The majority of studies that have assessed depression in posttreatment cancer survivors have included in their sample individuals with disparate cancer diagnoses. As such, few studies exist in the literature examining the prevalence of depression in patients with a single cancer diagnosis. Several exceptions to this are studies that have focused on depression in breast cancer survivors. In one such study, longer term survivors of breast cancer had a clearly increased risk of depression (between 22 and 30%) compared to those with benign breast disease (less than 10%).38 In another, Kornblith and Ligibel37 pointed out that a significant subset of breast cancer survivors continue to experience significant depression and anxiety as long as 4 years posttreatment. They note that depression seems to be mediated in long-term survivors of breast cancer by ongoing medical sequelae, such as lymphedema.
In a study of 121 head and neck cancer survivors, Derks and colleagues43 found that over the course ofthe year following treatment, the number ofpatients reporting significant depressive symptomatology increased. This was also tied to a decrease in social support and lower Karnofsky performance scores. These results suggest that functional status and the absence of social support likely contribute to the development of depression.
8.2. Treatment Type, Age, and Prior History of Depression
Some relationship has been observed between the type of treatment provided to the cancer survivor (e.g., chemotherapy, surgery, stem cell transplant) and depression. In a study of 63 women following chemotherapy for ovarian cancer, Hipkins and colleagues44 assessed levels of anxiety and depression. Thirty-three percent of their sample met clinical criteria for depression immediately after discontinuation of chemotherapy. After 3 months, the rate of clinical depression dropped to 19% (though interestingly, the rates of anxiety disorders increased immediately from post chemotherapy). In their sample, medical parameters, such as stage of disease, response to treatment, Ca125 levels, and performance status were not associated with worse psychological outcome.
Middelboe et al.45 assessed 36 patients before and after chemotherapy using the Hamilton Depression Scale (Ham-D), with scores greater than 12 qualifying as minor depression and greater than 17 as major depression. At baseline, prior to any chemotherapy, 12 (33%) individuals were between 13-17 and 5 (14%) were above 17 on the Ham-D. At 3-month follow-up, these percentages were 5 (17%) and 3 (10%) respectively, while at the 6-month follow-up 3 (13%) and 2 (9%) were above the cutoffs. As such, although nearly half the sample evidenced at least minor depression before treatment, by the end of treatment this had dropped to slightly over a quarter, with further reduction thereafter.
There appear to be few differences in rates of depression based on surgery type in breast cancer after 1 year postsurgery. Women receiving lumpectomy surgery as opposed to lumpectomy and radiation or mastectomy had higher rates of depression initially, but rates of depression were roughly equal between groups at 1-year follow-up.46,47 Ganz and colleagues48 report similar findings, with no differences in depression or emotional functioning in women receiving mastectomy versus lumpec-tomy at the end of primary treatment.
In a study of older adults greater than 5 years posttreatment, Deimling and colleagues49 found a 25% incidence of depression. They hypothesized that increasing age may be a risk factor for depression. In addition, they found that individuals who had received chemotherapy were more likely to be depressed. Patients who continued to experience physical or functional impairment were also more likely to be depressed.
Hjermstad and colleagues50 performed a prospective study of 128 patients undergoing conventional chemotherapy, autologous stem cell transplant, or allogeneic transplant and followed these patients for 3-5 years posttreatment. The authors found that patients receiving allogeneic transplantation displayed more symptoms in the first months posttransplant. In both transplanted groups, gradual improvement in functional status and symptoms occurred for 4—6 months, then stabilized at baseline levels. Only minor changes occurred after the first year. All groups reported more fatigue than population values after 3 years. Interestingly, the autologous transplant group reported less optimal quality of life and more fatigue compared to the allogeneic group, but there were no differences between groups in terms of depression.
Somewhat different findings were reported by Syrjala and colleagues51 in a prospective, longitudinal study of 94 stem cell transplant survivors. The authors reported that only 19% of patients recovered fully by 1 year posttransplant, with the proportion of fully functional survivors increasing to 63% by 5 years. Patients who had more experience with cancer treatment before their transplant showed more rapid recovery from depression. Risk factors for depression after transplant included chronic graft versus host disease (GVHD), less social support before transplant, and female gender. Overall, there have been mixed results in terms of the impact of various treatments (chemotherapy, radiotherapy, surgery) on rates of depression. By and large, the type of treatment does not seem to have a significantly predictive role in depression. It does, however, appear that rates of depression are higher in individuals receiving the most intensive treatment (e.g., stem cell transplantation) and this appears related to the long duration to recovery.
Age has also been studied in terms of depressive risk. Deimling et al.'s49 speculation that age may increase depression risk was contradicted by Schroevers, Ranchor, and Sanderman.52 These authors conducted a longitudinal study, following three different age groups of cancer survivors over time from diagnosis to 8 years afterwards. They found that younger survivors were more likely to be depressed at the time of diagnosis and during treatment, but at 8-year follow-up, the group differences in depression were gone, suggesting no difference between groups in depressive risk years after treatment. These findings were similar to those of Weitzner et al.5 who found no significant relationship between age and depression in long-term survivors. Overall, the available information suggests that age is not reliably correlated with depression.
As noted by Syrjala et al. above, depression after cancer treatment is also correlated with a previous history of depression.54 Presence of depression and anxiety at time of admission has also been correlated with increased risk of depression after stem cell transplant.55 In addition, availability of social support appears to lead to decreased risk of depression in patients with head and neck cancer.56 In this same population, younger age, advanced disease, and lower performance status have been correlated with increased risk of depression after treatment ends.57,58
Cancer represents both an acute and long-term stressor, which can generate a variety of coping responses. Research has for some time investigated the ways in which coping during cancer treatment may impact psychological distress. Only recently, however, has coping been investigated in samples of patients who have completed cancer treatment. The implication of coping mechanisms on development of depression after cancer treatment is reviewed in this section. A brief caveat is in order: coping is a multidimensional concept, and has been measured using a variety of assessment techniques and theoretical models. Discussion of these theoretical constructs is beyond the scope of this paper, but readers are directed to the work of Deimling and colleagues49 for a review.
Hack and Degner59 performed a longitudinal study of the relationship between coping style and distress. They found that there was a positive correlation between acceptance/resignation at baseline (6 months or less after diagnosis) and depression at the 3-year follow-up. McCaul and colleagues60 investigated recently diagnosed, early stage breast cancer patients and found that avoidant coping was associated with depression at baseline (time of diagnosis) and also at 4 months post-baseline. Moorey and colleagues investigated a relatively new coping questionnaire, the Cancer Coping Questionnaire (CCQ),61 and found that greater use of coping strategies was associated with lower levels of depression. Nordin and Glimelius62 assessed patients with gastrointestinal cancer during the period from diagnosis until 1 year later. They found that patients demonstrating helplessness/hopelessness at baseline were more likely to be depressed 1 year later. Schou et al.63 found that cancer survivors displaying high levels of dispositional optimism were less likely to be depressed 1 year following initial surgery. The relationship between depression, coping strategies, and the approaches individuals take to a cancer diagnosis and treatment needs to be looked at in different cancers with different trajectories of recurrence or different mortality and morbidity profiles.
Schou's finding was replicated by Deimling et al.,64 who investigated 321 older adults greater than 5 years post-diagnosis, and found that survivors with high levels of optimism were less likely to be depressed. In addition, survivors who utilized venting or denial as coping mechanisms were more depressed. The most powerful predictor of depression was functional impairment. Interestingly, the authors found that African-American survivors had significantly lower levels of depression than Caucasian survivors. The flip side of the trait of optimism is a tendency toward negativity (neuroticism), which was found to increase risk for depressive symptoms in one study of women after breast cancer surgery.65
In summary, it appears that the coping mechanisms utilized, and also the dis-positional traits (i.e., optimism versus negativity) of cancer survivors may play a key role in predicting depression after cancer treatment ends. This relatively new area of research certainly merits further investigation and clarification in the future.
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It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.