Anxiety, depression and cancer

Cancer care must incorporate the psychosocial and biological The clinical oncologists of all stripes have, for too long, overlooked or ignored the psychological factors that may, for all we know at present, play a surprisingly large role in individual susceptibility to neoplasia. They are certainly influential in affecting the course of treatment, the adaptation to the illness, and hence, in some ways, not all of which are yet understood, affect the outcome of treatment. Lewis Thomas in the foreword to the Handbook of Psychooncology, 19891 The publication of the Handbook of psychooncology,1 later to grow into the substantial textbook Psycho-oncology,2 heralded the beginning of the field of psychooncology. Psychological factors had long been linked with the cause or progress of much human illness, and yet were being increasingly ignored because of a lack of substantial evidence and a strengthening of the biological understanding of disease. The work represented by the publication of these volumes identified the beginning of both a clinical and research interest that continues strongly to this day. Cancer is the first field of medicine where psychosocial factors have been taken seriously. This was partly because of the potency of cytotoxic drugs and the severity of adverse effects. This led to a need to consider “quality of life”, and to balance this with gains in longevity of life. Quality of life is a subjective matter that requires consideration of complex psychosocial and relational matters and values. These cannot be measured by blood tests. In addition, cancer, more than any other disease, confronts us all with serious existential issues. It challenges the sense of control we might think we have over our lives, and raises the possibility of the purposelessness and futility of life, as well as raising questions about what is a good life and a good death. The field of psychooncology has contributed much over the years. We have seen serious attention given to communicating “bad news” to patients and to “truth telling”, maximising patients’ involvement in care decisions and maintaining dignity. Various behavioural and psychological interventions have been shown to be effective in relieving patients’ anxiety and depression. Attention has been given to the stress that carers and loved ones experience through the cancer journey, and how strained the support networks can be at times; at other times and for other people, the cancer journey can be a “growth” experience.3 The articles in this Medical Journal of Australia supplement showcase the quality of work currently being done in this area. They range from the use of a large epidemiological survey to tease out the connections between cancer and depression,4 to descriptions of systemic interventions of screening and psychosocial care.5 There is evidence for the effectiveness of psychosocial interventions in relieving distress and assisting in psychosocial adjustment for people in the experience of cancer, although much work remains to be done. Current levels of evidence have been well summarised in published National Health and Medical Research Council (NHMRC) guidelines.6 However, these interventions are not routinely offered by cancer services to patients and their families. So, despite the development of an evidence base over the past few decades, and the acknowledged good things happening in the clinical domain in the area of communication skills for health professionals,7 clinical practice lags behind evidence and standards of best practice. To correct this, we need champions in the field talking about the issue, consumers and carers participating in the research and sharing their experiences, and leading practice-policymakers and health providers with the moral courage to fully implement “evidence-based” and humane care beyond the trial phase. The importance of this is not diminishing as medical science takes us into new areas (such as genetic screening, which is producing a cohort of people who, while well, live with the anxiety of developing cancer at any time in their life), which throw up ever- new ethical and clinical challenges. beyondblue and Cancer Council Australia are committed to working together towards seeing the development of an integrated approach to cancer care incorporating the psychosocial and biological; and beyondblue will continue to encourage and support research that advances knowledge and improved practice in the area by investing in applied research and by partnering with Cancer Australia in the NHMRC’s Priority-driven Collaborative Cancer Research Scheme.

David M Clarke PhD, FRACGP, FRANZCP

Objectives: To examine the prevalence and predictors of depression and anxiety in palliative care patients with cancer in Western Australia and New South Wales.Design, setting and participants: A descriptive study of 266 consecutive patients at a range of inpatient and outpatient settings including home care, hospices, and private and tertiary care hospitals in WA and NSW from 1 March to 30 June 2002.Main outcome measures: Self-reported anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) at a cut-off score of ≥ 8 on each subscale (depression and anxiety) for possible cases, and of ≥ 11 for probable cases; a cut-off score of ≥ 19 was used for probable combined depression and anxiety.Results: Patients included 200 in WA and 66 in NSW. For the whole sample, 45.8% of patients were possibly depressed and 22.7% probably depressed; 36.9% were possibly anxious and 19.8% probably anxious. About 25% of patients had probable combined depression and anxiety. Logistic regression analyses indicated that past anxiety in the family predicted probable depression, while age, marital status and past depression predicted probable anxiety. Age and past depression predicted probable combined depression and anxiety.Conclusions: These findings underscore the need for routine screening for anxiety and depression in palliative care settings, including questions about past personal and family history of anxiety and depression, and the need for a range of interventions and support services.

Moira O’Connor BA(Hons), MSc, PhD · Kate White RN, MN, PhD · Linda J Kristjanson BN, MN, PhD · Kerry Cousins RN, BN · Lesley Wilkes PhD, RN, CM

Objective: To assess symptoms of depression and anxiety in patients with head and neck cancers (HNCs) before and after radiotherapy.Design, participants and setting: Prospective observational study of 102 outpatients with HNCs at a tertiary cancer centre in Melbourne between 1 May 2008 and 30 May 2009. Eligibility criteria were a first-time diagnosis of HNC, age over 17 years, and agreement to undergo cancer treatment involving radiotherapy with curative intent. Data were collected before commencement of radiotherapy and again 3 weeks after completing treatment.Main outcome measures: Symptoms of depression and anxiety as assessed by the Hospital Anxiety and Depression Scale (HADS); physical and psychosocial aspects of quality of life as assessed by the Functional Assessment of Cancer Therapy–Head and Neck (FACT-H&N).Results: Seventy-five participants completed pretreatment and posttreatment questionnaires. Mean depression scores increased significantly from before to after treatment, while anxiety scores decreased significantly over the same period. The prevalence of mild to severe depression was 15% before treatment and 31% after treatment. The prevalence of mild to severe symptoms of anxiety was 30% before treatment, reducing to 17% after treatment. Posttreatment depression was predicted by pretreatment depression and receiving chemotherapy. Posttreatment anxiety was predicted by pretreatment anxiety and male sex.Conclusions: These findings suggest that rates of depression in patients with HNCs increase after cancer treatment, with a third of patients experiencing clinically significant symptoms of depression after radiotherapy.

Kate A Neilson BBSc(Hons), DPsych(Clinical) · Annabel C Pollard RN, GradDipAppPsych. MPsych(Clinical) · Ann M Boonzaier BA(Hons), MA(Psychology), DPsych(Clinical) · June Corry MD, FRACP, FRANZCR · David J Castle MD, MRCPsych, FRANZCP · Karen R Mead BAHons(Psychology), MPsych(Clinical) · Marcelle C L Gray BA(Psychology), PGradDip(Psychology) · David I Smith BBSc(Hons), MPsych, PhD · Tom Trauer PhD, ABPsS, MAPsS · Jeremy W Couper MD, MMed(Psych), FRANZCP

Objectives: To assess the prevalence and predictors of depression and anxiety in women with ovarian cancer and their caregivers, to compare levels of depression and anxiety with community norms, and to explore the relationship between patients and their nominated caregivers.Design, setting and participants: Prospective cohort study of 798 women with invasive ovarian cancer recruited between 1 January 2002 and 30 June 2006 through the nationwide Australian Ovarian Cancer Study, and 373 of their caregivers.Main outcome measures: Depression and anxiety as assessed with the Hospital Anxiety and Depression Scale, and the role of demographic variables, disease and treatment variables, psychosocial variables, and use of mental health and support services as potential predictors.Results: Rates of anxiety and depression among patients were significantly lower than in previous reports, although clinical depression rates (5.9%) were significantly higher than community norms (3.0%; χ2 = 24.0; P < 0.001). Caregivers also reported higher levels of depression (χ2 = 21.1; P < 0.001) and anxiety (χ2 = 17.6; P < 0.001) compared with norms. There was no difference within patient–caregiver pairs for depression (P = 0.1), while caregivers reported significantly higher anxiety than patients (P < 0.01). In patients, higher symptom burden, lower optimism and current specialist mental health treatment all significantly predicted both depression and anxiety, while lower social support was a significant predictor of patient anxiety only. In caregivers, lower social support and lower optimism were significant predictors of depression and anxiety. Patients being treated for mental health was also a predictor of their caregiver’s depression.Conclusions: While depression is significantly more common in women with ovarian cancer than in the general population, it is caregivers of such patients who report much higher levels of both subclinical and clinical depression and anxiety.

, the Australian Ovarian Cancer Study Group and the Australian Ovarian Cancer Study Group Quality of Life Study Investigators

Objective: To assess psychosocial distress in patients with early (localised) and advanced (metastatic) prostate cancer (PCA) at diagnosis (Time 1) and 12 months later (Time 2), and identify psychosocial factors predictive of later distress.Design, participants and setting: Observational, prospective study of 367 men with early (211) or advanced (156) PCA recruited as consecutive attendees at clinics at seven public hospitals and practices in metropolitan Melbourne between 1 April 2001 and 30 December 2005. Both groups completed questionnaires at Time 1 and Time 2.Main outcome measures: Health-related quality of life as assessed by the Short Form 36-item Health Survey; psychological distress, including depression and anxiety as assessed by the Brief Symptom Inventory; and coping patterns as assessed by the Mini-Mental Adjustment to Cancer scale.Results: Over the 12 months, both the early and advanced PCA group showed reduced vitality and increased depression and anxiety; this effect was greater in the advanced PCA group. Mental health, social functioning and role-emotional functioning also deteriorated in the advanced group. Predictors of depression at Time 2 for the early PCA group were depression, vitality and a fatalistic coping pattern at Time 1; anxiety at Time 2 was predicted by anxiety and vitality at Time 1. In the advanced PCA group, depression at Time 2 was predicted by depression and mental health at Time 1; anxiety at Time 2 was predicted by anxiety, mental health, cognitive avoidance and lower anxious preoccupation at Time 1.Conclusions: Men with early PCA experience decreasing vitality and increasing psychological distress over the 12 months following diagnosis; this trend is accelerated after diagnosis with advanced PCA. A fatalistic coping pattern at diagnosis of early PCA predicts later depression while cognitive avoidance and lower anxious preoccupation at diagnosis of advanced PCA predict later anxiety.

Jeremy W Couper MD · Anthony W Love PhD · Gillian M Duchesne MD · Sidney Bloch PhD · Michelle Macvean PhD · Judy V Dunai PhD · Marita Scealy DPsych · Anthony Costello MD · David W Kissane MD

Objective: To investigate whether the observed elevated levels of psychological distress in cancer survivors relate specifically to aspects of cancer diagnosis, to treatment or to disability.Design, participants and setting: Self-reported questionnaire data on demographic, health and lifestyle factors and mental health from 89 574 Australian men and women aged 45 years or older, sampled from the Medicare database for the 45 and Up Study from 1 February 2006 to 30 April 2008. Logistic regression was used to examine the risk of high levels of psychological distress in relation to cancer diagnosis and disability, adjusting for age, sex, income and education.Main outcome measure: High psychological distress (Kessler Psychological Distress Scale score ≥22).Results: Overall, 7.5% of participants had high levels of psychological distress. Among cancer survivors, the median time since diagnosis was 7.3 years. Compared with people without cancer, the odds ratios (95% CIs) for psychological distress were: 1.17 (1.09–1.26) in people reporting having had any cancer apart from non-melanoma skin cancer; 1.34 (1.08–1.67) in those with cancer diagnosed in the previous year; 1.53 (1.33–1.76) for those reporting treatment for cancer in the previous month and 1.11 (1.03–1.19) for those with cancer but without recent treatment. Using individuals with neither cancer nor disability as the reference group, the adjusted odds ratio (95% CI) for psychological distress was 6.51 (5.95–7.12) in those reporting significant disability but no cancer, 1.14 (1.04–1.24) in those without disability but with cancer and 5.81(4.88–6.91) in those with both cancer and disability.Conclusion: The risk of psychological distress in individuals with cancer relates much more strongly to their level of disability than it does to the cancer diagnosis itself.

Emily Banks MBBS, PhD, FAFPHM · Julie E Byles PhD · Richard E Gibson BSc · Bryan Rodgers MSc, PhD · Isabel K Latz MSc · Ian A Robinson BSc · Anna B Williamson PhD · Louisa R Jorm BVSc, MSc, PhD

Objective: To evaluate the efficacy of an interactive self-help workbook in reducing distress, and improving quality of life (QOL) and coping for women recently diagnosed with breast cancer.Design: Randomised controlled trial comparing the use of the workbook and that of an information booklet.Participants and setting: 49 women with Stage 0 to II breast cancer diagnosed in the previous month and recruited from 1 February 2007 to 1 February 2008, in two urban Australian public hospitals.Main outcome measures: The primary outcome measures were depression, anxiety, and posttraumatic stress. Secondary outcomes included QOL, body image, and the coping styles helplessness/hopelessness, cognitive avoidance and anxious preoccupation.Results: After controlling for baseline levels, interactions at 3-month follow-up showed that participants in the workbook group had significantly lower levels of posttraumatic stress (F [1,89] = 7.01; P = 0.01), helplessness/hopelessness (F [1,89] = 4.75; P = 0.03), and cognitive avoidance (F [1,89] = 4.95; P = 0.03) than those in the control (information booklet) group. However, women in the workbook group had significantly poorer body image than those in the control group (F [1,89] = 6.43; P = 0.01). At 6 months, only the body image interaction remained significant (F [1,93] = 7.44; P = 0.01).Conclusion: These results suggest that a self-help workbook can be an effective, short-term intervention for improving posttraumatic stress, cognitive avoidance, and certain depressive symptoms in women recently diagnosed with breast cancer. However, issues related to body image need to be dealt with differently.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12609000934246.

Lisa J Beatty · Bogda Koczwara · Janet Rice · Tracey D Wade

Objective: To describe the outcomes and clinical experience of a 12-week pilot study of routine distress screening of newly admitted patients to an acute haematology and oncology ward.Design, patients and setting: Bedside measurement of psychological distress, and collection of demographic and clinical data for 115 newly admitted patients in an acute haematology and oncology ward of The Alfred hospital in Melbourne between 5 June and 25 August 2006.Main outcome measures: Psychosocial distress as measured by the Distress Thermometer and Problem Checklist, and 18-item Brief Symptom Inventory; rate of referral to psychology and social work services in the 12 weeks before and 12 weeks during the pilot study; ward staff feedback on the benefits and challenges associated with routine distress screening.Results: 51% of patients were identified as being significantly distressed, of whom 47% had not received psychosocial support before screening. A significantly higher number of emotional and physical problems were reported by significantly distressed patients. Referrals to psychology and social work services during the pilot study increased, highlighting that screening directed more patients into care. Staff were generally positive about the ability of routine screening to help them care for their patients, and most agreed that some form of routine screening should continue.Conclusion: The use of routine distress screening by inpatient cancer services can significantly improve their capacity to offer psychosocial care.

Stuart J Lee BA(Hons), DPsych · Lynda J Katona BA(Hons), MPsych · Sue E De Bono BA, BSW · Katrina L Lewis RN

Objective: To assess the impact of an 8-week structured mindfulness-based cognitive therapy (MBCT) program on individuals experiencing distress as a consequence of cancer.Design, setting and participants: Prospective study of 16 participants with a history of cancer and five carers of people with cancer recruited from August 2008 to February 2009 through calls to the Cancer Council South Australia Helpline. Participants were assessed for anxiety and depression before and after undergoing a course in MBCT between 30 September and18 November 2008 and 20 February and 10 April 2009.Main outcome measures: Depression, anxiety and mindfulness as measured by the Beck Depression Inventory-II (BDI-II), State–Trait Anxiety Inventory (STAI), and Freiburg Mindfulness Inventory (FMI), respectively, and a consumer-centred evaluation.Results: There were significant reductions in depression (F [1,24] = 6.37; P = 0.012; partial-η 2 = 0.27) and anxiety (F [2,34] = 9.43; P = 0.001, partial-η 2 = 0.36) and mindfulness (F [2,32] = 8.36; P = 0.001; partial-η 2 = 0.34) following the intervention, and these effects were sustained at the 3-month follow-up. Reliable change indices further support these findings. Participants’ scores on measures of depression and anxiety decreased as a function of increased mindfulness, as reflected by significant (P < 0.05) negative correlations between FMI scores and BDI-II scores (ranging from r = − 0.46 to r = − 0.79) and STAI scores (ranging from r = − 0.46 to r = − 0.50) scores at all time points.Conclusion: The MBCT program appears to be an efficacious intervention for use among people affected by cancer who also experience symptoms of depression and anxiety.

Greg R Sharplin BHSc(Hons), BSc · Simeon B W Jones BHSc(Hons), BA · Barbara Hancock DipNurs, DipCouns · Vikki E Knott BA(Hons), PhD · Jacqueline A Bowden MPH, BA(Hons) · Hayley S Whitford PhD

Objective: To test the feasibility and acceptability of a telephone-based program to screen survivors of colorectal cancer (CRC) for distress, and to refer distressed patients to their treating health service.Design, setting and participants: A prospective, multicentre study involving 59 patients with CRC recruited from six public and private health services in Melbourne, Victoria, from 15 June 2008 to 22 September 2009. Patients who had completed adjuvant chemotherapy for CRC were contacted (7–10 days after recruitment [outcall one] and again 4 weeks later [outcall two]) by the Cancer Council Victoria’s helpline nurse, and screened for distress with the Distress and Impact Thermometer (DIT); participants were given tailored information and support and those with distress scores of ≥ 5, and impact scores of ≥ 4, were referred for follow-up. Telephone interviews were conducted 4 weeks after outcall two. Participating helpline and health service staff were surveyed on the feasibility and acceptability of the service.Main outcome measure: Anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS).Results: Of the 59 patients (87%) who agreed to participate, 63% were men; their mean age was 59 years (SD, 9.5 years). HADS depression decreased significantly from baseline (mean score, 4.93; SD, 4.22) to follow-up (mean score, 3.84; SD, 4.10; Z = − 2.375; P = 0.02). However, there was no significant difference in HADS anxiety between baseline (mean score, 5.29; SD, 4.11) and follow-up (mean score, 4.78; SD, 3.65). Outcall one generated two referrals (4% of participants) and outcall two generated four referrals (8%); five of these six participants took up the referrals. Satisfaction with the program among participants was high; 82% found outcall one “quite or very helpful” and 79% found outcall two “quite or very helpful”. Helpline and health service staff reported a straightforward process that did not adversely affect workloads. Conclusion: This model of care carries the potential to meet ongoing psychosocial needs of survivors of CRC.

Patricia M Livingston PhD · Melinda J Craike PhD · Victoria M White PhD · Amanda J Hordern PhD · Michael Jefford MPH, PhD, FRACP · Mari A Botti PhD · Carrie Lethborg PhD · John C Oldroyd PhD