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ORIGINAL ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 1  |  Page : 14-18  

Depression in cancer patients undergoing chemotherapy in a tertiary care hospital of North Bengal, India


1 Intern, North Bengal Medical College, Darjeeling, West Bengal, India
2 Assistant Professor, Department of Community Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
3 Professor and Head, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication16-Feb-2017

Correspondence Address:
Sutanay Bhattacharyya
P-40 Meghnad Abasan, Rabindra Pally, Krishnapur, Kolkata - 700 101, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.200252

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   Abstract 

Background: Detection of cancer and subsequent chemotherapy can lead to clinical depression in many cancer patients. Objectives: The study was conducted to find out the extent of depression in cancer patients undergoing chemotherapy and determine the factors associated with depression. Methods: A cross-sectional descriptive study was conducted at the Chemotherapy Day Care Centre of North Bengal Medical College and Hospital from May to June 2013. A total of 174 cancer patients were selected and interviewed after obtaining informed consent and Institutional Ethics Committee Clearance. Brief Edinburgh Depression Scale was used to find out depression with a score of 6 and above indicating depression. Data obtained was analyzed using SPSS software version 20. Logistic regression was used to see the relative importance of multiple contributing factors toward depression. Results: Out of 174 cancer patients, 97 (55.7%) were found to be depressed. Depression was comparatively higher in patients ≥50 years; in males; those belonging to religion other than Hindus; who received higher education; had monthly family income ≥5000 rupees and were involved in moderate or heavy work. Nearly 70.6% of blood cancer patients; 64.3% of those who had been receiving chemotherapy for ≥6 months and 56.9% of those in their 4th or less cycle of chemotherapy were found to be depressed. Conclusion: The study revealed depression is substantially high among cancer patients undergoing chemotherapy in this area. Diagnosis and treatment of cancer patients need to be complemented by psychological support for the cancer patients.

Keywords: Cancer, chemotherapy, depression


How to cite this article:
Bhattacharyya S, Bhattacherjee S, Mandal T, Das DK. Depression in cancer patients undergoing chemotherapy in a tertiary care hospital of North Bengal, India. Indian J Public Health 2017;61:14-8

How to cite this URL:
Bhattacharyya S, Bhattacherjee S, Mandal T, Das DK. Depression in cancer patients undergoing chemotherapy in a tertiary care hospital of North Bengal, India. Indian J Public Health [serial online] 2017 [cited 2017 Jul 22];61:14-8. Available from: http://www.ijph.in/text.asp?2017/61/1/14/200252


   Introduction Top


Patients with cancer have a high rate of psychiatric co-morbidity; approximately one-half exhibit emotional difficulties.[1],[2] The psychological complications generally take the form of adjustment disorder, depressed mood, anxiety, impoverished life satisfaction, or loss of self-esteem.[3],[4] Depression is the most common psychological disorder in cancer patients.[5] Cancer-related depression is a pathological affective response to loss of normality and one's personal world as a result of cancer diagnosis, treatment, or impending complications. A long course of treatment, repeated hospitalizations, and the side-effects of chemotherapy along with the stigma of being diagnosed with cancer has a significant effect on the psyche of the cancer patients.[6] Cancer and subsequent chemotherapy can have an additive effect in causing depression; however, it is difficult to determine which one contributes more. Zielinska-Wieczkowska and Betlakowski using the Zung Self-Rating Depression Scale found a slightly higher existence of depression (0.2% higher) in cancer patients who underwent chemotherapy than in patients who had not received chemotherapy till then.[7] Several studies have indicated that such depression not only causes great suffering but also diminishes the quality of life, amplifies pain and other symptoms, decreases adherence to anti-cancer treatments, leads to suicide in certain cases and acts as a psychological burden on the family.[8],[9],[10],[11]

Depression in cancer patients can interfere with treatment and recovery and may subsequently increase their morbidity and mortality.[12] Recognition of depression and determining the appropriate level of intervention, ranging from brief counseling and support groups to medication and psychotherapy is an important aspect of cancer care, which unfortunately is missing in most palliative care settings.[13]

There is little published literature based on the psychological profile of cancer patients in India receiving chemotherapy. This study aims to generate information which could later be expanded on to further address this issue.

The objectives of the present study were to determine the magnitude of depression and its associated factors among cancer patients attending the Chemotherapy Day Care Centre, in North Bengal Medical College and Hospital (NBMCH), West Bengal, India.


   Materials and Methods Top


Study type and setting

A cross-sectional descriptive study was conducted at the Chemotherapy Day Care Centre in the Department of Radiotherapy, NBMCH, West Bengal, India during May and June 2013.

Study population

All cancer patients receiving chemotherapy during the study were selected as the study population. Patients who were very sick and unable to communicate and those who refused to give consent had been excluded from the study.

Sampling

The sample size was calculated based on the anticipated prevalence of depression among cancer patients as 29%,[14] confidence interval of 95%, and absolute precision of 10%. Furthermore a design effect of 2 to compensate for systematic sampling and a 10% non-response rate was considered to get the final sample size of 174. After record analysis of previous 1 year data of patients visit in Chemotherapy Day Care Center, it was seen that average patient visit is 40 per day. Two days in a week were randomly selected for collecting the data. Thus, data were collected during 16 days (2 days per week for 2 months). Approximate patients visiting the Chemotherapy Day Care Centre during this period were 640 (40 patients per day for 60 days). Thus, on each day 174/16–11 patients were interviewed and data collected. Systematic random sampling was used to recruit 11 patients per day. Sampling interval was calculated as 640/174 = 3.67 rounded off to 4. On each day of data collection, a single digit was randomly selected between 1 and 4. From the queue of patients coming for chemotherapy, the first patient to be interviewed on that day corresponded to the random number selected. Thereafter, every 4th eligible patient was selected and interviewed.

Data collection tools and techniques

A questionnaire consisting of sociodemographic details, treatment record of the cancer patients and the Brief Edinburgh Depression Scale (BEDS) to screen and measure depression was used. BEDS is a short, sensitive and easy to use instrument designed to screen for depression, exclusively in patients suffering from cancer. There are six items in the BEDS questionnaire which mainly focus on the subjective feelings of worth and sadness, rather than the somatic symptoms of reduced appetite, weight loss which are common with any cancer patient. Each item has a score ranging from 0 to 3; a minimum score of 0 and a maximum score of 18 can be obtained. A score of 6 or above is indicative of depression.[15] This method has been used recently to determine depression among cancer patients and compare with other psychological assessment protocols and in other studies.[15],[16],[17]

Cancer patients coming to the Chemotherapy Day Care were interviewed using the questionnaire. The information was further validated from existing records of the patients. While assessing the depression using the BEDS, the patients were asked to suggest the answer, among the available options for each question, on the basis of how they felt in the month before the interview. The options for each question were interpreted to the patients to obtain the most accurate answer. A subject once interviewed was not interviewed again on his/her subsequent visits to the center.

Data analysis

After collecting all data, data entry was performed in Microsoft Excel. Data were organized and presented by applying principles of descriptive statistics. The extent of depression has been evaluated on the basis of BEDS score with a score of 6 or above indicating depression.[15] IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp was used for analysis. Logistic regression analysis was applied with the presence of depression considered as 1 and absence of depression as 0. Literature review suggested the selection of independent variables as predictors of depression. The sociodemographic predictors used for the study were age group of the patients, gender, religion educational status, monthly family income (in rupees), and physical activity status. The treatment history predictors included type of cancer, duration of chemotherapy (in months), chemotherapy cycle, and the presence of co-existing diseases.

Ethical considerations

Approval was taken from the Institutional Ethics Committee of North Bengal Medical College, Darjeeling before conducting the study. Informed consent was obtained from the patients before interviewing them. Anonymity and confidentiality were ensured throughout the study.


   Results Top


Of 174 cancer patients, 97 (55.7%) of them had depression (BEDS score ≥6) as evaluated using the BEDS. The mean (average) score in BEDS was 6.7 with standard deviation (σ) of 4.07 for all the cases. For those cases who did not have depression (BEDS score <6), this value was 2.8 ± 1.5 (n = 77), and for those cases which had depression it was 9.8 ± 2.6 (n = 97). The median and interquartile range values for the same groups were 4 (IQR-3) and 10 (IQR-3), respectively.

The majority were in the age group of 50 years and above (54.6%); were males (51.1%); Hindus by religion (74.7%); and did not receive any formal education (43.7%). Most of the cancer patients had <5000 rupees family income (73.6%); were married (85.1%) and had a sedentary lifestyle (59.8%). Depression was highest among the patients with the age group of 50 years and above, in male cancer patients and those belonging to religions other than Hindu as compared to their respective corresponding groups. Those who received secondary and higher education and had monthly family income of more than 5000 rupees and above had higher odds of being depressed than their counterparts (adjusted odds ratio [AOR]: 1.10 and 1.29, respectively). The relation between sociodemographic predictors of the cancer patients and the presence of depression in them is shown in [Table 1]. After controlling for the predictors, the model explained between 4.2% (Cox and Snell R-square) and 5.6% (Nagelkerke R square) of the variance of depression in the study subjects and correctly classified 80.4% of cases. The contribution of the independent variables was not significant, though the model fitted well from nonsignificant (P = 0.922) Hosmer and Lemeshow statistic.
Table 1: Sociodemographic correlates of depression among study subjects derived by binary logistic regression analysis (n=174)

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Among the 174 study subjects, 46 (23.6%) had gastrointestinal cancer. The proportion of depression was found to be highest among blood cancer patients (70.2%), as compared to other cancer types. The presence of depression in different cancer types is shown in [Figure 1]. Except for breast cancer, the proportion of depression was high in all the patients having other types of cancers. Nearly 42.5% of them had been receiving chemotherapy for <2 months before the day of the interview.
Figure 1: Number of depression cases in different types of cancer (n = 174).

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Patients who had been receiving chemotherapy for more than 6 months had higher odds of being depressed (AOR: 3.37 [0.98–11.56]). 66.7% of the cancer patients were in their 4th or less cycle of chemotherapy. Those patients in their ≤4th cycle of chemotherapy were found to be having more depression (56.9%) than the other groups in the same category. 15.5% of the cancer patients had associated diseases apart from cancer and cancer patients without any associated diseases were found to be have higher odds of depression (AOR: 1.14 [0.56–2.33]) [Table 2]. After controlling for the predictors, the model explained between 2.3% (Cox and Snell R-square) and 3.1% (Nagelkerke R square) of the variance of depression in the study subjects and correctly classified 84.5% of cases. Although there was a good fit of the model as evident from nonsignificant P value (0.626) from Hosmer and Lemeshow statistic, the contribution of the independent variables was not significant when adjusted with other variables.
Table 2: Treatment history correlates of depression among the study subjects derived by binary logistic regression analysis (n=174)

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   Discussion Top


Depression often goes undiagnosed and untreated among cancer patients which may have a deleterious effect on not only the quality of life but also affect the course of the disease and compliance.[18] The results of this study confirm that cancer patients receiving chemotherapy do suffer from depression and it was also evident that there is a liaison between participant demographic attributes and depressive symptoms.

In the present study, the proportion of depression in this study was found to be 55.7%. Rhondali et al. estimated the depression in 146 cancer outpatients using the same scale and the frequency of depression was 29%.[14] In a study in India, the depression was found to be 16.2% in cancer patients using the Hospital and Anxiety Depression Scale.[6] Variation in the extent of the depression could be due to use of different depression scales, different study population and different study setting.

The present study revealed that older patients were more likely to suffer from depression which was similar to the results as obtained by Polikandrioti et al.[19] This may be explained by the fact that elderly patients have a number of comorbid conditions which may contribute to the increased the presence of depression and may be a predictor of survival and resource requirements.

In consonance with the results obtained by Pandey et al.,[6] males were found to more depressed than their female counterparts. However, the results of Keller and Henrich were found to be contradictory; female cancer patients were more depressed than the males.[20] Inconsistent gender difference may be due to multicultural nature of the studies.

Education and monthly family income indirectly reflect their standard of living and the capacity to afford treatment.[21] However, in this study both higher education and higher socioeconomic status were found to be predictors of depression. This can be explained by the nature of study setting, where most of the patients come from academically and financially deprived households.[22]

Long period of treatment, repeated hospitalizations and side effects of chemotherapy exact a toll on the psychological and emotional status of the patient.[23] Cancer patients who had been undergoing chemotherapy for more than 6 months had greater odds of being depressed. This could be attributed to the fact that the long duration of chemotherapy and repeated visits to the hospital having a deteriorating effect on the psychological profile of these patients. Spagnola et al. in their study suggested of a decline in a patient's psychological status through the course of their chemotherapy treatment.[24]

Having a co-existent illness is one of the strongest risk factors for having depression in cancer patients.[25],[26] However, the present study revealed that depression among the patients who had other disease conditions was lower (37%) compared to those who did not have other diseases (59.2%). The reason for this remains unknown.

Although depression in cancer patients have been dealt with by many authors,[27],[28],[29],[30] this is one of the first studies to be done in this part of the country. The findings of this study can be relevant to the health care professionals who can initiate psychological screening at an early phase. However, the small sample size of the study may be the reason for which none of the predictors were found statistically significantly associated with the presence of depression. A larger sample may be needed to quantify the association. Moreover, the cross-sectional nature of the study limits the detection of the alteration of the psychological status over a period in these patients. In addition, self-reporting by the patients may be influenced by specific contexts, situations, and cultures and by a variety of individual and developmental differences.


   Conclusion Top


The extent of depression among cancer patients undergoing chemotherapy in our setup was found to be on the higher side. Clinicians attending the clinic should be made aware, encouraged and empowered to pay attention to the psychological condition of the patients and appropriate intervention for a better quality of life of the patients. Such intervention measures may include psychological counseling, group sessions, and even medication in the form of anti-depressants once the diagnosis of depression has been established.

Acknowledgment

The authors gratefully acknowledge the support from the Indian Council of Medical Research (ICMR) to the first author under the short-term studentship (STS) project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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