Abstract
Depression is prevalence in patients with laryngeal cancer. In this study, we aim to investigate whether psychological intervention could reduce the depression of patients receiving cancer treatment. In this study, 258 patients with laryngeal cancer were assigned into two groups with or without psychological intervention. The depression symptoms of all patients were assessed using Hamilton depression rating scale (HAMD) and Hamilton anxiety rating scale (HAMA). Europe Organization for research and Treatment of cancer Quality of life Questionnaire (EORTC QLQ-C30) was used to measure the life quality of the participants. Other measurements including general attitudes towards psychology services, hospitalization duration and expenses were analyzed. We found that patients with intervention showed more positive attitudes towards psychology services compared to those in control group. Hospitalization duration and expenses were significantly less in intervention group compared to control group. In addition, the intervention group showed a significantly lower HAMD and HAMA scores and improved life quality than control group. Patients aged lower than 40 years showed more obvious reductions in HAMD and HAMA scores and better life quality compared to older patients. In conclusion, our study demonstrated that psychological intervention was necessary and effective in patients with laryngeal cancer during treatment.
Keywords: Laryngeal cancer, depression, psychological intervention, hamilton depression rating scale (HAMD), hamilton anxiety rating scale (HAMA)
Introduction
Early studies demonstrated that the prevalence of depression was dramatically higher in cancer patients than it in general populations [1,2]. Depression has been considered and evidenced as an important factor contributing to reduced quality of life, compromised outcomes of cancer treatment, higher suicide rate and longer hospitalization duration [3-5]. Cancer patients with depression show an about 25% to 39% increase of mortality risk [6].
It was stated that the types of primary cancer affected depression prevalence rate [7]. Compared to patients with other cancer types such as breast cancer and skin cancer, patients with head and neck cancer (HNC) were reported to have the highest level of anxiety. Up to 57% patients with head and neck cancer are suffering from depression [8,9], which is far more than the average incidence rate of other cancers. This may be due to numerous factors such as disfigurement and impairments in daily activities including breathing, swallowing, and taste [10]. Nowadays, early diagnosis and appropriate treatment lead to the increase of the 5-year survival rate of HNC [11,12]. Posttreatment depression therefore becomes a major concern that may affect the survival of patients.
Psychological intervention has been shown as an effective method to alleviate the depression symptoms of cancer patients [13]. Most previous studies reported that life quality was significantly improved in patients with HNC after psychological intervention [13]. It was suggested that psychological intervention was needed for patients with HNC as early as diagnosis [14]. However, due to the lack of psychosocial service in China and low compliance of patients for psychological treatment, patients receiving psychological intervention are relatively rare [15]. On the other hand, patients are not aware of the importance of psychological services and even reluctant to receive the services [16]. In particular, it remains unclear whether the old and young patients have different responses to the psychological intervention. Therefore, since 2016, our hospital had specially organized a group of psychologists and counselors, aiming to improve emotional well-being of patients with laryngeal cancer as an important part of standard treatment. This clinical study aimed to evaluate the patient own awareness of their psychological state and the impact of psychological intervention on depression and life quality.
Methods
Patients
Patients who were over 18 years old, pathologically diagnosed with laryngeal cancer (within one month), had normal level of consciousness, were able to understand the essence of this clinical trial and recognized the entire operation process were eligible in this study. Patients who previously had received treatment from a psychologist or distress symptom was confirmed to be too severe to participate by the caregiver were excluded in this study. All eligible participants were required to provide written consents and complete a questionnaire to further confirm their eligibility to ensure the balance of subsequent randomization. The questionnaire survey mainly assessed demographics, symptom distress scores (Edmonton Symptom Assessment System, ESAS), current emotional distress (Hospital Anxiety and Depression Scale, HADS), and previous experience of receiving psychiatric/psychology services elsewhere.
The detailed procedure of this study is shown as Figure 1. In the end, 258 participants were randomly divided into two groups using the Pocock-Simon randomization method according to their age, gender, and HADS scores: control group (n = 128) and intervention group (n = 130). For the control group, only standard nursing care was provided. For the intervention group, we provided psychological intervention. All assessments were collected at two time points: baseline (T1) and 3 months after treatment (T2). Researchers and principal investigators were blind about the group, and study participants do not know the purpose of this study. All studies were approved by the Ethics Commitment of Weifang People’s Hospital, and written consent was derived from each patient.
Figure 1.
Outline of the study. CG, control group. IG, intervention group. HAMA, Hamilton anxiety rating scale; Hamilton depression rating scale, HAMD; EORTC QLQ-C30, Europe Organization for research and Treatment of cancer Quality of life Questionnaire.
Intervention procedure
For intervention group, doctor introduced the entire treatment process to the patients, and informed possible surgical treatment risks, complications, and psychological pressures that the patient may confront during the entire treatment process. Pre-trained and professional psycho-oncologists were assigned to educate a group of the patients (6-8 patients each group). Each week, the psycho-oncologists provided 6 lessons until patients were not able to continue due to the cancer treatment. These 6 lessons are structurally composed of the following topics: 1. Tumor-specific depression; 2. Health improvement and coping strategies; 3. Treatment sequelae; 4. Postoperative tumor progression and fear of recurrence; 5. Doctor-patient communication; 6. Social resources and professional support. All the lessons were designed for patients to fully understand the psychological problems they may confront to during the treatment process and the psychological service which they may obtain help. The concept of the psychological intervention was to reduce their sense of shame of having psychological problem and to lead them to accept that psychological problem is a normal physiological response to external pressure. Each lesson was about 120 min including explanation using PowerPoint, group discussions, worksheets, and guided scenario simulations. All patients were free to contact with psycho-oncologists when necessary.
Control group
For control group, doctor introduced the patients about the entire treatment process and informed the possible surgical risks and complications. Control group did not receive the lesions but were free to contact with psycho-oncologists. The Intervention group and Control group received the same routine nursing care. Patients were suggested to communicate using body language, keep oral cleanliness, and stop drinking and smoking.
Outcomes
The general attitudes towards psychology service were assessed using five questions. The questions were modified from a previous report [15]. Hospitalization expenses and duration were analyzed from the records of the hospital. Expenses includes the cost from outpatient department, emergency, hospitalization and counselling costs. Patients were blind to their group assignment, and the doctors measuring HAMD, HAMA and QOL scores were also blind to the patient group assignment.
The Hamilton depression rating scale (HAMD) and Hamilton anxiety rating scale (HAMA) were used to evaluate the depression severity patients at T1 and T2. Europe Organization for research and Treatment of cancer Quality of life Questionnaire (EORTC QLQ-C30) [17] was used to measure the overall life quality of the participants.
Statistical analysis
All data analysis was conducted using SPSS software (version 17.0; SPSS Inc., Chicago, IL, USA). To compare the difference between the groups, a Student’s t-test and chi-square test were used. Paired student’s t-test was used to compared the difference in one group at T1 and T2. A p value less than 0.05 was considered to be statistical significance.
Results
Patient characteristic
Totally 258 patients were included and 226 patients were analyzed in this study. The sociodemographic and medical history of all patients were recorded and compared between control and intervention groups. No significant difference was noted as shown in Table 1.
Table 1.
Sociodemographic and medical data of the participants
| Characteristic | Control group | Intervention group | P value |
|---|---|---|---|
| (n = 121) | (n = 105) | ||
|
| |||
| N (%) | N (%) | ||
| Sociodemographic data | |||
| Age (y) | 0.499 | ||
| < 40 | 55 (45.4) | 47 (44.8) | |
| ≥ 40 | 66 (54.6) | 58 (55.2) | |
| Sex | 0.647 | ||
| Male | 82 (67.8) | 70 (66.7) | |
| Female | 39 (32.2) | 35 (33.3) | |
| Marital status | 0.342 | ||
| Single | 23 (19.0) | 19 (18.1) | |
| Married | 98 (81.0) | 86 (81.9) | |
| Highest level of education | 0.151 | ||
| High school or higher | 60 (49.6) | 51 (48.6) | |
| Secondary school | 53 (43.8) | 47 (44.8) | |
| Primary school or lower | 8 (6.6) | 7 (6.6) | |
| Employment status | 0.808 | ||
| Full- or part-time | 103 (85.1) | 91 (86.7) | |
| Not employed | 18 (14.9) | 14 (13.3) | |
| Smoking history | 0.615 | ||
| Never smoked | 39 (32.2) | 33 (31.4) | |
| Former smoker | 35 (29.0) | 30 (28.6) | |
| Current smoker | 47 (38.8) | 42 (40.0) | |
| Alcohol history | 0.670 | ||
| Never | 33 (27.3) | 26 (24.8) | |
| Active drinker | 57 (47.1) | 51 (48.6) | |
| Former Drinker | 31 (25.6) | 28 (26.6) | |
| Medical data | |||
| TNM stage | 0.522 | ||
| Phase I | 35 (29.0) | 30 (28.6) | |
| Phase II | 42 (34.7) | 37 (35.2) | |
| Phase III | 25 (20.7) | 21 (20.0) | |
| Phase IV | 19 (15.6) | 17 (16.2) | |
| Treatment type | 0.387 | ||
| Surgery | 83 (68.6) | 74 (70.5) | |
| Radiotherapy | 54 (44.6) | 42 (40.0) | |
| Chemotherapy | 44 (36.4) | 37 (35.2) | |
TNM, tumor node metastasis.
General attitudes to psychology services
We firstly confirmed the attitudes of all participants to psychology services using several main questions as shown in Table 2. For patients in control group, their attitudes to psychology services did not change over time. The attitudes in intervention group and control group had no significant difference before intervention. However, patients received intervention showed dramatically more positive attitudes to psychology services. Significantly higher proportion of patients who received intervention believed the services were helpful compared to patients in control group.
Table 2.
General attitudes towards psychology services
| Outcomes | Control group | Intervention group | P value between two groups§ | ||
|---|---|---|---|---|---|
| (CG = 121) | (IG = 105) | ||||
|
|
|
||||
| T1 | T2 | T1 | T2 | ||
| Do you think psychology services is helpful for your treatment? | |||||
| Yes | 47 (38.8) | 51 (42.1) | 43 (41.0) | 71 (67.6)††† | < 0.001 |
| No | 34 (28.1) | 32 (26.4) | 27 (25.7) | 15 (14.3)††† | < 0.001 |
| Don’t know | 40 (33.1) | 38 (31.5) | 35 (33.3) | 19 (18.1)††† | < 0.001 |
| Who would you seek for help when you think you are in depression? | |||||
| Friends and family | 77 (63.6) | 78 (64.5) | 67 (63.8) | 69 (65.7) | 0.314 |
| Religious organization | 13 (10.7) | 11 (9.1) | 10 (9.5) | 9 (8.6)† | 0.117 |
| Psychologist | 30 (24.8) | 31 (25.6) | 27 (25.7) | 60 (57.1)††† | < 0.001 |
| General practitioner | 26 (21.5) | 27 (22.3) | 22 (21.0) | 24 (22.9) | 0.230 |
| others | 12 (10.0) | 11 (9.1) | 10 (9.5) | 8 (7.6)†† | 0.016 |
| How do you feel about talking to a psychologist? | |||||
| Open | 41 (33.9) | 39 (32.2) | 36 (34.3) | 53 (50.5)††† | < 0.001 |
| Hesitated | 52 (43.0) | 55 (45.5) | 44 (41.9) | 40 (38.1)††† | < 0.001 |
| rejective | 28 (23.1) | 27 (22.3) | 25 (23.8) | 12 (11.4)††† | < 0.001 |
| Patients consulting psycho-oncologists for help | |||||
| N/A | 33 (27.3) | N/A | 69 (65.7) | < 0.001 | |
P < 0.05 T2 vs T1.
P < 0.01 T2 vs T1.
P < 0.001 T2 vs T1.
Comparison of T2 between Intervention group and Control group.
Hospitalization duration and hospitalization expenses
We compared the hospitalization duration and expenses between control and intervention groups. It was found that patients received intervention showed a shorter time of hospitalization and less hospitalization expense (Table 3), suggesting that intervention may improve the body status of those patients.
Table 3.
Comparison of the hospitalization duration and hospitalization expenses between the two groups
| Outcomes | Control group | Intervention group | P value |
|---|---|---|---|
| Mean ± SD | Mean ± SD | ||
| Hospitalization duration (days) | 23.4±5.5 | 18.5±6.7 | 0.007 |
| Hospitalization expenses (RMB) | 21,154±3,416 | 20,731±2,653 | 0.043 |
Improved psychological status by intervention
To evaluate whether intervention was useful in the patients, we evaluated HAMD, HAMA, EORTC QLQ-C30, cognitive and social functions in the two groups. As expected, at T2 time, HAMD and HAMA scores were significantly reduced in patients received intervention compared to those in control group (Table 4), as no significant change was observed at T1 between the two groups. The life quality of patients in intervention group were similar at T1. However, at T2, the life quality and social function of patients in intervention group were significantly higher than those in control group. Although there was no significant difference in cognitive function between these two groups, it could be implicated that intervention functioned positively for improvement of psychological status and life quality of these patients.
Table 4.
Comparison of HAMD, HAMA and QOL score of each dimension between the two groups
| Outcomes | Control group | Intervention group | P value between two groups§ | ||
|---|---|---|---|---|---|
|
|
|
||||
| T1 | T2 | T1 | T2 | ||
| HAMD score | 27.2±3.4 | 21.9±4.6†† | 27.6±3.3 | 16.5±3.5††† | < 0.001 |
| HAMA score | 25.8±4.9 | 16.7±8.1††† | 26.2±4.5 | 8.3±2.2††† | < 0.001 |
| EORTC QLQ-C30 | |||||
| Global QOL | 83.4±5.2 | 61.3±8.3††† | 84.9±5.5 | 72.5±6.9†† | 0.007 |
| Physical function | 92.6±4.7 | 75.3±6.9††† | 91.8±4.4 | 82.6±7.3†† | 0.003 |
| Role function | 89.4±6.4 | 72.7±8.8††† | 90.2±5.9 | 88.6±9.0† | < 0.001 |
| Emotional function | 90.3±4.6 | 57.8±15.2††† | 90.5±4.9 | 83.5±12.7†† | < 0.001 |
| Cognitive Function | 84.1±7.5 | 73.2±13.7††† | 84.7±7.8 | 75.2±12.8††† | 0.074 |
| Social Function | 87.2±6.5 | 56.7±15.7††† | 88.5±6.4 | 66.3±15.4††† | 0.005 |
Data were expressed as mean ± SD.
P < 0.05 T2 vs T1.
P < 0.01 T2 vs T1.
P < 0.001 T2 vs T1.
Comparison of T2 between Intervention group and Control group.
Age affects intervention results
As the stress of patients at different ages may be varied, we further investigated whether age plays a role in the intervention outcomes. We compared the changes of HAMD score, HAMA score and EORTC-QLQ-C30 in the two groups. Interestingly, in control group, we found that patients aged ≥ 40 showed significantly higher reduction of HAMD than patients < 40 age (Table 5), implicating that younger patients may be more vulnerable to depression compared to older patients. However, the intervention group showed that patients aged ≥ 40 had a lower reduction of HAMD score compared to the patients < 40 age. The change in HAMA score of the intervention group showed the same trend as HAMD score. However, compared to control group, intervention apparently improved the psychological status of patients regardless of ages.
Table 5.
Effect of Psychology Services intervention on HAMD, HAMA and QOL scores by age
| Outcomes | Age | |||
|---|---|---|---|---|
|
| ||||
| < 40 | ≥ 40 | |||
|
|
|
|||
| Control group (n = 55) | Intervention group (n = 47) | Control group (n = 66) | Intervention group (n = 58) | |
| Δin score | Δin score | Δin score | Δin score | |
| HAMD score | -5.37±4.89 | -12.69±8.53*** | -6.46±5.27& | -11.83±8.14***,& |
| HAMA score | -9.42±6.05 | -19.49±10.83*** | -9.73±7.01 | -16.24±9.06***,&& |
| EORTC QLQ-C30 | ||||
| Global QOL | -20.58±13.35 | -9.59±6.27*** | -26.44±14.16&& | -14.35±7.61***,&& |
| Physical function | -15.49 | -7.45*** | -18.21&& | -11.23***,&& |
| Role function | -15.57 | -1.27*** | -16.91& | -2.31***,&& |
| Emotional function | -32.04 | -5.49*** | -33.28& | -9.04***,&&& |
| Cognitive Function | -7.26 | -7.44 | -14.37&&& | -11.16***,&&& |
| Social Function | -24.07 | -19.26*** | -34.18&&& | -25.49***,&&& |
Data were expressed as mean ± SD.
P < 0.001, Control group vs Intervention group.
P < 0.05 age < 40 group vs age ≥ 40 group.
P < 0.01 age < 40 group vs age ≥ 40 group.
P < 0.001 age < 40 group vs age ≥ 40 group.
We also found that patients < 40 had a less reduction of life quality compared to older patients over time in both control and intervention group. However, compared to control group, intervention significantly improved the life quality of all patients.
Discussion
Depression after cancer diagnosis is not a neglected factor that could influence the survival of patients. According to previous researches, the prevalence rate of depression was about 12.5% in cancer patients, which was almost four-times higher than others [18]. Depression was suggested to be associated with poor prognosis and worse survival rate [6]. Particularly, antidepressant medication showed little impact on depression assessed using Edinburgh depression scale (EDS) and Patient Health Questionnaire 9 (PHQ9) [19] in patients with advanced cancers. Depression prevention may potentially benefit the outcomes of cancer treatments. The incidence of depression was stated to be associated with a lower survival rate in patients with head and neck cancer [20]. Therefore, it becomes important to confirm whether psychological intervention is effective among patients with head and neck cancer.
In this study, we focused on patients with laryngeal cancer. We assessed whether intervention reduced the psychological distress of patients receiving cancer treatments. Although previous studies demonstrated that depression in cancer patients was associated with various psychosocial stressors such as inflammation, psychological interventions have been shown to benefit individuals with reduced depressive burden [21]. Importantly, psychological intervention could promote patient survival, demonstrated form a study on patients with breast cancer [22]. In a range of other cancer types, psychological intervention was shown to be effective to reduce depression symptoms [23,24].
A recent study on patients with laryngeal cancer demonstrated that psychological intervention improved HAMD, HAMA, and EORTC QLQ-C30 scores over time and significantly decreased the duration of hospitalization and total expenses [25]. However, in that study, they did not demonstrate the characteristics between the control and intervention groups, which could affect the results of the research. Here, we included sociodemographic and medical data of all participants in the two groups to confirm the results were not dependent on other elements but only intervention treatment. We also analyzed the general attitudes towards psychology services. About half of participants believed in psychology services in both control and intervention groups. Interestingly, patients with positive attitudes to psychology services dramatically increased after intervention. The results, on the other hand, implicated the effectiveness of psychological intervention. Consistent with the study, our data showed that the duration and expenses of hospitalization were also significantly less in intervention group compared to control group, suggesting that intervention could be a positive contributor to postoperative recovery.
Indeed, the decreases of HAMD and HAMA scores in intervention group over time provided a strong evidence indicating the effectiveness of intervention in those patients. Notably, the HAMD and HAMA scores in intervention group after treatments were significantly reduced compared to those of control group. These results indicate that intervention is a useful method to prevent depression of patients with laryngeal cancer. Although there are a number of studies investigating the impact of surgery such as laryngectomy on postoperative depression of patients with laryngeal cancer [26], whether psychological intervention play positive role for the recovery and psychological status of the patients are rare. Another previous study reported that a Helpless-Hopeless mental adjustment response had a correlation with worse depression, reduced life quality and poorer survival rate in patients with laryngeal cancer [27]. Our study also found that life quality was significantly improved in patients with intervention compared to those without after laryngeal cancer treatment. Taken together, these evidences suggest that psychological intervention may alter the mental adjustment response of patients, and therefore leading to a better outcome. However, we did not assess whether the intervention also had an association with survival rate, which is necessary in further studies. In addition, it is interesting to investigate whether the mental adjustment response is also changed after psychological intervention in further studies.
Importantly, previous data reported that age was an essential factor associated with depression severity [10]. They found that older patients (aged about 62 years) showed significantly higher Beck’s Depression Inventory (BDI) score than younger patients (aged about 54 years) with laryngeal cancer [10], implicating that older patients have more severe mental problem. This finding was supported by numerous other previous studies on patients with laryngeal cancer [10,26]. As depression patients who are older than 65 have a higher risk of suicide [28], further studies not only need to compare the survival rate among patients with different ages after intervention and also considered suicide rate.
Here, we found that patients older than 40 years also had a positive response to intervention. Our study provides the evidence that even in older patients, intervention could be an effective method to treat cancer induced depression. Indeed, the decreases of HAMD and HAMA scores in younger patients aged lower than 40 years were significantly more than older patients after intervention. Inversely, the younger patients showed less global QOL reduction compared to older patients. Despite these results demonstrating that intervention have a better outcome in patients younger than 40 years old compared to older patients, intervention showed dramatically impact on reduction of depression symptoms and improvement of life quality. We suggest that it is better to adjust the methods of psychological intervention when treating older patients, which may significantly improve the outcomes.
Conclusion
In conclusion, we found that psychological intervention during cancer treatment of laryngeal patients significantly reduced HAMD and HAMA scores and improved life quality quantified as EORTC QLQ-C30. Age was an important factor affecting the outcomes of the intervention, as younger patients (< 40 years old) showed higher reductions in HAMD and HAMA scores and lower decrease in QLQ-C30 compared to older patients (≥ 40 years old). Our study demonstrated that psychological intervention had a positive impact on the reduction of depression and improvement of life quality of patients with laryngeal cancer.
Disclosure of conflict of interest
None.
References
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