Abstract

Introduction: Major depressive disorder is a major mental health problem and is the fourth most important cause of loss of disability-adjusted life years worldwide. Aim: The study aimed to assess the association of depression among women diagnosed with breast cancer. Methodology: A descriptive, cross-sectional study was done on 102 females diagnosed with breast cancer. Women were recruited using purposive sampling technique. Patients were evaluated on Mini International Neuropsychiatric Interview Version 6.0.0 to screen other psychiatric comorbidities. Hamilton depression 17-item, rating scale was used to measure severity of depression. Results: The prevalence of depression was 47.05% in women diagnosed with breast cancer. Majority of the patients (54.1%) had mild depression. Correlations of clinical and Sociodemographic variables with parameters of depression were not significant. Conclusions: Depression is commonly associated psychiatric morbidity in patients diagnosed with breast cancer. The severity of depression is independent of the sociodemographic and clinical variables of patients with breast cancer.

Introduction

Across the world, breast cancer is a leading cause of death in females, and it is the most commonly diagnosed cancer in this population.[1] In Asia, breast cancer incidence peaks among women at the age of 40 years, whereas in the United States and Europe, it peaks among women at the age of 60 years.[1] In India, around 50% of breast cancer is among premenopausal women. More than one lac patients are diagnosed with breast cancer annually in India as per the Indian Council of Medical Research – Population-Based Cancer Registries data 2014.[1]

Diagnosis of cancer generates varying levels of stress and emotional upset in individuals and their families. The commonly encountered challenges in patients with breast cancer are fear of dying, distortion of self-image, loss of self-esteem, change in social role, disruption of the family integrity, and financial difficulties.[2]

Loss or distortion of the symbols of femininity due to breast cancer in women leads to low self-esteem, negative body image, false self-perception, social isolation, and communication or relationship problems with family members or friends.[3],[4] Cancer treatment also results in loss of feminine physical characteristics through hair loss (secondary to chemotherapy) or the loss of one or both breasts (following mastectomy).[5] It may lead to the development of “cancer stigma” among women. Impact of cancer on the physical and psycho-social well-being is enormous. Patients diagnosed with cancer often encounter social rejection and isolation, resulting in poor well-being along with poor health outcomes.[6]

Patients with cancer often experience pain, sleep disturbances, loss of appetite, anxiety, hopelessness, worry, and apprehension related to future. Distinguishing between normal levels of sadness and depressive disorders is a critical step.[7] Similarly, many myths are associated with cancer. The common myths about cancer are as follows:

• Depression is inevitable, normal, and expected in all individuals with cancer

• Sufferings and painful deaths are seen all patients of cancer.

There is little role of treatment in cancer patients. These myths may misguide the patient, the caregivers, as well as the clinicians. Considering depression to be normal and inevitable in breast cancer, it may result in under-diagnosis and nontreatment of depression. As an essential element of cancer management, early detection of depression and timely intervention are highly crucial. Evidence suggests that relaxation techniques and other psychological interventions have been effective to reduce psychological symptoms in women with a new diagnosis of gynecological cancer.[8]

Individual differences in response to diagnosis and adjusting are seen among people living with cancer. Simple sadness or a blue mood is not considered as depression.[9],[10] Patients with major depression have recognizable symptoms that can and should be diagnosed and treated because they adversely affect the quality of life. At the time of diagnosis of cancer, depressive symptoms may present and it might be the on-going depressive disorder, hence needs focused evaluation.[11],[12]

Depression is a frequently discussed entity in the context of cancer; however, it is often challenging to evaluate it in the context of cancer as many of the symptoms of cancer and side effects of cancer treatment (pain, fatigue, loss of weight, and appetite) often resemble with depression.[12] Comorbid depression negatively affects the treatment of both cancer and depression. It may lead to poor adherence to treatment recommendations, hence resulting in poor outcomes.

India, being a heavily populous country, caters nearly one-sixth of the world's population. India accounts for a major chunk of global burden of diseases including cancers as well as depression. However, depression is understudied in Indian women, diagnosed with breast cancer. The development of studies from this perspective can have meaningful implications in holistic care of breast cancer and comorbid depression. Taking into account such aspects, this study aims to verify the occurrence and pattern of depression from the signals and symptoms evidenced, in women diagnosed with breast cancer.

Methodology

The study was conducted during 2016–2017 (November 2016 to April 2017), in a tertiary care teaching hospital located in North India. The study was approved by the Institute's Ethics Committee, and all patients were recruited after obtaining written informed consent.

The study had a cross-sectional design, and the sample was recruited by purposive sampling. The women, who were attending the outpatient services of the Department of Endocrine Surgery and Surgical Oncology, King George's Medical College, Lucknow, Uttar Pradesh, with the diagnosis of breast cancer, were approached. They were explained the purpose of the study and were given freedom of choice, to accept or refuse to participate in the study.

Patients diagnosed with breast cancer (as confirmed by fine needle aspiration cytology or tissue biopsy) within 1 year were included in the study. Female patients who were receiving chemotherapy, aged above 80 years or <18>

Tools for assessment

Patients were assessed on a semi-structured pro forma for sociodemographic and clinical details. MINI 6.0.0 version was used to rule out the psychiatric comorbidities.[13] The diagnosis of depression was confirmed using the International Classification of Diseases-10, diagnostic criteria research.[14] Severity of depression was assessed using Hamilton depression (HAM-D) rating scale (17-item version).[15]

Procedure

All female patients diagnosed with Breast cancer attending the abovementioned outpatient settings were assessed on selection criteria. Sociodemographic data were collected on the semi-structured pro forma, after obtaining the informed consent. Subjects were screened using MINI 6.0.0 for other psychiatric comorbidities. HAM-D (17-item) was administered to assess the severity of depression. The patients, who were found to be suffering from depression or any other psychiatric morbidity, were referred to Outpatient Department of Psychiatry for appropriate treatment.

Statistical analysis

The data collected were first coded and summarized in Microsoft Excel data sheet and analyzed based on objectives of the study using STATA-23 software (StataCorp LLC, Texas, USA). Descriptive analysis was carried out using mean and standard deviation (SD) with range for continuous variables and in terms of frequency and percentage for categorical variables. The continuous variables were compared using Student's t-test. The ordinal and nominal variables of the two groups were compared using the Chi-square test. Relationship between various domains of depression and other variables was studied using Pearson's correlation coefficient.

Results

A total of 250 women diagnosed with breast cancer were screened, and among them, 114 patients met the inclusion criteria. The most common reason for noninclusion was patient receiving chemotherapy, as defined for this study. On further evaluation, 12 patients were excluded who had other psychiatric comorbidity. The final sample comprised 102 patients, which was further categorized into two groups (Group A and Group B). Groups A included patients with breast cancer who had depression as per the screening tool MINI (n = 48) and Group B consisted of patients of breast cancer who did not have any psychiatric illness as per MINI (n = 54). Group A comprised the study group and Group B comprised the control group for comparison of sociodemographic and clinical variables. HAM-D was applied on Group A subjects only.

Sociodemographic and clinical characteristics of the patients

The mean (±SD) age of the patients was 43.34 ± 8.62 years with a majority of the patients belonging to the age group of 41–50 years (36.7%). Majority of the patients in the study were homemakers (90.0%) and illiterates (60%). Majority (86.7%) of the patients were married and belonged to Hindu religion (90%), living in joint family (50%), from a rural background (60%) area with monthly family income of 2500 INR (50%) [Table 1].

| Figure 1  Bar diagram showing the prevalence of symptoms of depression (according to Hamilton Depression Score) (n = 48)

Relationship between sociodemographic and clinical variable with severity of depression

[Table 3] depicts that age, duration of diagnosis of breast cancer, and stage of malignancy were not statistically significantly correlated with severity of depression.

1.  Indian Council of Medical Research. National Cancer Registry, Annual Report. New Delhi: Indian Council of Medical Research; 2012
2.  Watson M, St James-Roberts I, Ashley S, Tilney C, Brougham B, Edwards L. et al. Factors associated with emotional and behavioural problems among school age children of breast cancer patients. Br J Cancer 2006; 94: 43-50
3.  Banning M, Hafeez H, Faisal S, Hassan M, Zafar A. The impact of culture and sociological and psychological issues on Muslim patients with breast cancer in Pakistan. Cancer Nurs 2009; 32: 317-24
4.  Wellisch DK. The psychologic impact of breast cancer on relationships. Semin Oncol Nurs 1985; 1: 195-9
5.  Rosman S. Cancer and stigma: Experience of patients with chemotherapy-induced alopecia. Patient Educ Couns 2004; 52: 333-9
6.  Kagawa-Singer M, Dadia AV, Yu MC, Surbone A. Cancer, culture, and health disparities: Time to chart a new course?. CA Cancer J Clin 2010; 60: 12-39
7.  Freeman HP. Poverty, culture, and social injustice: Determinants of cancer disparities. CA Cancer J Clin 2004; 54: 72-7
8.  Block SD. Assessing and managing depression in the terminally ill patient. ACP-ASIM end-of-life care consensus panel. American College of Physicians – American Society of Internal Medicine. Ann Intern Med 2000; 132: 209-18
9.  Petersen RW, Quinlivan JA. Preventing anxiety and depression in gynaecological cancer: A randomised controlled trial. BJOG 2002; 109: 386-94
10.  Massie MJ, Holland JC. The cancer patient with pain: Psychiatric complications and their management. Med Clin North Am 1987; 71: 243-58
11.  Lynch ME. The assessment and prevalence of affective disorders in advanced cancer. J Palliat Care 1995; 11: 10-8
12.  Massie MJ. Prevalence of depression in patients with cancer. JNCI Monographs 2004; 2004: 57-71
13.  Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E. et al. The mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59 Suppl 20: 22-33
14.  World Health Organization. ICD 10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization; 1993
15.  Williams JB. A structured interview guide for the Hamilton depression rating scale. Arch Gen Psychiatry 1988; 45: 742-7
16.  Srivastava V, Ansari MA, Kumar A, Shah AG, Meena RK, Sevach P. et al. Study of anxiety and depression among breast cancer patients from North India. J Clin Psychiatry 2016; 2: 1-7
17.  Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: Five year observational cohort study. BMJ 2005; 330: 702
18.  Chaturvedi SK, Peter Maguire G, Somashekar BS. Somatization in cancer. Int Rev Psychiatry 2006; 18: 49-54
19.  Theobald DE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clin Cornerstone 2004; 6 Suppl 1D S15-21
20.  Tavio M, Milan I, Tirelli U. Cancer-related fatigue (review). Int J Oncol 2002; 21: 1093-9

| Figure 1  Bar diagram showing the prevalence of symptoms of depression (according to Hamilton Depression Score) (n = 48)

1.  Indian Council of Medical Research. National Cancer Registry, Annual Report. New Delhi: Indian Council of Medical Research; 2012
2.  Watson M, St James-Roberts I, Ashley S, Tilney C, Brougham B, Edwards L. et al. Factors associated with emotional and behavioural problems among school age children of breast cancer patients. Br J Cancer 2006; 94: 43-50
3.  Banning M, Hafeez H, Faisal S, Hassan M, Zafar A. The impact of culture and sociological and psychological issues on Muslim patients with breast cancer in Pakistan. Cancer Nurs 2009; 32: 317-24
4.  Wellisch DK. The psychologic impact of breast cancer on relationships. Semin Oncol Nurs 1985; 1: 195-9
5.  Rosman S. Cancer and stigma: Experience of patients with chemotherapy-induced alopecia. Patient Educ Couns 2004; 52: 333-9
6.  Kagawa-Singer M, Dadia AV, Yu MC, Surbone A. Cancer, culture, and health disparities: Time to chart a new course?. CA Cancer J Clin 2010; 60: 12-39
7.  Freeman HP. Poverty, culture, and social injustice: Determinants of cancer disparities. CA Cancer J Clin 2004; 54: 72-7
8.  Block SD. Assessing and managing depression in the terminally ill patient. ACP-ASIM end-of-life care consensus panel. American College of Physicians – American Society of Internal Medicine. Ann Intern Med 2000; 132: 209-18
9.  Petersen RW, Quinlivan JA. Preventing anxiety and depression in gynaecological cancer: A randomised controlled trial. BJOG 2002; 109: 386-94
10.  Massie MJ, Holland JC. The cancer patient with pain: Psychiatric complications and their management. Med Clin North Am 1987; 71: 243-58
11.  Lynch ME. The assessment and prevalence of affective disorders in advanced cancer. J Palliat Care 1995; 11: 10-8
12.  Massie MJ. Prevalence of depression in patients with cancer. JNCI Monographs 2004; 2004: 57-71
13.  Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E. et al. The mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59 Suppl 20: 22-33
14.  World Health Organization. ICD 10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization; 1993
15.  Williams JB. A structured interview guide for the Hamilton depression rating scale. Arch Gen Psychiatry 1988; 45: 742-7
16.  Srivastava V, Ansari MA, Kumar A, Shah AG, Meena RK, Sevach P. et al. Study of anxiety and depression among breast cancer patients from North India. J Clin Psychiatry 2016; 2: 1-7
17.  Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: Five year observational cohort study. BMJ 2005; 330: 702
18.  Chaturvedi SK, Peter Maguire G, Somashekar BS. Somatization in cancer. Int Rev Psychiatry 2006; 18: 49-54
19.  Theobald DE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clin Cornerstone 2004; 6 Suppl 1D S15-21
20.  Tavio M, Milan I, Tirelli U. Cancer-related fatigue (review). Int J Oncol 2002; 21: 1093-9