Elsevier

The Lancet Oncology

Volume 12, Issue 2, February 2011, Pages 160-174
The Lancet Oncology

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Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies

https://doi.org/10.1016/S1470-2045(11)70002-XGet rights and content

Summary

Background

Substantial uncertainty exists about prevalence of mood disorders in patients with cancer, including those in oncological, haematological, and palliative-care settings. We aimed to quantitatively summarise the prevalence of depression, anxiety, and adjustments disorders in these settings.

Methods

We searched Medline, PsycINFO, Embase, and Web of Knowledge for studies that examined well-defined depression, anxiety, and adjustment disorder in adults with cancer in oncological, haematological, and palliative-care settings. We restricted studies to those using psychiatric interviews. Studies were reviewed in accordance with PRISMA guidelines and a proportion meta-analysis was done.

Findings

We identified 24 studies with 4007 individuals across seven countries in palliative-care settings. Meta-analytical pooled prevalence of depression defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria was 16·5% (95% CI 13·1–20·3), 14·3% (11·1–17·9) for DSM-defined major depression, and 9·6% (3·6–18·1) for DSM-defined minor depression. Prevalence of adjustment disorder alone was 15·4% (10·1–21·6) and of anxiety disorders 9·8% (6·8–13·2). Prevalence of all types of depression combined was of 24·6% (17·5–32·4), depression or adjustment disorder 24·7% (20·8–28·8), and all types of mood disorder 29·0% (10·1–52·9). We identified 70 studies with 10 071 individuals across 14 countries in oncological and haematological settings. Prevalence of depression by DSM or ICD criteria was 16·3% (13·4–19·5); for DSM-defined major depression it was 14·9% (12·2–17·7) and for DSM-defined minor depression 19·2% (9·1–31·9). Prevalence of adjustment disorder was 19·4% (14·5–24·8), anxiety 10·3% (5·1–17·0), and dysthymia 2·7% (1·7–4·0). Combination diagnoses were common; all types of depression occurred in 20·7% (12·9–29·8) of patients, depression or adjustment disorder in 31·6% (25·0–38·7), and any mood disorder in 38·2% (28·4–48·6). There were few consistent correlates of depression: there was no effect of age, sex, or clinical setting and inadequate data to examine cancer type and illness duration.

Interpretation

Interview-defined depression and anxiety is less common in patients with cancer than previously thought, although some combination of mood disorders occurs in 30–40% of patients in hospital settings without a significant difference between palliative-care and non-palliative-care settings. Clinicians should remain vigilant for mood complications, not just depression.

Funding

None.

Introduction

Of all the possible mood complications associated with cancer, depression has been most extensively investigated. Depression is one of the most common mental health problems worldwide; its 30-day prevalence in the community is about 5% with an incidence of about 9% over 12 months.1 Depression is known to be a substantial complication in patients with cancer, and its prevalence is higher in these patients than in the general population.2, 3, 4 In two studies,5, 6 the relative risk of depression in patients with cancer exceeded that of patients who had stroke, diabetes, and heart disease. In cancer settings, evidence shows that depression causes serious suffering and distress, reduces participation with medical care, and potentially prolongs duration of stay in hospital.7, 8 Depression is also a significant determinant of quality of life and survival.9, 10 Yet depression is often overlooked by busy cancer professionals in palliative-care and non-palliative-care settings.11

Although low rates of depression recognition and treatment are concerning, there might be several mitigating explanations. First, those making the diagnosis are most often cancer specialists who are not trained in mental health, and find operational (syndromal) diagnoses and formal screening questionnaires cumbersome.12 Second, symptoms of depression suggested by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV)13 and International Classification of Diseases 10 (ICD10)14 are generic and might not be appropriate in cancer settings. Third, depression is only one, albeit important, mood disorder that clinicians have to be aware of. Fourth, prevalence of depression seems to be modest, and its onset often unpredictable. Despite many years of research, prevalence of depression in patients with cancer is still subject to much debate.15 The picture is especially unclear because most published work has relied on depression symptom-screening methods rather than diagnostic instruments.16 Diagnostic instruments are the criterion (gold) standard and include a diagnostic algorithm, clinical significance criteria, and minimum duration to support a robust diagnosis (webappendix p 1). Although depression in patients with advanced cancer has been researched, the actual rate of depression is still not clear. Reviews of depression in palliative-care settings show a prevalence of between 1% and 69%.17 Many investigators have stated that depression is a more common problem in palliative-care settings than in others and propose demographic (age, sex) and disease-based (tumour stage, tumour type) risk factors.18, 19 Only one previous meta-analysis has examined predictors of prevalence, although no pooled rate was reported. Van't Spijker and colleagues20 identified 50 studies of psychological and psychiatric problems using various self-report scales, but only eight with formal interviews. They reported low rates of psychological and psychiatric problems in patients with breast cancer and in studies of women only, and noted that studies with young patients (mean age <50 years) reported significantly more depression, as did older studies published before 1988.

In view of uncertainties about the prevalence of depression and related mood disorders in patients with cancer, we aimed to quantitatively summarise the prevalence of robustly defined depression, anxiety, and adjustment disorders in oncological, haematological, and palliative-care settings. Our secondary aim was to examine the main correlates of depression in these settings.

Section snippets

Search strategy and selection criteria

AJM and NM designed the review protocol and extraction forms in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.21 A systematic search of Medline, PsycINFO, and Embase abstract databases was done by AJM and NM, from inception to November, 2010. Four full text collections were also searched and when necessary, authors of the publications were contacted directly for primary data. Sample searches are shown in webappendix p 2.

We included

Results

We identified 433 relevant articles; 369 included patients with cancer who were assessed with an interview-based diagnostic method (figure 1). Ten potentially valid studies were excluded because they contained duplicate data presented elsewhere (webappendix p 3). Several others were excluded because of issues with the criterion standard (webappendix p 3); most studies that were excluded provided insufficient data for analysis. 94 studies were eligible for quantitative review: 24 in palliative

Discussion

Although several informative systematic reviews have been published, no previous studies have quantitatively analysed such a robust dataset of mood disorder in cancer settings.15, 16, 17, 20, 116 Massie and colleagues15 estimated that the prevalence of depression in patients with cancer was 0–38%, and Hotopf and colleagues17 estimated 5–26%. Findings from two small meta-analyses of methods to diagnose mood disorders showed a prevalence of 13·2%16 and 12·7%116 in studies with convenience

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