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The Impacts of Cancer on Mental Health
As the number of cancer survivors in the United States approaches 14 million, with a projection of 18 million by 2022 (Siegel et al., 2012), intensive research and intervention dedicated to enhancing both the quality and length of people’s lives after cancer diagnosis is generating progress on both fronts.
In the United States, mortality from cancer has declined 20% from its peak in 1991, primarily as a result of a decrease in tobacco use and improvement in early detection and treatment of cancer (Siegel and Jemal, 2013). In light of the observations that many cancers now have less dire prognoses, public awareness of the disease is greater, and evidence-based informational and psychosocial resources for survivors and their loved ones are increasingly available, cancer no longer carries the severe stigma and grave consequences it did in prior decades. Nonetheless, progress is uneven, limitations exist in development of and access to medical and psychosocial care, and a diagnosis of cancer can remain a serious threat to health and well-being.
Consequences of Cancer for Mental Health
Much of the research pertaining to cancer and psychological health focuses on several domains of health-related quality of life (e.g., social, physical, and psychological health-related quality of life), negative mood and general psychological distress, and more specifically on depression and anxiety, which are addressed here. We highlight two recent reviews conducted by Mitchell et al., 2011 and Mitchell et al., 2013, although we note that estimates of prevalence can vary widely across studies and reviews. Psychological consequences specific to cancer, such as fear of cancer recurrence, also are summarized. Rather than focusing solely on distress and psychopathology, research also has addressed positive psychological consequences, such as finding benefit in the experience of cancer.
Prevalence of Depression and Anxiety
A meta-analysis (Mitchell et al., 2011) of 24 studies, in which psychological disorders were assessed through interviews conducted by trained professionals in hospital inpatient and outpatient palliative care settings, which typically are used by people with advanced cancers, demonstrated a 25% prevalence of depressive disorders. In 70 studies of hospital oncologic and hematologic clinic cancer patients (inpatient and outpatient), depression prevalence was 21%. The Mitchell et al. (2011) meta-analysis demonstrated that prevalence of all anxiety disorders was 10% in palliative care settings and 10% in oncologic/hematologic settings, as diagnosed by structured interview.
Several studies have assessed the specific presence of posttraumatic stress disorder (PTSD) related to cancer. In studies using validated, structured interviews or questionnaires with cutoffs to indicate PTSD, the majority of studies suggested approximately a 5% rate of cancer-related PTSD, although estimates vary depending on the assessment method, diagnosis duration, and other factors (e.g., see Kangas et al., 2002, for a review).
When adjustment disorders also were considered, Mitchell et al. (2011) estimated that up to 38% of adults with cancer meet criteria for depression, anxiety, or adjustment disorders in hospital settings, suggesting that a 30–40% overall prevalence of some mood complication is similar to that estimated by self-report questionnaires. Interestingly, average age and sex of patients, as well as setting (palliative vs. non-palliative care) were not associated with disorder prevalence, except that women tended to be judged to have adjustment disorders more than did men. Rates of depression were lower in more recently published studies than research published before 1990. Methodologically higher quality studies were associated with somewhat lower prevalence rates.
Mitchell et al. (2011) pointed out that patients were typically within five years of cancer diagnosis in their review, although many studies did not report diagnosis duration. In a second meta-analysis, Mitchell et al. (2013) identified 43 studies of adults whose cancer had been diagnosed at least two years previously were assessed for depression or anxiety with either a validated questionnaire or interview, and included comparison with either a healthy sample or partners. The 11.6% prevalence of depression in cancer survivors did not differ significantly from the 10.2% prevalence in healthy controls, although cancer survivors were significantly more likely to report anxiety (17.9%) than were controls (13.9%). Depression and anxiety prevalence did not differ between cancer survivors and their partners (although anxiety was higher in spouses if one outlier study was removed). The prevalence estimates in partner studies were higher than those in studies with healthy controls, perhaps because cancer on average had been diagnosed more recently in partner studies (4 years vs. 7 years, respectively). Mitchell et al. (2013)pointed out that persistent anxiety has been under-recognized in longer-term cancer survivors (also see Traeger et al., 2012, for a description of specific anxiety disorders in cancer survivors).
Cancer-Specific Consequences for Mental Health
Although research indicates that most cancer survivors do not develop psychological disorders, cancer is not psychologically benign. Intrusive thoughts and feelings about cancer are common, as are attempts to avoid those thoughts and feelings. Cancer-related intrusive thoughts/feelings are particularly prominent in the months following diagnosis, with evidence of decline across time (see Kangas et al., 2002, for a review). Following medical treatment completion, fear of cancer recurrence is a frequent experience. Although it appears that fear of recurrence is modest to moderate, on average, stronger fear can be triggered by relevant events (e.g., a cancer screening appointment), and a minority of patients report high and sustained fear (Kangas et al., 2002). Another common and distressing effect of cancer and its treatment is fatigue, which has both psychological and physical components. Estimated prevalence of significant cancer-related fatigue is 25% or more during treatment, and for a minority, fatigue can persist for months or years (Bower, 2008). Pain associated with cancer and its treatment, which occurs in the majority of adults during particular medical treatments and in those with advanced disease (Van den Beuken-van Everdingen et al., 2007), can produce serious psychological consequences, particularly if pain becomes chronic.
Certainly, the individual diagnosed with cancer is not the only one influenced by the disease. Friends and loved ones also are affected. Distress in partners typically has a small to moderate relation with patients’ distress, as demonstrated by meta-analytic correlation of r=0.29, p<.001 ( Hagedoorn et al., 2008). Cancer patients and their partners did not differ significantly in levels of distress (also see Mitchell et al., 2013). In the meta-analysis (Hagedoorn et al., 2008), women reported more distress than men, regardless of whether they were patient or partner.
Positive Psychological Adjustment and Finding Benefit in the Cancer Experience
Although the majority of research on mental health in the cancer population focuses on negative consequences, research also addresses its positive concomitants (seeStanton, 2010, for a review). Across multiple cancers, the majority of survivors report finding benefit in the experience, such as strengthened interpersonal relationships, enhanced life appreciation, a more robust sense of self-competence, a greater focus on central life priorities, deepened spirituality, and improved health-related behaviors. Consistent with theories of personal growth in the aftermath of traumatic experiences (e.g., Calhoun and Tedeschi, 2006), precursors of cancer-related benefit finding include higher disease impact (e.g., perceived life threat), and greater personal engagement (e.g., use of approach-oriented coping strategies such as problem-focused coping and active acceptance of the diagnosis).
Whether the perception of cancer-related benefits translates into sustained change in the self or relationships appears individually variable. The associations of engagement in benefit finding with salutary psychosocial and health-related outcomes, such as lower depressive symptoms or cortisol (a hormone associated with stress), are similarly variable. The act of finding benefit in the cancer experience can be valuable in itself, as cancer survivors devote themselves to pursuing cherished relationships and life priorities.
This excerpt is taken from Cancer and Mental Health by J.F. Wiley, A.L. Stanton from the Reference Work Encyclopedia of Mental Health, Second Edition. To learn more about psycho-oncology research on the consequences of cancer diagnosis and treatment for the psychological health of adults click here. The Encyclopedia of Mental Health, Second Edition presents a comprehensive overview of the many genetic, neurological, social, and psychological factors that affect mental health, also describing the impact of mental health on the individual and society and illustrating the factors that aid positive mental health. Check it out here.
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