Psychiatric disorders and associated factors in cancer: results of an interview study with patients in inpatient, rehabilitation and outpatient treatment

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Abstract

An association between mental disorders, especially affective and anxiety disorders, and cancer has been reported in many studies. The present study investigated current (4-weeks-, 12-months-, and lifetime-prevalence rates of comorbid mental disorders in cancer patients. Through a cross-sectional design, 517 patients (75% female patients) from two acute inpatient care clinics, two rehabilitation clinics and nine specialised practices for oncology were examined with standardised scales for psychological burden and quality of life. Somatic parameters were assessed through standardised medical records. In the second-stage-examination, a sample of 200 patients was interviewed with standardised clinical interview (CIDI) in order to obtain DSM-IV diagnoses of mental disorders. Differences in the type of mental disorders were examined for gender, treatment setting, severity of cancer and physical impairment. Prevalence rates of mental disorders were 23.5% for the 4-weeks, 40% for the 12-months, and 56.5% for the lifetime periods. The current and 12-months rates of affective and anxiety disorders were approximately 25–33% higher than prevalence rates found in recent epidemiological studies of the general population. These higher rates were, however, mainly due to the preponderance of female patients with a higher risk for mental disorders compared with males. The most prevalent current disorders were affective (9.5%), and anxiety disorders (13%). Female gender was associated with an approximately 2-fold risk of mental disorders during the patient's lifespan. Current diagnosis of affective disorders in women was highly related to the cancer. Physical impairment was also associated with the frequency of current psychiatric disorders, especially affective and anxiety disorders. The frequency of mental disorders in cancer patients does not differ from results of recent international epidemiological studies of the normal population. The slightly higher rates of anxiety disorders are mainly due to phobias (simple, social and agoraphobia) without urgent need for treatment. A relatively large portion of patients, however, fulfil the criteria of minor depressive disorder which deserves clinical attention.

Introduction

Primary reactions of patients to the diagnosis of a tumour are often followed by a period of emotional instability marked with increased anxiety, depressive mood and decrease of daily activities. These reactions are an adaptation to the disease. In the following period, most patients are able to cope with the illness, its effects and the change of life, either alone or with the help of attending physicians, family and friends. However, a proportion of cancer patients develop psychiatric disorders following the diagnosis which requires special treatment. A number of patients also have psychiatric disorders, that already exist premorbidly or recur because of the increased strain as a result of the disease and its treatment (e.g. recurrent depressive disorders).

In the past 20 years, numerous studies on the prevalence of psychiatric disease in tumour patients have been conducted 1, 2, 3, 4, 5, 6, 7. These studies focused on the examination of depressive disorders which are frequently associated with cancer. In their review, DeFlorio and Massie [8] described 49 studies and van't Spijker and colleagues in their meta-analysis [9] described 58 studies between 1980 and 1994, in which this association was examined. Noyes and colleagues [10] reported on 23 studies concerning the prevalence of anxiety disorders in tumour patients within the past 25 years which partly overlapped with the studies from the aforementioned reviews 8, 9. In the meantime, the results of these studies and their clinical implications have also been considered in numerous other reviews and chapters 11, 12, 13, 14, 15, 16, 17. The prevalence rate for general psychiatric burden or psychiatric disorders among cancer patients ranges between 5 and 50% ([9], see also 12, 18, 19, 20), for depressive disorders between 0 and 46% and for anxiety disorders between 0.9 and 49%. DeFlorio and Massie [8] report a similar range of 1–53% for the occurrence of depressions, while Noyes and colleagues [10] report 15–28% for anxiety disorders.

The large variations in the prevalence rates are due to methodical and clinical differences. Comorbidity studies are based on different: (a) instrumentation (questionnaire versus clinical interview or standardised clinical interview procedures), (b) classification systems (now ICD-10 and DSM-IV), (c) time periods of prevalence and (d) clinical differences in tumour patients (e.g. tumour site, stage, setting). In addition, there are difficulties in making a diagnosis because of symptom overlap, particularly depression (e.g. weight reduction, sleep disturbance, loss of energy) and somatic symptoms caused by the cancer and treatment 21, 22, 23, 24.

Up to now, it has not been possible to differentiate the prevalence of mental disorders in different types of tumour diseases. The exception is pancreatic carcinoma which is associated with a high prevalence of depressive disorders. The stage or severity of the tumour disease is most likely correlated to the frequency of the depressive disorders 2, 11, 20. Furthermore, several risk factors are verified empirically with regard to their influence on the development of depressive disorders (e.g. uncontrolled pain, absence of social support 13, 21).

The question of whether there are gender differences regarding the type and frequency of mental disorders in cancer patients is also not definitely answered: In contrast to epidemiological studies of the general population, the majority of studies show no significant gender differences. However, there are also studies that show significant gender differences or non-significant trends, e.g. regarding the frequency of anxiety disorders [9]. Furthermore, it is not clear whether inpatients of a primary care clinic or a rehabilitation centre are more or less frequently psychologically disturbed than outpatients. The present study examines the following questions:

  • To what extent are cancer patients burdened regarding their current well-being ?

  • What is the 4-weeks, 12-months and lifetime prevalence of various mental disorders in cancer patients?

  • To what extent are mental disorders comorbid among cancer patients?

  • Are there differences in the prevalence with regard to gender, the severity of the tumour, physical function or treatment setting (outpatient versus inpatient treatment)?

Section snippets

Study sample

The inpatient and rehabilitation samples were recruited from four oncology units, one from the Freiburg Medical Centre (department of Gynaecology and Obstetrics), two from the Clinic for Tumourbiology in Freiburg (primary care and rehabilitation department), and one from another rehabilitation clinic. Because of this access, a higher rate of female patients was expected in the study sample. The outpatient sample comes from one outpatient clinic and eight specialised practices for oncology and

Patients

A total of 517 cancer patients from 13 institutions (four clinics, nine practices) were examined (Table 1). Nearly all patients gave their consent to fill in the questionnaire (return rate: 96%). Of these, 39% of the patients included in the study were interviewed with the CIDI. The goal to interview every second patient was reached very well in the inpatient (51%), the rehabilitation setting (44%), and partially in the outpatient sample (32%). This was due to the fact that interviews were

Discussion

To our knowledge, this study is the first with a relatively large-patient sample, which has documented the prevalence rates of different mental disorders (affective, anxiety, substance-related disorders, etc.) using the fully standardised CIDI analogous to epidemiological population studies (up until now, only one study has been conducted in a small sample of 22 patients [34]). With this procedure, a simultaneous documentation of the frequency of mental disorders in different, explicitly

Acknowledgements

This work resulted from a research project (grant: 01 GD 9802/4) of the Freiburg/Bad Saeckingen Rehabilitation Research Network. The project is supported by the Federal Ministry of Education and Research (BMBF) and the Federation of German Pension Insurance Institutes (VDR). It was supported, in part, also by grants from Hoffmann LaRoche and Aventis to M. Härter and W. Marschner. We sincerely thank the following clinics and practices for their co-operation and support in collecting the data:

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