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Depression and quality of life in cancer patients with and without pain: the role of pain beliefs

Depression and quality of life in cancer patients with and without pain: the role of pain beliefs Background: Pain is said to be one of the most feared and distressing symptoms of cancer and one that disrupts all aspects of life. The purposes of this study were: 1) to compare depression and quality of life among Iranian cancer patients with and without pain; and 2) to determine the relationships between pain beliefs and depression and quality of life. Method: A consecutive sample of gastrointestinal cancer patients attending to Tehran Cancer Institute were entered into the study. Three standard instruments were used to measure quality of life (the EORTC QLQ-C30), depression (the HADS) and pain beliefs (the PBPI). Results: A total of 142 hospitalized gastrointestinal cancer patients, 98 with pain and 44 without pain were studied. The main findings of this study were that cancer patients with pain reported significantly lower levels of role functioning, emotional functioning and global quality of life. They also showed higher levels of depression than cancer patients who did not experience pain. Among patients with pain, higher scores on pain permanence and pain consistency were positively and significantly associated with higher depression. Also, higher scores on pain consistency were negatively and significantly associated with global quality of life. Conclusion: This study has demonstrated the effect of cancer pain on patients' quality of life and emotional status and has supported the multidimensional notion of the cancer pain experience in cancer patients. Although these data are correlational, they provide additional support for a biopsychosocial model of chronic pain. the area of neuro-oncology [4], there has not been a sig- Background Pain is said to be one of the most feared and distressing nificant reduction in the prevalence of pain in patients symptoms of cancer [1,2] and one that disrupts all aspects with cancer [5]. of life [3]. Research has demonstrated that despite the effective analgesic therapy and an array of treatment Cancer pain has a significant impact on the overall quality modalities currently available as a result of advances in of a cancer patient's life by influencing physical, psycho- Page 1 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 logical, and spiritual aspects [6]. Pain is the end product instance, in a study [17] after controlling for demograph- of a complex process that may involve emotional, spirit- ics, employment status and pain severity, pain beliefs and ual, cognitive, and sensory components [7]. Cancer pain cognitions accounted for a significant amount of the vari- has characteristics of both chronic and acute pain. Like ance in general activity, pain interference, and affective acute pain, cancer pain is directly associated with tissue distress. The importance of beliefs about the meaning of damage. When cancer pain persists and worsens, it can symptoms, how they should be managed, ability to con- serve as a sign of the progression of disease [8] and can trol pain, and worry about the future have been shown to create a sense of hopelessness because patients fear that be associated with psychological functioning, physical their lives are not worth continuing or patients lose the functioning, coping, and response to treatment [18]. meaning of living if they must live in pain [9]. However, up until the last decade, very few researchers addressed the cognitive dimension of pain in cancer During the past two decades, a small body of research has patients. Given the high importance of pain belief in qual- accumulated that suggests a relationship between pain ity of life [16], it is reasonable to assess the impact that and mood disturbance in patients with cancer. Gerber- pain beliefs, may have on depression and health-related shagen et a1. [10] studied health-related quality of life quality of life in cancer patients. Thus, this aimed: 1) to inpatients with prostate cancer patients with and without compare depression and quality of life among Iranian pain. They found that depressive symptoms are signifi- cancer patients with and without pain; and 2) to deter- cantly more frequent in pain patients than in patient with- mine the relationships between pain beliefs and depres- out pain. Another study compared patients with and sion and quality of life. without pain who were matched by site and progression of disease [8]. Patients with pain scored higher on meas- Methods ures of depression as well as anxiety, hostility, and soma- Design and data collection tization. This study was conducted at a large teaching hospital (Imam Hospital) in Tehran, Iran from November 2005 to Pain is a multidimensional experience, far beyond a noci- April 2006. The intention was to interview all gastrointes- ceptive signal. It is rooted in our socio-cultural context tinal cancer inpatients attending the hospital for their and belief system [11]. Beliefs about cause, control, dura- treatments. To be included in the study patients had to be tion, outcome and blame are especially important. Even a) over the age of 18 years, b) diagnosed within the last 12 Lame et al. [12] indicated that quality of life in chronic months, and c) conscious and able to communicate. pain is more associated with beliefs about pain, than with Patients were classified into two groups: pain group and pain intensity. pain-free group based on the presence or absence of can- cer related pain. A psychologist in a face-to-face interview Although certain cognitions and beliefs may be adaptive administrated the questionnaires. In the first part of the and help patients to cope with the experience of pain, oth- investigation, depression and health-related quality of life ers may actually contribute to increased pain and affective was compared between cancer patients with and without distress. Identification of adaptive and maladaptive pain- pain. The second part of the study addressed the associa- related beliefs and cognitions might improve our under- tion between pain belief and depression and quality of standing of individual responses to chronic pain and con- life. Verbal consents obtained from all patients prior to tribute to more effective treatment interventions [13]. interview. The Ethics Committee of the Tehran University Cognitive-behavioral models of chronic pain emphasize of Medical Sciences approved the study. the importance of pain-related cognitions and beliefs in pain adjustment [14]. Pain beliefs serve the function of Measures 1. Depression helping human beings to gain a stable understanding of the events that they have, are, or will be experiencing [15]. Depression was evaluated by the Hospital Anxiety and The belief that pain is understandable has been associated Depression Scale (HADS). It is a 14-item questionnaire with better treatment compliance and use of adaptive cop- consisting of two subscales: anxiety and depression. Each ing strategies, while the belief that pain is mysterious has item is rated on a four-point scale giving maximum scores been associated with greater use of catastrophizing [16]. of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to be a significant "case" of In chronic non-cancer pain, it is generally agreed that the psychological morbidity, while scores of 8–10 represents meaning assigned to pain can play an important role in "borderline", and 0–7 "normal" [19]. The psychometric the experience of pain and in the response to treatment. properties of the Iranian version of the HADS are well Several studies have demonstrated the impact of pain cog- documented [20]. nition on patients' pain experience, disability, distress, non-adherence, and outcome of treatment [12,17,18]. For Page 2 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 2. Quality of life scores are differed in response to patients' experiences of Quality of life was assessed using the European Organiza- pain. Among patients experiencing cancer-related pain, tion for Research and Treatment of Cancer Quality of Life Pearson's correlation (r) was used to explore the relation- Questionnaire (EORTC QLQ-C30). This is a core cancer- ship among pain-related beliefs, depression and global specific questionnaire containing 30 items measuring quality of life. A p value < 0.05 was regarded to be statisti- functioning, global quality of life, and disease- and treat- cally significant. ment related symptoms [21]. The validation study of the Iranian version of the EORTC QLQ-C30 showed that it is Results a reliable and valid measure of quality of life in cancer Patients' characteristics patients [22]. For the present analysis we only used the A total of 98 cancer patients with pain and 44 cancer functioning and global quality of life scores where a patients without pain (n = 142) participated in the study. higher score indicates a better condition. Patients in the pain and pain-free groups were similar in their demographics and clinical characteristics. The 3. Pain beliefs detailed demographic and clinical data are summarized in Pain beliefs was measured using the Pain Beliefs and Per- Table 1. ceptions Inventory (PBPI). This is a 16-item scale that measures the extent of agreement or disagreement with Functioning, global quality of life, and depression certain beliefs about pain [23]. The instrument measures Functioning, global quality of life and depression scores four dimensions of pain beliefs: (1) constancy, the belief for cancer patients with and without pain are presented in that pain is constant; (2) permanence, the belief that pain Table 2. is permanent; (3) self blame, the belief that one is to blame for one's pain, and (4) mystery, the belief that pain Comparison of functioning and global quality of life is confusing and mysterious. Respondents rated the state- scores between cancer patients with and without pain ments on a Likert scale from completely agree to com- indicated that those who experienced pain showed a sig- pletely disagree. For each dimension scores range between nificant lower degree of global quality of life (P < 0.0001), -8 and 8. Higher scores on each dimension indicate more physical (P = 0.001), emotional (P = 0.014) and role func- maladaptive beliefs and perceptions about pain. The vali- tioning (P < 0.0001). In addition, the analysis showed dation study of the Iranian version of the PBPI proved that that patients in the pain group had significantly higher it is a reliable and valid measure of pain beliefs and per- levels of depressive symptoms than patients in the pain- ceptions. [24]. free group (P < 0.0001). Statistical analysis For patients with pain (n = 98), the mean (SD) pain Descriptive statistics were used to describe the sample beliefs scores on the PBPI were: pain permanence: - characteristics in terms of demographic and disease- 4.45(2.5); self-blame: -1.33(4.6); pain consistency: - related variables. The t-test was employed to determine if 2.71(3.6); mysteriousness: 1.92(3.4). Table 1: Demographic and clinical characteristics of the study sample Patients with pain (n = 98) Patients without pain (n = 44) P value No. (%) No. (%) Age (mean, SD) 54.2 (14.2) 54.6 (14.2) 0.82 Education (mean, SD) 3.3 (4.4) 4.5 (5.7) 0.21 Sex 0.57 Male 53 (54.1) 26 (59.1) Female 45 (45.9) 18 (40.9) Marital status 0.1 Married 84 (85.7) 38 (86.4) Single 7 (7.1) 6 (13.6) Widowed 7 (7.1) 0 (0) Cancer site 0.18 Esophagus 29 (29.6) 12 (27.3) Stomach 29 (29.6) 13 (29.5) Small intestine 5 (5.1) 0 (0) Colon 17 (17.3) 14 (31.8) Rectum 18 (18.4) 5 (11.4) Page 3 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 Table 2: Functioning, global quality of life, depression, and pain beliefs scores in patients with pain and without pain Patients with pain (n = 98) Mean (SD) Patients without pain (n = 44) Mean P (SD) Functioning and global quality of life scores* Physical functioning 78.6 (19.7) 82.7 (14.2) 0.21 Role functioning 62.9 (28.3) 81 (20.5) < 0.001 Emotional functioning 60.6 (22.9) 74.6 (17.4) < 0.001 Cognitive functioning 94.7 (14.1) 96.2 (12.3) 0.54 Social functioning 80.9 (23.2) 84.8 (16.4) 0.31 Global quality of life 57.9 (23.6) 72.3 (14.2) < 0.001 Depression score** HADS-D 9.2 (3.97) 6.8 (3) < 0.001 Pain beliefs scores*** Pain permanence -4.45 (2.5) NA Self-blame -1.33 (4.6) NA Pain consistency -2.71 (3.6) NA Mysteriousness 1.92 (3.4) NA *. Higher scores indicate a better condition. ** HADS-D: Depression score derived from the Hospital Anxiety and Depression Scale. Higher score indicates a greater symptom. *** Higher scores indicate more maladaptive beliefs. NA: not applicable. Relationships between pain-related beliefs, depression and study showed that pain has deleterious effects on cancer global quality of life for Patients with Pain patients' emotional status. In this study, patients with can- Pain consistency was significantly correlated with depres- cer pain had significantly lower role, emotional function- sion (r = 0.32, P = 0.001) and global quality of life (r = - ing and global quality of life scores than patients without 0.31, P = 0.002). Pain permanence was significantly corre- cancer pain. lated with depression (r = 0.3, P = 0.003), but not with global quality of life. In addition, there were no significant Depressive symptoms are significantly more frequent in relationships between depression, quality of life and self- pain patients than in patient without pain. These results blame and mysteriousness (Table 3). from the current study conducted in Iran is consistent with prior studies conducted in other countries [10,25,26] where patients with cancer pain reported significantly Discussion The results of this study provide several important impli- higher levels of perceived emotional distress due to pain cations for understanding the impact of cancer pain on than did those without pain. Lin et al. [25] studying Tai- patients' quality of life and depression. The findings of wanese cancer patients with and without pain found that this study support the multidimensional notion of the cancer patients with pain reported significantly lower lev- cancer pain experience [8] and demonstrate the effect of els of performance status and higher levels of total mood cancer pain on the psychological aspect of Iranian cancer disturbance than did cancer patients who did not experi- patients' quality of life. There have been few studies that ence pain after controlling for sex, disease stage, and directly compare emotional status of cancer patients with- recruitment site. In a study of 200 American cancer out pain to those with pain. In contrast to the physiologi- patients who were experiencing pain and 169 cancer cal components of cancer pain, there has been little prior patients who were pain-free, Glover et al. [26] found that research on other aspects of cancer pain experiences, such patients who experienced cancer pain scored significantly as psychological or emotional distress. The results of this higher on anxiety, depression, anger, fatigue, confusion, Table 3: Relationship of pain beliefs, depression and global quality of life (n = 98) Depression r (p)* Global quality of life r (p) Pain permanence 0.3 (0.003) -0.12 (0.25) Self-blame 0.13 (0.21) -0.14 (0.17) Pain consistency 0.32 (0.001) -0.31 (0.002) Mysteriousness 0.18 (0.07) -0.09 (0.37) * r = correlation coefficient, p = significant level. Page 4 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 and total mood disturbance. It is argued that pain might Although our findings should not be interpreted as indi- play a causal role in producing depression [27]. For cating that negative beliefs cause mood disturbance, they patients with progressive life-threatening diseases, pain do indicate the need for further research examining this can add greatly to the debilitating effects of the disease relationship. It is likely that there might be a mutual rela- and foster hopelessness and fear [28]. Cancer threatens tion among these variables. Greater use of longitudinal patients' existence and cancer pain may cause suffering designs should help in understanding the ability of beliefs which leads to emotional distress for cancer patients [29]. and cognitions to predict quality of life in patients who suffer from cancer related pain. However, the results of The cognitive dimension of pain refers to the way patients this study should be read with caution. This was a descrip- think about their pain and what the pain means for them, tive design and it would be useful to replicate this study in terms of thoughts, beliefs, attitudes, and self-efficacy using measures obtained by other methods, especially expectations. The meaning patients ascribe to their pain behavioral observations. may differ among different individuals [30]. Beliefs about pain are assumed to play an important role in the process Conclusion The findings demonstrated that Iranian cancer patients, of coping by influencing both the initiation of coping strategies and a person's level of adjustment. The way a similar to cancer patients in other countries, are affected patient copes with pain is influenced by the thoughts by cancer pain in many dimensions of their lives. The sim- about their pain and what the pain means for them [31]. ilarity in these patients' responses indicates that the nega- Although a considerable body of knowledge exists on the tive impact of cancer pain is not culture specific. It is role of pain cognitions in non-cancer patients, only a few important for clinicians to make every effort to prevent studies in cancer patients have shown that pain beliefs are cancer pain and to relieve pain effectively and promptly. associated with pain intensity. Arathuzik [32] found that Based on experiences from Western countries, pain ther- cognitive and emotional factors appeared to play a central apy that addresses only one component of the pain expe- role in the response to pain and in the coping methods rience might be destined to fail [36]. Interventions that used to deal with pain. Also it was found that a cognitive- address the multidimensional aspect of pain by relieving behavioral intervention can change the ability to decrease the patient's physical burden, psychological disturbance, pain [33]. Zimmerman et al. [34] found a relationship and emotional distress are more likely to lead to long- between pain intensity and psychological status. In gen- term benefits, not only for patients in Western countries eral, the cognitive dimension of cancer pain received less but also for Iranian patients. Our findings also have impli- attention compared to other aspects of cancer pain such as cations for treatment by providing an explicit rationale for physical pain. targeting the reduction of maladaptive beliefs. The results of the present study replicate and extend previ- Competing interests ous findings about relationship between pain beliefs and The authors declare that they have no competing interests. emotional functioning. In this study higher score on some pain beliefs and perceptions including pain permanence Authors' contributions and pain consistency were positively and significantly AT was the main investigator and wrote the first draft of associated with higher depression. Also, higher scores on the manuscript. AM supervised the study, analyzed the pain consistency were negatively and significantly associ- data and wrote the final draft of the manuscript. RR super- ated with global quality of life. These are similar to find- vised the study. ZT contributed to the study design. MM ings from previous studies where it was found that pain contributed to the data collection. All authors read and beliefs and cognitions were related to pain adjustment approved the final manuscript. [17,24,35]. Asghari et al [24] studied the impact of pain- related beliefs in the adjustment to cancer pain. They Acknowledgements We wish to thank Cancer Research Centre of Tehran Cancer Institute for asserted that higher scores on pain beliefs in cancer their help to carry out this study. patients are positively and significantly associated with more severe pain and higher levels of pain interference. References Also examining the effects of pain beliefs in cancer 1. Bruera E, Kim HN: Cancer pain. JAMA 2003, 290:2476-2479. patients demonstrated that perceived control over pain 2. Foley KM: Advances in cancer pain. Arch of Neurol 1999, had a direct effect on symptom distress and mediated the 56:413-416. 3. Foley KM: Pain assessment and cancer pain syndromes. In effect of beliefs about pain and pain level on symptom Textbook of palliative medicine 2nd edition. Edited by: Doyle D, Hanks distress. Patients' perceived control over pain maybe an G, MacDonald N. Oxford: Oxford University Press; 1998. 4. Foley KM: Controlling cancer pain. Hosp Pract (Minneap) 2000, important component in pain management [35]. 35(4):111-112. 5. Vainio A, Aveinen A: Prevalence of symptoms among patients with advanced cancer: an international collaborative study. J Pain Symptom Manage 1996, 12:3-10. Page 5 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 6. Ahmedzai S: Recent clinical trials of pain control: impact on 31. De Wit R, van Dam F, Litjens MJ, Abu-Saad HH: Assessment of quality of life. Eur J Cancer 1995, 31:S2-S7. Pain Cognitions in Cancer Patients with Chronic Pain. J Pain 7. Chapman CR: Psychological interventions or pain: potential Symptom Manage 2001, 2:911-924. mechanisms. In Assessment and treatment of cancer pain. Progress in 32. Arathuzik MD: The appraisal of pain and coping in cancer pain research and management Volume 12. Edited by: Payne R, Patt RB, patients. West J Nurs Res 1991, 13:714-731. Hill CS. IASP, Seattle; 1998. 33. Arathuzik D: Effects of cognitive-behavioral strategies on pain 8. Ahles TA, Blanchard EB, Ruckdeschel JC: Multidimensional nature in cancer patients. Cancer Nurs 1994, 17:207-214. of cancer pain. Pain 1983, 17:277-288. 34. Zimmerman L, Story KT, Gaston-Johansson F, Rowles JR: Psycho- 9. Ferrell BR: The impact of pain on quality of life: a decade of logical variables in cancer pain. Cancer Nurs 1994, 19:44-53. research. Nurs Clin North Am 1995, 30:609-616. 35. Vallerand AH, Templin T, Hasenau SM: Factors that affect func- 10. Gerbershagen HJ, Ozgur E, Straub K, Dagtekin O, Gerbershagen K, tional status in patients with cancer-related pain. Pain 2007, Petzke F, Heidenreich A, Lehmann KA, Sabatowski R: Prevalence, 132:82-90. severity, and chronicity of pain and general health-related 36. Ashburn MA, Staats PS: Management of chronic pain. Lancet quality of life inpatients with localized prostate cancer. Eur J 1999, 353:1865-1869. Pain 2008, 12:339-350. 11. Boothby JL, Thorn BE, Stroud MW, Jensen MP: Coping with pain. Pre-publication history In Psychosocial factors in pain Edited by: Gatchel RJ, Turk DC. New York: Guilford Press, Clinical Perspective; 1999. The pre-publication history for this paper can be accessed 12. Lame IE, Peters ML, Vlaeyen JWS, Kleef M, Patijn J: Quality of life in here: chronic pain is more associated with beliefs About pain, than with pain in tensity. European Journal of Pain 2005, 9:15-24. 13. Jensen MP, Turner JA, Romano JM, Lawler BK: Relationship of pain http://www.biomedcentral.com/1471-2407/8/177/pre specific beliefs to chronic pain adjustment. Pain 1994, pub 57:361-369. 14. Meagher RB: Cognitive-behavioral therapy in health psychol- ogy. In Handbook of clinical health psychology Edited by: Millon T, Green C, Meagher R. New York: Plenum Press; 1982. 15. Thorn BE, Williams DA: Cognitive behavioral management of chronic pain. In Innovations in clinical practice: a sourcebook Volume 12. Edited by: Vandecreek L, Knapp S, Jackson T. New York: Profes- sional Resource Press; 1992. 16. Williams DA, Keefe FJ: Pain beliefs and the use of cognitive- behavioral coping strategies. Pain 1991, 46:185-190. 17. Stroud MW, Thorn BE, Jensen MP, Boothby JL: The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients. Pain 2000, 84:347-352. 18. Turk DC, Okifuji A: Psychological factors in chronicpain: evo- lution and revolution. Journal of Consulting and Clinical Psychology 2002, 70:678-690. 19. Zigmond AS, Snaith PR: The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983, 67:337-361. 20. Montazeri A, Vahdaninia M, Ebrahimi M, Jarvandi S: The Hospital Anxiety and Depression Scale (HADS): translation and vali- dation study of the Iranian version. Health Qual Life Outcomes 2003, 1:14. 21. Aaronson NK, Ahmedzai S, Bergman B: The European Organiza- tion for Research and Treatment of Cancer QIQ-C30: A quality of life instrument for use in international clinical trails in oncology. J Natl Cancer Inst 1993, 85:265-376. 22. Montazeri A, Harirchi I, Vahdani M, Khaleghi F, Jarvandi S, Ebrahimi M, Haji-Mahmoodi M: The European Organization for Research and Treatment of Cancer Quality of life Question- naire(EORTC QLQ-C30): Translation and validation study of the Iranian version. Support Care Cancer 1999, 7:400-406. 23. Williams DA, Thorn BE: An empirical assessment of pain beliefs. Pain 1989, 36:351-358. 24. Asghari A, Karimzadeh N, Emarlow P: The role of pain-related beliefs in adjustment to cancer pain. Journal of Shahed University in press. 25. Lin CC, Lai Yl, Ward SE: Effect of Cancer Pain on Performance Status, Mood States, and Level of Hope Among Taiwanese Publish with Bio Med Central and every Cancer Patients. J Pain Symptom Manage 2003, 25:29-37. scientist can read your work free of charge 26. Glover J, Dibble SL, Dodd MJ: Mood states of oncology outpa- tients: does pain make a difference? J Pain Symptom Manage "BioMed Central will be the most significant development for 1995, 10:120-128. disseminating the results of biomedical researc h in our lifetime." 27. Spiegel D, Sand S, Koopman C: Pain and depression in patients Sir Paul Nurse, Cancer Research UK with cancer. Cancer 1994, 74:2570-2578. 28. Chapman CR, Gavrin J: Suffering: the contributions of persist- Your research papers will be: ent pain. Lancet 1999, 353:2233-2237. available free of charge to the entire biomedical community 29. Georgesen J, Dungan JM: Managing spiritual distress in patients with advanced cancer pain. Cancer Nurs 1996, 19:376-383. peer reviewed and published immediately upon acceptance 30. Blackwell P: Ascribed meaning: a critical factor in coping and cited in PubMed and archived on PubMed Central pain attenuation in patients with cancer-related pain. J Palliat Care 1991, 1991:5-14. yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Cancer Springer Journals

Depression and quality of life in cancer patients with and without pain: the role of pain beliefs

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Springer Journals
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Copyright © 2008 by Tavoli et al; licensee BioMed Central Ltd.
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Biomedicine; Cancer Research; Oncology; Surgical Oncology; Health Promotion and Disease Prevention; Biomedicine general; Medicine/Public Health, general
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1471-2407
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10.1186/1471-2407-8-177
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Abstract

Background: Pain is said to be one of the most feared and distressing symptoms of cancer and one that disrupts all aspects of life. The purposes of this study were: 1) to compare depression and quality of life among Iranian cancer patients with and without pain; and 2) to determine the relationships between pain beliefs and depression and quality of life. Method: A consecutive sample of gastrointestinal cancer patients attending to Tehran Cancer Institute were entered into the study. Three standard instruments were used to measure quality of life (the EORTC QLQ-C30), depression (the HADS) and pain beliefs (the PBPI). Results: A total of 142 hospitalized gastrointestinal cancer patients, 98 with pain and 44 without pain were studied. The main findings of this study were that cancer patients with pain reported significantly lower levels of role functioning, emotional functioning and global quality of life. They also showed higher levels of depression than cancer patients who did not experience pain. Among patients with pain, higher scores on pain permanence and pain consistency were positively and significantly associated with higher depression. Also, higher scores on pain consistency were negatively and significantly associated with global quality of life. Conclusion: This study has demonstrated the effect of cancer pain on patients' quality of life and emotional status and has supported the multidimensional notion of the cancer pain experience in cancer patients. Although these data are correlational, they provide additional support for a biopsychosocial model of chronic pain. the area of neuro-oncology [4], there has not been a sig- Background Pain is said to be one of the most feared and distressing nificant reduction in the prevalence of pain in patients symptoms of cancer [1,2] and one that disrupts all aspects with cancer [5]. of life [3]. Research has demonstrated that despite the effective analgesic therapy and an array of treatment Cancer pain has a significant impact on the overall quality modalities currently available as a result of advances in of a cancer patient's life by influencing physical, psycho- Page 1 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 logical, and spiritual aspects [6]. Pain is the end product instance, in a study [17] after controlling for demograph- of a complex process that may involve emotional, spirit- ics, employment status and pain severity, pain beliefs and ual, cognitive, and sensory components [7]. Cancer pain cognitions accounted for a significant amount of the vari- has characteristics of both chronic and acute pain. Like ance in general activity, pain interference, and affective acute pain, cancer pain is directly associated with tissue distress. The importance of beliefs about the meaning of damage. When cancer pain persists and worsens, it can symptoms, how they should be managed, ability to con- serve as a sign of the progression of disease [8] and can trol pain, and worry about the future have been shown to create a sense of hopelessness because patients fear that be associated with psychological functioning, physical their lives are not worth continuing or patients lose the functioning, coping, and response to treatment [18]. meaning of living if they must live in pain [9]. However, up until the last decade, very few researchers addressed the cognitive dimension of pain in cancer During the past two decades, a small body of research has patients. Given the high importance of pain belief in qual- accumulated that suggests a relationship between pain ity of life [16], it is reasonable to assess the impact that and mood disturbance in patients with cancer. Gerber- pain beliefs, may have on depression and health-related shagen et a1. [10] studied health-related quality of life quality of life in cancer patients. Thus, this aimed: 1) to inpatients with prostate cancer patients with and without compare depression and quality of life among Iranian pain. They found that depressive symptoms are signifi- cancer patients with and without pain; and 2) to deter- cantly more frequent in pain patients than in patient with- mine the relationships between pain beliefs and depres- out pain. Another study compared patients with and sion and quality of life. without pain who were matched by site and progression of disease [8]. Patients with pain scored higher on meas- Methods ures of depression as well as anxiety, hostility, and soma- Design and data collection tization. This study was conducted at a large teaching hospital (Imam Hospital) in Tehran, Iran from November 2005 to Pain is a multidimensional experience, far beyond a noci- April 2006. The intention was to interview all gastrointes- ceptive signal. It is rooted in our socio-cultural context tinal cancer inpatients attending the hospital for their and belief system [11]. Beliefs about cause, control, dura- treatments. To be included in the study patients had to be tion, outcome and blame are especially important. Even a) over the age of 18 years, b) diagnosed within the last 12 Lame et al. [12] indicated that quality of life in chronic months, and c) conscious and able to communicate. pain is more associated with beliefs about pain, than with Patients were classified into two groups: pain group and pain intensity. pain-free group based on the presence or absence of can- cer related pain. A psychologist in a face-to-face interview Although certain cognitions and beliefs may be adaptive administrated the questionnaires. In the first part of the and help patients to cope with the experience of pain, oth- investigation, depression and health-related quality of life ers may actually contribute to increased pain and affective was compared between cancer patients with and without distress. Identification of adaptive and maladaptive pain- pain. The second part of the study addressed the associa- related beliefs and cognitions might improve our under- tion between pain belief and depression and quality of standing of individual responses to chronic pain and con- life. Verbal consents obtained from all patients prior to tribute to more effective treatment interventions [13]. interview. The Ethics Committee of the Tehran University Cognitive-behavioral models of chronic pain emphasize of Medical Sciences approved the study. the importance of pain-related cognitions and beliefs in pain adjustment [14]. Pain beliefs serve the function of Measures 1. Depression helping human beings to gain a stable understanding of the events that they have, are, or will be experiencing [15]. Depression was evaluated by the Hospital Anxiety and The belief that pain is understandable has been associated Depression Scale (HADS). It is a 14-item questionnaire with better treatment compliance and use of adaptive cop- consisting of two subscales: anxiety and depression. Each ing strategies, while the belief that pain is mysterious has item is rated on a four-point scale giving maximum scores been associated with greater use of catastrophizing [16]. of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to be a significant "case" of In chronic non-cancer pain, it is generally agreed that the psychological morbidity, while scores of 8–10 represents meaning assigned to pain can play an important role in "borderline", and 0–7 "normal" [19]. The psychometric the experience of pain and in the response to treatment. properties of the Iranian version of the HADS are well Several studies have demonstrated the impact of pain cog- documented [20]. nition on patients' pain experience, disability, distress, non-adherence, and outcome of treatment [12,17,18]. For Page 2 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 2. Quality of life scores are differed in response to patients' experiences of Quality of life was assessed using the European Organiza- pain. Among patients experiencing cancer-related pain, tion for Research and Treatment of Cancer Quality of Life Pearson's correlation (r) was used to explore the relation- Questionnaire (EORTC QLQ-C30). This is a core cancer- ship among pain-related beliefs, depression and global specific questionnaire containing 30 items measuring quality of life. A p value < 0.05 was regarded to be statisti- functioning, global quality of life, and disease- and treat- cally significant. ment related symptoms [21]. The validation study of the Iranian version of the EORTC QLQ-C30 showed that it is Results a reliable and valid measure of quality of life in cancer Patients' characteristics patients [22]. For the present analysis we only used the A total of 98 cancer patients with pain and 44 cancer functioning and global quality of life scores where a patients without pain (n = 142) participated in the study. higher score indicates a better condition. Patients in the pain and pain-free groups were similar in their demographics and clinical characteristics. The 3. Pain beliefs detailed demographic and clinical data are summarized in Pain beliefs was measured using the Pain Beliefs and Per- Table 1. ceptions Inventory (PBPI). This is a 16-item scale that measures the extent of agreement or disagreement with Functioning, global quality of life, and depression certain beliefs about pain [23]. The instrument measures Functioning, global quality of life and depression scores four dimensions of pain beliefs: (1) constancy, the belief for cancer patients with and without pain are presented in that pain is constant; (2) permanence, the belief that pain Table 2. is permanent; (3) self blame, the belief that one is to blame for one's pain, and (4) mystery, the belief that pain Comparison of functioning and global quality of life is confusing and mysterious. Respondents rated the state- scores between cancer patients with and without pain ments on a Likert scale from completely agree to com- indicated that those who experienced pain showed a sig- pletely disagree. For each dimension scores range between nificant lower degree of global quality of life (P < 0.0001), -8 and 8. Higher scores on each dimension indicate more physical (P = 0.001), emotional (P = 0.014) and role func- maladaptive beliefs and perceptions about pain. The vali- tioning (P < 0.0001). In addition, the analysis showed dation study of the Iranian version of the PBPI proved that that patients in the pain group had significantly higher it is a reliable and valid measure of pain beliefs and per- levels of depressive symptoms than patients in the pain- ceptions. [24]. free group (P < 0.0001). Statistical analysis For patients with pain (n = 98), the mean (SD) pain Descriptive statistics were used to describe the sample beliefs scores on the PBPI were: pain permanence: - characteristics in terms of demographic and disease- 4.45(2.5); self-blame: -1.33(4.6); pain consistency: - related variables. The t-test was employed to determine if 2.71(3.6); mysteriousness: 1.92(3.4). Table 1: Demographic and clinical characteristics of the study sample Patients with pain (n = 98) Patients without pain (n = 44) P value No. (%) No. (%) Age (mean, SD) 54.2 (14.2) 54.6 (14.2) 0.82 Education (mean, SD) 3.3 (4.4) 4.5 (5.7) 0.21 Sex 0.57 Male 53 (54.1) 26 (59.1) Female 45 (45.9) 18 (40.9) Marital status 0.1 Married 84 (85.7) 38 (86.4) Single 7 (7.1) 6 (13.6) Widowed 7 (7.1) 0 (0) Cancer site 0.18 Esophagus 29 (29.6) 12 (27.3) Stomach 29 (29.6) 13 (29.5) Small intestine 5 (5.1) 0 (0) Colon 17 (17.3) 14 (31.8) Rectum 18 (18.4) 5 (11.4) Page 3 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 Table 2: Functioning, global quality of life, depression, and pain beliefs scores in patients with pain and without pain Patients with pain (n = 98) Mean (SD) Patients without pain (n = 44) Mean P (SD) Functioning and global quality of life scores* Physical functioning 78.6 (19.7) 82.7 (14.2) 0.21 Role functioning 62.9 (28.3) 81 (20.5) < 0.001 Emotional functioning 60.6 (22.9) 74.6 (17.4) < 0.001 Cognitive functioning 94.7 (14.1) 96.2 (12.3) 0.54 Social functioning 80.9 (23.2) 84.8 (16.4) 0.31 Global quality of life 57.9 (23.6) 72.3 (14.2) < 0.001 Depression score** HADS-D 9.2 (3.97) 6.8 (3) < 0.001 Pain beliefs scores*** Pain permanence -4.45 (2.5) NA Self-blame -1.33 (4.6) NA Pain consistency -2.71 (3.6) NA Mysteriousness 1.92 (3.4) NA *. Higher scores indicate a better condition. ** HADS-D: Depression score derived from the Hospital Anxiety and Depression Scale. Higher score indicates a greater symptom. *** Higher scores indicate more maladaptive beliefs. NA: not applicable. Relationships between pain-related beliefs, depression and study showed that pain has deleterious effects on cancer global quality of life for Patients with Pain patients' emotional status. In this study, patients with can- Pain consistency was significantly correlated with depres- cer pain had significantly lower role, emotional function- sion (r = 0.32, P = 0.001) and global quality of life (r = - ing and global quality of life scores than patients without 0.31, P = 0.002). Pain permanence was significantly corre- cancer pain. lated with depression (r = 0.3, P = 0.003), but not with global quality of life. In addition, there were no significant Depressive symptoms are significantly more frequent in relationships between depression, quality of life and self- pain patients than in patient without pain. These results blame and mysteriousness (Table 3). from the current study conducted in Iran is consistent with prior studies conducted in other countries [10,25,26] where patients with cancer pain reported significantly Discussion The results of this study provide several important impli- higher levels of perceived emotional distress due to pain cations for understanding the impact of cancer pain on than did those without pain. Lin et al. [25] studying Tai- patients' quality of life and depression. The findings of wanese cancer patients with and without pain found that this study support the multidimensional notion of the cancer patients with pain reported significantly lower lev- cancer pain experience [8] and demonstrate the effect of els of performance status and higher levels of total mood cancer pain on the psychological aspect of Iranian cancer disturbance than did cancer patients who did not experi- patients' quality of life. There have been few studies that ence pain after controlling for sex, disease stage, and directly compare emotional status of cancer patients with- recruitment site. In a study of 200 American cancer out pain to those with pain. In contrast to the physiologi- patients who were experiencing pain and 169 cancer cal components of cancer pain, there has been little prior patients who were pain-free, Glover et al. [26] found that research on other aspects of cancer pain experiences, such patients who experienced cancer pain scored significantly as psychological or emotional distress. The results of this higher on anxiety, depression, anger, fatigue, confusion, Table 3: Relationship of pain beliefs, depression and global quality of life (n = 98) Depression r (p)* Global quality of life r (p) Pain permanence 0.3 (0.003) -0.12 (0.25) Self-blame 0.13 (0.21) -0.14 (0.17) Pain consistency 0.32 (0.001) -0.31 (0.002) Mysteriousness 0.18 (0.07) -0.09 (0.37) * r = correlation coefficient, p = significant level. Page 4 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 and total mood disturbance. It is argued that pain might Although our findings should not be interpreted as indi- play a causal role in producing depression [27]. For cating that negative beliefs cause mood disturbance, they patients with progressive life-threatening diseases, pain do indicate the need for further research examining this can add greatly to the debilitating effects of the disease relationship. It is likely that there might be a mutual rela- and foster hopelessness and fear [28]. Cancer threatens tion among these variables. Greater use of longitudinal patients' existence and cancer pain may cause suffering designs should help in understanding the ability of beliefs which leads to emotional distress for cancer patients [29]. and cognitions to predict quality of life in patients who suffer from cancer related pain. However, the results of The cognitive dimension of pain refers to the way patients this study should be read with caution. This was a descrip- think about their pain and what the pain means for them, tive design and it would be useful to replicate this study in terms of thoughts, beliefs, attitudes, and self-efficacy using measures obtained by other methods, especially expectations. The meaning patients ascribe to their pain behavioral observations. may differ among different individuals [30]. Beliefs about pain are assumed to play an important role in the process Conclusion The findings demonstrated that Iranian cancer patients, of coping by influencing both the initiation of coping strategies and a person's level of adjustment. The way a similar to cancer patients in other countries, are affected patient copes with pain is influenced by the thoughts by cancer pain in many dimensions of their lives. The sim- about their pain and what the pain means for them [31]. ilarity in these patients' responses indicates that the nega- Although a considerable body of knowledge exists on the tive impact of cancer pain is not culture specific. It is role of pain cognitions in non-cancer patients, only a few important for clinicians to make every effort to prevent studies in cancer patients have shown that pain beliefs are cancer pain and to relieve pain effectively and promptly. associated with pain intensity. Arathuzik [32] found that Based on experiences from Western countries, pain ther- cognitive and emotional factors appeared to play a central apy that addresses only one component of the pain expe- role in the response to pain and in the coping methods rience might be destined to fail [36]. Interventions that used to deal with pain. Also it was found that a cognitive- address the multidimensional aspect of pain by relieving behavioral intervention can change the ability to decrease the patient's physical burden, psychological disturbance, pain [33]. Zimmerman et al. [34] found a relationship and emotional distress are more likely to lead to long- between pain intensity and psychological status. In gen- term benefits, not only for patients in Western countries eral, the cognitive dimension of cancer pain received less but also for Iranian patients. Our findings also have impli- attention compared to other aspects of cancer pain such as cations for treatment by providing an explicit rationale for physical pain. targeting the reduction of maladaptive beliefs. The results of the present study replicate and extend previ- Competing interests ous findings about relationship between pain beliefs and The authors declare that they have no competing interests. emotional functioning. In this study higher score on some pain beliefs and perceptions including pain permanence Authors' contributions and pain consistency were positively and significantly AT was the main investigator and wrote the first draft of associated with higher depression. Also, higher scores on the manuscript. AM supervised the study, analyzed the pain consistency were negatively and significantly associ- data and wrote the final draft of the manuscript. RR super- ated with global quality of life. These are similar to find- vised the study. ZT contributed to the study design. MM ings from previous studies where it was found that pain contributed to the data collection. All authors read and beliefs and cognitions were related to pain adjustment approved the final manuscript. [17,24,35]. Asghari et al [24] studied the impact of pain- related beliefs in the adjustment to cancer pain. They Acknowledgements We wish to thank Cancer Research Centre of Tehran Cancer Institute for asserted that higher scores on pain beliefs in cancer their help to carry out this study. patients are positively and significantly associated with more severe pain and higher levels of pain interference. References Also examining the effects of pain beliefs in cancer 1. Bruera E, Kim HN: Cancer pain. JAMA 2003, 290:2476-2479. patients demonstrated that perceived control over pain 2. Foley KM: Advances in cancer pain. Arch of Neurol 1999, had a direct effect on symptom distress and mediated the 56:413-416. 3. Foley KM: Pain assessment and cancer pain syndromes. In effect of beliefs about pain and pain level on symptom Textbook of palliative medicine 2nd edition. Edited by: Doyle D, Hanks distress. Patients' perceived control over pain maybe an G, MacDonald N. Oxford: Oxford University Press; 1998. 4. Foley KM: Controlling cancer pain. Hosp Pract (Minneap) 2000, important component in pain management [35]. 35(4):111-112. 5. Vainio A, Aveinen A: Prevalence of symptoms among patients with advanced cancer: an international collaborative study. J Pain Symptom Manage 1996, 12:3-10. Page 5 of 6 (page number not for citation purposes) BMC Cancer 2008, 8:177 http://www.biomedcentral.com/1471-2407/8/177 6. Ahmedzai S: Recent clinical trials of pain control: impact on 31. De Wit R, van Dam F, Litjens MJ, Abu-Saad HH: Assessment of quality of life. Eur J Cancer 1995, 31:S2-S7. Pain Cognitions in Cancer Patients with Chronic Pain. J Pain 7. Chapman CR: Psychological interventions or pain: potential Symptom Manage 2001, 2:911-924. mechanisms. In Assessment and treatment of cancer pain. Progress in 32. Arathuzik MD: The appraisal of pain and coping in cancer pain research and management Volume 12. Edited by: Payne R, Patt RB, patients. West J Nurs Res 1991, 13:714-731. Hill CS. IASP, Seattle; 1998. 33. Arathuzik D: Effects of cognitive-behavioral strategies on pain 8. Ahles TA, Blanchard EB, Ruckdeschel JC: Multidimensional nature in cancer patients. Cancer Nurs 1994, 17:207-214. of cancer pain. Pain 1983, 17:277-288. 34. Zimmerman L, Story KT, Gaston-Johansson F, Rowles JR: Psycho- 9. Ferrell BR: The impact of pain on quality of life: a decade of logical variables in cancer pain. Cancer Nurs 1994, 19:44-53. research. Nurs Clin North Am 1995, 30:609-616. 35. Vallerand AH, Templin T, Hasenau SM: Factors that affect func- 10. Gerbershagen HJ, Ozgur E, Straub K, Dagtekin O, Gerbershagen K, tional status in patients with cancer-related pain. Pain 2007, Petzke F, Heidenreich A, Lehmann KA, Sabatowski R: Prevalence, 132:82-90. severity, and chronicity of pain and general health-related 36. Ashburn MA, Staats PS: Management of chronic pain. Lancet quality of life inpatients with localized prostate cancer. Eur J 1999, 353:1865-1869. Pain 2008, 12:339-350. 11. Boothby JL, Thorn BE, Stroud MW, Jensen MP: Coping with pain. Pre-publication history In Psychosocial factors in pain Edited by: Gatchel RJ, Turk DC. New York: Guilford Press, Clinical Perspective; 1999. The pre-publication history for this paper can be accessed 12. Lame IE, Peters ML, Vlaeyen JWS, Kleef M, Patijn J: Quality of life in here: chronic pain is more associated with beliefs About pain, than with pain in tensity. European Journal of Pain 2005, 9:15-24. 13. Jensen MP, Turner JA, Romano JM, Lawler BK: Relationship of pain http://www.biomedcentral.com/1471-2407/8/177/pre specific beliefs to chronic pain adjustment. Pain 1994, pub 57:361-369. 14. Meagher RB: Cognitive-behavioral therapy in health psychol- ogy. In Handbook of clinical health psychology Edited by: Millon T, Green C, Meagher R. New York: Plenum Press; 1982. 15. Thorn BE, Williams DA: Cognitive behavioral management of chronic pain. In Innovations in clinical practice: a sourcebook Volume 12. Edited by: Vandecreek L, Knapp S, Jackson T. New York: Profes- sional Resource Press; 1992. 16. Williams DA, Keefe FJ: Pain beliefs and the use of cognitive- behavioral coping strategies. Pain 1991, 46:185-190. 17. Stroud MW, Thorn BE, Jensen MP, Boothby JL: The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients. Pain 2000, 84:347-352. 18. Turk DC, Okifuji A: Psychological factors in chronicpain: evo- lution and revolution. Journal of Consulting and Clinical Psychology 2002, 70:678-690. 19. Zigmond AS, Snaith PR: The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983, 67:337-361. 20. Montazeri A, Vahdaninia M, Ebrahimi M, Jarvandi S: The Hospital Anxiety and Depression Scale (HADS): translation and vali- dation study of the Iranian version. Health Qual Life Outcomes 2003, 1:14. 21. Aaronson NK, Ahmedzai S, Bergman B: The European Organiza- tion for Research and Treatment of Cancer QIQ-C30: A quality of life instrument for use in international clinical trails in oncology. J Natl Cancer Inst 1993, 85:265-376. 22. Montazeri A, Harirchi I, Vahdani M, Khaleghi F, Jarvandi S, Ebrahimi M, Haji-Mahmoodi M: The European Organization for Research and Treatment of Cancer Quality of life Question- naire(EORTC QLQ-C30): Translation and validation study of the Iranian version. Support Care Cancer 1999, 7:400-406. 23. Williams DA, Thorn BE: An empirical assessment of pain beliefs. Pain 1989, 36:351-358. 24. Asghari A, Karimzadeh N, Emarlow P: The role of pain-related beliefs in adjustment to cancer pain. Journal of Shahed University in press. 25. Lin CC, Lai Yl, Ward SE: Effect of Cancer Pain on Performance Status, Mood States, and Level of Hope Among Taiwanese Publish with Bio Med Central and every Cancer Patients. J Pain Symptom Manage 2003, 25:29-37. scientist can read your work free of charge 26. Glover J, Dibble SL, Dodd MJ: Mood states of oncology outpa- tients: does pain make a difference? J Pain Symptom Manage "BioMed Central will be the most significant development for 1995, 10:120-128. disseminating the results of biomedical researc h in our lifetime." 27. Spiegel D, Sand S, Koopman C: Pain and depression in patients Sir Paul Nurse, Cancer Research UK with cancer. Cancer 1994, 74:2570-2578. 28. Chapman CR, Gavrin J: Suffering: the contributions of persist- Your research papers will be: ent pain. Lancet 1999, 353:2233-2237. available free of charge to the entire biomedical community 29. Georgesen J, Dungan JM: Managing spiritual distress in patients with advanced cancer pain. Cancer Nurs 1996, 19:376-383. peer reviewed and published immediately upon acceptance 30. Blackwell P: Ascribed meaning: a critical factor in coping and cited in PubMed and archived on PubMed Central pain attenuation in patients with cancer-related pain. J Palliat Care 1991, 1991:5-14. yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes)

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