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Depression and anxiety in cancer patients: Evidence for different causes
Journalof PsychosomnficReseurch, Vol. 29, No. 2, pp. 133-138. 1985. Printed in Great Britain.
DEPRESSION
AND ANXIETY
EVIDENCE
0022-3999185 f3.00+ .oO 0 1985 Pergamon Press Ltd.
IN CANCER
FOR DIFFERENT
PATIENTS:
CAUSES
JANET K. ROBINSON,MAUREENL. BOSHIER,DANIELA. DANSAK and KATHIEJ. PETERSON (Received
30 May 1984; accepted in revisedfortn
27 August
1984)
Abstract-Fifty-seven cancer patients currently receiving treatment were classified into three groups: (1) those who.stated they were depressed/anxious for reasons other than cancer at any time in the past, including the interview day, (2) those who stated they were depressed/anxious solely related to cancer during the past or currently, (3) those who stated they were not depressed/anxious at anytime either in the past or currently, or had only ‘normal’ symptoms. Patients who were depressed for reasons other than cancer scored higher on self-rated anxiety, depression, and somatization. Patients who were depressed solely due to cancer were not significantly different from those with ‘normal’ symptoms. The findings suggest the importance of adequate differential diagnosis. The use of anti-depressant treatment with a subset of depressed cancer patients is also suggested. INTRODUCTION DURING the past decade, a large number of papers have been written about the emotional impact of cancer. Depression and anxiety have been the most commonly studied emotional sequelae to the diagnosis of cancer. In these reports, different criteria have been used for the diagnosis of the depressive syndrome, the rating scales have been different, and the stages of the disease have differed across studies. Some of the results have been conflicting as to the prevalence and degree of symptomatology. An area that has been touched upon, yet not fully explored, is that of whether the identified anxiety or depression of a patient was related to the diagnosis of cancer, whether the currently identified emotions were pre-existing, or whether these emotions were due to some other circumstances currently present in the cancer patient’s life. Peck [l] found that 27 of 50 cancer patients were diagnosed as having a psychiatric disorder, and in all but one of these it antedated their current medical illness. In a later study, Peck and Boland [2] found that 33 of 50 patients had a significant degree of anxiety and depression, and that these states had been the result of the cancer itself, as they did not exist prior to the current illness. Peteet [3], in distinguishing different types of depression in his population, raised the question of whether the depression may or may not be related to the diagnosis and prognosis of the cancer patients in his study who had severe depression from those who did not. The prevalence of depression and anxiety is still unclear perhaps due to the varied manners of researching these issues [5]. The prevalence of depression has been reported as high as 56% combining the DSM II depressive syndromes into a category of ‘depressed’ [6]. Craig and Abeloff [7] administered the SCL-90 and concluded that 53% of their sample suffered from moderate to high levels of depression. Plumb and Holland [4], based on the results of interviews and self-ratings, found that about one third of their cancer patients had experienced significant depressive symptoms during the preceeding 30 days. Overall, the recent literature Request reprints from: Janet Robinson, M.A.Ed., Psychiatry University of New Mexico Hospital/BCMC--‘IS, 2211 Lomas, 87106, U.S.A. 133
Consultation and Liaison Service, N.E., Albuquerque, New Mexico
134
J. K. ROBINSONet al.
reports that depressive symptoms can be expected to be present in between 20-30’70 of the cancer patient population [4, 61. Peck [l] has found that anxiety was the most common response to a diagnosis of cancer. Levine [6] found that none of his sample qualified for a diagnosis of anxiety. Hinton [8] found that of his patients, 42 patients were classified as depressed or anxious, and that some showed significant features of both affective elements. It has been particularly difficult for researchers to clarify whether the somatic symptoms are secondary to depression or secondary to cancer. Many of the scales used to quantify depression include somatic symptoms such as fatigability, loss of appetite, and weight loss, which are common both in depression and cancer. Plumb and Holland [9] found that cancer patients and suicide attempters were indistinguishable on somatic symptom scales, whereas they were significantly different in affective depressive symptoms. Silverfarb [lo] concludes that assessing direct somatic effects of cancer as opposed to these symptoms being signs of a psychiatric illness poses a major problem to researchers. It is believed that psychological factors will play an increasingly important role in the management of patients as our technology becomes more advanced and more diagnostic categories of cancer are classified as chronic illness as opposed to illness of short term survival [l 1, 12, 131. This raises the question of how we may distinguish those persons who will experience more depression and anxiety over their course of treatment for cancer compared to those whose psychological reaction will leave them more emotionally intact. Weisman and Worden [13] called attention to the fact that the cancer patient at high risk of developing distress had not been differentiated from the one who copes well. The purpose of this study was to examine if the current degree of self-reported anxiety and depression which is attributed to having cancer differs from a current or past history of anxiety and depression attributed to other life events in patients presently being treated for cancer. SUBJECTS The subjects were drawn from two tertiary treatment centers in New Mexico: The Cancer Research and Treatment Center (CRTC), affiliated with the School of Medicine at the University of New Mexico, and the St. Joseph Hospital, a private hospital in Albuquerque, New Mexico. The CRTC is an out-patient facility which administers both radiation therapy and chemotherapy. The St. Joseph Hospital population was drawn from the oncology ward, a ward that was created for patients needing hospitalization for chemotherapy and palliative care. Consecutive patients were referred to the study by their primary physicians at the respective centers. Because of the tertiary nature of these treatment facilities, most patients had been diagnosed weeks prior to the referral, and had had varying amounts of prior treatment (i.e. surgery, out-patient chemotherapy, and/or radiation). No attempt was made in the study to compare inpatients and outpatients. The project was explained to the patients, they were asked to participate in the assessment, and informed consent was obtained. A total of 57 patients completed the interview and the self-rating scales. There were 24 males (42.1%) and 33 females (57.9%). Their ages ranged from 18 to over 80 (modal group was ages 60-69). 74% were non-Spanish white, 19% Spanish-American, and 7% were ‘other’ including Blacks, Native Americans, and Orientals. METHODS The research reported here is a component of an evaluation project run by the Rehabilitation and Continuing Care Section of the New Mexico Cancer Control Project. The section’s goal was to develop models of psycho/social intervention to increase the quality and quantity of life of cancer patients in New Mexico. One part of the project consisted of an assessment of the patient’s needs. The method included a semi-structured interview comprised of demographic data, history of cancer diagnosis and treatment, nutritional assessment, physical assessment, social service assessment, and psychiatric history. The other portion of the assessment was the administration of two self-rating questionnaires: the Social Adjustment
Depression
and cancer
135
Self-Report [14] and the Symptom Questionnaire (SQ) [15]. The present paper is limited to a portion of the findings derived from the interview-administered psychiatric history and the self-administered Symptom Questionnaire. The remaining findings have been reported elsewhere 1161. The semi-structured portion of the psychiatric interview included the following questions on which the patients were to rate themselves: Have you ever had problems with anxiety or depression? Did you receive treatment for these problems? Did you ever take drugs for these problems? Was the anxiety or depression solely related to your diagnosis of cancer? The Kellner Symptom Questionnaire (SQ) [IS] is a state measure of distress based on the original list of symptoms of the Symptom Rating Test (SRT) [17]. The subjects answer each item ‘yes’ or ‘no’. The questionnaire contains four scales based on factor analyses: anxiety, depression, hostility, and somatic symptoms. The SQ has evolved from the SRT with the aim of making it more sensitive for research. A number of validation studies have been carried out on the individual scales 115, 18, 191. In drug trials, the SQ has been found to be equally sensitive or more sensitive in detecting differences between a psychotropic drug and placebo than observer rating scales or other self-rating scales [20, 211. It has somewhat different psychometric properties from the SRT. For example, it is less sensitive in detecting individual psychiatric patients in case-finding studies but tends to be more sensitive in detecting significant differences in distress levels between populations or between drug effects [IS, 18,20,21]. The SQ was administered with the instruction to report how the patient had been feeling during the past week, including the interview day. The sample was divided into three groups: (1) patients who said they had suffered from depression or anxiety at sometime in their life either in the past or currently, which was not related to cancer, (2) patients whose depression or anxiety either in the past or currently, was solely related to the cancer diagnosis, and (3) patients who either denied ever having problems or who said that they felt they had experienced a ‘normal’ amount of depression or anxiety in their lives. RESULTS
Among the 57 patients, 17 (30%) stated they had been depressed or anxious either currently or in the past not due to cancer, 7 (12%) had been depressed or anxious either currently or in the past solely because of having cancer, and 33 (58%) had had no problems or ‘normal, expected’ problems in their lifetime. The groups for anxiety and groups for depression coincidentally have the same number of patients in each cell. Thirty-four of the 57 cases reported either having depression and/or anxiety. Thus 59.6% of our sample reported having depression or anxiety either currently or in the past. In 14 cases (24.6%), the patients reported having both anxiety and depression, whereas in the other 20 cases, the 2 symptoms reportedly did not coexist. There was a trend for those who stated that their depression or anxiety was not related to their cancer diagnosis to score higher on all scales of the SQ. The next highest was that group of patients who reported depression or anxiety related only to their cancer diagnosis. The lowest scores were the ‘no problem or normal problem’ group. The differences on the individual scales were as follows: (1) Patients who stated they had been depressed currently or ever in their life for reasons other than cancer (Group I, Table I) presently had more somatic symptoms than the other two groups (Group II, Group III). They were also significantly more depressed and anxious than those who stated they never had had any problems (Group III). (2) Patients who stated they had been anxious currently or ever in their life for reasons other than cancer (Group I, Table II) presently were significantly more anxious and depressed than those who reported no problems (Group III). (3) Patients who stated they were depressed or anxious currently or ever in their lifetime solely because of cancer (Group II, Tables I and II) did not differ significantly on any of the scales from those who said they had no problems (Group III); there was a non-significant trend to have higher self-rating scores.
136
J. K. ROBINSONet al. TABLE
1 .-KELLNER
SYMPTOM
QUESTIONNAIRE OF CANCER
score
Group*
Anxiety
Depression
Somatiration
Hostility
Mean
DEPRESSION
SCORES
IN THREE
GROUPS
PATIENTS
Differences between groups?
F-value
P
I II III
12.2 9.3 6.6
A AB B
6.15
0.0004
I
11.8 8.1 5.9
A AB B
8.88
0.0005
11 III I II 111
12.5 8.4 1.5
A
7.30
0.002
I II III
4.5 3.4 2.3
2.91
0.06
B B A AB B
‘Groups: Group I = Depression not related to the cancer diagnosis (n = 17) Group II= Depression related to the cancer diagnosis (n = 7) Group III= Normal or no problems (n = 33) *Duncan’s Multiple Range Test (two-tailed); means with the same letter are not significantly different.
TABLE II.-KELLNER
Score
SYMPTOMQUESTIONNAIREANXIETY SCORES IN THREE GROUPS OF CANCER PATIENTS Differences between groups?
Group*
Mean
F-value
Anxiety
I II 111
11.2 9.6 7.1
A AB B
3.14
0.05
Depression
I II III
10.4 8.1 6.6
A AB B
3.18
0.05
Somatization
I II III
10.7 10.4 1.9
A A A
2.19
0.12
Hostility
I 11 111
4.4 3.7 2.3
A A A
2.96
0.06
P
*Groups: Group I = Depression not related to the cancer diagnosis (n = 17) Group II = Depression related to the cancer diagnosis (n = 7) Group III= Normal or no problems (n = 33) tDuncan’s Multiple Range Test (two-tailed); means with the same letter are not significantly different. DISCUSSION
The findings show that patients who stated that they had been depressed or anxious currently or at any time in the past for reasons other than cancer had significantly higher anxiety and depression scores than those who did not report these affects. The findings suggest that patients who are depressed or anxious for causes other than cancer had significantly more somatic symptoms than the other two groups.
Depression
and cancer
137
This would suggest that a substantial proportion of current somatic symptoms are related to a depressive syndrome in patients who have cancer and are depressed. This finding may be of practical importance in the treatment of somatic symptoms in cancer patients, because somatic symptoms caused by depression tend to remit with antidepressant treatment [22, 23, 241. Unexpectedly, patients who said that they were anxious or depressed either in the past or currently solely because of cancer did not differ significantly in the selfrating scales from those who said they had no problems or judged their symptoms to be ‘normal’; this finding must be seen as a preliminary result which needs further examination and replication since this group was composed of only a small number of patients. The cutoff points for abnormal scores on the Symptom Questionnaire [15] (one standard deviation above the mean for a normal population) are as follows: anxiety, 9 and above; depression, 8 and above; somatic, 7 and above; hostility, 8 and above. The finding in this study suggests that the mean of Group III (who stated that they were not anxious or depressed or that the symptoms were ‘normal’) had mean scores which were well within the range of normal people who had no disease. This study also found that patients whose depression is secondary to their diagnosis of cancer had mean scores which also fall within the range of normal people who had no disease. This would suggest that cancer patients who report depression due to cancer may be reporting on a different clinical syndrome than what clinicians usually call depression. This may result in a misunderstanding of what patients are reporting as depression by the clinician, and may lead to the overdiagnosis of depression in the medically ill. Certainly this points to the importance of an adequate differential diagnosis of depression in the cancer patient. Patients who stated that they were depressed had high depression and anxiety scores and the same applied to patients who stated that they were anxious. This has been found in previous studies, with several populations of normals and psychiatric patients with self-rating scales and observer rating scales [17, 25, 26, 271; thus, the coexistence of anxiety and depression is a consistent finding and is not limited to cancer patients. These researchers recommend further investigation into types of distress cancer patients experience and the appropriate treatment modalities for these different groups. Preliminary results suggest that attempting to distinguish whether the reported affect is solely due to the cancer diagnosis or not is a promising discriminatory division which needs to be further examined. These researchers also recommend that further research include interviewer ratings on distress besides selfreports, since it has been reported that cancer patients may deny their dysphoric emotions [4]. It is possible that the group which denied significant depression (Group III) may have been denying current or past depression, which an observer assessment may be able to detect. Nevertheless, this study suggests that there are significant differences in this sample of cancer patients between those who report current or past depression and those who report normal or no depression on the scales of depression, anxiety, and somatization. In summary, it appears that psychological distress may have numerous origins in cancer patients and that it may not always be the medical illness itself. This points to the importance of there being an adequate differential diagnosis of psychological symploms in order to offer the most appropriate treatment. By using a question-
138
.I. K. ROBINSONet al.
naire with a refined somatic scale, it was found that a large proportion of somatic symptoms in depressed cancer patients appears to be caused by depressive illness unrelated to their cancer; in these patients, somatic symptoms as well as depression may be relieved with pharmacological and anti-depressant treatment. Acknowledgement-1 would like to express my appreciation port, and review of this research.
to Dr. Robert
Kellner for his guidance,
sup-
REFERENCES
5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25 26. 27.
PECK A. Emotional reactions to having cancer. Am J Roentgen01 Radium Ther Nucl Med 1972; 114: 591-599. PECK A, BIJLAND J. Emotional reactions to radiation treatment. Cancer 1977; 40: 180-184. PETEET JR. Depression in cancer patients. An approach to differential diagnosis and treatment. JAMA 1979; 241: 1487-1489. PLUMB M, HOLLAND J. Comparative studies of psychological function in patients with advanced cancer II. Interviewer rated current and past psychological symptoms. Psychosom Med 1981; 43: 243-254. FRIEDENBERGS I, GORDON W, HIBBARD M, LEVINE L, WOLF C, DILLER L. Psychosocial aspects of living with cancer: A review of the literature. Int J Psychiat &fed 1981-1982; 11: 303-329. LEVINE PM, SILVERFARB PM, LIPOWSLI ZJ. Mental disorders in cancer patients: A study of 100 psychiatric referrals. Cancer 1978; 42: 1385-1391. CRAIG TJ, ABELOFF MD. Psychiatric symptomatology among hospitalized cancer patients. Am J Psychiat 1974; 131: 1323-1327. HINTON J. Psychiatric consultation in fatal illness. Proc R Sot Med 1972; 65: 1035-1038. PLUMB M, HOLLAND J. Comparative studies of psychological function in patients with advanced cancer I. Self-reported depressive symptoms. Psychosom Med 1977; 39: 264-276. SILBERFARB PM, MAURER LH, CROUTHAMEL CS. Psychosocial aspects of neoplastic disease-I: Functional status of breast cancer patients during different treatment regimes. Am J Psychiat 1980; 137: 45&455. DEROGATISLR, ABELOFF MD, McBfTH CD. Cancer patients and their physicians in the perception of psychological symptoms. Psychosomatics 1976; 17: 197-201. VINEY L, WESTBROOK M. Patterns of anxiety in the chronically ill. Br JMed Psycho1 1982; 55: 87-95. WEISMAN AD, WoRofN JW. The existential plight in cancer: significance of the first 100 days. Int J Psychiat Med 1976-1977; 7: l-15. WEISSMANMM, SHOLOMSKASD, JOHN K. The assessment of social adjustment: an update. Arch Gen Psychiat 1981; 11: 1250-1258. KELLNER R. Abridged Manual of the Symptom Questionnaire. Mimeograph. UNM Department of Psychiatry 1983. Final Report of the New Mexico Cancer Control Program to the National Cancer Institute. Contract No NOl-CN65173. KELLNER R, SHEFFIELD BF. A self-rating scale of distress. Psycho1 Med 1973; 3: 88-100. FAVA GA, KELLNER R, MUNARI F. The Hamilton depression rating scale in normals and depressives. Acta Psychiatr Stand 1982; 66: 26-32. FAVA GA, KELLNER R, PERINA GI, FAVA M. Italian validation of the symptom questionnaire (SQ). Can J Psychiat 1983; 28: 117-123. KELLNER R, COLLINS AC, SHULMAN RS. The short term antianxiety effects of propranolol HCL. J Clin Pharmacol 1974; 14: 301-304. KELLNER R, RADA RT, ANDERSEN T, PATHAK D. The effects of chlordiazepoxide on self-rated depression, anxiety and well-being. Psychopharmacology 1979; 64: 185-191. Covr L, LIPMAN RS, DEROGATIS LR, SMITH JE, PATTISON JH. Drugs and group psychotherapy in neurotic depression. Am J Psychiat 1974; 131: 191-198. KAHN RJ, MCNAIR DM, COVI L, DOWNING RW, FISHER S, LIPMAN RS, RICKELS K, SMITH VK. Effects of psychotropic agents on high anxiety subjects. Psychopharmacol Bull 1981; 17: 97-103. SHEEHAN DV, BALLENGERJ, JACOBSEN Cl. Treatment of endogenous anxiety with phobic, hysterical, and hypochondriacal symptoms. Arch Gen Psychiat 1980; 37: 51-59. MCNAIR DM, LORR M. An analysis of mood in neurotics. JAbnorm Sot Psycho1 1964; 69: 620-627. RICKELS D. Drug use in outpatient treatment. SupplAm JPsychiat 1968; 124: 20-31. MCNAIR DM, FISHER S. Separating anxiety from depression. In: Psychopharmacology: A Generation of Progress (Edited by Lipton M, DiMascio A, Killam KF). New York: Raven Press, 1978.
DEPRESSION
AND ANXIETY
EVIDENCE
0022-3999185 f3.00+ .oO 0 1985 Pergamon Press Ltd.
IN CANCER
FOR DIFFERENT
PATIENTS:
CAUSES
JANET K. ROBINSON,MAUREENL. BOSHIER,DANIELA. DANSAK and KATHIEJ. PETERSON (Received
30 May 1984; accepted in revisedfortn
27 August
1984)
Abstract-Fifty-seven cancer patients currently receiving treatment were classified into three groups: (1) those who.stated they were depressed/anxious for reasons other than cancer at any time in the past, including the interview day, (2) those who stated they were depressed/anxious solely related to cancer during the past or currently, (3) those who stated they were not depressed/anxious at anytime either in the past or currently, or had only ‘normal’ symptoms. Patients who were depressed for reasons other than cancer scored higher on self-rated anxiety, depression, and somatization. Patients who were depressed solely due to cancer were not significantly different from those with ‘normal’ symptoms. The findings suggest the importance of adequate differential diagnosis. The use of anti-depressant treatment with a subset of depressed cancer patients is also suggested. INTRODUCTION DURING the past decade, a large number of papers have been written about the emotional impact of cancer. Depression and anxiety have been the most commonly studied emotional sequelae to the diagnosis of cancer. In these reports, different criteria have been used for the diagnosis of the depressive syndrome, the rating scales have been different, and the stages of the disease have differed across studies. Some of the results have been conflicting as to the prevalence and degree of symptomatology. An area that has been touched upon, yet not fully explored, is that of whether the identified anxiety or depression of a patient was related to the diagnosis of cancer, whether the currently identified emotions were pre-existing, or whether these emotions were due to some other circumstances currently present in the cancer patient’s life. Peck [l] found that 27 of 50 cancer patients were diagnosed as having a psychiatric disorder, and in all but one of these it antedated their current medical illness. In a later study, Peck and Boland [2] found that 33 of 50 patients had a significant degree of anxiety and depression, and that these states had been the result of the cancer itself, as they did not exist prior to the current illness. Peteet [3], in distinguishing different types of depression in his population, raised the question of whether the depression may or may not be related to the diagnosis and prognosis of the cancer patients in his study who had severe depression from those who did not. The prevalence of depression and anxiety is still unclear perhaps due to the varied manners of researching these issues [5]. The prevalence of depression has been reported as high as 56% combining the DSM II depressive syndromes into a category of ‘depressed’ [6]. Craig and Abeloff [7] administered the SCL-90 and concluded that 53% of their sample suffered from moderate to high levels of depression. Plumb and Holland [4], based on the results of interviews and self-ratings, found that about one third of their cancer patients had experienced significant depressive symptoms during the preceeding 30 days. Overall, the recent literature Request reprints from: Janet Robinson, M.A.Ed., Psychiatry University of New Mexico Hospital/BCMC--‘IS, 2211 Lomas, 87106, U.S.A. 133
Consultation and Liaison Service, N.E., Albuquerque, New Mexico
134
J. K. ROBINSONet al.
reports that depressive symptoms can be expected to be present in between 20-30’70 of the cancer patient population [4, 61. Peck [l] has found that anxiety was the most common response to a diagnosis of cancer. Levine [6] found that none of his sample qualified for a diagnosis of anxiety. Hinton [8] found that of his patients, 42 patients were classified as depressed or anxious, and that some showed significant features of both affective elements. It has been particularly difficult for researchers to clarify whether the somatic symptoms are secondary to depression or secondary to cancer. Many of the scales used to quantify depression include somatic symptoms such as fatigability, loss of appetite, and weight loss, which are common both in depression and cancer. Plumb and Holland [9] found that cancer patients and suicide attempters were indistinguishable on somatic symptom scales, whereas they were significantly different in affective depressive symptoms. Silverfarb [lo] concludes that assessing direct somatic effects of cancer as opposed to these symptoms being signs of a psychiatric illness poses a major problem to researchers. It is believed that psychological factors will play an increasingly important role in the management of patients as our technology becomes more advanced and more diagnostic categories of cancer are classified as chronic illness as opposed to illness of short term survival [l 1, 12, 131. This raises the question of how we may distinguish those persons who will experience more depression and anxiety over their course of treatment for cancer compared to those whose psychological reaction will leave them more emotionally intact. Weisman and Worden [13] called attention to the fact that the cancer patient at high risk of developing distress had not been differentiated from the one who copes well. The purpose of this study was to examine if the current degree of self-reported anxiety and depression which is attributed to having cancer differs from a current or past history of anxiety and depression attributed to other life events in patients presently being treated for cancer. SUBJECTS The subjects were drawn from two tertiary treatment centers in New Mexico: The Cancer Research and Treatment Center (CRTC), affiliated with the School of Medicine at the University of New Mexico, and the St. Joseph Hospital, a private hospital in Albuquerque, New Mexico. The CRTC is an out-patient facility which administers both radiation therapy and chemotherapy. The St. Joseph Hospital population was drawn from the oncology ward, a ward that was created for patients needing hospitalization for chemotherapy and palliative care. Consecutive patients were referred to the study by their primary physicians at the respective centers. Because of the tertiary nature of these treatment facilities, most patients had been diagnosed weeks prior to the referral, and had had varying amounts of prior treatment (i.e. surgery, out-patient chemotherapy, and/or radiation). No attempt was made in the study to compare inpatients and outpatients. The project was explained to the patients, they were asked to participate in the assessment, and informed consent was obtained. A total of 57 patients completed the interview and the self-rating scales. There were 24 males (42.1%) and 33 females (57.9%). Their ages ranged from 18 to over 80 (modal group was ages 60-69). 74% were non-Spanish white, 19% Spanish-American, and 7% were ‘other’ including Blacks, Native Americans, and Orientals. METHODS The research reported here is a component of an evaluation project run by the Rehabilitation and Continuing Care Section of the New Mexico Cancer Control Project. The section’s goal was to develop models of psycho/social intervention to increase the quality and quantity of life of cancer patients in New Mexico. One part of the project consisted of an assessment of the patient’s needs. The method included a semi-structured interview comprised of demographic data, history of cancer diagnosis and treatment, nutritional assessment, physical assessment, social service assessment, and psychiatric history. The other portion of the assessment was the administration of two self-rating questionnaires: the Social Adjustment
Depression
and cancer
135
Self-Report [14] and the Symptom Questionnaire (SQ) [15]. The present paper is limited to a portion of the findings derived from the interview-administered psychiatric history and the self-administered Symptom Questionnaire. The remaining findings have been reported elsewhere 1161. The semi-structured portion of the psychiatric interview included the following questions on which the patients were to rate themselves: Have you ever had problems with anxiety or depression? Did you receive treatment for these problems? Did you ever take drugs for these problems? Was the anxiety or depression solely related to your diagnosis of cancer? The Kellner Symptom Questionnaire (SQ) [IS] is a state measure of distress based on the original list of symptoms of the Symptom Rating Test (SRT) [17]. The subjects answer each item ‘yes’ or ‘no’. The questionnaire contains four scales based on factor analyses: anxiety, depression, hostility, and somatic symptoms. The SQ has evolved from the SRT with the aim of making it more sensitive for research. A number of validation studies have been carried out on the individual scales 115, 18, 191. In drug trials, the SQ has been found to be equally sensitive or more sensitive in detecting differences between a psychotropic drug and placebo than observer rating scales or other self-rating scales [20, 211. It has somewhat different psychometric properties from the SRT. For example, it is less sensitive in detecting individual psychiatric patients in case-finding studies but tends to be more sensitive in detecting significant differences in distress levels between populations or between drug effects [IS, 18,20,21]. The SQ was administered with the instruction to report how the patient had been feeling during the past week, including the interview day. The sample was divided into three groups: (1) patients who said they had suffered from depression or anxiety at sometime in their life either in the past or currently, which was not related to cancer, (2) patients whose depression or anxiety either in the past or currently, was solely related to the cancer diagnosis, and (3) patients who either denied ever having problems or who said that they felt they had experienced a ‘normal’ amount of depression or anxiety in their lives. RESULTS
Among the 57 patients, 17 (30%) stated they had been depressed or anxious either currently or in the past not due to cancer, 7 (12%) had been depressed or anxious either currently or in the past solely because of having cancer, and 33 (58%) had had no problems or ‘normal, expected’ problems in their lifetime. The groups for anxiety and groups for depression coincidentally have the same number of patients in each cell. Thirty-four of the 57 cases reported either having depression and/or anxiety. Thus 59.6% of our sample reported having depression or anxiety either currently or in the past. In 14 cases (24.6%), the patients reported having both anxiety and depression, whereas in the other 20 cases, the 2 symptoms reportedly did not coexist. There was a trend for those who stated that their depression or anxiety was not related to their cancer diagnosis to score higher on all scales of the SQ. The next highest was that group of patients who reported depression or anxiety related only to their cancer diagnosis. The lowest scores were the ‘no problem or normal problem’ group. The differences on the individual scales were as follows: (1) Patients who stated they had been depressed currently or ever in their life for reasons other than cancer (Group I, Table I) presently had more somatic symptoms than the other two groups (Group II, Group III). They were also significantly more depressed and anxious than those who stated they never had had any problems (Group III). (2) Patients who stated they had been anxious currently or ever in their life for reasons other than cancer (Group I, Table II) presently were significantly more anxious and depressed than those who reported no problems (Group III). (3) Patients who stated they were depressed or anxious currently or ever in their lifetime solely because of cancer (Group II, Tables I and II) did not differ significantly on any of the scales from those who said they had no problems (Group III); there was a non-significant trend to have higher self-rating scores.
136
J. K. ROBINSONet al. TABLE
1 .-KELLNER
SYMPTOM
QUESTIONNAIRE OF CANCER
score
Group*
Anxiety
Depression
Somatiration
Hostility
Mean
DEPRESSION
SCORES
IN THREE
GROUPS
PATIENTS
Differences between groups?
F-value
P
I II III
12.2 9.3 6.6
A AB B
6.15
0.0004
I
11.8 8.1 5.9
A AB B
8.88
0.0005
11 III I II 111
12.5 8.4 1.5
A
7.30
0.002
I II III
4.5 3.4 2.3
2.91
0.06
B B A AB B
‘Groups: Group I = Depression not related to the cancer diagnosis (n = 17) Group II= Depression related to the cancer diagnosis (n = 7) Group III= Normal or no problems (n = 33) *Duncan’s Multiple Range Test (two-tailed); means with the same letter are not significantly different.
TABLE II.-KELLNER
Score
SYMPTOMQUESTIONNAIREANXIETY SCORES IN THREE GROUPS OF CANCER PATIENTS Differences between groups?
Group*
Mean
F-value
Anxiety
I II 111
11.2 9.6 7.1
A AB B
3.14
0.05
Depression
I II III
10.4 8.1 6.6
A AB B
3.18
0.05
Somatization
I II III
10.7 10.4 1.9
A A A
2.19
0.12
Hostility
I 11 111
4.4 3.7 2.3
A A A
2.96
0.06
P
*Groups: Group I = Depression not related to the cancer diagnosis (n = 17) Group II = Depression related to the cancer diagnosis (n = 7) Group III= Normal or no problems (n = 33) tDuncan’s Multiple Range Test (two-tailed); means with the same letter are not significantly different. DISCUSSION
The findings show that patients who stated that they had been depressed or anxious currently or at any time in the past for reasons other than cancer had significantly higher anxiety and depression scores than those who did not report these affects. The findings suggest that patients who are depressed or anxious for causes other than cancer had significantly more somatic symptoms than the other two groups.
Depression
and cancer
137
This would suggest that a substantial proportion of current somatic symptoms are related to a depressive syndrome in patients who have cancer and are depressed. This finding may be of practical importance in the treatment of somatic symptoms in cancer patients, because somatic symptoms caused by depression tend to remit with antidepressant treatment [22, 23, 241. Unexpectedly, patients who said that they were anxious or depressed either in the past or currently solely because of cancer did not differ significantly in the selfrating scales from those who said they had no problems or judged their symptoms to be ‘normal’; this finding must be seen as a preliminary result which needs further examination and replication since this group was composed of only a small number of patients. The cutoff points for abnormal scores on the Symptom Questionnaire [15] (one standard deviation above the mean for a normal population) are as follows: anxiety, 9 and above; depression, 8 and above; somatic, 7 and above; hostility, 8 and above. The finding in this study suggests that the mean of Group III (who stated that they were not anxious or depressed or that the symptoms were ‘normal’) had mean scores which were well within the range of normal people who had no disease. This study also found that patients whose depression is secondary to their diagnosis of cancer had mean scores which also fall within the range of normal people who had no disease. This would suggest that cancer patients who report depression due to cancer may be reporting on a different clinical syndrome than what clinicians usually call depression. This may result in a misunderstanding of what patients are reporting as depression by the clinician, and may lead to the overdiagnosis of depression in the medically ill. Certainly this points to the importance of an adequate differential diagnosis of depression in the cancer patient. Patients who stated that they were depressed had high depression and anxiety scores and the same applied to patients who stated that they were anxious. This has been found in previous studies, with several populations of normals and psychiatric patients with self-rating scales and observer rating scales [17, 25, 26, 271; thus, the coexistence of anxiety and depression is a consistent finding and is not limited to cancer patients. These researchers recommend further investigation into types of distress cancer patients experience and the appropriate treatment modalities for these different groups. Preliminary results suggest that attempting to distinguish whether the reported affect is solely due to the cancer diagnosis or not is a promising discriminatory division which needs to be further examined. These researchers also recommend that further research include interviewer ratings on distress besides selfreports, since it has been reported that cancer patients may deny their dysphoric emotions [4]. It is possible that the group which denied significant depression (Group III) may have been denying current or past depression, which an observer assessment may be able to detect. Nevertheless, this study suggests that there are significant differences in this sample of cancer patients between those who report current or past depression and those who report normal or no depression on the scales of depression, anxiety, and somatization. In summary, it appears that psychological distress may have numerous origins in cancer patients and that it may not always be the medical illness itself. This points to the importance of there being an adequate differential diagnosis of psychological symploms in order to offer the most appropriate treatment. By using a question-
138
.I. K. ROBINSONet al.
naire with a refined somatic scale, it was found that a large proportion of somatic symptoms in depressed cancer patients appears to be caused by depressive illness unrelated to their cancer; in these patients, somatic symptoms as well as depression may be relieved with pharmacological and anti-depressant treatment. Acknowledgement-1 would like to express my appreciation port, and review of this research.
to Dr. Robert
Kellner for his guidance,
sup-
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