The Prevalence, associated factors, and predicted variables of
depression and Anxiety in Qatari cancer patients: A Cross-Sectional
Study.
Majid Ali Al Abdulla(1), Shuja Reagu(1), Moza Alishaq(2) , Noora Al Hammadi(3),
Mohammed Hassan Elkordy(2) , Hafedh Ghazouani(2), Ahmed H. Assar(1).
1. Dr. Majid Ali Al Abdulla, Dr. Shuja Reagu, Dr. Ahmed H. Assar - Senior Consultant, Mental
Health Services, Hamad Medical Corporation
2. Dr. Moza Alishaq - Deputy Chief of Corporate Quality improvement , Patient Safety and Risk
Management.
3. Dr. Noora Al Hammadi - Senior Consultant, Oncology, Hamad Medical Corporation
4. Dr.Mohammed Hassan Elkordy - Clinical Research Analyst, Corporate Quality Improvement and
Patient Safety, Hamad Medical Corporation.
5. Hafedh Ghazouani - Quality Reviewer, Corporate Quality and Patient Safety, Hamad Medical
Corporation.
6. Dr. Ahmed H. Assar – Clinical Fellow , Mental Health Services, Hamad Medical Corporation.
INTRODUCTION:
Cancer is undoubtedly one of the biggest health challenges we face today, being the second leading cause of death
worldwide. Recent estimates suggest a significant number of deaths have been reported. In 2018, this devastating
disease tragically killed approximately 9.6 million people. The fact that it accounts for one in three deaths in developed
countries is shocking [1-2].
Qatar National Cancer Registry data shows Qatar is not immune to this trend. This data analysis provides a clear
picture of cancer prevalence in Qatar, with an increase of around 1,500 new cancer diagnoses per year. This number
will likely increase due to various lifestyle factors, such as increased life expectancy and an aging population. In 2019,
the rate of this disease had increased to 17.97 cases per 100,000. This worrying statistic also implies a mortality rate
of approximately 7% [3].
If a person is diagnosed with cancer, they may be more vulnerable to mental disorders than healthy people due to the
significant psychological impact. The disease can significantly impact mental health and manifest itself in a variety
of ways. This phenomenon could be caused by the many difficulties that cancer brings. The sudden onset of cancer
can cause patients to experience a range of intense emotions, including shock, disbelief, anger, depression, anxiety,
and deep sadness [4-5].
About a third of cancer patients suffer from mental disorders, the most common being depression. Failure to address
these mental health issues can result in serious consequences such as lower treatment adherence, lower chances of
survival, higher healthcare costs, and a worsening of the patient's overall quality of life [6]. Literature from developed
countries suggests that cancer patients have higher rates of depression and anxiety compared to the general population
and that comorbidity with depression may lead to increased morbidity and worse cancer outcomes [7-8].
Even though depression and anxiety are the most common complications in patients with cancer, they are frequently
overlooked. Furthermore, the psychosocial requirements of patients with cancer, whether they have a mental illness
history or not, are frequently overlooked during cancer therapy, which is primarily focused on addressing somatic
symptoms and side effects. Earlier detection and improved treatment of cancer make people live longer with cancer.
[9-10]
STUDY OBJECTIVE:
Our study aims to investigate the Prevalence of depression and anxiety among cancer patients in Qatar. In addition,
we analyse associated sociodemographic and clinical factors and identify variables that predict the severity of these
diseases.
METHODS & MATERIALS:
Study Design:
We conducted a comprehensive cross-sectional observational study in Doha, Qatar.
Study Period and Area:
The study was conducted at the National Centre for Cancer Care and Research (NCCCR) outpatient clinic from
February 11, 2023, to March 30, 2023.
Description of Study Participants and Samples
We adhered to the sample size guidelines of the World Health Organization in our prevalence study (Lwanga and
Lemeshow, 1991) [12]. Our random sampling method resulted in a 95% confidence level with a standard deviation of
0.5 and a margin of error rate of 5%. As a result, based on these parameters, we determined that a minimum of 347
participants per group was required. We targeted individuals 18 years of age for our survey. We collected and collected
600 responses.
Consequently, 67 were declined, 33 were incomplete, and 26 needed more information. Five hundred forty-one people
were in the study, some of whom had non-cancerous haematological conditions. They were analyzed and evaluated
501 eligible individuals. Our data collection process was optimized by enlisting the expertise of five skilled and
experienced nursing researchers. They conducted survey interviews utilizing cutting-edge state-of-the-art notebook
computers and electronic pens, all seamlessly integrated with computer touch-screen technology. The questionnaire
took just ten minutes to finish. Our team has reviewed and cross-referenced all the provided data to ensure accuracy.
We removed any records with incomplete data as well as any information that was missing. The data was meticulously
documented using an Excel spreadsheet and coding techniques to ensure accuracy. We conducted a thorough analysis
of the integrity of the data to determine whether it is suitable for further research.
The data collection tool
The study was structured around a relational screening model utilizing the Patient Health Questionnaire-9 (PHQ-9)
and General Anxiety Disorder-7 (GAD-7).
Patient Health Questionnaire-9 (PHQ-9)
The PHQ-9 is a self-report tool that can be used to identify depression and the severity of its symptoms [13]. The
range of possible responses is from "not at all" to "nearly every day." The total scores on the questionnaire range from
zero (0) to 27, with higher scores indicating more severe depressive symptoms. The PHQ-9 consists of nine main
questions and one supplementary question. The answer to each question is scored from 0 to 3, depending on the
incidence of a given symptom in the past two weeks (3—most frequent symptoms). The maximum score was 27,
indicating the highest severity of depressive symptoms. The norm is a score of <5; the range of 5–9 means mild
depression, 10–14 moderate depression, 15–19 moderately severe depression, and 20–27 severe depression
(Tomaszewski et al., 2011) [14].
General Anxiety Disorder-7(GAD-7)
The GAD-7 is a seven-item self-report instrument used to assess the severity of GAD and general anxiety symptoms
[14]. Each item asks the individual to rate the severity of their symptoms over the past two weeks using a four-point
Likert scale with possible responses ranging from "Not at all" to "Nearly every day." The total scores range from zero
(0) to 21, with higher scores indicating more expressed anxiety symptoms. In the current study, we used cut-points of
5, 10, and 15 as indicators of mild, moderate, and severe anxiety, as proposed by scale authors [15].
Variables
Dependent variables
The severity of depression (dependent variable) is defined by a score of 5. The range of 5–9 indicates mild depression,
10–14 indicates moderate depression, 15–19 indicates moderately severe depression, and 20–27 indicates severe
depression. On the other hand, our anxiety levels were measured using cut-off points of 5, 10, and 15 as indicators of
mild anxiety, moderate anxiety, and severe anxiety, respectively.
Independent variables
The research analyzed demographic data by categorizing age into 20-year intervals. Gender was distinguished between
males and females, while ethnicity was classified as Arab or non-Arab. Based on the clinical findings, cancer types
were divided into hematologic malignancies or solid tumors. The study also investigated cancer stages I, II, III, and
IV. Additionally, it analyzed participants' marital status, categorizing them as single, married, or divorced.
Further, the job function of employers was segmented into 12 diverse categories, ranging from housewives and
healthcare professionals to engineering and computer workers, drivers, business professionals, educators, office staff,
clerical support workers, unskilled laborers, and retired personnel. Furthermore, based on education level, individuals
were classified into four groups: illiterate, primary, secondary, and tertiary. Moreover, the duration since cancer
diagnosis was classified into three groups: less than 12 months, between 12 and 60 months, and over 60 months.
Additionally, 'Yes' was recorded for specific variables when respondents confirmed their history of psychiatric illness,
family history of psychiatric illness or cancer, comorbidities, COVID-19 infection, or previous hospitalization due to
COVID-19. Finally, three distinct stages have been identified for the treatment phase: maintaining a disease-free state,
relapse or progression, and newly diagnosed cases.
Statistical analysis
We used descriptive statistics to evaluate the demographic characteristics, medical history, and levels of depression
and anxiety among the participants. We reported frequencies and percentages for categorical variables and means and
standard deviations for continuous variables. Additionally, we executed an inferential analysis to evaluate symptom
severity among various groups using various statistical tests, including parametric (t-tests and ANOVA) and nonparametric (Kruskal-Wallis and Mann-Whitney U) tests. The second step involved examining the connection between
depression levels, anxiety levels, and other variables through the use of both the chi-square test and Fisher's exact test.
In addition, we utilized the biserial correlation coefficient to investigate the link between binary and ordinal variables
that relate to the frequency of depression and anxiety disorders.
We measured the Prevalence of depression and anxiety symptoms in our patients by following the authors' advice for
the PHQ-9 and GAD-7 cut-off points. We then divided the total number of patients by those who met the criteria.
Upon further review, it was determined that only 3% of the data for these crucial outcomes was missing. We used
diverse imputations to estimate and replace the missing values to guarantee accuracy. Our analysis involved the use
of logistic regression for bidirectional analysis. Our first attempt was to model an ordinal variable using quantitative
and qualitative explanatory variables to determine whether demographic, social, and clinical factors influence anxiety
and depression. If a score is 0, it means there is no anxiety or depression, while if it's 1, it means both are present. We
selected patients experiencing depression and anxiety to create precise reference groups.
Additionally, we examined potential risk factors and predictors of anxiety and depression symptoms in cancer patients
using ordinal regression to include odds ratios (OR) with 95% confidence intervals (CIs). The results were statistically
significant, with a p-value less than 0.05. The statistical analysis was performed using Stata software version 15.1.
Ethical considerations
The study was approved by Hamad Medical Corporation's research ethics committee. Participants were informed
about the study's purpose, confidentiality was assured, and participation was voluntary. All responses were anonymous
and used for research purposes only. The study adhered to the Strengthening the Reporting of Observational Studies
in Epidemiology guidelines for comprehensive and transparent reporting.
RESULTS
1. Demographic and clinical characteristics of the study population
Table 1 provides a detailed summary of the study participants' demographic, social, and clinical characteristics. There
were 501 participants in the study, of which 50.6% were male. The participants were, on average, 47.9 years old (SD
= 11.4 years), and 74% were Arab by ethnicity.
According to the study, 19.76% of the participants were found to have haematological malignancies. The Prevalence
of other types of cancer was reported as follows: colorectal cancer (9.38%), breast cancer (8.98%), and pancreatic
cancer (12.18%). Moreover, 43 cancer cases were unspecified, of which 12 had no further information. In addition, a
significant proportion of participants (41.12%) had co-existing medical conditions. Further, the survey respondents
comprised 83% singles, 14% married, 1% divorced, and 13% widowed. Also, 41% of respondents were homemakers,
39% worked in the service sector, 15% were unemployed, 14% were in the healthcare sector, and 12% were in the
technology sector. Regarding cancer stages, 25% of the participants were at stage I, 33% at stage II, 55% at stage III,
24% at stage IV, and 4% had an unknown stage. Treatments: 5.0% radiotherapy, 21.4% chemotherapy, 9.3% surgery.
12.7% radiation therapy and chemotherapy. 11.3% chemotherapy and surgery. 29% radiation therapy and surgery.
11.3% comprehensive treatment with chemotherapy, radiation therapy, and surgery. Remarkably, a fraction of
approximately 10% of the participants received alternative treatment approaches. These encompassed innovative
treatments such as immunotherapy, hormone therapy, and targeted therapy.
Nearly half of the participants had completed tertiary education (48.5%), whereas illiteracy was observed in only 5.1%
of the study participants, followed by secondary education in 38.32% and primary education in 7.98%. On average,
cancer was diagnosed 18 months after the first self-reported symptoms (SD = 17.8 months), and it was treated for 12.5
months (SD = 20.5 months). In addition, 33.13 percent of participants have a family history of cancer, 3.19 percent
have a family history of mental illness, and 2.40 percent themselves have been affected by mental illness. Among the
participants, 21% were infected with COVID-19, and 30% were hospitalized due to COVID-19 symptoms. Most study
participants (52.31%) were in remission or disease-free. Only 9.18% had recently been diagnosed with cancer, but a
significant percentage (38.52%) had experienced a relapse or progression of their disease.
Table (1): The participants' demographic, social and clinical characteristics, personality traits, and quality of
life
Variables
Values
Proportions
99
61
47
45
44
40
39
32
25
17
15
37
19.76%
12.18%
9.38%
8.98%
8.78%
7.98%
7.78%
6.39%
4.99%
3.39%
2.99%
7.39%
Cancer type
Blood Cancer (Hematological Malignancies)
Pancreatic / liver cancer
Colon/rectal Cancer
Breast cancer
Ovary/cervix/uterus cancer
Trachea/bronchus/ lung cancer
Head /neck cancer
Prostate /testis cancer
Kidney/urinary tract/bladder
Brain /central nervous system cancers
Endocrine / Thyroid Cancer
Others*
Age
Less than 40 years
40-60 years
60 years plus
Mean ± SD, years
129
25.80%
301
60.10%
71
14.20%
47.9±11.4^
Gender
Male
Female
283
218
56.50%
43.50%
372
239
74.20%
26.80%
70
418
13
14.00%
83.41%
2.59%
122
102
69
41
33
24.35%
20.36%
13.77%
8.18%
6.59%
Socio-ethnic groups
Arabic group
Non-Arabic group
Family Status
Single
Married
Divorced
Occupation category
Housewives
Service
Not working
Healthcare
Engineering and computer
Drivers
Business
Education
Office
Clerical support worker
Unskilled labor
Retired
29
24
23
23
13
16
6
5.79%
4.79%
4.59%
4.59%
2.59%
3.19%
1.20%
26
40
192
243
5.19%
7.98%
38.32%
48.50%
12
2.40%
16
3.19%
166
33.13%
206
41.12%
233
46.51%
41
8.18%
62
110
111
121
97
12.38%
21.96%
22.16%
24.15%
19.36%
262
193
46
52.30%
38.52%
9.18%
156
107
95
28
25
22
68
31.2%
21.4%
19.0%
5.6%
5.0%
4.4%
13.6%
Education
Illiterate
Primary
Secondary
Tertiary
History of Psychiatry Illness
Yes
Family history of psychiatry
Yes
Family history of cancer
Yes
Comorbidities
Yes
COVID-19 infection
Yes
Hospital Due to COVID-19
Yes
Tumor stage
Stage I
Stage II
Stage III
Stage IV
Stage not known
Phase of treatment
The maintenance or disease-free phase
The relapse or progression phase
Newly diagnosed
Treatment modality
Combination of Chemotherapy and surgery
Chemotherapy
Combination of Chemotherapy, radiotherapy, and surgery
Combination of radiotherapy and Chemotherapy
Radiotherapy
Cancer-related surgery
Others**
Time since Diagnosis
Mean ± SD, months
Less than 12 months
47.9±43.38 ^
99
19.8%
[12-60 [ months
More than 60 months
312
90
62.3%
17.9%
Note:Categorical variables are presented as numbers (%); continuous variables
are presented as mean ± standard deviation.
^ Data reflect mean ± SD.
** Hormonotherapy. Bone marrow transplant, immunotherapy, and supportive
therapy.
2-Prevalence of depression and anxiety status according to severity among cancer patients
A study of 500 cancer patients found 378 with depression. The overall prevalence rate for depression is 75.05% (95%
CI: 62.00, 84.37), with an average PHQ-9 score of 3.28 ± 3.90 points. Of these, 20% suffer from mild depression,
40% from mild depression, 1% from moderate depression, 20% from moderate depression and 7.98% from severe
depression.
Additionally, 352 of the 500 participants reported experiencing anxiety symptoms. Overall, 70.25% of the population
is anxious (95% CI: 59.12, 74.85), and their average GAD-7 score is 3.17 ± 3.41 points. Furthermore, 15.56%, 48.30%,
4.19%, and 2.19% of patients were categorized as mild, mild-to-moderate, moderate, and severe anxiety, respectively.
An illustration of the Prevalence of depressive and anxiety symptoms based on severity levels is provided in Table 2.
Table (2): Prevalence of depressive and anxiety symptoms
Variables
Number (%)
Level of depression
Normal
125(24.95%)
Minimal
106(21.15%)
Mild
216(43.11%)
Moderate
41(8.18%)
Moderately severe
9(1.79%)
Severe
4(7.98%)
Overall depression
376(75.05%)
Level of Anxiety
Normal
149(29.74%)
Minimal
78(15.56%)
Mild
242(48.30%)
Moderate
21(4.19%)
Severe
11(2.19%)
Overall Anxiety
352(70.25%)
3- Correlation for the variables examined
A point biserial correlation coefficient (rpbi) was calculated to examine the relationship between sociodemographic
variables and symptoms of depression and anxiety. It is shown in Table 3 that the study found a weak yet significant
positive correlation between depression symptoms and cancer stage (rpbi = 0.05, p < 0.05), followed by a family
history of cancer (rpbi = 0.04, p < 0.04), and having undergone hormone therapy (rpbi = 0.08, p < 0.05). The study
has also found a weak positive correlation between anxiety severity and psychiatric history (rpbi = 0.08, p < 0.05),
radiation therapy (rpbi = 0.10, p < 0.05), and gender (rpbi = 0.12, p < 0.05).
Table 3: The relationship of depression, anxiety, sociodemographic, and clinical variables
Variables
Cancer type
Tumor stage
Date of cancer Diagnosis
History of Psychiatry Illness
Family history of psychiatry
Family history of Cancer
Comorbidities
COVID 19 infection
Hospitalization Due to COVID-19
Surgical Treatment
Exposure to chemotherapy or target therapy
Exposure to Radiotherapy
Hormone therapy
Age
Gender
Family Status (Single / Married / Divorced)
Education (Illiterate / Primary /
Secondary/tertiary)
Occupation
Phase of treatment
Depression
Anxiety
rpbi
P-value
rpbi
P-value
0.05
0.01
0.04
0.02
0.02
0.09
0.08
0.04
0.04
0.03
0.06
0.05
0.08
0.01
0.06
0.04
<0.05
>0.05
>0.05
>0.05
>0.05
<0.05
<0.05
>0.05
>0.05
>0.05
>0.05
>0.05
<0.05
>0.05
>0.05
>0.05
0.04
0.02
0.03
0.08
0.06
0.07
0.01
0.04
0.03
0.03
0.09
0.10
0.05
0.06
0.12
0.05
>0.05
>0.05
>0.05
<0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
<0.05
>0.05
>0.05
<0.05
>0.05
0.01
>0.05
0.03
>0.05
0.05
0.06
>0.05
>0.05
0.04
0.02
>0.05
>0.05
Note:* The point biserial correlation coefficient (rpbi) is an enhanced version of
Pearson's correlation coefficient used to measure the association between binary
and continuous variables.
*Significant at the .05 level, two-sided test.
4- Factors associated with depression and anxiety
Our analysis, which utilized ANOVA and Student's t-test, revealed that certain groups of participants had higher scores
on the PHQ-9 depression scale than others. These groups include individuals employed in the driving profession (with
an average score of 8.0 [SD: 4.0]), those with primary school education (with a mean score of 8.1 [SD: 6.0]),
participants with psychiatric illnesses (with a mean score of 7.8 [SD: 5.8]), individuals who have undergone
chemotherapy (with an average score of 5.3 [SD: 4.4]), participants with stage I cancer (with a mean score of 5.6
[SD: 4.3]), and those who have received radiotherapy (with a mean score of 6.9 [SD: 4.4]).
During our examination, we discovered that anxiety levels varied significantly among different groups. According to
the GAD-7 score, some groups showed higher anxiety levels than others. Among all the participants, those in the
driving profession had the highest mean GAD-7 score of 6.5 (SD: 5.5). Additionally, individuals who had completed
only primary school had a mean GAD-7 score of 6.8 (SD: 5.2), while those with mental illness had a mean GAD-7
score of 6.2 (SD: 4.7). Participants with a family history of mental illness had a mean GAD-7 score of 6.5 (SD: 3.9).
Those who received radiation or hormone therapy scored a mean 5.6 (SD: 4.6) and 5.6 (SD: 4.2), respectively. Table
5 compares participants' depression and anxiety scores.
Table 4: A comparison of participant characteristics, depression, and anxiety scores based on the PHQ-9 and
GAD-7 scales.
Variables
n
%
Depression
PHQ-9
PHQ-9
Mean ±
Median
SD
Score
Score
Anxiety
P-value
n
GAD-7
Mean ± SD
Score
GAD-7
Median
Score
21
%
79
%
4.55±3.56
3
4.46±3.55
3
20
%
14
%
4.55±3.56
3
4.46±3.55
3
9%
4.67±3.73
3
%
P-value
Cancer type
Hematological
Malignancies
97
Solid tumor
27
9
Hematological
Malignancies
Pancreatic / liver
cancer
Colon/rectal Cancer
97
41
32
26
%
74
%
4.49±3.
39
4.45±3.
25
26
%
11
%
4.49±3.3
9
4.40±3.1
7
5.01±3.6
9
9%
3
72
>0.05
4
28
0
3
72
3
4
<0.05
49
30
>0.05
>0.05
Breast cancer
Ovary/cervix/uterus
cancer
Trachea/bronchus/
lung cancer
Head /neck cancer
Prostate /testis
cancer
Kidney/urinary
tract/bladder
Brain /central
nervous system
cancers
Endocrine / Thyroid
Cancer
Others*
22
6%
29
8%
30
8%
33
9%
27
7%
22
6%
10
3%
7
2%
26
7%
5.19±3.8
3
4.14±3.2
0
4.45±3.2
5
4.73±3.8
4
4.13±3.4
3
4.61±4.3
5
4.72±3.5
3
3.77±2.7
2
4.03±3.2
1
4
29
9%
5.43±4.14
4
3
35
10
%
4.28±4.17
3
3
28
8%
4.54±3.62
3
3
36
10
%
4.83±3.92
4
3
19
5%
4.51±3.65
3
3
17
5%
4.41±3.80
3
4
8
2%
4.86±3.83
4
3
5
2%
4.36±3.71
3
3
23
6%
4.45±4.02
3
25
%
59
%
16
%
5.02±3.92
4
4.60±3.68
3
4.23±4.09
3
15
8
21
6
45
%
61
%
4.63±3.83
3
4.60±3.72
3
21
4
13
8
61
%
39
%
4.53±3.72
3
4.87±3.95
3
4.26±2.99
3
28
4
16
%
81
%
4.67±3.90
3
11
3%
4.91±4.30
4
Age
Less than 40 years
94
40-60 years
21
7
60 years plus
65
25
%
58
%
17
%
5.19±3.
96
5.09±4.
12
4.88±4.
77
87
4
4
>0.05
20
8
57
3
>0.05
Gender
Male
Female
15
5
22
1
41
%
59
%
5.18±4.
28
5.02±4.
14
4
>0.05
4
>0.05
Socio-Ethnic groups
Arabic group
Non-Arabic group
23
1
14
5
61
%
39
%
5.85±4.
74
5.21±4.
50
4
>0.05
4
>0.05
Family Status
Single
58
Married
30
6
15
%
81
%
Divorced
12
3%
4.96±3.
65
5.08±4.
25
6.10±5.
57
57
4
4
>0.05
3.5
Occupation category
>0.05
24
%
19
%
15
%
Housewives
90
Service
70
Not working
55
Healthcare
35
9%
Engineering and
computer
24
6%
Drivers
23
6%
Business
22
6%
Education
18
5%
Office
17
5%
Clerical support
worker
7
2%
Unskilled labor
11
3%
Retired
8
2%
5.28±4.
40
6.17±4.
75
3.21±2.
41
4.17±3.
21
6.30±4.
47
8.00±4.
02
6.05±5.
33
3.38±2.
42
4.35±3.
93
3.42±2.
29
4.09±3.
94
2.33±1.
21
19
%
20
%
14
%
4.76±3.81
3
4.77±3.76
4
3.38±2.57
3
31
9%
4.77±3.81
4
20
6%
6.24±5.39
5
22
6%
6.59±5.54
5
4
67
5
71
3
50
3
5
6
<0.05
<0.05
5
17
5%
4.17±2.60
3
3
27
8%
3.20±2.33
3
3
17
5%
5.64±3.62
4
3
12
3%
2.83±1.16
2
3
10
3%
4.20±3.91
3
2
8
2%
3.00±1.41
2
24
7%
4.83±4.16
4
27
8%
6.81±5.26
5
13
2
16
9
38
%
48
%
4.75±3.57
4
4.15±3.51
4
56
%
44
%
6.25±4.76
5
4.58±3.79
3
20
6%
6.50±3.96
5.5
33
2
94
%
Education
Illiterate
23
6%
Primary
28
7%
Secondary
Tertiary
14
8
17
7
39
%
47
%
4.78±5.
04
8.11±6.
01
4.78±3.
80
4.91±3.
88
4
7
<0.05
4
4
<0.05
History of Psychiatry Illness
Yes
No
12
36
4
3%
97
%
7.80±5.
83
5.01±4.
12
5
<0.05
4
19
6
15
6
<0.05
Family history of psychiatry
Yes
No
14
36
2
4%
96
%
5.73±5.
08
5.06±4.
15
4
>0.05
4
<0.05
4.54±3.76
3
Family history of cancer
Yes
No
13
6
24
0
36
%
64
%
5.17±4.
16
5.04±4.
22
4
>0.05
4
12
8
21
8
36
%
62
%
4.41±3.64
3
4.78±3.88
3
11
8
23
4
34
%
66
%
4.81±3.75
3
4.15±3.80
3
17
9
19
5
51
%
55
%
4.73±3.74
3
4.50±3.82
3
29
8%
4.27±3.09
4
32
3
92
%
4.64±3.83
3
23
%
30
%
25
%
22
%
4.77±3.56
3
4.38±3.26
3
4.71±3.98
3
4.81±4.19
4
20
0
57
%
4.34±3.39
3
10
0
28
%
21
%
4.80±4.24
3
5.12±4.07
3
57
%
4.70±3.78
3
>0.05
Comorbidities
Yes
No
15
8
21
8
42
%
58
%
4.65±4.
06
5.42±4.
26
3
>0.05
4
>0.05
COVID-19 infection
Yes
No
18
4
19
2
49
%
51
%
4.88±4.
18
5.29±4.
20
4
>0.05
4
>0.05
Hospitalization Due to COVID-19
Yes
No
32
34
4
9%
91
%
4.36±3.
14
5.15±4.
27
3
>0.05
4
>0.05
Tumor stage
Stage I
73
Stage II
95
Stage III
87
Stage IV
12
1
19
%
25
%
23
%
32
%
5.61±4.
31
5.02±4.
12
4.45±3.
61
4.19±3.
55
4
82
4
10
4
<0.05
3
87
3
79
>0.05
Phase of treatment
The maintenance
or disease-free
phase
The relapse or
progression phase
Newly diagnosed
19
8
53
%
4.85±3.
80
10
2
27
%
20
%
5.26±5.
00
5.48±3.
99
76
3
3
>0.05
74
3
>0.05
Surgical treatment
Yes
23
4
62
%
5.30±4.
23
4
>0.05
20
1
>0.05
14
2
No
38
%
4.73±4.
10
3
15
1
43
%
4.48±3.78
3
30
6
87
%
13
%
4.86±3.97
4
3.80±2.90
3
30
%
70
%
5.69±4.69
4
Chemotherapy treatment
28
8
Yes
No
68
77
%
18
%
5.37±4.
41
4.15±3.
24
4
<0.05
3
46
>0.05
Radiotherapy treatment
11
9
25
7
Yes
No
32
%
68
%
6.90±4.
79
4.63±3.
081
5
<0.05
3
10
6
24
6
<0.05
4.19±3.26
3
5.62±4.23
4
Hormone treatment
Yes
87
28
9
No
23
%
77
%
5.19±4.
38
4.77±3.
47
4
83
>0.05
4
26
9
24
%
76
%
<0.05
4.25±3.01
3
5.02±3.56
4
4.53±3.74
4
4.65±4.30
4
Time since diagnosis
<12 months
79
[12-60] months
22
9
>60 months
68
21
%
61
%
18
%
5.44±4.
70
5.01±4.
59
5.00±3.
58
4
4
4
69
>0.05
22
0
63
20
%
63
%
18
%
>0.05
Note: T-test (Student T-test) was used to compare two groups, while variance
analysis F-test was used for more than two groups. A significant difference was
identified with a p-value of less than 0.05*.
4- Anxiety and depression predictor variables
The risk factors for depression and anxiety in cancer patients are presented in Table 5. The analysis shows that women
are 59% more likely to develop depression than men. Individuals between the ages of 40 and 60 are 143% more likely
to experience depression. Retirees have a 24% lower chance of experiencing depression than people in other
professions, while office workers have a 34% lower chance. Completing secondary school reduces depression risk by
0.22 times. People with comorbidities are 63% more likely to develop depression, while those diagnosed with stage 4
cancer have a 2.10 times higher probability of depression. Also, the analysis found that women are 66% more likely
to develop anxiety than men. Married people are 84% less likely to suffer from anxiety disorders. Service workers are
72% more likely to suffer from anxiety disorders, while education workers are 1.39 times more likely to suffer from
anxiety disorders. Participants with a college degree are 1.47 times more likely to have anxiety disorders. These
determinants have a significant impact on the likelihood of developing anxiety. Additionally, participants with
comorbid medical conditions have a 63% increased chance of developing anxiety disorders. People diagnosed with
stage IV cancer have a 0.96 times higher likelihood of developing anxiety. On the other hand, those in the relapse
phase are 0.50 times less likely to experience anxiety. However, those who have undergone radiological treatment are
0.51 times more likely to suffer from anxiety.
Table 5: Determining and predicting depression and anxiety risk factors using logistic regression
Depression
Variables
Odds Ratio†
CI95%‡
Anxiety
P-value
Odds Ratio†
CI95%‡
P-value
Cancer type
Hematological Malignancies
Solid tumor
1
1.02 (0.44,
2.48)
>0.05
1
1.26
(0.50,1.88)
>0.05
Age
Less than 40 years
40-60 years
60 years plus
1
2.43(1.26,
4.68)
0.23 (0.09,
0.54)
<0.05
<0.05
1
1.27
(0.39,1.52)
0.61(0.40,1.83
)
>0.05
>0.05
Gender
Male
Female
0.41 (0.19,
0.90)
1
<0.05
0.34 (0.15,
0.73)
1
<0.05
Socio-Ethnic groups
Arabic group
Non-Arabic group
0.41(0.08,2.03)
1
>0.05
1.10
(0.55,2.44)
1
>0.05
Family Status
Single
Married
Divorced
1
1.39
(1.51,3.76)
5.47
(0.67,44.62)
>0.05
>0.05
1
0.16 (0.04,
0.59)
3.24 (0.03,
27.21)
<0.05
>0.05
Occupation category
Not working
Clerical support worker
Drivers
1
0.30
(0.07,1.26)
0.92
(0.26,3.19)
1
>0.05
>0.05
0.18
(0.031,1.01)
0.46
(0.11,1.99)
>0.05
>0.05
Education
Engenering and computer
Healthcare
Housewives
Office
Retired
Unskilled labour
Drivers
1.27
(0.32,4.94)
1.10
(0.32,3.75)
1.09
(0.33,3.53)
0.59
(0.21,1.60)
0.66
(0.16,0.92)
0.76 (0.11,
5.00)
0.71 (0.17,
2.92)
3.06
(0.78,11.94)
>0.05
>0.05
>0.05
>0.05
<0.05
<0.05
>0.05
>0.05
Service
1.01(0.40,2.53)
>0.05
Business
0.93
(0.26,3.19)
>0.09
2.39
(1.07,32.54)
0.73
(0.14,2.92)
1.29
(0.13,2.17)
0.43 (0.21,
2.01)
1.01(0.20,4.12
)
0.61(0.40,33.3
1)
1.04
(0.18,3.46)
2.46
(0.51,11.81)
1.72
(1.06,16.99)
0.61
(0.36,3.19)
<0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
<0.05
>0.05
Education
Illiterate
Primary
Secondary
Tertiary
1
0.37(0.08,1.61)
0.22
(0.05,0.96)
0.45
(0.11,1.88)
1
>0.05
<0.05
>0.05
0.36
(0.09,1.44)
0.42
(0.05,0.97)
2.47
(1.08,5.63)
>0.05
>0.05
<0.05
History of Psychiatry Illness
Yes
No
1.09
(0.16,11.42)
1
0.96
(0.16,5.69)
1
Family history of psychiatry
Yes
No
3.58
(0.35,36.24)
1
>0.05
1.29
(0.27,5.99)
1
>0.05
Family history of cancer
Yes
No
1.61 (0.98,
2.70)
1
>0.05
1.23 (0.75,
2.00)
1
>0.05
Comorbidities
Yes
1.63(1.0,
2.66)
<0.05
1.20 (0.75,
1.91)
>0.05
No
1
1
COVID-19 infection
Yes
No
1.58
(0.98,2.53)
1
>0.05
1.17 (0.74,
1.85)
1
>0.05
Hospitalization Due to COVID-19
Yes
No
0.94(0.40,
2.22)
1
>0.05
0.68 (0.30,
1.53)
1
>0.05
Tumor stage
Stage I
Stage II
Stage III
Stage IV
1
0.76 (0.33,
1.76)
0.57 (0.25,
1.30)
2.10
(1.154,3.82)
>0.05
>0.05
<0.05
1
0.37 (0.16,
0.86)
0.43
(0.18,1.01)
1.96
(1.08,3.61)
>0.05
>0.05
<0.05
Phase of treatment
The maintenance or diseasefree phase
The relapse or progression
phase
Newly diagnosed
0.80 (0.45,
1.41)
0.64 (0.34,
1.18)
1
>0.05
>0.05
0.80 (0.43,
1.47)
0.50 (0.25,
0.97)
1
>0.05
<0.05
Surgical treatment
Yes
No
1.46 (0.88,
2.42)
1
>0.05
1.51 (1.09,
2.44)
1
<0.05
Chemotherapy treatment
Yes
No
1.37 (0.78,
2.41)
1
>0.05
1.51 (0.88,
2.59)
1
>0.05
Radiotherapy treatment
Yes
No
1.57 (0.90,
2.73)
1
>0.05
0.79
(0.46,1.35)
1
>0.05
Hormone treatment
Yes
No
0.66
(0.37,1.19)
1
>0.05
0.94
(0.53,1.68)
1
>0.05
Time since diagnosis
<12 months
[12-60] months
>60 months
0.61
(0.27,1.39)
1.07
(0.58,1.98)
>0.05
>0.05
0.86
(0.46,1.56)
0.74
(0.41,1.34)
1
>0.05
>0.05
1
Note: *p < .05; † OR = Odds ratio ‡ CI = Confidence Interval
DISCUSSION
Mental disorders like depression and anxiety can have a significant impact on cancer patients' health. Oncology
settings are mainly concerned with this issue. However, Qatar lacks information about these disorders and their causes
in Qatar. Our research involved 371 cancer patients receiving outpatient treatment. The study found that 75% suffered
from anxiety, while 70% experienced depression. These findings were consistent across all cancer types. Mental health
conditions can significantly impact cancer patients' well-being. Our research investigates how demographics, clinical
conditions, and behaviour influence anxiety and depression levels.
Our study reveals that Qatar has a significantly higher prevalence of depression than other nations. Our analysis of
depression revealed that the majority of participants (75.5%) reported being clinically depressed. The majority of cases
were associated with milder symptoms, accounting for 40.1% or more of the total number of depression cases. The
prevalence rate of depression in this study is significantly higher than the rates found in two previous comprehensive
studies that examined depression prevalence among cancer patients. The first study, conducted by Krebber and
Mitchell et al., reviewed 211 articles. It found that depression rates varied from 8% to 24% depending on the type of
cancer, the stage of the disease, and the diagnostic method used [16]. The second study, which examined 66 studies,
estimated that depression prevalence among cancer patients was 16.3% [17].
On the other hand, studies have shown that depression is more commonly found among cancer patients in Qatar
compared to other countries. Our research found a prevalence rate that is higher than most studies, with rates ranging
from 43% in Pakistan (95% CI ranging from 26% to 64%)[18],39% in Italy (95% CI ranging from 25% to 57%)[19],
13% in Taiwan (95% CI ranging from 4% to 36%)[20], and 14% in Germany (95% CI ranging from 10% to 19%)[21].
However, this study confirms that cancer patients often experience psychological or psychiatric complications, which
may be influenced by cultural differences, tools used to measure depression, and the stressful outpatient interview
environment.
In our study, which was conducted in an outpatient setting, we discovered notable distinctions from Walker et al.'s
findings. Their research reported varying rates of depression among different patient groups, ranging from 5% to 16%
for outpatients, 4% to 14% for inpatients, 4% to 11% for mixed-outpatient patients, and 7% to 49% for patients
receiving palliative care [22].
Our research has revealed that various factors greatly influence higher scores of depression. Among these factors, the
type of breast cancer stands out. Previous studies have unmistakably demonstrated that the occurrence of depression
poses a considerable risk for individuals diagnosed with certain types of breast cancer [23]. Furthermore, it has been
found that being a driver can have a profound effect on depression, as supported by a recent study [24]. This study
has revealed a significant and alarming 84% rise in reported cases of depression among drivers since 2017. Our
research has also uncovered specific factors that increase the likelihood of experiencing higher levels of depression.
These include individuals who have completed only primary education, those suffering from psychiatric disorders,
and those who have undergone chemotherapy [25]. The increased occurrence of chemotherapy as a primary form of
treatment may be due to patients with terminal and unfavorable prognoses choosing it [26].
Our research has revealed significant insights into the connection between depression severity and various factors,
including the stage of cancer, hormone therapy, and family history. The results suggest that specific groups of
individuals, such as women, those with comorbidities, middle-aged adults (between the ages of 40 and 60) [27]., and
those with Stage IV cancer [28], are particularly susceptible to developing depression. It is intriguing to note that our
findings align with previous studies conducted in Iran, particularly about patients with Stage IV cancer and individuals
who have undergone radiation therapy. Moreover, these factors can substantially contribute to the Prevalence of
depression, likely due to the physical changes resulting from the illness and its treatments. This has been reinforced
by previous research that highlights the profound impact of images on self-image and sexual drive, both of which can
have detrimental effects on mental health, particularly regarding depression [29]. Furthermore, there are several
possible reasons for the occurrence of psychological disorders in such patients, including disease-related
complications such as pain, disfigurement, reliance on or breakdown of the family unit, social and financial setbacks,
and even mortality [30].
Our study has revealed a remarkable finding concerning anxiety levels among our participants. Interestingly, the
results have revealed that 70.25% of individuals have faced intense anxiety, while 48.50% have encountered milder
levels. These findings highlight the alarming Prevalence of anxiety disorders among cancer patients, surpassing global
research in this area. Remarkably, our observations indicate that anxiety rates in comparison to other countries are
strikingly high. The report exhaustively examined anxiety rates in various countries, revealing that Germany reported
a rate of 12.3% [31], Iran 46% [32], China 43.5% [33]., India 46.91% [34]., and Sudan 26.7%.[35]. In addition, our
study revealed a fascinating finding that surpassed the insights of an enlightening meta-analysis conducted by Mitchell
AJ. It uncovered that anxiety disorders impacted approximately 10% of a vast population of 10,071 cancer patients
representing 14 diverse countries, as well as 4,007 cancer patients from seven different countries [36]. To explain this
striking difference, we have identified several contributing factors. These include variations in cancer types, screening
methods, sociodemographic elements, and even depression severity. After conducting a thorough analysis, we have
identified several key factors that contribute to anxiety among cancer patients. These include the type of cancer,
clinical characteristics, sociodemographic elements, and the severity of depression. Extensive investigation and
analysis are required to understand these underlying factors better. Our research has found a link between anxiety
disorders and factors such as a history of mental health issues, radiation therapy, and gender disparities [37].
Moreover, our research reveals that specific variables are associated with elevated scores on factors that directly
influence anxiety. These variables include a personal history of mental illness, driving profession, completed primary
education, family history of mental illness, female gender, and prior radiation and or hormone therapy. At the same
time, another research suggests that education level is not associated with anxiety levels [38].
Our research has uncovered a multitude of risk factors that significantly increase the likelihood of anxiety in cancer
patients. Advanced-stage cancer is associated with various risk factors, including a personal history of mental illness,
previous exposure to radiation or hormone therapy, and being female [39]. Furthermore, a study conducted by Aass
N. et al. has revealed a strong connection between anxiety and being female, the level of physical activity, and
limitations in social roles. These findings are supported by a recent study led by Huppert JD and his team, emphasizing
the importance of considering these factors in treatment planning to provide the best possible care for patients in
advanced stages of cancer [40]. While it is true that chemotherapy or other anti-cancer treatments can lead to a decrease
in appetite and intense emotions such as sadness, anger, anorexia, and anxiety, it is crucial to acknowledge that
chemotherapy remains a highly effective treatment that significantly improves survival rates[41]. To further validate
this point, a study involving oncology patients conducted by Aass N. and colleagues demonstrated that anxiety was
predicted by factors such as being female, impaired physical activity, and poor social role functioning, while fatigue
predicted depression. These findings further strengthen the evidence supporting the effectiveness of chemotherapy
[42].
Oncology patients should be monitored closely for depression and anxiety symptoms. There is evidence that providing
psychosocial support reduces depression, anxiety, and pain in this population[43].18 Early detection of anxiety and
depression in this population can help in making effective treatment interventions, including education, support,
psychotherapy, and psychopharmacology, which can have a significant impact on improving the quality of life[44].
The main limitation of this study lies in its use of cross-sectional methods, which restrict our ability to establish
causality between variables and only allow us to identify associations. A further restriction arises from the relatively
small number of individuals in specific cancer subgroups, largely because of the overall smaller population in these
categories across the country. Thus, our ability to accurately determine the prevalence of depressive and anxiety
symptoms in patients with specific types of cancer may be compromised. Moreover, excluding incomplete
questionnaires through repetition and collaboration poses a limitation. Despite the constraints, this study is the first of
its kind in Qatar and one of the few conducted in Gulf countries. As a result, our understanding of the potential impact
of depression and anxiety on cancer treatment in this region has improved significantly.
CONCLUSION
Common psychiatric conditions such as depression and anxiety disorders often affect patients undergoing oncology
treatment. It is of utmost importance to acknowledge the significant impact these conditions have on the well-being
and functionality of these individuals. Thus, it is vital to implement suitable treatment interventions once clinically
significant psychological disorders are diagnosed. Doing so can significantly improve these patients' overall quality
of life.
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