Comorbidity of posttraumatic stress symptoms and depressive symptoms among gastric cancer patients
Introduction
Gastric cancer was found in 2000 as the fourth most common cancer with an estimated of 880,000 new cases worldwide each year. It was also known as the second most frequent cause of cancer death worldwide with an estimated 650,000 deaths (Stewart and Kleihaus, 2003). The overall survival rate of gastric cancer patients was estimated around 12% in two studies (Cenitagoya et al., 1998, Heise et al., 2009). Due to this high mortality rate, the diagnostic and statistical manual of mental disorders (American Psychiatric Association, 2000) explicitly regarded cancer as a life threatening medical condition that might trigger posttraumatic stress disorder (PTSD). In the context of medical illness and critical care, cancer is considered as a prolonged traumatic event that can improve or exacerbate depending on medical factors. For this instance, cancer is considered a prolonged and continuous trauma (See for example: Jackson et al., 2007, Sukantarat et al., 2007, Tedstone and Tarrier, 2003). Accordingly, it was reported that 0–6% of those suffering from cancer met PTSD criteria when assessed with a diagnostic-structured interview, and 5–19% when assessed with self-administered questionnaires (Kangas et al., 2002).
In addition, depression is the most prevalent mental disorder among different kinds of cancer patients. In a six-wave longitudinal study along one year, it was found that the rate of depression among esophagus or the gastroesophageal junction cancer patients ranged from 27% to 44% (Bergquist et al., 2007). Another study which screened for depression among head and neck cancer patients found that about 20% of the patients suffered from minor or major depression (Katz et al., 2004). These rates were also found among breast cancer patients, where 13–28% were identified as suffering from major depression (Mehnert and Koch, 2007, Ozalp et al., 2008).
Since the appearance of PTSD in the DSM-III (American Psychiatric Association, 1980), depression was found to frequently co-occur with it (Bottomley, 1998, Massie, 2004, Sellick and Crooks, 1999). A large body of clinical and epidemiological research has identified various links between extreme stress, depression, and PTSD (Ginzburg et al., 2010). For example, PTSD and major depressive disorder (MDD) were the most frequent diagnoses at both 3 and 12 months after all-cause physical injury (O’Donnell et al., 2004). A recent study suggests that PTSD is the dominant disorder following traumatic events, which impels the development of comorbid anxiety and depression and endorses a lifetime triple comorbidity that is related to impaired functioning (Ginzburg et al., 2010). Cancer can also result in the comorbidity of PTSD and depression or other mental diseases, due to the grave danger this disease comprises (Akechi et al., 2004). By comorbidity we hereby refer to an elevated risk of having both diagnosis (PTSD and depression) assuming, based on previous studies, that the appearance of PTSD is related to the onset of depression. For example, the risk of having a second mental disorder like depressive disorder (DD) or general anxiety disorder (GAD) in women diagnosed with a cancer-related PTSD was 22 times higher than in patients without cancer-related PTSD (Mehnert and Koch, 2007). The understanding of the nature of this comorbidity among gastric cancer patients is crucial for treatment issues. In a previous study we found that among hospital personnel under prolong and continues stress situation an elevated risk for depression was not necessarily related to an elevated risk for PTSD, but almost in all cases of an elevated risk for PTSD an elevated risk for depression also existed (Palgi et al., 2009). If so, life threatening and prolonged disease, like gastric cancer, is expected to create high risk for clinical level of depression as well as PTSD. The relation between these diagnoses after the cancer onset has pivotal consequences on the participant’s prognosis (Brintzenhofe-Szoc et al., 2009). In this regard, whereas depression is not assumed to be a strong predictor for PTSD, it can be assumed that PTSD would be found as a strong predictor for depression.
Although gastric cancer is one of the most common types of cancer, its relation to psychological distress and depressive symptoms has been understudied, much like other types of abdominal cancer (Clark et al., in press).
Following the literature it was suggested that a life threatening event, as in the case of cancer, would be related to the onset of PTSD and depressive symptoms. Therefore, the aim of this study was to examine the common prevalence of risk for clinical level of PTSD and risk for clinical level of depression among gastric cancer. Additionally, it was assumed that the prediction of risk for clinical level of depression would be significantly higher among those who suffer from risk for clinical level of PTSD. It was hypothesized therefore that 1) Most gastric cancer patients with an elevated risk for clinical level of PTSD would also suffer from an elevated risk for clinical level of depression but not vice versa: Few of those who have an elevated risk for clinical level of depression would have an elevated risk for clinical level of PTSD. 2) An elevated risk for clinical level of PTSD would predict an elevated risk for clinical level of depression beyond demographic factors and cancer-related factors.
Section snippets
Design
This study used a cross-sectional descriptive design.
Sample and settings
Participants were 123 consecutive post treatment gastric outpatients recruited from the oncology unit at Tel Aviv Sourasky Medical Center. Patients were interviewed in the hospital which led to a high response rate of 90% (initial sample n = 136).
Patients were included in the study if they met the following criteria: 1) age above 18; 2) reporting no history of substance abuse or dependence; Exclusion criteria: 1) suffering from other
Results
The demographics of the two groups (with and without a clinical level of PTSD) are shown in Table 1. There were no differences in age, stage of cancer, and length of cancer between participants with and without a clinical level of PTSD. Participants with a clinical level of PTSD were characterized with a lower percentage of women (χ2 = 2.17; p = .03), and married participants (χ2 = 3.42; p = .001), and also reported less emotional support (χ2 = 1.99; p = .046) compared to those without a
Discussion
This study examined the major psychosocial effects of cancer as expressed in the comorbidity of an elevated risk for PTSD and depression. As hypothesized, when an elevated risk of clinical level of PTSD and depression were cross-tabulated, it was found that 94.1% of the participants who suffered from an elevated risk for clinical level of PTSD also suffered from an elevated risk for clinical level of depression. However, only 46.4% of the participants who suffered from an elevated risk for
References (40)
- et al.
Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale)
American Journal of Preventive Medicine
(1994) - et al.
Impact of war stress on posttraumatic stress symptoms in hospital personnel
General Hospital Psychiatry
(2007) - et al.
Mixed anxiety/depression symptoms in a large cancer cohort: prevalence by cancer type
Psychosomatics
(2009) - et al.
Mini-mental state: a practical method for grading the cognitive state of patients for the clinician
Journal of Psychiatric Research
(1975) - et al.
Comorbidity of posttraumatic stress disorder, anxiety and depression: a 20-year longitudinal study of war veterans
Journal of Affective Disorders
(2010) - et al.
Posttraumatic stress disorder following cancer: a conceptual and empirical review
Clinical Psychology Review
(2002) - et al.
The effect of prolong exposure to war stress on the comorbidity of PTSD and depression among hospital personnel
Psychiatry Research
(2009) - et al.
Mind and cancer: does psychosocial intervention improve survival and psychological well-being?
European Journal of Cancer
(2002) - et al.
Posttraumatic growth in cancer: reality or illusion?
Clinical Psychology Review
(2009) - et al.
Posttraumatic stress disorder following medical illness and treatment
Clinical Psychology Review
(2003)