Annals of Oncology Advance Access published online on September 5, 2007
Annals of Oncology, doi:10.1093/annonc/mdm353
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© 2007 European Society for Medical Oncology
Requestioning depression in patients with cancer: Contribution of somatic and affective symptoms to Beck's Depression Inventory
1 Department of Haematology and Medical Oncology
2 Psychiatric Clinic, Friedrich-Schiller-University, Jena, Germany
3 Institute of Medical Biometry, Epidemiology and Informatics, Johannes Gutenberg University Mainz, Germany
4 Department of Geriatrics, Ruhr-University Bochum, Marienhospital Herne, Germany
5 Psychiatric Clinic, University of Berlin, Germany
* Correspondence to: Dr U. Wedding, Department of Haematology and Medical Oncology, Friedrich-Schiller-University, Erlanger Allee 101, D-07747 Jena, Germany. Phone: +49–3641–9324216; fax: +49–3641–9324217; E-mail: ulrich.wedding{at}med.uni-jena.de
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Abstract |
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Background: Depressive symptoms are a major complaint reported by cancer patients. Somatic and affective symptoms can contribute to depression.
Patients and methods: We investigated the prevalence of somatic and affective depressive symptoms with the Beck Depression Inventory (BDI) in 213 hospitalized cancer patients prior to the start of chemotherapy.
Results: Seventeen of 213 patients (8%) were screened positive for major depression; 40 (19%) had mild to moderate depressive symptoms. The corresponding figures for somatic and affective symptoms were 33.3% and 2.8% in the patients with major depression and 23.0% and 8.0% in those with mild to moderate depressive symptoms. Female patients, patients with solid tumour and those with functional limitations had significantly higher mean scores. All differences were related to higher scores in somatic and not in affective items.
Conclusions: Most alterations in the BDI in cancer patients are related to somatic and not to affective symptoms and may be attributed not to depression but to severity of the underlying disease.
affective items, cancer, depression, functional status, somatic items
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introduction |
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TopAbstractintroductionmethodsresultsdiscussionconflict of interestAcknowledgementsReferences |
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Cancer is one of the world's most common diseases [1]. Cancer patients often suffer from a variety of symptoms. The symptoms can be categorized as physical/ somatic or emotional/ affective. Some of the symptoms reported in cancer patients, e.g. loss of appetite, fatigue and insomnia, can occur in depression as well and are used as diagnostic criteria for depression. Weissman et al. report a point prevalence of major depression in otherwise healthy community-living people of 4.5–9.3% in women and 2.3–3.2% in men [2]. Masie provides an extensive, systematic review on the prevalence of depression in cancer patients. The reported prevalence of depression in cancer patients varies from lower than 1% to greater than 50%. They reported a prevalence of major depression of 0–38%, and of 0–58% for depression spectrum syndromes [3].
Depression has been studied in patients with cancer using a range of assessment tools. Self-report forms, brief screening instruments and structured clinical interviews are used. Widely used assessment instruments for screening are the Beck Depression Inventory (BDI) [4], the Hospital Anxiety and Depression Scale (HADS) [5] and the Structured Clinical Interview (SCID) according to the Statistical Manual of Mental Disorders (DSM-IV) [6,7]. Ten of the 93 trials reported in the systematic review by Masie et al. used the BDI for investigation of depression in cancer patients [3]. The results of these trials, including the number of patients, their diagnoses and the prevalence rates of depression are reported in Table 1. Additional reports published more recently have been added.
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The BDI is one of the most widely used instruments to screen for depression and to measure the intensity of depression [4]. The BDI was originally developed for use in psychiatric patients. Later on, it was used in other disease contexts [8] and also in the general population [9]. It has been translated into a variety of languages. A German manual is provided by Hautzinger et al. [10].
A variety of risk factors of depression in cancer patients and terminally ill patients have been identified, such as pain, impaired functional status, social deficits, advanced illness and history of depression [11,12]. Presence of depression in cancer patients has been linked to a reduced chance of survival in a variety of tumours, e.g. breast cancer [13] and ovarian cancer [14].
Symptoms in cancer patients and in patients with depression can be identical, e.g. loss of weight or appetite and fatigue. Such symptoms can occur in cancer patients (a) as symptoms of cancer, (b) as a reaction on diagnosis and prognosis, (c) as side-effects of treatment and (d) as symptoms of a comorbid depression. Thus there is a risk of misclassifying symptoms of cancer as depression or symptoms of depression as cancer related.
Against this background, we therefore analysed data of BDI measurement collected within a prospective trial on decision making in elderly cancer patients, aged 60 and older, and a control group of younger patients with cancer, younger than 60 years. We asked to what extent affective items compared to somatic items contribute to the total BDI score in cancer patients and compared results to that of a healthy control group.
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methods |
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The study was conducted in the Department of Haematology and Oncology at the University Hospital Jena, Germany. The study was approved by the ethical committee of the Friedrich-Schiller-University of Jena.
patients
Patients aged 18+ years, newly admitted to the hospital in order to undergo first-line chemotherapy treatment for current cancer stage, were asked to participate in a clinical trial on decision making in cancer patients. In addition participants were asked whether they agreed to have a psychiatric evaluation, including depression, anxiety-, adjustment-, personality-disorders, and existential orientation. The first patient was included on 06/12/1999, the last on 29/08/2005. Informed consent was obtained by their physician after the patients had been informed about the diagnosis of cancer and stage and receiving a recommendation to undergo chemotherapy. For all patients, data on sex, age, kind of tumour — classified as solid or haematological — diagnosis and treatment approach — curative vs. non-curative — were documented from the patient's records. Treatment approach, classified as curative vs. non-curative, was judged by the responsible physician based on tumour characteristics, such as diagnosis, histology and stage, and patients characteristics, such as age, functional status and comorbidity.
functional status
Patients over-all physical fitness was measured according to ECOG Performance Status (ECOG Status). ECOG Performance Status (ECOG-PS) consists of a 5-point scale: 0 = asymptomatic, 1 = symptomatic but completely ambulant, 2 = symptomatic, <50% in bed during the day, 3 = symptomatic, >50% in bed, but not bedbound, 4 = bedbound. For further analysis, patients were grouped into those with a good ECOG Status (0–1) and in those with a poor ECOG Status (2–4). The questionnaire was filled in by the physician responsible for the trial.
comorbidity
Comorbidity was documented according to Cumulative Illness Rating Scale Geriatric Version (CIRS-G) [15,16]. For further analysis patients were grouped into those with at least one severe or very severe comorbidity (= comorbidity level 3–4) compared to those without severe or very severe comorbidity (= comorbidity level 0–2). Comorbidity data were available in 202 of 213 patients.
beck depression inventory
The BDI contains 21 items. Each item can be answered on a 4-point scale between 0 and 3 according to the intensity of the item within the last week. The total score is obtained from the sum scores of the 21 items. The highest score possible is thus 63. A sum score of 0–10 is a normal result, 11–17 mild to moderate depressive symptoms and 18+ a clinically relevant depression. The cognitive-affective subscale is constructed from the first 13 items, the somatic-performance subscale from items 14–21 [17]. A detailed manual for the German version is provided by Hautzinger et al. [10]. He also provides detailed data on BDI for a healthy German control group, consisting of 86 persons, without psychiatric or psychosomatic disorders and although otherwise healthy, median age 55 years. Within this trial, the questionnaire was completed by a trained assessor during an interview with the patient and results were checked by a professional. The median time from trial entry to the interview was 13 days.
missing items
In some patients the item was not asked or documented in the patients' charts. Mean BDI score was 5.8 in the eight patients with missing ECOG-PS (2.1 for affective items, and 3.6 for somatic items respectively), 9.8 in the 11 patients with missing comorbidity data (3.4 for affective items, and 6.4 for somatic items respectively), and 8.3 in the 28 patients with missing information on former depression (2.9 for affective, and 5.4 for somatic items). These patients were not excluded from further analysis.
statistics
Data management and data analysis were performed with the statistical packages SPSS® version 12 and SAS® release 8.02. To assure high quality of data concerning completeness, rightness and consistency, plausibility checks were performed. Statistical measurements (frequency, relative frequency, mean and standard deviation (SD)) were calculated for the variables. To test statistical significance of categorical data, Fisher's Exact Test was used. Differences between mean scores in BDI were calculated according to the Mann–Whitney U-test (n = 2 independent groups) and the Kruskal–Wallis test (n 
3 independent groups). The results of a statistical test with P-value <0.05 is called significant and with P-value <0.10 a trend.
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results |
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Of 427 patients aged 18+ years, newly admitted to the hospital in order to undergo chemotherapy for cancer and included in a clinical trial on decision making in cancer, 213 (49.9%) agreed to have the additional psychiatric evaluation. These 213 patients were included in the analysis. Patients' characteristics are presented in Table 2. More male than female patients were included, corresponding to the higher incidence rate of cancer in male than in female patients. Mean age was 57.0 years (SD = 14.8, range 19–88). No significant difference was seen between the sex of patients younger (female: 42.2%) and older than 60 years (female: 45.2%; P = 0.660). Patients older than 60 years did not have statistically significantly more often solid tumours (45.2%) than younger patients (38.5%; P = 0.335); 83.9% of patients suffering from a solid tumour had metastatic disease. The treatment approach for patients older than 60 years was statistically significantly more often non-curative (75.0%) than for younger patients (48.1%; P <0.001). An ECOG-PS of 2–4 was associated with higher frequency of a non-curative treatment approach (P = 0.018). Age correlated with the number of level 3–4 comorbidities (r = 0.346, P <0.001).
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The mean BDI score was: 8.4 for all patients, 9.3 for female and 7.7 for male patients (P = 0.046); in somatic items 5.5 for all patients, 5.1 for female and 6.0 for male patients (P = 0.044); and in affective items 2.9 for all patients, 3.3 for female and 2.6 for male patients (P = 0.357), respectively. The prevalence of major depression and of mild to moderate depressive symptoms is reported in Table 3 for all patients. A separate analysis of the 13 affective and 8 somatic items demonstrated that somatic items contribute to most of the pathological results in the BDI score.
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Table 4 reports the mean score per item and provides a comparison with the single item mean score of a normative sample. In addition, results are reported separately for female and male patients. The data demonstrate that the main differences between healthy controls and cancer patients are related to somatic items, in all somatic items, but in loss of libido cancer patients score substantially higher than healthy controls. In the affective items a mixed picture occurs. Cancer patients have higher levels of dissatisfaction and sadness, but lower levels of sense of failure, guilt and irritability. In addition, mean scores for affective items do not differ between the cancer patients we report on and the German standard population (2.9 vs. 3.4), other than the sum score (8.4 vs. 6.5) and the mean score for somatic items (5.5 vs. 3.1).
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A comparison of the mean BDI score according to patients' characteristics is provided in Table 5. Female patients compared to male patients, those with solid tumour compared to a haematological neoplasia, and patients with functional impairment in ECOG-Status compared to those without functional impairment in ECOG-Status had a significant higher mean BDI score. ECOG-PS correlates with the BDI score (all items: r = 0.22, P = 0.002; somatic items: r = 0.22, P = 0.002; affective items: r = 0.19, P = 0.007). A trend was observed when comparing patients with non-curative instead of a curative treatment approach. In all cases the differences were caused by changes in somatic and not in affective items. Age and comorbidity did not influence the BDI score, neither the sum score, nor the affective or somatic subscales.
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The data on mean BDI scores in all, in somatic and in affective items per diagnosis are presented in Table 6. As the number of patients was too low, we have not presented the data separately for male and female patients and we did not perform a statistical analysis.
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discussion |
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TopAbstractintroductionmethodsresultsdiscussionconflict of interestAcknowledgementsReferences |
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As symptoms of cancer and of depression can be identical, there is a risk of misdiagnosing cancer patients as depressive or to overlook depression in cancer patients. Symptoms resulting in the diagnosis of depression can be classified as somatic or affective. We analysed to what extent the prevalence of major depression or depressive symptoms in the reported cohort of cancer patients was related to somatic or affective items and compared the results to published data of a healthy control group. If major depression and depressive symptoms were mainly caused by changes in somatic items, the items might in fact be changed by cancer-related symptoms and not by depression. If differences from a healthy control group were mainly related to somatic items and not to affective items, this might mainly be related to symptoms of cancer and not to true depression.
As summarized in Table 1, this is the third largest report on cancer patients and measurement of depression by BDI. The reported values of BDI in our cohort of cancer patients are well above the mean values 6.45 (SD 5.2, range 0–19) reported for a German healthy control group—86 persons, without psychiatric or psychosomatic disorders and although otherwise healthy, of median age 55 years. The rates of depression (9.1%) and depressive symptoms (16.6%) found in our population of cancer patients are in line with that described by other authors in cancer patients and summarized by Masie [3].
Our major findings are that major depression and depressive symptoms—according to BDI criteria—are mainly related to somatic and not to affective items and that differences compared to a healthy control group exist mainly in the somatic and not in the affective items. As a result, we consider the BDI to be an inadequate instrument to screen for depression in cancer patients or, more generally, in patients with somatic disorder that have symptoms similar to somatic symptoms of depression.
A detailed analysis of changes in somatic and affective items has only been done by very few other authors reporting results of BDI measurement in cancer patients. Plumb and Holland measured BDI in 97 cancer patients, 66 of their relatives and in 99 physically healthy persons who attempted suicide. No difference in somatic depressive symptoms was found between the two patient groups and no difference between affective depressive symptoms between the cancer patients and their relatives. The authors therefore conclude that somatic depressive symptoms reflect advanced disease, but affective symptoms should be a reason for psychiatric consultation [18]. Hahn et al. reported a prevalence of depression measured by BDI in 19 of 124 patients (15%). All depressed patients endorsed some somatic symptoms, but according to their work these alone were insufficient to score in the range of depression [19]. For non-cancer patients Trentini et al. reported a higher score in the group of elderly adults (60+ years) compared to younger adults (<60 years) in the somatic items subscale but not in the affective items subscale; this translated into a significant higher total BDI [20]. Within our data we could neither observe an age-dependent increase in the mean BDI score nor in the BDI-derived affective or somatic sum score. This is in line with the results reported by Aass et al. for cancer patients. The depression rate was 9%, with a higher prevalence in in-patients, in those functionally impaired and those with metastases, relapse or progression. Age was not a risk factor for depression [21].
The analysis has some limitations. The group of cancer patients is heterogeneous, including patients with different diagnoses, different stages and different treatment approaches. The distribution of the different diagnoses does not well reflect their frequency in the general population. With 58.2% of the patients suffering from haematological types of cancer, the relative frequency of patients with this kind of tumour is well above that in the general cancer population, but reflects the population in our hospital. We included only hospitalized patients, who might be more severely affected by the disease than patients treated in an out-patients setting, and we included a high number of patients with non-curative treatment approach (61.3%). The trend for a higher mean score in patients with a non-curative treatment approach was only seen in the total score and the somatic subscale, but not in the affective items. The higher mean BDI scores in patients with solid tumours compared to patients with malignant haematological disorders is also reported by Devlen et al. [22,23]. As the difference is related to somatic items only, it has to be questioned whether this is a true difference or whether it is caused by a lower rate of somatic symptoms, such as loss of appetite or pain in lymphoma compared to carcinoma patients. All in all, the results may not be applicable to all cancer patients and should be validated in homogeneous patient samples.
A further limitation is that the 57 patients who had an BDI score of more than 10 did not receive a further standardized diagnostic work up, including the gold standard DSM-IV based clinical interview by a professional. However, even with these limitations in mind, the reported results have further and major implications [1]. As not every cancer patient can receive the gold standard of diagnosis of depression (DMS-IV interview by a professional) appropriate screening instruments have to be identified. The aim should be to have a two-step approach: short screening of every cancer patient and detailed diagnosis in those who screen positive. Future research should address which screening instruments are insensitive to symptoms caused by cancer [2]. Data on prevalence of depression in cancer patients and on the adverse effect of depression on survival, at least when diagnosed according to BDI criteria, have to be requestioned [3]. Psychooncologists and oncologists should be aware that somatic items of depression may be misleading in cancer patients. Close interaction between oncologists and psychooncologists is necessary to identify those patients in whom somatic symptoms similar to that of depression are related directly to the tumour and may improve through effective cancer treatment, and not to overlook those cancer patients with comorbid depression so that appropriate treatment may be initiated.
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conflict of interest |
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No financial or personal relationship with other people or organizations that could inappropriately influence the presented work exists for any author.
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Acknowledgements |
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The study was supported by German Cancer Aid (Grant No. 70-2445-Hö-3). Ulrich Wedding is currently research fellow of the Forschungskolleg Geriatrie of the Robert Bosch Foundation Stuttgart, Germany.
Received for publication April 10, 2007. Revision received June 8, 2007. Accepted for publication June 11, 2007.
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