Professional Documents
Culture Documents
%
Reference N female Patients % depressed Method Specific findings Gender difference
Hinton 1972 (14) 50 72 Hospitalized; 58% Interview 42% anxious; 34% Not cited for depression;
terminally ill; mixed adjustment reaction; more psychiatric
neoplasms, one 10% confusional referrals for breast
collagen-vascular state cancer; fewer men
with lung cancer
referred; low referrals
for digestive
neoplasms
Levine 1978 (15) 100 51 Hospitalized; all stages 56% Interview; DSM- 40% OBS; 26% OBS 2:1 female to male ratio
and sites II criteria misdiagnosed as to psychiatric referrals;
depressed by NS trend of more OBS
referring physicians; in males than females
58% of depressed in under 60
had metastases
Massie 1979 (16) 334 57 Hospitalized; and 49%; 5% extreme; Interview; DSM- 15% organic; all Women referrals higher
ambulatory; all 24% severe; II criteria patients with severe than men; 1:13 M:F
stages and sites 71% mild to or extreme
moderate depression had
advanced cancer
Massie and Holland 546 Not Hospitalized and 9% major Interview; DSM- 59% of referrals Not cited
1987 (17) cited ambulatory; all depression; 26% III criteria depressed or
stages; all sites; adjustment suicidal; good
referred for disorder with premorbid func-
psychiatric depressed mood tioning with only
consultation 11% psychiatric
history
Razavi 1990 (18) 128 Not Hospitalized; mixed; 26% major Semistructured Depression higher in Not cited
cited 88 psychiatric depression; 46% interview from predeterminal or
referrals out of total adjustment the Diagnostic terminal
of 210 (141 females disorder Interview
69 males) Schedule;
HADS
*DSM-II, Diagnostic Manual of Mental Disorders, 2nd edition; OBS, organic brain syndrome; NS, not significant; HADS, Hospital Anxiety and Depression Scale.
Adapted with permission from Oxford University Press (9).
Fras et al. 110 Not Pancreatic and colon cancer Semi-structured interview; 50% (pancreas); 13% (colon) 76% psychiatric symptoms in those with
(1967) (20) cited MMPI pancreatic cancer; psychiatric symptoms
appeared before other symptoms in
patients with pancreatic cancer
Koenig et al. 36 50 Hospitalized; advanced MMPI 25% Cancer patients less psychopathology than
(1967) (21) bowel cancer depressed psychiatric inpatients
Peck et al. 50 54 Ambulatory radiotherapy: Clinical interview Major depression-not cited; 10% severe depression; 32% moderate
(1972) (22) all sites; all stages 74% affective symptoms depression; 32% mild depression
Craig et al. 30 63 Hospitalized; all sites, SCL-90 53% 13% severe depression; 40% moderate
(1974) (23) advanced depression; 30% anxious
Morris et al. 160 100 Breast biopsy and Interview; HRSD 22% depression in mastectomy Mastectomy patients had persistent
(1977) (24) mastectomy patients depression (22%) at 2 years compared
with benign patients (8%)
Plumb et al. 97 52 Hospitalized, all sites, BDI 23% cancer patients depressed; 19% moderate severity; 4% severe; cancer
(1977) (25) advanced; compared to 54% psychiatric patients patients and their next of kin were less
99 psychiatric inpatients depressed depressed than physically healthy
with recent suicide suicide attempt patients
attempt
Maguire et al. 201 100 117 ambulatory breast Clinical interview 26% moderate or severe Control benign patients had 12%
(1978) (25) cancer patients; 89 depression after mastectomy depression
benign disease
Silberfarb et al. 146 100 Hospitalization status not Structured interview; open- 10% depression in primary Physical disability did not relate to
(1980) (26) indicated; 34% primary ended questions; modified cancer diagnosis; 15% in emotional disturbances; first recurrence
disease; 36% recurrent; psychiatric status scale recurrent; 4.5% advanced of breast cancer most disturbing time;
(Table continues)
Davies et al. 72 40 Hospitalized; oropharyngeal Leeds Scale for Self- 22% Patients and investigators were blind to
(1986) (36) cancer assessment of Depression; biopsy results; more depression (29 vs.
General Health 15%) in those with positive biopsy
Questionnaire
Evans et al. 83 100 All hospitalized women DSM-III; HRSD 23% major depression; 24% DST 40% sensitivity, 80% specificity
(1986) (37) with gynecological adjustment disorder with
cancer (excluding depressed mood
ovarian)
Holland et al. 218 36 Ambulatory; 107 advanced POMS Major depression-not cited; 21 Pancreatic cancer patients had higher
(1986) (38) pancreatic, 111 advanced median depression than gastric cancer among
gastric POMS gastric; 38 median men only
POMS pancreatic
Joffe et al. 21 29 Hospitalized; pancreas 12, SADS-L; SCL-90-R; BDI, Major depression: 33% 19% of new pancreatic cancer patients had
(1986) (39) gastric, 9 STAI, RDC pancreas; 0% gastric; major a history of major depression in the
depression and adjustment year prior to diagnosis; DST: Pancreas
disorder: 50% pancreas, 6 of 6 nonsuppression (1 major
11% gastric depression): Gastric: 5 of 6
nonsuppression (0 major depression)
Devlen et al. 90 48 Ambulatory; Hodgkins Semi-structured interview 19% depressed; 27% Retrospective study; with interviews
(1987a) (40) disease and non- borderline depression conducted a mean of 32 mo after
Hodgkins lymphoma diagnosis
Devlen et al. 120 47 Ambulatory; Hodgkins Semi-structured interview 8% depressed in year after Prospective study with interviews at
(1987b) (41) disease and non- treatment baseline, 2, 6, and 12 mo after
Hodgkins lymphoma diagnosis
(Table continues)
Goldberg et al. 320 100 Newly diagnosed, Modified RSCL; pre- 32% depressed malignant; 24% At 1 y, depression had decreased (21%
(1992) (58) hospitalized for breast operative, 6 and 12 mo depressed benign biopsy depressed) in both groups
cancer surgery post-operatively
Maraste et al. 133 100 Ambulatory; adjuvant HADS 1.5% depressed; 14% anxiety Age and surgery related anxiety; anxiety
(1992) (59) radiotherapy; breast in ages 5059 y was 44% in
cancer mastectomy vs. 4% in conservative
surgery
Sneed et al. 133 67 Hospitalized; newly BSI; HIS-GWB Major depression-not cited Women with gynecological and breast
(1992) (60) diagnosed; mixed sites cancer had less depression, anxiety,
and stages hostility, somatization, psychological
distress than men and women with other
cancers
Alexander et al. 60 40 Hospitalized on oncology DSM-III-R; clinical interview 13% depressed; 20% Those who were unaware of cancer
(1993) (61) unit in India; mixed sites adjustment disorder; 40 diagnosis (33%) or considered the
and stages psychiatric disorder; 7% treatment curative (82%) had less
anxiety disorders psychiatric morbidity
Carroll et al. 809 51 Various cancer sites HADS 17.7% anxiety disorder 9.9%
(1993) (62) depressive disorder
Cathcart et al. 257 100 Ambulatory; women with Clinical interview 15% tamoxifen treated group; 4.5% of 155 women receiving tamoxifen
(1993) (63) node negative breast 3% in those not receiving had to discontinue it secondary to
cancer; 155 women tamoxifen depression
received tamoxifen; 102
received no tamoxifen
Pinder et al. 139 100 86 hospitalized, 53 HADS interview 13% depressed; 25% anxiety Depression more prevalent in low
(Table continues)
Aass et al. 716 63 Various cancer sites HADS, EORTC; QLQ-C33; 9% depression; 15% anxious
(1997) (79) HOC Questionnaire
Allen et al. 42 33 Adolescents 1220 y, BDI, STAI 38% mild to severe depression;
(1997) (80) cancer variable 9.5% anxious
Chochinov et 197 52 Advanced terminally ill BDI; VAS; Semi-structured 12.2% depression, 7.6% major
al. (1997) cancer diagnostic interview depression, 4.6% minor
(81) depression
Pasacreta 79 100 Breast cancer, 37 mo after Interview with DIS; CES-D; 9% depression disorder
(1997) (82) diagnosis Symptom distress scale; 24% depression symptoms
ESDS and Cognitive
capacity screening test
Berard et al. 456 75 Breast; head and neck; HADS; BDI, Structured 14% depression overall; 8%
(1998) (83) lymphoma psychiatric Interview depression (overlap with
both scales)
Buccheri 133 Not Newly diagnosed lung SDS; QOL questionnaire 44.2% moderately or severely
(1998) (84) initially citied cancer depressed
95
completed
study
Kissane et al. 303 100 Early stage breast cancer HADS, MILP, EORTC-QLQ 45% psychiatric disorder; 42% 8.6% anxiety disorder
(1998) (85) depression and/or anxiety;
27.1% minor depression;
9.6% major depression
Montazeri et al. 129 40 Lung cancer HADS (administered at Baseline: 6% borderline
(Table continues)
DeLeeuw et al. 197 22 Head and neck cancer CES-D; EORTC; QOL 42% depression 6 mo to 3 y
(2001) (102) initially; C303 after treatment
123 at the
end of 3 y
Hutton et al. 18 28 Head and neck cancer HADS 22.2% anxious; 22.2%
(2001) (103) (previously treated) depression; 22.2%
psychiatric distress
Montazeri et al. 56 100 Breast cancer HADS administered before Anxiety: 29% initially 2% after
(2001) (104) and 1 y after support group group
Depression: 14% initially 0%
after group
*NS, not significant at P 0.05. AMTS: 10-Question, Abbreviated Mental Test Score; BDI, Beck Depression Inventory; BHS, Beck Hopelessness Scale; BSI,
Brief Symptom Inventory; CIDI, Composite International Diagnostic Interview; CAPPS, Current and Past Psychopathological Scales; CES-D, Center for
Epidemiology Self-report Depression Scale; CPRS, Copenhagen Psychiatric Rating Scale; CRS, Carroll Rating Scale for Depression; CAPPS, Current and Past
Psychiatric Adjustment Scale; DACL, Lubin Depression Adjective Check List-form E; DIS, Diagnostic Interview Schedule; DSM-II, Diagnostic Manual of Mental
Disorders, 2nd edition; DMS-III, Diagnostic and Statistical Manual of Mental Disorders, 3rd edition; EORTC-QLQ-C30, European Organization for Research and
Treatment of Cancer-Quality of Life Questionnaire; EPQ Eysenck Personality Questionnaire; ESDS, Enforced Social Dependency Scale; FLIC, Functional Living
Index of Cancer; GAIS, Global Adjustment to Illness Scale; GARS, Global Assessment of Recent Stress; HRSD, Hamilton Rating Scale for Depression; HAS,
Hamilton Anxiety Scale; HADS, Hospital Anxiety and Depression Scale; HDS, Hamilton Depression Scale; HIS-GWB, Rand Health Insurance Study-General
Well-Being Schedule; IBQ, Illness Behavior Questionnaire; KPS, Karnofsky Performance Status Scale; MADRS, Montgomery Asberg Depression Rating Scales;
findings usually were not reported by demographic variables, other cancers, such as colon (13%25%) (20,21), gynecological
and racial minorities were always underrepresented. (12%23%) (37,53,79), and lymphoma (8%19%) (40,41).
A limitation of many studies is that the effects of cancer
treatments and non-cancer-related variables that affect mood GENDER DIFFERENCES
often are not accounted for. For example, although the cortico-
steroids, vincristine, vinblastine, procarbazine, L-asparaginase, A meta-analysis of 58 studies conducted between 1980 and
amphotericin B, interferon, and tamoxifen cause depression in 1994 demonstrated that cancer patients were significantly more
some people, research groups usually have not presented data depressed than the general population and that there were sig-
about cytotoxic drug or hormone use when describing their nificant differences among groups with regard to sex, age, and
findings. type of cancer (108). DeFlorio and Massie (109) reviewed 49
Although Newport and Nemeroff and McDaniel and col- studies of the prevalence of depression in individuals with
leagues (105107), acknowledged the many reasons why it is cancer with a particular emphasis on gender differences. Among
difficult to compare studies (different definitions of depression, the 49 studies they reviewed, 30 included both males and
cancer type or stage, time since diagnosis, varying cancer treat- females. Six research groups did not examine (or report) gender
ments, personal history of depression, and treatment for depres- differences; the remaining 23 found no gender differences in the
sion), importantly, they underscore several general observations. prevalence of depression at a significance level of P.05. How-
The severity of medical illness, as manifested by significant ever, 10 research groups found either gender differences in
pain, declining performance status, or the need for ongoing subsets of patients, nonsignificant trends, or differences in other
treatment, is associated with a high risk of comorbid depression. parameters such as psychiatric morbidity, anxiety, and denial.
Whether high rates of depression associated with some cancers Four studies reported increased depression in the subsets of
are caused by the pathophysiologic effect of the tumor (i.e., female patients. Craig and Abeloff (23) found a nonsignificant
paraneoplastic syndromes associated with breast, testis, or lung trend for females to have more psychological symptoms in a
cancers), treatment effects, or other unidentified factors remains study of 30 (63% female) cancer patients. Lloyd and colleagues
to be described. Cancer, exclusive of site, is associated with a (30) found significantly higher psychiatric morbidity (anxiety
rate of depression that is higher than in the general population. and depression) among women in a study of 40 (38% female)
hospitalized and ambulatory patients with different stages of
CANCER TYPES HIGHLY ASSOCIATED WITH lymphoma.
DEPRESSION Pettingale and colleagues (46) studied 168 patients with
breast cancer or with lymphoma and found that the women with
Cancer types highly associated with depression include oro- lymphoma had a tendency to be more depressed and were more
pharyngeal (22%57%) (36,100), pancreatic (33%50%) (20,39), anxious than were men with lymphoma and women with breast
breast (1.5% 46%) (67,74), and lung (11% 44%) (84,86). A cancer. Women were more anxious than men at 3 months and 1
less high prevalence of depression is reported in patients with year follow-up; women with breast cancer were more anxious
Hormones and Depression in Women With Breast Cancer In a study of 107 newly diagnosed head and neck cancer
patients, Kugaya and colleagues (94) reported that 16.8% had
Cathcart and colleagues (63) studied 257 women with lymph major depression or an adjustment disorder and 33.6% met the
node-negative breast cancer, 155 of whom were treated with criteria for alcohol dependence, 6.5% for alcohol abuse, and
tamoxifen and 102 who were not. On the basis of clinical 32.7% for nicotine dependence. An association of advanced
interview, 15% of the tamoxifen-treated group had depression cancer stage and living alone with psychological distress was
compared with 3% of those not taking tamoxifen. Of the 23 also found to be significant. Baile and colleagues (57) found that
women with depression, eight had mild symptoms and no alcohol use was prevalent in patients with both benign and
change in tamoxifen dose was made, eight had significant de- malignant head and neck lesions.
pression requiring a dose reduction to relieve symptoms, and In a study of negative and positive influences of social
seven had to discontinue tamoxifen secondary to depression. support on depression in patients with head and neck cancer, de
Fallowfield and colleagues (112) studied 488 British women, Leeuw and colleagues (92) found that the availability of support
ages 33 67 years, who were at high familial risk of developing led to fewer depressive symptoms, but the effect of received
breast cancer in a longitudinal, randomized (tamoxifen 20 mg support was equivocal. In another report, de Leeuw and col-
daily), placebo-controlled study. The participants average Gen- leagues (102) assessed the predictive values of numerous pre-
eral Health Questionnaire score was slightly lower than the treatment variables. Tumor stage, sex, depressive symptoms,
average in a large British population study. Using four instru- openness to discuss cancer in the family, available support,
ments, including the General Health Questionnaire30, they received emotional support, tumor-related symptoms, and size
found that 16.9% of women taking tamoxifen reported depres- of an informal social network were calculated 6 months to 3
sion as having been somewhat/quite a bit/very much of a prob-
years after treatment. They concluded that these variables could
lem since taking part in the trial, in comparison with 21.4% of
be used to accurately predict which head and neck cancer
the placebo group. Although this study was of women at high
patients were more likely to become depressed up to 3 years
risk (not women with breast cancer), it is of interest because
after treatment.
placebo-treated patients had more depression than those taking
In a study of 18 head and neck cancer patients, Hutton and
tamoxifen.
Williams (103) found that the degree of depression and distress
Prevalence of Depression in Women With Advanced Breast decreased with increasing age. Hammerlid and colleagues (87)
Cancer studied 357 head and neck cancer patients and found that pa-
tients who reported a higher level of mental distress and fre-
Studies evaluating the correlation of depression with disease quently scored as a possible or probable case of psychiatric
progression in women with breast cancer have shown inconsis- disorder were patients who had lower performance status and
tent results. Silberfarb and colleagues (26) found less depression more advanced disease.
In a study of depression and anxiety in 129 lung cancer Source N Prevalence, % Assessment
patients, before and after diagnosis, Montazeri and colleagues Holland, 1986 (38) 111 MDNC 21 POMS
(86) found that 10% of patients had severe anxiety symptoms median POMS
and 12% had symptoms of depression at first presentation to Joffee, 1986 (39) 9 0% MD SADS-L, SCL-90-R, BDI,
11% MD Adj STAI, RDC criteria
their chest physician. Depression, but not anxiety, increased by Dis
10% at follow-up. Hopwood and Stephens (93) studied 987 lung
cancer patients and found that depression was common and *Adj Dis adjustment disorder; MD major depression; MDNC major
persistent and that it was more prevalent for those patients with depression not cited; POMS The Profile of Mood States; SADS-L Schedule
more severe symptoms and functional limitations. Depression for Affective Disorder and Schizophrenia and Lifetime; SCL-90-R Hopkins
was more prevalent in patients with small cell lung cancer than Symptom Checklist 90-Revised; BDI Beck Depression Inventory; STAI
State-Trait Anxiety Inventory; RDC Research Diagnostic Criteria.
those with nonsmall cell lung cancer (NSCLC).
In a study of 129 newly diagnosed NSCLC patients, using a
clinical interview that generated a DSM-III diagnosis, Akechi the prevalence of depression in adults with lymphoma, pancre-
and colleagues (98) reported a high prevalence of psychiatric atic cancer (Table 5), gastric cancer (Table 6), and colon cancer.
disorders. The most common psychiatric disorder at baseline Wide ranges in the reported prevalence of depression are noted,
was nicotine dependence (67%), followed by adjustment disor- but in general, patients with lymphoma, gastric cancer, or colon
ders (14%), alcohol dependence (13%), and major depression cancer have a less high prevalence of depression than those with
(5%). pancreatic cancer. The high prevalence of depression in patients