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© 2003 American Society for Clinical Oncology Depression and Psychological Distress in Patients During the Year After Curative Resection of Non–Small-Cell Lung CancerFrom the Psycho-Oncology Division, National Cancer Center Research Institute East, and Psychiatry Division, National Cancer Center Hospital East, Kashiwa, Chiba; Psychiatry Division, National Shikoku Cancer Center, Matsuyama, Ehime; Thoracic Oncology Division, National Cancer Center Hospital East, Kashiwa, Chiba; and Division of Occupational Therapy, Institute of Health Sciences, Hiroshima University School of Medicine, Hiroshima, Japan. Address reprint requests to Yosuke Uchitomi, MD, PhD, Psycho-Oncology Division, National Cancer Center Research Institute East, Kashiwanoha 6-5-1, Kashiwa, Chiba 277-8577, Japan; email: yuchitom{at}east.ncc.go.jp.
Purpose: There have been few psychosocial studies of patients after curative resection of non–small-cell lung cancer (NSCLC). The purpose of this study was to clarify the clinical course of depression and psychological distress of such patients during the year after surgery and to identify predictors of their long-term outcome. Patients and Methods: A total of 212 patients completed assessments during a 12-month follow-up period after curative resection of NSCLC. Psychological measurements at 1, 3, and 12 months after surgery were conducted using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (ed 3), Revised, and the Profiles of Mood States (POMS) scale. Univariate and multivariate analyses were used to identify predictors of psychological outcome according to these two methods of assessment. Results: The prevalence of depression did not change during the year after curative resection (range, 4.7% to 8.0%). The total POMS score was also unaltered during the year after surgery: the anger-hostility (P < .001) and tension-anxiety subscale scores (P < .026) had increased at 12 months, but the vigor-activity subscale score had also increased (P < .001). All predictors of psychological outcome at 12 months included a depression episode after the diagnosis of lung cancer or at 1 month after surgery. Less-educated status was also a significant predictor of depression at 12 months. Conclusion: These results suggest the need for psychosocial support even after curative resection of NSCLC and indicate that an approach that includes repetitive perioperative assessment of depression and careful attention to less-educated patients might be of benefit to patients in ameliorating depression and psychological distress during the year after curative resection.
LUNG CANCER is the most common form of cancer and the most common cause of cancer-related deaths in the world.1,2 Since the 1980s, extensive quality-of-life (QOL) research has been introduced in clinical trials on lung cancer patients,3,4 but few of these studies have examined psychological distress after curative resection of non–small-cell lung cancer (NSCLC).5–7 Although surgical treatment for early-stage NSCLC is generally considered curative, the outcome of NSCLC is still unsatisfactory: The postoperative 5-year survival rate is 79.0% for patients with pathologic stage IA disease, 59.7% for those with stage IB disease, 56.9% for those with stage IIA disease, and 45.0% for those with stage IIB disease.8 There are survivors after curative resection of NSCLC, despite the overall grim statistics. The psychological distress of NSCLC patients after surgery also seems to be less well understood in the context of curative cancer treatment.3,4 Psychological distress, including depression, is an essential element of the QOL of cancer patients and, thus, depression has a great impact on their QOL.9–11 Depression may be associated with treatment decision making, such as choosing chemotherapeutic agents,12 and with the shorter survival of lung cancer patients.13,14 Nevertheless, other studies have revealed that medical staff are poor at detecting emotionally distressed or depressed cancer patients.15–17 Depression is common in cancer patients and occurs throughout the course of their illness.18–20 Previous reports21–25 on depression after a diagnosis of lung cancer have revealed that 15% to 44% of patients experience some form of depression, including major depression and adjustment disorders with depressive mood, on the basis of Diagnostic and Statistical Manual for Mental Disorders, Revised (DSM-III-R) criteria,26 or clinically probable and borderline depression, on the basis of the Hospital Anxiety and Depression Scale (HADS).27 Because lung cancer and its treatment varies with histologic type and disease stage, previous studies have merely shown that some patients may experience depression after curative resection of NSCLC. We therefore first examined the prevalence of depression using the Structured Clinical Interview for DSM-III-R (SCID)28 in a large, homogeneous, consecutive, prospectively designed sample of NSCLC patients during the 3 months after curative resection, and found that the 1-month prevalence of depression at 1, 2, and 3 months after surgery was 9.0%, 9.4%, and 5.8%, respectively.29 Although the prevalence of depression was lower than in lung cancer patients as a whole, including patients with advanced and small-cell lung cancer, it was not so low that it was negligible (0.9% to 3.7% in the general populations).30–32 Factors associated with psychological distress, including depression, in various cancers have included physical variables, such as pain, fatigue, other symptom burden, and poor performance status (PS),25,33–35 whereas other studies have indicated sociodemographic and psychosocial variables, such as younger age36 and social support, including marital status.37 Because physical variables, such as PS and dyspnea, would be expected to improve by 6 or 9 months after surgery,5–7 psychosocial factors may more strongly predict depression and psychological distress after curative resection in NSCLC patients than physical factors. Previous studies that examined the prevalence of depression and factors associated with depression in lung cancer patients have entailed certain drawbacks, such as small sample size,21–23,25 a heterogeneous subject population that included subjects with all histologic types and all disease stages,21–23 measurement of depression by self-report measures with limited accuracy,23,24,34 and design as a cross-sectional or short-term follow-up study.21–25,29,34 In this study, we chose to use a structured clinical interview, after which clinical intervention for psychiatric disorders had to be recommended by feedback to the attending physician as both a means of clarifying the clinical course of depression by rigorous methods during the year after curative resection of NSCLC and a means of identifying factors predictive of long-term outcome. We also used reliable, valid, self-administered instruments to assess psychological distress during the year after surgery.
Participants Consecutive newly diagnosed patients were invited to participate in the study after curative resection of NSCLC conducted at the Thoracic Oncology Division, National Cancer Center Hospital East, Kashiwa, Japan. The eligibility criteria were 18 years of age or older; awareness of the diagnosis of cancer; ability to speak Japanese; standard surgical treatment (lobectomy or pneumonectomy with mediastinal lymph node dissection); no evidence of brain tumor on computerized tomography or magnetic resonance images of the head; no history of or current chemotherapy, immunotherapy, or radiation therapy; no active concomitant cancer; curative resection on the basis of pathology reports of an International Union Against Cancer (UICC) disease stage of pT1 to pT3, pN0/1, pM0;38 and no severe medical conditions at 1 month after surgery.
Procedure Pathologic disease stage was obtained from the patients’ medical charts, and PS, pain, and dyspnea were based on semistructured interviews conducted in the interview room of the Outpatient Service, Thoracic Oncology Division, National Cancer Center Hospital East, by two psychiatrists (Y.U., I.M.) 1 month after surgery. The evaluation of PS was based on the Eastern Cooperative Oncology Group criteria. Pain and dyspnea were graded on a four-point verbal scale: (0) absent, (1) mild, (2) moderate, and (3) severe. At 1, 3, and 12 months after surgery (median intervals after surgery, 31 days, 92 days, and 377 days, respectively), a semistructured interview was conducted to obtain information on demographic and clinical characteristics and was immediately followed by psychological measurements using the SCID28 and the Profiles of Mood States (POMS) scale.39 A blood specimen was collected at 12 months after surgery to determine smoking status chemically. Most measures at baseline, including measures of depression and the POMS, could not be performed before surgery for NSCLC, mainly because we judged that the baseline interview before surgery would be stressful to most patients. They had only been informed by the hospital of the day they would be admitted for surgical treatment of NSCLC 1 or 2 days in advance. Another reason was the practical problem of not being able to interview patients because of the brief interval between the time they were admitted and the operation (usually 2 or 3 days). We therefore scheduled the baseline interview at 1 month after surgery, by which time patients had been informed of the final pathologic diagnosis. When patients were diagnosed with depression, we recommended psychiatric consultation to the attending physician. When patients agreed, routine psychiatric consultations were provided. Our study was, therefore, limited because we were unable to observe the natural course of depression and psychological distress during the year after curative resection.
Measures As expected, it was difficult to determine whether somatic symptoms, such as appetite loss, insomnia, and fatigue, were attributable to depression or surgical treatment. There are four approaches to diagnose depression of the medically ill patient: to exclude somatic symptoms (exclusive); to substitute psychological symptoms for somatic symptoms (substitutive); to count somatic symptoms toward a depression diagnosis unless symptom is clearly and fully accounted for by a general medical condition (etiologic); and to include somatic symptoms (inclusive).40 Because the rater must make a judgment about the cause of individual symptoms, the etiologic approach may be less reliable than the exclusive, substitutive, and inclusive approach. We elected to use an inclusive diagnostic approach (to prevent underdiagnosis of depression), which is considered to be the most important approach in the clinical setting, although this approach may result in overestimation of depression in the medically ill patient. The reliability of the interview ratings was determined by having a second rater (Y.U.) attend a random sample consisting of 30 interviews (4.8%). The interrater agreement (kappa) values for the diagnosis of depression, major depression, and minor depression were 0.78, 1.00, and 0.65, respectively. Ratings for each of the nine individual items were also reliable, with the kappa values ranging from 0.65 to 1.00. Patients’ psychological distress was assessed using the POMS scale, a 65-item self-rating scale measuring six emotional states (tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment), and its summary score, the total mood disturbance (TMD) score.39 The validity and reliability of the Japanese version of the POMS have been confirmed.41
Plasma cotinine concentrations were blindly determined in duplicate by a high-performance liquid chromatography method with ultraviolet detection according to the method described by Hariharan et al.42 The minimum quantifiable concentration was 2 ng/mL. Patients with a cotinine concentration of less than 20 ng/mL were classified as nonsmokers, and patients with concentration of
Statistical Analysis The predictors examined were age, sex, education, marital status, whether the patient lived alone, employment status, type of surgery, preoperative %VC, preoperative %FEV1, preoperative PS, preoperative smoking status, smoking status at 12 months after surgery, history of nicotine dependence, history of depression before being told of the diagnosis of NSCLC, history of depression between the diagnosis of NSCLC and surgery, and PS, pain, dyspnea, depression, and POMS-TMD score at 1 month after surgery. After the results for the correlations between biomedical and psychosocial variables related to depression and the POMS-TMD score at 12 months after surgery in the univariate comparisons (P < .25) had been examined carefully, they were entered into multivariate models to examine the predictive factors of depression and the POMS-TMD score at 12 months after surgery. A logistic regression analysis with backward elimination was then used with alpha = 0.05 as the significance criterion to select the final models of depression, and multiple regression analysis with backward elimination was performed to examine the predictors of the POMS-TMD score at 12 months. In all statistical evaluations, P values of 0.05 or less were considered indicative of significant differences. SPSS 10.0J for Windows statistical software (SPSS Japan Institute Inc., Tokyo, Japan, 2000) was used for all data analyses.
Curative resection was confirmed by the final pathologic report of disease stage in 262 (86.5%) of the 303 NSCLC patients who underwent standard surgery between June 1996 and April 1999. At the time of the 1-month interview, three patients could not be contacted and 20 refused to participate in the study (10 of them because of the psychological burden, three because of the psychological and physical burden, four because of the physical burden, and three for unknown reasons). By the time of the 3-month follow-up, two patients had been lost to follow-up, two had died, and seven refused to participate (four because of the psychological burden, one because of the physical burden, one because of time constraints, and one for unknown reasons). By the time of the 12-month follow-up, five patients had been lost to follow-up, seven had died, three were too ill to participate, and one refused to participate for unknown reasons. Thus, the final study group consisted of 212 patients, representing 80.9% of all eligible patients. Data for the eligible patients who had undergone successful surgical resection but did not participate in the study (n = 50, 19.1%) were available in regard to age, sex, education, marital status, preoperative PS, and clinical disease stage. More of the nonparticipants were unmarried (26.1% of nonparticipants v 16.0% of participants, P = .018), and significantly more nonparticipants had advanced clinical stage disease (stage IIIA: 30.0% of nonparticipants v 6.6% of participants, P < 0.001), but the two groups did not differ with respect to any other available data. Of the 17 nonparticipants who refused to participate at the time of the follow-up examinations for reasons that included psychological burden, one was diagnosed with major depression after referral to the Psychiatry Division. After psychiatric referral, one of the 10 patients who could not be contacted was diagnosed with major depression, and one of the three who were judged to be too ill to participate was diagnosed with minor depression. The mean age ± SD of the 212 cancer patients who participated in the study was 62.1 ± 10.8 years (median, 63.5; range, 22 to 83), 39.6% were female, 84% were married, 7% lived alone, and 33% had a junior high school education or less. Smoking status was as follows: current smokers, 80 (37.7%); ex-smokers, 54 (25.5%); and nonsmokers, 78 (36.8%). Of the current and ex-smokers, 89 participants had a history of nicotine dependence. Preoperative PS was grade 0 in 148 patients (69.8%), grade 1 in 63 patients (29.7%), and grade 2 in one patient (0.5%). Pathologic stage I disease was the most common stage (n = 165; 77.8%), followed by pathologic stage II (n = 33, 15.6%), and pathologic stage IIIA (n = 14; 6.6%). Lobectomy was performed in 203 patients (95.8%) and pneumonectomy in nine (4.3%). Preoperative respiratory function was generally good: 19 patients (9.0%) had a %VC below 80%, and 44 (20.8%) had a %FEV1 below 70%. According to the results of the serum cotinine assay 1 year after surgery, 21 of the current smokers (n = 80) and none of the ex-smokers (n = 54) had continued to smoke.
Table 1
The 1-month prevalence of depression at 1, 3, and 12 months was 8.0%, 5.2%, and 4.7%, respectively, and none of the differences in 1-month prevalence of depression during the year were significant (Table 1  ). The 1-month prevalence of minor depression at 1, 3, and 12 months was 3.3%, 2.4%, and 3.3%, respectively, with no significant changes during the year. The 1-month prevalence of major depression at 1, 3, and 12 months was 4.7%, 2.8%, and 1.4%, respectively, showing a tendency to decrease, but none of the differences in 1-month prevalence of depression during the year were significant.
The clinical course of the depression is shown in Fig 1
Four of the 10 patients with major depression at 1 month and none of the seven subjects with minor depression at 1 month were referred to the Psychiatry Division by the attending physician immediately after the 1-month interview. After psychiatric intervention, two of the four patients with major depression at 1 month were not diagnosed with depression at 3 months, but the other two were still diagnosed with major depression and under psychiatric treatment. At the 12-month follow-up, one patient was still diagnosed with major depression, but the other three were not diagnosed with depression. Only two of the five patients with minor depression at 3 months were referred to the Psychiatry Division, and neither patient was diagnosed with depression at the 12-month follow-up. Of the six patients referred to the Psychiatry Division, all received supportive psychotherapy and/or antidepressant treatment, and five were not diagnosed with depression at 12 months after surgery.
There was no change in the POMS-TMD score during the year after surgery (Table 1
The results of the univariate analysis are shown in Table 2
The results of the multivariate analysis are shown in Table 3  . Depression and the POMS-TMD score at 1 month were significant predictors of the outcome at 12 months. History of depression between the diagnosis of lung cancer and surgery was also a significant predictor in the POMS model. Junior high school education or less was a significant predictor in the depression model.
After the six patients referred to the Psychiatry Division were excluded, the same predictors continued to be significant in both the depression model (depression at 1 month, odds ratio [OR] = 8.14, P = .030; 95% CI, 1.23 to 53.93, junior high school education or less, OR = 9.18, P = .009, n = 206, 95% CI, 1.73 to 48.74) and the POMS model (POMS-TMD at 1 month, standardized coefficient = 0.47, P < .001; history of depression after lung cancer before surgery, standardized coefficient = 0.18, P = .003, n = 204). After the 22 patients given recommendations for psychiatric consultation were excluded, junior high school education or less did not remain a significant predictor in the depression model (OR = 5.13, , P = .055, n = 190, 95% CI, 0.97 to 27.19) but the POMS-TMD score at 1 month continued to be a significant predictor in the POMS model (standardized coefficient = 0.53, P < .001, n = 188).
Because the predictors in both models included perioperative depression, that is, a depression episode between the diagnosis of lung cancer and surgery or at 1 month, the data were separated according to whether the patients had experienced perioperative depression and then reanalyzed (Table 4
In the models of the subjects with perioperative depression (Table 4B ), junior high school education or less became a significant predictor in the POMS-TMD model. No significant predictors remained in the depression models of the subjects with perioperative depression (n = 37), although all three subjects diagnosed with depression at 12 months had a junior high school education or less.
This study is the first to prospectively assess depression and psychological distress in NSCLC patients during a 1-year period after curative resection and to identify predictors of their psychological outcome at 12 months after surgery. Our study was designed to obtain comprehensive data concerning depression by using a rigorous diagnostic method and reliable, valid, self-administered instruments. However, most measurements at baseline, including measures of depression and psychological distress, could not be obtained before surgery for NSCLC, thereby limiting the comparison of overall degree of change from preoperative psychological functioning. Moreover, we should indicate that recommendations for psychiatric consultation to the attending physicians in 22 cases at 1 or 3 months after surgery and psychiatric interventions in six cases may have affected the prevalence of depression and psychological distress. The high attrition rate (19.1%) together with the fact that 17 (41.5%) of the 41 surviving nonparticipants refused to participate for reasons that included psychological burden mean that the prevalence of depression and psychological distress at 3 months and 12 months may have been underestimated. Despite several limitations, our finding showed that the prevalence of depression did not significantly change during the year after surgery (range, 4.7% to 8.0%). This finding appears to be supported by the finding that the NSCLC patients’ psychological distress measured by POMS-TMD did not change during the year after surgery, even after the six patients referred to the Psychiatry Division or the 22 patients given recommendations for psychiatric consultation were excluded. Even though the prevalence of depression was much lower than among lung cancer patients as a whole, including patients with advanced and small-cell lung cancer (15% to 44%),21–25 it was not low enough to be considered negligible (0.9% to 3.7% in the general population).30–32 Although there have been no long-term studies of depression after surgery for NSCLC, one study5 examined global QOL according to the Quality of Life Index43 before and 1, 3, 6, and 9 months after surgery in 117 consecutive subjects who underwent thoracotomy for a certain or presumptive diagnosis of lung cancer. Dales et al5 observed deterioration of QOL during the first 3 months postoperatively in those with a final diagnosis of cancer (n = 91) and found that although their QOL rebounded to its preoperative level, it did not reach the level of those in whom the final diagnosis was not cancer (n = 26). Our results are similar to their findings in that QOL did not reach the level of those without a final diagnosis of cancer during the 9 months after surgery. Neither depression nor QOL of the NSCLC patients after curative resection appears to decrease spontaneously. Depression should be assessed repeatedly and should not be underrecognized even after curative resection. Because depression at 1 month was a significant predictor, easy self-administered screening tools, such as the HADS,44,45 might be beneficial to patients during the first year after successful surgical treatment of NSCLC. Another noteworthy finding in this study was that the prevalence of depression did not significantly decrease during the year after surgery, even though only three (18%) of the 17 patients with depression at 1 month after surgery were diagnosed with depression at 12 months. Seven (70%) of the 10 patients with depression at 12 months were diagnosed for the first time. In two studies that prospectively assessed depression before and after treatment for inoperable NSCLC,24,25 the clinical course of the depression could be explained in part by a transient reaction to the diagnosis and treatment of cancer, by persistence of the reaction over time, or by worsening of the PS and the development of pain and dyspnea. In contrast, the results of our study showed a significant reduction of PS, pain, and dyspnea during the year after surgical treatment of early NSCLC; these findings are consistent with previous reports.5–7 One possible explanation for the finding that in most of the patients diagnosed with depression at 12 months it was diagnosed for the first time, is that junior high school education or less was a significant predictor of depression, although it became a marginal and not significant predictor after subjects with depression at 1 month were excluded (P = .053, n = 195). The results of the study indicate that medical professionals should pay careful attention to less-educated NSCLC patients after curative resection. There was no change in the NSCLC patients’ psychological distress measured by POMS-TMD during the year after surgery, although all six subscale scores of the NSCLC patients in this study were below the mean scores of healthy Japanese populations 60 years of age or more on the Japanese version of the POMS.41 Despite the significant reduction in PS to the preoperative level, both the anger-hostility and tension-anxiety score of the POMS increased during the year after surgery; however, there was a favorable change in the vigor-activity score. Because a history of depression between the diagnosis of lung cancer and surgery was a significant predictor, on the basis of the results of our study as a whole, repetitive perioperative assessments of depression as well as careful attention to less-educated patients might lead to early detection of and early treatment for depression, resulting in amelioration of depression and psychological distress during the year after curative resection of NSCLC. Although it has been recommended that cancer patients be routinely screened for distress,46 accumulating data indicate that screening programs for depression consume considerable resources and are not an efficient means of improving the mental health outcome of medical patients.47 If the sensitivity (91.5%) and the specificity (65.4%) of the HADS used to screen for depression in Japanese cancer patients45 were applied in this study, the positive predictive value would be 25.3% for depression between the diagnosis of lung cancer and surgery and 19.3% for depression at 1 month after surgery, and at least 2.5 and 2.4 patients/mo, respectively, would have to be interviewed by medical professionals with knowledge of the diagnostic procedures for depression to make routine screening efficient enough to be practical. Being informed of a diagnosis of lung cancer could be considered to be an acute stressful life event, as would a diagnosis of any serious physical illness. According to the severity of psychosocial stressors scale of the DSM-III-R,26 being diagnosed with a serious illness is graded as an extremely severe psychosocial stressor, the same as the death of a spouse; the grade is between a severe event (eg, divorce) and a catastrophic event (eg, death of a child). Previous studies on the death of a spouse have demonstrated a high prevalence of major depression that decreased over time but remained higher than in the controls (33% to 35% at 1 month after the loss, 23% to 25% at 2 months, 16% to 17% at 13 months, respectively).48,49 The prevalence of major depression in this study appears to be much lower than following an extremely severe psychosocial stressor such as the death of a spouse, and it shows a tendency to decrease during the year after surgery. There were several limitations to this study. First, there was sampling bias, because the results were obtained from only one institution, which was a teaching cancer center hospital. Second, recommendations for psychiatric consultation were made to the attending physicians. Moreover, there was a high attrition rate—many nonparticipants refused to participate for reasons that included psychological burden, and psychiatric intervention occurred for six patients with depression. In fact, five of the six patients referred to the Psychiatry Division were not diagnosed with depression at 12 months after surgery. Therefore, the prevalence of depression and psychological distress may have been underestimated as a result. Thus, if the depression in these five patients had persisted without psychiatric interventions, the prevalence of depression, major depression, and minor depression at 3 and 12 months would have been as high as 6.1%, 3.8%, and 2.4%, respectively, at 3 months, and 7.1%, 2.8%, and 4.2%, respectively, at 12 months. Third, it was disappointing that most measurements at baseline, including measures of depression and psychological distress, could not be obtained before surgery for NSCLC, thereby limiting the comparison of overall degree of change from preoperative psychological functioning. The short preoperative period results from a difference in our institution’s medical procedure. Preoperative psychological status in this study may not really reflect baseline mental health because of the high stress of the moment. Fourth, the prevalence of major depression in Asian countries is generally lower than in western countries, possibly because of cross-cultural differences (ie, social stigma, cultural reluctance to endorse mental symptoms, and low divorce rate).50–52 The interpretation of the results in this study is cautious. Fifth, depression may have been overestimated because we elected to use an inclusive diagnostic approach. This approach includes somatic symptoms, regardless of whether the rater judges that the symptom is caused by medical or psychological causes, prevents underdiagnosis of depression, and is reliable because of the high interrater agreement.53 Because other approaches do not offer a clear significant advantage in measuring depression and the need for treatment,54 the inclusive approach may be recommended with limitations in the clinical oncology setting. Finally, although the simple four-point verbal pain rating scale is the most widely used in the clinical context, the fact that we did not use a pain rating scale with higher sensitivity to change may have adversely affected the pain and dyspnea assessments in this study.55 Depression is not routinely assessed even in patients with unresectable NSCLC, although the majority of the previous extensive research on QOL has addressed the need for psychosocial support for such patients. Furthermore, patients face uncertainty and fear of recurrence after curative resection, even though surgical treatment for early-stage NSCLC is generally considered curative. This study revealed that the prevalence of depression did not reach a negligible level and did not change after curative resection for NSCLC. It also provided information indicating that perioperative depression and less-educated status were significant predictors of depression at 12 months after surgery. Overall, the study indicates that the psychological status of resectable NSCLC patients needs to be systematically addressed during their overall rehabilitation, including pain and dyspnea management. In addition, this study identified an area that is under studied in the literature regarding cancer survivorship, especially in the context of curative treatment. In the future, a randomized trial of coordinated psychosocial interventions on the basis of patient screening and treatment should be performed with the aim of ameliorating depression and psychological distress during the year after curative resection.
We are grateful to the patients and the physicians of the Thoracic Oncology Division, National Cancer Center Hospital East, and for a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare.
1. Parkin DM, Pisani P, Ferlay J: Estimates of the worldwide incidence of 25 major cancers in 1990. Int J Cancer 80:827–841, 1999[CrossRef][Medline] 2. Pisani P, Parkin DM, Bray F, et al: Estimates of the worldwide mortality from 25 cancers in 1990. Int J Cancer 83:18–29, 1999[Medline]
3. Bernhard J, Ganz PA: Psychosocial issues in lung cancer patients (part 1). Chest 99:216–223, 1991
4. Montazeri A, Gillis CR, McEwen J: Quality of life in patients with lung cancer: A review of literature from 1970 to 1995. Chest 113:467–481, 1998 5. Dales RE, Belanger R, Shamji FM, et al: Quality-of-life following thoracotomy for lung cancer. J Clin Epidemiol 47:1443–1449, 1994[CrossRef][Medline] 6. Nou E, Aberg T: Quality of survival in patients with surgically treated bronchial carcinoma. Thorax 35:255–263, 1980[Abstract] 7. Hamelmann H, Thermann M, Muller-Schwefe T, et al: Surgically treated bronchial carcinoma patients: Results of systematic follow-up. Thorac Cardiovasc Surg 31:41–44, 1983[Medline]
8. Naruke T, Tsuchiya R, Kondo H, et al: Prognosis and survival after resection bronchogenic carcinoma based on the 1997 TNM-staging classification: The Japanese experience. Ann Thorac Surg 71:1759–1764, 2001 9. Cella DF: Quality of life outcomes: Measurement and validation. Oncology 11:S233–S246, 1996 (suppl) 10. Vissor MRM, Smets EMA: Fatigue, depression and quality of life in cancer patients: How are they related? Support Care Cancer 6:101–108, 1998[CrossRef][Medline] 11. Harrison J, Haddad P, Maguire P: The impact of cancer on key relatives: A comparison of relative and patient concerns. Eur J Cancer 31A:1736–1740, 1995[Medline] 12. Colleoni M, Mandala M, Peruzzotti G, et al: Depression and degree of acceptance of adjuvant cytotoxic drugs. Lancet 356:1326–1327, 2000[CrossRef][Medline]
13. Buccheri G: Depressive reactions to lung cancer are common and often followed by a poor outcome. Eur Respir J 11:173–178, 1998
14. Faller H, Bulzebruck H, Drings P, et al: Coping, distress, and survival among patients with lung cancer. Arch Gen Psychiatry 56:756–762, 1999 15. Maguire P, Booth K, Elliott C, et al: Helping health professionals involved in cancer care acquire key interviewing skills: The impact of workshops. Eur J Cancer 32A:1486–1489, 1996[CrossRef][Medline]
16. Razavi D, Delvaux N, Hopwood P: Improving communication with cancer patients. A challenge for physicians. Ann N Y Acad Sci 809:350–360, 1997
17. Passik SD, Dugan W, McDonald MV, et al: Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol 16:1594–1600, 1998 18. Derogatis LR, Morrow GR, Fetting J, et al: The prevalence of psychiatric disorders among cancer patients. JAMA 249:751–757, 1983[Abstract] 19. Massie MJ, Holland JC: Depression and the cancer patient. J Clin Psychiatry 51:12–17, 1990[Medline] 20. Minagawa H, Uchitomi Y, Yamawaki S, et al: Psychiatric morbidity in terminally ill cancer patients. Cancer 78:1131–1137, 1996[CrossRef][Medline] 21. Hughes JE: Depressive illness and lung cancer: II. Follow-up of inoperable patients. Eur J Surg Cancer 11:21–24, 1985 22. Ginsburg ML, Quirt C, Ginsburg AD, et al: Psychiatric illness and psychosocial concerns of patients with newly diagnosed lung cancer. Can Med Assoc J 152:701–708, 1995[Abstract] 23. Montazeri A, Milroy R, Hole D, et al: Anxiety and depression in patients with lung cancer before and after diagnosis: Findings from a population in Glasgow, Scotland. J Epidemiol Community Health 52:203–204, 1998[Medline]
24. Hopwood P, Stephens RJ: Depression in patients with lung cancer: Prevalence and risk factors derived from quality-of-life data. J Clin Oncol 18:893–903, 2000 25. Akechi T, Okamura H, Nishiwaki Y, et al: Psychiatric disorders and associated and predictive factors in patients with unresectable nonsmall cell lung carcinoma. Cancer 92:2609–2622, 2001[CrossRef][Medline] 26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (ed 3), Revised. Washington, DC, American Psychiatric Press, 1987 27. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370, 1983[Medline] 28. Spitzer RL, Williams JBW, Gibbon M, et al: Structured Clinical Interview for DSM-III-R. Washington, DC, American Psychiatric Press, 1990 29. Uchitomi Y, Mikami I, Kugaya A, et al: Depression after successful treatment for nonsmall cell lung carcinoma. Cancer 89:1172–1179, 2000[CrossRef][Medline] 30. Hasegawa K: The epidemiological study of depression in late life. J Affect Disord S3–S6, 1985 (suppl 1) 31. Regier DA, Boyd JH, Burke JD Jr, et al: One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry 45:977–986, 1988[Abstract]
32. Steffens DC, Skoog I, Norton MC, et al: Prevalence of depression and its treatment in an elderly population: The Cache County study. Arch Gen Psychiatry 57:601–607, 2000 33. Kaasa S, Malt U, Hagen S, et al: Psychological distress in cancer patients with advanced disease. Radiother Oncol 27:193–197, 1993[CrossRef][Medline] 34. Cella DF, Orofiamma B, Holland JC, et al: The relationship of psychological distress, extent of disease, and performance status in patients with lung cancer. Cancer 60:1661–1667, 1987[CrossRef][Medline] 35. Dugan W, McDonald MV, Passik SD, et al: Use of the Zung Self-Rating Depression Scale in cancer patients: Feasibility as a screening tool. Psychooncology 7:483–493, 1998[CrossRef][Medline] 36. Wenzel LB, Fairclough DL, Brady MJ, et al: Age-related differences in the quality of life of breast carcinoma patients after treatment. Cancer 86:1768–1774, 1999[CrossRef][Medline]
37. Revenson TA, Wollman CA, Felton BJ: Social supports as stress buffers for adult cancer patients. Psychosom Med 45:321–331, 1983
38. Mountain CF: A new international staging system for lung cancer. Chest 89:225S–233S, 1986 (suppl) 39. McNair D, Lorr M, Droppleman L: EITS Manual for the Profile of Mood States. San Diego, CA, Educational and Industrial Testing Service, 1971
40. Kathol RG, Mutgi A, Williams J, et al: Diagnosis of major depression in cancer patients according to four sets of criteria. Am J Psychiatry 147:1021–1024, 1990 41. Yokoyama K, Araki S, Kawakami N, et al: Production of the Japanese edition of Profile of Mood States (POMS): Assessment of reliability and validity. Jpn J Public Health 37:913–918, 1990
42. Hariharan M, VanNoord T, Greden JF: A high-performance liquid-chromatographic method for routine simultaneous determination of nicotine and cotinine in plasma. Clin Chem 34:724–729, 1988 43. Spitzer WO, Dobson AJ, Hall J, et al: Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. J Chronic Dis 34:585–597, 1981[CrossRef][Medline] 44. Hopwood P, Howell A, Maguire P: Screening for psychiatric morbidity in patients with advanced breast cancer: Validation of two self-report questionnaires. Br J Cancer 64:353–356, 1991[Medline]
45. Kugaya A, Akechi T, Okuyama T, et al: Screening for psychological distress in Japanese cancer patients. Jpn J Clin Oncol 28:333–338, 1998 46. Holland JC: Preliminary guidelines for the treatment of distress. Oncology 11:109–114, 1997
47. Gilbody SM, House AO, Sheldon TA: Routinely administered questionnaires for depression and anxiety: Systematic review. BMJ 322:406–409, 2001 48. Bornstein PE, Clayton PJ, Halikas JA, et al: The depression of widowhood after thirteen months. Br J Psychiatry 122:561–566, 1973[Medline]
49. Zisook S, Shuchter SR: Depression through the first year after the death of a spouse. Am J Psychiatry 148:1346–1352, 1991 50. Weissman MM, Bland RC, Canino GJ, et al: Cross-national epidemiology of major depression and bipolar disorder. JAMA 276:293–299, 1996[Abstract]
51. Compton WM, Helzer JE, Hwu HG, et al: New methods in cross-cultural psychiatry: Psychiatric illness in Taiwan and the United States. Am J Psychiatry 148:1697–1704, 1991 52. Nakane Y, Ohta Y, Radford M, et al: Comparative study of affective disorders in three Asian countries: II. Differences in prevalence rates and symptom presentation. Acta Psychiatr Scand 84:313–319, 1991[Medline] 53. Koenig HG, Pappas P, Holsinger T, et al: Assessing diagnostic approaches to depression in medically ill older adults: How reliably can mental health professionals make judgments about the cause of symptoms? J Am Geriatr Soc 43:472–478, 1995[Medline] 54. Koenig HG, George LK, Peterson BL, et al: Depression in medically ill hospitalized older adults: Prevalence, characteristics, and course of symptoms according to six diagnostic schemes. Am J Psychiatry 154:1376–1383, 1997[Abstract] 55. Caraceni A, Cherney N, Fainsinger R, et al: Pain measurement tools and methods in clinical research in palliative care: Recommendations of an expert working group of the European Association of Palliative Care. J Pain Symptom Manage 23:239–255, 2002[CrossRef][Medline] Submitted December 27, 2001; accepted August 20, 2002. This article has been cited by other articles:
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
20 ng/mL were classified as smokers. 
2 test and the Wilcoxon rank sum test, respectively. Associations between continuous variables were examined by calculating Spearman rank correlation coefficients. The changes over time in the POMS scores were tested using the Wilcoxon test or the Friedman test. The percentages of patients with depression were compared across the two or three time points by the McNemar test or the Cochran Q test. 
