Fast track — ArticlesPrevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies
Introduction
Of all the possible mood complications associated with cancer, depression has been most extensively investigated. Depression is one of the most common mental health problems worldwide; its 30-day prevalence in the community is about 5% with an incidence of about 9% over 12 months.1 Depression is known to be a substantial complication in patients with cancer, and its prevalence is higher in these patients than in the general population.2, 3, 4 In two studies,5, 6 the relative risk of depression in patients with cancer exceeded that of patients who had stroke, diabetes, and heart disease. In cancer settings, evidence shows that depression causes serious suffering and distress, reduces participation with medical care, and potentially prolongs duration of stay in hospital.7, 8 Depression is also a significant determinant of quality of life and survival.9, 10 Yet depression is often overlooked by busy cancer professionals in palliative-care and non-palliative-care settings.11
Although low rates of depression recognition and treatment are concerning, there might be several mitigating explanations. First, those making the diagnosis are most often cancer specialists who are not trained in mental health, and find operational (syndromal) diagnoses and formal screening questionnaires cumbersome.12 Second, symptoms of depression suggested by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV)13 and International Classification of Diseases 10 (ICD10)14 are generic and might not be appropriate in cancer settings. Third, depression is only one, albeit important, mood disorder that clinicians have to be aware of. Fourth, prevalence of depression seems to be modest, and its onset often unpredictable. Despite many years of research, prevalence of depression in patients with cancer is still subject to much debate.15 The picture is especially unclear because most published work has relied on depression symptom-screening methods rather than diagnostic instruments.16 Diagnostic instruments are the criterion (gold) standard and include a diagnostic algorithm, clinical significance criteria, and minimum duration to support a robust diagnosis (webappendix p 1). Although depression in patients with advanced cancer has been researched, the actual rate of depression is still not clear. Reviews of depression in palliative-care settings show a prevalence of between 1% and 69%.17 Many investigators have stated that depression is a more common problem in palliative-care settings than in others and propose demographic (age, sex) and disease-based (tumour stage, tumour type) risk factors.18, 19 Only one previous meta-analysis has examined predictors of prevalence, although no pooled rate was reported. Van't Spijker and colleagues20 identified 50 studies of psychological and psychiatric problems using various self-report scales, but only eight with formal interviews. They reported low rates of psychological and psychiatric problems in patients with breast cancer and in studies of women only, and noted that studies with young patients (mean age <50 years) reported significantly more depression, as did older studies published before 1988.
In view of uncertainties about the prevalence of depression and related mood disorders in patients with cancer, we aimed to quantitatively summarise the prevalence of robustly defined depression, anxiety, and adjustment disorders in oncological, haematological, and palliative-care settings. Our secondary aim was to examine the main correlates of depression in these settings.
Section snippets
Search strategy and selection criteria
AJM and NM designed the review protocol and extraction forms in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.21 A systematic search of Medline, PsycINFO, and Embase abstract databases was done by AJM and NM, from inception to November, 2010. Four full text collections were also searched and when necessary, authors of the publications were contacted directly for primary data. Sample searches are shown in webappendix p 2.
We included
Results
We identified 433 relevant articles; 369 included patients with cancer who were assessed with an interview-based diagnostic method (figure 1). Ten potentially valid studies were excluded because they contained duplicate data presented elsewhere (webappendix p 3). Several others were excluded because of issues with the criterion standard (webappendix p 3); most studies that were excluded provided insufficient data for analysis. 94 studies were eligible for quantitative review: 24 in palliative
Discussion
Although several informative systematic reviews have been published, no previous studies have quantitatively analysed such a robust dataset of mood disorder in cancer settings.15, 16, 17, 20, 116 Massie and colleagues15 estimated that the prevalence of depression in patients with cancer was 0–38%, and Hotopf and colleagues17 estimated 5–26%. Findings from two small meta-analyses of methods to diagnose mood disorders showed a prevalence of 13·2%16 and 12·7%116 in studies with convenience
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