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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 2  |  Page : 195-200

Prevalence of anxiety and depressive symptoms in female breast cancer patients


1 166 Military Hospital, Jammu, Jammu and Kashmir, India
2 Department of Psychiatry, 166 Military Hospital, Jammu, Jammu and Kashmir, India
3 Department of Psychiatry, Military Hospital, Pathankot, Punjab, India
4 Department of Paediatrics, 166 Military Hospital, Jammu, Jammu and Kashmir, India
5 Department of Anaesthesiology and Critical Care, Level III Hospital, Goma, Democratic Republic of the Congo

Date of Submission26-Jun-2020
Date of Decision01-Aug-2020
Date of Acceptance19-Aug-2020
Date of Web Publication08-Oct-2021

Correspondence Address:
Dr. Harpreet Singh Dhillon
Department of Psychiatry, 166 Military Hospital, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_179_20

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  Abstract 


Background: Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer deaths among females worldwide. Once an individual encounters this diagnosis, she may go through a mix of emotions such as shock, disbelief, fear, anxiety, guilt, sadness, grief, depression, and anger. The present study attempts to find the prevalence of anxiety and depression in female breast cancer patients presenting in a tertiary care hospital. Methods: A total of 100 consecutive cases of female breast cancer patients, who were admitted to the oncology ward at the time of evaluation, either for follow-up or treatment, were taken as cases, in a tertiary care hospital over a period of 1½ year. Baseline demographic data of cases were entered in a semi-structured pro forma on admission. The General Health Questionnaire (GHQ-12) was used to assess distress. The prevalence and severity of anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. The patients were also evaluated for relationship between depressive and anxiety symptoms and various other sociodemographical factors. Chi-square test was used as the statistical tool to analyze the data. Results: The mean GHQ-12 score was 16.44 (standard deviation = 4.66), with 26% of patients showing evidence of distress and 18% evidence of severe problems and psychological distress. Nearly 36% of the breast cancer patients had significant anxiety scores (mean = 8.34). Almost 34% of the breast cancer patients had significant depression scores (mean = 8.27). Younger patients (<50 years) showed significantly high incidence of depression. Conclusion: The results of the study showed that both anxiety and depression were significantly higher in breast cancer patients, emphasizing the need for dedicated service provision (psych-oncology units at cancer centers). Various sociodemographic factors studied (except age) did not show any statistically significant difference in the incidence of anxiety or depression.

Keywords: Anxiety, breast cancer, demography, depression


How to cite this article:
Sahu VK, Dhillon HS, Divinakumar K J, Dhillon GK, Sasidharan S. Prevalence of anxiety and depressive symptoms in female breast cancer patients. Indian J Soc Psychiatry 2022;38:195-200

How to cite this URL:
Sahu VK, Dhillon HS, Divinakumar K J, Dhillon GK, Sasidharan S. Prevalence of anxiety and depressive symptoms in female breast cancer patients. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 9];38:195-200. Available from: https://www.indjsp.org/text.asp?2022/38/2/195/327823




  Introduction Top


Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer deaths among women worldwide, with an estimated 1.7 million cases and 521,900 deaths in 2012.[1] Breast cancer is the second most common malignancy in Indian women, and the incidence of breast cancer is on the rise in India.[2] Over the last few decades, there have been outstanding advances in breast cancer management leading to earlier detection of disease and the development of more effective treatments, leading to significant decline in breast cancer deaths and improved outcomes for women living with the disease.[3],[4] Despite the improvements in survival rates, a diagnosis of breast cancer initiates a complex psychological adjustment process that may last for years, not only for the woman herself, but also for those around her.

Anxiety and depressive disorders are the two common psychiatric disorders in breast cancer patients. These psychiatric disorders lead to patient's maladaptive illness behavior and worsen the disease course and the treatment outcomes.[5] Anxiety is often experienced prior to treatment, whereas depression generally emerges post treatment.[6],[7] The diagnosis of anxiety or depression in isolation of each another is difficult because symptoms frequently overlap.[8] The estimated rate of anxiety and depression among women with breast cancer falls between 10% and 37% with highest incidence immediately post diagnosis followed by gradual reduction.[9],[10] This wide range in incidence could be due to difference in assessment methods, assessment during various stages of disease/different treatment modalities being used, and other sociodemographic factors.[11] In addition, there are psychosocial factors relating to patient's environment such as social support, family functioning, problem-solving or coping styles, which are associated with anxiety and depressive disorders.[12]

Depression is known to be associated with certain treatment modalities, especially chemotherapy[10] and disfiguring surgeries, such as mastectomy. Depression seems to influence the prognosis and even the survival of cancer patients. Satin et al. conducted a meta-analysis with 27 studies on mortality in cancer patients and depression, and a significant effect of depression on mortality was reported (risk ratio: 1.25, P < 0.001).[13] Various other trials also found that a decrease in the severity of depressive symptoms is associated with improved survival in cancer patients.[14],[15] However, these findings remain inconclusive as various other studies failed to replicate them.[16],[17],[18] In view of the above, various guidelines for the treatment of cancer recommend that all cancer patients should be screened for depression, anxiety, and other less defined psychiatric symptoms, for example, pain and fatigue (National Institute of Health).[19]

However, many a times, these psychiatric disorders in cancer patients seem to be ignored and left untreated. Passik et al. showed that physicians tend to underestimate the degree of psychological distress experienced by their patients, which results in inadequate treatment.[20] Other difficulties to detect depression in cancer patients are lack of specific skills to diagnose mental disorders,[21] lack of time in busy oncological settings, and reluctance of the patient to discuss emotional well-being.[21],[22] Although clinicians may not be able to prevent some of the chronic or late medical effects of cancer, they have a vital role in mitigating the negative emotional and behavioral sequelae.

Recognizing and treating effectively those who manifest symptoms of anxiety or depression will reduce the human cost of cancer.[23] The present study attempts to find the prevalence of anxiety and depression in female breast cancer patients presenting in a tertiary care hospital.


  Methods Top


Study design

It was an observational cross-sectional study.

Inclusion criteria

  1. Female patients diagnosed as a case of breast cancer
  2. Patients consenting for the assessment
  3. Age group between 20 and 85 years.


Exclusion criteria

  1. Any other cancer diagnosis prior to breast cancer
  2. Diagnosis of mental retardation, or untreated mental disease.


This study was carried out at an urban tertiary care center from January 2014 to June 2015 after taking hospital ethics committee's approval. The center provides medical, surgical, and radio-therapeutic treatment. Out of a total of 123 consecutive cases of patients with breast cancer, who were admitted to the oncology wards at the time of evaluation (follow-up and treatment), 23 were excluded as per the exclusion criterion and 100 were enrolled into the study. These cases included newly diagnosed cases as well as known cases for surgery or for follow-up cycles of chemotherapy or radiotherapy. Baseline demographic data of cases were collected by the principal investigator and entered in a semi-structured pro forma on admission. The semi-structured pro forma contained personal particulars, detailed sociodemographic profile, and elaborate details about the illness in addition to a detailed mental status examination. The General Health Questionnaire (GHQ-12)[24] was used to assess nonspecific distress. They were then assessed for the prevalence and severity of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS).[25] All the patients who were found to have anxiety and depression scores above 7 were then interviewed by a psychiatrist for the diagnosis of anxiety and/or depression based on the ICD-10 criteria for research. After diagnosis, the patients were given appropriate treatment.

Statistical analysis

The statistical software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA) was used for analyses of the data, and Microsoft Word and Excel were used to generate graphs and tables. Results on continuous measurements were presented as mean ± standard deviation (SD), and results on categorical measurement were presented in number (%). Level of statistical significance was fixed at P = 0.05 and any value <0.05 was considered to be statistically significant. Chi-square analysis was used to find the significance of the study parameters on a categorical scale.

The GHQ-12 comprises six items, and each item is rated on a 4-point scale (less than usual, no more than usual, rather more than usual, or much more than usual). The GHQ-12 has high reliability and validity with Cronbach's alpha coefficient value of 0.93 in a study on the Indian population. The most common scoring method is Likert scoring style (0-1-2-3).[24] The score ranges between 0 and 36. Score >15 suggests evidence of distress and score >20 suggests severe problems and psychological distress.

The HADS is the most extensively validated scale for screening emotional distress in cancer patients. The scale was found to have a Pearson's coefficient of 0.86 between test retest subscale scores (P < 0.001) over a mean 3-week period. The internal consistency with Cronbach's alpha for the total scale and both subscales was found to be ranging from 0.71 to 0.90. It has 14 items: 7 related to anxiety and 7 to depression. Scoring is from 0 to 3, and the score ranges from 0 to 42. The norms give an idea of the level of anxiety and depression (0–7 = normal, 8–10 mild, 11–14 = moderate, and 15–21 = severe).[25]


  Results Top


The age range of the study group was 30–80 years with a mean age of 53.63 years and a standard deviation of 10.63 years. All the patients in the sample were married. The mean education of cancer patients was 9.49 years of schooling, 16% patients had an education less than class V, 69% of the patients had educational qualification between class VI–XII, and 15% were educated above class XII. Majority (95%) of the patients were homemakers. More than half (52%) of the patients were from rural background. The distribution of patients as per staging of cancer was 18%, 34%, 37%, and 11% in Stages I, II, III, and IV, respectively. As per the duration of diagnosis, 41% of the patients were diagnosed within the last 6 months, while 59% were diagnosed for >6 months. The distribution of patients as per the treatment modalities was as follows: 48% with chemotherapy, 11% radiotherapy, 35% were operated, and 4% were treatment-naive patients [Table 1]. Two percent of the patients were in palliative treatment group who used to report to hospital at the time of exacerbations of the symptoms such as uncontrollable pain, nausea, vomiting, and other physical symptoms.
Table 1: Demographic and cancer-related variables

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The distribution of patients as per various scales is shown in [Table 2]. The mean GHQ-12 score was 16.44 (SD = 4.66); 26% of the patients showed evidence of distress and 18% showed evidence of severe problems and psychological distress. The anxiety scores in this study ranged from 3 to 17 with a mean of 8.34. The percentage of patients with anxiety and depression cutoff scores above 7 was 36% and 34%, respectively.
Table 2: Distribution of depression and anxiety scores in breast cancer patients

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The proportion of patients scoring above the cutoff (>7) for anxiety was higher (44.44%) in ≤50 years' age group as compared to 31.25% in the age group of >50 years. Patients with higher number of school years had higher anxiety scores. The anxiety scores above the cutoff were higher (60%) in employed patients compared to 34.73% in the homemaker group. The anxiety scores were comparable with respect to domicile with 36.53% of patients from rural background and 35.41% patients from urban background above the cutoff. The prevalence of anxiety scores above the cutoff was higher in advanced stage (38.8%, 38.2%, 24.3%, and 63.3% in Stages I, II, III, and IV, respectively). Patients with shorter duration of diagnosis (<6 months) had higher anxiety scores (39.02% vs. 33.89%) than patients with >6 months of disease duration. The prevalence of anxiety scores above the cutoff among various treatment modalities was 33.3%, 36.3%, 34.2%, 100%, and 50% in chemotherapy, radiotherapy, operated, palliative, and treatment-naïve groups, respectively. The anxiety scores in the treatment-naïve group were higher (50%) as compared to 35.4% in patients who received some form of the above-mentioned treatments [Table 3].
Table 3: Association between demographic and cancer-related variables and anxiety and depression scores of Hospital Anxiety and Depression Scale

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The depression scores above the cutoff (>7) were statistically significantly higher (47.22%) in ≤50 years' age group compared to 26.56% of cancer patients >50 years (P = 0.047). The relation between depression scores above the cutoff value and education revealed an inconsistent pattern, with the highest proportion (36.23%) of patients in the education bracket of 6–12 years. Patients with employment had higher (40%) depression score as compared to 33.68% of patients from the homemaker group. Depression scores above the cutoff were comparable as per domicile, with 34.61% in rural background versus 33.33% patients from urban background. The prevalence of depression scores above the cutoff value was highest in advanced stage of disease, namely 38.8%, 35.2%, 24.3%, and 54.5% in the Stage I, II, III, and IV, respectively. The proportion of patients with depression scores above the cutoff was higher (36.58%) with shorter duration of diagnosis compared to 32.20% of patients with >6 months of duration of diagnosis. Depression scores above the cutoff were highest in the palliative group followed by the treatment-naïve group among various treatment modalities. In the treatment-naïve group, 50% of the patients had depression scores above the cutoff compared to 33.3% in patients who received some form of treatments [Table 3].


  Discussion Top


Significant advances have been made in the treatment of malignant diseases, but advances in psychological management of these patients will depend on awareness, knowledge, and sensitivity to the emotional distress associated with cancer and cancer treatments.

The prevalence of anxiety and depression in this study group was 36% and 34% respectively. These figures are substantially higher than the prevalence of global general rate[26] for anxiety disorders (2.9%–5.8%) and depression (3.6%–5.4%), thus emphasizing the psychological distress associated with a diagnosis of cancer even after significant advances in treatment modalities. Fann et al.[10] in an epidemiological review of breast cancer patients, reported prevalence of depression in the range of 15%–30%. Burgess et al.[9] found a point prevalence of 33% for depression and anxiety in a sample of 222 women with breast cancer. These findings closely coincide with those of the current study.

The anxiety and depression scores were comparatively higher in younger age group (<50 years), i.e., 44.44% versus 31.25% in anxiety and 47.22% versus 26.56% in depression, respectively. These findings are in agreement with those of Howard-Anderson et al. and Burges et al.[9],[27] This may be attributed to the greater psychological impact on body image, fertility-related apprehensions, and early menopausal concerns in younger women.

The prevalence of anxiety appeared to increase with higher education, whereas that of depression appeared to decrease with higher education. These differences were, however, statistically not significant. This observation of education having no association with depression/anxiety is in agreement with a Turkish study in 2010.[28] However, it is in contrast to other studies which found higher education to be protective against anxiety and depressive symptoms in breast cancer patients.[29]

Employed patients experienced greater anxiety (60% vs. 34.7%) and depression (40% vs. 33.6%) than homemakers in the current study, which corroborates with the findings of Bulotiene et al. and could be explained by the apprehensions of being able to fulfill job requirements post diagnosis/treatment.[30] However, the total number of employed patients (n = 5) was very less and hence this result is difficult to generalize.

The anxiety and depression scores were marginally higher in rural population. This was in accordance with Tsaras et al.[31] who found anxiety 3.8 times and depression 2.6 times higher in rural residents. This could be attributed to poor awareness, late detection of disease at advanced stage, limited health-care/treatment modalities, distance, and finances incurred in repeated visits to specialized centers in cities.

As per staging of disease, 48% of patients were in the late (III and IV) stage, which was comparable with the review by Hebert et al., which reported that 50%–55% of breast cancer cases were detected at late (III and IV) stage.[32] This trend indicates that early-stage disease, which is potentially treatable, is going undetected until very late, thus emphasizing the need for better screening/detection tools in the community. The prevalence of anxiety and depression scores was highest in Stage IV disease in accordance with multiple other studies.[31],[33] This could be explained due to the natural course of disease progression, debilitating long-term side effects of treatment, disfiguring surgeries causing body image distress, caregiver burnout, etc.

Patients with <6 months' duration of diagnosis had higher anxiety and depressive symptoms. These observations were statistically not significant but supported the trend that the prevalence of anxiety and depression decreases during the period of observation. This is in concurrence with those of Burgess et al.,[9] who found that the prevalence of depression and anxiety reduced consistently from 33% at the time of diagnosis to 24% at 3 months and 15% at 1 year from the diagnosis. This could be explained on the basis of patient coming on terms with the cancer diagnosis after initial adjustment difficulties.

The prevalence of significant anxiety and depression scores among various treatment modalities was highest in the palliative group followed by the treatment-naïve group with comparable results in other modalities. The differences were not statistically significant, which is in agreement with Burgess et al.,[9] who found no effect of modality of treatment on the incidence of anxiety/depression. However, Fann et al.[10] reported higher risk for major depression in patients who received chemotherapy for breast cancer treatment in comparison to other treatment modalities. This could be due to chemotherapy-induced premature menopause and consequent estrogen decline. Both patients (100%) on palliative therapy had higher anxiety scores, consistent with that of Grenfeld et al., who reported elevated mean scores of anxiety and depression in patients with terminal stage of the disease.[34] Patients who received some form of treatment had lesser anxiety and depressive scores compared to treatment-naïve patients, consistent with multiple other studies.[9],[10],[35]

The strength of the study is the use of structured, reliable, and widely accepted scales and appropriate statistical tools to assess the prevalence of both anxiety and depressive symptoms. Limitations include a relatively small sample size impacting the generalizability of findings, and a cross-sectional study design with which causality could not be ascertained. A longitudinal study with a larger sample size and community follow-up in future is envisaged in the near future for further confirming the findings.


  Conclusion Top


The prevalence of anxiety and depression was significantly higher in breast cancer patients as compared to that of the general population. The health-care workers should be sensitized about the topic leading to early identification, evaluation, and management. Psycho-oncology unit with a psychiatrist should exist in virtually all cancer centers, providing specialized treatment and reducing emotional distress in cancer survivors and their caregivers.

Acknowledgments

The authors would like to thank all the participants who consented to participate in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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