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ScienceDirect Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

ASEAN-Turkey ASLI (Annual Serial Landmark International) Conferences on Quality of Life 2016

AMER International Conference on Quality of Life, AicQoL2016Medan 25 – 27 February 2016, Medan, Indonesia

Depressive Symptoms among Cancer Patients Undergoing Chemotherapy Suzana Yusofa*, Fatin Nadzirah Zakariab, Nina Keterina Hashimb, Razif Dasimanb a Department of Nursing, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia Department of Basic Science, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia

b

Abstract Objective: To investigate the level of depressive symptoms among cancer patients undergoing chemotherapy and its association with sociodemographic data. A cross-sectional study was conducted among cancer patient in General Hospital Kuala Lumpur. One hundred eleven (111) cancer patients undergoing chemotherapy were evaluated, and their participation was on a voluntary basis. A well-constructed and validated questionnaire was used to assess the depressive symptom including their demographic and sociographic data. The results of the present investigation revealed that the level of depressive symptom in cancer patients did not affect between gender, ages and chemotherapy’s cycle as there showed no significant difference. However, the result showed a significant difference between marital statuses. This finding would be useful and beneficial to healthcare services which might improve in management and intervention on psychological of patient undergoing chemotherapy. Other factors that contributed to depression among cancer patient also need to be investigated. © 2015 The Authors. Published by Elsevier Ltd. © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license Peer-review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers) and cE-Bs (Centre (http://creativecommons.org/licenses/by-nc-nd/4.0/). for Environment-Behaviour Studies, Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. Peer-review under responsibility of the Association of Malaysian Environment-Behavior Researchers, AMER (ABRA malaysia) Keywords: Depression; cancer patient; chemotherapy

* Corresponding author. Tel.: +603-3258-4350; fax: +603-32584599. E-mail address: [email protected]

1877-0428 © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the Association of Malaysian Environment-Behavior Researchers, AMER (ABRA malaysia) doi:10.1016/j.sbspro.2016.10.233

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Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

1. Introduction Cancer is the second leading cause of death (Polikandrioti et al., 2008). The risk factors that lead to cancer include chemical carcinogens, age, lifestyle factors, radiation, infection and immune system. Surgery, chemotherapy, and radiotherapy are the most common treatment of cancer to cure or control from spreading throughout the body (Tim, 2012). Patient diagnosed with cancer commonly having depressive symptoms (Kim et al., 2006). About 1525% of cancer patients are affected by depression reports by The National Cancer Institute (2008) (Bayer, 2009). Chemotherapy is a type of cancer treatment that uses drugs to destroy the cancer cells. The cancer patient receiving chemotherapy may lead to depressive symptoms and worsening during chemotherapy (Polikandrioti et al., 2008). According to National Cancer Registry (2011), the symptoms of depression were included sadness, loss of interest, changes in eating and sleeping habits, nervousness, slow physical and mental responses, feeling guilty, unable to focus and frequent thoughts of death or suicide. In diagnosing depression, physical and mental state assessment, as well as laboratory investigations, were commonly evaluated. Apart from genetic factor, nutritional intakes and family history, the demographic factors were also contributed to depressive symptoms in cancer patients who undergone chemotherapy. The previous study had been shown that women have the higher prevalence of depressive symptoms than male. On the other hand, depression level decreases inversely with increases of age (Miaskowski, 2004). Other study conducted by Beyer (2009) claimed that young unmarried women have the higher risk of developing depression. This finding was parallel with Hann et al. (2002) who stated that high social support from family member results in reducing the depression symptoms. However, there were limited finding on the association between the level of depressive symptoms and demographic factors such as age, gender, marital status as well as chemotherapy’s cycle. Hence, these findings can provide a baseline information that may potentially be important for the healthcare provider in providing accurate and efficient management, especially in the cancer patient. 2. Materials and methods 2.1. Sampling One hundred eleven (111) respondents of the cancer patient who was undergoing chemotherapy at General Hospital Kuala Lumpur were evaluated. The researchers have explained the purpose of conducting the research to the respondents before data collection. All experiments were conducted according to the guideline proved by Ethic Committee of UiTM Puncak Alam (UiTM 600-FSK (PT. 5/2)), the director of Kuala Lumpur Hospital, Head of Department of Oncology Unit and National Medical Research (reference number 15333). All data collection were kept confidentially and only been used for academic purposes. 2.2. Selection criteria Some criteria must be included to form a sample population. Inclusion Criteria x 18 years of age and above x Cancer patient undergoing chemotherapy x Conscious patient Exclusion Criteria x Cancer patient undergoing radiotherapy 2.3. Questionnaire The researcher used the survey as the instrument for data collection. The level of the depressive symptom of respondents was scored using the Center for Epidemiologic Studies Depression Scale (CESD) tool. The questionnaire consists of three parts. Part A includes the question related to sociodemographic data such as gender,

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age, marital status, chemotherapy's cycle, stages and type of cancer. Part B includes the question regarding on the level of depression symptoms whereas Part C includes the respondent's feeling to depression. All respondents have fulfilled the questionnaire within 15 minutes and were scored according to the scoring system as indicated below: x Score less than 15 : not appear to be experiencing high levels of depressive symptom x Score 15-21 : mild to moderate depressive symptom x Score more than 21 : high level of depressive symptom 2.4. Statistical data analysis Statistical Package for Social Science (SPSS) software was used in this study. Data was analyzed by using descriptive analysis followed by Spearman’s Rank Correlation Test to identify the relationship between variables. P< 0.10 was considered as significant differences. 3. Results From a total of 111 respondents in the study, there were 67 (60.4%) male patients and 44 (39.6%) female patients. Sixty-one (55%) of the patients involved in this study were above 50 years of age, followed by 34 (36.6%) of 30-49 years old and 16 (14.4%) of 18-29 years old. About marital status, 13 (11.7%) were unmarried, 92 (82.9%) married and 6 (5.4%) were divorced. Based on data of chemotherapy cycle during the study, 9.0% was in the first cycle, 16.2% was in the second cycle, 20.7% was in the third cycle, and 54.1% was in the forth cycle and above (See Table 1). Table 1. Sociodemographic data Characteristic Gender

Age

Marital status

Chemotherapy cycles

n

%

Male

7

60.4

Female

44

39.6

18-29

16

14.4

30-49

34

36.6

Above 50

61

55

Single

13

11.7

Married

92

82.9

Divorced

6

5.4

1st

10

9.0

2nd

18

16.2

3rd

23

20.7

4th and above

60

54.1

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Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192 Table 2. Level of depressive symptoms of cancer patients undergoing chemotherapy Depressive symptoms

n

%

No experiencing depressive symptoms

60

54.1

Mild to moderate depressive symptoms

24

21.8

Possibility of major depressive symptoms

27

24.3

For the level of the depressive symptom of the total sample in the study, there was 54.1% ) for the total of no depressive symptom which, (21.8 [n=24]) was the total of mild to depressive symptom level. The high-level depressive symptom associated with major depression is much higher compare to moderate depressive symptom level with total (24.3% [n= 27]). In regard to gender, from 111 of cancer patient undergoing chemotherapy, for males, (53.7% [n=36) having no depressive symptom, (22.4% [n=15]) was mild to moderate of depressive symptom and (23.9% [n=16]) was high level of depressive symptom associated with major depressive symptom. While female gender, (54.5% [n=24]) was no depressive symptom, (20.5% [n=9]) was mild to moderate of depressive symptom and (25% [n=11]) was a high level of the depressive symptom associated with the major depressive symptom. Regarding age category, for 18-29 years old, (62.5% [n=10) having no depressive symptom, (18.75% [n=3]) was mild to moderate of depressive symptom and (18.75% [n=3]) was the high level of depressive symptom associated with major depressive symptom. While 30 – 49 years old, (53% [n=18]) was no having depressive symptom, (29.4% [n=10]) was mild to moderate of depressive symptom and (17.6% [n=6]) was the high level of the depressive symptom associated with the major depressive symptom. For 50 years old and above, (52.5% [n=32) having no depressive symptom, (18% [n=11]) was mild to moderate of depressive symptom and (29.5% [n=18]) was high level of depressive symptom associated with major depressive symptom. Regarding marital status of participants, for single, (69.2% [n=9) having no depressive symptom, (7.7% [n=1]) was mild to moderate of depressive symptom and (23% [n=3]) was high level of depressive symptom associated with major depressive symptom. While for married, (55.4% [n=51]) was no having depressive symptom, (20.7% [n=19]) was mild to moderate of depressive symptom and (23.9% [n=22) was the high level of the depressive symptom associated with the major depressive symptom. For divorced, (0% [n=0) having no depressive symptom, (66.7% [n=4]) was mild to moderate of depressive symptom and (33.3% [n=2]) was high level of depressive symptom associated with major depressive symptom (See Table 3). Table 3. Sociodemographic data and level of depressive symptoms Level of depressive symptoms Characteristics

Gender

Age

No depressive symptoms

Mild to moderate of depressive symptoms

High level of depressive symptom associated with major depressive symptoms

n

%

n

%

n

%

Male

3

18.75

10

29.4

11

18

Female

3

18.75

6

17.6

18

29.5

18-29

10

62.5

3

18.75

3

18.75

30-49

18

53

10

29.4

6

17.6

Above 50

32

52.5

11

18

18

29.5

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Marital status

Chemotherapy cycle

Single

9

69.2

1

7.7

3

23

Married

51

55.4

19

20.7

22

23.9

Divorced

0

0

4

23.9

2

33.3

1st

7

70

0

0

3

30

2nd

7

38.9

5

27.8

6

33.3

3rd

12

55.2

8

34.8

3

13

4th and above

34

56.7

11

18.3

15

25

This study was used nonparametric test Spearman Rank correlation to identify the association between variables which met the objective 2 and 3. The statistical analysis showed no correlation between the level of depressive symptom and gender, p=0.992. The statistical analysis also showed no correlation between the level of depressive symptom and the age of participant during the study, p=0.380. According to marital status, the statistical analysis showed the correlation between the level of depressive symptom and marital status, p=0.064 with the confidence interval of 90%. Regarding the current chemotherapy cycle during the study, the statistical analysis also showed no correlation between the level of depressive symptom and the current chemotherapy’s cycle during the study, p=0.682. (see Table 4) Table 4. Association between gender, age, marital status, current chemotherapy cycle and the levels of the depressive symptom (90% of confidence interval) Variables

p-value

Gender

p=0.992

Age

p=0.380

Marital status

p=0.064

Current chemotherapy cycle

p=0.682

4. Discussion Based on (Inaba, et al., 2005), the most of the cross study stated that woman, unmarried person, lower education person, low income, or occupational prestige have the higher risk for depressive disorder than man, the married, and higher advantaged socioeconomic status (SES) position. In this study, the number of samples according to gender differences also had been observed where the majority of the samples are the man than the woman, the similar finding with another study (Lavdaniti, 2012). The statistical result showed that 54.1% did not have depressive symptom, 21.6% experienced mild to the moderate depressive symptom, and 24.3% had high-level depressive symptom associated with major depression. There was no significant difference found between age, sex, marital status, and educational level in the study conducted by Rezaei, and Adib-hajbaghery (2008). 4.1. Gender From the result analysis of the present study on gender differences, there is no statistically significant from gender differences as per the previous study conducted by Polikandrioti et al., (2008) that showed women experienced higher depression than man but no significant statistics. The finding of the current research is parallel with the research finding by Farooqi, & Ahsan, (2009), Hann, et al., (2002), Linden, W. et al., (2012), Inaba, et al., (2005). The result of Farooqi, & Ahsan, (2009)'s study also supported the result of this study. The cross-sectional study was carried on gender differences in anxiety and depression among Pakistani cancer patients using HADS. 100

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patients (male = 50, female = 50) were taken as samples, and the result shows that there were no significant differences between gender and depression. The study conducted by Lavdaniti, (2012) revealed that there was no statistically significant difference in the relationship between depression and gender. Lavdaniti, (2012) believed that the depression level affects men and women equally. Linden, et al., (2012) suggested that gender differences influenced in their willingness to express depression and women tend to apply emotional approach coping skills. Newport, & Nemeroff, (1998) stated that depression was a common clinical entity with the lifetime risk of Major depressive disorder (MDD) had been 20% to 25% of women and 7% to 12% for men where the point of prevalence is 5% to 9% for women and 2% to 3% for men. The Cross-National Collaborative Group found higher lifetime and 12-month rates of major depressive disorder among women compared to men across all ten nations, including Taiwan, South Korea, urban women in Seoul and women in Taiwan. 4.2. Age In the term of age in this study, younger patients are less depressed than older patients. (Fann, et al., 2008) In his study stated that younger patients have the higher risk of depression especially the first year after diagnosis of having breast cancer. However, no significant difference was found between level of depression and age in this study which is similar to Polikandrioti et al., (2008) who mentioned that his study does not show a direct association between depression level and age. The result of Lavdaniti, (2012) also showed there was no statistically significant between depression and age. In the meta-analysis of the study conducted by (Chang-quan, et al., 2010) showed there was no significant difference between old age cancer patient and depression. However, the study by Linden, et al., (2012) mentioned that there were higher prevalence rate of depression level among younger age cancer patients than lower prevalence rate of depression level in older age cancer patients (Linden, et al., (2012) (Kim, et al., 2006). The researchers believed that higher prevalence rate of depression level among younger age due to more disruption in daily life while the older age already had physical function impairments and they had prepared cognitively and emotionally in accepting the illness (Linden, et al., 2012) (Polikandrioti et al., 2008). Hopwood, (2000) found that there was a slight trend for lower depression level in older patients, but the variable did not achieve statistical significance (p = .058). In the literature review of Trask, (2004), using HADS tool as a unitary scale with 11 as a threshold level, it was found that a significant of 70% in identifying psychiatric disorder and this varied by the age of the women. However, < women 50 years of age showed 90% sensitive and 40% false positive rate using 11 as a threshold level, but in > women 50 years of age, the sensitive was 57%, and the false positive rate was 3%. Study conducted by Miaskowski, (2004) showed that there was interaction between age and gender on the depression level using Center for Epidemiological Studies-Depression scale (CES-D) where if age increased by 1 year for men, depression level reduced by 0.33 units; while as age increased by 1 year in women, depression raised by 0.16 units. According to Ahles, & Saykin, (2002), there was speculation that older adult might be exposed to the chemotherapy’s side effect to cognitive function. So, the age at treatment can be a predictor of the level of chemotherapy-induced cognitive changes. 4.3. Marital status Marital distress and depression always occur especially among women (Rehman, et al., 2008). The interesting finding in this research is about the marital status where in this study, there are statistically significant differences between depression level and marital status. It found that divorced patients faced more depression than married patients. This present study finding matched with the previous research conducted by Lavdaniti, (2012). The CrossNational Collaborative Group cater across all ten nations including Taiwan and South Korea found that separated and divorced individuals showed higher major depression prevalence compared to the married person (Inaba, et al., 2005). The possible explanation for this is because divorced patients did not have moral support from the family members than the married patients that had moral support from the family members (Lavdaniti, 2012). Similar to other study by Pasquini, Biondi, (2007) mentioned that social support also played an important role alleviating depression among cancer patients and family counseling should be implemented to educate the family members


about depression among cancer patients (Pasquini, & Biondi, (2007) (Hann, et al., 2002). Hann, et al., (2002) also shared the same confirmed result that increasing in social support were linked with the low level of depression among cancer patients. Hann, et al., (2002) also stated that having larger social support significantly associated with low depression level for women but not significant for men. In a study conducted by (Inaba, et al., 2005) it was stated that unmarried and formerly-married individual exhibit higher depression level scores than the married. 4.4. Chemotherapy cycle In the present study, there is no significant difference between depression and chemotherapy cycles. This finding is consistent with Khudhair, (2009) who mentioned that there were no significant differences found between depression level and chemotherapy cycle. The study conducted by Beyer, (2009) showed there were no significant differences in the number of depressed patients before and after treatment, and levels of depression were not significantly different for either type of cancers. Pandey, et al., (2006) also mentioned there was no relationship between chemotherapy cycle and depression. However, research conducted by Polikandrioti et al., (2008) showed that those undergoing chemotherapy with no response felt more depressed than those who had responded after chemotherapy treatment.( Polikandrioti et al., 2008) (Pandey, et al., 2006) The study conducted by Jim, et al., (2011) stated that there were significant differences on the main effect of chemotherapy cycle and depression where the depression was found on the infusion day with the higher level of depression than the later infusion. (Fann, et al., 2008) also showed the same result where women who received chemotherapy reported more psychological distress and depression compared to those who did not receive chemotherapy. Although cancer diagnosis was a marked stressor, there were other psychological and biological stressors that accompany cancer and developing the depressive syndrome. Chemotherapeutic agents, surgical procedures, and radiotherapy were the biological stressors experienced by cancer patients that include the effect of treatment as well as the consequences of paraneoplastic syndromes (Newport, & Nemeroff, 1998). The result of Cantor, et al., (2003) study showed that 70 years and over cancer patients were treated at one academic tertiary cancer center, faced deteriorations in emotional and functional after chemotherapy treatment. This deterioration was higher in patients who faced severe side effects from chemotherapy treatment than those who did not, and among tumor progression patients than those with partial or complete treatment. The study conducted by Pandey, et al., (2006) showed that side effect symptoms appearance among cancer patients receiving chemotherapy. The symptoms are like tiredness, loss of appetite, dryness of mouth, nausea, and sleep disturbances. For breast cancer patients undergoing chemotherapy, the chemotherapy adverse effect involved are of fertility, sexuality and menopause-associated health problems (e.g., osteoporosis and cardiovascular disease) that can lead to high distress level (Fann, et al., 2008). Khudhair, (2009) stated that the relationship between depression level and the physical symptoms among cancer patients was limited. This result showed that the depression symptoms among cancer patients undergoing chemotherapy may arise from the disease itself. 5. Conclusion In conclusion, there was no association between the level of the depressive symptom with age, gender and chemotherapy's cycle, indicating that the depression was caused by the disease itself. However, there was a significant difference between marital statuses on depression indicating that moral support from the family member can minimize the depression level among cancer patient who was undergoing chemotherapy. This finding may be useful for the health care provider to identify the potential depression patient. Other factors that contributed to depression among cancer patient also need to be investigated. Conflict of Interest We declare that we have no conflict of interest.

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Acknowledgement The authors are grateful to Head of Oncology Department, General Hospital Kuala Lumpur, nurses, student nurses and staff for their cooperation and providing necessary research facilities.

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