Abstract
Depression in patients with cancer negatively influences their physical symptoms, treatment success, coping, and quality of life and is associated with increased mortality. The reported prevalence of emotional distress in patients followed in hematology varies widely across studies. This study investigated the prevalence of depression and explored the possible associated factors in patients followed in a hematological department.
Methods
in this descriptive cross-sectional study of patients followed in the hematology department of the University Hospital Mohammed VI of Marrakesh between August 2020 and December 2020, depression symptoms were assessed using Mini International Neuropsychiatric Interview test and Beck Depression Inventory.
Results
150 patients participated. Regarding their underlying pathology, 60% (90 patients) of patients were newly diagnosed with leukemia, and 8% patients were admitted for chronic anemia and 12% for lymphoma. Forty-eight percent of them had a characterized depressive episode. Four percent of these episodes were severe, 55% were moderate, and 41% were mild. Among all the factors, multivariate analysis showed that high prevalence of depression was associated with female gender and poor prognosis estimation by the patient.
Keywords: Depression, Hematology, Prevalence, Treatment, Marrakesh
1. Introduction
Patients with hematological disorder experience a heavy and long therapeutic process and have the highest rate of depression and anxiety.1 Unresolved depression has been proven to affect physical symptoms, cause nonadherence to treatment, and decrease the quality of life.2
Studies interested in patients with cancer state a close association between depression and increased mortality.3,4 Few data are available concerning the prevalence rates of depression reported in this specific population. Rates reported range from 8% to 24%. In a study conducted in Australia, about 20% of outpatients receiving treatment for hematologic cancer experience clinically significant levels of anxiety and/or depression.5,6
In developing countries, limited studies have evaluated the psychological profile among patients with hematological affections. In a recent meta-analysis conducted by Zoe J. et al., depressive and anxiety disorders were evaluated among patients with cancer living in low- and lower-middle-income countries (LLMIC). The pooled prevalence of major depression was 21% (95% CI, 15 to 28).7
The main objective of this study was to investigate the prevalence of depression in a population of patients followed in a hematology department, mainly suffering from malignant hemopathies, and to explore factors that may be associated with depression in this high-risk population.
2. Materials and methods
We conducted a descriptive cross-sectional study among patients followed in hematology department in the University Hospital Mohammed VI of Marrakesh. Our survey occurred between August 2020 and December 2020.
Ethical approval was obtained from the protocol review committee of the medical center’s cancer institute.
To be included, patients had to be aged more than 16 years to have a diagnosis of hematologic affection followed in the day hospital unit, in the hospitalizations unit, or in the marrow transplant department for therapeutic cures. Patients whose general condition was severely impaired were excluded.
Data on depression were collected using anonymous questionnaires; patient sociodemographics, disease status, and treatment information were also obtained from patients and medical records. Symptoms of depression were assessed by Mini International Neuropsychiatric Interview test (MINIT).8 The questionnaire comprised ten Likert-type statements scored from 0 (do not agree at all) to 3 (agree fully).
To estimate the severity of depression episodes, we used Beck Depression Inventory (BDI). The scores range from 0 to 39, with each of the 13 items scoring from 0 (not at all) to 3 (almost every day). Scores of 0–4 represent no depression, 5 to 7 represent mild depression, scores ranging from 8 to 15 indicate moderate depression, and scores greater than 16 designate severe depression.
The interview was conducted with patients in dialectal Arabic, and questions of the MINI test and the BECK scale was reformulated in Arabic.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS).
The statistical method used in the data analysis was the Chi-2 test. A difference is considered statistically significant when the p-value is strictly less than 0.05 (p < 0.05).
3. Results
3.1. Sample characteristics
A total of 116 patients were approached, all of whom agreed to participate. The majority of patients were male (60%) (69 patients). The mean age of the patients was 43 years (range from 15 to 76 years). The most represented age group was between 15 and 36 years (41.3%, 62 patients). Characteristics of patients are shown in Table 1.
Table 1.
Demographic and clinical characteristics of patients.
| Characteristics | N | % |
|---|---|---|
| Sex | ||
| Male | 69 | 59.6 |
| Female | 47 | 40.4 |
| Age | ||
| <36 | 48 | 41 |
| 36–50 | 24 | 21 |
| >50 | 44 | 38 |
| Familial situation | ||
| Married | 66 | 57 |
| Unmarried | 50 | 43 |
| Educational level | ||
| None | 48 | 41 |
| Medium | 53 | 46 |
| High | 15 | 13 |
| Socio-economic level | ||
| Low | 64 | 55 |
| Medium/high | 52 | 45 |
| Diagnosis | ||
| leukemia | 90 | 77.6 |
| Lymphoma | 17 | 14.6 |
| Multiple myeloma | 7 | 6 |
| Other hematologic cancers | 2 | 1.8 |
| Main symptom | ||
| Adenopathy | 51 | 44 |
| Asthenia | 36 | 31 |
| Pain | 15 | 13 |
| Other | 14 | 12 |
| Familial support | ||
| Oui | 88 | 75.9 |
| Non | 28 | 24.1 |
| Patient prognosis estimation | ||
| Curable | 76.8 | 80 |
| Incurable | 23.2 | 20 |
IV: intravenous.
Regarding their underlying pathology, 77% (90 patients) of patients were newly diagnosed with leukemia and 15% (17 patients) with lymphoma (Table 1).
Concerning treatment, 78% (91 patients) of patients received IV chemotherapy and 4% (5 patients) had a BMT, 67.2% of them started their treatment between 0 and 12 months, while 32.8% of patients had started their treatment more than 1 year before the time of our survey.
The diagnosis announcement was made by a hematologist in 74% of cases, the most common reaction was shock, described by 54% of patients followed by fear of death in 19% of cases.
At diagnosis, 65% of patients reported a poor understanding of their disease and nearly 20% felt that their disease was incurable.
3.2. Prevalence and risk factors of depression
According to the MINI test, 48% (56 patients) of patients had a characterized depressive episode (CDE) at the time of the survey, 44% (25 patients) had mild depression, 54% (30 patients) had moderate depression, and less than 2% (1 patients) had severe depression.
According to DSM-IV criteria, 23% (27 patients) of patients had a persistent depressive disorder at the time of our study.
In bivariant analysis, among the different risk factors studied, only sex and patient estimation of prognosis showed a significant difference (p < 0.05) (Table 2). Indeed, depression was diagnosed in women and in patients who felt that their disease was not curable.
Table 2.
Bivariant analysis of risk factors associated with depression.
| Variable with no significance | Variable with significance | ||||||
|---|---|---|---|---|---|---|---|
|
|
|
||||||
| CDE | No CDE | P value | CDE | No CDE | P value | ||
|
|
|
|
|
||||
| n = 56 | n = 60 | n = 56 | n = 60 | ||||
| Age in years: | Sex: | ||||||
| <40 | 50% | 50% | 0.756 | Female | 63.8% | 36.2% | 0.006 |
| 40–60 | 50% | 50% | Male | 37.7% | 62.3% | ||
| >60 | 41.7% | 48.3% | |||||
| Familial situation: | Patient’s estimation of his pathology: | ||||||
| Married | 48.2% | 51.8% | 0.904 | 0.04 | |||
| unmarried | 49.2% | 50.8% | curable | 44,6% | 55.4% | ||
| incurable | 65,5% | 34.5% | |||||
| Educational level: | |||||||
| None | 48.9% | 51.1% | 0.954 | ||||
| Medium/Hight | 48.4% | 51.6% | |||||
| Socio-economic level | |||||||
| Low | 52.2% | 47.8% | 0.474 | ||||
| Medium/high | 46.3% | 53.7% | |||||
| Diagnosis: | |||||||
| Leukemia | 44.4 | 55.6 | 0.9 | ||||
| Lymphoma | 64.7 | 35.3 | |||||
| Multiple myeloma | 71.4 | 28.6 | |||||
| Treatment | |||||||
| IV Chemotherapy | 45.7% | 54.3% | 0.35 | ||||
| Oral chemotherapy | 55.6% | 44.4% | |||||
| Bone marrow transplantation | 83.3% | 16.7% | |||||
| Other treatment | 34.1% | 65.9% | |||||
CDE: Characterized depressive episode.
Patients with myeloma had a high rate of depression (71.4%), followed by lymphoma (64.4%). Patients admitted for BMT had the highest rate of depression (83.3%) compared with other types of treatment.
4. Discussion
The main findings of this study were as follows: a prevalence of depression of 48% in a sample of 116 adult patients with hematological diseases. In multivariate analysis, a high prevalence of depression was associated with female gender and poor prognosis estimation by the patient. The prevalence of depression in our study is higher than that reported in several papers (23% in Malaysia and 17% in Australia, 22% in pooled prevalence in LLMIC); moreover, C.G. Ng et al. demonstrated a similar prevalence rate (35.3%) in his hematological cancer patients.2,6,7,9 Comparison of observed prevalence rates between the studies calls for cautious interpretation because of the use of different diagnostic tools and at different point times of diagnosis. Our study is probably the first to report the prevalence of depression using the DSM-V MINI Test in hematological affection population in North Africa. Indeed, there are very few reports that specifically evaluated the psychological impact of hematological cancer diagnosis in patients in this region.
Most studies have shown consistently that women exhibit more depressive symptoms. Cristian Decat Bergerot found significantly more depressed women than men (p < 0,05), as did Dayu Shi 2020 in a sample of patients with chronic myeloid leukaemia (p < 0.001),10,11 In our study, women had significantly more depression 63% than men 37% (p = 0.036).
Age also has an impact on the occurrence of depressive episodes; according to several studies, an inverse relationship between depression and age is clear; the prevalence rates were higher in the youngest age group and lowest in older adults. In our sample, this difference was not significant (p > 0.05).12–14
The prevalence of depression can differ based on the type of underlying disease.5 In our study, the small sample size of other hemopathies except leukemia led to methodological difficulties, we did not have sufficient statistical power to determine the chi-square (p) test for different subgroups, and we noticed that among hematologic cancer patients, myeloma and lymphoma showed the highest rate (71% and 64.7% respectively) of depression. The psychological distress associated with lymphoma is well described, and several studies have consistently found an increased risk of depression in these patients; Simone et al. found a rate of 18% in a population of 180 patients with Hodgkin’s lymphoma, and a rate of 17% in patients with B lymphoma.15
Regarding the type of treatment received, our study demonstrated that depression was more present in patients who had received an autologous marrow transplant, but not significantly (p = 0.35). Similarly, Clinton-McHarg et al., in a heterogeneous sample including several hematological cancers, noted no significant difference between depression and the type of treatment received.6 Montgomery C, Pocock M, Santos FR et al., showed that patients undergoing intravenous chemotherapy were the most depressed.16,17
Alexander and all, in his study, found that 82% of patients considered their disease curable, and these optimistic patients had considerably less depression than the others. We found 80% of the patients considered their disease curable, and they also had a lower depression rate (44.6%) than the less optimistic patients who considered their disease incurable (65.5%); this is statistically significant p = 0.04.
One of the limitations of this study is that it is a cross - sectional study that does not allow us to evaluate the causal relationship between depression and the different risk factors studied. Another weakness of this study is the small sample size of other hematological cancers except leukemia.
In conclusion, this study is one of the few studies that specifically explored psychological distress in patients with hematological affections in our region. These results demonstrated a high prevalence of depression symptoms among our patients and revealed an important need for psychosocial care as an established part of cancer care in our medical system, especially in hematological department.
Future research could explore models of delivery and effective and culturally appropriate treatment options, which could be integrated into comprehensive global cancer care.
Acknowledgments
We thank all the clinical staff who participated in elaborating this work.
Footnotes
Author contributions
Fatima Zahra Lahlimi was involved in conceptualization and writing the research article. Oumaima Maghnouj, Khawla Khalil, Safaa Chaabane, and Illias Tazi were included in writing the original draft, revision, and editing. All authors approved the final version.
Conflict of interest
We have no conflicts of interest to disclose.
Consent
We obtained consent from all subjects included in the study in accordance with the journals patient consent policy.
Funding statement
This research received no specific grant from any funding agency in the public, commercial, or notfor- profit sectors.
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