Assessing anxiety and depression with respect to the quality of life in cancer inpatients receiving palliative care

https://doi.org/10.1016/j.ejon.2015.04.006Get rights and content

Abstract

Purpose

The study aimed at assessing the presence of anxiety and depression in cancer inpatients receiving palliative care at an oncology department using the Hospital Anxiety and Depression Scale (HADS) and determining whether anxiety and depression contribute to a lower quality of life controlled for pain and illness severity.

Method

This cross-sectional study comprised 225 advanced cancer inpatients (a mean age of 65.1 years). Data were collected with the HADS, EORTC QLQ-C30 and Karnofsky Performance Status scale.

Results

Anxiety (HADS-a ≥8) was found in 33.9% and depression (HADS-d ≥8) in 47.6% of patients. Higher anxiety scores were observed in patients living with a partner (p = 0.042) and non-religious patients (p = 0.045). Correlations were found between anxiety, depression and all quality of life dimensions (r = 0.31–0.63). Multiple regression analysis showed that anxiety and depression contribute to lower physical and emotional functioning. Patients with anxiety (HADS-a ≥8) and depression (HADS-d ≥8) reported a lower total quality of life (p < 0.01).

Conclusion

Management of anxiety and depression in cancer patients receiving palliative care may contribute to improvement in certain quality of life dimensions.

Introduction

Depression is one of the most prevalent emotional disorders in cancer patients (Castelli et al., 2011). The presence of depression in patients with advanced cancer is reported to range from 3% to 69% (Delgado-Guay et al., 2009, Holtom and Barraclough, 2000, Hotopf et al., 2002, Smith et al., 2003). And Block (2000) states that depression is found in as many as 77% of terminal cancer patients.

The period of dying is often associated with fear and anxiety. Death anxiety may manifest itself as dread, panic, maladaptive behavior, poor coping mechanisms or somatic problems (Kissane and Patsy, 2003). In their systematic review, Hotopf et al. (2002) identify 15 studies using the Hospital Anxiety and Depression Scale (HADS) to assess depression in patients with terminal chronic disease; the presence of depression ranged from 14% to 66%. In the published studies of cancer patients, anxiety is usually more prevalent than depression (Delgado-Guay et al., 2009, Hotopf et al., 2002).

Both anxiety and depression are common in patients with pain and other burdensome symptoms, as they are in the terminal stage of the disease (Smith et al., 2003). Some authors claim that there is an association between physical symptoms and the presence of anxiety and depression (Delgado-Guay et al., 2009, Mystakidou et al., 2004, Smith et al., 2003). According to Teunissen et al. (2007), however, the relationship between anxiety, depression and physical symptoms in palliative care is limited. The authors found no correlation between these factors. Both anxiety and depression may be affected by information about the prognosis of the disease. Cripe et al. (2012) found that men who had full prognostic discussions had less depression but greater anxiety.

Underdetection and undertreatment of depression is a serious problem in palliative care (Stiefel et al., 2001). Depression related to the diagnosis of cancer and requiring therapeutic intervention is often underrecognized, underdiagnosed (Néron et al., 2007) and, subsequently, undertreated (Lloyd-Williams and Hughes, 2008). Castelli et al. (2011) draw attention to the fact that medical visits focus mainly on somatic aspects of the disease and depression is often considered a normal reaction to cancer. Raudenská and Javůrková (2011) discuss difficulties in diagnosing depression in terminally ill patients, one of which is the common opinion of both patients and oncologists that sadness is a normal reaction to the process of dying. As a result, they fail to distinguish between natural or existential grief and clinical depression. Some physicians may avoid diagnosing mental problems, hoping to protect both their patients and themselves from extra burdens such as side effects of psycho-pharmacological medications. As the oncology nurse is the health-care team member most familiar with the patient (Hughes, 2006), they can play an important role in diagnosing anxiety and depression. They are the first to notice emotional/behavioral changes in the patient and bring them to the physician's attention (Hughes, 2006). McDonald et al. (1999) study the degree to which nurses recognize levels of depressive symptoms in their patients with cancer as compared with patient-rated depression. The most frequent agreement between nurses and patients is observed when patients report few or no depressive symptoms. A marked tendency exists to underestimate the level of depressive symptoms in patients who are more severely depressed. Therefore, more attention should be paid to diagnosing depression in cancer nursing, including the use of available measuring tools. With these instruments, nurses can identify patients with depression and cooperate in their treatment (Valente and Saunders, 1997). Frequently, oncology nurses care for patients with co-morbid psychiatric conditions and have an opportunity to recognize the symptoms and signs of depression and use relevant interventions. Cutcliffe et al. (2001) report certain commonality between mental health nurses and palliative care nurses, mainly because of their establishment of a therapeutic relationship with patients. Based on their meta-analysis, Singer et al. (2010) claim that although one-third of cancer patients in acute care suffer from mental disorders and need appropriate therapy, there is a lack of paid positions for mental health care professionals in acute cancer care in some countries; as a result, undertreatment occurs in 40%–90% of cases. The authors stress that psycho-social support should also be offered by oncology nurses.

Cancer patients' anxiety and depression adversely affect their quality of life (QoL) (Castelli et al., 2011, Mystakidou et al., 2004, Little et al., 2005, Saevarsdottir et al., 2006, Smith et al., 2003) and decision making and cause caregiver distress, increasing their risk of suicide (Castelli et al., 2011). Lloyd-Williams and Hughes (2008) point to the fact that anxiety is often associated with fear of illness and death, causing physical symptoms and leading to a vicious circle of thought processes that significantly impairs patients' QoL.

Although the impact of anxiety and depression on QoL has been confirmed repeatedly and the goal of palliative care is the achievement of the best possible QoL for patients and their families (Rec, 2003), little attention has been paid to these issues in oncology nursing research and practice (Little et al., 2005). Therefore, monitoring of patients' mental health is an integral part of the multidisciplinary care that is provided. Training of non-psychiatric staff should have the highest priority. A proactive, flexible and comprehensive strategy embracing clinical, scientific and educational aspects is advocated (Stiefel et al., 2001). Additionally, oncology nurses should be prepared to notice changes in patients' QoL and look for their causes (Saevarsdottir et al., 2006), including those stemming from mental health problems.

The objectives of the survey presented were: (1) to use the HADS to determine the presence of anxiety and depression in hospitalized patients in whom curative care has been discontinued; (2) to verify the reliability of a Czech version of the HADS; (3) to ascertain differences in the presence of anxiety and depression with respect to socio-demographic characteristics; (4) to ascertain the relationship between depression and anxiety, and age, health status, and various dimensions of QoL; and (5) to determine whether any such effect could be wholly attributable to the associations of depression with pain or severity of illness.

Section snippets

Design

Observational, cross-sectional study.

Population

The study group comprised 225 patients of University Hospital, Ostrava in whom cancer therapy had been discontinued due to incurable progression of cancer. The patients were admitted to receive palliative care and treatment for their symptoms. The inclusion criteria were as follows: age over 18 years, orientation to person, place and time, with discontinued curative care for cancer. All patients meeting the above criteria (n = 305) were approached to take

Sample characteristics

The entire group comprised 225 cancer patients with a mean age of 65.1 years (SD, 12.6 years; range, 31–93 years). Socio-demographic and illness characteristics of the group are shown in Table 1.

Reliability of the Czech version of the HADS

First, reliability of the Czech version of the HADS was evaluated. Cronbach's alpha was 0.80 for the HADS-a and 0.79 for the HADS-d. The item-total correlation ranged from 0.42 to 0.79 in the HADS-d and from 0.57 to 0.74 in the HADS-a. The test–retest reliability was found to be adequate (r > 0.7) for

Discussion

Consistent with other studies (Martin et al., 2004, Woolrich et al., 2006), the HADS proved to be reliable in the present study. The HADS questionnaire is also a valid tool for palliative care, with specificity (0.85), sensitivity (0.77) and positive predictive value (0.48) being confirmed by Le Fevre et al. (1999). The use of the HADS is recommended as the first step in assessing depression in oncology departments. In case of higher scores, further tests should be used to diagnose depression (

Conclusion

An important principle in palliative care is to provide the highest possible quality of life to patients in their terminal stage. The goals of palliative care and concepts of what contributes to overall anxiety and depression are similar across different countries and cultures. The results of both this study and foreign studies alike consistently confirm an association between the presence of depression in cancer patients and lower QoL. Thus, in palliative care patients, anxiety and depression

Conflict of interest

None to declare.

Acknowledgments

Supported by project Identification of Patient and Family Needs in Palliative Care Related to Quality of Life (IGA MZ ČR NT 13417-4/2012).

The authors thank Ing. Hana Tomášková, Ph.D. for statistical analysis of the data.

References (41)

  • M. Delgado-Guay et al.

    Symptom distress in advanced cancer patients with anxiety and depression in the palliative care setting

    Supportive Care in Cancer

    (2009)
  • P.M. Fayers et al.

    The EORTC QLQ-C30 Scoring Manual

    (2001)
  • A. Girgis et al.

    Palliative Care Needs Assessment Guidelines

    (2006)
  • N. Holtom et al.

    Is the Hospital Anxiety and Depression Scale (HADS) useful in assessing depression in palliative care?

    Palliative Medicine

    (2000)
  • M. Hotopf et al.

    Depression in advanced disease: a systematic review

    Palliative Medicine

    (2002)
  • C.Y. Huang et al.

    An exploratory study of religious involvement as a moderator between anxiety, depressive symptoms and quality of life outcomes of older adults

    Journal of Clinical Nursing

    (2012)
  • M. Hughes

    Psychiatry for the non-psychiatric nurse: caring for the oncology patient with depression or anxiety

    Oncology Nursing Forum

    (2006)
  • D.A. Karnofsky et al.

    The use of the nitrogen mustards in the palliative treatment of carcinoma

    Cancer

    (1978)
  • D. Kissane et al.

    Psychological and existential distress

  • P. Le Fevre et al.

    Screening for psychiatric illness in the palliative care inpatient setting: a comparison between the Hospital Anxiety and Depression Scale and the General Health Questionnaire-12

    Palliative Medicine

    (1999)
  • Cited by (44)

    • Effects of internet-based cognitive behavioral therapy on anxiety and depression symptoms in cancer patients: A meta-analysis

      2022, General Hospital Psychiatry
      Citation Excerpt :

      It is estimated that by 2030 this number will reach 21.6 million, and the substantial increase in the cancer burden will in turn increase the demands on healthcare systems [1]. In addition, cancer diagnosis and the ensuing treatment are often associated with substantial physical and psychosocial challenges, including fatigue, discomfort, pain, stress, distress, anxiety and depressive symptoms [2–4]. Among them, anxiety (17.9%) and depressive (11.6%) symptoms are highly prevalent but often neglected mental disorders [5].

    • Depression in internal medicine inpatients at the time of hospital discharge and referral to primary care

      2022, European Journal of Psychiatry
      Citation Excerpt :

      New methods and strategies may be promising, such as the combined treatment by psychiatrists and PC practitioners52 or the new, stepped care models.53 Strategies of collaborative care have been reported to improve the quality of life in depression in patients with severe physical comorbidity, such as cancer patients,54 and clinically relevant improvements, cost-effective, have been reported in patients with acute cardiac illness.12 Psychiatric consultation in the PC setting, which has been shown to be effective in other areas of the discipline,55 could certainly be effective in this specific problem.

    • Magnitude and factors associated with preoperative depression among elective surgical patients at University of Gondar comprehensive specialized hospital, North West Ethiopia: A cross-sectional study

      2022, Annals of Medicine and Surgery
      Citation Excerpt :

      Although depression is common and associated with a high burden due to disability and mortality, only a small percentage are recognized when it comes to patients awaiting surgical interventions. Moreover, under detection and under treatment of depression continues to be a serious [7]. Reason of under recognition and treatment of depression in patients seeking a surgical intervention and its impact on surgical and anesthetic management outcomes still remain unknown [8].

    • Patient Preferences for Anxiety and Depression Screening in Cancer Care: A Discrete Choice Experiment

      2021, Value in Health
      Citation Excerpt :

      People living with a diagnosis of cancer often experience high levels of anxiety and depression (A&D), and this has been observed across different demographic backgrounds, cancer types, and stages.1,2 Comorbid A&D experienced by patients with cancer are strongly associated with poorer quality of life,3 poorer survival,4 and an increased risk of suicide.5 In busy cancer services, A&D are often undetected or underestimated,6 and many patients report unmet needs for psychosocial care.7

    • Rapid screening of depression and anxiety in cancer patients: Interview validation of emotion thermometers

      2021, Asian Journal of Psychiatry
      Citation Excerpt :

      The most balanced cutoff score for generalized anxiety measured by GAD-7 confirmed the results of previous findings and the commonly used anxiety limits (Kadan-Lottick et al., 2005; Spitzer et al., 2006). Anxiety and depression have been found to negatively affect the QoL of cancer patients (Ociskova et al., 2017; Buzgova et al., 2005). ET is based on the original distress thermometer, which has a long tradition in oncology (Hegel et al., 2008a, 2008b; Mitchell et al., 2010).

    View all citing articles on Scopus
    View full text