Mental Health Disorders Common Even Before Cancer Diagnosis

Pam Harrison

May 05, 2016

The incidence of common mental disorders starts to increase months before patients are diagnosed with almost any type of cancer except nonmelanoma skin cancer, and higher rates of mental health disorders persist for at least 10 years, a Swedish study shows.

"Our previous work showed highly increased risks of suicide and cardiovascular events shortly after a cancer diagnosis, but we felt that suicide and cardiovascular events likely represented only the tip of the iceberg for the enormous psychological turmoil related to a newly received cancer diagnosis," Donghao LU, MD, Karolinska, Institute, Stockholm, Sweden, told Medscape Medical News.

"Findings from this study support existing guidelines of integrating psychological management into cancer care and call for extended vigilance for multiple mental disorders in cancer care, already from the diagnostic workup onwards."

The study was published online April 28 in JAMA Oncology.

Dr Lu and colleagues identified all persons who had been born in Sweden and were living there in 1990 and followed them from January 1991 through December 2010.

Within this nationwide data set, they identified 326,404 patients who received their first diagnosis of cancer between January 2001 and December 2009. The prediagnostic period was defined as the period from 2 years before the patient received the cancer diagnosis to the time of diagnostic workup; the postdiagnostic period was defined as the period from the date of diagnosis to 10 years thereafter.

The median age of patients when they received their cancer diagnosis was 69 years.

"Patients with cancer and cancer-free individuals were individually matched on year of birth and sex," Dr Lu noted.

All participants were followed from the earliest possible entry in January 1999 to after they had been diagnosed with a mental health disorder, had died, or had emigrated from Sweden as of December 2010, whichever came first.

The diagnosis of a mental health disorder was ascertained using inpatient or outpatient hospital records. The mental health disorders assessed included stress reaction or adjustment disorder; depression; anxiety; substance abuse; and somatoform or conversion disorder.

Alcohol and tobacco use were excluded from substance abuse disorders because both are known risk factors for cancer, the study authors note.

Milder forms of mental symptoms were assessed by tallying the use of relevant psychiatric medications.

"In total, we identified 3355 patients and 10,296 patients with a new diagnosis of the studied mental disorder during the prediagnostic period and the postdiagnostic period, respectively," the authors report.

Ten months before receiving their diagnosis, the relative rate of mental health disorders increased by 10%; it peaked a week after patients had been told they had cancer.

The magnitude of that rate increase dropped rapidly after the initial week, but the incidence of mental health disorders was still higher than in the general population 10 years later.

"Largely similar results were observed for all major cancer types except nonmelanoma skin cancer," the authors write.

"The rate increase was greater for cancers of poor prognosis both before and after diagnosis compared with other cancers (P < .001 for both)."

Dr Lu and colleagues note that the use of relevant psychiatric medications increased 1 month prior to receiving the cancer diagnosis, to 12.2% from 11.7%. Use then peaked at 18.1% around the third month following the diagnosis, after which the use of psychiatric medication declined slowly to 15.4% 2 years after receiving a cancer diagnosis.

Not Surprising

Asked if he was surprised that the increased risk for mental health disorders persisted out to 10 years, Dr Lu indicated that the finding was not surprising to the team.

"Multiple studies have demonstrated a high prevalence of mental disorders, especially depression, both during survivorship and at the end of life among cancer patients," he said.

The rise in mental health disorders almost a year prior to being diagnosed with cancer might suggest that patients were already experiencing symptoms at that time point. Mood disturbances that preceded the cancer diagnosis might also represent the stress of undergoing a diagnostic workup for suspected cancer.

Dr Lu and colleagues saw no real variation in rates of mental health disorders between patients whose cancer was either locally advanced or localized and those whose cancer was metastatic or not metastatic by the end of the first year, at which point patients with the same cancers were compared with each other.

"This pattern lends support to the view that, during the diagnostic workup, the experience of psychological distress does not highly correlate with the severity of a malignancy," the authors state.

"[A] growing body of evidence suggests that the workup for a suspected cancer, regardless of the eventual diagnosis result, clearly affects health and well-being, particularly in terms of the psychosocial spheres of function," the authors write.

Survivorship Expert

Commenting on the study, survivorship expert Karen Syrjala, PhD, Fred Hutchinson Cancer Center, Seattle, Washington, said that the finding that the onset of mood disturbances occurs prior to a cancer diagnosis reflects her own experience with cancer patients.

"I think this finding suggests that people are aware that something physiologic is going on. Perhaps a combination of fatigue and inflammation may be instigating some of that initial mood difficulty," Dr Syrjala told Medscape Medical News.

Nor was she surprised by the fact that mood disorders persist long after a cancer had been treated.

"Cancer does change many people's lives quite profoundly, and it actually can be quite difficult to recover from it along with all the physiologic changes treatment can cause," Dr Syrjala said.

"And while it would seem logical that disfigurement from cancer treatment would perpetuate the distress, we don’t find a very clear association with physical changes or even disfigurement and the level of mood disruption that people have," she added.

"So I think the bigger picture here is, if you are feeling mentally strong and confident, you are likely able to adjust to any physical changes, and if you're not, you are vulnerable, and disfigurement becomes a place that people focus if they are also distressed."

The authors and Dr Syrjala have disclosed no relevant financial relationships.

JAMA Oncol. Published online April 28, 2016. Abstract

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