Prognostic Factors of Depression in Patients With Cancer Undergoing Chemotherapy and Radiotherapy


Zahra Shayan 1 , Zahra Shahkolahi 2 , Niloofar Ahmadlo 3 , Leila Vafaee 4 , Leila Shayan 5 , *

1 Department of Community Medicine, The Medical School, Shiraz University of Medical Sciences, Shiraz, IR Iran

2 Department of Pediatric and Neonatal Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, IR Iran

3 Department of Radiation Oncology, Shiraz University of Medical Sciences, Shiraz, IR Iran

4 Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, IR Iran

5 Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran

How to Cite: Shayan Z, Shahkolahi Z, Ahmadlo N, Vafaee L, Shayan L. Prognostic Factors of Depression in Patients With Cancer Undergoing Chemotherapy and Radiotherapy, Health Scope. 2014 ; 3(4):e18609. doi: 10.17795/jhealthscope-18609.


Health Scope: 3 (4); e18609
Published Online: November 26, 2014
Article Type: Research Article
Received: March 1, 2014
Accepted: April 16, 2014


Background: Cancer is one of the chronic diseases, which increases the risk of depression. The main causes of depression among these patients are pain due to metastasis, limited social activities and disability.

Objectives: The aim of this research was to determine the prevalence of depression and relevant factors in patients with cancer referred to Shiraz Nemazee hospital for chemotherapy and radiotherapy.

Patients and Methods: This was a cross-sectional study on 260 patients with cancer. To diagnose depression, the Beck questionnaire was used. To analyze data, logistic regression was more appropriate than the univariate analysis, because it simultaneously considers the effects of each of the predictors.

Results: The prevalence of depression was 47.4%. There was a statistically significant association between depression and income (P < 0.001), family history of depression (P = 0.001), satisfaction with her or his condition (P < 0.001), disease duration (P < 0.001) and education (P = 0.025). Logistic regression revealed that the main effective factors were disease duration more than five years (OR = 5.9, P = 0.013), lack of satisfaction with her or his condition (OR = 19.6, P < 0.001) and family history of depression (OR = 2.4, P = 0.049).

Conclusions: Consultation sessions are necessary to reduce depression of patients with cancer. Since depression may reduce quality of life and reaction to treatment, curing depression may relatively reduce side effects of disease for patients to have less pain and problems.

1. Background

Depression is a very common disorder around the world occurred in all ages and races, both in women and men. Cancer is one of the chronic diseases, which increases the risk of depression in individual. The main causes of depression in patients with cancer are pain due to metastases, decreased social activity and disability (1, 2). Depression has a negative effect on quality of life, duration of hospitalization and outcome of treatment of patients with cancer. Therefore, evaluation and treatment of this disorder in these patients are very essential. In addition to common medical problems and distress, depressed person feels that he or she is ostracized by his or her family and community. Depression is known as a risk factor, which reduces survival in patients with cancer and is an important factor to reject treatment of these patients (3-6). Rajabizadeh et al. reported that the prevalence of depression in 110 patients with cancer was 67.3% in Kerman city (7). Tavoli et al.’s study showed that the prevalence rates of depression and anxiety were 57% and 47.2%, respectively in colon and stomach cancers (8). The study of Malekian on 173 patients with cancer showed that the prevalence of depression was 32.9% and it was more common in woman aged 50 to 65 years (9). The results of Zheng’s study in Shanghai with 7967 patients with cancer reported the prevalence of depression as 24.74% (10). In another study conducted by Chen and Zheng on 1400 women with breast cancer, almost 26% of them had moderate to severe depression and 13% had clinical depression 18 months after diagnosis of their disease (11). The study of So showed the prevalence of depression as 34.4% in women with breast cancer in Hong Kong (12). Nelson et al.’s study on 716 men with prostate cancer showed that after controlling the disease stage, there was a significant association between depression and use of hormone therapy, time of disease diagnosis, physical and social health and age (13). It seems that treatment of cancer, either chemotherapy or radiotherapy is effective on depression rate in patients with cancer. Pandey et al.’s study on 117 patients with cancer revealed that 23% of patients receiving chemotherapy had depression (14). Cazzaniga et al. showed that radiotherapy in patients with cancer causes depression and anxiety. Nevertheless, they stated that providing patients with information and their own satisfaction decreased anxiety and depression following radiotherapy (15). Souza et al. studied 102 patients with cancer under chemotherapy and observed that 10.8% and 1.9% of them had moderate and severe depression, respectively (16). Mashhadi et al. studied 400 patients with cancer after diagnosis of malignancy and before chemotherapy or radiotherapy and reported the prevalence of depression as 26.5% (17). Therefore, due to the high prevalence of depression in patients with cancer and its effects on cancer and disease process and response to treatment, researchers suggested experts and physicians to use counseling sessions and antidepressants drug as one of the main components of treatment for patients with cancer (18, 19).

2. Objectives

The aim of this study was to examine the prevalence of depression and identify predictor variables of depression in patients with cancer undergoing chemotherapy or radiotherapy using logistic regression.

3. Patients and Methods

In this cross-sectional study, 260 samples were selected with a confidence level of 95%, precision of 6% (d = 1.5p) and prevalence of 40% depression. Patients were those referred to chemotherapy and radiotherapy wards in Shiraz Nemazee hospital in 2007. They entered the research until the number of samples reached 260. Patients who agreed to participate in this research were selected. Data was collected using a series of forms completed during face-to-face interviews. The first part of the questionnaire included demographic characteristics and medical condition and the second instrument was Persian version of the Beck depression test. Then, the questionnaire was read by the investigator and the patient could choose the best answer. If the patient was unaware of his or her disease status, the disease data was extracted from his or her records. Beck depression test is one of the most common and reliable psychological tests applicable in all classes and social environment and is not dependent on culture. In this test, different aspects of depression can be evaluated. It contains 21 items, each with four possible responses. Each response is assigned a score ranging from 0 to 3, indicating different levels of depression symptoms. The sum of individual item scores provided a total dimensional score of depression as the outcome variable. Intensity of depression can be classified as 0-10 without depression, 11-15 borderline symptoms, 16-20 slight depression, 21-30 moderate depression, 31-40 severe depression and more than 40 as very severe depression. Scores above 15 denote depression (7). Besides, independent variables included gender, age, marital status, education, location, income status, satisfaction from her or his condition, family history of depression, type of cancer, knowledge about the disease, type of treatment and duration of cancer. Data analysis was performed using SPSS software, version 16 (SPSS Institute, Chicago, Illinois). Univariate and multivariate analysis are two famous methods of statistical analysis. Univariate analysis involves a single variable while multivariate analysis involves a dependent variable and more than one independent variable. Logistic regression is one of the multivariate analyses used when the dependent variable is a dichotomy.In univariate analysis, we cannot calculate odds ratio when the independent variables are continuous, but it is possible in logistic regression. Also, the multivariate findings are more relevant due to controlling the effects of each of the predictors simultaneously. We used t-test and Chi-square test for univariate analysis. After finding significant variables, we used logistic regression to determine variables affecting depression and to obtain odds ratio. P value below 0.05 was considered as statistically significant.

4. Results

Totally, 260 patients with cancer referred for chemotherapy and radiotherapy in Nemazee hospital in 2007. Eleven patients (4%) were excluded due to incomplete questionnaires. The reliability of the depression questionnaire was 0.85 using Cronbach’s alpha coefficient. From 249 patients, 88 were male (35.3%) and 161 female (64.7%); their age ranged from 18 to 87 years with a mean ± SD of 49.08 ± 14.7 years. According to classification of depression score, 85 patients (34.1%) had normal results, 46 (18.5%) borderline depression, 46 (18.5%) slight depression, 52 (20.9%) moderate depression, 15 (6%) severe depression and five (2%) very severe depression. Generally, a score above 15 is considered as depression. Accordingly, the prevalence of depression was 47.4%. Using univariate analysis, it was found that there was a statistically significant association between depression and education (p = 0.025), income status (P < 0.001), family history of depression (P = 0.001), satisfaction from his or her condition (p < 0.001) and duration of cancer (P = 0.001). Nonetheless, there was not a statistically significant association between depression and gender, age, marital status, type of cancer, knowledge about the disease and type of treatment (Tables 1, 2). After entering significant variables in logistic regression model, the results showed that 70% of cases were classified correctly as depressed and non-depressed groups, which may seem good. Besides, the results indicated that logistic regression is appropriate for data (P = 0.577), showing that the model prediction is not significantly different from observed values. Of variables entered logistic regression, only satisfaction from his or her condition, family history of depression and duration of cancer were good predictors of depression in patients. Odds depression in patients with a family history of depression was 4.2 times more than those without family history of depression (OR = 2.4, P = 0.05). Odds depression in patients with disease duration more than five years was 9.5 times higher than those with disease duration of less than one year (OR = 5.9, p = 0.013). In addition, odds depression in patients who were not satisfied with the current situation was 19.6 times higher than those who were satisfied (OR = 19.6, P < 0.001) (Table 3).

Table 1. The Prevalence of Depression by Demographic Characteristics a
VariablesDepressionTotalP Value
Male35 (39.8)53 (60.2)88 (100)
Female83 (51.6)78 (48.4)161 (100)
Marital status0.902
Single13 (48.1)14 (51.9)27 (100)
Married96 (48.0)104 (52.0)200 (100)
Divorced or widowed9 (42.9)12 (57.1)21 (100)
Illiterate27 (44.3)34 (55.7)61 (100)
Primary39 (63.9)22 (36.1)61 (100)
guidance schooling16 (45.7)19 (54.3)35 (100)
High school20 (44.4)25 (55.6)45 (100)
university15 (32.6)31 (67.4)46 (100)
Urban90 (47.9)98 (52.1)188 (100)
Rural28 (45.9)33 (54.1)61 (100)
Income statusP < 0.001
Desirable or highly desirable21 (31.8)45 (68.2)66 (100)
Relatively desirable52 (44.1)66 (55.9)118 (100)
Undesirable42 (67.7)20 (32.3)62 (100)
Satisfaction from his or her conditionP < 0.001
Completely satisfied20 (30.8)45 (69.2)65 (100)
Somewhat satisfied67 (44.7)83 (53.3)150 (100)
Not satisfied31 (93.9)2 (6.3)33 (100)
Family history of depression0.001
No89 (42.6)120 (57.4)209 (100)
Yes28 (71.8)11 (28.2)39 (100)

aData are presented as No. (%).

Table 2. The Prevalence of Depression by Clinical and Therapeutic Variables a
VariablesDepressionTotalP Value
Knowing The Disease0.674
No42 (45.7)50 (54.3)92 (100)
Yes76 (48.4)81 (51.6)157 (100)
Type of Treatment0.172
Chemotherapy5 (45.5)6 (54.5)11 (100)
Radiotherapy31 (38.8)49 (61.3)80 (100)
Chemotherapy and radiotherapy81 (51.6)76 (48.4)157 (100)
Type of Cancer0.312
Breast43 (46.7)49 (53.3)92 (100)
Brain9 (33.3)18 (66.7)27 (100)
Head and neck17 (44.7)21 (55.3)38 (100)
Others48 (52.7)43 (47.3)91 (100)
Duration of Cancer0.001
< 1 year52 (39.4)80 (60.6)132 (100)
1 to 5 year49 (51.6)46 (48.4)95 (100)
> 5 year15 (83.3)3 (16.7)18 (100)

aData are presented as No. (%).

Table 3. Determination of Odds Ratio of Depression Using Significant Variables
VariablesOdds Ratio95% Confidence IntervalP Value
Lower BoundUpper Bound
University a1.0
High school0.90.332.380.81
guidance schooling1.20.423.300.76
Income status
Desirable or highly desirable a1.0
Relatively desirable1.40.652.880.4
Satisfaction from his or her condition
Completely satisfied a1.0
Somewhat satisfied1.50.753.090.24
Not satisfied19.63.8899.10.001
Family history of depression
No a1.0
Duration Of Cancer
< 1 year a1.0
1 to 5 years1.40.702.530.33
> 5 years5.914.424.20.013

aReference group.




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