Stress, anxiety, depression, and resilience in cancer patients on radiotherapy.

BACKGROUND: The diagnosis of cancer may cause extreme disruption in the life of an individual because in the minds of most people the disease is associated with extreme pain, suffering, and death. AIM: This study aimed to assess stress, anxiety, depression, and resilience among cancer patients undergoing treatment with radiotherapy.
MATERIALS AND METHODS: Consecutive cancer patients taking radiotherapy treatment from a tertiary care hospital were included in the study with their written informed consent. Subjects suffering from comorbid medical or psychiatric disorders were excluded from the study. Demographic and clinical details of the patients were recorded on a specially prepared pro forma. Depression Anxiety and Stress Scale (DASS) and Abbreviated Connor-Davidson Resilience Scale were administered. Scoring of the scales was carried out as per the test manual. The data were tabulated and analyzed using the SPSS software.
RESULTS: The study sample included 100 patients (38 male and 62 females) with a confirmed diagnosis of cancer receiving radiotherapy. Based on the scores obtained on the DASS, depression was present in 24 patients, anxiety was significantly high in 25 patients, while stress was significantly high in five patients. Male patients undergoing radiotherapy had significantly higher scores on resilience and significantly lower scores on depression anxiety and stress compared to female patients. In patients undergoing radiotherapy, stress, anxiety, and depression were significantly negatively correlated while resilience. Anxiety, gender, and resilience were found to be significant predictors of depression based on multiple regression analysis.
CONCLUSION: Cancer patients undergoing radiotherapy suffer from depression, anxiety, and stress which are negatively correlated with resilience. Resilience is significantly higher in males, while anxiety, depression, and stress are significantly higher in females. In addition to therapy aimed at reducing depressive and anxiety symptoms, psychiatric management should also aim to increase the resilience of these patients. Copyright:

Even a cursory reading of history reveals that certain diseases gained notoriety in societies at particular times and no disease has sustained as strong of a negative stigma as cancer. Advances in cancer treatment have resulted in cure of some cancers and greatly improved prognosis of most others. Despite this, the diagnosis of cancer is seen as a threat to a person's general sense of security since the disease is associated with pain, suffering, disfigurement, and death.[1] Cancer accounts for nearly three lakh deaths annually in India, exceeded only by heart disease.[2] Cancer is far more than a physical illness: the psychosocial impact of cancer and cancer treatment, because it is multifaceted and potentially long lasting, often extends into the disease-free survival period. The nature and intensity of this impact vary widely, depending on tumor sites, disease staging, nature of treatment, patient's life circumstances, personal resources, and resilience.[345]

Psychiatric morbidity in cancer patients is a reality. However in oncology patients, the psychiatric morbidity is frequently neither identified nor treated as there is a tendency to explain away the symptoms experienced by the patient as effects of cancer or its treatment. Clinicians are also fearful of stigmatizing the patient due to diagnosis of a psychiatric disorder. Evaluation of 384 cancer patients revealed that 41.7% had psychiatric disorders. The most common disorders were adjustment disorders (22.6%), major depressive disorder (10.9%), delirium (6.5%), and hypomania (1.6%). Multivariate analysis showed that age, past history of chemotherapy, radiotherapy, and surgery for cancer were significant predictors of psychiatric disorders.[6]

Assessment of 534 patients attending the radiotherapy outpatient services with the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 (GAD-7) Questionnaire revealed that 46.4% had psychiatric morbidity (either depressive disorder or GAD). Higher stage of malignancy (from early, advanced to metastasis) and low socioeconomic status were associated with a higher prevalence of depressive disorder and GAD.[7] Among men suffering from prostatic cancer, 27% reported clinically significant levels of depression, while 20% is expected in the general population.[8] The diagnosis and subsequent treatment of head-and-neck cancer can have a potentially devastating impact on psychological functioning.[9] Sleep disturbances and psychological distress are the most common adverse effects with diagnosis and treatment in nasopharyngeal cancer.[10] Apart from the diagnosis, the treatment of cancer may also have an adverse psychological impact. The oldest form of cancer treatment, surgery, probably has the least adverse impact except when associated with gross changes in appearance and function (e.g. mastectomy, amputation, and colostomy).[111]

In this nuclear age, people have been repeatedly explained and are aware of the hazards of exposure to radiation and the necessity of avoiding it. Therefore, on being told that they would be exposed to radiation cancer treatment may cause stress and anxiety. Moreover, during radiotherapy, the patient has to lie alone on a table with a large machine overhead which can produce fear, a sense of isolation, and anxiety. The side effects of radiotherapy are also troublesome. In the USA, about 350,000 cancer patients receive radiation therapy each year. Cancer patients frequently report fears of the treatment (e.g. being “burned,” or causing sterility, sickness, or vomiting). In addition, 60% of the patients have significant anxiety prior to treatment and 80% of them afterward.[9]

While a number of studies have evaluated the adverse psychological effects of cancer, it is believed that the study of resilience may help us to enable more positive psychosocial outcomes of cancer treatment. Resilience is the ability to recover quickly or adapt to adverse events such as serious health problems, relationship problems, or financial and workplace stressors.[1213] A recent study found that resilience was significantly associated with higher levels of perceived social support and low hopelessness.[14]

Very few Indian studies have evaluated the levels of anxiety, depression, stress, and resilience in cancer patients on radiotherapy and no study has especially focused on patients from rural areas. In view of the above, the present study was undertaken to assess the levels of anxiety, depression, stress, and resilience in cancer patients undergoing radiotherapy at a rural medical college.

MATERIALS AND METHODS

This prospective cross-sectional analytical study was conducted at Pravara Rural Hospital and Rural Medical College, Loni, by the Department of Psychiatry in collaboration with the Radiotherapy Department. Institutional ethical committee approval was obtained before starting the study. All the subjects gave written informed consent.

Study population

One hundred consecutive cancer patients taking radiotherapy treatment and fulfilling inclusion and exclusion criteria were enrolled in the study.

Inclusion criteria

Patients with confirmed diagnosis of cancer undergoing radiotherapy or chemotherapy treatment in Pravara Rural Hospital

Patients are stable, communicative, and willing to give their consent.

Exclusion criteria

Patients suffering from chronic physical disorder

Patients with a history of mental illness or suffering from a psychiatric disorder

Patients with previous or current use of sleep medications.

Tools used in the study

Sociodemographic questionnaire

This self-made questionnaire which included demographic variables such as sex, age, education, religion, occupation, number of children, and marital status.

Depression Anxiety Stress Scale

The Depression Anxiety Stress Scale (DASS) is a 21-item self-report inventory that measures depression, anxiety, and stress. The scale has adequate reliability. The test–retest reliability is likewise considered adequate with 71 for depression, 79 for anxiety, and 81 for stress. Both exploratory and confirmatory factor analyses have supported the proposition of the three factors (P < 0.05). The DASS Depression scale correlates 0.74 with the Beck Depression Scale, while the DASS Anxiety Scale correlates 0.81 with the Beck Anxiety Inventory.[1516]

The Abbreviated Connor–Davidson Resilience Scale

The Abbreviated Connor–Davidson Resilience Scale (CD-RISC2) is a 2-item version of the Connor–Davidson Resilience Scale, having adequate internal consistency, test–retest reliability, convergent validity, and divergent validity as well as correlation with full scale.[17]

Procedure

Consecutive cancer patients registered in the oncology department for radiotherapy treatment were approached to take part in the study. After explaining the aims and objectives of the study and obtaining written informed consent, they were included in the study. The sociodemographic and clinical details of the subjects were first recorded in the self-made pro forma. After that, the DASS and CD-RISC2 were administered individually to the patients. The scoring of the scales was done as per the test manual. Then, the collected data were tabulated and analyzed using appropriate statistical tests.

Statistical analysis

Statistical analysis was carried out using t-test, Chi-square test, Mann–Whitney U-test, and Spearman's correlation.

RESULTS

The study included 100 patients (38 male and 62 females) undergoing radiotherapy for the treatment of cancer. The demographic details are given in Table 1. Majority of the subjects were married, Hindu, farmers, and hailed from nuclear families. The most common site of cancer was head and neck followed by breast and cervix [Table 1]. Mean (±standard deviation.) scores of stress, anxiety, depression, and resilience are shown in Table 2 and Figure 1. In patients on radiotherapy, applying the cutoff scores of the DASS, it was found that 25, 24, and 5 patients had high levels of anxiety, depression, and stress, respectively [Figure 2]. In patients undergoing radiotherapy, stress, anxiety, and depression were positively correlated, while resilience was negatively correlated to anxiety, depression, and stress [Table 3]. Further analysis revealed that male patients on radiotherapy had significantly higher resilience and significantly lower anxiety, depression, and stress as compared to female patients [Table 4].

Table 1

Demographic and clinical characteristics of the cancer patients on radiotherapy (n=100)

Characteristics of cancer patients	Values
Age (years), mean (±SD)	52.59 (±12.73)
Age distribution (years), n (%)
≤20	1 (1)
21-40	16 (16)
41-60	52 (52)
61-80	30 (30)
≥81	1 (1)
Gender, n (%)
Male	38 (38)
Female	62 (62)
Marital status, n (%)
Married	88 (88)
Unmarried	1 (1)
Widow/Widower	11 (11)
Education, n (%)
Illiterate	48 (48)
Up to class 5	14 (14)
Class 6-10	25 (25)
Class 11-12	5 (5)
>12	8 (8)
Religion, n (%)
Hindu	80 (80)
Muslim	16 (16)
Others	4 (4)
Family type, n (%)
Nuclear	53 (53)
Joint	34 (34)
Extended	13 (13)
Occupation, n (%)
Farmer	68 (68)
Housewife	12 (12)
Service	12 (12)
Trader	5 (5)
Student	2 (2)
Unemployed	1 (1)
Habits, n (%)
Alcohol	21 (21)
Tobacco	23 (23)
Site of cancer, n (%)
Carcinoma of the head and neck	27 (27)
Carcinoma of the breast	26 (26)
Carcinoma of the cervix	21 (21)
Other genitourinary carcinoma	10 (10)
Others	16 (16)

SD - Standard deviation

Table 2

Scores obtained by the cancer patients on radiotherapy (n=100) on the Depression Anxiety Stress Scale and Resilience Scale

Scales	Mean score (±SD)
Depression	5.81 (±4.57)
Anxiety	5.73 (±4.02)
Stress	6.24 (±4.35)
Resilience	5.45 (±1.95)

SD - Standard deviation

Figure 1

Mean values of resilience, depression, anxiety, and stress in cancer patients on radiotherapy

Figure 2

Severity of anxiety, depression, and stress in cancer patients on radiotherapy

Table 3

Correlations of stress, anxiety, depression, and resilience in cancer patients on radiotherapy

Spearman’s rho	Stress	Anxiety	Depression	Resilience
Stress
Correlation coefficient	1.000	0.744**	0.648**	−0.579**
Significance (two tailed)	-	0.000	0.000	0.000
n	100	100	100	100
Anxiety
Correlation coefficient	0.744**	1.000	0.756**	−0.646**
Significance (two tailed)	0.000	0.000	0.000
n	100	100	100	100
Depression
Correlation coefficient	0.648**	0.756**	1.000	−0.599**
Significance (two tailed)	0.000	0.000	0.000
n	100	100	100	100
Resilience
Correlation coefficient	−0.579**	−0.646**	−0.599**	1.000
Significance (two tailed)	0.000	0.000	0.000
n	100	100	100	100

**Correlation is significant at the 0.01 level (two tailed)

Table 4

Characteristics of male and female cancer patients on radiotherapy

	On radiotherapy
	Male (n=38), n (%)	Female (n=62), n (%)	T test*/Mann-Whitney U-test	P
Age	53.08 (13.53)	52.29 (12.32)	0.299*	0.765 (NS)
Stress	4.55 (3.58)	7.27 (4.48)	756.500	0.003 (S)
Anxiety	3.92 (2.95)	6.84 (4.20)	687.000	0.000 (S)
Depression	3.32 (3.09)	7.34 (4.67)	583.500	0.000 (S)
Resilience	6.21 (1.55)	4.98 (2.03)	773.000	0.003 (S)

NS - Nonsignificance, S - Significance

A multiple regression was run to find out if age, stress, anxiety, and resilience can predict depression. It was found that only anxiety, gender, and resilience are useful to predict depression. The multiple linear regression model summary and overall fit statistics show that that the adjusted R2 of our model is 0.636 with the R2= 0.647. This means that the linear regression explains 64.7% of the variance in the data. The Durbin–Watson value is = 2.046. This is between the two critical values of 1.5 and 2.5, thereby indicating that there is no first-order linear autocorrelation in our multiple linear regression data [Table 5].

Table 5

Multiple linear regression: Model summary

Model summaryd
Model	R	R2	Adjusted R2	SE of the estimate	Durbin- Watson
1	0.776a	0.602	0.597	2.89799
2	0.793b	0.629	0.621	2.81085
3	0.804c	0.647	0.636	2.75594	2.046

aPredictors: (Constant), anxiety, bPredictors: (Constant), anxiety, gender, cPredictors: (Constant), anxiety, gender, resilience, dDependent variable: Depression. SE - Standard error

The linear regression's F-test is highly significant [Table 6] implying that the model explains a significant amount of the variance in depression rate. From Table 7, it is also obvious that out of the predictor variables, anxiety, gender, and resilience are important factors in predicting depression. Anxiety and gender are significant, and the coefficients are positive which indicate that greater the anxiety, greater the depression. On the other hand, resilience is also a significant factor, but its coefficient is negative, implying an inverse relation between resilience and depression, which is what we would expect.

Table 6

Multiple linear regression: Analysis of Variance (ANOVA)

ANOVAa
Model	Sum of squares	df	Mean square	F	Significance
1
Regression	1242.350	1	1242.350	147.927	0.000b
Residual	823.040	98	8.398
Total	2065.390	99
2
Regression	1299.004	2	649.502	82.206	0.000c
Residual	766.386	97	7.901
Total	2065.390	99
3
Regression	1336.253	3	445.418	58.645	0.000d
Residual	729.137	96	7.595
Total	2065.390	99

aDependent variable: Depression, bPredictors: (Constant), anxiety, cPredictors: (Constant), anxiety, gender, dPredictors: (Constant), anxiety, gender, resilience

Table 7

Multiple linear regression: Coefficients

Coefficientsa
Model	Unstandardized coefficients		Standardized coefficients β	T	Significance	Collinearity statistics
	B	SE				Tolerance	VIF
1
Constant	0.757	0.507		1.495	0.138
Anxiety	0.882	0.073	0.776	12.163	0.000	1.000	1.000
2
Constant	−1.520	0.982		−1.548	0.125
Anxiety	0.810	0.075	0.713	10.777	0.000	0.874	1.144
Gender	1.658	0.619	0.177	2.678	0.009	0.874	1.144
3
Constant	1.597	1.706		0.936	0.351
Anxiety	0.697	0.090	0.613	7.754	0.000	0.589	1.698
Gender	1.495	0.612	0.160	2.444	0.016	0.862	1.160
Resilience	−0.404	0.182	−0.172	−2.215	0.029	0.610	1.640

aDependent Variable: depression. SE - Standard error, VIF - Variance inflation factor

DISCUSSION

A major finding of the present study was that the higher than “normal” levels of anxiety, depression, and stress were observed in 25%, 24%, and 5% of the cancer patients hailing from rural areas undergoing radiotherapy treatment. Similar findings were reported by the number of earlier workers. An earlier Indian study on 50 cancer patients found that depression and anxiety were present in 44% of patients.[1] Another study found anxiety depression and stress in 18.09%, 29.41%, and 4.07% of 221 cancer patients.[13] Similarly in 534 cancer patients undergoing radiotherapy, 46.4% had psychiatric morbidity comprising depressive disorder (37.5%) or in the form of GAD (35.8%).[7] Another study found that the prevalence of anxiety and depression in breast cancer patients was 31.7% and 22.0%, respectively.[18] In 1346 patients undergoing radiotherapy for head-and-neck cancer, the prevalence of emotional distress was 46%, anxiety was 26%, depression was 9%, and claustrophobia was 27%. Emotional distress (P < 0.001), depression (P < 0.001), and anxiety (P < 0.001) were significantly higher in women.[19] Anxiety is mentioned as one of the common systemic toxicities of radiotherapy treatment along with pain, fatigue, and anorexia.[20] It is therefore possible that the anxiety seen in our patients was a side effect of radiotherapy.

On the other hand, the findings of few studies are somewhat in disagreement with our findings and reported lower levels of depression and anxiety. Assessment of 63 cancer patients receiving radiotherapy with the Hospital Anxiety and Depression scale (HADS) revealed that 13% of the patients suffered from anxiety and 8% from depression. Probable psychiatric morbidity was found in only 10% of the study population in the form of a severe combination of depression and anxiety (indicated by a total HADS score >19).[21] In a radiation oncology clinic, the screening of 119 patients with a simple screening tool for anxiety and depression (PHQ4) resulted in 21% screening positive for the PHQ-4 composite score.[22]

In oncology, depression is associated with a decline in survival and adherence to treatment leading to a worse prognosis. Estimates indicate that approximately 10%–25% of cancer patients present a major depressive disorder.[23] In our study, 24% of cancer patients had depression. This finding is in agreement with an earlier Indian study which reported that 21.5% out of 270 cancer patients had depression. They found that among patients with depression, 22% had moderately severe to severe depression, while in our study, only 16.7% had moderate depression.[24]

Age was not a predictor of depression in our study. This finding is in agreement with a previous study which reported that neither anxiety nor depression was related to age.[7] However in 702 adults with a history of cancer, younger patients (18–59 years old) were more likely than older patients (≥60 years) to have a 12-month history of an anxiety or depressive disorder.[25] A scoping review of 34 studies revealed that adolescents and young adults, however defined, are a distinct group within the oncology population with an increased risk of distress, depression, and anxiety.[26] One reason for the discrepant findings could be the fact that our sample consisted of middle-aged and older persons with very few adolescents and young adults.

The finding of significantly higher depression, anxiety, and stress in female cancer patients is not in agreement with a previous study which reported that neither anxiety nor depression was related to gender.[7] On the other hand, our findings are congruent with the findings of a Canadian study which found that in 1346 patients with cancer of head and neck undergoing radiotherapy, emotional distress (P < 0.001), depression (P < 0.001), and anxiety (P < 0.001) were significantly more in women.[19]

Another important finding of our study was that in cancer patients, stress, anxiety, and depression are positively correlated. However, resilience is negatively correlated to stress, anxiety, and depression. Resilience is a person's ability to maintain their physical and psychological well-being in the face of adversity. A study of 970 patients of gastrointestinal cancer revealed that cancer is a disease-causing severe psychological distress in patients. Resilience was the main factor affecting psychological distress in these patients[27] In addition, our findings are congruent with another study involving 327 bladder cancer and 268 renal cancer patients. The prevalence of depression and anxiety in bladder cancer patients was 78.0% and 71.3%, respectively, and in renal cancer patients, 77.6% and 68.3%, respectively. Depression and anxiety were positively related to psychological stress and negatively related to resilience. In addition, the relations of stress with depression and anxiety were partially mediated by resilience.[28]

An important lesson learned from the study was that by implementing a simple screening tool, we could identify about 25% and 24% of the patients as having significant levels of anxiety and depression, respectively. They received the benefits of psychiatric consultation and treatment. Under routine conditions, these patients would have been deprived of psychiatric treatment.

Limitations

The present study has some limitations. The sample size was modest and the number of patients in different cancer groups was too small to draw any concrete conclusion. Anxiety, depression, stress, and resilience were evaluated using screening instruments only.

Other clinical and psychosocial factors that may influence anxiety and depression such as time since diagnosis, level of disability due to illness and treatment, social support, coping, and so on were not evaluated.

CONCLUSION

The present study suggests that psychiatric morbidity in the form of depressive and anxiety disorders is common among patients with cancer. Stress, anxiety, and depression are significantly positively correlated to each other, while all three are significantly negatively correlated to resilience. In addition to reducing depressive and anxiety symptoms, resilience development should be included in depression and anxiety prevention and treatment strategies

Implications

Depression in cancer patients needs to be identified as it has major implications in the course and prognosis of illness. Data from various studies have convincingly documented that once an individual is diagnosed with cancer, psychological factors including stress and depression may influence the course of illness and also the overall quality of life. Concurrent psychiatric counseling will improve the quality of life of such patients. Psychiatric therapy of cancer patients apart from combating depression, anxiety, and stress should also attempt to improve resilience in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.