Frequency and Severity of Depression in Cancer Patients Presenting to Tertiary Care Hospital

Introdution: Cancer and depression, independently, cause massive human suffering worldwide. By the end of 2030 the unipolar major depression disorder could be as the chief source of ailment as estimated by World Health Organization. Objective: Objective of this study is to detect prevalence the frequency and severity of the depression in cancer patients presenting to tertiary care hospital of Karachi. Methodology: The current prospective cross-sectional research was performed over a period of six months from August 2020 to January 2021 on 179 patients in the Department of Oncology of Civil Hospital Karachi, after approval of synopsis from CPSP and the ethical committee of Civil Original Research Article Kumar et al.; JPRI, 33(10): 59-70, 2021; Article no.JPRI .66191 60 Hospital. All patients who fulfilled the inclusion criteria and visited OPD of Civil hospital were selected in the study. Informed consent was taken after explaining the procedure, risks and benefits of the study.Patients were assessed clinically by using ICD-10 criteria and then for validity and reliability, patients were screened for presence of depression and its severity through PHQ9.Patients scoring higher than 4 was labeled as having depression and PHQ-9 score of 5 to 9, 10 to 14, 15 to 19, 20-27 were labeled mild, moderate, moderately severe and severe depression correspondingly. Observed data was entered in the predesigned Performa was gathered and SPSS version 20.0 was used for data analysis. Mean ± SD of age was 47.75±14.901years. Out of 179 patients 95 (53.1%) were male and 84 (46.9%) were female. 93(52%) cancer patients were depressed while 86(48%) were normal. Patients suffering from mild depression were 3.2%, moderate depression were 54.85%, moderately severe depressed were 19.4%, while 22.6% cancer patients were severely depressed. It is to be concluded that out of 179cancer patients 93(52%) diagnosed to have depression while 86(48%) did not have depression. Based on our study findings, it is suggested that depression commonly presented in cancer patients and there is a need to screen all cancer patients for depressive disorder.


INTRODUCTION
Cancer and depression, independently, cause massive human suffering worldwide [1]. By the end of 2030 the unipolar major depression disorder could be as the chief source of ailment as estimated by World Health Organization [1]. It is anticipated that over than 03.0 million individuals will be diagnosed as having cancer in the UK by the end of 2030 [2]. In the year 2008 about 169.0 million years of healthy life vanished because of cancer throughout the globe [1]. In year 2012 nearly 14.1 million new cases of cancer with about 08.2 million cancer related deaths were reported from all over the globe [3]. It is seen that severe anxiety, pain, lethargy, and disturbed functioning was more bin subjects of cancer with co morbid depression in comparison to cancer subjects without depression [2]. Suicidal feelings and noncompliance to cancer medications are the major issues in these subjects [2]. The occurrence of depressive disorders in cancer subjects is four times more than that of the common people. These disorders are highly variable; in Iran 50.0% where as in China up to 67.0% subjects with cancer patients had been suffering from depressive ailments [3]. Universally, most of the community centered researches had described the pervasiveness of depression in patients suffering from cancer as 10.00 to 25.00% in comparison to 03.3 to 21.4% in common inhabitants [3]. The pervasiveness of interview based diagnosed depression for subjects suffering from all types of cancer was analysed as 16.0% and 13.0% [2]. The management of depressive disorders in cancer subjects is essential. The psychiatrists must be involved to treat the cancer subjects with comorbid depression, because of increased occurrence of mood disorders in the habitants and the adverse outcomes of unmanaged depressive ailments on their quality of life [3]. Therefore, improved approaches for the diagnosis and management of subjects with depression reaching at cancer care facilities are desirable [2]. The effective treatment of depression in subjects with cancer had been introduced by the United Kingdom National Institute of Health and Care Excellence and the United States Institute of Medicine [2]. In USA all subjects suffering from cancer must be screened for psychosocial ailments especially for depression [4]. In 2012 new cases of all types of cancer were 148000 from all over Pakistan [5].
Depression from mild to severe was reported to be 65.0% in cancer patients of Urban Sindh-5 and about 66.00% amongst cancer subjects all over Pakistan [6]. The rationale of this study is that because previous study [3] was done in OPD patients of private sector teaching hospitals. This study was done exclusively in public sector hospital (Civil Hospital Karachi). It is needed to have the knowledge about the number of cancer subjects attending cancer facilities having depression and those subjects who are prone to develop depression. Conversely there are deficient statistics to reply these elementary queries. Hence there is high need to do more research.
Aim of this study is to detect prevalence the frequency and severity of the depression in cancer patients presenting to tertiary care hospital of Karachi.

MATERIALS AND METHODS
The current prospective cross-sectional research was performed on 179 patients over a period of six months August 2020 to January 2021 in the Department of Oncology of Civil Hospital Karachi. After institutional ethical committee approval, 179 patients with Cancer were recruited using non-probability consecutive sampling technique. After identifying patient, the demographic profile of the patients was noted and patients giving consent to participate in study was assessed clinically by researcher using ICD-10 criteria and then for validity and reliability patients were screened for presence of depression and its severity through PHQ-9 [4][5][6]. PHQ-9 was explained by researcher to participants. Five minutes were given to respondents to encircle the options ranging from 0 -3. The score "0" denotes no any symptom existing. The score "1" denotes symptoms existing for up to 07 days. If symptoms persist for longer than 07 days it was scored as "2". If symptoms remained persisting every day from the consecutive 02 weeks it was scored as "3". Patients scoring higher than 4 were labeled as having depression. PHQ-9 score of 5 to 9, 10 to 14, 15 to 19 and 20 to 27 present mild, moderate, moderately severe and severe depression correspondingly. Spitzer and colleagues developed the Patient Health Questionnaire-9 (PHQ-9). It is a self-scored variety of the Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument. It approximately evaluates common mental disorders. The PHQ-9 assesses depressive symptoms based on nine DSM-IV criteria. There are four choices of response for each item ranging from 0 ("not at all") to 3 ("nearly every day"). It has been proposed that total PHQ-9 scores of 05, 10, 15, and 20 represent depression categorized from mild, moderate, moderately severe, to severe. Time to complete scale was less than 5 minutes. Confidentially of patient was maintained.

Inclusion Criteria
 All cancer patients including male and female aged between 18 years and 65 years irrespective of site, duration and stage of cancer.  Those giving informed consent.

Exclusion Criteria
 Patients with physical illnesses other than cancer.
 Not willing to be part of study

Data Analysis
Data was analyzed on SPSS version 21. Mean and standard deviation was calculated from all continuous variables like age, income and duration of cancer diagnosis. Frequency and percentage was calculated for all categorical variables like gender, educational status, occupation, site of cancer and screening and severity was determined through Patient Health Questionnaire (PHQ-9) score. Post-stratification chi square test was applied for gender, education, occupation, duration stage and site of cancer to control the effect modifier value < 0.05 was reflected as statistically significant.

RESULTS
179 patients were included to assess the frequency and severity of depression in cancer subjects and the results were analyzed.  Table 3.
The frequency of depression in cancer patients was found to be 93(52%) while 86(48%) were normal as shown in Fig. 2.
In severity of depression 21 (22.6%) had severe, 51 (54.85), 18 (19.4%) and 3(3.2%) had moderate, moderately severe and mild depression respectively as shown in The outcome variable i.e. depression was stratified with respect to effect modifier of the study, significant difference was observed when it was stratified with respect to age, site of cancer, current treatment and family however, non-significant difference was Table 1 Descriptive Statistics Age (In years)

Mean
Std. Deviation

DISCUSSION
Distinct skilled health care providers like; physician and nurses and casual caretakers, such as family fellows or supporters, offer carefulness to persons with different situations comprising increased age, dementedness and cancers. A prolonged stress is usually observed by this, and caretakers usually expertise deleterious emotional, social and physical possessions on their everyday life and wellbeing [7]. The consequences of oncological ailments on the individuals, especially a family member, consenting the duty to care the patient's [8][9][10]. Throughout the mollifying stages of the patient's ailment, they could advance to more physical stress due to augmented imposition on their job, due to fatigue and to the restricted time existing for rest and caring of itself [11]. Depressing symptom remain as the most considerably care giving impairment, with the frequency approximating for depressive disorders ranging from 12.0% to 30.0% [11,12]. Socio-economic features of caretaker and sufferer and illness associated features had been well recognized in association with depression. Symptoms of depression are related per responsibilities and burden of care giving. Rendering to typical strain managing mockups the constructive views impact the assessment of tense circumstances [8,13,14] subjects having strong SOC (sense of coherence)even with tremendously acute situations like; giving care to the family fellows can provide encouraging results and can efficiently manage thru tension and retain worthy wellbeing position. The SOC is the capability of persons to activate their overcoming properties throughout episodes of misery. SOC is the sort of adaptable overcoming responses for gathering the challenges of care giving to the family participants and to conclude the consequence of the care giving. The psychological distress in giving care to subjects suffering from cancer can be prevented [15]. Boyoung Park in his study reported that the pervasiveness of depression was 82.2% amongst family caretakers of cancer subjects [16]. In a research performed in Korea, reported a 67.0% prevalence of depression [17].  [8]. Frequency of depression reported by Gozum was also a bit higher than that of this study. The reasons behind these diverse rates in different populaces are due to the common features and conFIGurations of these inhabitants are unlike. The most cancer patients in China suffer from high level of depression, the pervasiveness of depression was noted as 67.3%. This prevalence of depression is much greater than the rates of depression in non-Chinese equivalents [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. This difference in frequency of depression among care givers may be due to sample size difference or some methodological differences for measurement of depression among caregivers. But the main difference can be explained on the basis of cultural/ethnic values difference. In our set up the treatment of cancer patients is very much expensive but at Government level some tertiary level hospitals providing the treatment to cancer patients free of cost but still caregivers had a strong emotional relation and affiliation especially in this part of the world may be a protective factor for caregivers. We don't have specialized palliative care centers for such patients. However economical problems, lack of members for care giving and other social, psychosocial and interpersonal characteristics makes it a bit difficult for the caregivers not to stay stress free. Socio-economic features of caretakers play the greatest significant role in interpreting the depression, representing 28.5% of the detected unevenness in depression. Regular earnings and duration are appeared to be certainly related with symptoms of depression, these results are in accord to researches done in past. Caretakers having a lesser amount of monthly earnings and deprived sleep, suffer from increased symptoms of depression [20,21]. Even though the tense occasions are unavoidable, it is likely to recognize a caretaker with greater risks of undesirable consequences, evaluate the grade at which the caretaker's life and well-being might be adversely influenced. The interferences which might decrease the undesirable effects of the care giving should be recommended. Recognition of the psychological, behavioral and physiological issues of caring for a subject with cancer offers a tremendous occasion for primary avoidance. The assessment by the primary care physicians is a common barrier in the primary prevention [7]. It is observed that adequate knowledge regarding the illness may reduce the depression rates. A multi-disciplinary approach is needed for the managements of cancer subjects. There are many emotive influences on subjects and their family members during different stages of cancer treatment. Consequently, it is very essential that during every step of treatment, a thorough psycho-social care must be provided to subjects and their family members.

CONCLUSION
It is to be concluded that out of 179 cancer patients 93(52%) diagnosed to have depression while 86(48%) did not have depression. Based on our study findings, it is suggested that depression commonly presented in cancer patients and there is a need to screen all cancer patients for depressive disorder.

CONSENT AND ETHICAL APPROVAL
The study processed after approval of synopsis from CPSP and the ethical committee of Civil Hospital. Informed consent was taken from the patients after explaining the procedure, risks and benefits of the study.