Edited by: Joanne Shaw, The University of Sydney, Australia
Reviewed by: Seockhoon Chung, University of Ulsan, South Korea; Nor Zuraida Zainal, University of Malaya, Malaysia; Gerry Michael Humphris, University of St Andrews, United Kingdom
†These authors share first authorship
This article was submitted to Psycho-Oncology, a section of the journal Frontiers in Psychology
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Depression and anxiety persist in cancer patients, creating an additional burden during treatment and making it more challenging in terms of management and control. Studies on the prevalence of depression and anxiety among cancer patients in the Middle East are limited and include many limitations such as their small sample sizes and restriction to a specific type of cancer in specific clinical settings. This study aimed to describe the prevalence and risk factors of depression and anxiety among cancer patients in the inpatient and outpatient settings.
A total of 1,011 patients (399 inpatients and 612 outpatients) formed the study sample. Patients’ psychological status was assessed using the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ-9), and the Generalized Anxiety Disorder 7-item (GAD-7) scale. The prevalence rate of depressive and anxious symptomatology was estimated by dividing the number of patients who exceeded the borderline score: 10 or more for each subscale of the HADS scale, 15 or more for the GAD-7 scale, and 15 or more in the PHQ-9 by the total number of the patients. Risk factors were identified using logistic regression.
The prevalence of depressive and anxious symptomatology among all patients was 23.4% and 19.1–19.9%, respectively. Depressive symptomatology was more prevalent across patients who were hospitalized (37.1%) compared with patients in the outpatient setting (14.5%) (
Our study findings demonstrated a higher prevalence of depressive and anxious symptomatology in the inpatient setting and advanced disease stages. In addition, the underutilization of antidepressant therapy was observed. There is a need to consider mental disorders as part of the treatment protocol for cancer patients. Enhanced clinical monitoring and treatment of depression and anxiety of cancer patients are required.
In cancer patients, psychological problems such as depression and anxiety persist and can cause an additional burden during their treatment, making it more challenging in terms of its management and control (
In 2018, a total of 10,898 new cancer cases were diagnosed in Jordan within a population of 9,903,798. An age-standardized incident rate was 157.8 per 100,000, while the age-standardized mortality rate was 89.7 per 100,000. The top five most prevalent cancers were breast cancer, lung cancer, colorectal cancer, bladder cancer, and leukemia (
This was a cross-sectional study conducted at the King Hussein Cancer Center (KHCC) in Amman, Jordan, between October 2019 and February 2020. According to the last available statistics in 2015, KHCC provides medical care to around 60.0% of all cancer patients in Jordan (
Data were collected from the inpatient and outpatient settings using a convenience sampling technique. Cancer patients who have any type of cancer from any stage and who are willing to participate in the study formed the study population. The inclusion criteria were (a) patients aged 18 years and above with a confirmed cancer diagnosis and (b) patients who had no apparent cognitive deficit. Patients were excluded if they were (a) below 18 years of age and (b) unable to participate in this study due to physical or emotional distress. This is due to the difficulties in detecting depression in cancer patients with emotional distress because of patients’ reluctance to discuss their emotional well-being (
The target sample size was estimated based on the WHO recommendations for the minimal sample size needed for a prevalence study (
Previously validated assessment scales, the Patient Health Questionnaire (PHQ)-9, Generalized Anxiety Disorder 7-item (GAD-7) scale, and Hospital Anxiety and Depression Scale (HADS) were used to assess depressive and anxious symptomatology among the study participants. These screening instruments were frequently used and validated as brief screening tools among cancer patients for depressive and anxious symptomatology (
Different assessment scales were used to fit the inpatient and outpatient settings, as recommended by previous literature. The HADS and GAD-7 instruments were previously validated to be used for hospitalized patients (secondary care settings) in multiple previous studies, including studies on patients with cancer (
The use of a pre-existing scale has the advantage of using a validated and tested instrument, which increases the reliability of its measure. The PHQ-9 and the GAD-7 instruments ask the patients about the degree of applicability of each item (question), using a 4-point Likert scale. Patients’ responses ranged from 0 to 3, where 0 means “Not at all” and 3 means “Nearly every day.” The HADS instrument is a 14-question questionnaire that asks the patients about the degree of applicability of each item (question), using a 4-point Likert scale. Patients’ response ranges from 0 to 3, where 0 means “Often” and 3 means “Very seldom” or from “Not at all” to “Most of the time.”
Prevalence rates of depressive and anxious symptomatology were determined using a cut-off point as recommended by the authors of the PHQ-9, GAD-7, and HADS scale. At the inpatient setting using the HADS instrument, depressive and anxious symptomatology were defined as a total score of (10 or more) at “depression subscale” or “anxiety subscale,” respectively (
The prevalence rate of depressive symptomatology was estimated by dividing the number of patients who exceeded the borderline score by the total number of patients. The same procedure was followed to calculate the prevalence rate of anxious symptomatology in the inpatient and the outpatient settings.
The HADS instrument was used in the inpatient setting, which includes two subscales (anxiety and depression) with seven items for each. Items are scored from 0 to 3, generating a total score ranging from 0 to 21 on each subscale. A total score of 0–7 indicates a normal case, 8–10 a borderline case, and 11–21 an abnormal case of depressive or anxious symptomatology according to the subscale score (
The PHQ-9 instrument was used in the outpatient setting, which includes nine items. Items are scored from 0 to 3, generating a total score ranging from 0 to 27. A total score of 0–4 indicates minimal depression, 5–9 mild depression, 10–14 moderate depression, 15–19 moderately severe depression, and 20–27 severe depression (
Descriptive statistics were used to describe patients’ demographic characteristics, medication use, and comorbidities. Continuous data were reported as mean ± SD. Categorical data were reported as percentages (frequencies). Logistic regression was used to estimate odds ratios (ORs), with 95% confidence intervals (CIs) for anxious or depressive symptomatology. Logistic regression models were carried out using anxious or depressive symptomatology scores above the cut-off points as highlighted in the section “Materials and Methods.” The cut-off point for the PHQ-9 and GAD-7 scale that was used to identify severe depressive symptomatology and severe anxious symptomatology in the outpatient setting was 15 and above. The cut-off for the HADS scales that was used to identify depressive symptomatology and anxious symptomatology in the inpatient setting was 10 and above (whether for the depression or anxiety subscale). A two-sided
Out of 1,041 patients who were approached during the study period, a total of 1,011 patients (response rate of 97.1%) participated in the study: inpatient setting = 399, outpatient setting = 612.
The baseline characteristics of the patients in the inpatient and the outpatient settings.
Male | 560 (55.4%) | 225 (56.4%) | 335 (54.7%) | 0.861 |
54.9 (15.2) | 55.6 (± 15.6) | 54.4 (± 15.0) | 0.245 | |
Single | 99 (9.8%) | 37 (9.3%) | 62 (10.1%) | 0.935 |
Married | 833 (82.4%) | 331 (83.2%) | 502 (82.0%) | 0.672 |
Divorced | 23 (2.3%) | 8 (2.0%) | 15 (2.5%) | 0.830 |
Widowed | 55 (5.4%) | 22 (5.5%) | 33 (5.4%) | 1.000 |
Employed | 276 (27.3%) | 103 (25.8%) | 173 (28.3%) | |
Unemployed | 471 (46.6%) | 172 (43.1%) | 299 (48.9%) | 0.082 |
Retired | 264 (26.1%) | 124 (31.1%) | 140 (22.9%) | |
Lower than 500 JD** | 737 (72.9%) | 327 (82.0%) | 410 (67.0%) | |
500 to 1000 JD** | 197 (19.5%) | 54 (13.5%) | 143 (23.4%) | |
1000 to 1500 JD** | 35 (3.5%) | 7 (1.8%) | 28 (4.6%) | |
1500 JD** or above | 42 (4.2%) | 11 (2.8%) | 31 (5.1%) | 0.078 |
Yes | 186 (18.4%) | 80 (20.1%) | 106 (17.3%) | 0.116 |
No | 445 (44.0%) | 146 (36.6%) | 299 (48.9%) | |
Don’t know | 380 (37.6%) | 173 (43.4%) | 207 (33.8%) | |
Stage 1 | 10 (5.4%) | 2 (2.5%) | 8 (7.5%) | 0.331 |
Stage 2 | 18 (9.7%) | 5 (6.3%) | 13 (12.3%) | 0.343 |
Stage 3 | 25 (13.4%) | 8 (10.0%) | 17 (16.0%) | 0.537 |
Stage 4 | 133 (71.5%) | 65 (81.3%) | 68 (64.2%) | |
Surgery | 40 (4.0%) | 40 (10.0%) | 0 | |
Chemotherapy | 566 (56.0%) | 190 (47.6%) | 376 (61.4%) | |
Combination of surgery and chemotherapy | 352 (34.8%) | 119 (29.8%) | 233 (38.1%) | |
Radiotherapy | 298 (29.5%) | 116 (29.1%) | 182 (29.8%) | 0.832 |
Don’t receive treatment (on palliative therapy) | 36 (3.6%) | 36 (9.0%) | 0 | |
Yes | 432 (42.7) | 220 (55.1) | 212 (34.6) | |
Yes | 251 (24.8) | 148 (37.1) | 103 (16.8) | |
Yes | 39 (15.5) | 21 (14.1) | 18 (17.5) | 0.126 |
Sertraline | 9 (29.0) | 2 (10.0) | 7 (63.6) | |
Citalopram | 5 (16.1) | 5 (25.0) | 0 | |
Mirtazapine | 2 (6.5) | 2 (10.0) | 0 | |
Fluoxetine | 2 (3.2) | 1 (5.0) | 1 (9.1) | |
Amitriptyline | 1 (3.2) | 1 (5.0) | 0 | |
Escitalopram | 1 (3.2) | 0 | 1 (9.1) | |
Fluvoxamine | 1 (3.2) | 0 | 1 (9.1) | |
Paroxetine | 1 (3.2) | 0 | 1 (9.1) | |
52.2 (± 17.4) | 50.4 (± 18.7) | 54.6 (± 15.9) | 0.550 | |
Yes | 16 (51.6) | 10 (50.0) | 6 (54.5) | 0.689 |
Yes | 21 (67.7) | 12 (60.0) | 9 (81.8) | 1.000 |
Yes | 25 (80.6) | 14 (70.0) | 11 (100.0) | 1.000 |
Anxiety | 11 (35.5) | 5 (25.0) | 6 (54.5) | |
Depression | 26 (83.9) | 15 (75.0) | 11 (100.0) | |
Yes | 36 (92.3) | 19 (90.5) | 17 (94.4) | 0.366 |
Physicians | 34 (94.4) | 18 (94.7) | 16 (94.1) | |
Nurse | 1 (2.8) | 1 (5.3) | 0 | |
Pharmacist | 1 (2.8) | 0 | 1 (5.9) | |
Yes | 27 (75.0) | 15 (78.9) | 12 (70.6) | 0.546 |
The most common cancer type in the study was blood cancer (
Around 42.7% (
The mean age of the patients when they started using antidepressants was 52.2 years (±17.4). Around 51.6% (
The main reasons patients consider the healthcare professionals’ instructions important include the notion that they increase the safety (27.3%,
The prevalence of depressive symptomatology among all patients was 23.4% (
Prevalence of depression and anxiety among the patients’ stratified by severity.
Minimal depression | 282 (46.1%) |
Mild depression | 165 (27.0%) |
Moderate depression | 76 (12.4%) |
Moderately severe depression | 56 (9.2%) |
Severe depression | 33 (5.4%) |
Normal | 339 (55.4%) |
Mild anxiety | 142 (23.2%) |
Moderate anxiety | 80 (13.1%) |
Severe anxiety | 51 (8.3%) |
Normal | 195 (48.9%) |
Abnormal borderline case | 56 (14.0%) |
Abnormal case | 148 (37.1%) |
Normal | 208 (52.1%) |
Abnormal borderline case | 49 (12.3%) |
Abnormal case | 142 (35.6%) |
Mild anxiety | 168 (42.1%) |
Moderate anxiety | 81 (20.3%) |
Severe anxiety | 150 (37.6%) |
Prevalence of depression and anxiety stratified by type of cancer and severity.
Outpatient settings (n = 612) | Minimal depression | 74 (57.8) | 10 (50.0) | 59 (45.7) | 30 (39.5) | 15 (42.9) | 12 (34.3) | 11 (47.8) | 9 (39.1) | 9 (37.5) | 8 (47.1) | 7 (36.8) | 7 (46.7) | 9 (60.0) | 4 (33.3) |
Mild depression | 32 (25.0) | 4 (20.0) | 42 (32.6) | 19 (25.0) | 5 (14.3) | 6 (17.1) | 6 (26.1) | 7 (30.4) | 10 (41.7) | 3 (17.6) | 7 (36.8) | 3 (20.0) | 4 (26.7) | 4 (33.3) | |
Moderate depression | 11 (8.6) | 4 (20.0) | 10 (7.8) | 10 (13.2) | 5 (14.3) | 10 (28.6) | 5 (21.7) | 5 (21.7) | 2 (8.3) | 3 (17.6) | 3 (15.8) | 2 (13.3) | 0 | 3 (25.0) | |
Moderately severe depression | 7 (5.5) | 1 (5.0) | 10 (7.8) | 13 (17.1) | 5 (14.3) | 6 (17.1) | 1 (4.3) | 3 (13.0) | 0 | 2 (11.8) | 2 (10.5) | 0 | 1 (6.7) | 1 (8.3) | |
Severe depression | 4 (3.1) | 1 (5.0) | 8 (6.2) | 4 (5.3) | 5 (14.3) | 1 (2.9) | 0 | 0 | 3 (12.5) | 0 | 0 | 3 (20.0) | 1 (6.7) | 1 (8.3) | |
Mild anxiety | 22 (17.2) | 7 (35.0) | 34 (26.4) | 20 (26.3) | 10 (28.6) | 9 (25.7) | 4 (17.4) | 7 (30.4) | 3 (12.5) | 6 (35.3) | 5 (26.3) | 2 (13.3) | 3 (20.0) | 3 (25.0) | |
Moderate anxiety | 10 (7.8) | 3 (15.0) | 14 (10.9) | 14 (18.4) | 5 (14.3) | 8 (22.9) | 2 (8.7) | 4 (17.4) | 3 (12.5) | 2 (11.8) | 2 (10.5) | 2 (13.3) | 3 (20.0) | 3 (25.0) | |
Severe anxiety | 6 (4.7) | 1 (5.0) | 13 (10.1) | 5 (6.6) | 6 (17.1) | 5 (14.3) | 2 (8.7) | 1 (4.3) | 3 (12.5) | 1 (5.9) | 0 | 3 (20.0) | 1 (6.7) | 1 (8.3) | |
Inpatient settings ( |
|||||||||||||||
Normal | 25 (50.0) | 11 (52.4) | 36 (53.7) | 16 (36.4) | 23 (48.9) | 6 (60.0) | 8 (44.4) | 7 (41.2) | 7 (50.0) | 5 (27.8) | 8 (53.3) | 8 (61.5) | 6 (46.2) | 7 (50.0) | |
Abnormal borderline case | 6 (12.0) | 0 | 9 (13.4) | 7 (15.9) | 8 (17.0) | 3 (30.0) | 1 (5.6) | 3 (17.6) | 4 (28.6) | 1 (5.6) | 1 (6.7) | 1 (7.7) | 3 (23.1) | 3 (21.4) | |
Abnormal case | 19 (38.0) | 10 (47.6) | 22 (32.8) | 21 (47.7) | 16 (34.0) | 1 (10.0) | 9 (50.0) | 7 (41.2) | 3 (21.4) | 5 (27.8) | 6 (40.0) | 4 (30.8) | 5 (38.5) | 4 (28.6) | |
Normal | 28 (56.0) | 11 (52.4) | 43 (64.2) | 17 (38.6) | 25 (53.2) | 4 (40.0) | 9 (50.0) | 8 (47.1) | 7 (50.0) | 4 (22.2) | 8 (53.3) | 10 (76.9) | 8 (61.5) | 6 (42.9) | |
Abnormal borderline case | 5 (10.0) | 1 (4.8) | 8 (11.9) | 4 (9.1) | 7 (14.9) | 4 (40.0) | 2 (11.1) | 2 (11.8) | 4 (28.6) | 2 (11.1) | 1 (6.7) | 0 | 2 (15.4) | 4 (28.6) | |
Abnormal case | 17 (34.0) | 9 (42.9) | 16 (23.9) | 23 (52.3) | 15 (31.9) | 2 (20.0) | 7 (38.9) | 7 (41.2) | 3 (21.4) | 5 (27.8) | 6 (40.0) | 3 (23.1) | 4 (30.8) | 4 (28.6) | |
Mild anxiety | 25 (50.0) | 11 (52.4) | 35 (52.2) | 10 (22.7) | 22 (46.8) | 4 (40.0) | 7 (38.9) | 7 (41.2) | 8 (57.1) | 2 (11.1) | 5 (33.3) | 7 (53.8) | 5 (38.5) | 5 (35.7) | |
Moderate anxiety | 8 (16.0) | 1 (4.8) | 13 (19.4) | 9 (20.5) | 7 (14.9) | 1 (10.0) | 5 (27.8) | 5 (29.4) | 3 (21.4) | 5 (27.8) | 6 (40.0) | 3 (23.1) | 3 (23.1) | 2 (14.3) | |
Severe anxiety | 17 (34.0) | 9 (42.9) | 19 (28.4) | 25 (56.8) | 18 (38.3) | 5 (50.0) | 6 (33.3) | 5 (29.4) | 3 (21.4) | 4 (22.2) | 4 (26.7) | 3 (23.1) | 6 (46.2) | 7 (50.0) |
In the inpatient setting, logistic regression analysis identified the following groups as being at a higher risk of depressive symptomatology: a) patients with metastatic cancer, OR: 2.62 (95% CI 1.61–4.28) and b) patients at an advanced stage of the disease, stage 3, OR: 5.26 (95% CI 1.05–26.41) and stage 4, OR: 2.73 (95% CI 1.61–4.62). In the outpatient setting, patients with metastatic cancer were the only group that showed a statistically significant increased risk of depressive symptomatology, OR: 3.36 (95% CI 1.33–8.50), compared with others.
Regarding anxious symptomatology, in the inpatient setting the following groups were identified to be at a higher risk using the HADS: a) patients with metastatic cancer, OR: 2.10 (1.29–3.42) and b) patients at stage four of the disease, OR: 2.39 (95% CI 1.42–4.04). On the other hand, patients who are treated with a combination of chemotherapy and surgery showed a lower risk of anxious symptomatology, OR: 0.54 (95% CI 0.33–0.86). On the basis of the GAD-7 scale, the only patient group that showed a higher risk of anxious symptomatology was the group with metastatic cancer, OR: 2.23 (95% CI 1.32–3.74). In the outpatient setting, unemployed patients—OR: 1.89 (95% CI 1.03–3.35)—and patients with metastatic cancer—OR: 2.47 (95% CI 1.15–5.33)—were at higher risk of anxious symptomatology (
Logistic regression analysis.
Male (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Female | 1.12 (0.75–1.68) | 1.21 (0.80–1.82) | 1.43 (0.91–2.26) | 1.29 (0.64–2.59) | 1.64 (0.92–2.90) |
Less than 50 years | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
50 years and above | 0.76 (0.50–1.18) | 1.03 (0.66–1.60) | 0.87 (0.54–1.42) | 0.81 (0.39–1.65) | 0.68 (0.38–1.21) |
Single (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Married | 1.15 (0.66–1.99) | 1.15 (0.66–2.00) | 0.83 (0.45–1.50) | 0.80 (0.34–1.90) | 1.03 (0.48–2.17) |
Divorced | 1.73 (0.43–7.01) | 1.85 (0.46–7.50) | 3.29 (0.81–13.40) | – | 0.78 (0.10–6.07) |
Widowed | 0.63 (0.24–1.63) | 0.52 (0.19–1.44) | 1.21 (0.46–3.18) | 1.14 (0.26–4.99) | 0.33 (0.04–2.47) |
Employed (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Unemployed | 1.15 (0.76–1.73) | 1.35 (0.90–2.04) | 1.37 (0.86–2.17) | 1.45 (0.71–2.95) | 1.89 (1.03–3.35)* |
Retired | 1.16 (0.75–1.80) | 1.05 (0.67–1.63) | 0.89 (0.54–1.47) | 0.74 (0.30–1.83) | 0.81 (0.39–1.66) |
Below 500 JD (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
500 to 1000 JD | 0.68 (0.36–1.27) | 0.81 (0.44–1.50) | 0.68 (0.33–1.42) | 1.05 (0.46–2.39) | 0.68 (0.32–1.44) |
1000 to 1500 JD | 1.28 (0.28–5.79) | 1.37 (0.30–6.19) | 0.52 (0.06–4.38) | 1.37 (0.31–6.05) | 1.90 (0.63–5.72) |
More than 1500 JD | 0.97 (0.28–3.37) | 0.67 (0.18–2.57) | 0.70 (0.15–3.27) | 0.57 (0.08–4.33) | 0.35 (0.05–2.65) |
Less than 12 years (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
12 years and above | 1.10 (0.72–1.67) | 0.71 (0.47–1.08) | 0.85 (0.53–1.37) | 1.42 (0.68–2.95) | 1.35 (0.74–2.46) |
No (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Yes | 2.62 (1.61–4.28)*** | 2.10 (1.29–3.42)** | 2.23 (1.32–3.74)** | 3.36 (1.33–8.50)* | 2.47 (1.15–5.33)* |
1 (Reference) | 1:00 | 1.00 | 1.00 | 1:00 | 1.00 |
2 | 0.42 (0.05–3.79) | 1.21 (0.20–7.33) | 0.79 (0.09–7.13) | 3.33 (0.71–15.69) | 3.44 (0.92–12.94) |
3 | 5.26 (1.05–26.41)* | 0.60 (0.12–3.00) | 1.92 (0.45–8.20) | 1.10 (0.14–8.55) | 2.44 (0.68–8.80) |
4 | 2.73 (1.61–4.62)*** | 2.39 (1.42–4.04)** | – | 2.29 (0.95–5.49) | 1.30 (0.56–3.02) |
Don’t receive treatment (Reference) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Chemotherapy | 1.12 (0.74–1.67) | 1.11 (0.74–1.67) | 1.13 (0.72–1.80) | 0.79 (0.39–1.62) | 0.85 (0.47–1.53) |
Combination of surgery and chemotherapy | 0.77 (0.49–1.20) | 0.54 (0.33–0.86)* | 0.84 (0.50–1.40) | 1.28 (0.62–2.62) | 1.19 (0.66–2.14) |
Radiotherapy | 1.51 (0.97–2.34) | 1.10 (0.70–1.72) | 1.48 (0.91–2.41) | 1.90 (0.92–3.90) | 1.01 (0.54–1.90) |
Surgery | 1.02 (0.52–2.00) | 1.55 (0.80–3.00) | 1.06 (0.50–2.25) | – | – |
This study aimed to identify the prevalence of depressive and anxious symptomatology among cancer patients and to identify key risk factors using validated assessment tools. Additionally, we explored the pattern of use of antidepressants among the study participants. Several dimensions were investigated in this study, including patients’ characteristics, the prevalence of anxious and depressive symptomatology according to the type of cancer and treatment settings (inpatient versus outpatient). Our findings showed that the prevalence of depressive and anxious symptomatology among cancer patients was 23.4% and 19.1–19.9%, respectively. Increased likelihood of depressive and anxious symptomatology was detected among patients in the inpatient setting (37.1% and 35.6–37.6%, respectively). Screening of frequently prescribed anxiolytics and antidepressants was investigated, revealing that for the most part, SSRIs were prescribed, but as low as 15.5% of depressed and anxious patients received the required treatment (
Our research employed two validated tools (GAD-7 and HADS) to assess the prevalence of anxiety among cancer patients in the inpatient setting, and both of them were reliable and showed a significant correlation (correlation coefficient: 0.812) in terms of the prevalence of anxiety (37.6% versus 35.6% in the inpatient setting). The increased cancer-specific depressive symptomatology was noted across settings (inpatient and outpatient) and was significantly higher in the inpatient settings.
Several factors may impact the development of depression and anxiety among cancer patients, including the cancer type, stage, grade, and treatment option (
In addition to the type of cancer, the treatment option impacted the prevalence of anxiety and depression among cancer patients. Cancer treatments that entail chemotherapy may induce depression through specific biological mechanisms. Furthermore, the literature reported that antiemetic medications, steroids, and androgen suppression therapy (for prostate cancer) were reported to induce depression (
This study also explored the pattern of use of antidepressants among cancer patients stratified by type, where the rate of using antidepressants among patients diagnosed with depression was as low as 15.5%. Low use of antidepressant therapy is an alarming sign, especially for cancer patients who are receiving specialized cancer services (
The majority of patients were prescribed selective serotonin reuptake inhibitor (SSRI) antidepressants (sertraline, citalopram, fluoxetine, fluvoxamine, and paroxetine), while tetracyclic antidepressants (mirtazapine) and tricyclic antidepressants (amitriptyline) were prescribed to a lesser extent. The selection of an anxiolytic or antidepressant medication needs to be made under clear guidelines that consider interactions with chemotherapeutic and other concurrently administered medication, as well as side effects, to enable identification of specific contraindications. Sertraline and citalopram are usually recommended for depression and anxiety treatment, as they have the least tendency for interactions and are usually well tolerated (
Our findings suggest that severe depressive and anxious symptomatology are substantially more common in patients with cancer in the inpatient than in the outpatient setting. This significant difference could be attributed to the severity of the disease, where hospitalized treatment of cancer patients is mainly employed for the management of acute phases, initial onsets, severe cases, or late stages. A previous study involving more than 5,000 patients has reported that more symptoms of anxiety are associated with cancer within the inpatient setting and in patients in the advanced stages, whereas patients at early stages demonstrated lower anxiety symptoms. Furthermore, disease stage was associated with depression, particularly in men (
Further analysis using logistic regression was conducted to identify patients at risk of developing depressive and anxious symptomatology. Similar to reported data, the prevalence of anxiety and depression among women is higher than in men (
To the best of our knowledge, this is the first and largest study in the Middle East region to investigate the prevalence of depressive and anxious symptomatology and use of antidepressants among cancer patients without restriction on the type of cancer or clinical settings. Previous studies have focused on a specific type of cancer (breast cancer and colorectal cancer) (
We have explored the prevalence of depressive and anxious symptomatology among cancer patients without any restriction on the age, gender, duration of the disease, or treatment phase. Our broad inclusion criteria have enabled us to explore the difference in severity of depressive and anxious symptomatology among different demographic groups and across different stages of the treatment and the course of illness. This study has many strengths that increase its value and reliability: (a) using validated assessment tools for depressive and anxious symptomatology, (b) anxious symptomatology was assessed using two assessment tools (HADS and GAD-7), and both of them showed consistent findings, (c) employing a large sample size, (d) not restricting the inclusion criteria for the specific type of cancer or specific settings (inpatients or outpatients), which increased the generalizability of our findings, and (e) our exclusion criteria minimized the risk of deriving imprecise information (related to the patients’ psychological status) from any suspected physical or emotional distress. On the other hand, this study has limitations: (a) the study design itself, a cross-sectional study design, limited our ability to identify causality between study variables, as it is only capable of showing an association between variables, and (b) the sample size of a few cancer subgroups was small due to a small population in this category nationwide. This might affect our ability to determine the prevalence of depressive and anxious symptomatology among patients with specific types of cancer, especially types for which we have a very low number of patients, such as head and neck cancer; (c) the use of convenience sampling techniques might affect the generalizability of our findings as a prevalent study and may introduce sampling bias (which might not precisely represent the targeted population); (d) the use of different assessment tools to describe the prevalence of depressive symptomatology between the inpatient and the outpatient settings might not provide a fair comparison; (e) there is a lack of non-responder data; and (f) the antidepressant medication information is based on small subsamples making conclusions difficult to sustain. Therefore, our findings should be interpreted carefully.
Our study demonstrated a higher prevalence of both depressive and anxious symptomatology within the inpatient setting and advanced stages of the disease. There is a need for cancer management clinical guidelines to consider early assessment and management of depression and anxiety and to continue to monitor it throughout treatment.
The original contributions presented in the study are included in the article/
Approval for this study was obtained from the Institutional Review Board Committee at King Hussein Cancer Centre in Jordan (No. 19 KHCC 94). For patients who agreed to participate, the study’s aim and objectives were explained thoroughly. Information sheets were provided to the patients for further clarification about the study. In addition, patients were informed that their agreement to participate in the study is considered as a written consent.
AN contributed to the study design and did the data analysis. AN, AH, NM, and HK conducted the study and collected the data. AN, ED, NM, and HA wrote the first draft of the article. AN, HA, ED, HA, and NM were involved in interpretation of the data. All authors reviewed the manuscript for important intellectual content, provided final approval of the version to be published, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We would like to thank the King Hussein Cancer Center for the support in conducting this research.
The Supplementary Material for this article can be found online at:
Type of cancer among the patient stratified by settings.
Questions about antidepressants treatment.
Characteristics of antidepressants utilization and patients’ knowledge about them.