PerspectiveIn the Journals

Cancer diagnosis increases risk for mental disorders, psychiatric medication use

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April 28, 2016

Patients diagnosed with cancer faced an increased risk for common mental disorders — such as depression, anxiety and stress reaction/adjustment disorder — for up to 10 years, according to the results of a matched cohort study conducted in Sweden.

The risk for mental disorders appeared stronger among patients whose cancers had poorer prognoses, results showed.

“Our previous work has shown highly increased risks for suicide and cardiovascular events among patients with cancer,” Donghao Lu, MD, PhD candidate in the department of medical epidemiology and biostatistics at Karolinska Institutet in Stockholm, told HemOnc Today. “These events, however likely, only represent the tip of the iceberg for the enormous psychological turmoil related to a newly received cancer diagnosis. Further, accumulating evidence suggests that the cancer diagnostic workup may also bring about severe psychological distress.”

However, the degree to which diagnostic workups may increase the risk for stress-related health outcomes, such as mental disorders, remains unknown, Lu said.

Lu and colleagues evaluated 2001 to 2010 data from Swedish population and health registers. They identified 304,118 patients with cancer (median age at diagnosis, 69 years; 46.9% female), as well as 3,041,174 cancer-free controls whom they matched to patients based on sex and year of birth.

The researchers estimated time-varying HRs — adjusted for age, sex, education level and calendar period — for the first clinical diagnosis of mental disorders beginning 2 years before cancer diagnosis, continuing through the time of diagnosis and for up to 10 years after diagnosis.

Key study endpoints included the relative risks for depression, anxiety, substance abuse, somatoform/conversion disorder, and stress reaction/adjustment disorder during the periods preceding and following a cancer diagnosis, as compared with individuals without cancer.

Overall, there were 3,355 patients with a new mental disorder diagnosis in the prediagnostic period, and 10,296 patients with a new mental disorder in the postdiagnostic period.

The researchers observed an increase in the relative rate for all studied mental disorders beginning 10 months before a cancer diagnosis (HR = 1.1; 95% CI, 1.1-1.2). The increase reached its peak in the first week following diagnosis (HR = 6.7; 95% CI, 6.1-7.4).

Although a steady decrease began following the peak period, patients with cancer still experienced an elevated risk for mental disorders up to 10 years after receiving their diagnosis (HR = 1.1; 95% CI, 1.1-1.2).

The risk appeared comparable for all disorders studied; however, the highest rate occurred for stress reaction/adjustment disorder immediately following diagnosis.

Women appeared at greater risk for mental disorders than men immediately before (HR = 1.9 vs. HR = 1.7) and immediately following (HR = 7.6 vs. HR = 5.4) diagnosis. Younger patients and those with higher education levels had higher HRs after diagnosis but not before.

The increased risk for mental disorders persisted across cancer types, with the exception of nonmelanoma skin cancer.

Patients with poorer-prognosis cancers had higher relative rates before and after diagnosis (P < .001 for both). Having advanced or metastatic cancers did not increase risk for mental disorders compared with localized or nonmetastatic disease; however, mental disorders occurred more frequently by the end of follow-up among patients with locally advanced cancer and those with metastatic breast and lung cancers.

To assess milder mental conditions and symptoms, Lu and colleagues evaluated the use of related psychiatric medications among patients diagnosed with cancer in 2008 and 2009.

Compared with matched controls, patients with cancer used psychiatric medications more frequently 1 month before diagnosis (12.2% vs. 11.7%; corrected P = .04). This rate peaked 3 months after diagnosis (18.1% vs. 11.9%; corrected P < .001) and then declined, but still remained elevated 2 years after diagnosis (15.4% vs. 12.7%; corrected P < .001).

The greatest use of psychiatric medicines occurred among patients with lung cancers, central nervous system cancers and other severe conditions. Conversely, patients with nonmelanoma skin cancer had no increase.

The researchers acknowledged their reliance on inpatient and outpatient specialist care to determine clinical diagnoses as a study limitation.

“Our findings support the existing guidelines of integrating psychological management into cancer care, and call for the extended vigilance for multiple mental disorders in cancer care,” Lu said. “We are currently examining the temporal pattern of stress experience, as well as its related health outcomes, within the time period of the cancer diagnostic workup and by patient characteristics. Our aim is to identify specific time windows or high-risk groups for potential clinical intervention.” – by Cameron Kelsall

For more information:

Donghao Lu, MD, can be reached at

Disclosure: The researchers report no relevant financial disclosures.

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Karen Syrjala

Karen Syrjala

We have lots of data that indicate the elevated psychological needs of people after a cancer diagnosis. There are two things that stand out about this report. First, the increase in those psychological needs occurs well before a diagnosis. Second, those needs remain elevated for as long as 10 years.

The population-based cohort used for this study — which included more than 3 million people in Sweden — provides strong and indisputable evidence of elevated mental health needs across cancer diagnoses and stage of disease. However, this study only identified cases of mental disorders that met a threshold of diagnosis or medication treatment by a health care provider. Many patients with cancer suffer without being diagnosed or treated for their mental health needs. This potential underdiagnosis and a disparity in access to care is suggested by the finding that less educated patients were less likely to be diagnosed with mental disorders.

Other meta-analyses reported that as many as 38% of patients with cancer have psychological distress that needs treatment, so these results are consistent with smaller studies. We need longitudinal studies to understand the course of these mental health disorders over time, to identify who is at greater risk and to determine who may benefit from more regular monitoring.

This important research underlines that psychological needs are normal before, during and long after treatment. We need to anticipate these needs, and let patients and their caregivers know that mental upheaval is a normal response to an abnormal physical and mental situation. Then we need to be ready with resources to meet these predictable mental health changes, even years after treatment.

We need to be clear with patients and caregivers in normalizing the emotional impact of cancer and its treatment. We also want to recognize — and let patients and caregivers know — that psychological needs do not end when treatment ends, even when there is no evidence of disease. Often during active treatment, patients are focused on fighting the disease and do not wish to engage in processing their emotions or changing behaviors that might help their mood in the long term. It can be months or years after treatment when we see patients seeking to process their experiences. We want to be ready with resources at the points people are ready for them, whenever that might be.

Patients feel a lot of pressure to “be positive” and make lemons out of lemonade from their diagnosis. Although that can be very adaptive, at the point that a person needs or wants to make sense of their experience or feels the weight of what they have gone through, we want to provide the support to process that experience in a genuine way that allows for the positive and negative. That can be hard to hear for family members who also have been through a lot and want to put it behind them, and for health care providers who want to celebrate successes in a context of other suffering. Medications are essential to help people manage, especially during the acute phase of care, but they may not be sufficient to meet patient needs during or after their cancer treatment.

Karen Syrjala, PhD
Fred Hutchinson Cancer Research Center

Disclosure: Syrjala reports no relevant financial disclosures.