key: cord-0851651-aw0avwhu
authors: Alrubai, Tahseen; Khalil, Arwa Mohsun; Zaki, Rasha; Sinno, Loubna; AL Tabbah, Samaa
title: The psychological health of patients diagnosed with cancer in Iraq during the COVID‐19 pandemic: A single center study
date: 2021-11-09
journal: Psychooncology
DOI: 10.1002/pon.5851
sha: d916035dd5d1fe094658d2bb8bee442fd8c018bc
doc_id: 851651
cord_uid: aw0avwhu

OBJECTIVE: The objective of this study was to assess the psychological health status of patients diagnosed with cancer in Iraq during the COVID‐19 pandemic. The study aim was to measure the prevalence of depression, anxiety, and stress among patients diagnosed with cancer. Secondary aims were to assess the association between depression, anxiety, and stress with sociodemographic characteristics, cancer‐specific characteristics, patients' experience in healthcare visit, risk perception towards COVID‐19, and health concern during the outbreak. METHODS: A cross‐sectional study was conducted between September 1, 2020 and December 1, 2020 at an Oncology clinic in Baghdad. Included in the study were two hundred patients diagnosed with cancer. Data collected included: demographic variables (age, gender, residential location, marital status, education, employment status), clinical characteristics and cancer‐specific parameters (duration since cancer diagnosis, cancer type, treatment duration, clinic visits frequency), experience during the pandemic (skipping or postponing treatment or periodical tests, suffering from new body pain, fear of acquiring the infection, fear of health deterioration), as well as psychological health status (depression, anxiety, stress). Pain, risk perception towards COVID‐19, and health concern were measured using categorical Likert scale with responses being no, sometimes, and often. The psychological health status was measured by the “Depression, Anxiety, and Stress Scale” (DASS‐21). Cut‐off scores of the DASS‐21 greater than 9, 7, and 14 represent a positive screen of depression, anxiety, and stress, respectively. RESULTS: The prevalence of patients who screened positive for depression was 22.0%, anxiety 22.0%, and stress 13.5%. The prevalence of depression, anxiety and stress were significantly more in those who had university or higher education (34.3%, p‐value <0.0001; 32.3%, p‐value <0.0001; 19.2%, p‐value = 0.02 respectively). Those were four times more likely to have depression and two times more likely to have anxiety than participants who had school education (OR = 4.40 CI [1.98–9.77], p‐value <0.0001; OR = 2.55 CI [1.15–5.65], p‐value = 0.02, respectively). The prevalence of anxiety was significantly the highest in the age group 16–39 years (40.9%) compared to 22.3% in the age group 40–64 years and 10.3% in the group ≥65 years (p‐value = 0.02). Patients ≥65 years of age were less likely to develop anxiety compared to younger patients (OR = 0.44 CI [0.22–0.89], p‐value = 0.02). As for the patients' experience in healthcare visit, 66 patients (33.0%) skipped or postponed their treatment or tests due to the outbreak. Around (8%) sometimes suffered from new body pain. Those who sometimes suffered from new body pain had significantly more depression than patients who did not suffer new pain or often had new pain (50.0% vs. 15.0% vs. 28.1% respectively, p‐value = 0.002). Those were two times more likely to be depressed (OR = 2.18 CI [1.29–3.68], p‐value = 0.003). Around (50%) of the patients were often afraid that their health would deteriorate during the outbreak. Those were significantly more depressed (31.7%, p‐value = 0.002), anxious (30.7%, p‐value <0.0001) and stressed (21.8%, p‐value = 0.002) than those who did not have fear of losing their health and were two times more likely to have anxiety and stress. CONCLUSION: These findings, especially the association between developing new pain and depression, raised concerns regarding the psychological health in patients diagnosed with cancer during COVID‐19 pandemic. It is crucial to implement psychological health screening for patients diagnosed with cancer during the pandemic to help prevent any psychological health problems. The DASS‐21 could be used as a screening tool for distress in these patients.

Since its inception in December 2019, the novel coronavirus disease is spreading rapidly both locally and internationally. 1, 2 In only a span of a month, the disease caused by the virus was announced a public health emergency by the World Health Organization (WHO) and was declared a pandemic by March 2020. 3, 4 The escalating global morbidity and mortality of COVID-19 has raised significant public health concerns. 5 Between September and November 2020, reported COVID-19 cases across Iraq continued to rise with a regular average of 2,500 daily reported cases. The number of individuals who have contracted the virus as of 5 December 2020 were 564,200 cases, with a number of deaths that has reached to a total of 12,432. 6 In terms of emotions and cognition, the uncertainty of COVID-19 affected people psychologically and mentally. People were worried about getting sick, how long the pandemic would last, and what the future would bring. 7, 8 According to the Centers for Disease Control and Prevention (CDC), some groups; in particular, patients diagnosed with cancer, may be more vulnerable to the psychological and mental effects of coronavirus, and they may react more strongly to the stress of this crisis. 9, 10 Patients diagnosed with cancer and survivors had a lot to deal with before the COVID-19 pandemic began. Under usual circumstances, they are prone to psychological consequences associated with their condition. 11 Their diagnosis and treatment are major stressors that contribute to serious health problems such as loss of appetite and insomnia, as well as psychological problems, such as anxiety and depression. [12] [13] [14] They often feel worried about their future, the influence of their treatment on their lives, the side effects of their treatment, new body pain that they may feel, and the fear that their cancer will return or get worse. [15] [16] [17] Indeed, cancer-related distress and intense unpleasant emotions that interfere with functioning have been listed as common negative consequences of their diagnosis. 18 Compared with general populations, patients diagnosed with cancer are at a higher risk of psychological and mental health problems. 19 Now, the stress of their weakened immune system, the increased risk of exposure to the virus and the risk of the infectious respiratory disease, 20, 21 the uncertainty about the duration of the pandemic, and the fear of postponing their treatments cause additional anxiety for them. During this pandemic, they are finding it difficult to cope with their cancer condition. [22] [23] [24] In addition to their preexisting psychological burden, the challenges are great for them in the specific context of COVID-19, especially because cancer has a considerable share (20%) in COVID-19 mortality rate. 25 In addition, previous studies have shown the possible effects of COVID-19-related anxiety on decisionmaking processes such as postponement of surgical procedures and chemotherapy. 26 Patients with cancer are more susceptible to the COVID-19 pandemic due to immunosuppression induced by both their illness and the treatments they have undergone. This causes them fear and anxiety, and as a result, it can influence their treatment decisions. 27 Some patients postpone their follow-up appointments, chemotherapy treatments, or scheduled procedures and surgeries because they believe hospitals pose a risk of disease transmission. 27, 28 Moreover, it has been reported that having a higher frequency of worrying about 2 -ALRUBAI ET AL. cancer management due to COVID-19, having a higher frequency feeling of overwhelming psychological pressure from COVID-19, and having a higher level of fatigue and pain were the predominant risk factors for mental health problems in cancer patients. 29 In light of the above, we hypothesized that patients diagnosed with cancer are at risk of not just having adverse physical outcomes from COVID-19 pandemic, but they are also vulnerable to psychological problems such as depression, anxiety, and stress. The objective of this study was to assess the psychological health status of patients diagnosed with cancer in Iraq during the COVID-19 pandemic. The study aim was to measure the prevalence of depression, anxiety, and stress among patients diagnosed with cancer. The secondary aims were the association between depression, anxiety, and stress with sociodemographic characteristics, cancer-specific characteristics, and patients' experience in healthcare visit, risk perception towards COVID-19, and health concern during the outbreak.

A cross-sectional study was conducted between 1 September 2020 and 1 December 2020 at an Oncology clinic in Baghdad to assess the psychological health of patients diagnosed with cancer visiting the clinic during the COVID-19 pandemic. Two hundred participants were included in the study. These were patients already diagnosed with cancer and are following up their treatment or are performing check-up visits at the clinic during the period of COVID-19 pandemic.

The clinic is located in Baghdad. It treats patients with solid malignancies coming from all over Iraq. The clinic is connected to a laboratory and imaging center offering advanced computerized tomography (CT) scan, magnetic resonance imaging (MRI), and positron emission tomography (PET) scan.

Included in the study were all patients already diagnosed with cancer and are receiving their treatment or are performing check-up visits at the clinic during the data collection period between 1 September 2020 and 1 December 2020.

Excluded from the study were patients with known mental health problems or those who were being treated with psychotropic medications. Also excluded were patients diagnosed with advanced or metastatic cancer.

Participants completed the survey during their visit to the clinic. A questionnaire was used to collect the data. A nurse informed the patients about the study and explained to them details about it. An informed consent was presented to them where the nurse read it and explained it to them. The nurse then handed the patients the questionnaire where they self-reported their replies to the questions. Data collected included demographic variables such as age, gender, residential location, marital status, education, and employment status. Data pertaining to loosing appetite and sleeping problems defined as lack of sleep, insomnia, or irregular sleep during the pandemic were collected. Data about the patients' clinical characteristics and cancer-specific parameters such as duration since cancer diagnosis, cancer type, duration of treatment, and frequency of clinic visits were recorded. Data regarding patients' experience in healthcare visit, risk perception towards COVID-19, and health concern during the pandemic were also recorded. These consisted of skipping or postponing treatment or periodical tests due to COVID-19 pandemic, suffering from new body pain, fear of acquiring the infection or spreading it to relatives, and fear of health deterioration during the outbreak. Pain, risk perception towards COVID-19, and health concern were measured using categorical Likert scale with responses being no, sometimes, and often.

Furthermore, their psychological health status (depression, anxiety, and stress) during the pandemic was recorded. The latter was measured using a validated scale: the "Depression, Anxiety, and Stress Scale (DASS-21)". The scale has been demonstrated to be a reliable and valid measure for assessing mental health status in patients and general population though it was not validated in Iraq. 30 The Internal Consistency Reliability (Cronbach's Coefficient α) of the DASS-21 was 0.91 for depression, 0.80 for anxiety and 0.84 for stress. 31 It represents a psychometrically viable tool when assessing distress in patients diagnosed with cancer. Items on the depression scale assess symptoms of dysphoric mood while those on the anxiety scale measure symptoms pertaining to physiological hyperarousal, and items on the stress scale evaluate negative affectivity. 32 The score for each item ranges from zero (did not apply to me at all) to three (applied to me very much or most of the time).

The total depression subscale score was divided into normal (0-9), mild depression (10-13), moderate depression (14) (15) (16) (17) (18) (19) (20) , severe depression (21) (22) (23) (24) (25) (26) (27) , and extremely severe depression (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) . The total anxiety subscale score was divided into normal (0-7), mild anxiety (8-9), moderate anxiety (10) (11) (12) (13) (14) , severe anxiety (15) (16) (17) (18) (19) , and extremely severe anxiety . The total stress subscale score was divided into normal (0-14), mild stress (15) (16) (17) (18) , moderate stress (19) (20) (21) (22) (23) (24) (25) , severe stress (26) (27) (28) (29) (30) (31) (32) (33) , and extremely severe stress (34) (35) (36) (37) (38) (39) (40) (41) (42) . 30 

The study was approved by the Institutional Review Board of Iraqi health authorities under the number (14082020OR). Written informed consent was obtained from all participants. ALRUBAI ET AL. 

The Statistical Package for Social Sciences (SPSS version 24) was used for data management and analyses. Bivariate analyses were conducted using the Chi square test or Fisher's exact test (as appropriate) for categorical variables (comparing depression, anxiety and stress with respect to demographics, loss of appetite, sleeping problems clinical characteristics, cancer-specific parameters, experience in healthcare visit, risk perception towards COVID-19, and health concern) while student's t-test or one-way analysis of variance (ANOVA) were used for continuous variables (depression, anxiety and stress scores). Categorical variables were presented as number and percent whereas continuous variables were presented as mean and standard deviation. Furthermore, multivariate logistic regression was carried out to identify the predictors of depression, anxiety, and stress. Results were presented as odds ratios (OR) with 95% confidence intervals (CI). p-value <0.05 indicated statistical significance.

A total of 200 patients were included in the present study of which (69.5%) were in the age group between 40 and 64 years. The percentage of females was (91.5%). The majority of patients resided in Baghdad (83.0%), were married (79.5%), and unemployed (63.5%).

Most of the patients had breast cancer (71.0%) while 6.5% had colon cancer (Table 1) .

Using the pre-defined cut-off scores for the DASS-21 to measure depression (score>9), anxiety (score>7) and stress (score>14), the prevalence of patients who screened positive for depression was 22.0%, anxiety 22.0%, and stress 13.5%. As a comorbidity, 29 Figure S1 ).

Regarding the association between patients' demographic characteristics and psychological distress, using the Chi square test, the prevalence of depression was significantly the highest in the age p-value <0.0001) ( Table 3) .

Regarding cancer characteristics, most of the patients 131 (65.5%) were diagnosed more than 12 months ago and the majority had breast cancer (70.5%). Around (67%) were taking treatment for more than 12 months and (75%) visited the clinic every two months.

There was no statistically significant association between these characteristics and the development of psychological problems ( 

Patients diagnosed with cancer undergoing active treatment have the highest level of concern of getting infected by COVID-19. 33 Furthermore, patients diagnosed with cancer are considered a higher risk-group and have specific recommendations against COVID-19. All of this causes psychological depression, anxiety, and stress among them. [34] [35] [36] In this cross-sectional study, we assessed the psychological health status (depression, anxiety, and stress) of patients diagnosed with cancer in Iraq during the COVID-19 pandemic. Moreover, we assessed the association between depression, anxiety, and stress with sociodemographic characteristics, cancer-specific characteristics, patients' experience in healthcare visit, risk perception towards COVID-19, and health concern during the outbreak.

We found that the prevalence of depression was 22.0%, anxiety Our multivariate analysis showed that the significant factors for developing depression were higher education, loss of appetite, and suffering new body pain. Regarding anxiety, we found that the significant factors for developing anxiety were younger age, higher education, sleeping problems, and fear of health deterioration. As for stress, our multivariate analysis showed that the significant factor for developing stress was fear of health deterioration.

We found loss of appetite was a significant factor for developing depression. In a study carried out by Ammar et al., they reported that loss of appetite and mood swings have become quite common during COVID-19 pandemic, especially lockdown periods. 44 The association between loss of appetite and psychological distress among patients diagnosed with cancer have been already reported in many studies. 13, 14, 45 This can be explained by the fact that depressionrelated appetite loss is associated with hypoactivation of insular regions that support monitoring the body's physiological state. Importantly, the interactions among these regions also contribute to individual differences in the depression-related appetite changes. 46 In our study, we reported that around 8% of the patients In our study, the prevalence of anxiety (40.9%, p-value = 0.02) was significantly the highest in the age group 16-39 years. This association of anxiety with younger age can be explained by the fact that younger age patients diagnosed with cancer are more emotionally sensitive to a diagnosis of cancer than that in older groups. 48 Moreover, younger individuals experience intense social stressors but lack the necessary coping mechanisms, whereas people acquire increased wisdom as they age. 49 Another interpretation can be that younger patients diagnosed with cancer have higher rates of anxiety because they are socially more active and they go daily to work therefore this adds to their anxiety and fear of getting infected. 50 Our results were opposite to what was reported by Wang el al.

where lower levels of anxiety were significantly associated with younger age. 29 In our study, those who had sleeping problems experienced more anxiety than those who slept regularly. Similarly, Wang et al.

reported that those who had good sleep quality were associated with lower risk of anxiety. 29 This can be explained by the fact that sleep disturbances were always regarded as associated with depression and anxiety. 54 Moreover, recently there has been a great deal of evidence suggesting that sleep disturbances precede depression. [55] [56] [57] Regarding the professional characteristics, we found that higher education was a significant factor for developing depression and anxiety This can be interpreted by the fact that those with higher education have more knowledge of the higher risk of serious complications if infected by COVID-19 virus and the underlying fear of how the potential healthcare-capacity issues will interfere with the optimal treatment of their disease. 58 Highly educated individuals may be more anxious and stressed about adhering to COVID-19 safety recommendations than those with low levels of education. 59 

The authors thank all the participants in this study for their dedicated participation. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

There are no actual or potential competing interests to disclose in relation to this article.

The study was approved by the Institutional Review Board of Iraqi health authorities under the number (14082020OR). Written informed consent was obtained from all participants.

All the authors contributed equally to this paper.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

A novel coronavirus from patients with pneumonia in China

Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges

The COVID-19 pandemic: the public health reality

Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations

The outbreak of COVID-19 coronavirus and its impact on global mental health

Groups at Higher Risk for Severe Illness

Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry

Depression and anxiety among people living with and beyond cancer: a growing clinical and research priority

Impact of the mental health and dynamic referral for oncology (MHADRO) program on oncology patient outcomes, health care utilization, and health provider behaviors: a multi-site randomized control trial

The association between malnutrition and psychological distress in patients with advanced head-and-neck cancer

Effects of nutritional and psychological status in gastrointestinal cancer patients on tolerance of treatment

Depression and anxiety in patients with cancer

First-onset mental disorders after cancer diagnosis and cancerspecific mortality: a nationwide cohort study

Spiritual care, pain reduction, and preferred place of death among advanced cancer patients in Soweto, South Africa

Suicide in cancer patients within the first year of diagnosis

Suicidal thoughts in cancer patients: clinical experience in psycho-oncology

Cancer Research UK. The Immune System and Cancer

Roles of the immune system in cancer: from tumor initiation to metastatic progression

Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and selfreport instruments

Prevalence of depression in patients with cancer

COVID-19 and cancer: a comprehensive review

Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy

Fewer cancer diagnoses during the COVID-19 epidemic in The Netherlands

How does COVID-19 fear and anxiety affect chemotherapy adherence in patients with cancer

Breast cancer and COVID-19: the effect of fear on patients' decision-making process

Epidemiology of mental health problems among patients with cancer during COVID-19 pandemic

A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak

Psychometric evaluation and normative data for the depression

anxiety, and stress scales-21 (DASS-21) in a nonclinical sample of U. S. adults. Eval Health Prof

Multiple group confirmatory factor Analysis of the DASS-21 depression and anxiety scales: how do they perform in a cancer sample

Understanding the psychological impact of COVID-19 pandemic on patients with cancer, their caregivers, and health care workers in Singapore

COVID19 prevention & care; A cancer specific guideline

COVID-19 Rapid Guideline: Delivery of Systemic Anticancer Treatments

Repository of Advisory Documents for Cancer Treatment during the Coronavirus (COVID-19) Pandemic. 2020

Prevalence of Anxiety and Depression Among Cancer Patients during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Investigation of mental health and its influence on Chinese cancer patients using a multidisciplinary screening flow: an epidemiological survey in the west of China

Prevalence of depression in adults with cancer: a systematic review

Depression and anxiety in ovarian cancer: a systematic review and meta-analysis of prevalence rates

Post-traumatic stress disorder and cancer

Anxiety and depression in cancer patients during the COVID-19 pandemic: a single-centre study

A survey on physical and mental distress among cancer patients during the COVID-19 epidemic in Wuhan

Effects of COVID-19 home confinement on eating behaviour and physical activity: results of the ECLB-COVID19 international online survey

Why am I never hungry? What to know? Medical News Today

Depression-related increases and decreases in appetite: dissociable patterns of aberrant activity in reward and interoceptive neurocircuitry

When mental illness and cancer collide: an investigation of the predictors of outcomes for cancer patients with a history of mental health problems

Depression in adolescents and young adults with cancer

Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies

Treatment of anxiety and depression in adolescents and young adults with cancer

Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis

Depression and anxiety in cancer patients before and during the SARS-CoV-2 pandemic: association with treatment delays

Psychological distress among adults in home confinement in the midst of COVID-19 outbreak

Depression in sleep disturbance: a review on a bidirectional relationship, mechanisms and treatment

Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID-19 pandemic: a systematic review and meta-analysis

Effects of covid-19 lockdown on mental health and sleep disturbances in Italy

COVID-19, anxiety, sleep disturbances and suicide

Oncology during the COVID-19 pandemic: challenges, dilemmas and the psychosocial impact on cancer patients

Knowledge, attitudes, and practices towards COVID-19 pandemic among quarantined adults in Tigrai region

Cancer during Corona Pandemic: plight of cancer patients when two evils join hands

Stigma and discrimination (SAD) at the time of the SARS-CoV-2 pandemic

Prevalence of mental health conditions in cancer patients in acute care--a meta-analysis

COVID-19 pandemic stressors and psychological symptoms in breast cancer patients