo. com

Code Number: cr06031

Abstract

Keywords: Cancer, depression, socio-demographic profile

Introduction

The incidence of cancer is increasing in developing countries, including India, due to increase in life expectancy as well as higher detection rates due to improved diagnostics. Given the limited resources and enormity of disease burden, most oncologists tend to neglect the psycho-social aspect of cancer, concentrating mostly on the physical symptoms. Cancer not only affects the organ systems physically but also the mind in the form of psychiatric disorder. This may be due to fear of death or lifelong treatment related morbidity. In developing countries, getting socially ostracized may be an additional factor compelling patients to become more mentally distressed. In addition, the huge financial implications attendant to the disease and its management may be the source of further distress, especially if the patient is the sole breadwinner of the family. These psychiatric disorders not only affect the patient but also the family members and, at times, the treatment outcome too. The failure to detect and treat elevated levels of distress may jeopardize the outcome of cancer therapies, decrease patient's quality of life and increase health care cost.[1]

It has been long reported that not only symptomatic but minimally symptomatic and ambulatory cancer patients also have a high prevalence of psychiatric disorder.[1],[2] Passik et al. showed that physicians tend to underestimate the degree of psychological distress experienced by their patients, which results in inadequate treatment.[3] Appropriate treatment of these disorders can be both clinically efficacious and cost-effective too.[4] With this background, a study was conducted at Acharya Harihar Regional Cancer Center (AHRCC), Cuttack, India, in collaboration with Department of Psychiatry, Shriram Chandra Bhanja (SCB) Medical College, Cuttack, India, to assess the prevalence of psychiatric disorder amongst cancer patients.

Aims

To estimate the prevalence of psychiatric disorder among the asymptomatic or minimally symptomatic cancer patients on active anticancer treatment and correlate it with several socio-demographic parameters.

Materials and Methods

Patients who attended the outpatient department of our regional cancer center from January-June 2003 were screened for inclusion. They were considered suitable if the following criteria were met:

1. Absence of severe physical symptoms like pain, dysphagia, abdominal distension, etc.
2. Karnofsky Performance Status (KPS) ≥80.
3. No history of prior psychiatric illness or previous malignancy.
4. Age between 20 and 60 years and were on active anticancer treatment.
5. No history of hypothyroidism, diabetes mellitus or intracranial space occupying lesion.
6. No history of drug, alcohol or cannabis abuse.

A written consent was obtained from all patients enrolled in the study. The patients were given a psychiatric assessment questionnaire, which was translated in local language from the Prime-MD[5] developed according to Diagnostic and Statistical Manual of Mental Disorders-IV Edition (DSM-IV). The subjects were required to fill the questionnaire independently without any prompting and return it on the same day or next working day. In event of any difficulty, explanation regarding the questionnaire could be given, but assistance in filling was not allowed. Patients who were unable to read or write were prompted by their literate attendants. The demographic and the medical data were obtained from the subjects and their medical records. The statistical analysis was done using SPSS software version 10.5. Correlation of prevalence of psychiatric disorder with socio-demographic parameters was done using the Chi-square test.

Results

Two hundred consecutive patients attending the outpatient clinic were screened, of which only 47 fulfilled the eligibility criteria and were served the questionnaire. Of these, 38 (81%) patients returned the questionnaire duly filled-in; they form the dataset for this study. [Table - 1] depicts the socio-demographic parameters of the study population and its correlation with the prevalence of psychiatric disorder. The median age of the respondents was 52 years (range 28-58 years). Males and females were equally represented. Thirty-two respondents (84%) had received education in high school or above. Twenty-one (55%) were from rural areas, whereas 22 (58%) belonged to the high-income group. Twenty-five (66%) respondents were from nuclear family. Awareness of diagnosis and prognosis was present in 79 and 76% respondents respectively. Only 18% had good knowledge about cancer. Sixty-three percent had upper aero-digestive tract (UADT) malignancy; 16%, genitourinary tract malignancy; 21%, hemato-lymphoid or others.

Of the 38 respondents, 24 (63%) were diagnosed to have some psychiatric disorder. All these 24 patients were suffering from depression - 15 (63%) from major depression and 9 (37%) from minor depression. Only 6 of 24 (25%) patients had anxiety disorder that was associated with either minor or major depression. The prevalence of psychiatric disorder in patients who were aware of the diagnosis and prognosis was 58 and 55% respectively. This was significantly higher ( P -value 0.019 and 0.05 respectively) as compared to the patients who were not aware of their diagnosis and prognosis [Table - 2].

There was no significant correlation of psychiatric disorder with other socio-demographic parameters. The type of cancer (UADT, gastrointestinal, genitourinary, etc.), extent of disease (limited versus advanced) and modality of treatment (radiotherapy versus others) had no impact upon the prevalence of psychiatric disorder in this study population.

Discussion

Distress of some degree is always associated with a diagnosis of cancer. It is described as an unpleasant emotional experience of psychological, social or spiritual nature that may interfere with the patient's ability to cope with cancer and its treatment. It ranges from common normal feelings of vulnerability, sadness and fear to problems that can become a disability, such as depression, anxiety, panic, social isolation and spiritual crisis and sometimes may lead to extreme steps like suicide.

Data regarding the prevalence of psychiatric disorder in asymptomatic or minimally symptomatic cancer patients are sparse. Most of the data are from developed countries, where the socio-demographic scenarios are different from developing countries. Psychiatric disorders are more prevalent in patients suffering from chronic diseases such as cancer than in the general population.[6],[7] Severe and persistent depressive disorder is up to four times more common in cancer patients as compared to the general population. The prevalence of any psychiatric disorder amongst cancer patients ranges from 14 to as high as 85% in different clinical and psycho-social settings.[8],[9] Berard et al.[8] reported a 14% prevalence of depression in a cohort of 456 patients attending an outpatient radiotherapy department, which is similar to the 15% estimate in 124 adult patients recorded by Hahn et al.[10] in another radiation oncology clinic. These estimates are however considerably lower than those of other studies,[2],[9],[11],[12] where the prevalence of psychiatric disorder in patients with advanced or terminal disease ranges from 25 to 85%.

In ambulatory head and neck cancer patients, Kugaya et al. identified certain risk factors which predicted for depressed mood.[13] These included advanced disease, being unmarried and a feeling of hopelessness/helplessness. Head and neck cancer patients who were no longer being actively treated but attending a follow-up clinic or support group were more likely to have reduction in the degree of depression and distress with time.[14]

In advanced disease, the incidence of psychological distress is more and is associated with poor performance status, malnutrition, pain and other psychological dysfunction.[11] Burkberg et al. have reported about the clear association of depression with greater degree of physical disability.[12] Other negative life events and poor quality of social supports were also associated with depression, even in less disabled patients.

Other psychiatric disorders such as anxiety or personality disorders are seen less commonly. Stark et al. reported that 48% of patients with cancer have some anxiety and 23% have significant anxiety.[15] The stress caused by a diagnosis of cancer and its treatment may precipitate a preexisting anxiety disorder. Factors that can increase the likelihood of developing anxiety disorder in cancer patients include a prior history of anxiety disorder, severe pain, anxiety at the time of diagnosis, functional limitation, lack of social support, female sex and advanced disease.[16] In patients with advanced disease, anxiety is not often caused by fear of death but by the issue of uncontrolled pain, isolation, abandonment and dependency.

All the patients in this study were either asymptomatic or minimally symptomatic. Most of them were having local or loco-regional disease and a majority of them were treated with radical intent, but still the incidence of psychiatric disorder was high in comparison to Western published literature because the socio-demographic profile of our patients was different from the Western setting. This study also shows that depression is significantly higher in patients who are aware of the diagnosis and prognosis ( P -value 0.019 and 0.05 respectively). Although other socio-demographic parameters did not significantly correlate with prevalence of psychiatric disorder in this study set conducted in a small regional cancer center in India, the same may not be applicable in another sociocultural setting. Empowering patients and relatives with information about the disease and treatments is an essential component of a sound and ethical clinical practice. But in developing countries where the awareness of cancer is very low, the percentage of patients who are unaware of the diagnosis and prognosis is expected to be high, which is clearly shown in our study (25 and 33% respectively).

When the questionnaire was served, all the patients were on active anticancer therapy. Although there was no significant difference in the incidence of psychiatric disorder among the different treatment groups, yet the overall incidence was high because anticancer therapy has a significant effect on the psycho-social aspects, including financial burden to the family.

Conclusion

Acknowledgments

References

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