Differences in depressive and anxiety symptoms between cancer and noncancer patients with psychological distress.

BACKGROUND: Cancer patients are particularly vulnerable to psychological problems. The purpose of the present study was to compare differences in psychological difficulties, including depression and anxiety, between cancer patients and noncancer patients. This study assessed the differences in depressive and anxiety symptoms between patients with and without cancer.
MATERIALS AND METHODS: Participants included 219 patients at The Cancer Center, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea, who reported depressive or anxiety symptoms between April 2014 and April 2016. Patients were categorized into cancer and noncancer groups based on medical histories showing a diagnosis of any type of cancer. The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were used to evaluate psychological distress at each patient's first visit. Patients' charts were reviewed for clinical data, including BDI and BAI scores and duration of cancer treatment, and for demographic data such as age and sex.
RESULTS: The results showed that patients in the cancer group experienced greater discomfort related to somatic symptoms; higher BDI subscale scores were related to work difficulties, insomnia, loss of appetite, somatic worries (fatigue), and loss of libido compared with patients in the noncancer group. The BAI subscale scores for fear of the worst happening, feeling unsteady, feeling terrified or afraid, a sense of choking, fear of dying, and feeling scared were higher in patients with than in those without cancer.
CONCLUSION: High levels of depressive symptoms related to somatic discomfort and anxiety symptoms related to fear of cancer were associated with considerable psychological distress in patients with cancer diagnosis and treatment.

INTRODUCTION

Cancer patients are particularly vulnerable to psychological problems, probably because they experience a stronger emotional reaction on the initial diagnosis of this malignant disease compared to those diagnosed with other diseases.[1] It is also likely that psychological difficulties will manifest during the cancer treatment process. Distress in this population is associated with decreased functioning during chemotherapy, a deterioration in the quality of life due to long hospital stays and increased medical expenses. Furthermore, in the case of the elderly, cancer has an impact on a clinical level.[2] A study of data from the National Health Insurance Service of South Korea revealed that 10.43% of newly diagnosed major cancer patients are diagnosed with psychiatric disorders and use mental health services.[3] Among these cancer patients with mental illness, incidence rates were highest for anxiety, depressive, and sleep disorders. In addition, female cancer patients are more likely to have comorbid psychiatric disorders than males and older age is a risk factor for psychiatric comorbidities.[3] The psychological problems associated with cancer can also impact on the disease course, morbidity, hospital stays, treatment compliance and efficacy, and possibly also prognosis and mortality.[4] Thus, the treatment of psychological problems among cancer patients is an important issue in oncology.

In general, cancer patients tend to suppress their emotions and inferring psychological problems in others is difficult. Emotions may be manifested indirectly, such as through somatic symptoms or vague anxiety[5] and are more likely to be misinterpreted because indirect somatic symptoms, such as body aches, shortness of breath, fatigue, chest pounding, fever, and trembling can be misconstrued as components of the cancer symptoms themselves. In such cases, neither medical staff nor the patient perceives these issues to be psychological problems, such that and misdiagnosis is a strong possibility, in turn impeding early initiation of psychological interventions.

Much research has demonstrated that early evaluations and therapeutic interventions for psychological problems in cancer patients have a positive impact on their prognosis.[6] In addition, there is a movement toward providing efficient screening tools with strong psychometric properties to better identify psychological problems during routine clinical practice.[7] The most frequently used screening tools for such disorders are self-report questionnaires.[38] However, it is difficult to discriminate between the physical symptoms caused by cancer and those caused by psychological difficulties. In addition, it is difficult to distinguish the symptoms of cancer patients from the physical symptoms associated with depression in patients in general. Therefore, it is important to understand the differences between depression and anxiety symptoms in cancer patients versus noncancer patients because this could be helpful for screening and for distinguishing patients with psychiatric symptoms from cancer patients.

Thus, the purpose of the present study was to compare differences in psychological difficulties, including depression and anxiety, between cancer patients and noncancer patients. Self-report questionnaires, which are typically used to assess such symptoms, were employed and subscale scores on these instruments were analyzed to determine the characteristics of psychological stress in cancer patients.

MATERIALS AND METHODS

Patients and procedure

The medical charts of 219 patients at The Cancer Center, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea, who reported depressive or anxiety symptoms between April 2014 and April 2016, were reviewed retrospectively. All participants underwent clinical and psychological assessments and were categorized into cancer and noncancer groups based on a medical history of any type of cancer. The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were used to evaluate psychological distress at the first visit of each patient. Patients' charts were reviewed for clinical data, such as BDI and BAI scores and duration of cancer treatment, in addition to demographic data such as age and sex. The study protocol was approved by the Institutional Review Board of The Cancer Center, Dongnam Institute of Radiological and Medical Sciences.

Instruments

The BDI is a self-report scale that assesses the level of depression. The BDI was created by Beck in 1961 and was revised in 1978. The Korean version of the BDI was verified by Rhee et al.[9] It consists of 21 items that are scored from 0 to 3 and index depressive, cognitive, emotional, and physical symptoms. Total BDI scores range from 0 to 63 where higher scores indicate more severe depression. The BAI is an inventory created by Beck in 1988 to measure clinical anxiety while minimizing the overlap between depression and anxiety scales. The Korean version of the BAI was verified by Kwon et al.[10] It consists of 21 items that index the cognitive, emotional, and physical components of anxiety. Total BAI scores range from 0 to 63 where higher scores indicate more severe anxiety.

Statistical analyses

SPSS software (ver. 18.0; SPSS Inc., Chicago, IL, USA) was used to conduct all statistical analyses. Independent sample t-tests were performed to analyze age and sex differences between cancer and noncancer patient groups, as well as differences in BDI and BAI subscale scores. P < 0.05 was considered to indicate statistical significance.

RESULTS

The final analyses in the present study included 219 patients; there were no significant differences between the cancer and noncancer groups regarding demographic characteristics [Table 1]. The mean age of the cancer patients was 53.5 ± 10.50 years, and the mean age of the noncancer patients was 50.7 ± 13.66 years (P = 0.091). There were 29 males (26.0%) and 79 females (74.0%) in the cancer patient group and 37 males (33.3%) and 74 females (66.6%) in the noncancer patient group (P = 0.296).

Table 1

Demographic characteristics of the patients at their index episode

	Cancer (n=108)	Noncancer (n=111)	Significance (P)
Age (mean±SD)	53.5±10.50	50.7±13.66	0.091
Sex (male), n (%)	29 (26.0)	37 (33.3)	0.296

*P<0.05. SD – Standard deviation

Scores on the BDI and BAI for cancer and noncancer patient groups are summarized in Table 2. The total BDI score of the cancer patient group (27.21 ± 1.16) did not differ significantly from that of the noncancer patient group (25.02 ± 1.15; P = 0.412); however, there were significant group differences for several BDI subscales. Regarding the “guilt” factor, the cancer patient group had a mean score of 1.18 ± 0.89, while the noncancer patient group scored 1.10 ± 0.09 (P = 0.025). For the “work difficulties” factor, the cancer patient group scored 1.74 ± 0.08, and the noncancer patient group scored 1.41 ± 0.08 (P = 0.011). For the “loss of appetite” factor, the cancer patient group scored 1.61 ± 0.09, and the noncancer patient group scored 1.29 ± 0.09 (P = 0.043). For the “somatic worries” variable, the cancer patient group scored 1.62 ± 0.08, and the noncancer patient group scored 1.29 ± 0.08 (P = 0.011). Finally, for the “loss of libido” variable, the cancer patient group scored 2.09 ± 0.17, and the noncancer patient group scored 1.49 ± 0.17 (P < 0.001).

Table 2

Age-adjusted model of Beck Depression Inventory and Beck Anxiety Inventory between cancer and noncancer groups at their index episode

	Cancer (n=108)	Noncancer (n=111)	Significance (P)
BDI
Sadness	1.03±0.09	1.00±0.08	0.850
Pessimism	1.23±0.10	1.12±0.10	0.497
Feelings of failure	0.89±0.10	0.94±0.09	0.920
Dissatisfaction	1.44±0.09	1.53±0.09	0.418
Guilt	1.18±0.89	1.10±0.09	0.025*
Punishment	1.23±0.12	1.11±0.12	0.634
Self-hate	1.00±0.09	1.00±0.09	0.147
Self-accusation	1.15±0.10	1.29±0.10	0.392
Suicidal thoughts	0.78±0.07	0.80±0.07	0.076
Weeping	1.13±0.09	1.16±0.09	0.275
Irritability	1.18±0.09	1.21±0.09	0.825
Social withdrawal	1.47±0.10	1.26±0.09	0.236
Indecision	1.01±0.08	0.97±0.08	0.201
Change in self-awareness	0.91±0.08	0.75±0.09	0.383
Work difficulties	1.74±0.08	1.41±0.08	0.011*
Insomnia	1.99±0.09	1.84±0.09	0.018*
Tiredness	1.28±0.09	1.29±0.09	0.301
Loss of appetite	1.61±0.09	1.28±0.09	0.043*
Loss of weight	1.25±0.08	1.20±0.07	0.864
Somatic worries	1.62±0.08	1.29±0.08	0.004*
Loss of libido	2.09±0.17	1.49±0.17	<0.001*
Total	27.21±1.16	25.02±1.15	0.412
BAI
Numbness or tingling	0.95±0.08	0.72±0.08	0.130
Feeling hot	1.09±0.08	1.07±0.08	0.547
Wobbliness in legs	0.88±0.09	0.70±0.09	0.192
Unable to relax	1.33±0.08	1.27±0.08	0.256
Fear of the worst happening	1.29±0.10	1.20±0.09	0.021*
Dizzi or lightheaded	1.07±0.09	1.13±0.09	0.302
Heart pounding or racing	1.19±0.09	1.17±0.09	0.540
Unsteady	1.54±0.08	1.53±0.08	0.028*
Terrified or afraid	1.18±0.10	1.08±0.10	0.024*
Nervous	1.69±0.09	1.65±0.08	0.412
Feeling of choking	0.80±0.08	0.53±0.08	0.034*
Hands trembling	0.71±0.08	0.65±0.08	0.853
Shaky or unsteady	0.73±0.08	0.65±0.08	0.633
Fear of losing control	0.99±0.09	0.90±0.09	0.107
Difficulty breathing	0.87±0.09	0.65±0.09	0.190
Fear of dying	1.01±0.09	0.68±0.09	0.006*
Scared	0.89±0.09	0.72±0.09	0.028*
Indigestion	1.05±0.09	1.12±0.09	0.331
Fainting/light headed	0.89±0.09	0.77±0.09	0.534
Face flushed	1.05±0.09	1.10±0.09	0.777
Sweating (not due to heat)	1.18±0.10	1.21±0.10	0.964
Total	22.37±1.24	20.49±1.22	0.136

*P<0.05. BAI – Beck Anxiety Inventory; BDI – Beck Depression Inventory; SD – Standard deviation

The mean total BAI score of the cancer patient group (22.37 ± 1.24) did not differ significantly from that of the noncancer patient group (20.49 ± 1.22; P = 0.136); however, there were significant group differences for several BAI subscales. For the “fear of the worst happening” factor, the cancer patient group scored 1.29 ± 0.10, and the noncancer patient group scored 1.20 ± 0.09 (P = 0.021). For the “unsteady” variable, the cancer patient group scored 1.54 ± 0.08, and the noncancer patient group scored 1.53 ± 0.08 (P = 0.028). For the “terrified or afraid” factor, the cancer patient group scored 1.18 ± 0.10 and the noncancer patient group scored 1.08 ± 0.10 (P = 0.024). For the “feeling of choking” factor, the cancer patient group scored 0.80 ± 0.08, and the noncancer patient group scored 0.53 ± 0.08 (P = 0.034). For the “fear of dying” factor, the cancer patient group scored 1.01 ± 0.09, and the noncancer patient group scored 0.68 ± 0.09 (P = 0.006). Finally, for the “scared” variable, the cancer patient group scored 0.89 ± 0.09, and the noncancer patient group scored 0.72 ± 0.09 (P = 0.028).

DISCUSSION

The primary goal of the present study was to identify differences in the psychological distress pattern between cancer and noncancer patients. Although there was no significant difference between these groups in the overall level of depression, there were several significant differences for the depression subscales. The cancer patient group had significantly higher scores than the noncancer patient group for guilt, work difficulties, loss of appetite, somatic worries, and loss of libido. These factors are closely related to physical dysfunction, consistent with previous findings showing that cancer-related somatic symptoms are strongly influenced by physical, cognitive, and emotional factors. For example, associations between somatic symptoms, illness perception, depression, anxiety, and cancer incidence itself have been reported.[11]

Severe somatic symptoms magnify the disabilities resulting from cancer and reduce overall well-being and quality of life.[12] Leventhal's self-regulatory model[13] has been widely used to describe how individuals respond to somatic symptoms, regardless of etiology. This model proposes that, when experiencing somatic symptoms, individuals develop certain cognitive and emotional perceptions of their illness that motivate illness behaviors to cope with these symptoms. Illness can be conceptualized as a stressful experience; representations of illness are in effect cumulative because information is adopted, discarded, and modified as necessary. Therefore, representations of illness are linked with the selection of coping mechanisms, action plans, and outcomes.[14] In this context, the physical symptoms of cancer patients may relate to psychological coping mechanisms, which in turn are based on the information they are cognizant of. Cognitive behavioral therapy remains the gold standard for the psychotherapeutic treatment of psychological problems, including in cancer patients. These techniques can help correct faulty perceptions and discourage maladaptive psychological coping mechanisms.[1315]

Another explanation regarding the psychological distress experienced by cancer patients has been tested thoroughly in various stages of the disease. A meta-analysis showed that cancer patients are more depressed than the general population, but that there are no differences between cancer patients and the general population regarding the levels of anxiety and general psychological distress.[12] Psychological distress in cancer patients increases the risk of relapse following treatment and decreases compliance with antineoplastic therapy.[16] Psychological distress may also be an independent risk factor for increased mortality, although there have been contradictory findings,[1617] and might shorten survival in patients through reduced self-care and adherence to anticancer treatments.[18]

According to the preliminary studies,[19] cancer patients are treated with chemotherapy and/or surgery because these treatments can increase survival rates. However, these treatments also affect the quality of life and long-term therapy reduces overall physical function; in this context, patients may experience a significant loss of appetite and libido, increased physical anxiety, and job difficulties. In the case of elderly cancer patients, there is also a strong possibility of impairment in general memory, working memory (instantaneous memory), executive function, concentration, and the speed of information processing. Vardy and Tannock[20] suggested that the cognitive function of cancer patients is related to fatigue, depression, anxiety, hormones, psychological factors, and treatment-related factors. Thus, depression may result from cognitive dysfunction, and its manifestation may be consistent with the tendency of patients to be most concerned about physical functioning.[20]

In the present study, there were no significant differences in anxiety level between cancer and noncancer patient groups; however, there were several significant differences in anxiety subscale scores. The cancer patient group had significantly higher scores on the unsteady, terrified or afraid, and feeling of choking subscales. Carver et al.[21] proposed that positive emotions can be understood in the context of the behavioral approach system in humans, which mediates the pursuit of goals and interests, drive, and fun seeking. On the other hand, negative emotions, particularly anxiety, are related to the older behavioral inhibition system, which is protective and protects us from danger by promoting the avoidance of behaviors that reduce the chance of survival. In other words, cancer patients often begin to have concerns about the treatment following their diagnosis and may have significant anxiety regarding death as treatment progresses. Hwang et al.[22] found that psychological distress significantly increases in the final 2–3 months, and especially in the last month, before death. In the present study, anxiety levels were highest among the chronic cancer patients and differed significantly from those of the subacute group. This result is highly relevant in the context of those of the preliminary study and suggests that specific anxiety factors associated with different types of cancer group should be considered.

The present study had some limitations that should be addressed. First, this study was conducted as a retrospective study. So, there was a lack of information about cancer stage assignment, education level, degree of social support, and other psychosocial factors. Second, since the data were collected using self-report instruments, it will be necessary to analyze the subscale scores by factor analysis. Nevertheless, the present study found that high levels of depressive symptoms were related to somatic discomfort, while anxiety symptoms were related to fear of cancer. Furthermore, these variables were associated with considerable psychological distress in patients diagnosed with cancer and in those undergoing cancer treatment. The present study provides a good basis for further research on the specific characteristics of psychological distress in cancer patients.

CONCLUSION

High levels of depressive symptoms related to somatic discomfort and anxiety symptoms related to fear of cancer were associated with considerable psychological distress in patients with cancer diagnosis and treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.