cancer diagnosis and mental health
Introduction
Cancer diagnosis and treatment evokes despair in patients. Compared with healthy individuals, cancer patients are at a high risk of psychological problems. It has been estimated that approximately one-third of cancer patients in the world are affected by mental disorders, with depression and anxiety being the two most common psychiatric comorbidities. Left untreated, psychotic symptoms in cancer patients can lead to negative consequences such as decreased treatment adherence, increased treatment cost, poor quality of life, and decreased survival rate.
Long-term projections indicate a 1.8-fold increase in cancer incidence in the Middle East by 2030. Though studies on the prevalence of depression and anxiety among cancer patients in the Middle East are limited, recently, more attention has been paid to the rapidly increasing prevalence of psychiatric problems in patients with terminal illnesses, including cancer. As is well known, the pandemic brings mental health problems on a global level. A recently published population study in China reported higher scores for anxiety, depression, stress, post-traumatic stress disorder, anger, impulsivity, and suicidal ideation in people suffering from mental health problems. This also means the pandemic is likely to create or exaggerate psychiatric distress in cancer patients.
The current study aimed to assess the prevalence of psychotic symptoms and the mental health status of cancer patients in Iraq during the pandemic. Furthermore, the authors aimed to assess the impact of socio-demographic and clinical characteristics on mental health outcomes, including anxiety, depression, and stress.
Materials and Methods
Study design and participants
Between 1 September 2020 and 1 December 2020, 200 patients with a confirmed cancer diagnosis or who are undergoing check-up visits were recruited from an oncology clinic in Baghdad for participation in the study. The exclusion criteria were: patients with advanced or metastatic cancer; those with mental health problems; and patients on psychotropic medications. Patients who met inclusion criteria and provided consent were given a self-reported questionnaire.
Measures
Socio-demographic and clinical characteristics
Socio-demographic characteristics included sex, age, residence location, marital status, and employment status. Sleep quality was assessed by self-report, where participants were asked questions about their lack of sleep, irregular sleep, or insomnia. Clinical characteristics measured included, time since cancer diagnosis, cancer type, treatment duration, and frequency of hospital visits. Since the pandemic was at its peak when this study was carried out, participants were asked about the number of missed or skipped hospital visits, suffering from new body pain, fear of health deterioration, as well as pandemic-related stress, fear, or anxiety.
Mental health outcomes
The mental health status was measured by the “Depression, Anxiety, and Stress Scale” (DASS‐21). Cutoff scores of the DASS‐21 equal to or above 9, 7, and 14 indicated a high risk of depression, anxiety, and stress, respectively.
Statistical analysis
The sample characteristics were presented using mean and standardized deviation (SD) for continuous variables and using numbers for categorical variables. Bivariate analyses were conducted using the Chi-square test or Fisher’s exact test. Hierarchical linear regression models were applied to explore the contributions of sociodemographic characteristics, factors related to the pandemic, and support for psychological health outcomes. All analyses were conducted using SPSS version 24.0.
Results
- A total of 121 patients aged between 40 – 64 years were included in the study, and most of them were females (91.5%). The majority of the patients were married (79.5%), unemployed (63.5%), and lived in Baghdad (83%). Over two thirds of the patients (71%) had breast cancer, 6.5% had colon cancer, and 22.5% had other cancer types.
- The prevalence of depressive symptoms in the participants was 22% (n = 44). The overall mean score was 5.36 ± 7.99. Sixteen participants had moderate depressive symptoms (36.4%), 7 (15.9%) had severe depression, and 7 (15.9%) had very severe depressive symptoms.
- The prevalence of anxiety symptoms in the study group was 22% (n = 44). The mean score on the anxiety scale was 4.32 ± 6.35. Nineteen participants (43.2%) had moderate anxiety symptoms, 5 (11.4%) had severe, and 9 (20.4%) had very severe anxiety symptoms. The prevalence of combined anxiety–depression was present in 14.5% of cases (29 patients).
- The prevalence of stress in the study group was 13.5% (n = 27). The mean score of the Stress Scale was 7.19 ± 8.5. Six participants (22.2%) had moderate stress, 8 (29.6%) had severe, and 4 cases (14.8%) had very high-stress levels.
- Regarding the relationship between the demographic characteristics and the psychiatric disorders, depression was more prevalent in the age group 16 –39 years (36.4%) compared to the 40 – 64 years (10.3%), and ≥65 years groups (OR = 0.46 CI {[0.24 – 0.87]}; P = 0.02).
- Anxiety was most prevalent in the 16-39 year age group (4.9%), followed by 22.3% in the 40-64 year age group and 10.3% in the 65 year age group (OR = 0.41 CI [0.21- 0.79]; P = 0.02).
- The mean depression, anxiety, and stress scores were significantly higher in the age group 16–39 years compared to the other two age groups (p=0.001 for depression and anxiety scores; p= 0.003 for anxiety scores).
- The mean age for depression, anxiety, and stress was 49.45 ± 11.78 years (p = 0.005), 49.93 ± 12.67 years (p = 0.01), and 49.63 ± 12.29 years (p = 0.05), respectively.
- Higher education was associated with higher rates of depression, anxiety, and stress (34.3%, p = 0.0001; 32.3%, p = 0.0001; and 19.2%, p = 0.02 respectively).
- Meanwhile, employed patients had a significantly higher prevalence of anxiety than non-working or unemployed patients (31.5% vs 16.5%; p = 0.01).
- Nearly 10% (n = 20) of participants had appetite loss during the pandemic outbreak, of which 45% had high depression and 50% had anxiety issues. Depression was more common in patients who lost their appetite than in those who did not.
- Patients who had sleeping problems were more depressed (48.1%; p = < 0.0001) and anxious than those who did not experience insomnia or lack of sleep (51.9%; p = < 0.0001).
- Correlation analysis did not show any significant correlation between cancer-related characteristics and mental health outcomes.
- About 66 patients (33%) skipped or postponed their hospital visits during the study period. 8% of the participants were reported to suffer from new body pain and they were more depressed than the ones without new pain (50% vs 15%; p = 0.0002).
- Lastly, about 54% of patients (n=108) often expressed fear of acquiring coronavirus infection, and they were more depressed (31.5%; OR = 1.79 CI [1.05-3.104]; P = 0.03) and anxious (31.5%; OR = 2.42 CI [1.40 – 4.20]; P = 0.002). Similarly, 57.5% (n = 115) of patients often feared spreading the disease to their relatives, and 50% were often afraid that their health would deteriorate during the pandemic. And, both of these groups were more depressed, anxious, and stressed.
DISCUSSION
The first pandemic of this century has caused a lot of changes within the health system, worldwide. It is not difficult to guess that the extent of distress among patients with a cancer diagnosis has increased about how this global crisis will influence their therapies and overall health. The findings of this single-center cross-sectional study suggest a need for screening for the prominence of mental health conditions in Iraqi cancer patients.
In the current study, the prevalence of anxiety, depression, and perceived stress in the study group was high (22%, 22%, and 13.5%, respectively). The prevalence of mixed anxiety and depression in the study group was 14.5%. This was consistent with studies by Wang C et al. which showed a high prevalence of psychological distress among cancer patients in China and Singapore during the pandemic. The results of the present study were lower than those of Kennedy et al. who found that anxiety was prevalent in a rate of 19.1% of the examined cancer patients, their caregivers, and healthcare workers in Singapore. The observed differences may be due to the differences in the severity of cancer, treatment status, and prevalence of pandemic in different regions. Song and Li reported that the prevalence of anxiety, depression, and PTSD was 10.2%, 13%, and 1.4%, respectively, among cancer patients (n = 2279) from nine Chinese medical centers. Moreover, it further indicated that the current pandemic added an extra emotional burden for cancer patients, increasing their psychological distress. As stated, the current results revealed a high prevalence of mental disorders in cancer patients in Iraq, with 33% of patients skipping or postponing their cancer care visits to clinics.
This study also showed that younger patients (16–39 years old), patients with higher education, and those with appetite loss, insomnia, and fear of health deterioration are more anxious and depressed. Fear of health deterioration was found to be the most significant contributor to developing stress in the study population. In this study, about 8% of the patients suffered from new body pain during the pandemic and were more depressed than patients who did not suffer new pain or often had new pain. This was consistent with Wang et al., who reported stressors like body pain as a risk factor for mental health problems in patients with a cancer diagnosis during the outbreak.
Limitations
The use of a small sample, since the study was conducted in a single center with outpatients, was one of the limiting factors for the generalization of the results. Further longitudinal studies on a larger sample are needed to ascertain the findings of the study. Next, self-reported questionnaires did serve the purpose of assessing psychological problems among patients. However, psychiatric interviews by certified psychiatrists are needed to provide more information on the risk factors. Third, the majority of the participants were women with breast cancer. Finally, not all cancer patients with psychological problems may visit clinics for further treatment; this makes it less possible to generalize mental health outcomes
Conclusion
In conclusion, this study raised vital concerns about the high prevalence of mental health problems in patients with a cancer diagnosis during a pandemic. It is crucial to implement systematic mental health screening to reduce their perceived level of distress and improve their quality of life.
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