INTRODUCTION

Mental disorders such as depression, anxiety and delirium occur in a significant number of adult cancer patients, particularly as disease advances and as cancer therapies become more aggressive.¹ Many researchers have reported that six mental disorders occur more frequently in cancer patients to warrant a detailed assessment and clinical intervention. Three represent direct reaction to illness; adjustment disorders, major depression and delirium. Others (primarily anxiety disorders, personality disorders and major depressive illness) are pre-existing conditions often exacerbated by the illness.² Derogatis et al. found that 47% of the cancer patients had sufficient distress to receive a diagnosis of a psychiatric disorder. Adjustment disorder with depressed mood and / or anxious mood was by far the most common diagnosis (68%), major depressive disorder was next (13%), followed by organic mental disorders (8%), personality disorders (7%) and pre-existing anxiety disorders (4%).³ Alexander et al reported mental disorders in 40% of cancer patients admitted to an oncology unit in a general hospital, and major depression was seen in 13% of the sample.⁴ In another study, delirium has been found to occur in 25% to 40% of patients with cancer at some time during their illness and has been reported to be as high as 85% in patients with advanced disease.⁵ Among the most common causes of mental disorders in cancer patients the major losses resulting from the severity and type of disease and treatment adverse effects are most important. The non-medical factors like inadequate family support system, tense home atmosphere, personal traits, family conflicts, and financial constraints are also found to be the causal factors behind patients’ emotional disturbances⁶. The objective of this study was to identify the common types of mental disorders in cancer patients with reference to patients’ age, gender, education, home atmosphere, family support system and cancer type.

MATERIAL AND METHODS

This study was conducted on newly diagnosed cancer patients registered at Shaukat Khanum Memorial Cancer Hospital and Research Centre between January 1999 to December 2000. Purposive sampling method was used to include only those patients in this study who were at least eighteen years old, had histologically confirmed diagnosis of cancer and had not received cancer treatment previously.

Patients who had a previous physical disability or a previous diagnosis of a mental disorder were excluded from the study. There were thirty-five patients whose interviews could not be completed due to language difficulties because they all were “Pushto speaking”. All patients were interviewed by a trained clinical psychologist (single investigator). Data regarding patients’ age, gender, marital status, and types of cancer was recorded on a data capture form. Patients were also interviewed using Mini Mental State Examination (MMSE) and Structured Clinical Interview according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (SCID-IV) to record the presence and absence of a mental disorder.⁷ The Mini Mental State Examination is a widely used method for assessing cognitive status. It provides standardized context in which to assess, report and discuss changes in cognition. The sensitivity and specificity of MMSE at the 26/27 cut off point were 91% and 63% respectively⁸.

The Standardized Clinical Interview for Diagnostic and Statistical Manual – fourth edition (SCID - I) is a semi-structured interview for making the DSM IV Axis I diagnosis. The biggest advantage of SCID - RV (research version) is that it is much easier to modify for a particular study and its coverage is more complete (i.e. it includes full diagnostic criteria for disorders and subtypes). Frequency of each mental disorder was calculated in percentages. Chi-square test was utilized to check for any association between categorical variables for qualitative data.

RESULTS

Adjustment disorder was the most common type of mental disorders seen in 20.8% of all cancer patients; mood disorders especially depression was observed in 17.8% and anxiety disorders in 16.8%. The younger patients were more frequently diagnosed with anxiety disorders (31.3%) whereas depression was more common in the age group of 45 to 55 years (33.9%). Patients belonging to the age group of 25 to 35 years and 35 to 45 years were having adjustment disorders 25.6% and 26.2% respectively. It was also observed that all patients diagnosed with delirium were above the age of 55 years. Overall, the relationship between patients’ age and type of a mental disorder was highly significant. (Table 1) Adjustment disorder was seen among 53.9% of female patients and 46.1% in males. Anxiety disorder was seen in 66.1% of male patients whereas depression was more common among females (76.9%). (Table 2). The illiterate patients suffer more from a formal mental disorder when they were diagnosed with cancer. Among the illiterate group of patients, 22.5% had depression, 25.4% had anxiety disorder and 22.5% were diagnosed with adjustment disorder. Whereas among the educated group (patients with more than 10 years of education), only 9.5% had depression, 8.6% anxiety disorder and 18.1% developed adjustment disorders. (Table 3). Among the patients who reported their home atmosphere as tense, 46.1% had depression, 33.9% developed anxiety disorders and 34.2% suffered from adjustment disorders. The relationship between patients’ home atmosphere and type of a mental disorder was significant statistically. (Table 4). The association between patients’ family support system and the types of mental disorders they suffer was highly significant. Among the patients reporting inadequate family support system, 47.7% had depression, 46.1% experienced adjustment disorders and 35.5% were suffering from anxiety disorders. (Table 5). Anxiety disorder was the most common type of mental disorder observed in 27.4% of patients having carcinoma of breast, 30.6% in those having lymphomas and 20.9% in leukemia patients. Adjustment disorder was common in patients with carcinoma of breast (32.9%) , leukemia (28.9%) and lymphoma (19.7%), whereas depression was more frequently diagnosed in patients with carcinoma of breast (30.8%), genitourinary cancers (26.1%) and leukemia (15.4%). Overall, the association between cancer types and types of mental disorders was statistical significant. (Table 6).

Table-1: Age of Cancer Patients with Reference to Types of Mental Disorders. Values are numbers and percentages.

Age (Years)

Adj. Dis*

Anx. Dis**

Delirium

Mood Dis***

Somato****

None

Total

Below 25

21 (21.2)

(27.6)

31 (31.3)

(50.0)

0 (0)

(0)

11 (11.8)

(16.9)

0 (0)

(0)

36 (36.3)

(23.4)

99 (27.1)

25 – 35

22 (25.6)

(28.9)

14 (16.3)

(22.6)

0 (0)

(0)

18 (20.9)

(27.7)

2 (2.3)

(100)

30 (34.9)

(19.5)

86 (23.6)

35 – 45

22 (26.2)

(28.9)

9 (10.7)

(14.5)

0 (0)

(0)

12 (14.3)

(18.4)

0 (0)

(0)

41 (48.9)

(26.6)

84 (23)

45 – 55

8 (14.3)

(10.5)

6 (10.7)

(9.7)

0 (0)

(0)

19 (33.3)

(29.2)

0 (0)

(0)

23 (41.1)

(14.9)

56 (15.3)

55 – 65

3 (13)

(3.9)

2 (8.7)

(3.2)

4 (17.4)

(66.6)

1 (4.3)

(1.5)

0 (0)

(0)

13 (56.5)

(8.4)

23 (6.3)

Above 65

0 (0)

(0)

0 (0)

(0)

2 (11.8)

(33.3)

4 (23.5)

(6.1)

0 (0)

(0)

11 (64.7)

(7.1)

17 (4.6)

Total

76 (20.8)

62 (16.8)

6 (1.6)

65 (17.8)

2 (0.5)

154 (42.5)

365 (100)

Chi Square = 103.942, df = 25, P Value = 0.000