Article Type : Research Article
Authors : Saina C, Gakinya B and Songole R
Keywords : Breast cancer; Depression; Associated factors; Chemotherapy; Employment; Cancer stage; Prevalence
Abstract
Background: Depression is
the presence of sadness, empty or irritable mood, accompanied by somatic and
cognitive changes. The prevalence of depression has particularly goneun recognized
among patients with breast cancer and remains untreated hence potentially
resulting in complications of physical symptoms, increased functional
impairment, and poor treatment outcome. Additionally, the lack of adequate data
on depression among patients with breast cancer makes it hard to ascertain how
this mental health problem affects the efficacy of cancer treatments. This
study therefore seeks to contribute to the data on prevalence of depression
among patients with breast cancer at MTRH hence leading to better mental health
management of patients with breast cancer which will ultimately contribute to their
recovery outcomes.
Objective: To determine
the prevalence of depression among patients with breast cancer at admitted at
MTRH.
Methods: This study
adopted a cross-sectional study design in which the target population were the
patients with breast cancer situated at the breast cancer clinic, medical and
surgical wards of MTRH in Eldoret. Using census sampling, the study arrived at
102 respondents but ended up using 79.The tools of data collection included the
Hamilton Depression Rating Scale. (HAM-D) which
was used to diagnose and measure the severity of depression. A questionnaire
was also used to obtain socio-demographic and clinical information.
Results: A total of
seventy-nine patients were interviewed, 98% of them were females. The mean age
was 40±7.8 years. The prevalence of depression among patients with breast
cancer was 59.5%. Patients with late-stage breast cancer had 61% increased odds
of having depression (AOR=1.61, 95% CI: 0.63, 4.17; p=0.319) than patients with
early-stage breast cancer.
Conclusion: There was a
high prevalence of depression among patients with breast cancer (59.4%). Being
employed, the use of chemotherapy, and the late stage of cancer were
significantly associated with having depression.
Recommendation: Screening and interventions for depression
should be initiated for all patients with breast cancer especially for those at
a late stage of cancer, those on chemotherapy and those who lack employment.
The severity of cancer among the human population has been increasing
globally. The number of cancer cases is expected to more than double worldwide
over the next 20-40 years [1]. In the year 2009,
it was the third leading cause of death globally. Breast cancer together with
lung, colon/rectum, and prostate cancers are some of the most common types of
cancers worldwide. Breast cancer is specifically reported to be a leading
cancer diagnosis among women worldwide with more than 210,000 new cases and
40,000 deaths per year in the U.S.A. According to various studies carried out,
it has been noted that the prevalence of depression among cancer patients
ranges from 10%-58% [2,3]. Major depression was
found to be as high as 38%. Cancer is also an emerging problem in Africa. In
Kenya, canceris the third leading cause of mortality representing approximately
7% of the national mortality rate. The Eldoret cancer registry also noted that
the cancer of the cervix, followed by breast cancer and cancer of the esophagus
as the most prevalent types of cancers among women in Kenya respectively [4]. Study of Kenyatta National Hospital revealed
that the top three cancers in that hospital were cervical cancer (62.12%),
breast cancer (11.8%) and colorectal cancer (6.2%). Kassaman, Wangari and
Lusambili study of Moi Teaching and Referral Hospital (MTRH) found that the
three most prevalent cancers in that hospital were Karposis sarcoma (18.6%),
breast cancer (15.4%) and cervical cancer (8.2%). The diagnosis of breast
cancer, and subsequent management of the disease in most of the cases, can be
an upsetting and harrowing experience that profoundly affects how the patient
feels and increases the chances depression. Some of the risk factors associated
with cancer include: climate change, personal diet, genetics and harmful
chemicals emitted by industries and other carcinogenic substances [5]. A raft of measures touching on life style changes
has been proposed to tackle cancer. Theseinclude: reduce tobacco use, increase
physical activity, control weight, improve diet, utilizing safer sex practices,
avoid excess sun exposure and routine cancer screening. Breast cancer has
therefore been recognized as a serious threat to the livelihood of affected
persons and those that relate with the patients. Cancer imposes a heavy
financial toll on affected patients and the people close to them. Additionally,
it also has serious effects on the mental wellbeing of patients due to the
harrowing experience that patients go through. Although the physical aspects of
the impact of cancer to patients is recognized and a lot of effort goes to
alleviating this hardship, the mental challenges that often accompany being
diagnosed with breast cancer are often overlooked. Cancer can have adverse
effects on the mental status of the individuals leading to depression and
anxiety notes that the physical and mental health of cancer patients needs to
be addressed throughout treatment and the continuum of the survivorship care [6].
Breast
Cancer and mental health
Depression is a mental illness which is defined
as a range of moods -from low spirits to severe problems that interferes with
everyday life. Bhowmik, Anjan, Choudhury, and notes that depression is a common
mental disorder that presents with depressed mood, loss of interest or
pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low
energy, and poor concentration [7]. Depression
might manifest a number of symptoms that include but not limited to insomnia,
loss of concentration, irritability and feelings of sadness or unhappiness. There
is increased risk of depression among women with breast cancer. This calls for
preventive and therapeutic measures in order to improve the mental health and
quality of life of patients during treatment and the post recovery period. In
most sub–Saharan African countries, breast cancer remains the leading cause of
cancer related deaths among women. Revealed that 23% of all female cases of cancer
in Kenya are breast cancer. Breast cancer diagnosis and its treatment are
recognized to be stressful times which underscores the need for clinicians to actually
identify its psychological sequel such as depression in vulnerable patients.
The early detection and treatment of depression in cancer patients is not only
significant in improving their quality of life but also in increasing their
survival rates. Most of the effort in tackling breast cancer in Kenya has been
channeled towards screening and physical treatment with little focus on the
mental status of the patients of breast cancer. Cancer treatment does require
facilities and equipment in order to effectively reduce mortality rates,
however, treatment should also respond to the mental needs of patients since
depression can significantly affect the short- and long-term outcome of
treatment. In spite of breast cancer being one of the leading causes of mortality
among cancer related diseases, little effort is placed on the care of the
mental health of breast cancer patients as seen by the lack of mention of
mental health by cancer related studies. Few studies have delved into and
appreciate the need for mental healthcare among this group and the factors that
may aggravate the possibility of having depression notes that a breast cancer
diagnosis can have wide ranging impact on the individual, family and the entire
society. Breast cancer patients are specifically susceptible to depression and
anxiety. Depression affects the cancer patient’s treatment and recovery
outcomes as well as quality of life and their survival. Furthermore, people
with a previous history of using psychiatric services are very vulnerable and
are at a very high risk of mortality following the diagnosis of cancer.
Unfortunately, the mental health of individuals not withstanding whether they
are diagnosed with breast cancer or any other ailment is often ignored. A
number of individual factors that are likely to affect the development of
depression among breast cancer patients. This includes: age, gender, ethnicity,
sexuality, disability, religion, biological factors, co-morbid conditions,
marital and cohabitation status. Other characteristics that may not be directly
arising from the individual but influenced by external factors include social
and contextual factors, prior psychological factors, and psychological response
to diagnosis and cancer treatment. This reveals that breast cancer treatment is
complicated with a plethora of issues that may aggravate the outcome of
treatment. Although depression is likely to be frequent in patients with breast
cancer in Sub Saharan-Africa and especially in Kenya, it is not an adequately
recognized and treated condition among breast cancer patients. The impact of
inadequate attention on depression in this group of cancer patients causes
amplification of physical symptoms, increased functional impairment and poor treatment
adherence. This results in unnecessary lose if lives. In this backdrop, this
study used the Hamilton Depression Rating Scale (HAM-D) to determine the
prevalence of depression among patients with breast cancer. This will go a long
way in ensuring common mental health problems that affect breast cancer
patients at MTRH are not ignored hence improving recovery outcomes of patients.
To determine the prevalence of depression among
patients with breast cancer admitted at MTRH.
This section presents the methods and materials used in conducting this
study.
Study
design
Kothari (2004) defines the research design as the arrangement of
conditions for collection and analysis of data in a manner that aims to combine
relevance to the research purpose with economy in procedure. This study adopted
a descriptive cross-sectional study design focusing on the patients with breast
cancer at MTRH. All patients with a confirmed diagnosis of breast cancer and
who met the inclusion criteria were recruited for the study.
Overview
of study area
Recruitment of the study subjects was carried out at the breast cancer
out-patient clinic at Chandaria cancer and chronic disease management center
and in-patient’s unit (surgical, medical wards) at MTRH in Eldoret, Uasin Gishu
County, Kenya. MTRH is the second largest national referral hospital and covers
the western Kenya region with a population of about 16 million. It is a
teaching and referral hospital used by Moi University. The hospital serves
patients from western Kenya, north rift, and south rift regions, Eastern Uganda
and Southern Sudan. MTRH was chosen for the study because it is a national
teaching and referral hospital that has an oncology clinic that covers the
western Kenya region and therefore serves a significant size of the population
in cancer diagnosis and treatment. In addition, MTRH is a busy referral center
and likely to have sufficient patient numbers for the study.
Cancer
treatment at MTRH
All types of cancer patients both pediatrics and adult (gynecological,
surgical, and medical) patients are attended to at the center. The oncology
clinic is run on Mondays and Wednesdays between 8.00 am to 2.00 pm, but remains
open for patients who come on any other day of the week.
Census
sampling
Census sampling is defined as a statistical method of research where all
members of the population are studied [8]. A
census is an attempt to list all elements of in a group and to measure one or
more elements in that group. Some of the benefits that necessitate a use of
this type of sampling technique is the need for enough number of participants
in order to have a high degree of confidence in the survey results. The study
populations were breast cancer patients above 18 years seen at the out-patient
clinic at MTRH, those admitted to the medical ward with confirmed cancer of the
breast and the patients in the surgical ward admitted for surgical procedures. The
number of patients with a histological diagnosis of breast cancer was 102 from
January2016-December 2016. This study therefore sought to all co-opt all 106
breast cancer patients but ended up using 79 patients for the study.
Inclusion
criteria
·
Adults (aged 18 or older) who have been confirmed to
have breast cancer;
·
Patients in the medical/surgical wards who have been
confirmed to have breast cancer;
·
Patients at Chandaria cancer and chronic disease
management center outpatient clinic who have been confirmed to have breast
cancer.
Exclusion
criteria
·
Patients in a coma;
·
Patients with emotional instability.
Data
collection
The following section identifies the tools used in collecting data and
the procedures adhered to in dealing with patients during data collection. This
study utilized the HAM-D scale and questionnaire to collect data.
HAM-D
scale
A 17-item Hamilton Depression Rating Scale (HAM-D) was used to assess
depression severity among patients. The total score is obtained by summing the
score of each item, 0–4 (symptom is absent, mild, moderate, or severe) or 0–2
(absent, slight or trivial, clearly present). For the 17-item version, scores
can range from 0 to 54. Since its development in 1960 by Dr. Max Hamilton of
the University of Leeds, England, the scale has been widely used in clinical
practice and became a standard in research trials. The Hamilton Depression
Rating Scale has proven useful for determining the level of depression before,
during, and after treatment [9]. The Ham-D scale
has demonstrated reliability, validity, and efficiency in adults [10].
The scale has been translated into several languages including French,
German, Italian, Thai, and Turkish. In comparison to the Beck Depression
Inventory, a meta-analysis suggested that after treatments, the HAM-D was more
'sensitive to change' on retesting, and this is probably why it has been so
widely used in clinical trials.
Questionnaire
A questionnaire containing the patients’ unique number of
identifications was also used. The questionnaire was designed for adults and
used to rate the severity of their depression by probing: mood, feelings of
guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight
loss, and somatic symptoms. The study also followed a number of clinical
procedures when collecting data from the patients which are highlighted below.
Clinical
procedures
Patients admitted were recruited for the study within 72 hours. In
addition, the principal investigator recruited 2 research assistants who were
trained by the researcher on how to carry out the study. Their main
responsibility was to assist with the identification of the new patients,
retrieving their files, and getting all the required information from the
participants.
Data
processing and analysis
Data processing is defined as the steps involving in editing, coding,
classification and tabulation of collected data [11].
The sole purpose of processing is to prepare the data for analysis. The study
data collection forms were checked at the end of each day for completeness and
appropriate filling and then the data was coded before it was entered into
SPSS. In order to ensure data safety and protection, a personal computer was
used during the study to store the collected data. The personal computer was
password protected. During analysis, descriptive statistics was used especially
for continuous data. Means, median and mode was also used for categorical data
which was displayed as frequencies and percentages. Data was analyzed using
STATA version 14. Furthermore, inferential statistics such as Chi-square and
Fisher’s exact tests were used to measure associations of categorical
variables.
Ethical
consideration
The study adhered to the Nuremburg code of research ethics which governs
how research participants are co-opted in a study by seeking informed consent
from the participants. In addition, the appropriate research standards
including proper citations to avoid plagiarism was strictly adhered to.
Patients were informed on all the procedures of the study and informed consent
was sought from the 79 respondents before enrolment. Confidentiality of the
patient’s mental status with regard to depression was kept. Additionally, the
patients who were found to have depression were sent for review by a
psychiatrist and further follow up only after their consent was sought.
Approval to carry out the study in MTRH was sought from:
·
The institutional research and ethics committee to
carry out the study;
·
The chief executive officer MTRH.
Conceptual
framework
This study was guided by the conceptual framework illustrated in figure 1 that shows that variables associated with breast cancer patients i.e., age, sex, marital status, education levels, employment status and chemotherapy were found to have an impact on the onset of symptoms that are associated with depression (Figure 1).
Figure 1: Conceptual Framework.
This section presents the significant findings of this study.
Sociodemographic
Characteristics
A total of 79 respondents participated in the study. The mean age was 40 (SD=7.8) years suggesting that most cancer patients were above 40 years of age. Of those who responded (98.7%) were females and the majority were married 86.1%. More than half of the respondents had achieved a tertiary level of education at 58.2%. 79.7% had some form of employment while a paltry 20.3% were unemployed. 43% of the respondents had suffered from some form of substance abuse while 57% had never suffered from substance abuse problems. Of the respondents who had suffered from some form of substance abuse, 17.7% abused alcohol while 16.6% abused other forms of drugs as illustrated in table 1 (Table 1).
Table 1: Socio Demographic Characteristics.
Variables |
Levels |
N(%) Mean
+ SD |
Age
years |
|
40+7.8 |
Sex |
Female Male |
78(98.7) 1(1.3) |
Marital
status |
Married Never
married |
68(86.1) 11(13.9) |
Education
levels |
Primary Secondary Tertiary |
4(5.1) 29(36.7) 46(58.2) |
Employment |
Employed Unemployed |
63(79.7) 16(20.3) |
Substance
use |
Alcohol Opiate Khat Others |
14(17.7) 4(5.1) 1(1.3) 16(20.3) |
Prevalence
of depression
The prevalence of depression among breast cancer patients at MTRH as illustrated in figure one revealed that more than half (59.4%) of the breast cancer patients had depression. Most of the patients with depression had mild depression (35%). Only 6% had severe depression while 18% had moderate depression (Figure 2).
Figure 2:
Prevalence of Depression among breast cancer patients.
Factors
associated with depression
Some of the factors that may be associated with depression and that were the primary focus of this study are age, marital status, chemotherapy, surgical treatments, hormonal therapy, cancer stages, employment, and level of education. The results illustrated in table three revealed that the late stage of cancer, employment, and use of chemotherapy was statistically significant (0.002, 0.047, and 0.048) respectively. Hence suggesting that depression is related to stage two of the cancer, unemployment and use of chemotherapy (Table 2).
Table 2: Factors associated with depression.
Variables |
Total N=79 |
Depre =yes N=32 |
Depre =NO N=47 |
P-VALUE | |||||||||||||||
Age |
40±7.8 |
39.5±6.8
|
40.4±8.5
|
0.599
| |||||||||||||||
|
|
|
|
| |||||||||||||||
Surgical treatment |
35(44.3) |
12(37.5) |
23(48.9) |
0.315 | |||||||||||||||
Hormonal therapy |
58(78.4) |
21(65.6) |
37(78.7) |
0.196 | |||||||||||||||
Gender female |
78(98.7) |
32(100) |
46(97.9) |
0.406 | |||||||||||||||
Marital status Married |
68(86.1) |
29(90.6) |
39(83) |
0.335 | |||||||||||||||
Employment Employed |
63(79.7) |
29(90.6) |
34(72.3) |
0.047 | |||||||||||||||
Substance use Alcohol Opiate Tobacco Khat |
16(20.3) 14(17.7) 4(5.1) 6(7.6) 1(1.3) |
4(12.5) 4(12.5) 0(0) 2(6.2) 0(0) |
|
| |||||||||||||||
Educational levels
|
|
|
|
0.42
| |||||||||||||||
|
|
|
|
0.048
|
Findings
of the unadjusted odds ratio
On further analysis of the relationship between depression among breast cancer patients and their employment status, stage of cancer and mode of treatment, the study found out that the odds of being diagnosed with depression among patients with breast cancer among those who were employed had increased odd of 270%, compared to the unemployed, OR: 3.7(95% CI: 1.07, 17.27). The findings between the relationship between depression and mode of treatment revealed that compared to adjuvant chemotherapy, the participants on neoadjuvant chemotherapy and palliative chemotherapy had 830% and 850% increased odds of having a diagnosis of depression among patients with breast cancer (OR: 9.43(95% CI: 1.5, 185.32) and 9.5(95% CI: 1.62, 181.81) respectively. This finding was statistically significant. The study also discovered that compared to the early stage of cancer, the participants with late stage of cancer had 61% increased odds of having a diagnosis of depression among patients with breast cancer, OR: 1.61(95% CI: 0.63, 4.17) (Table 3).
Table 3: Results of the unadjusted and adjusted analysis of depression among patients with breast cancer.
Variable |
Unadjusted
ORs (95% CIs) |
P-Value |
Age |
0.98(0.93,1.04) |
0.609 |
Marital
Status: Married |
1.98(0.52,9.65) |
0.342 |
Employment
Status: Employed |
3.7(1.07,17.27) |
0.058 |
Substance
Use |
0.4(0.1,1.31) |
0.152 |
Alcohol |
0.53(0.13,1.76) |
0.321 |
Tobacco |
0.72(0.09,3.92) |
0.711 |
Cancer
Stage 3 |
1.61(0.63,4.17) |
0.32 |
Cancer
Stage 4 |
1.66(0.67,4.19) |
0.274 |
Surg_Tx |
0.63(0.25,1.55) |
0.316 |
Hormonal
Therapy |
0.52(0.18,1.42) |
0.199 |
Chemotherapy |
|
|
Adjuvant
Chemotherapy |
Ref |
|
Neoadjuvant
Chemotherapy |
9.43(1.5,185.32) |
0.044 |
Palliative
Chemotherapy |
9.5(1.62,181.81) |
0.039 |
Education
Level |
|
|
Primary |
Ref |
|
Secondary |
0.45(0.05,4.23) |
0.459 |
Tertiary |
0.84(0.09,7.49) |
0.867 |
Breast cancer is the most commonly diagnosed cancer worldwide and the
leading cause of cancer death, with roughly 1.4 million new breast cancer cases
and 458,000 deaths in 2008 [12-14]. It is also a
major cause of mortality among cancer related diseases. However, little
attention is paid towards the heavy mental toll of cancer both to the women and
those who interact with them. The findings from this study revealed that more
than half (59.4%) of the breast cancer patients had depression. Most of the
patients with depression had mild depression (35%). Only 6% had severe
depression while 18% had moderate depression. These findings agree with
previous data on prevalence of depression among breast cancer patients. For
instance, noted that cancer and treatment-related symptoms can be major
stressors in a patient with breast cancer who is undergoing treatment for the
disease [15]. The adverse effects of breast
cancer or treatment-related symptoms and types of treatment have been
associated with different domains of quality of life [16].
High levels of depression in breast cancer can also influence coping with
cancer and quality of life adversely [17]. More
than half of the patients with breast cancer in this study had depression of
some form. This shows that breast cancer patients face serious mental health
challenges. However, most of the breast cancer patients (35%) only had mild
depression while 18% had moderate depression. There may be room to cure the
mental health challenges of patients before they become severe and which will
require more input to cure. Studies in western countries reported a prevalence
ranging from 1-56% [18]. Some studies conducted
in developed countries revealed a depression prevalence of more than 42% which
can also be attributed to an increasingly large aging population. This compared
to 59.4% of patients in MTRH show that prevalence falls within a similar margin
however a higher rate of depression in developed countries might be as a result
of a higher aged population. Research conducted in other contexts however has
found a lower prevalence of depression among breast cancer patients. Findings
from a study done in Croatia revealed a prevalence of depression of 36.5% among
breast cancer patients [19]. Another study
conducted in Nigeria revealed a prevalence of 37.2% [20].
The prevalence of depression was 22.0%. In Asian studies, the prevalence was
between 12.5%-31% among patients who had breast cancer [21].
The prevalence of depression among breast cancer patients in Ethiopia was 9.1%.
The relatively lower prevalence of depression among patients from Nigeria,
Ethiopia and Croatia might be attributed to a smaller sample size and a different
methodology being used. However, the prevalence of depression found with this
study standing at 59.4% is almost twice as high as the rate of prevalence among
breast cancer patients in most of the other contexts as illustrated previously noted
a prevalence rate of 38%, in Croatia 36.5%; in Nigeria, 37.2%; in Asia,
12.5%-31%. Notwithstanding the possible reasons for the lower numbers in other
contexts, the of prevalence of depression in MTRH is very high and calls for a
lot of attention and concern. Study conducted in Athens revealed a prevalence
of 38.2%. These findings were lower compared to this study because of the
difference in economic status, and that the government provides funding that assists
the patients with their treatment and they also have good, functioning health
systems. Other studies that have been conducted in the study location e.g.,
reported a prevalence of 13.6% in Eldoret. This figure is lower than that found
in our study probably because the study was focused on the entire cancer
population. It is clear that the prevalence of psychological distress among
breast cancer patients is high. This is true for patients with breast cancer at
MTRH (59.4%) and as revealed by other studies showing an almost similar rate of
prevalence. However, a prevalence of 59.4% in the study area is higher than the
reported average range of prevalence between 1.5% to 46% reported in some other
contexts globally. Breast cancer patients especially at MTRH are at higher risk
of developing severe depressive disorders.
Associated
factors of depression
Further analysis also revealed factors by the patients with breast
cancer that may be associated to increased risk of depression. Of the factors
that were under scrutiny in this study, it was revealed by table three in the
results section that having a late stage of cancer (0.002), employment (0.047),
and use of chemotherapy (0.048) was statistically significant therefore
suggesting that prevalence of depression among breast cancer patients at MTRH
is related to stage two of the cancer, unemployment and use of chemotherapy.
These findings suggest that these are the primary factors that increase the
risk of falling into depression among the patients with breast cancer
especially at MTRH. These findings agree with that factors like Chemotherapy
may lead to an increased risk of depression during treatment. The skills and
strength to cope with the recovery challenges and problems caused by the
disease are also associated with the stage of the disease and treatment
environment. In yet another study by, it was revealed that there was a
correlation between prevalence of depression and level of household income
among Chinese women hence suggesting that earning which is primarily through
employment has an impact on the mental status of women. However, most of the
research appears to be focused on how employment affects cancer survivorship in
the post recovery period.
Unemployment
The diagnosis of breast cancer has significant cost implications to the
patient because treatment and management of cancer is often expensive. It is
likely that the lack of employment has an impact on the ability of the patients
to afford cancer treatment, to have a much comfortable lifestyle and on their
strength and ability to survive. Few studies have been conducted on the impact
of unemployment during treatment of breast cancer patients. Most of the
research focuses on the impact of breast cancer on impact on employment and
impairments that also arise out of the disease. There is need to address the
status of employment among cancer patients because a majority of those who are
diagnosed with cancer may be relying on salaries to pay for treatment. The mean
age of breast cancer patients in this study was found to be 40 years
illustrating that most of the patients were above the age of 40. It is also
likely that a number of these patients are well approaching retirement age or
already retired thus making the access to funds for treatment even more critical.
The affordability of treatment of breast cancer remains costly to the patient
with estimates suggesting that it could be at least 40% of household income in
Kenya. The loss of employment by breast cancer patients puts them at risk of
not being able to afford treatment which affects their mental preparedness and
may lead to depression and significantly affect their survival outcomes.
Chemotherapy
A number of studies have previously found that depression in breast
cancer patients seems to be tied to chemotherapy cycles. For instance, concluded
that there was no significant difference or relationship between depression
level and chemotherapy cycle. The number of people who survive breast cancer
has significantly increased in recent years due to advances in detection and
treatment, aggressiveness of the treatment exposes the patients to various
treatment side-effects. One of this effects that is often overlooked is
depression. Although illustrated that patients undergoing chemotherapy with
little response were likely to feel depressed than in instances where the
chemotherapy session leads to no response; agrees that depression is a frequent
diagnosis following the diagnosis of breast cancer and that in an already
burdened mental state after the diagnosis of breast cancer, the difficulties
due to chemotherapy and a series of social and family problems escalate the
issue which can quickly lead to depression. That symptoms that may be related
to depression were common among breast cancer patients undergoing chemotherapy
with weakness and dry mouth being the most prominent symptoms recorded. The
researcher concludes and recommends for adoption of innovative approaches that
reduce tumors in record time and with less side effects. The literature stated
above partly agrees with findings of this study that showed that compared to
adjuvant chemotherapy, the participants on neoadjuvant chemotherapy and
palliative chemotherapy had 830% and 850% increased odds of having a diagnosis
of depression among patients with breast cancer (OR: 9.43(95% CI: 1.5, 185.32)
and 9.5(95% CI: 1.62, 181.81) respectively. Neoadjuvant chemotherapy refers to
the use of chemotherapy to reduce the size of tumors prior to the main
treatment [26]. Perhaps this causes more anxiety
among cancer patients because they are waiting for the outcome of the approach
and are very uncertain of the outcome. This might therefore be a source of
depression. That adjuvant chemotherapy may lead to increased risk of depression
and anxiety or both but only after treatment. Palliative chemotherapy on the
other hand as defined by chemotherapy that is given in the non-curative setting
to optimize symptom control, improve quality of life (QoL) and ideally to
improve survival [27]. Women undergoing
chemotherapy present with a higher rate of depression but never mentioned what
type of chemotherapy presented most risk to depression among this group.
Palliative chemotherapy is offered to the terminally ill not to cure but to
improve survival and quality of life. The fact that the breast cancer is
untreatable puts strain on the mental health of patients and it is easy to
develop a feeling of hopelessness which may lead to depression. Although
depression occurs commonly across patients with breast cancer at the end of
life, it is not inevitable. Furthermore, the data on depression among the
terminally ill is not precise [28]. There is
under diagnosis and misdiagnosis of depression among patients with breast
cancer that are terminally ill which can result in needless suffering. The
plethora of symptoms that plague terminally ill patients can result in
uncertainty on whether the symptoms are as a result of the physical toll of the
disease or they are symptoms of depression. Confirms that terminally ill breast
cancer patients are faced with enormous symptom burden with the prevalence of
depression being 48% of the affected population. That most breast cancer
patients try to accept their potential demise and the importance of a
supportive environment to help the patients accept their condition [29]. There is need for more robust studies on
depression among breast cancer patients particularly undergoing palliative
care.
Cancer
stage
The study also discovered that compared to the early stage of cancer,
the participants with late stage of cancer had 61% increased odds of having a
diagnosis of depression among patients with breast cancer, OR: 1.61(95% CI:
0.63, 4.17) shown in Table. This agrees with who stated that psychiatric
disorders are more prevalent among cancer patients than the general population
with the most common mental disorder affecting such patients being depression [30]. Although some attention particularly in the
western countries has been pointed towards the mental distress among such
patients, there seems to be a lack of adequate recognition of this challenge.
This is partly because of a lack of disclosure by breast cancer patients and
that the patients also underestimate their symptoms. Notes that fatigue, loss
of energy, insomnia and hypersomniaare almost universal symptoms associated
with advanced breast cancer. Most critically, it was found that tiny
differences in the application of symptom severity thresholds could cause huge
variations in the prevalence rates of depression [31-50].
That patients with advanced cancer were more
likely to fall into depression than those ones whose cancers where in early
stages. Surprisingly, the presence of metastases was not associated with
depression in women with breast cancer. The reason for this is still unclear. In
another study by, it was found that a younger age is a well-known risk factor
for emotional distress when it comes to breast cancer. However, the
relationship between age and depression among patients with breast cancer was
not significant in this study [51-60].
This study has traversed through the prevalence of depression among
patients with breast cancer which has revealed that 59.4% of the patients at
MTRH were found to have some form of depression. This figure was markedly
higher than depression rates among breast cancer patients in studies conducted
in other contexts across Asia and developing countries. The rate of depression
in these other studies was within the range of 12%-40% with most of the
prevalence rates in the region of 30%-37%. Having a prevalence rate of 59.4% is
twice as high as the prevalence rates mentioned in most of the other research
papers cited in this study therefore revealing that depression is a major
problem among breast cancer patients at MTRH. It is also an indication of the
lack of attention towards the mental status of these patients. Further analysis
revealed that the three most primary factors that were significantly associated
to increased risk of depression among patients with breast cancer was
employment status, stage of cancer and use of chemotherapy. Subsequent
discussions illustrated that employment status was a major source of concern
because lack or employment lessens the ability of patients to afford critical
care therefore increasing their chances of mortality. The realization that
affording treatment is not easy and yet the disease is fatal if not adequately
and quickly treated can easily be a source of depression among breast cancer
patients. Previous literature also revealed that the cost of treatment in Kenya
is 40% of the household income. Breast cancer is therefore a huge burden to the
patient’s financial capability and will likely worsen the mental status of the
patient if they are unemployed leading to hopelessness and eventually
depression. The study also illustrated that chemotherapy particularly adjuvant
and palliative chemotherapy had a heavy toll on the breast cancer patients with
significant after effects including weakness. The lack of attention on the
mental status of breast cancer patients particularly during terminal cancer was
found to be a major source concern because depression is a common ailment in
the terminally ill patients. Depression can cause of unnecessary suffering for
the patients. Part of the reason for lack of attention on the depression among
the terminally ill was also partly as a result of the patients underestimating
their feelings and therefore not reporting their symptoms. The caregivers were
also responsible for underdiagnoses and misdiagnosis of depression among breast
cancer patients. This calls for adoption of innovative and effective approaches
that are unlikely to cause more severe outcomes on the mental status of breast
cancer patients. Chemotherapy is also tied to the stage of breast cancer
because the stage of cancer determines the type of chemotherapy treatment that
breast cancer patients will be given. This study found that patients in
advanced stage have increased chances of falling into depression compared to
those one in earlier stages of cancer. Previous studies have also attested to
this and have noted the most prevalent symptoms among breast cancer patients in
the advanced stage to be fatigue, loss of energy, insomnia and hypersomnia.
These are symptoms of depression. Although some attention particularly in the
western countries has been pointed towards the mental distress among such
patients, there still seems to be a lack of adequate recognition of this
challenge. Care should be exercised in the application of symptom severity
which can cause huge variations on the rate of depression hence causing a
hugely erroneous picture of the rate of depression among breast cancer patients [61-70].
Recommendations
The above information obtained from this study has major clinical
significance, mainly in the development of guidelines for early identification
of depression among breast cancer patients. This study therefore recommends:
·
Early psychological support should be incorporated
into the management of patients with breast cancer;
·
Screening for depression should be initiated for a
patient with cancer at all points of interaction with patients;
·
MTRH and other stakeholders should invest in the
establishment of new funds and the strengthening of already existing funds that
are meant to support the treatment and care of breast cancer patients
especially for those patients that lack employment. This will go a long way in
ensuring some form of relief to the patient with regard to the ability to
afford effective treatment and therefore bringing hope to the patient and
possibly helping them to avoid depression;
·
More investment by MTRH in creating further awareness
to the public on the need for routine and early screening in order to avoid the
diagnosis of cancer in its late stages. This will reduce the frequency of
patients with advanced breast cancer and therefore the rate of depression among
patients will also reduce;
·
Owing to the heavy physical toll of chemotherapy
(palliative and adjuvant chemotherapy) to the breast cancer patients, there is
need to:
Accompany the chemotherapy sessions
with frequent psychological tests for depression and common mental health
challenges [71-75];
·
Need for basic sensitization and education among care
givers on how to isolate symptoms related to depression from those that are as
a result of the physical effects of the breast cancer and other mental health
problems;
·
Need for sensitization and education programmers
targeting patients in order to eliminate the fear, stigma and wrong assumptions
about mental health issues in order to encourage reporting of all feelings that
may be symptoms of depression by breast cancer patients;
·
Special attention to be paid to patients under
palliative care with very frequent mental assessments to foster acceptance.
Suggestion
for Further research
·
Need for more research to determine the extent to
which different treatment methods of breast cancer affect the rate of
depression in Kenya;
·
Need for more research to determine the level of
awareness of mental health issues among care givers of breast cancer patients;
Further research on the status and ability of
breast cancer patients to access treatment and its effect on mental health
status of patients.