Distress overlaps with anxiety and depression in patientswith head and neck cancer

Manoj Pandey1*, Nandkumar Devi2, Bejoy C. Thomas3, S. Vinod Kumar2, Rita Krishnan2 and K. Ramdas3

1 Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India2 Department of Psychology, HH the Maharajah’s College for Women, Trivandrum, Kerala, India3 Department of Radiation Oncology, Regional Cancer centre, Trivandrum 695011, Kerala, India

* Correspondence to: SurgicalOncology, Institute of MedicalSciences, Banaras HinduUniversity, Varanasi 221 005,India. E-mail: manojpandey@vsnl.com

Abstract

Psychological problems in cancer patients often go unrecognized until they are specifically

sought. This is more in patients with depression as they are reluctant to complain about their

symptoms. The present study was carried out to evaluate the relation of distress with anxiety

and depression in 123 patients with head and neck cancers using Distress Inventory for Cancer

version 2 (DIC2) and the Hospital Anxiety and Depression scale (HADS). The mean DIC 2

scores were 24.6 while that of subscales ranged from 2.6 to 11.0. Fifteen patients were found to

have clinical caseness for anxiety while 12 (10%) were caseness for depression. Total distress,

emotional and social distress subscales were found to have positive correlation with anxiety and

depression suggesting a possible overlap of two constructs. In multivariate analysis only belief

in god was found to significantly affect the distress. Results of present study suggest significant

psychological morbidity in head neck cancer patients undergoing curative treatment. This is the

first study reporting on the psychometric properties of distress inventory on cancer version 2

since its validation, the results suggest a possible overlap of two constructs similar to that seen

with other tools on distress and this may have major implications for clinical practice.

Copyright # 2006 John Wiley & Sons, Ltd.

Keywords: distress; anxiety; depression; cancer; head and neck; oral cavity

Introduction

The word cancer is always equated with fear,pessimism and fatalism. In the past oncologicalrehabilitation was considered an oxymoron andonly few cancer patients had any hope to survivelong. With changing scenario and recent advancesin diagnosis and management of cancer themortality rates are declining resulting in a growingnumber of cancer survivors.Head and Neck cancers account for 4% of all

malignancies. The incidence is highest in France[1]. In India, high incidences are reported fromTrivandrum, Nagpur, New Delhi and Mumbai,making it the commonest cancer among males, andthird commonest among females [2]. It is one of thetobacco related cancer and hence is preventable.Other peculiarity of head and neck cancer is that itstreatment in from of radiotherapy or surgery hashigh impact on psychosocial, physical and func-tional aspects of an individual. The disfigurementfrom the treatment cannot be understated beside itseffect on functions like taste, swallowing, speech,breathing, eating, etc.Psychology plays an important role in terms of

attitudes and beliefs about life and cancer andalso helps in predicting behavior. The effect of

psychological and physical stress, mood, anxietyand depression has been earlier examined. Watsonet al. [3] examined cognitive response to cancer andsuggested that a ‘fighting spirit’ is negativelycorrelated with anxiety and depression whereasfatalism, helplessness, and anxious preoccupationwere found to be related to lower mood. Vickeryet al. [4] studied psychological and physical stressfrom head and neck cancer that can be substantialfor patients and partners. Partners reported greaterstress than patients and the disease was found tohave significant effect on it.

Distress in specific reference to cancer has beendefined as ‘an unpleasant emotional experience of apsychological (cognitive, behavioral, emotional)social and/or spiritual nature that may interferewith the ability to cope effectively with cancer, itsphysical symptoms and its treatment. Distressextends along a continuum ranging from commonnormal feelings of vulnerability, sadness and fearsto problems that can become disabling such asdepression, anxiety, panic, social isolation andspiritual crisis’ [5]. However, as suggested by ourearlier work, identifying a patient somewhere alongthe beginning and middle of the continuum, beforethe clinical stages of anxiety and depression sets in,is an ideal objective [6–9]. Distress inventory for

Received: 9 April 2006

Revised: 1 October 2006

Accepted: 2 October 2006

Copyright # 2006 John Wiley & Sons, Ltd.

Psycho-OncologyPsycho-Oncology 16: 582–586 (2007)Published online 16 November 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1123

cancer version 2 (DIC 2) has been developed toscreen cancer patients in early middle part of thedistress continuum before the anxiety or depressionsets in (Thomas BC 2006 unpublished data), whileHADS is a tool to screen for anxiety anddepression [10].The present study is based on a primary cross-

sectional survey of patients with head and neckcancers carried out to evaluate distress, anxiety anddepression in patients undergoing treatment withcurative intent.

Patients and Methods

A total of 130 patients with head and neck cancerwere approached for a cross-sectional survey. Afterobtaining written informed consent interviews wereconducted. Of these seven questionnaires wereincomplete and hence were excluded. The studywas approved by institute ethics committee.

Tools

Distress inventory in cancer (Version 2) (DIC 2), isa 33 item questionnaire that measures the globaldistress in cancer patients. The responses arerecorded on a 5 point Likert scale. It also providesix subscale scores, i.e. emotional distress, spiritualdistress, social distress, medical distress, activity ofdaily living and familial distress [11]; (Thomas BCet al. 2006, unpublished data).Hospital anxiety and Depression scale (HADS)

is a 14 item questionnaire consisting of twosubscales anxiety and depression. Each item israted on a four point scale from 0 to 3, giving amaximum score of 21 on each subscale. Score of 11or more is considered significant ‘case’ of psycho-logical morbidity (clinical caseness for anxiety anddepression) while score of 8–10 represent mooddisorder [12]. Validated Malayalam translation wasused with the permission of copyright owners [10].Personal Data Sheet, a comprehensive personal

information datasheet was developed that recordedthe patient demographics, Socio-economic andmedical (disease and treatment) details.

Statistical analysis

Data was analyzed using one way Analysis ofvariance (ANOVA) followed by Schiff’s post hoctest where applicable. Correlation analysis wasused to compare the tools, subscales, demographicand disease variables.

Results

The mean age of the patients was 54.2 years (S.D.11.8; median 55.0 years). There were 93 (75.6%)males and 30 (24.4%) females in the sample.

Majority of the patients belonged to low socioeconomic group (67; 54.5%) while 35 (28.5%) wereof middle class and only 21(17.1%) were of uppersocial class. Majority of the patients were marriedand were living with their spouse at the time ofinterview (110; 89.4%), while only 13 patients wereeither divorced/Windowed or were single; similarlymajority of the patients were Hindu (80; 66%)followed by 23 (16%) Muslim and 29 (18%)Christians.Majority of the patients had only primary

education (63; 51.2%) followed by 51 (41.4%)who had secondary education and only 9 (7.3%)have had higher education. The distribution wasalmost similar for spouse education [primary 62(50.4%), secondary 37 (30%)], however morespouses had higher education (24; 19.5%).Most of the patients in the study had T2 disease

(35; 28.5%) followed by T1 (27; 22%), T3 (23;18.7%), Tx (22; 17.9%) and T4 (16; 13%). Nodalstatus was N0 for 71 (57.7%), N1 for 29 (23.6%)and N2 for (18.7%). Majority of the patients werebeing treated by a single modality (80; 65%) be itsurgery (39; 31.8%) or radiotherapy (41; 33.3%),Rest of the 43 (35%) patients received multi-modality treatment. Only 28 (22.7%) patientsreceived either neoadjuvant or adjuvant che-motherapy. Patients reported on their past habitsand nearly 60% (n ¼ 72) of the sample hadsmoked; 50 (40%) chewed tobacco and over 40%consumed alcohol prior to diagnosis. Over 95% ofthe subjects stated to have strong belief in god andmost of them visited their respective places ofworship. About 70% (n ¼ 87) reported that theycould not come to accept that they had cancerhowever none of them denied the diagnosis. Lessthen 5% reported being angry or cheated in life andover 60% stated that situation made them sadwithout resolve.The mean distress score was 24.6 (range

3.7–63.6). While that of subscales ranged from2.6 to 25.0 (Table 1). Fifteen patients were found tohave clinical caseness for anxiety and 12 (10%) had

Table 1. Anxiety, depression and distress in head and neckcancer patients

Mean Median SD Range

Distress inventory for

cancer}2 (DIC 2)

Emotional distress 25.4 24 8.7 10–43

Spiritual distress 10.9 10 4.1 5–25

Social distress 8.9 8.0 3.28 6–22

Medical distress 4.47 4.0 1.15 4–11

Activities of daily living 2.6 1.0 1.84 1–5

Family specific distress 11.68 11.0 5.96 0–31

Total DIC 2 24.6 22.7 11.5 3.7–63.6

HADS

Anxiety score 4.68 3.0 4.9 0–19

Depression score 5.05 4.0 3.7 0–19

Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 16: 582–586 (2007)

DOI: 10.1002/pon

583Anxiety and depression in patients with head and neck

clinical caseness for depression. Mood disturbancesfor anxiety and depression were seen in 17 (14%)and 20 (16%), respectively. The mean score ofanxiety was 4.68� 4.9 (range 0–19) and fordepression it was 5.05� 3.7 (range 0–19). Oncorrelating DIC 2 with HADS, a significantcorrelation of anxiety was seen with emotionaldistress (r¼ 0.686), family distress (r¼ 0.364),social distress (r¼ 0.289) and total DIC 2 score(r¼ 0.626), while depression correlated with emo-tional distress (r¼ 0.614), family distress(r¼ 0.329), social distress (r¼ 0.292) and globaldistress (r¼ 0.568) (Table 2). Both anxiety anddepression showed significant correlations withactivity of daily living (r¼ 0.199 and 0.263,respectively).Table 3 shows correlation of HADS, DIC-2 and

its subscales with various socio-demographic fac-tors, habits, disease-related factors and belief in

god. However in multivariate analysis only belief ingod was found to be significantly affecting thedistress levels (b ¼ 0.336 p¼ 0.03).

Discussion

There is ample evidence that psychological morbidityamong cancer patients often go unrecognized untilthey are specifically sought. This is more so in patientswith depression as these patients are reluctant tocomplain about their symptoms and also because theprominent symptom is not always the obvious one[13]. Up to 20% of the patients may show severedepression, grief, lack of control, personality change,anger and anxiety. These can differ widely from littledisruption of mood to clinical states of anxiety anddepression [14]. However persistent deterioration inmood does not seem to be related to previous

Table 2. Correlation of DIC 2 and its subscales with HADS

Emotional

distress

(ED)

Spiritual

distress

(SPD)

Social

distress

(SD)

Medical

distress

(MD)

Activity

of daily

living (ADL)

Family

distress

(FSD)

DIC 2

total

Anxiety Depression

ED 1.0

SPD �0.07 1.0

SD 0.3** 0.238** 1.0

MD 0.161 0.079 0.003 1.0

ADL 0.254** �0.02 0.151 0.171 1.0

FSD 0.385** 0.166 0.272** 0.269** 0.303** 1.0

DIC 2 0.837** 0.326** 0.547** 0.318** 0.385** 0.624** 1.0

Anxiety 0.686** �0.12 0.289** 0.187* 0.199* 0.364** 0.626** 1.0

Depression 0.614** �0.057 0.292** 0.85 0.263** 0.329** 0.568** 0.66** 1.0

*Significant 50.05; ** highly significant 50.001.

Table 3. Correlation of DIC and HADS with Socio demographic, medical and patient-related factors

Emotional

distress

Spiritual

distress

Social

distress

Medical

distress

ADL Family

distress

DIC 2 Anxiety Depression

Sex 0.05 �0.22* �0.08 0.016 0.078 �0.29** �0.015 0.124 �0.026

Social status �0.321** 0.09 0.012 0.007 �0.158 0.709 �0.23* �0.10 �0.165

Religion 0.08 �0.239** �0.013 �0.08 0.04 0.06 �0.001 0.059 0.113

District �0.02 �0.001 �0.106 �0.09 �0.05 �0.20* �0.08 �0.116 �0.146

Marital status 0.064 �0.083 �0.099 �0.65 �0.149 �0.525** �0.03 0.009 0.017

Patient Education �0.289** 0.212** �0.05 �0.004 �0.06 0.04 0.153 �0.167 �0.185*

Spouse education �0.014 �0.05 �0.113 �0.018 �0.186* �0.54** �0.07 �0.05 �0.09

Married Children 0.06 �0.08 �0.08 0.221* 0.014 �0.308** 0.02 0.018 �0.068

Employed children 0.05 �0.06 �0.08 0.225* �0.002 �0.311** 0.02 0.016 �0.075

Distance travelled �0.292** 0.174 0.04 �0.01 �0.185* �0.230* �0.182* �0.08 �0.188*

Spouse occupation 0.07 �0.08 �0.116 0.006 �0.135 �0.558** �0.02 0.12 �0.003

Site of Disease �0.06 0.04 0.001 �0.08 0.02 0.10 �0.01 �0.06 0.141

T-stage 0.119 �0.10 �0.156 0.07 0.05 0.07 0.05 �0.009 0.151

N-stage 0.109 �0.08 �0.05 0.132 0.172 0.118 0.08 0.01 0.09

Composite stage 0.132 �0.08 �0.04 0.163 0.196* 0.171 0.112 0.03 0.22*

Smoking 0.000 �0.25** �0.15 �0.01 �0.05 �0.248** �0.112 0.02 �0.06

Chewing �0.164 0.126 �0.03 �0.15 �0.05 �0.185* �0.127 �0.257** �0.216*

Alcohol �0.06 �0.10 �0.13 �0.04 �0.03 �0.232** �0.124 �0.10 �0.06

Belief in God 0.04 0.173 0.199** 0.02 �0.02 0.03 0.197* �0.03 �0.02

*Significant 50.05; ** highly significant 50.001.

ADL-activity of daily living; DIC2- Distress inventory for cancer version 2.

584 M. Pandey et al.

Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 16: 582–586 (2007)

DOI: 10.1002/pon

psychiatric history [15], lack of social support [16],age and lack of intimate relationship [14]. Psycho-logical morbidity in advanced cancer is reported tobe related to functional status and lower socialclass [14].Relationship among preoperative anxiety, use of

coping strategies, preoperative self care and reso-cialization behavior was studied in patients whosustained facial disfigurement/dysfunction afterhead neck surgery using state trait anxiety In-ventory (STAI) and the ways of coping question-naire. Self-care was found to precede reduction ofanxiety and a negative relation between self careand anxiety was observed [17]. Our study found anegative correlation of distress with social class,occupation and belief in god. Researchers havefound clinically significant levels of anxiety anddepression in cancer patients treated with radio-therapy even after 3 months of treatment [18], thesates of clinically significant anxiety and depressionwere however lower in the present study eventhough majority of the patients were on treatmentat the time of interview. This could be due to thefact that majority had early disease and werecurable. Others have also reported similar findingsthat head and neck cancer patients manage welldespite disability and dysfunction after treatmentand patients’ expectations, emotional response anddesired outcomes are determined by socio-culturalfactors causing different patient groups to viewtheir overall quality of life (QOL) outcomes somewhat differently [19].HADS is primarily a screening tool and subjects

that test positive for either anxiety or depressioncan not be conclusively diagnosed as havinganxiety or depression as for this DSM IV criteriaand full psychiatric evaluation is needed. Themorbidity prevalence as estimated by HADS rangefrom 13 to 40% for anxiety and 7–33% fordepression [20–23].Duffy et al. [24] examined the relationship

between smoking, alcohol intake, depressive symp-toms and QOL in head and neck cancer patients.They found smoking and depression negativelyassociated with QOL. Previous duration of tobaccoconsumption prior to illness has also been found tosignificantly predict psychological distress [26]. Inour study too, the spiritual distress, and familyspecific distress were found to negatively correlatewith smoking and family specific distress. Anxietyand depression were negatively correlated withchewing tobacco, while alcohol intake negativelycorrelated with family specific distress.A number of head and neck cancer patients show

significant clinical depression [23]; however, in ourstudy the number of patients with clinical casenessfor depression, as identified by HADS, was low.This could probably reflect low incidence ofdepression in population in general. Telfer andSheperd [27] reported on the use of HADS in

patients with maxillofacial cancers. A total of 47%patients exhibited psychiatric disturbances, 33%were anxious while 15% were depressed. In theonly other study using HADS from India, Cha-turvedi et al. [28] suggested interventions tominimize cancer associated anxiety and depressionto improve QOL. In a recent study Hassanein et al.[29] evaluated the relationship of functional statuswith psychological morbidity and found a strongcorrelation between two. The prevalence of anxietyand depression in their series was 25%. Anxietyand depression status has been correlated withdelay in seeking medical consultation in patientswith head and neck cancer and has also beenshown to have an inverse relationship with tumorsize, i.e. patients with small tumors has higheranxiety and hence presented early [30]. Anxiety anddepression has also been found to correlate withdysphagia [31], and fear of recurrence [25]. Long-itudinal studies however failed to show any changebetween before and after treatment scores [32]. Thepresent study is unique as it aims to identifypatients in early and middle of the distresscontinuum, apart from screening for clinical case-ness for anxiety and depression, beside exploringthe role, if any, played by demographical andtumor variables and belief in god. This is the firststudy reporting on the use of DIC 2 in head andneck cancer patients.Further studies on a larger homogenous popula-

tion may be required to clearly elucidate therelationship of distress, anxiety and depression inhead and neck cancer patients.

Acknowledgements

This work comprises part of the postgraduate (Psychology)dissertation works of Ms Devi N, ‘Measurement of distress,anxiety, depression and quality of life of head and neckcancer patients undergoing treatment by different mod-alities’ submitted to the University of Kerala in July, 2004.The study was approved by the Institute Review Board andthe Institute Ethics Committee. Written consent wasobtained from all the patients participating in this study.The HADS is under copyright and the publisher is: nfer-

Nelson, The Chiswick Centre, 414 Chiswick High Road,London W4 5TF, UK http://www.nfer-nelson.co.uk. Per-mission was obtained for its translation and use, thetranslation were approved by the copyright owners afterexamining the back translations.The authors work on Quality of Life in breast cancer is

funded by a grant from the Indian Council of MedicalResearch (ICMR) New Delhi, India vide grant number 5/13/74/2000/NCD-III.

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DOI: 10.1002/pon