SPECIAL ISSUE PAPER

First Anxiety, Afterwards Depression: PsychologicalDistress in Cancer Patients at Diagnosis and afterMedical TreatmentFrancisco Gil1*†, Gema Costa2, Ines Hilker1 & Llucia Benito3

1Psycho-oncology Unit, Duran i Reynals Hospital, Institut Català d’Oncologia, L’Hospitalet de Llobregat, Barcelona, Spain2Department of Psychiatry, Hospital de Mataró, Mataró, Barcelona, Spain3Control and Preventive Service, Duran i Reynals Hospital, Institut Català d’Oncologia, L’Hospitalet de Llobregat, Barcelona, Spain

Abstract

Objective: The purpose of this study was to assess psychosocial changes at two particular moments: at cancerdiagnosis and 2–4 weeks after having finished treatment.

Material and methods: A total of 67 cancer outpatients were assessed in this study. The inclusion/exclusion criteriawere as follows: ambulatory cancer patients aged 18 years or older and receiving medical treatment. Patients with aperformance status <50 or with cognitive impairment (≥3 errors in the Pfeiffer Questionnaire) were excluded. Theinclusion period ranged from 1 April 2005 to 30 April 2007. The scales used were the 14-item Hospital Anxiety andDepression Scale (HADS), which has two subscales for anxiety (seven items) and for depression (seven items), the Qualityof Life Short Form 36 Questionnaire, the Mental Adjustment Scale and the Medical Outcomes Study Questionnaire formeasuring social support. All data were compared with sociodemographic and medical characteristics.

Results: Patients had higher levels of pre-treatment versus post-treatment anxiety (HADS-Anxiety mean, 7.41 versus 6.69),whereas depression scores were higher post-treatment versus pre-treatment (HADS-Depression mean, 3.14 versus 3.89).After medical treatment, patients were more fatigued, with lower performance status (Karnofsky Index), less socialsupport and less quality of life, but no differences in coping styles were found. Women had higher levels of anxietythan men. Patients with psychiatric antecedents had higher levels of distress, but these differences were only observedafter diagnosis and not after the treatment. In general, head and neck cancer patients had higher levels of distress, worsecoping and worse social functioning.

Conclusions: Cancer patients require special consideration before and after treatment. Anxiety is the symptom thatcharacterizes diagnosis, whereas depression is more common after medical treatment. The head and neck cancerpatients were the group with the highest complexity. Copyright © 2012 John Wiley & Sons, Ltd.

Received 8 February 2012; Accepted 20 July 2012; Revised 14 June 2012

Keywords

cancer; distress; quality of life; coping; social support

*Correspondence

Francisco Gil, Psycho-oncology Unit, Duran i Reynals Hospital, Institut Català d’Oncologia, L’Hospitalet de Llobregat, Barcelona, Spain.†E-mail: fgil@iconcologia.net

This study received ethical approval from the Ethics Board of the Hospital Universitario de Bellvitge, L’Hospitalet, Barcelona, Spain.

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.2445

IntroductionThe diagnosis of cancer is accompanied by a sense ofthreat and incertitude about your life. After diagnosis,fear of suffering and death produces feelings of anxiety(Akechi, Nakano, Akizuki et al., 2002; Alonso, Prieto,& Antón, 1995; Annunziata, Muzzati, & Bidoli, 2010).And after ending cancer treatment, fear of recurrence mayevoke feelings of depression in metastatic gastrointestinaland lung cancer patients (Boyes, Girgis, D’Este, &Zucca, 2011).

Stress Health (2012)© 2012 John Wiley & Sons, Ltd.

Approximately one in four cancer patients is diag-nosed with a psychiatric disorder (Brintzenhofe-Szoc,Levin, Li, Kissane, & Zabora, 2009; Bultz et al., 2011),and a significant proportion of cancer patients at allstages of disease will suffer emotional and psychologicalmorbidity as a result of diagnosis and treatment(Colmes, 2001; Brintzenhofe-Szoc et al., 2009). In alandmark study by Derogatis et al., 47% (101 of 215patients) of cancer patients presented some type ofmental disorder, the most common being psychological

First Anxiety, Afterwards Depression F. Gil et al.

adjustment disorders (anxiety and/or depressive mood;68%) and clinical depression (13%) (Costa, Salamero,& Gil, 2007). A study with 277 cancer patients in Italy,Portugal and Spain reported that 28.5% of these patientswere defined as clinical cases requiring psychologicalcare (Costa & Gil, 2009a). Likewise, cancer patients havea higher risk of suicide than the general population.Akechi et al. found that 62 of 1713 cancer patients(4%) referred for psychiatric treatment had some formof suicidal behaviour, generally associated with depres-sion and low performance status (Costa & Gil, 2009b).Likewise, low social support is a predictor of depressionand anxiety disorder (Derogatis, Morrow, Fetting et al.,1983). These data show the necessity of integratingscreening for distress in routine care (Gil, Costa, &Pérez, 2010; Gil et al., 2008). However, only a small num-ber of oncologists use standardized measure of distress(smi2445-bib-0012Gil, Grassi, Travado, Tomamichel, &González, 2005; smi2445-bib-0013Gil, Grassi, Travado,Tomamichel, & Gonzalez, 2005).

Distress has been defined by the National Comprehen-sive Cancer Network as an unpleasant experience ofa psychological, social and/or spiritual nature, whichextends on a continuum from normal feelings ofvulnerability, sadness and fears to disabling problemssuch as depression, anxiety, social isolation and spiritualcrisis, branding distress as the sixth vital sign in cancer care,after being considered as vital signs body temperature,pulse (or heart rate), blood pressure, respiratory rate andpain (Gil et al., 2005, 2005).

The purpose of this study was to assess psychosocialchanges at two specific moments: upon cancer diagnosisand at 2–4weeks post-treatment.

Methods

Sample/participants

The study sample consisted of 67 ambulatory cancerpatients aged 18 years or older who were receiving medicaltreatment at the Hospital Duran i Reynals, CatalanInstitute of Cancer, L’Hospitalet, Barcelona, Spain.

Procedure

All patients who agreed to participate in the study wereassessed by a clinical psychologist during the diseasetrajectory: after diagnosis (pre-treatment) and beforemedical treatment (surgery, chemotherapy or radio-therapy) and 2–4weeks after having finished medicaltreatment. The role of the clinical psychologist was onlyto explain the purpose of the study to patients and todistribute the questionnaires; no psychological supportservices were offered. Once the informed consent formwas signed, several different psychological measureswere used to assess the possible changes at two specificmoments: upon cancer diagnosis and 2–4weeks post-treatment. The questionnaires described as follows werecompleted at one of our outpatient consultations:

(1) The Hospital Anxiety and Depression Scale(HADS; Grassi et al., 2004) assesses psychologicaldistress, which is a 14-item questionnaire withtwo subscales (seven items each) for anxiety anddepression symptoms. Each item is rated on afour-point Likert scale from 0 to 3.

(2) The Medical Outcomes Study Social SupportSurvey (MOS-SSS; Hill et al., 2011) assessesthe multidimensionality of perception of socialsupport in cancer patients. It has 20 items, withfour domains: emotional/informational support,affective support, interaction support and instru-mental support. In each domain, except for item1, the MOS-SSS scale scores range from 1 (never)to 5 (always). A high score represents a highperception of social support. Item 1 assesses qual-itative support (e.g. number of close friends orrelatives). We can obtain a global index of socialsupport with the sum of the other 19 items.

(3) The Mental Adjustment Scale (Hinz et al., 2009)is used to assess the cognitive responses to acancer diagnosis. It is a 40-item self-ratingquestionnaire that uses a four-point Likert scale,which includes the following five behaviouralstyles: fighting spirit (16 items) is when patientsfully accept the diagnosis, characterized by theadoption of an optimistic attitude; helpless–hopeless (six items) is characterized by feelingsof giving up and engulfment by knowledge ofthe diagnosis; anxious pre-occupation (nine items)is characterized by constant pre-occupation withcancer and feelings of threat; fatalism (eight items)shows an attitude of resigned, passive acceptanceof the cancer; and avoidance (denial; one item)is when patients avoid the word ‘cancer’ by usingvarious euphemisms.

(4) The Medical Outcome Study Short Form-36(MOS SF-36; Holland & Bultz, 2007) provides ageneral measure of health-related quality of lifein eight domains: physical functioning, limitationsin performing roles because of physical healthproblems (physical roles), bodily pain, generalhealth, vitality, social functioning, limitations inperforming roles due to emotional health pro-blems (emotional roles) and mental health. Ineach domain, MOS SF-36 scale scores range from 0(the worst possible measured health) to 100 (thebest possible measured health) with higher scoresrepresenting better functioning. The questionnairealso provides two general health domains: physicalhealth and mental health. The MOS SF-36has been translated and adapted into Spanishand has shown satisfactory reliability and valid-ity (Holmes, 2008; Ibbotson, Maguire, Selby,Priestman, & Wallace, 1994).

In addition to the psychological measures describedearlier, we also collected data on the following:

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F. Gil et al. First Anxiety, Afterwards Depression

(5) Symptoms: pain, anorexia, constipation, insomnia,tiredness and dry mouth. All patients wereasked about the presence and the intensity ofthese six physical symptoms, with intensityrecorded on a scale from 0 (minimum) to 10(maximum).

(6) Pfeiffer Questionnaire: used to detect cognitivedeficit. The cut-off score is ≥3 errors (Inen,Ranchor, Sanderman et al., 2008).

(7) Karnofsky performance status: this scaleassesses functional capacity. It has a range from100 (intact functional capacity) to 0 (death)(Karnofsky & Burchenal, 1949).

(8) Medical and sociodemographic characteristics

of patients.

Statistical analysis

The SPSS version 17.0 (SPSS, Inc., Chicago, IL, USA)was used for statistical analyses. First, we used adescriptive univariate analysis with all the variables ofthe study. After the first analysis, we used an analysisof variance of a factor for repeated measures. In ourcase, the factor was the time, with two differentmoments: the first moment was after diagnosis andbefore starting cancer treatment (time 1), and thesecond moment was during the follow-up (2–4weeksafter having ended cancer treatment; time 2).

Results

Subjects

Of the 92 cancer patients invited to participate in thestudy, 25 refused to participate owing to emotional dif-ficulties in talking about the illness, physical symptomsor lack of time. The median time between diagnosisand the clinical interview was 6months (range, 12 daysto 190months). Forty-two were women, with a meanage of 52 years, 85% married, 51% with high schoollevel or higher, 91% had at least a child, 61% had rela-tives with cancer and 40% had relatives died of cancer.Twenty-two per cent had previous psychiatry history,and 36% had previous familial psychiatric history.Fifty-four percent had breast cancer, 25% had headand neck cancer, 19% had colorectal cancer, and 2%had digestive cancer. Ninety-nine percent of themhad a local or loco-regional illness (Table I).

There were no errors in the Pfeiffer Questionnaire,and patients had good performance status (KarnofskyIndex) before and after cancer treatment but with morefatigue after the treatment (Table II).

Psychological distress and coping

Women were more anxious than men after the diagnosis(mean, 8.16 versus 6.16; p=0.05). But less helpless–hopeless (mean, 7.57 versus 9.04; p=0.05). The presenceof psychiatric history increases the level of distress butonly after the diagnosis and not after ending medicaltreatment (mean, 14.53 versus 9.41; p=0.00). In 46 ofthe 67 patients evaluated (69%), pre-treatment anxiety

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scores were higher (mean score, 7.41) than the cut-offlevel of 7; for post-treatment, only 56% of the patientsremained above the cut-off level, with a mean anxietyscore of 6.69, a non-significant difference (p= 0.14).All scores above 7 are considered possible clinicalcases. Pre-treatment and post-treatment scores on theHADS-Depression (mean, 3.14 versus 3.89, respectively;p=0.05) indicated that depression scores worsened aftertreatment, with 22% of the patients above the cut-offlevel of 7 after treatment versus only 12% before. Thetotal HADS score was similar before and after cancertreatment [mean, 10.56 (29% of the patients above thecut-off) versus 10.58 (29%); p=0.97; Table II; Figure 1].

After treatment, patients with head and neck cancerwere more distressed (HADS-Total) than other groupof patients (head and neck cancer, 14.78; breast cancer,8.88; colorectal cancer, 10; p= 0.05). In terms of copingscores, head and neck cancer patients had higher levelsof anxious pre-occupation than other patients (headand neck cancer, 23.42; breast cancer, 22.49; colorectalcancer, 19.91; p= 0.05).

Quality of life

The level of quality of life after treatment is lower thanbefore treatment. After treatment, as physical function-ing is worse than before (mean, 80.36 versus 74.90;p= 0.03), more limitations in performing roles wereobserved, because of physical health problems (mean,57.60 versus 37.19; p= 0.00), more bodily pain (mean,70.83 versus 58.90; p= 0.00), less vitality (mean, 68.86versus 50.90; p= 0.00) and worse social functioning(mean, 83.33 versus 70.83, p= 0.00). Patients withpsychiatric history had lower levels of vitality (mean,53.75 versus 73.59; p= 0.00). No differences in qualityof life were observed between the patients whenconsidering cancer diagnosis.

Social support

In general, patients received less social support aftercancer treatment (mean, 87.46 versus 83.52; p= 0.00).In particular, patients had less emotional (mean,36.19 versus 34.11; p= 0.00), instrumental (mean,18.70 versus 17.87; p= 0.01) and affective support(mean, 14.42 versus 13.89; p= 0.01) after treatment(Table II). Men (mean, 61.87 versus 76.10; p= 0.04)and head and neck cancer patients had less social func-tioning compared with other patients (head and neckcancer, 51.13; breast cancer, 75.59; colorectal cancer,78.12; p= 0.02). Women perceived less social support(instrumental support) than men (mean, 16.40 versus19.26; p= 0.00) after medical treatment.

DiscussionCancer patients are more anxious at diagnosis andmore depressed after cancer treatment. The higherlevels of anxiety at the start of cancer treatment mayprofit from mental health support (Lo, Zimmermann,Rydall et al., 2010; Martinez de la Iglesia, Dueñas, Onis

Table I. Sociodemographic and medical characteristics

Demographics (N= 67)

Age (years) Mean: 52 years Standard deviation: 10.64

Sex Men 25 37%

Women 42 63%

Civil status Married 57 85%

Divorced 5 8%

Single 4 6%

Widowed 1 1%

Educational level Less than high school 33 49%

High school 29 43%

University 5 8%

Children 0 6 9%

1 18 27%

2 30 45%

3 9 13%

4 4 6%

Relatives with cancer Yes 41 61%

No 26 39%

Relatives died of cancer Yes 27 40%

No 40 60%

Personal psychiatric history Yes 15 22%

No 52 78%

Familial psychiatric history Yes 24 36%

No 43 64%

Cancer diagnosis Breast 36 54%

Head and neck 17 25%

Colorectal 13 19%

Digestive 1 2%

Cancer status Local 44 66%

Locoregional 22 33%

Advanced 1 1%

Type of treatment Surgery 55 82%

Radiotherapy 30 45%

Chemotherapy 27 41%

First Anxiety, Afterwards Depression F. Gil et al.

et al., 2001). Several studies have established the sensitivity,specificity and optimal cut-off scores of somemeasures, asthe distress thermometer (DT) and the HADS. Cut-offscores of 4 on the DT and 10 for the HADS have indicatedacceptable sensitivity and specificity to detect a currentpsychiatric disorder (Patel, Sharpe, Thewes, Bell, & Clarke,2011; Pirl, Muriel, Hwang et al., 2007). The emotionalimpact after notifying the presence of cancer can explainthe higher levels of distress at diagnosis. However, onceended the cancer treatment, patients aremore aware aboutthe meaning of a cancer diagnosis in their life, and we canobserve a growing awareness of the impact of the illness onall domains of life, feeling more depressed (Boyes et al.,2011). Another possible explanation receives supportby the secure base literature (Razavi & Delvaux, 1995;Stanton, Ganz, Rowland et al., 2005). The patient can seehis or her oncologist as his or her secure base; but thefrequency of medical contact decreases during the surveil-lance phase of treatment, and he or she can begin to worrymore about recurrence. It is very common to be informed

by patients and their relatives, once ended chemotherapyand radiotherapy treatments, that they do not want to wait3 or 4months until the next visit with their doctor. Theyfeel that the follow-up is too far away, and they need tobe in contact with their doctor. We find support for thisidea in a previous study in which we observed that chemo-therapy treatment reduced the level of emotional distress(Bultz et al., 2011).

Other possible explanation is the presence of phys-ical symptoms, once ended the treatments. Fatigueand pain are associated with higher levels of anxietyand depression symptoms during the follow-up(Schwarz, Krauss, Höckel et al., 2008). Likewise, thelower level of quality of life and the less social supportreceived after cancer treatment can increase the levelof emotional distress. The prevalence of high levels ofpsychosocial morbidity after ending cancer treatmentsemphasizes the need for routine psychosocial assessmentthroughout the cancer trajectory (Vahdaninia, Omidvari,& Montazeri, 2010).

Stress Health (2012)© 2012 John Wiley & Sons, Ltd.

Table II. Medical and psychological characteristics before and after the cancer treatment

Before (mean and SD) After (mean and SD) p

Symptoms Pain 2.71 (0.87) 3.44 (0.85) >0.05

Anorexia 1.44 (0.71) 1.23 (0.72) >0.05

Constipation 1.69 (0.81) 1.75 (0.79) >0.05

Insomnia 2.34 (0.82) 2.59 (0.88) >0.05

Fatigue 2.65 (0.85) 5.26 (0.75) <0.05

Dry mouth 2.19 (0.75) 3.69 (1.00) >0.05

Karnofsky Index 83.46 (9.01) 80.76 (7.36) <0.05

Pfeiffer Index No errors (intact) No errors (intact) >0.05

HADS Anxiety 7.41 (4.11) 6.69 (3.81) 0.14

Depression 3.14 (3.16) 3.89 (3.55) 0.05

Total 10.56 (6.68) 10.58 (6.83) 0.97

MAC Fighting spirit 51.79 (6.09) 50.47 (7.44) 0.13

Helpless–hopeless 7.64 (2.37) 8.12 (3.05) 0.21

Anxious pre-occupation 22.33 (5.10) 21.86 (4.11) 0.42

Fatalism 21.48 (4.73) 21.50 (5.07) 0.97

Avoidance 1.52 (0.92) 1.45 (0.70) 0.56

MOS Emotional/informational support 36.19 (4.46) 34.11 (6.28) 0.00

Instrumental support 18.70 (2.12) 17.87 (2.88) 0.01

Interactional support 18.14 (2.58) 17.63 (2.68) 0.12

Affective support 14.42 (1.18) 13.89 (1.82) 0.01

Total support 87.46 (9.14) 83.52 (12.42) 0.00

SF-36 Physical functioning 80.36 (21.89) 74.90 (16.92) 0.03

Physical roles 57.60 (34.87) 37.19 (24.48) 0.00

Bodily pain 70.83 (26.90) 58.90 (27.41) 0.00

General health 66.69 (20.18) 63.56 (19.65) 0.19

Vitality 68.86 (21.66) 50.90 (22.89) 0.00

Social functioning 83.33 (24.52) 70.83 (25.46) 0.00

Emotional roles 89.35 (22.62) 84.72 (21.76) 0.14

Mental health 67.54 (20.56) 70.27 (22.71) 0.30

SD: standard deviation; HADS: Hospital Anxiety and Depression Scale; MAC: Mental Adjustment Scale; MOS: Medical Outcomes Study; SF-36:

Short Form.

After ending the treatmentDiagnosis

5

10

15

HADS AnxietyHADS Depression

HADS Total

Figure 1 Hospital Anxiety and Depression Scale scores in the diag-

nosis and after the cancer treatment

F. Gil et al. First Anxiety, Afterwards Depression

Head and neck cancer patients present more com-plexity and worse psychological adjustment. Stomachcancer, pancreatic cancer, lung cancer and head and neckcancer have higher levels of mixed anxiety/depressionsymptoms (Ware & Sherbourne, 1992).

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LimitationsThis study has several limitations. The first limitation isthe small sample size (67 patients). Another limitationis that the results are only applicable to certain cancerlocalizations (breast, head and neck, colorectal anddigestive). And finally, we only evaluated patients withlocal or locoregional cancer status, with only a fewcases of metastatic cancer.

ConclusionWe found that anxiety and depressive symptoms arecommon both before and after treatment for cancer.The increase in depression following treatment wasremarkable and merits further attention. It seems clearthat physicians need to pay particular attention to thepatient’s psychological status not only before treatmentbut also afterwards to refer at-risk patients to psycho-oncology services for treatment. Future research isneeded to assess the reasons for these high levels ofanxiety and depression symptoms before and aftertreatment, particularly post-treatment, which was themost surprising finding in our study.

First Anxiety, Afterwards Depression F. Gil et al.

AcknowledgmentsThis research was supported by a grant fromthe Agency of Technology Evaluation and MedicalResearch (AATRM 102/19/2004). We express our

gratitude to these cancer patients who kindlyvolunteered to participate in this study. We wishto thank Bradley Londres for his assistance in editingthe text.

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