Variability in Anxiety and Depression Over Time Following Diagnosis in Patients with Prostate Cancer

Anxiety and Depression in Patients with Prostate Cancer, at Cancer Diagnosis and after a One-Year Follow-Up

Prostate cancer (PCa) is the most prevalent among men, and psychological symptoms may affect many patients. This study aims to describe the prevalence of probable anxiety and depression before PCa treatments and after one year and to identify sociodemographic and clinical factors associated with these outcomes. Between February 2018 and March 2020, 292 patients recently diagnosed with PCa were recruited at the Instituto Português de Oncologia—Porto. The Hospital Anxiety and Depression Scale (HADS) was used to define probable anxiety and depression (cutoff = 11). The prevalence of probable anxiety remained stable from baseline to one year (7.8% vs. 8.5%, p = 0.866) while there was an increase in probable depression (3.1% vs. 6.8%, p = 0.012). After one year, probable depression persisted in 55.6% of patients with probable depression at baseline and 47.8% of those with probable anxiety at the first assessment had normal anxiety scores. At baseline, anxiety was more frequent among dwellers in rural areas (adjusted odds ratio—aOR, 95%CI: 2.80, 0.91–8.58) and less frequent in patients with body mass index 25–29.9 kg/m² (aOR, 95%CI: 0.33, 0.12–0.91) compared to 18.5–24.9 Kg/m², while those living alone had higher odds of depression (aOR, 95%CI: 6.35, 1.43–28.30). The frequency of anxiety and depression fluctuated during the course of treatment. Monitoring these symptoms would identify the most affected patients, contributing for a better use of mental health services.

Cross-cultural differences in men on active surveillance' anxiety: a longitudinal comparison between Italian and Dutch patients from the Prostate cancer Research International Active Surveillance study

Background

Men diagnosed with localized prostate cancer (PCa) on active surveillance (AS) have shown to cope with anxiety caused by living with an ‘untreated cancer’ and different factors can influence the tolerance level for anxiety in these patients. The present study analyzes Italian (Milan) and Dutch (Rotterdam) men prospectively included in the Prostate cancer International Active Surveillance (PRIAS) trial, aiming to explore whether socio-demographic factors (i.e. age, relationship status, education, nationality) may be relevant factors in conditioning the level of anxiety at AS entry and over time.

Methods

Italian and Dutch men participating in the IRB-approved PRIAS study, after signing an informed consent, filled in the Memorial Anxiety Scale for PCa (MAX-PC) at multiple time points after diagnosis. A linear mixed model was used to assess the relationship between the level of patient’s anxiety and time spent on AS, country of origin, the interaction between country and time on AS, patients’ relationship status and education, on PCa anxiety during AS.

Results

823 MAX-PC questionnaires were available for Italian and 307 for Dutch men, respectively. Median age at diagnosis was 64 years (IQR 60–70 years) and did not differ between countries. On average, Dutch men had a higher total MAX-PC score than Italian men. However, the level of their anxiety decreased over time. Dutch men on average had a higher score on the PCa anxiety sub-domain, which did not decrease over time. Minimal differences were observed in the sub-domains PSA anxiety and fear of recurrence.

Conclusion

Significant differences in PCa anxiety between the Italian and Dutch cohorts were observed, the latter group of men showing higher overall levels of anxiety. These differences were not related to the socio-demographic factors we studied. Although both PRIAS-centers are dedicated AS-centers, differences in PCa-care organization (e.g. having a multidisciplinary team) may have contributed to the observed different level of anxiety at the start and during AS.

Trial registration This study is registered in the Dutch Trial Registry (www.trialregister.nl) under NL1622 (registration date 11-03-2009), ‘PRIAS: Prostate cancer Research International: Active Surveillance—guideline and study for the expectant management of localized prostate cancer with curative intent’.

Anxiety, depression and urological cancer outcomes: A systematic review

PURPOSE

The interplay between physical and mental aspects of a cancer diagnosis are well recognised. However, little consensus exists on the impact of depression and anxiety on urological cancer outcomes. Therefore, this systematic review aimed to investigate the relationship between these conditions and functional or oncological outcomes in urological malignancy.

MATERIALS AND METHODS

A systematic search was conducted using PubMed, Embase, PsycINFO and Global Health databases up to June 2020. Studies evaluating the relationship of anxiety and depression disorders or symptoms on functional and mortality outcomes were included. Outcome measures included validated urinary, sexual, body image questionnaire scores and all-cause or disease-specific mortality.

RESULTS

Of 3,966 studies screened, 25 studies with a total of 175,047 urological cancer patients were included. Significant anxiety and depressive symptoms and disorders were found to impact functional outcomes in several cancer types. A consistent negative association existed for sexual function in prostate, testicular and penile cancer patients. Additionally, poorer urinary function scores were seen in prostate cancer, with increased body image issues in testicular and prostate cancer. Importantly, both overall and disease-specific mortality outcomes were poorer in bladder and prostate cancer patients.

CONCLUSIONS

Co-existing depression and anxiety appears to be negatively associated with functional and mortality outcomes in urological cancers. This appears especially evident in male cancers, including prostate and testicular cancer. Although not proving causation, these findings highlight the importance of considering mental wellbeing during follow-up for early recognition and treatment. However, current evidence remains heterogenous, with further studies required exploring patients at risk.

The Anxiety Depression Pathway Among Men Following a Prostate Cancer Diagnosis: Cross-Sectional Interactions Between Anger Responses and Loneliness

Anger has been a largely neglected emotion in prostate cancer research and intervention. This paper highlights the role of anger in the anxiety depression pathway among men with prostate cancer, and whether its impact is dependent on loneliness. Data are presented from a sample of men with prostate cancer (N = 105, M = 69.12 years, prostatectomy = 63.8%) and analysed using conditional process analysis. Dimensions of anger were evaluated as parallel mediators in bi-directional anxiety and depression pathways. Loneliness was evaluated as a conditional moderator of identified significant mediation relationships. Moderate severity depression (16.5%) was endorsed more frequently than moderate severity anxiety (8.6%, p = .008), with 19.1% of the sample reporting past two-week suicide ideation. Consistent with hypotheses, anger-related social interference (but not other dimensions of anger) significantly mediated the anxiety-depression pathway, but not the reverse depression-anxiety pathway. This indirect effect was conditional on men experiencing loneliness. Sensitivity analyses indicated the observed moderated mediation effect occurred for affective, but not somatic symptoms of depression. Findings support anger-related social interference (as opposed to anger frequency, intensity, duration or antagonism) as key to explaining the previously established anxiety-depression pathway. Results underscore the need for enhanced psychosocial supports for men with prostate cancer, with a particular focus on relational aspects. Supporting men with prostate cancer to adaptively process and manage their anger in ways that ameliorate negative social consequences will likely enhance their perceived social support quality, which may in turn better facilitate post-diagnosis recovery and emotional adjustment.

Active surveillance for favorable-risk prostate cancer: Is there a greater psychological impact than previously thought? A systematic, mixed studies literature review

OBJECTIVE

Active surveillance (AS) allows men with favorable-risk prostate cancer to avoid or postpone active treatment and hence spares potential adverse effects for a significant proportion of these patients. Active surveillance may create an additional emotional burden for these patients. The aim of the review was to determine the psychological impact of AS to inform future study in this area and to provide recommendations for clinical practice.

METHODS

Studies were identified through database searching from inception to September 2015. Quantitative or qualitative noninterventional studies published in English that assessed the psychological impact of AS were included. The Mixed Methods Appraisal Tool was used to assess methodological quality.

RESULTS

Twenty-three papers were included (20 quantitative and 3 qualitative). Quantitatively, the majority of patients do not report psychological difficulties; however, when appropriateness of study design is considered, the conclusion that AS has minimal impact on well-being may not be accurate. This is due to small sample sizes, inappropriately timed baseline, and inappropriate/lack of comparison groups. In addition, a mismatch in outcome was noted between the outcome of quantitative and qualitative studies in uncertainty, with qualitative studies indicating a greater psychological impact.

CONCLUSIONS

Because of methodological concerns, many quantitative studies may not provide a true account of the burden of AS. Further mixed-methods studies are necessary to address the limitations highlighted and to provide clarity on the impact of AS. Practitioners should be aware that despite findings of previous reviews, patients may require additional emotional support.

Randomized, double-blind, placebo-controlled study of methylphenidate for the treatment of depression in SSRI-treated cancer patients receiving palliative care

OBJECTIVE

To determine the effectiveness of methylphenidate for depression treatment in patients with advanced cancer.

DESIGN

An 18-day randomized, double-blind, placebo-controlled clinical trial of methylphenidate for treatment of depression in selective serotonin reuptake inhibitor-treated patients with advanced cancer in hospice or receiving palliative care. The primary outcome was depression remission, defined as a ≥50% reduction in score on the Montgomery-Asberg Depression Rating Scale.

RESULTS

Among 47 enrolled participants, 34 were randomized. At study day 18, 85% of the methylphenidate and 60% of the placebo group were in depression remission (P = .22). Mean time to depression remission was 10.3 days [standard error (SE) 1.8] in the methylphenidate and 8.1 (SE 1.3) in the placebo group (P = .48). The mean baseline score for the Hospital Anxiety and Depression Scale (HADS) was 10.4 in each group and decreased by 3.6 (SE 1.1) in the methylphenidate and 2.3 (SE 1.2) in the placebo group (P = .51) by day 18. Once in remission, 1 methylphenidate and 5 placebo participants relapsed to depression (P = .18). There was no difference in mortality between the groups during the trial. Trial results were limited by small sample size attributed to difficulties in recruiting terminally ill patients.

CONCLUSIONS

This trial failed to demonstrate that methylphenidate treatment in selective serotonin reuptake inhibitor-treated patients had a significant effect on depression remission in patients with advanced cancer. This study underscores the difficulties in conducting trials for symptom management in patients with shortened life expectancy.

Mode of prostate cancer detection is associated with the psychological wellbeing of survivors: results from the PiCTure study

PURPOSE

Many men with prostate cancer are asymptomatic, diagnosed following prostate specific antigen (PSA) testing. We investigate whether mode of detection, i.e. 'PSA detected' or 'clinically detected', was associated with psychological wellbeing among prostate cancer survivors.

METHODS

A cross-sectional postal questionnaire was administered in 2012 to 6559 prostate cancer (ICD10 C61) survivors up to 18 years post-diagnosis, identified through population-based cancer registries in Ireland. Psychological wellbeing was assessed using the Depression Anxiety Stress Scale-21. Logistic regression was used to investigate associations between mode of detection and depression, anxiety and stress, adjusting for socio-demographic and clinical confounders.

RESULTS

The response rate was 54 % (3348/6262). Fifty-nine percent of survivors were diagnosed with asymptomatic PSA-tested disease. Prevalence of depression (13.8 vs 20.7 %; p < 0.001), anxiety (13.6 vs 20.9 %; p < 0.001) and stress (8.7 vs 13.8 %; p < 0.001) were significantly lower among survivors diagnosed with PSA-detected, than clinically detected disease. After adjusting for clinical and socio-demographic factors, survivors with clinically detected disease had significantly higher risk of depression (odds ratio (OR) = 1.46 95 % CI 1.18, 1.80; p = 0.001), anxiety (OR = 1.36 95 % CI 1.09, 1.68; p = 0.006) and stress (OR = 1.43 95 % CI 1.11, 1.85; p = 0.006) than survivors with PSA-detected disease.

CONCLUSIONS

These findings contribute to the ongoing debate on benefits and risks of PSA testing and may be considered by policy makers formulating population-based prostate cancer screening policies. The relatively high prevalence of negative psychological states among survivors means that a 'risk-adapted approach' should be implemented to screen survivors most at risk of psychological morbidity for psychological health, and mode of detection could be considered as a risk stratum.

The Hot Flush Beliefs and Behaviour Scale for Men (HFBBS-Men) undergoing treatment for prostate cancer

OBJECTIVE

Hot flushes and night sweats (HFNS) are commonly experienced by men receiving treatment for prostate cancer. Cognitive behavioural therapy (CBT) has been found to be an effective treatment for HFNS in women, but cognitions and behavioural reactions to HFNS in men are under-researched. This study describes the development of the HFNS beliefs and behaviour scale for men.

METHODS

HFNS beliefs and behaviour items were generated from a qualitative study, from pilot interviews with men with prostate cancer and HFNS, and from scales used for women. 118 men with prostate cancer, aged above 18, English-speaking, who had minimum of seven HFNS weekly for at least 1 month, completed the initial measure, and measures of HFNS frequency, problem rating, anxiety and depression (HADS). Principal components analyses with orthogonal rotation determined the most coherent solution.

RESULTS

Exploratory factor analysis culminated in a 17-item HFNS beliefs and behaviour scale for men (HFBBS-Men) with three subscales: (1) HFNS social context and sleep, (2) Calm/Acceptance, (3) Humour/Openness. The subscales had reasonable internal consistency (Cronbach alpha 0.56-0.83). Validity was supported, by correlations between subscale 1, HFNS frequency, problem-rating and mood; men with locally advanced cancer more likely to adopt Calm/Acceptance and those with metastatic cancer Humour/Openness.

CONCLUSIONS

Preliminary analysis of the HFBBS-Men suggests that it is a psychometrically sound instrument, grounded in men's experiences. As a measure of cognitive and behavioural reactions to HF/NS, the HFBBS-Men should increase understanding of the mediators of outcomes of psychological interventions, such as CBT.

Diagnosing 'male' depression in men diagnosed with prostate cancer: the next step in effective translational psycho-oncology interventions?

BACKGROUND

Depression in men diagnosed with prostate cancer is associated with several adverse outcomes. However, some data suggest that standard methods of assessing depression in males via the criteria for Major Depressive Disorder (MDD) may omit several extra key symptoms of male depression. Therefore, this study tested the comparative effects of standard MDD-based diagnostic criteria for depression and criteria for 'male depression' in a sample of men diagnosed with prostate cancer.

METHOD

191 men diagnosed with prostate cancer completed a postal survey questionnaire containing questions about background variables, the Patient Health Questionnaire-9 for depression (PHQ9) and the Gotland Male Depression Scale (GMDS). Comparisons were made of the relative prevalence of depression according to these scales, plus a scale that combined the PHQ9 and GMDS extra items for male depression

RESULTS

Although there were significant correlations between total PHQ9 and GMDS scores, over one-third of variance in the GMDS was not accounted for by the PHQ9, and sensitivity of the PHQ9 against the GMDS showed that about 24% of those patients identified as depressed on the GMDS would not be similarly identified on the PHQ9. Different prevalence rates from the two scales suggested that they were assessing different sets of symptoms of depression. A combined PHQ9-GMDS scale of 15 items was used to produce a profile of male depression in these patients.

CONCLUSION

Adequate and reliable assessment of depression in men diagnosed with prostate cancer may require use of additional symptoms to those listed for MDD, and treatment planning and delivery could be more precise and effective using this methodology.

A longitudinal study of anxiety, depression and distress as predictors of sexual and urinary quality of life in men with prostate cancer

OBJECTIVE

To evaluate the prevalence of depression, anxiety and distress among active surveillance (AS) and radical prostatectomy (RP) patients. To evaluate the impact of these symptoms at baseline on urinary and sexual quality of life at follow-up.

PATIENTS AND METHODS

Patients managed with AS or RP who completed validated questionnaires assessing levels of depression, anxiety, distress and urinary (UF) and sexual function (SF) and bother comprised the final analytic cohort. These measures were completed at baseline, within 1 year, and between 1 and 3 years from baseline. Mixed model repeated measures analysis was used to examine associations between mental health at baseline and sexual and urinary outcomes in a subset of RP patients with complete follow-up.

RESULTS

Among 679 men who comprised the study cohort, baseline prevalence of moderate or higher levels of depression or anxiety were low (<5%), while levels of mild depression or anxiety ranged from 3-16% over time. Baseline levels of elevated distress ranged from 8-20%. Among men who provided data at baseline and follow-up, there were no significant differences between AS and RP patients in the proportion of men with elevated levels of depression, anxiety, or distress. Among 177 men who underwent RP and had complete follow-up moderate or higher levels of depression or anxiety appeared to be associated with post-treatment SF and bother, while elevated levels of distress were associated with post-treatment UF.

CONCLUSION

Moderate or higher levels of depression or anxiety were low in men with localised prostate cancer but were associated with sexual outcomes, while elevated distress was associated with urinary outcomes. Greater attention should be paid to mental health symptoms among men with prostate cancer, as these symptoms may be associated with quality of life outcomes.

Do patient-reported androgen-deprivation therapy side effects predict anxiety and depression among prostate cancer patients undergoing radiotherapy? Implications for psychosocial therapy interventions

Antiandrogen therapy (AAT) is a common adjunct treatment for prostate cancer (PCa) patients and has shown significant benefits to long-term outcomes from radiation or surgery. Although AAT has some adverse side effects and data from breast cancer patients indicate that such side effects from hormonal therapies may contribute to anxiety and depression and may also hinder AAT treatment compliance, this issue has not been investigated within a sample of PCa patients. This study explores the incidence of AAT side effects in a sample of PCa patients, the links between those side effects and anxiety and depression, the possible ways in which these factors may contribute to AAT treatment noncompliance in PCa patients, and how psychosocial treatments might be developed to attend to this issue. 147 PCa patients completed questionnaires on demographic factors, treatment compliance, AAT side effects, anxiety and depression. About 18% of the sample reported AAT side effects, and there was a significant association between the presence of side effects and elevated anxiety and depression scores. Increased frequency of side effects was significantly associated with elevated anxiety, but not depression. The most powerful relationship between AAT side effects and anxiety-depression was for the subfactors of (1) Fatigue, Pain and Discomfort, and (2) Psychological Agitation and Pessimism. Although fatigue, pain, and discomfort may be outcomes of the hormonal treatment itself, psychological agitation and pessimism represent a discrete psychological pathway between AAT side effects and anxiety and depression and (potentially) treatment noncompliance. Methods of addressing patients' loss of optimism in their treatment outcomes are discussed.

Stage of disease progression moderates the association between social support and depression in prostate cancer survivors

This study was designed to test the association between social support and depression at different stages of disease progression in men with prostate cancer.Seventy-one men with prostate cancer completed measures of social support and depression three times: T1 (at baseline), T2 (T1 + 2 months), and at T3 (T1 + 4 months). Stage of disease progression was significantly associated with increasing symptoms of depression. Stage of disease progression also moderated the association between social support and depression. Social support was associated with a subsequent worsening of depression for men with early-stage disease. For men with more advanced prostate cancer, social support was associated with improvements in subsequent depression. Social support has different prognostic value for psychological distress among men with prostate cancer depending upon the stage of their disease.

The role of Melancholia in prostate cancer patients' depression

BACKGROUND

Although it is well established that prostate cancer (PCa) patients are more likely to experience clinical depression than their age-matched non-prostate cancer peers, and that such depression can have negative effects upon survival, little is known about the underlying nature of the depressive symptomatology that these men experience. In particular, the incidence of melancholic symptoms of depression, which are signs of increased risk of suicide and resistance to treatment, has not previously been reported in PCa patients. The present study aimed to measure the incidence and nature of Melancholia in PCa depression.

METHOD

A sample of 507 PCa patients in Queensland, Australia, completed anonymous and confidential questionnaires about their background, treatment status, and depression. Data were analysed to select depressive symptoms that were part of the definition of Melancholia vs those which were not. Regression was used to determine the links between Melancholia and overall depressive status, and factor analysis revealed the underlying components of Melancholia, which were mapped over time since diagnosis for 3 years.

RESULTS

Psychometric data were satisfactory. Melancholia significantly predicted depressive status for the most depressed subset of patients, but not for the total sample. Melancholia was factored into its components of Anhedonia and Agitation, and the first of these was more powerful in predicting Melancholia. Variability over the 3 years following diagnosis was noted for each of these two components of Melancholia.

CONCLUSIONS

The strong presence of Melancholia in the depressive symptomatology of this sample of PCa patients suggests that some forms of treatment for depression may be more likely to succeed than others. The dominance of Anhedonia and Agitation over other symptoms of Melancholia also holds implications for treatment options when assisting these men to cope with their depression.

Pretreatment depressive symptoms and treatment modality predict post-treatment disease-specific quality of life among patients with localized prostate cancer

PURPOSE

This study examines the prevalence of depressive symptoms before prostate cancer treatment and explores associations among pre-treatment depressive symptoms and post-treatment disease-specific QOL, controlling for treatment modality, and demographic and clinical covariates.

MATERIALS AND METHODS

A case series of patients diagnosed with localized prostate cancer (T1-2N0M0) at a comprehensive cancer center was assessed. Of the 1,370 eligible patients, 869 (63.34%) completed questionnaires at diagnosis (baseline) and 6 months following treatment. Patients were treated with surgery (16.8%), brachytherapy (27.6%), or external beam radiation (EBRT; 55.6%). Depressive symptoms and disease-specific QOL were assessed with established measures (i.e., Center for Epidemiologic Studies Depression Scale (CES-D); sexual adjustment questionnaire (SAQ); and the American Urological Association symptom index).

RESULTS

A fifth of the sample (19.7%) reported clinically elevated levels of depressive symptoms at baseline. The proportion of clinically elevated levels of baseline depressive symptoms was higher among surgery patients compared with patients treated with brachytherapy or external beam radiation. Depressive symptoms at baseline and treatment modality significantly predicted sexual and urinary dysfunction, related bother, activity limitation due to urinary dysfunction at 6 months, controlling for, age, PSA level, Gleason score, relevant baseline indicators of sexual and urinary dysfunction, related bother, and activity limitation (P < 0.05).

CONCLUSIONS

Pretreatment depressive symptoms and treatment modality predict QOL after PrCa treatment. Health care providers should be sensitive to the display of depressive symptoms before PrCa treatment and consider preventative interventions, including preparing patients for the changes in disease-specific QOL and related bother following prostate cancer treatment.