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The prevalence of depression and anxiety among Chinese adults with cancer: a systematic review and meta-analysis

The prevalence of depression and anxiety among Chinese adults with cancer: a systematic review... Background: A lot of empirical studies have been conducted to evaluate the prevalence of depression and anxiety among Chinese adults with cancer. We aimed to conduct a meta-analysis in order to evaluate the prevalence and odds ratios of depression and anxiety in Chinese adults with cancer compared with those without. Methods: The three most comprehensive computerized Chinese academic databases-CNKI, Wangfang and Vip databases-were systematically screened through September 2012. PubMed and Web of Science (SCIE) were also searched from their inception until September 2012 without language restrictions, and an internet search was also used. Case–control studies assessing the prevalence of depression and anxiety among Chinese adults with cancer were analyzed. Study selection and appraisal were conducted independently by three authors. The non-weighted prevalence, pooled random-effects estimates of odds ratio (OR) and 95% confidence intervals (CI) were all calculated. Results: Seventeen eligible studies with a total of 3497 subjects were included. The prevalence of depression and anxiety were significantly higher in adults with cancer compared with those without (Depression: 54.90% vs. 17.50%, OR = 7.85, 95% CI = 5.56-11.07, P = 0.000; Anxiety: 49.69% vs. 18.37%, OR = 6.46, 95% CI = 4.36-9.55, P = 0.000), the same situation was also observed in subgroup of control groups, assessment methods and cancer types. Although no difference of depression was observed in studies utilizing clinical diagnosis compared with self-report, the OR of anxiety in adults with cancer compared with those without was higher in studies utilizing clinical diagnosis (OR = 8.42, 95% CI = 4.83-14.70) than self-reports (OR = 5.83, 95% CI = 3.64-9.34). The ORs of depression and anxiety in cancer patients compared with disease group (Depression: OR = 6.03, 95% CI = 4.23-8.61; Anxiety: OR = 4.40, 95% CI = 3.05-6.36) were lower than in those compared with normal group (Depression: OR = 13.58, 95% CI = 6.26-29.46; Anxiety: OR = 15.47, 95% CI = 10.00-23.95). Conclusions: We identified high prevalence rates of depression and anxiety among Chinese adults with cancer. The findings support that the prevalence of depression and anxiety among adults with cancer should receive more attention in Chinese medical settings. Background social dysfunction), significantly increase mortality rate Depression and anxiety are psychological and physio- and lead to a massive medical costs [3-6]. logical states characterized by a collection of physical, Cancer is considered as a serious and potentially life- emotional, and behavioral components [1,2]. They are threatening illness, and even as deadly diseases without common psychological disorders that can impair health- treatment (such as some advanced cancers), which has an related quality of life (including physical, emotional and effect on psychological and physiological states of patients. Unsurprisingly, various studies have demonstrated the high levels of depression and anxiety in cancer patients * Correspondence: liewang@mail.cmu.edu.cn using a variety of assessment methods. Based on foreign Department of Social Medicine, School of Public Health, China Medical reviews, which mainly included the studies from devel- University, 92 North 2nd Road, Heping District, Shenyang 110001, People’s oped countries like America and UK, the prevalence of Republic of China © 2013 Yang et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Yang et al. BMC Cancer 2013, 13:393 Page 2 of 15 http://www.biomedcentral.com/1471-2407/13/393 major depression and depressive symptoms in cancer to evaluate the overall prevalence of depression and anxiety patients were 0%-38% and 4.5%-58% respectively in Chinese adults with cancer before planning treatment [7-10]. The prevalence of anxiety varied from 0.9% to provision. Although there are many studies evaluating the 49% in one review of 58 studies [10], and the range was level of depression and anxiety in Chinese cancer patients, narrower (5.1%-23%) in large studies using standard- there are some gaps in literatures. First, some studies did ized psychiatric interviews [7,11]. In China, the preva- not use a control group. We cannot know the level of lence of depression and anxiety in cancer patients were depression and anxiety of cancer patients compared with 25.8%-58% and 32%-40% respectively [12-14]. other populations. Second, sample size of individual study Cancer patients might be vulnerable to depression and assessing psychological distress in cancer patients is usually anxiety for many reasons: reactions to cancer diagnosis, small. Last, a recent Chinese study used the data from 36 the presence of unpleasant symptoms associated with cancer registry sites in China and from Third Chinese cancer (such as pain, nausea and fatigue), and concerns Death Cause Survey (accepted by GLOBOCAN 2008) about disease recurrence or progression. Besides, the to estimate the incidence and mortality rates of cancers physiologic effects of certain treatments (such as high-dose in 2008. The numbers of new cases and deaths from cancer interferon therapy, radiotherapy and chemotherapy) also was 2.82 million (22.3% of world total) and 1.96 million influenced anxiety and depression [15,16]. Cancer patients (25.9%) in China in 2008, and the number will forecast to with depression may present with worthlessness, hopeless- hit 2.99 million and 2.07 million by 2010, 3.88 million and ness, lose of energy and interest and suicidal preoccupation 2.76 million by 2020, and 4.87 million and 3.60 million by [17,18]. And many cancer patients are also anxious, because 2030 [31]. Now there has not been a quantitative review, anxiety is a response to a threat like cancer [19,20], and namely meta-analysis, to assess the prevalence of depres- anxiety has been shown to frequently coexist with depres- sion and anxiety in Chinese adults with cancer compared sion [17,21]. Sometimes anxiety and depression after cancer with those without, and this situation is similar to foreign diagnosis are adaptive, and may not present a problem. countries. Many foreign reviews of cancer patients with However, some patients continue to have high levels of psychological distress were only the qualitative literature re- depression and anxiety that persist for weeks or months, views [9,32,33] or the included studies of the meta-analysis and the untreated anxiety and depression can lead to did not use control group as comparison [7]. difficulty with symptom control, hampered treatment Therefore, the present meta-analysis aims to synthesize decision-making, poor compliance with treatment, individual study evaluating depression and anxiety in prolongedrecoverytimes andimpairedquality of life Chinese adults with cancer, and to assess the prevalence [9,18,22,23]. and odds ratio (OR) of depression and anxiety in Chinese Nevertheless, evidence is accumulating to suggest that adults with cancer compared with those without. identification and treatment of depression and anxiety among cancer patients will result in reduction in disease Methods progression, improvement in survival rates, reduction in Literature search medical costs and improvement in quality of life [22,24,25]. A systematic search was conducted to identify published Two recent meta-analyses suggested that compared literature on the prevalence of depression and anxiety in with control group, psychological intervention effectively Chinese adults with cancer. The CNKI database (China improved physical and mental condition of Chinese cancer National Knowledge Infrastructure), Wanfang database, patients [26,27]. Likewise, some systematic reviews and Vip database, which are the three most comprehen- suggested that psychological interventions, like cognitive sive Chinese academic database, were searched from their behavioral therapy (CBT), could be effective against anxiety inception until September 2012. We used ‘depression or and depression in cancer patients and have good potential depressive disorders or depressive symptoms’ and ‘anxiety for dissemination in routine clinical practice in America or anxiety disorder or anxiety symptoms’ combined with [28,29]. Psychosocial interventions to treat depression and ‘cancer or oncology or malignant neoplasm or malignant anxiety were also effective even in patients with advanced tumour’ as search themes in the article titles, abstracts cancer [29,30]. and keywords. The reference lists of relevant articles It should be noted that before antidepressant/anxiolytic obtained were also screened. medication, and psychotherapy are performed for cancer In order to expand searches, PubMed and Web of patients with psychological disorders, the initial recommen- Science (SCIE) were searched from their inception dation is for evaluation, diagnostic studies, and correction until September 2012 without language restrictions, and of factors potentially contributing to psychological disor- an internet search was also used (e.g., www.google.com). ders [29]. Subsequently, effective interventions and special The search strategy was: (neoplasms[MeSH Terms] OR optimum care could be developed for cancer patients based cancer[Title/Abstract] OR neoplasms[Title/Abstract] OR on these findings. Consequently, the first thing we will do is oncology[Title/Abstract]) AND (China[MeSH] OR China Yang et al. BMC Cancer 2013, 13:393 Page 3 of 15 http://www.biomedcentral.com/1471-2407/13/393 [Title/Abstract] or Mainland China[Title/Abstract]) AND for comparability or for assessment of outcome or exposure (depression [MeSH] OR depressive disorder [MeSH] were categorized as having low quality (high risk of bias), OR depression[Title/Abstract] OR depressive disorder studies that scored in between were considered as having [Title/Abstract] OR depressive symptoms[Title/Abstract] medium quality (moderate risk of bias). Any disagreements OR anxiety[MeSH] OR anxiety disorders[MeSH] OR anx- with raters (LL and YW) were resolved by discussion and iety[Title/Abstract] OR anxiety disorders[Title/Abstract] the involvement of another author (LW). OR anxiety symptoms[Title/Abstract]). The screening of the abstracts/titles and full-text articles Meta-analysis were performed twice by three authors (YLY, LL and YW) Assessment of overall effect size independently to reduce reviewer bias and errors. The effect size of OR is defined as the ratio of odds (odds = Probability/(1-probability) of depression and anx- Inclusion and exclusion criteria iety occurring in cancer group compared with non-cancer We included all studies in which: (1) the subjects were group. An OR greater than 1 indicates that depression/ aged 18 or older; (2) the subjects of cancer group were anxiety is more likely to occur in cancer group compared patients diagnosed with cancer; (3) case–control studies with control group, while an OR less than 1 indicates that were eligible, including cancer group and non-cancer the depression/anxiety is less likely to occur in cancer control group; (4) studies were included to those involving group. The pooled random-effects estimates of OR and more than 30 adults with cancer; (5) the subjects had a 95% confidence intervals (CI) were calculated by standard depression and anxiety according to clinical diagnosis as methods using the inverse variance weighting method, described in DSM-IV (Diagnostic and Statistical Manual ensuring that the larger more precise estimates were given of Mental Disorders, Fourth Edition) [34] or CCMD relatively more weighting, and non-weighted prevalence (Chinese Classification of Mental Disorders) [35] or rates were also calculated. A random effects model was HRSD/HRSA (Hamilton Rating Scale for Depression used because it involves the assumption of statistical het- and Hamilton Rating Scale for Anxiety) [36,37], or the erogeneity between studies [40,41]. For zero cell counts, depression and anxiety of both cancer group and control the standard method of adding 0.5 to each cell count was group were identified by self-report questionnaires that used [42]. Overall effects were analyzed using the statis- previous studies have established the reliability of them as tical software Stata v11.0. a measure of depression and anxiety at home and abroad; (6) the prevalence of depression and anxiety were both Assessment of heterogeneity reported in cancer group and control group; (7) the sub- Heterogeneity was evaluated with the Q statistic and I jects were from Mainland China (Hong Kong and Macao statistic. The Q statistic is used to assess whether dif- were excluded due to the long-term European influence). ferences in results are compatible with chance alone. If We excluded studies in which: (1) the studies only included thepvalueof Q statisticisabove0.05, it indicates that cancer patients; (2) it was not sure if the control group there is no significant heterogeneity [43], but the Q excluded the cancer patients; (3) depression and anx- statistic is sensitive to the number of studies [44]. To iety were measured with the self-edited scales in China complement the Q statistics, the I statistic which denotes that are not widely used and accepted at home and the variance among studies as a proportion of the total abroad. Eligibility judgment and data extraction were variance was also calculated and reported, because I is recorded and carried out independently by two authors not sensitive to the number of studies [44]. Larger values 2 2 (LL and YW) in a standardized manner. Any disagree- of I show increasing heterogeneity. An I of 0% shows no ments with them were resolved by discussion and the observed heterogeneity, while 25% shows low, 50% moder- involvement of another author (LW). ate, and 75% high levels of heterogeneity [45]. Quality assessment Subgroup analyses Although the existing checklists and quality assessment When the hypothesis of homogeneity was rejected by the scales in observational studies is controversial [38], the Qstatistic andI statistic, subgroup analysis was conducted Newcastle-Ottawa Scale for assessing quality of observa- in order to explore potential moderating factors for hetero- tional and nonrandomized studies was adapted for use geneity [44]. Meanwhile, some studies in our meta-analysis [39]. The instrument evaluated observational studies included multiple groups (e.g. liver cancer patients and based on three criteria: selection of cases, comparability breast cancer patients were compared with a single control of study groups and assessment of outcome or exposure. group). Subgroup analysis was also used to make sure We defined three categories: the study was considered to that each patient was included only once in different have high quality (low risk of bias) if it scored seven points subgroups. In our study, subgroup analyses were conducted or above, studies that scored 1 or zero for selection or zero for moderating factors, including control groups’ type Yang et al. BMC Cancer 2013, 13:393 Page 4 of 15 http://www.biomedcentral.com/1471-2407/13/393 (disease control vs. normal control), assessment methods [47]. Then Begg’s test and Egger’s test were further used of depression/anxiety (clinical diagnosis vs. self-report to more objectively test for its presence (as implemented questionnaire) and cancer types. However, due to a few of in Stata v11) [48,49]. studies (the number is less than or equal to 3) separately reporting the OR for depression and anxiety in patients Results with breast cancer, lung cancer, liver cancer, the subgroup Study selection comparison of depression and anxiety in different types of A flowchart describing the inclusion and exclusion process cancer patients were not analyzed. is presented. As shown in Figure 1, we identified the possibly eligible articles through CNKI database (n = 549), Assessment of publication bias Wangfang database (n = 642) and Vip database (n = 119). The potential of publication bias of the included studies The titles and abstracts of these possibly eligible papers was first examined by funnel plot symmetry. A funnel were respectively studied by the three authors (YLY, LL and plot is a useful graph designed to check the existence of YW), and the full-text articles without duplicates (n = 112) publication bias in meta-analyses. A symmetric funnel were selected for further examination. Based on the shape indicates that publication bias is unlikely, but an full-text of these 112 studies we finally selected 17 asymmetric funnel suggests the possibility of publication studies for the present meta-analysis [50-66]. The most bias [46]. However, some authors have argued that visual important reasons for exclusion were: did not include interpretation of funnel plots is too subjective to be useful non-cancer control group (n = 46), did not both report Records identified through Records identified through Records identified through CNKI database searching Wangfang database searching Vip database searching n=549 n=642 n=119 Excluded based on Excluded based on Excluded based on title or abstract title or abstract title or abstract n=481 n=544 n=88 Full-text retrieved Full-text retrieved Full-text retrieved n=68 n=98 n=31 Full-text articles after duplicates removed Exclude: Did not include non-cancer n=112 control group (n=46) Did not both report the prevalence of depression/anxiety in cancer and non- cancer control group (n=38) Did not meet the number prescribed in each group (n=3) The depression and anxiety scale were not commonly used and accepted (n=3) Make not it sure if the control group excluded the cancer patients (n=2) Younger than age 18 (n=2) Used the wrong scale to measure depression/anxiety (n=1) Studies included in our meta-analysis n=17 Depression Anxiety cancer vs. disease control cancer vs. disease control group (N=14) group (N=12) Depression Anxiety cancer vs. normal control cancer vs. normal control group (N=8) group (N=6) Figure 1 Selection process of studies for the review (Chinese databases). Yang et al. BMC Cancer 2013, 13:393 Page 5 of 15 http://www.biomedcentral.com/1471-2407/13/393 the prevalence of depression/anxiety in cancer and articles and 2 master’s theses, were published from non-cancer control group (n = 38). Other reasons in- 2001 to 2010, except for one in 1989. Of the 17 studies cluded the simple size, the age of subjects, methods of three were conducted among breast cancer patients, depression and anxiety assessment, and the composition three among liver cancer patients (one study included of control group. both breast cancer and liver cancer patients), two among In order to expand searches, we also searched the lung cancer patients, one among esophageal cancer, one international databases of PubMed, SCIE (as shown in among nasopharynx and liver cancer patients, and other Figure 2), and an internet search (e.g., www.google.com). studies among different types of cancers. In all of these However, we did not find any literatures that met our in- studies, in addition to one study of primary liver cancer clusion and exclusion criteria through the international diagnosed by specialist physician [58], different types of databases search. cancer were confirmed by the physicians on the basis of cytologic and pathological diagnosis. Regarding to the Characteristics of included studies disease control group, chronic hepatitis [56,58], diabetes Due to the different types of control groups, the 17 studies [63], tuberculosis [51], benign tumor [62], and other with a total of 3497 subjects produced four subgroups: (1) non-cancer medical patients [50,52,54,55,57,60,61,65] depression in cancer vs. disease control group (N = 14); (2) were included. Finally, the levels of depression and anx- depression in cancer vs. normal control group (N = 8); iety were assessed by clinical diagnosis method in five (3) anxiety in cancer vs. disease control group (N = 12); studies [50,52,53,64,66], while that of the other twelve (4) anxiety in cancer vs. normal control group (N = 6) studies was assessed by self-report questionnaires like (Figure 1). Study characteristics were listed in Table 1. Self-rating Depression Scale (SDS) and Self-rating Anxiety The studies of this meta-analysis, including 15 journal Scale (SAS). Records identified Records identified through PubMed through SCIE database searching database searching n=108 n=34 Excluded based on title or Excluded based on title or abstract abstract 1.The subjects were in Hong 1.The subjects were in Kong, Taiwan, Macao and Hong Kong, Taiwan, other foreign country (n=19) Macao and other foreign 2.Caregivers (n=1) country (n=1) 3.The subjects were 2.Caregivers (n=1) non-cancerous samples (n=1) 3.Studies were case study 4.Studies were case study or or reviews (n=5). reviews (n=5). 4.Stusies were not relevant 5.Stusies were not relevant to to our topic (n=5). our topic (n=8). 6. Younger than age 18 (n=5) Full-text retrieved Full-text retrieved n=69 n=22 Full-text articles after Exclude: Case duplicates removed Exclude: Did not study/qualitative n=75 include non-cancer research/reviews (n=2) control group (n=47) Exclude: Subject Exclude: Subjects were were not cancer (e.g., in Hong Kong/Taiwan CHD/HPV) (n=6) (n=6) Exclude: Stusies Exclude: Not report the were not relevant to prevalence of our topic (n=2) depression/anxiety (n=6) Exclude: RCT (n=6) Figure 2 Selection process of studies for the review (international databases). Yang et al. BMC Cancer 2013, 13:393 Page 6 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 1 Characteristics of the included studies Author & Years Depression/ Participants Mean age Age range Depression/Anxiety Mean score Type of cancer Type of control Prevalence of Anxiety depression/ (cancer, n) assessment method anxiety (%) and cut-off (control, n) Yang & Bao, 2003 Depression 96 53.67 22–76 self-report 47.96 ± 6.73 Mixed Disease control 63.5 96 –– (SDS index ≥0.5) 32.32 ± 5.86 17.7 Anxiety 96 53.67 22–76 self-report 49.23 ± 7.68 Mixed Disease control 60.4 96 –– (SAS index ≥0.5) 34.06 ± 5.01 13.5 Tang, 2008 Depression 150 67 60–82 self-report – Mixed Disease control 48 50 –– (SDS total score ≥11) – 16 Long et al., 2008 Depression 46 51 36–63 self-report – Mixed Disease control 63.04 50 50 30–59 (SCL-90-D mean ≥ 1.5) – 6 Anxiety 46 51 36–63 self-report – Mixed Disease control 89.13 50 50 30–59 (SCL-90-A mean ≥ 1.39) – 62 Zhang et al., 2008 Depression 60 55.9 >18 self-report 52.70 ± 8.70 Mixed Disease control 73.3 60 54.8 >18 (SDS standard score ≥ 50) 43.98 ± 9.35 31.7 Depression 60 55.9 >18 self-report 52.70 ± 8.70 Mixed Normal control 73.3 60 54.8 >18 (SDS standard score ≥ 50) 38.43 ± 7.59 8.3 Anxiety 60 55.9 >18 self-report 52.95 ± 8.35 Mixed Disease control 70 60 54.8 >18 (SAS standard score ≥ 50) 45.82 ± 10.01 48.3 Anxiety 60 55.9 >18 self-report 52.95 ± 8.35 Mixed Normal control 70 60 54.8 >18 (SAS standard score ≥ 50) 35.92 ± 8.04 11.7 Tao et al., 2005 Depression 72 47 21–69 self-report 0.54 ± 0.05 Nasopharynx/ Disease control 77.8 liver cancer 30 43 22–65 (SDS index ≥ 0.51) 0.42 ± 0.06 23.3 Depression 72 47 21–69 self-report 0.54 ± 0.05 Nasopharynx/ Normal control 77.8 liver cancer 30 42 23–65 (SDS index ≥ 0.51) 0.39 ± 0.05 10 Anxiety 72 47 21–69 self-report 50 ± 8 Nasopharynx/ Disease control 83.3 liver cancer 30 43 22–65 (SAS standard score ≥ 41) 37 ± 5 40 Anxiety 72 47 21–69 self-report 50 ± 8 Nasopharynx/ Normal control 83.3 liver cancer 30 42 23–65 (SAS standard score ≥ 41) 32 ± 5 13.3 Liu et al., 2001 Depression 45 59.24 24–78 clinical diagnosis 16.78 ± 7.75 Mixed Normal control 55.56 45 –– (HRSD total score ≥ 17) 5.87 ± 4.67 4.44 Yang et al. BMC Cancer 2013, 13:393 Page 7 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 1 Characteristics of the included studies (Continued) Anxiety 45 59.24 24–78 clinical diagnosis 14.82 ± 6.51 Mixed Normal control 46.67 45 –– (HRSA total score ≥ 14) 6.47 ± 4.73 6.67 Zhang et al., 2009 Depression 100 58.86 35–76 clinical diagnosis 42.46 ± 12.74 Breast cancer Normal control 89 100 –– (HRSD total score ≥ 20) 34.97 ± 8.31 18 Anxiety 100 58.86 35–76 clinical diagnosis 43.24 ± 10.38 Breast cancer Normal control 78 100 –– (HRSA total score ≥ 14) 32.25 ± 8.26 22 Wang et al., 2005 Depression 60 58 34–75 self–report – Lung cancer Normal control 39.58 30 51 26–68 (SDS standard score ≥ 50) – 10 Anxiety 60 58 34–75 self-report – Lung cancer Normal control 43.75 30 51 26–68 (SAS standard score ≥ 50) – 6.67 Tian et al., 2005 Depression 112 55.3 36–72 self-report 52.21 ± 5.61 Liver cancer Disease control 53.6 152 45.6 30–60 (SDS standard score ≥ 50) 44.45 ± 7.66 16.4 Anxiety 112 55.3 36–72 self-report 51.1 ± 4.64 Liver cancer Disease control 51.8 152 45.6 30–60 (SAS standard score ≥ 50) 42.99 ± 7.17 24.3 Liu, 2006 Depression 124 48 18–70 clinical diagnosis 16.95 ± 0.70 Mixed Disease control 33.26 60 – 18–70 (HRSD total score ≥ 20) 6.80 ± 1.14 3.33 Anxiety 124 48 18–70 clinical diagnosis 9.39 ± 0.51 Mixed Disease control 29.84 60 – 18–70 (HRSA total score ≥ 17) 6.30 ± 0.83 6.67 Depression 124 48 18–70 clinical diagnosis 16.95 ± 0.70 Mixed Normal control 33.26 60 – 18–70 (HRSD total score ≥ 20) 4.67 ± 0.92 1.67 Anxiety 124 48 18–70 clinical diagnosis 9.39 ± 0.51 Mixed Normal control 29.84 60 – 18–70 (HRSA total score ≥ 17) 3.63 ± 0.67 1.67 Yuan & Zheng, 2004 Depression 30 36.1 34–38 self-report 41.83 ± 12.83 Breast cancer Disease control 23.3 30 35.3 25–47 (SDS standard score > 53) 35.63 ± 6.99 0 Anxiety 30 36.1 34–38 self–report 48.93 ± 13.35 Breast cancer Disease control 33.3 30 35.3 25–47 (SAS standard score > 50) 39.30 ± 9.01 3.3 Gao et al., 1989 Depression 245 46.1 20–76 self-report – Mixed Disease control 73.1 232 46.4 20–74 (CES-D total score ≥ 16) 10.96 ± 6.46 22.5 Anxiety 245 46.1 20–76 self-report – Mixed Disease control 31.1 232 46.4 20–74 (STAI total score ≥ 27) 13.92 ± 8.15 4.8 Chen & Gao, 2010 Depression 90 53.5 38–79 clinical diagnosis – Esophageal cancer Disease control 46.7 86 51.8 36–80 (HRSD total score ≥ 20) – 12.8 Anxiety 90 53.5 38–79 clinical diagnosis – Esophageal cancer Disease control 48.9 Yang et al. BMC Cancer 2013, 13:393 Page 8 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 1 Characteristics of the included studies (Continued) 86 51.8 36–80 (HRSA total score ≥ 7) – 17.4 She, 2009 Depression 142 44.53 15–82 self-report 50.85 ± 11.57 Mixed Disease control 60.6 149 44.53 15–82 (SDS standard score ≥ 50) 46.09 ± 12.16 38.3 Anxiety 142 44.53 15–82 self-report 47.80 ± 10.8 Mixed Disease control 47.2 149 44.53 15–82 (SAS standard score ≥ 50) 44.51 ± 10.04 23.5 Zhao et al., 2001 Depression 65 51.5 29–71 self-report 0.54 ± 0.08 Liver cancer Disease control 43.08 65 –– (SDS index ≥0.5) 0.27 ± 0.12 9.23 Anxiety 65 51.5 29–71 self-report 36.86 ± 6.47 Liver cancer Disease control 24.62 65 –– (SAS standard score ≥ 50) 27.1 ± 9.76 13.69 Depression 65 51.5 29–71 self-report 0.41 ± 0.09 Breast cancer Disease control 20 65 –– (SDS index ≥0.5) 0.27 ± 0.12 9.23 Anxiety 65 51.5 29–71 self-report 44 ± 8.36 Breast cancer Disease control 20 65 –– (SAS standard score ≥ 50) 27.1 ± 9.76 13.96 Wan et al., 2004 Depression 100 44.51 20–70 self-report 15.06 ± 11.5 Primary liver cancer Disease control 49 100 –– (CES-D total score ≥ 16) 11.03 ± 15.06 27 Depression 100 44.51 20–70 self-report 15.06 ± 11.5 Primary liver cancer Normal control 49 100 –– (CES-D total score ≥ 16) 8.08 ± 8.44 17 Zhang et al., 2003 Depression 155 – >18 Clinical diagnosis 21 ± 9 Lung cancer Normal control 43.2 155 – >18 (HRSD total score >8) 9 ± 4 16.1 Abbreviations: SDS self-rating depression scale, SAS self-rating anxiety scale, SCL-90-D symptom checklist 90-depression, SCL-90-A, symptom checklist 90-anxiety, HRSD hamilton rating scale for depression, HRSA hamilton rating scale for anxiety, CES-D center for epidemiologic studies depression scale, STAI state-trait anxiety inventory; -, no report. Yang et al. BMC Cancer 2013, 13:393 Page 9 of 15 http://www.biomedcentral.com/1471-2407/13/393 Risk of bias assessment situation was observed among control group (20.27% Ratings of study quality for each of the Newcastle- vs. 12.82%, P = 0.002). Ottawa criteria were presented in Table 2. As shown in Table 2, higher scores reflect the better study quality, Odds ratios of depression and anxiety in cancer patients and the average scores of all studies were above 5. Seven A pooled random effects meta-analysis was conducted studies were judged to have low quality for selection of using data from 17 studies, which estimated the levels of cases or assessment of outcome or exposure and two of depression and anxiety in adults with cancer compared high quality; other studies were rated as medium quality. with those without. This analysis included data for 1,711 adults with cancer and 1,740 without cancer. As shown Prevalence rates of depression and anxiety in cancer patients in Figures 3 and 4, the odds of depression was associated As shown in Table 3, the overall prevalence of depression with a 7.85-fold increased risk of cancer patients when and anxiety was higher in adults with cancer compared compared with control group (OR = 7.85, 95% CI = 5.58- with those without (P < 0.001). This finding was consistent 11.07; p = 0.000), and the odds of anxiety was also more when the prevalence was determined by control groups, than six times as high in cancer patients compared with method of depression/anxiety assessment and cancer types control group (OR = 6.46, 95% CI = 4.36-9.55; p = 0.000). (P < 0.001). However, the heterogeneity analysis of the effect sizes The overall prevalence of depression and anxiety were of depression (Q = 78.36, p = 0.000; I = 73.2%) and 54.6% and 49.69% in Chinese adults with cancer, and the anxiety (Q = 61.21, p = 0.000; I = 72.2%) showed that prevalence of depression and anxiety were 18.37% and there was a relatively high amount of heterogeneity in 17.50% in non-cancer group. This prevalence of depression our meta-analysis. was higher in studies utilizing self-reports than in studies using clinical diagnosis among cancer patients (58.11% vs. Subgroup analyses 47.49%, P = 0.000), and the same situation was also ob- As shown in Table 4, the ORs of depression and anxiety served among control group (19.65% vs. 11.90%, P = 0.000). were significantly increased in adults with cancer compared Meanwhile, the prevalence of anxiety was also higher with those without on moderating factors, including the in self-reports than in clinical diagnosis among cancer subgroup of control groups, assessment methods of depres- patients (51.74% vs. 44.93%, P = 0.012), and the same sion/anxiety and cancer types. The ORs of depression and Table 2 Assessment of study quality Studies Quality Indicators from Newcastle-Ottawa scale 1 2 3 4 5A 5B 6 7 8 Total score Yang & Bao, 2003 Yes No No Yes Yes Yes No Yes No 5 Tang, 2008 Yes No No Yes Yes Yes No Yes No 5 Long et al., 2008 Yes No No Yes Yes Yes No Yes No 5 Zhang et al., 2008 Yes No Yes Yes Yes Yes No Yes No 6 Tao et al., 2005 Yes No Yes Yes Yes Yes No Yes No 6 Liu et al., 2001 Yes No Yes Yes Yes Yes Yes Yes No 7 Zhang et al., 2009 Yes No Yes Yes Yes Yes No Yes No 6 Wang et al., 2005 Yes No Yes Yes Yes Yes No Yes No 6 Tian et al., 2005 Yes No No Yes Yes Yes No Yes No 5 Liu, 2006 Yes No Yes Yes Yes Yes Yes Yes No 7 Yuan & Zheng, 2004 Yes No No Yes Yes Yes No Yes No 5 Gao et al., 1989 Yes No No Yes Yes Yes No Yes No 5 Chen & Gao, 2010 Yes No No Yes Yes Yes No Yes No 5 She, 2009 Yes No No Yes Yes Yes No Yes Yes 6 Zhao et al., 2001 Yes No No Yes Yes Yes No Yes Yes 6 Wan et al., 2004 Yes No Yes Yes Yes Yes No Yes No 6 Zhang et al., 2003 Yes No Yes Yes Yes Yes Yes Yes No 7 Abbreviations: 1 indicates cases independently validated; 2, cases are representative of population; 3, community controls; 4, controls have no history of cancer; 5A, study controls for age/gender; 5B, study controls for additional factor(s); 6, ascertainment of depression/anxiety by blinded structured interview or secure record; 7, same method of ascertainment used for cases and controls; and 8, nonresponse rate the same for cases and controls. Yang et al. BMC Cancer 2013, 13:393 Page 10 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 3 Unadjusted prevalence of depression and anxiety in adults with and without cancer No. of studies No. of subjects Cancer subjects (%) Non-cancer subjects (%) Depression (All) 17 3484 54.90*** 17.50 Control group Disease control 13 2554 54.84*** 19.61 Normal control 8 1286 55.03*** 12.98 Method of depression assessment Clinical diagnosis 5 1010 47.49*** 11.90 Self-report questionnaire 12 2474 58.11*** 19.65 Cancer type Breast cancer 3 380 55.90*** 12.97 Lung cancer 2 400 42.33*** 15.14 Liver cancer 3 794 49.34*** 17.99 Anxiety (All) 14 2684 49.69*** 18.37 Control group Disease control 11 2154 46.64*** 20.30 Normal control 6 786 57.27*** 12.00 Method of depression assessment Clinical diagnosis 4 650 44.93*** 12.82 Self-report questionnaire 10 1974 51.74*** 20.27 Cancer type Breast cancer 3 390 58.46*** 16.41 Lung cancer 1 90 43.33*** 6.67 Liver cancer 2 394 41.81*** 21.20 *** Prevalence of depression and anxiety significantly greater in patients with cancer compared with a non-cancer control group (P < 0.001). Note: The No. of studies per row is based on the independent group of cancer vs. control group. However, some studies included multiple control groups (e.g., disease and normal control). Thus, the total No. of studies per subgroup of control group is higher than the total number of the included studies in our meta-analysis. anxiety in cancer patients compared with disease control P = 0.021; Egger’s test, P = 0.019) and anxiety (Begg’s test, group (Depression: OR = 6.03, 95% CI = 4.23-8.61, I = P = 0.15; Egger’s test, P = 0.017) in our meta-analysis. 65.5%; Anxiety: OR = 4.40, 95% CI = 3.05-6.36, I = 61.6%) were lower than in those compared with normal control Discussion group (Depression: OR = 13.58, 95% CI = 6.26-29.46, I = At the beginning of discussion, we would assess the het- 79.7%; Anxiety: OR = 15.47, 95% CI = 10.00-23.95, I =0%). erogeneity and study quality in the present meta-analysis. ORs were also obtained for studies using different First, we performed strict inclusion criteria, random effects methods of depression and anxiety assessment. Although models and subgroup analyses to control and reduce the no difference of depression was observed in studies utilizing heterogeneity. However, the heterogeneity was still rela- clinical diagnosis compared with self-report, a significant tively higher, and the conclusion should be considered smaller OR of anxiety was observed in studies utilizing with some caution. Second, the Newcastle-Ottawa Scale self-reports (OR = 5.83, 95% CI = 3.64-9.34, I =75.4%) was used to assess the study quality. We only identified compared with clinical diagnosis (OR = 8.42, 95% CI = two high-quality studies. The bias of medium-quality and 4.83-14.70, I = 36.6%). low-quality studies mainly included selection of cases and Due to the small number of studies, the subgroup assessment of outcome or exposure. Quality assessment comparison of depression and anxiety in different types indicated some methodological weaknesses, which could of cancer patients were not analyzed. weaken the internal validity. The overall prevalence of depression and anxiety in Publication bias Chinese patients with cancer were 54.9% (range: 20%-89%) Visual inspection of the funnel plot indicated some and 49.69% (range: 20%-89.13%) in our meta-analysis, publication bias, and the Begg’stestand Egger’stest suggesting that depression and anxiety also did coexist in further suggested publication bias in depression (Begg’stest, Chinese cancer patients, similar to this situation in foreign Yang et al. BMC Cancer 2013, 13:393 Page 11 of 15 http://www.biomedcentral.com/1471-2407/13/393 Study % % OR (95% OR (95% CI) CI) We Weight ight ID Yang & Bao (2003) 8. 8.10 (4. 10 (4.15, 15, 15. 15.81) 81) 5. 5.62 62 4. 4.85 (2. 85 (2.13, 13, 11. 11.02) 02) 5. 5.07 07 Tang (2008) Long et al. (2008) 26. 26.73 (7. 73 (7.20, 20, 99. 99.22) 22) 3. 3.50 50 Zhang et al. (2008) 5. 5.93 (2. 93 (2.69, 69, 13. 13.07) 07) 5. 5.19 19 30. 30.25 (10. 25 (10.28, 28, 89. 89.04) 04) 4. 4.19 19 Zhang et al. (2008) Tao et al. (2005) 11. 11.50 (4. 50 (4.18, 18, 31. 31.64) 64) 4. 4.41 41 Tao et al. (2005) 31. 31.50 (8. 50 (8.45, 45, 117. 117.43) 43) 3. 3.49 49 26. 26.88 (5. 88 (5.79, 79, 124. 124.72) 72) 2. 2.95 95 Liu et al. (2001) Zhang et al. (2009) 32. 32.36 (14. 36 (14.37, 37, 72. 72.89) 89) 5. 5.11 11 Wang et al. (2005) 6. 6.00 (1. 00 (1.64, 64, 22. 22.01) 01) 3. 3.54 54 5. 5.86 (3. 86 (3.32, 32, 10. 10.34) 34) 5. 5.98 98 Tian et al. (2005) Liu (2006) 13. 13.81 (3. 81 (3.21, 21, 59. 59.40) 40) 3. 3.13 13 Liu (2006) 28. 28.10 (3. 10 (3.76, 76, 210. 210.11) 11) 2. 2.07 07 19. 19.47 (1. 47 (1.06, 06, 358. 358.38) 38) 1. 1.17 17 Yuan & Zheng (2003) Gao et al. (1989) 9. 9.43 (6. 43 (6.20, 20, 14. 14.34) 34) 6. 6.45 45 5. 5.97 (2. 97 (2.80, 80, 12. 12.71) 71) 5. 5.31 31 Chen & Gao (2010) 2. 2.48 (1. 48 (1.55, 55, 3. 3.97) 97) 6. 6.29 29 She (2009) Zhao et al. (2001) 7. 7.44 (2. 44 (2.81, 81, 19. 19.69) 69) 4. 4.54 54 2. 2.46 (0. 46 (0.87, 87, 6. 6.93) 93) 4. 4.33 33 Zhao et al. (2001) 2. 2.60 (1. 60 (1.44, 44, 4. 4.69) 69) 5. 5.90 90 Wan et al. (2004) Wan et al. (2004) 4. 4.69 (2. 69 (2.44, 44, 9. 9.01) 01) 5. 5.68 68 3. 3.96 (2. 96 (2.32, 32, 6. 6.75) 75) 6. 6.09 09 Zhang et al. (2003) 7. 7.85 (5. 85 (5.56, 56, 11. 11.07) 07) 100. 100.0 00 0 Overall (I-squared = 73.2%, p = 0.000) NOTE: Weights are from random effects analysis Odd Ratio 1 1 5 10 20 Figure 3 Forest plot for the meta-analysis of depression in adults with and without cancer. Note: Some studies included multiple cancer types (e.g., liver and breast cancer) and control groups (e.g., disease and normal control) in our meta-analysis. Thus, the total number of independent group in the forest plot is higher than the total number of the included studies in our meta-analysis. Study % OR (95% CI) Weight ID Yang & Bao (2003) 9.74 (4.77, 19.89) 6.66 5.03 (1.69, 14.95) 5.15 Long et al. (2008) 2.49 (1.18, 5.28) 6.51 Zhang et al. (2008) Zhang et al. (2008) 17.67 (6.75, 46.25) 5.64 Tao et al. (2005) 7.50 (2.88, 19.55) 5.66 32.50 (9.58, 110.26) 4.67 Tao et al. (2005) 12.25 (3.31, 45.38) 4.37 Liu et al. (2001) Zhang et al. (2009) 12.57 (6.44, 24.54) 6.84 Wang et al. (2005) 10.71 (2.34, 49.08) 3.73 3.34 (1.98, 5.64) 7.42 Tian et al. (2005) Liu (2006) 5.95 (2.01, 17.62) 5.16 Liu (2006) 25.09 (3.35, 187.94) 2.62 Yuan & Zheng (2003) 14.50 (1.72, 122.40) 2.42 8.93 (4.60, 17.34) 6.87 Gao et al. (1989) 4.53 (2.26, 9.06) 6.74 Chen & Gao (2010) She (2009) 1.94 (1.20, 3.13) 7.59 Zhao et al. (2001) 2.03 (0.82, 5.01) 5.88 4.15 (1.75, 9.81) 6.05 Zhao et al. (2001) Overall (I-squared = 72.2%, p = 0.000) 6.46 (4.36, 9.55) 100.00 NOTE: Weights are from random effects analysis 1 1 5 10 20 Odd Ratio Figure 4 Forest plot for the meta-analysis of anxiety in adults with and without cancer. Note: Some studies included multiple cancer types (e.g., liver and breast cancer) and control groups (e.g., disease and normal control) in our meta-analysis. Thus, the total number of independent group in the forest plot is higher than the total number of the included studies in our meta-analysis. Yang et al. BMC Cancer 2013, 13:393 Page 12 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 4 Odds ratios of depression and anxiety in adults with and without cancer: subgroup analyses 2 § Subgroups No. of studies No. of subjects OR 95% CI Q I (%) P Depression Control group 0.013 Disease control 13 2554 6.03 4.23-8.61 37.63*** 65.5 Normal control 8 1286 13.58 6.26-29.46 34.56*** 79.7 Method of depression assessment 0.094 Clinical diagnosis 5 1010 12.41 5.16-29.84 23.33*** 78.6 Self-report questionnaire 12 2474 6.83 4.70-9.93 52.23*** 71.3 Cancer type - Breast cancer 3 380 10.84 1.44-81.85 14.83*** 86.5 Liver cancer 3 794 4.54 2.92-7.05 5.20 42.3 Lung cancer 2 400 4.20 2.57-6.88 0.34 0 Anxiety Control group 0.000 Disease control 11 2154 4.40 3.05-6.36 28.62** 61.6 Normal control 6 786 15.47 10.00-23.95 2.44 0 Method of anxiety assessment 0.013 Clinical diagnosis 4 650 8.42 4.83-14.70 6.31 36.6 Self-report questionnaire 10 1974 5.83 3.64-9.34 48.78*** 75.4 Cancer type - Breast cancer 3 390 8.24 3.49-19.44 4.22 52.6 Liver cancer 2 394 2.95 1.87-4.63 0.87 0 **p < 0.01. ***p < 0.001. P of comparison between these subgroups. Note: The No. of studies per row is based on the independent group of cancer vs. control group. However, some studies included multiple control groups (e.g., disease and normal control). Thus, the total No. of studies per subgroup of control group is higher than the total number of the included studies in our meta-analysis. -, no report. countries [17,21]. This situation should be noticed because studies, but other reviews included at least 46 studies. Our comorbid anxiety and depressive disorders tend to results may be overestimated due to the little studies and have severe symptoms, poorer outcomes and greater high data fluctuation. Second explanation might be that use of healthcare resources than those with a single dis- most of the included studies of these reviews are from de- order [67]. Meanwhile, the results were slightly higher veloped countries which have lower prevalence of mental than some empirical studies assessing the prevalence of health problems as compared to developing countries like depression and anxiety in China [12-14]. China [69]. Third explanation might be that depression and We also compared our results with other four relatively anxiety in cancer patients were assessed using different comprehensive reviews of depression/anxiety in cancer questionnaires. The included studies of these reviews patients: (1) the review of Pirl reported the prevalence mainly used the Hospital Anxiety and Depression Scale of depression (10%-25%) based on 350 English-language (HADS), but SDS/SAS was the most commonly used in literatures published between 1966 and 2001 [68]; (2) our meta-analysis. Last explanation might be that many Hotopf showed the prevalence of depression for self- studies of these reviews used clinical diagnosis like HRSD/ reporting questionnaire (29%) and clinical diagnosis (15%) HRSA, but only five studies of our meta-analysis employed based on 46 literatures published before 2000 [9]; (3) Van’t clinical diagnosis method. Some studies indicated that the Spijker indicated the prevalence of depression (0%-46%) prevalence of depression and anxiety would be overestimate and anxiety (0.9%-49%) from 58 studies published from by self-report questionnaires compared with standardized 1980 to 1994 [10]; (4) Mitchell reported the prevalence of clinical diagnoses [20,70]. depression (20.7%-24.6%) and anxiety (9.8%-10.3%) of 94 Only reporting the prevalence of depression and anxiety interview-based studies published before 2010 [7]. There in Chinese cancer patients is not enough, it is important might be several reasons for the different prevalence. First that comparable control groups are involved so that the explanation might be that we only identified 17 eligible level of depression and anxiety in cancer patients can be Yang et al. BMC Cancer 2013, 13:393 Page 13 of 15 http://www.biomedcentral.com/1471-2407/13/393 reliably and accurately determined. The level of depression diagnoses based on HRSD/HRSA, it was necessary to (OR = 7.85, 95% CI = 5.56-11.07) and anxiety (OR = 6.46, consider that our results might be influenced by small 95% CI = 4.36-9.55) were significantly higher in adults with number of studies. cancer compared with those without. This is the first meta- analysis reporting depression and anxiety in Chinese cancer Implication patients compared with those without. A meta-analytical There are several theoretical and practical implications review also reported depression and anxiety in cancer pa- through our meta-analysis. In theory, future studies tients compared with non-cancer group [10], but it yielded assessing psychological disorders among cancer patients an overall effect size of d-value (mean difference), rather should include and specify control group. Thus, they than OR/RR. could explore the difference levels of depression/anxiety Through the subgroups analysis of control groups between cancer patients and other populations, including (disease control vs. normal control), cancer patients other non-cancer diseases, and on the other hand, a whole compared with normal group experienced the higher new perspective would be provided for researchers on the level of depression/anxiety than them compared with use of self-reports and clinical diagnosis to assess depres- disease group at the0.05 significancelevel.Moreim- sion/anxiety in cancer patients when control groups were portantly, cancer patients were significantly more de- involved. In practice, first, some studies have shown that it pressed and anxious when compared with normal and is necessary to evaluate the prevalence of depression and disease groups, respectively. The majority of studies anxiety before any effects can be provided for optimum mainly focused on the psychological disorders in can- care among cancer patients and reduction of psychological cer patients and ignored the role and type of control disorders [17,18,29]. The present meta-analysis provided group [7-9,12-14,68]. The results showed that the odds the necessary preparations for oncologists and physicians of depression/anxiety were nearly 4–6times as high in to treat and manage depression and anxiety in Chinese cancer patients, even when compared with disease control cancer patients; second, although a brief psychological including patients with chronic hepatitis [56,58], diabetes intervention could promote the quality of life and reduce [63], tuberculosis [51], benign tumor [62], and other non- depression and anxiety among cancer patients [75], oncol- cancer medical patients [50,52,54,55,57,60,61,65]. However, ogists and physicians still remained poor at detecting and the different level of depression/anxiety between cancer treating their cancer patients’ psychological problems patients and non-cancer populations has been controver- [76-78]. There might be many reasons for this situation, sial. The study of Reyes-Gibby indicated that respondents but one of these reasons could be that oncologists and with a history of cancer had excess risk for depression physicians were unaware of the levels of depression and (OR = 1.21; 95% CI = 1.06-1.37) compared to those with- anxiety in cancer patients. This meta-analysis showed that out [71]. But some studies demonstrated that depression cancer patients had higher prevalence of depression and was common not only among cancer patients, but also anxiety, indicating that depression and anxiety in Chinese nearly equally among non-cancer diseases [72,73]. cancer patients should be received sufficient attention. Some studies suggested the discrepancy between clin- ical diagnosis and self-reports measuring depression/ Limitation anxiety among cancer patients [29,74], and indicated the The present meta-analysis had several limitations. First, results would be overestimate by self-report question- although some studies demonstrated that depression naires compared with clinical diagnoses [20,70]. Our re- and anxiety might play a causal role of cancer [25,79], sults seemed to be consistent with the conclusion above. the present meta-analysis was based on cross-sectional The prevalence of depression/anxiety in cancer patients studies, which could not determine the causation or was higher in self-reports compared with clinical diagno- temporality of this association between the development sis, and this situation also occurred in non-cancer group. of cancer and depression/anxiety. Second, a lot of studies However, when control groups were involved, we found showed that there was a significant relationship between that a significant smaller OR of anxiety was observed in depression/anxiety in cancer patients and age [18,80], can- studies utilizing self-reports compared with clinical diagno- cer type [10,81,82], gender [83,84], income [85] and so on, sis, although not significantly difference between clinical but our meta-analysis did not provide enough information diagnoses and self-reports of depression. This discrepancy and number of studies regarding these potential moderat- may result from the same reason that these studies only fo- ing factors. Third, although we employed subgroup analysis cused on the cancer patients and ignored the control group to explore potential sources of heterogeneity including con- when different assessment methods of depression and anx- trol group, methods of depression/anxiety assessment and iety were used [20,29,70,71]. However, only five and four cancer types, the subgroup analysis could not reduce I studies with a combined population of 1010 and 650 were to 50% or less in many cases. Fourth, only five and four conducted to measure depression/anxiety using clinical studies with a combined population of 1010 and 650 Yang et al. BMC Cancer 2013, 13:393 Page 14 of 15 http://www.biomedcentral.com/1471-2407/13/393 were conducted using HRSD/HRSA to measure clinically 8. Massie MJ: Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr 2004, 32:57–71. significant anxiety and depression. Thus, depression and 9. Hotopf M, Chidgey J, Addington-Hall J, Lan Ly K: Depression in advanced anxiety in our meta-analysis more often referred to the de- disease: a systematic review. Part 1. Prevalence and case finding. Palliat pressive symptom and anxiety symptom. Fifth, we did not Med 2002, 16:81–97. 10. 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Chinese JRehabil Theory Pract 2006, 12:192–193 (in China). twice when calculating the overall OR of depression/ 14. Li Z, Xu HY, Bao JJ, Tang YY: An investigation of emotional disorder in anxiety. This will overestimate the precision. Finally, the cancer inpatients. J Clinical Psychosom Dis 2007, 13:250–251 (in China). 15. Capuron L, Ravaud A, Dantzer R: Early depressive symptoms in cancer high risk of publication bias is another (and perhaps the patients receiving interleukin 2 and/or interferon alfa-2b therapy. most important) limitation. J Clin Oncol 2000, 18:2143–2151. 16. Zhang GZ, Yin ZQ, You XH, Dong YJ: A study on anxiety and depression of cancer patients undergoing radiotherapy and chemotherapy in the Conclusions initial stage and their coping state. Chinese Nurs Res 2007, 21:2852–2584 We conclude that Chinese adults with cancer had higher (in China). prevalence rates of depression and anxiety compared with 17. 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The prevalence of depression and anxiety among Chinese adults with cancer: a systematic review and meta-analysis

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Springer Journals
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2013 Yang et al.; licensee BioMed Central Ltd.
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1471-2407
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1471-2407
DOI
10.1186/1471-2407-13-393
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Abstract

Background: A lot of empirical studies have been conducted to evaluate the prevalence of depression and anxiety among Chinese adults with cancer. We aimed to conduct a meta-analysis in order to evaluate the prevalence and odds ratios of depression and anxiety in Chinese adults with cancer compared with those without. Methods: The three most comprehensive computerized Chinese academic databases-CNKI, Wangfang and Vip databases-were systematically screened through September 2012. PubMed and Web of Science (SCIE) were also searched from their inception until September 2012 without language restrictions, and an internet search was also used. Case–control studies assessing the prevalence of depression and anxiety among Chinese adults with cancer were analyzed. Study selection and appraisal were conducted independently by three authors. The non-weighted prevalence, pooled random-effects estimates of odds ratio (OR) and 95% confidence intervals (CI) were all calculated. Results: Seventeen eligible studies with a total of 3497 subjects were included. The prevalence of depression and anxiety were significantly higher in adults with cancer compared with those without (Depression: 54.90% vs. 17.50%, OR = 7.85, 95% CI = 5.56-11.07, P = 0.000; Anxiety: 49.69% vs. 18.37%, OR = 6.46, 95% CI = 4.36-9.55, P = 0.000), the same situation was also observed in subgroup of control groups, assessment methods and cancer types. Although no difference of depression was observed in studies utilizing clinical diagnosis compared with self-report, the OR of anxiety in adults with cancer compared with those without was higher in studies utilizing clinical diagnosis (OR = 8.42, 95% CI = 4.83-14.70) than self-reports (OR = 5.83, 95% CI = 3.64-9.34). The ORs of depression and anxiety in cancer patients compared with disease group (Depression: OR = 6.03, 95% CI = 4.23-8.61; Anxiety: OR = 4.40, 95% CI = 3.05-6.36) were lower than in those compared with normal group (Depression: OR = 13.58, 95% CI = 6.26-29.46; Anxiety: OR = 15.47, 95% CI = 10.00-23.95). Conclusions: We identified high prevalence rates of depression and anxiety among Chinese adults with cancer. The findings support that the prevalence of depression and anxiety among adults with cancer should receive more attention in Chinese medical settings. Background social dysfunction), significantly increase mortality rate Depression and anxiety are psychological and physio- and lead to a massive medical costs [3-6]. logical states characterized by a collection of physical, Cancer is considered as a serious and potentially life- emotional, and behavioral components [1,2]. They are threatening illness, and even as deadly diseases without common psychological disorders that can impair health- treatment (such as some advanced cancers), which has an related quality of life (including physical, emotional and effect on psychological and physiological states of patients. Unsurprisingly, various studies have demonstrated the high levels of depression and anxiety in cancer patients * Correspondence: liewang@mail.cmu.edu.cn using a variety of assessment methods. Based on foreign Department of Social Medicine, School of Public Health, China Medical reviews, which mainly included the studies from devel- University, 92 North 2nd Road, Heping District, Shenyang 110001, People’s oped countries like America and UK, the prevalence of Republic of China © 2013 Yang et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Yang et al. BMC Cancer 2013, 13:393 Page 2 of 15 http://www.biomedcentral.com/1471-2407/13/393 major depression and depressive symptoms in cancer to evaluate the overall prevalence of depression and anxiety patients were 0%-38% and 4.5%-58% respectively in Chinese adults with cancer before planning treatment [7-10]. The prevalence of anxiety varied from 0.9% to provision. Although there are many studies evaluating the 49% in one review of 58 studies [10], and the range was level of depression and anxiety in Chinese cancer patients, narrower (5.1%-23%) in large studies using standard- there are some gaps in literatures. First, some studies did ized psychiatric interviews [7,11]. In China, the preva- not use a control group. We cannot know the level of lence of depression and anxiety in cancer patients were depression and anxiety of cancer patients compared with 25.8%-58% and 32%-40% respectively [12-14]. other populations. Second, sample size of individual study Cancer patients might be vulnerable to depression and assessing psychological distress in cancer patients is usually anxiety for many reasons: reactions to cancer diagnosis, small. Last, a recent Chinese study used the data from 36 the presence of unpleasant symptoms associated with cancer registry sites in China and from Third Chinese cancer (such as pain, nausea and fatigue), and concerns Death Cause Survey (accepted by GLOBOCAN 2008) about disease recurrence or progression. Besides, the to estimate the incidence and mortality rates of cancers physiologic effects of certain treatments (such as high-dose in 2008. The numbers of new cases and deaths from cancer interferon therapy, radiotherapy and chemotherapy) also was 2.82 million (22.3% of world total) and 1.96 million influenced anxiety and depression [15,16]. Cancer patients (25.9%) in China in 2008, and the number will forecast to with depression may present with worthlessness, hopeless- hit 2.99 million and 2.07 million by 2010, 3.88 million and ness, lose of energy and interest and suicidal preoccupation 2.76 million by 2020, and 4.87 million and 3.60 million by [17,18]. And many cancer patients are also anxious, because 2030 [31]. Now there has not been a quantitative review, anxiety is a response to a threat like cancer [19,20], and namely meta-analysis, to assess the prevalence of depres- anxiety has been shown to frequently coexist with depres- sion and anxiety in Chinese adults with cancer compared sion [17,21]. Sometimes anxiety and depression after cancer with those without, and this situation is similar to foreign diagnosis are adaptive, and may not present a problem. countries. Many foreign reviews of cancer patients with However, some patients continue to have high levels of psychological distress were only the qualitative literature re- depression and anxiety that persist for weeks or months, views [9,32,33] or the included studies of the meta-analysis and the untreated anxiety and depression can lead to did not use control group as comparison [7]. difficulty with symptom control, hampered treatment Therefore, the present meta-analysis aims to synthesize decision-making, poor compliance with treatment, individual study evaluating depression and anxiety in prolongedrecoverytimes andimpairedquality of life Chinese adults with cancer, and to assess the prevalence [9,18,22,23]. and odds ratio (OR) of depression and anxiety in Chinese Nevertheless, evidence is accumulating to suggest that adults with cancer compared with those without. identification and treatment of depression and anxiety among cancer patients will result in reduction in disease Methods progression, improvement in survival rates, reduction in Literature search medical costs and improvement in quality of life [22,24,25]. A systematic search was conducted to identify published Two recent meta-analyses suggested that compared literature on the prevalence of depression and anxiety in with control group, psychological intervention effectively Chinese adults with cancer. The CNKI database (China improved physical and mental condition of Chinese cancer National Knowledge Infrastructure), Wanfang database, patients [26,27]. Likewise, some systematic reviews and Vip database, which are the three most comprehen- suggested that psychological interventions, like cognitive sive Chinese academic database, were searched from their behavioral therapy (CBT), could be effective against anxiety inception until September 2012. We used ‘depression or and depression in cancer patients and have good potential depressive disorders or depressive symptoms’ and ‘anxiety for dissemination in routine clinical practice in America or anxiety disorder or anxiety symptoms’ combined with [28,29]. Psychosocial interventions to treat depression and ‘cancer or oncology or malignant neoplasm or malignant anxiety were also effective even in patients with advanced tumour’ as search themes in the article titles, abstracts cancer [29,30]. and keywords. The reference lists of relevant articles It should be noted that before antidepressant/anxiolytic obtained were also screened. medication, and psychotherapy are performed for cancer In order to expand searches, PubMed and Web of patients with psychological disorders, the initial recommen- Science (SCIE) were searched from their inception dation is for evaluation, diagnostic studies, and correction until September 2012 without language restrictions, and of factors potentially contributing to psychological disor- an internet search was also used (e.g., www.google.com). ders [29]. Subsequently, effective interventions and special The search strategy was: (neoplasms[MeSH Terms] OR optimum care could be developed for cancer patients based cancer[Title/Abstract] OR neoplasms[Title/Abstract] OR on these findings. Consequently, the first thing we will do is oncology[Title/Abstract]) AND (China[MeSH] OR China Yang et al. BMC Cancer 2013, 13:393 Page 3 of 15 http://www.biomedcentral.com/1471-2407/13/393 [Title/Abstract] or Mainland China[Title/Abstract]) AND for comparability or for assessment of outcome or exposure (depression [MeSH] OR depressive disorder [MeSH] were categorized as having low quality (high risk of bias), OR depression[Title/Abstract] OR depressive disorder studies that scored in between were considered as having [Title/Abstract] OR depressive symptoms[Title/Abstract] medium quality (moderate risk of bias). Any disagreements OR anxiety[MeSH] OR anxiety disorders[MeSH] OR anx- with raters (LL and YW) were resolved by discussion and iety[Title/Abstract] OR anxiety disorders[Title/Abstract] the involvement of another author (LW). OR anxiety symptoms[Title/Abstract]). The screening of the abstracts/titles and full-text articles Meta-analysis were performed twice by three authors (YLY, LL and YW) Assessment of overall effect size independently to reduce reviewer bias and errors. The effect size of OR is defined as the ratio of odds (odds = Probability/(1-probability) of depression and anx- Inclusion and exclusion criteria iety occurring in cancer group compared with non-cancer We included all studies in which: (1) the subjects were group. An OR greater than 1 indicates that depression/ aged 18 or older; (2) the subjects of cancer group were anxiety is more likely to occur in cancer group compared patients diagnosed with cancer; (3) case–control studies with control group, while an OR less than 1 indicates that were eligible, including cancer group and non-cancer the depression/anxiety is less likely to occur in cancer control group; (4) studies were included to those involving group. The pooled random-effects estimates of OR and more than 30 adults with cancer; (5) the subjects had a 95% confidence intervals (CI) were calculated by standard depression and anxiety according to clinical diagnosis as methods using the inverse variance weighting method, described in DSM-IV (Diagnostic and Statistical Manual ensuring that the larger more precise estimates were given of Mental Disorders, Fourth Edition) [34] or CCMD relatively more weighting, and non-weighted prevalence (Chinese Classification of Mental Disorders) [35] or rates were also calculated. A random effects model was HRSD/HRSA (Hamilton Rating Scale for Depression used because it involves the assumption of statistical het- and Hamilton Rating Scale for Anxiety) [36,37], or the erogeneity between studies [40,41]. For zero cell counts, depression and anxiety of both cancer group and control the standard method of adding 0.5 to each cell count was group were identified by self-report questionnaires that used [42]. Overall effects were analyzed using the statis- previous studies have established the reliability of them as tical software Stata v11.0. a measure of depression and anxiety at home and abroad; (6) the prevalence of depression and anxiety were both Assessment of heterogeneity reported in cancer group and control group; (7) the sub- Heterogeneity was evaluated with the Q statistic and I jects were from Mainland China (Hong Kong and Macao statistic. The Q statistic is used to assess whether dif- were excluded due to the long-term European influence). ferences in results are compatible with chance alone. If We excluded studies in which: (1) the studies only included thepvalueof Q statisticisabove0.05, it indicates that cancer patients; (2) it was not sure if the control group there is no significant heterogeneity [43], but the Q excluded the cancer patients; (3) depression and anx- statistic is sensitive to the number of studies [44]. To iety were measured with the self-edited scales in China complement the Q statistics, the I statistic which denotes that are not widely used and accepted at home and the variance among studies as a proportion of the total abroad. Eligibility judgment and data extraction were variance was also calculated and reported, because I is recorded and carried out independently by two authors not sensitive to the number of studies [44]. Larger values 2 2 (LL and YW) in a standardized manner. Any disagree- of I show increasing heterogeneity. An I of 0% shows no ments with them were resolved by discussion and the observed heterogeneity, while 25% shows low, 50% moder- involvement of another author (LW). ate, and 75% high levels of heterogeneity [45]. Quality assessment Subgroup analyses Although the existing checklists and quality assessment When the hypothesis of homogeneity was rejected by the scales in observational studies is controversial [38], the Qstatistic andI statistic, subgroup analysis was conducted Newcastle-Ottawa Scale for assessing quality of observa- in order to explore potential moderating factors for hetero- tional and nonrandomized studies was adapted for use geneity [44]. Meanwhile, some studies in our meta-analysis [39]. The instrument evaluated observational studies included multiple groups (e.g. liver cancer patients and based on three criteria: selection of cases, comparability breast cancer patients were compared with a single control of study groups and assessment of outcome or exposure. group). Subgroup analysis was also used to make sure We defined three categories: the study was considered to that each patient was included only once in different have high quality (low risk of bias) if it scored seven points subgroups. In our study, subgroup analyses were conducted or above, studies that scored 1 or zero for selection or zero for moderating factors, including control groups’ type Yang et al. BMC Cancer 2013, 13:393 Page 4 of 15 http://www.biomedcentral.com/1471-2407/13/393 (disease control vs. normal control), assessment methods [47]. Then Begg’s test and Egger’s test were further used of depression/anxiety (clinical diagnosis vs. self-report to more objectively test for its presence (as implemented questionnaire) and cancer types. However, due to a few of in Stata v11) [48,49]. studies (the number is less than or equal to 3) separately reporting the OR for depression and anxiety in patients Results with breast cancer, lung cancer, liver cancer, the subgroup Study selection comparison of depression and anxiety in different types of A flowchart describing the inclusion and exclusion process cancer patients were not analyzed. is presented. As shown in Figure 1, we identified the possibly eligible articles through CNKI database (n = 549), Assessment of publication bias Wangfang database (n = 642) and Vip database (n = 119). The potential of publication bias of the included studies The titles and abstracts of these possibly eligible papers was first examined by funnel plot symmetry. A funnel were respectively studied by the three authors (YLY, LL and plot is a useful graph designed to check the existence of YW), and the full-text articles without duplicates (n = 112) publication bias in meta-analyses. A symmetric funnel were selected for further examination. Based on the shape indicates that publication bias is unlikely, but an full-text of these 112 studies we finally selected 17 asymmetric funnel suggests the possibility of publication studies for the present meta-analysis [50-66]. The most bias [46]. However, some authors have argued that visual important reasons for exclusion were: did not include interpretation of funnel plots is too subjective to be useful non-cancer control group (n = 46), did not both report Records identified through Records identified through Records identified through CNKI database searching Wangfang database searching Vip database searching n=549 n=642 n=119 Excluded based on Excluded based on Excluded based on title or abstract title or abstract title or abstract n=481 n=544 n=88 Full-text retrieved Full-text retrieved Full-text retrieved n=68 n=98 n=31 Full-text articles after duplicates removed Exclude: Did not include non-cancer n=112 control group (n=46) Did not both report the prevalence of depression/anxiety in cancer and non- cancer control group (n=38) Did not meet the number prescribed in each group (n=3) The depression and anxiety scale were not commonly used and accepted (n=3) Make not it sure if the control group excluded the cancer patients (n=2) Younger than age 18 (n=2) Used the wrong scale to measure depression/anxiety (n=1) Studies included in our meta-analysis n=17 Depression Anxiety cancer vs. disease control cancer vs. disease control group (N=14) group (N=12) Depression Anxiety cancer vs. normal control cancer vs. normal control group (N=8) group (N=6) Figure 1 Selection process of studies for the review (Chinese databases). Yang et al. BMC Cancer 2013, 13:393 Page 5 of 15 http://www.biomedcentral.com/1471-2407/13/393 the prevalence of depression/anxiety in cancer and articles and 2 master’s theses, were published from non-cancer control group (n = 38). Other reasons in- 2001 to 2010, except for one in 1989. Of the 17 studies cluded the simple size, the age of subjects, methods of three were conducted among breast cancer patients, depression and anxiety assessment, and the composition three among liver cancer patients (one study included of control group. both breast cancer and liver cancer patients), two among In order to expand searches, we also searched the lung cancer patients, one among esophageal cancer, one international databases of PubMed, SCIE (as shown in among nasopharynx and liver cancer patients, and other Figure 2), and an internet search (e.g., www.google.com). studies among different types of cancers. In all of these However, we did not find any literatures that met our in- studies, in addition to one study of primary liver cancer clusion and exclusion criteria through the international diagnosed by specialist physician [58], different types of databases search. cancer were confirmed by the physicians on the basis of cytologic and pathological diagnosis. Regarding to the Characteristics of included studies disease control group, chronic hepatitis [56,58], diabetes Due to the different types of control groups, the 17 studies [63], tuberculosis [51], benign tumor [62], and other with a total of 3497 subjects produced four subgroups: (1) non-cancer medical patients [50,52,54,55,57,60,61,65] depression in cancer vs. disease control group (N = 14); (2) were included. Finally, the levels of depression and anx- depression in cancer vs. normal control group (N = 8); iety were assessed by clinical diagnosis method in five (3) anxiety in cancer vs. disease control group (N = 12); studies [50,52,53,64,66], while that of the other twelve (4) anxiety in cancer vs. normal control group (N = 6) studies was assessed by self-report questionnaires like (Figure 1). Study characteristics were listed in Table 1. Self-rating Depression Scale (SDS) and Self-rating Anxiety The studies of this meta-analysis, including 15 journal Scale (SAS). Records identified Records identified through PubMed through SCIE database searching database searching n=108 n=34 Excluded based on title or Excluded based on title or abstract abstract 1.The subjects were in Hong 1.The subjects were in Kong, Taiwan, Macao and Hong Kong, Taiwan, other foreign country (n=19) Macao and other foreign 2.Caregivers (n=1) country (n=1) 3.The subjects were 2.Caregivers (n=1) non-cancerous samples (n=1) 3.Studies were case study 4.Studies were case study or or reviews (n=5). reviews (n=5). 4.Stusies were not relevant 5.Stusies were not relevant to to our topic (n=5). our topic (n=8). 6. Younger than age 18 (n=5) Full-text retrieved Full-text retrieved n=69 n=22 Full-text articles after Exclude: Case duplicates removed Exclude: Did not study/qualitative n=75 include non-cancer research/reviews (n=2) control group (n=47) Exclude: Subject Exclude: Subjects were were not cancer (e.g., in Hong Kong/Taiwan CHD/HPV) (n=6) (n=6) Exclude: Stusies Exclude: Not report the were not relevant to prevalence of our topic (n=2) depression/anxiety (n=6) Exclude: RCT (n=6) Figure 2 Selection process of studies for the review (international databases). Yang et al. BMC Cancer 2013, 13:393 Page 6 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 1 Characteristics of the included studies Author & Years Depression/ Participants Mean age Age range Depression/Anxiety Mean score Type of cancer Type of control Prevalence of Anxiety depression/ (cancer, n) assessment method anxiety (%) and cut-off (control, n) Yang & Bao, 2003 Depression 96 53.67 22–76 self-report 47.96 ± 6.73 Mixed Disease control 63.5 96 –– (SDS index ≥0.5) 32.32 ± 5.86 17.7 Anxiety 96 53.67 22–76 self-report 49.23 ± 7.68 Mixed Disease control 60.4 96 –– (SAS index ≥0.5) 34.06 ± 5.01 13.5 Tang, 2008 Depression 150 67 60–82 self-report – Mixed Disease control 48 50 –– (SDS total score ≥11) – 16 Long et al., 2008 Depression 46 51 36–63 self-report – Mixed Disease control 63.04 50 50 30–59 (SCL-90-D mean ≥ 1.5) – 6 Anxiety 46 51 36–63 self-report – Mixed Disease control 89.13 50 50 30–59 (SCL-90-A mean ≥ 1.39) – 62 Zhang et al., 2008 Depression 60 55.9 >18 self-report 52.70 ± 8.70 Mixed Disease control 73.3 60 54.8 >18 (SDS standard score ≥ 50) 43.98 ± 9.35 31.7 Depression 60 55.9 >18 self-report 52.70 ± 8.70 Mixed Normal control 73.3 60 54.8 >18 (SDS standard score ≥ 50) 38.43 ± 7.59 8.3 Anxiety 60 55.9 >18 self-report 52.95 ± 8.35 Mixed Disease control 70 60 54.8 >18 (SAS standard score ≥ 50) 45.82 ± 10.01 48.3 Anxiety 60 55.9 >18 self-report 52.95 ± 8.35 Mixed Normal control 70 60 54.8 >18 (SAS standard score ≥ 50) 35.92 ± 8.04 11.7 Tao et al., 2005 Depression 72 47 21–69 self-report 0.54 ± 0.05 Nasopharynx/ Disease control 77.8 liver cancer 30 43 22–65 (SDS index ≥ 0.51) 0.42 ± 0.06 23.3 Depression 72 47 21–69 self-report 0.54 ± 0.05 Nasopharynx/ Normal control 77.8 liver cancer 30 42 23–65 (SDS index ≥ 0.51) 0.39 ± 0.05 10 Anxiety 72 47 21–69 self-report 50 ± 8 Nasopharynx/ Disease control 83.3 liver cancer 30 43 22–65 (SAS standard score ≥ 41) 37 ± 5 40 Anxiety 72 47 21–69 self-report 50 ± 8 Nasopharynx/ Normal control 83.3 liver cancer 30 42 23–65 (SAS standard score ≥ 41) 32 ± 5 13.3 Liu et al., 2001 Depression 45 59.24 24–78 clinical diagnosis 16.78 ± 7.75 Mixed Normal control 55.56 45 –– (HRSD total score ≥ 17) 5.87 ± 4.67 4.44 Yang et al. BMC Cancer 2013, 13:393 Page 7 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 1 Characteristics of the included studies (Continued) Anxiety 45 59.24 24–78 clinical diagnosis 14.82 ± 6.51 Mixed Normal control 46.67 45 –– (HRSA total score ≥ 14) 6.47 ± 4.73 6.67 Zhang et al., 2009 Depression 100 58.86 35–76 clinical diagnosis 42.46 ± 12.74 Breast cancer Normal control 89 100 –– (HRSD total score ≥ 20) 34.97 ± 8.31 18 Anxiety 100 58.86 35–76 clinical diagnosis 43.24 ± 10.38 Breast cancer Normal control 78 100 –– (HRSA total score ≥ 14) 32.25 ± 8.26 22 Wang et al., 2005 Depression 60 58 34–75 self–report – Lung cancer Normal control 39.58 30 51 26–68 (SDS standard score ≥ 50) – 10 Anxiety 60 58 34–75 self-report – Lung cancer Normal control 43.75 30 51 26–68 (SAS standard score ≥ 50) – 6.67 Tian et al., 2005 Depression 112 55.3 36–72 self-report 52.21 ± 5.61 Liver cancer Disease control 53.6 152 45.6 30–60 (SDS standard score ≥ 50) 44.45 ± 7.66 16.4 Anxiety 112 55.3 36–72 self-report 51.1 ± 4.64 Liver cancer Disease control 51.8 152 45.6 30–60 (SAS standard score ≥ 50) 42.99 ± 7.17 24.3 Liu, 2006 Depression 124 48 18–70 clinical diagnosis 16.95 ± 0.70 Mixed Disease control 33.26 60 – 18–70 (HRSD total score ≥ 20) 6.80 ± 1.14 3.33 Anxiety 124 48 18–70 clinical diagnosis 9.39 ± 0.51 Mixed Disease control 29.84 60 – 18–70 (HRSA total score ≥ 17) 6.30 ± 0.83 6.67 Depression 124 48 18–70 clinical diagnosis 16.95 ± 0.70 Mixed Normal control 33.26 60 – 18–70 (HRSD total score ≥ 20) 4.67 ± 0.92 1.67 Anxiety 124 48 18–70 clinical diagnosis 9.39 ± 0.51 Mixed Normal control 29.84 60 – 18–70 (HRSA total score ≥ 17) 3.63 ± 0.67 1.67 Yuan & Zheng, 2004 Depression 30 36.1 34–38 self-report 41.83 ± 12.83 Breast cancer Disease control 23.3 30 35.3 25–47 (SDS standard score > 53) 35.63 ± 6.99 0 Anxiety 30 36.1 34–38 self–report 48.93 ± 13.35 Breast cancer Disease control 33.3 30 35.3 25–47 (SAS standard score > 50) 39.30 ± 9.01 3.3 Gao et al., 1989 Depression 245 46.1 20–76 self-report – Mixed Disease control 73.1 232 46.4 20–74 (CES-D total score ≥ 16) 10.96 ± 6.46 22.5 Anxiety 245 46.1 20–76 self-report – Mixed Disease control 31.1 232 46.4 20–74 (STAI total score ≥ 27) 13.92 ± 8.15 4.8 Chen & Gao, 2010 Depression 90 53.5 38–79 clinical diagnosis – Esophageal cancer Disease control 46.7 86 51.8 36–80 (HRSD total score ≥ 20) – 12.8 Anxiety 90 53.5 38–79 clinical diagnosis – Esophageal cancer Disease control 48.9 Yang et al. BMC Cancer 2013, 13:393 Page 8 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 1 Characteristics of the included studies (Continued) 86 51.8 36–80 (HRSA total score ≥ 7) – 17.4 She, 2009 Depression 142 44.53 15–82 self-report 50.85 ± 11.57 Mixed Disease control 60.6 149 44.53 15–82 (SDS standard score ≥ 50) 46.09 ± 12.16 38.3 Anxiety 142 44.53 15–82 self-report 47.80 ± 10.8 Mixed Disease control 47.2 149 44.53 15–82 (SAS standard score ≥ 50) 44.51 ± 10.04 23.5 Zhao et al., 2001 Depression 65 51.5 29–71 self-report 0.54 ± 0.08 Liver cancer Disease control 43.08 65 –– (SDS index ≥0.5) 0.27 ± 0.12 9.23 Anxiety 65 51.5 29–71 self-report 36.86 ± 6.47 Liver cancer Disease control 24.62 65 –– (SAS standard score ≥ 50) 27.1 ± 9.76 13.69 Depression 65 51.5 29–71 self-report 0.41 ± 0.09 Breast cancer Disease control 20 65 –– (SDS index ≥0.5) 0.27 ± 0.12 9.23 Anxiety 65 51.5 29–71 self-report 44 ± 8.36 Breast cancer Disease control 20 65 –– (SAS standard score ≥ 50) 27.1 ± 9.76 13.96 Wan et al., 2004 Depression 100 44.51 20–70 self-report 15.06 ± 11.5 Primary liver cancer Disease control 49 100 –– (CES-D total score ≥ 16) 11.03 ± 15.06 27 Depression 100 44.51 20–70 self-report 15.06 ± 11.5 Primary liver cancer Normal control 49 100 –– (CES-D total score ≥ 16) 8.08 ± 8.44 17 Zhang et al., 2003 Depression 155 – >18 Clinical diagnosis 21 ± 9 Lung cancer Normal control 43.2 155 – >18 (HRSD total score >8) 9 ± 4 16.1 Abbreviations: SDS self-rating depression scale, SAS self-rating anxiety scale, SCL-90-D symptom checklist 90-depression, SCL-90-A, symptom checklist 90-anxiety, HRSD hamilton rating scale for depression, HRSA hamilton rating scale for anxiety, CES-D center for epidemiologic studies depression scale, STAI state-trait anxiety inventory; -, no report. Yang et al. BMC Cancer 2013, 13:393 Page 9 of 15 http://www.biomedcentral.com/1471-2407/13/393 Risk of bias assessment situation was observed among control group (20.27% Ratings of study quality for each of the Newcastle- vs. 12.82%, P = 0.002). Ottawa criteria were presented in Table 2. As shown in Table 2, higher scores reflect the better study quality, Odds ratios of depression and anxiety in cancer patients and the average scores of all studies were above 5. Seven A pooled random effects meta-analysis was conducted studies were judged to have low quality for selection of using data from 17 studies, which estimated the levels of cases or assessment of outcome or exposure and two of depression and anxiety in adults with cancer compared high quality; other studies were rated as medium quality. with those without. This analysis included data for 1,711 adults with cancer and 1,740 without cancer. As shown Prevalence rates of depression and anxiety in cancer patients in Figures 3 and 4, the odds of depression was associated As shown in Table 3, the overall prevalence of depression with a 7.85-fold increased risk of cancer patients when and anxiety was higher in adults with cancer compared compared with control group (OR = 7.85, 95% CI = 5.58- with those without (P < 0.001). This finding was consistent 11.07; p = 0.000), and the odds of anxiety was also more when the prevalence was determined by control groups, than six times as high in cancer patients compared with method of depression/anxiety assessment and cancer types control group (OR = 6.46, 95% CI = 4.36-9.55; p = 0.000). (P < 0.001). However, the heterogeneity analysis of the effect sizes The overall prevalence of depression and anxiety were of depression (Q = 78.36, p = 0.000; I = 73.2%) and 54.6% and 49.69% in Chinese adults with cancer, and the anxiety (Q = 61.21, p = 0.000; I = 72.2%) showed that prevalence of depression and anxiety were 18.37% and there was a relatively high amount of heterogeneity in 17.50% in non-cancer group. This prevalence of depression our meta-analysis. was higher in studies utilizing self-reports than in studies using clinical diagnosis among cancer patients (58.11% vs. Subgroup analyses 47.49%, P = 0.000), and the same situation was also ob- As shown in Table 4, the ORs of depression and anxiety served among control group (19.65% vs. 11.90%, P = 0.000). were significantly increased in adults with cancer compared Meanwhile, the prevalence of anxiety was also higher with those without on moderating factors, including the in self-reports than in clinical diagnosis among cancer subgroup of control groups, assessment methods of depres- patients (51.74% vs. 44.93%, P = 0.012), and the same sion/anxiety and cancer types. The ORs of depression and Table 2 Assessment of study quality Studies Quality Indicators from Newcastle-Ottawa scale 1 2 3 4 5A 5B 6 7 8 Total score Yang & Bao, 2003 Yes No No Yes Yes Yes No Yes No 5 Tang, 2008 Yes No No Yes Yes Yes No Yes No 5 Long et al., 2008 Yes No No Yes Yes Yes No Yes No 5 Zhang et al., 2008 Yes No Yes Yes Yes Yes No Yes No 6 Tao et al., 2005 Yes No Yes Yes Yes Yes No Yes No 6 Liu et al., 2001 Yes No Yes Yes Yes Yes Yes Yes No 7 Zhang et al., 2009 Yes No Yes Yes Yes Yes No Yes No 6 Wang et al., 2005 Yes No Yes Yes Yes Yes No Yes No 6 Tian et al., 2005 Yes No No Yes Yes Yes No Yes No 5 Liu, 2006 Yes No Yes Yes Yes Yes Yes Yes No 7 Yuan & Zheng, 2004 Yes No No Yes Yes Yes No Yes No 5 Gao et al., 1989 Yes No No Yes Yes Yes No Yes No 5 Chen & Gao, 2010 Yes No No Yes Yes Yes No Yes No 5 She, 2009 Yes No No Yes Yes Yes No Yes Yes 6 Zhao et al., 2001 Yes No No Yes Yes Yes No Yes Yes 6 Wan et al., 2004 Yes No Yes Yes Yes Yes No Yes No 6 Zhang et al., 2003 Yes No Yes Yes Yes Yes Yes Yes No 7 Abbreviations: 1 indicates cases independently validated; 2, cases are representative of population; 3, community controls; 4, controls have no history of cancer; 5A, study controls for age/gender; 5B, study controls for additional factor(s); 6, ascertainment of depression/anxiety by blinded structured interview or secure record; 7, same method of ascertainment used for cases and controls; and 8, nonresponse rate the same for cases and controls. Yang et al. BMC Cancer 2013, 13:393 Page 10 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 3 Unadjusted prevalence of depression and anxiety in adults with and without cancer No. of studies No. of subjects Cancer subjects (%) Non-cancer subjects (%) Depression (All) 17 3484 54.90*** 17.50 Control group Disease control 13 2554 54.84*** 19.61 Normal control 8 1286 55.03*** 12.98 Method of depression assessment Clinical diagnosis 5 1010 47.49*** 11.90 Self-report questionnaire 12 2474 58.11*** 19.65 Cancer type Breast cancer 3 380 55.90*** 12.97 Lung cancer 2 400 42.33*** 15.14 Liver cancer 3 794 49.34*** 17.99 Anxiety (All) 14 2684 49.69*** 18.37 Control group Disease control 11 2154 46.64*** 20.30 Normal control 6 786 57.27*** 12.00 Method of depression assessment Clinical diagnosis 4 650 44.93*** 12.82 Self-report questionnaire 10 1974 51.74*** 20.27 Cancer type Breast cancer 3 390 58.46*** 16.41 Lung cancer 1 90 43.33*** 6.67 Liver cancer 2 394 41.81*** 21.20 *** Prevalence of depression and anxiety significantly greater in patients with cancer compared with a non-cancer control group (P < 0.001). Note: The No. of studies per row is based on the independent group of cancer vs. control group. However, some studies included multiple control groups (e.g., disease and normal control). Thus, the total No. of studies per subgroup of control group is higher than the total number of the included studies in our meta-analysis. anxiety in cancer patients compared with disease control P = 0.021; Egger’s test, P = 0.019) and anxiety (Begg’s test, group (Depression: OR = 6.03, 95% CI = 4.23-8.61, I = P = 0.15; Egger’s test, P = 0.017) in our meta-analysis. 65.5%; Anxiety: OR = 4.40, 95% CI = 3.05-6.36, I = 61.6%) were lower than in those compared with normal control Discussion group (Depression: OR = 13.58, 95% CI = 6.26-29.46, I = At the beginning of discussion, we would assess the het- 79.7%; Anxiety: OR = 15.47, 95% CI = 10.00-23.95, I =0%). erogeneity and study quality in the present meta-analysis. ORs were also obtained for studies using different First, we performed strict inclusion criteria, random effects methods of depression and anxiety assessment. Although models and subgroup analyses to control and reduce the no difference of depression was observed in studies utilizing heterogeneity. However, the heterogeneity was still rela- clinical diagnosis compared with self-report, a significant tively higher, and the conclusion should be considered smaller OR of anxiety was observed in studies utilizing with some caution. Second, the Newcastle-Ottawa Scale self-reports (OR = 5.83, 95% CI = 3.64-9.34, I =75.4%) was used to assess the study quality. We only identified compared with clinical diagnosis (OR = 8.42, 95% CI = two high-quality studies. The bias of medium-quality and 4.83-14.70, I = 36.6%). low-quality studies mainly included selection of cases and Due to the small number of studies, the subgroup assessment of outcome or exposure. Quality assessment comparison of depression and anxiety in different types indicated some methodological weaknesses, which could of cancer patients were not analyzed. weaken the internal validity. The overall prevalence of depression and anxiety in Publication bias Chinese patients with cancer were 54.9% (range: 20%-89%) Visual inspection of the funnel plot indicated some and 49.69% (range: 20%-89.13%) in our meta-analysis, publication bias, and the Begg’stestand Egger’stest suggesting that depression and anxiety also did coexist in further suggested publication bias in depression (Begg’stest, Chinese cancer patients, similar to this situation in foreign Yang et al. BMC Cancer 2013, 13:393 Page 11 of 15 http://www.biomedcentral.com/1471-2407/13/393 Study % % OR (95% OR (95% CI) CI) We Weight ight ID Yang & Bao (2003) 8. 8.10 (4. 10 (4.15, 15, 15. 15.81) 81) 5. 5.62 62 4. 4.85 (2. 85 (2.13, 13, 11. 11.02) 02) 5. 5.07 07 Tang (2008) Long et al. (2008) 26. 26.73 (7. 73 (7.20, 20, 99. 99.22) 22) 3. 3.50 50 Zhang et al. (2008) 5. 5.93 (2. 93 (2.69, 69, 13. 13.07) 07) 5. 5.19 19 30. 30.25 (10. 25 (10.28, 28, 89. 89.04) 04) 4. 4.19 19 Zhang et al. (2008) Tao et al. (2005) 11. 11.50 (4. 50 (4.18, 18, 31. 31.64) 64) 4. 4.41 41 Tao et al. (2005) 31. 31.50 (8. 50 (8.45, 45, 117. 117.43) 43) 3. 3.49 49 26. 26.88 (5. 88 (5.79, 79, 124. 124.72) 72) 2. 2.95 95 Liu et al. (2001) Zhang et al. (2009) 32. 32.36 (14. 36 (14.37, 37, 72. 72.89) 89) 5. 5.11 11 Wang et al. (2005) 6. 6.00 (1. 00 (1.64, 64, 22. 22.01) 01) 3. 3.54 54 5. 5.86 (3. 86 (3.32, 32, 10. 10.34) 34) 5. 5.98 98 Tian et al. (2005) Liu (2006) 13. 13.81 (3. 81 (3.21, 21, 59. 59.40) 40) 3. 3.13 13 Liu (2006) 28. 28.10 (3. 10 (3.76, 76, 210. 210.11) 11) 2. 2.07 07 19. 19.47 (1. 47 (1.06, 06, 358. 358.38) 38) 1. 1.17 17 Yuan & Zheng (2003) Gao et al. (1989) 9. 9.43 (6. 43 (6.20, 20, 14. 14.34) 34) 6. 6.45 45 5. 5.97 (2. 97 (2.80, 80, 12. 12.71) 71) 5. 5.31 31 Chen & Gao (2010) 2. 2.48 (1. 48 (1.55, 55, 3. 3.97) 97) 6. 6.29 29 She (2009) Zhao et al. (2001) 7. 7.44 (2. 44 (2.81, 81, 19. 19.69) 69) 4. 4.54 54 2. 2.46 (0. 46 (0.87, 87, 6. 6.93) 93) 4. 4.33 33 Zhao et al. (2001) 2. 2.60 (1. 60 (1.44, 44, 4. 4.69) 69) 5. 5.90 90 Wan et al. (2004) Wan et al. (2004) 4. 4.69 (2. 69 (2.44, 44, 9. 9.01) 01) 5. 5.68 68 3. 3.96 (2. 96 (2.32, 32, 6. 6.75) 75) 6. 6.09 09 Zhang et al. (2003) 7. 7.85 (5. 85 (5.56, 56, 11. 11.07) 07) 100. 100.0 00 0 Overall (I-squared = 73.2%, p = 0.000) NOTE: Weights are from random effects analysis Odd Ratio 1 1 5 10 20 Figure 3 Forest plot for the meta-analysis of depression in adults with and without cancer. Note: Some studies included multiple cancer types (e.g., liver and breast cancer) and control groups (e.g., disease and normal control) in our meta-analysis. Thus, the total number of independent group in the forest plot is higher than the total number of the included studies in our meta-analysis. Study % OR (95% CI) Weight ID Yang & Bao (2003) 9.74 (4.77, 19.89) 6.66 5.03 (1.69, 14.95) 5.15 Long et al. (2008) 2.49 (1.18, 5.28) 6.51 Zhang et al. (2008) Zhang et al. (2008) 17.67 (6.75, 46.25) 5.64 Tao et al. (2005) 7.50 (2.88, 19.55) 5.66 32.50 (9.58, 110.26) 4.67 Tao et al. (2005) 12.25 (3.31, 45.38) 4.37 Liu et al. (2001) Zhang et al. (2009) 12.57 (6.44, 24.54) 6.84 Wang et al. (2005) 10.71 (2.34, 49.08) 3.73 3.34 (1.98, 5.64) 7.42 Tian et al. (2005) Liu (2006) 5.95 (2.01, 17.62) 5.16 Liu (2006) 25.09 (3.35, 187.94) 2.62 Yuan & Zheng (2003) 14.50 (1.72, 122.40) 2.42 8.93 (4.60, 17.34) 6.87 Gao et al. (1989) 4.53 (2.26, 9.06) 6.74 Chen & Gao (2010) She (2009) 1.94 (1.20, 3.13) 7.59 Zhao et al. (2001) 2.03 (0.82, 5.01) 5.88 4.15 (1.75, 9.81) 6.05 Zhao et al. (2001) Overall (I-squared = 72.2%, p = 0.000) 6.46 (4.36, 9.55) 100.00 NOTE: Weights are from random effects analysis 1 1 5 10 20 Odd Ratio Figure 4 Forest plot for the meta-analysis of anxiety in adults with and without cancer. Note: Some studies included multiple cancer types (e.g., liver and breast cancer) and control groups (e.g., disease and normal control) in our meta-analysis. Thus, the total number of independent group in the forest plot is higher than the total number of the included studies in our meta-analysis. Yang et al. BMC Cancer 2013, 13:393 Page 12 of 15 http://www.biomedcentral.com/1471-2407/13/393 Table 4 Odds ratios of depression and anxiety in adults with and without cancer: subgroup analyses 2 § Subgroups No. of studies No. of subjects OR 95% CI Q I (%) P Depression Control group 0.013 Disease control 13 2554 6.03 4.23-8.61 37.63*** 65.5 Normal control 8 1286 13.58 6.26-29.46 34.56*** 79.7 Method of depression assessment 0.094 Clinical diagnosis 5 1010 12.41 5.16-29.84 23.33*** 78.6 Self-report questionnaire 12 2474 6.83 4.70-9.93 52.23*** 71.3 Cancer type - Breast cancer 3 380 10.84 1.44-81.85 14.83*** 86.5 Liver cancer 3 794 4.54 2.92-7.05 5.20 42.3 Lung cancer 2 400 4.20 2.57-6.88 0.34 0 Anxiety Control group 0.000 Disease control 11 2154 4.40 3.05-6.36 28.62** 61.6 Normal control 6 786 15.47 10.00-23.95 2.44 0 Method of anxiety assessment 0.013 Clinical diagnosis 4 650 8.42 4.83-14.70 6.31 36.6 Self-report questionnaire 10 1974 5.83 3.64-9.34 48.78*** 75.4 Cancer type - Breast cancer 3 390 8.24 3.49-19.44 4.22 52.6 Liver cancer 2 394 2.95 1.87-4.63 0.87 0 **p < 0.01. ***p < 0.001. P of comparison between these subgroups. Note: The No. of studies per row is based on the independent group of cancer vs. control group. However, some studies included multiple control groups (e.g., disease and normal control). Thus, the total No. of studies per subgroup of control group is higher than the total number of the included studies in our meta-analysis. -, no report. countries [17,21]. This situation should be noticed because studies, but other reviews included at least 46 studies. Our comorbid anxiety and depressive disorders tend to results may be overestimated due to the little studies and have severe symptoms, poorer outcomes and greater high data fluctuation. Second explanation might be that use of healthcare resources than those with a single dis- most of the included studies of these reviews are from de- order [67]. Meanwhile, the results were slightly higher veloped countries which have lower prevalence of mental than some empirical studies assessing the prevalence of health problems as compared to developing countries like depression and anxiety in China [12-14]. China [69]. Third explanation might be that depression and We also compared our results with other four relatively anxiety in cancer patients were assessed using different comprehensive reviews of depression/anxiety in cancer questionnaires. The included studies of these reviews patients: (1) the review of Pirl reported the prevalence mainly used the Hospital Anxiety and Depression Scale of depression (10%-25%) based on 350 English-language (HADS), but SDS/SAS was the most commonly used in literatures published between 1966 and 2001 [68]; (2) our meta-analysis. Last explanation might be that many Hotopf showed the prevalence of depression for self- studies of these reviews used clinical diagnosis like HRSD/ reporting questionnaire (29%) and clinical diagnosis (15%) HRSA, but only five studies of our meta-analysis employed based on 46 literatures published before 2000 [9]; (3) Van’t clinical diagnosis method. Some studies indicated that the Spijker indicated the prevalence of depression (0%-46%) prevalence of depression and anxiety would be overestimate and anxiety (0.9%-49%) from 58 studies published from by self-report questionnaires compared with standardized 1980 to 1994 [10]; (4) Mitchell reported the prevalence of clinical diagnoses [20,70]. depression (20.7%-24.6%) and anxiety (9.8%-10.3%) of 94 Only reporting the prevalence of depression and anxiety interview-based studies published before 2010 [7]. There in Chinese cancer patients is not enough, it is important might be several reasons for the different prevalence. First that comparable control groups are involved so that the explanation might be that we only identified 17 eligible level of depression and anxiety in cancer patients can be Yang et al. BMC Cancer 2013, 13:393 Page 13 of 15 http://www.biomedcentral.com/1471-2407/13/393 reliably and accurately determined. The level of depression diagnoses based on HRSD/HRSA, it was necessary to (OR = 7.85, 95% CI = 5.56-11.07) and anxiety (OR = 6.46, consider that our results might be influenced by small 95% CI = 4.36-9.55) were significantly higher in adults with number of studies. cancer compared with those without. This is the first meta- analysis reporting depression and anxiety in Chinese cancer Implication patients compared with those without. A meta-analytical There are several theoretical and practical implications review also reported depression and anxiety in cancer pa- through our meta-analysis. In theory, future studies tients compared with non-cancer group [10], but it yielded assessing psychological disorders among cancer patients an overall effect size of d-value (mean difference), rather should include and specify control group. Thus, they than OR/RR. could explore the difference levels of depression/anxiety Through the subgroups analysis of control groups between cancer patients and other populations, including (disease control vs. normal control), cancer patients other non-cancer diseases, and on the other hand, a whole compared with normal group experienced the higher new perspective would be provided for researchers on the level of depression/anxiety than them compared with use of self-reports and clinical diagnosis to assess depres- disease group at the0.05 significancelevel.Moreim- sion/anxiety in cancer patients when control groups were portantly, cancer patients were significantly more de- involved. In practice, first, some studies have shown that it pressed and anxious when compared with normal and is necessary to evaluate the prevalence of depression and disease groups, respectively. The majority of studies anxiety before any effects can be provided for optimum mainly focused on the psychological disorders in can- care among cancer patients and reduction of psychological cer patients and ignored the role and type of control disorders [17,18,29]. The present meta-analysis provided group [7-9,12-14,68]. The results showed that the odds the necessary preparations for oncologists and physicians of depression/anxiety were nearly 4–6times as high in to treat and manage depression and anxiety in Chinese cancer patients, even when compared with disease control cancer patients; second, although a brief psychological including patients with chronic hepatitis [56,58], diabetes intervention could promote the quality of life and reduce [63], tuberculosis [51], benign tumor [62], and other non- depression and anxiety among cancer patients [75], oncol- cancer medical patients [50,52,54,55,57,60,61,65]. However, ogists and physicians still remained poor at detecting and the different level of depression/anxiety between cancer treating their cancer patients’ psychological problems patients and non-cancer populations has been controver- [76-78]. There might be many reasons for this situation, sial. The study of Reyes-Gibby indicated that respondents but one of these reasons could be that oncologists and with a history of cancer had excess risk for depression physicians were unaware of the levels of depression and (OR = 1.21; 95% CI = 1.06-1.37) compared to those with- anxiety in cancer patients. This meta-analysis showed that out [71]. But some studies demonstrated that depression cancer patients had higher prevalence of depression and was common not only among cancer patients, but also anxiety, indicating that depression and anxiety in Chinese nearly equally among non-cancer diseases [72,73]. cancer patients should be received sufficient attention. Some studies suggested the discrepancy between clin- ical diagnosis and self-reports measuring depression/ Limitation anxiety among cancer patients [29,74], and indicated the The present meta-analysis had several limitations. First, results would be overestimate by self-report question- although some studies demonstrated that depression naires compared with clinical diagnoses [20,70]. Our re- and anxiety might play a causal role of cancer [25,79], sults seemed to be consistent with the conclusion above. the present meta-analysis was based on cross-sectional The prevalence of depression/anxiety in cancer patients studies, which could not determine the causation or was higher in self-reports compared with clinical diagno- temporality of this association between the development sis, and this situation also occurred in non-cancer group. of cancer and depression/anxiety. Second, a lot of studies However, when control groups were involved, we found showed that there was a significant relationship between that a significant smaller OR of anxiety was observed in depression/anxiety in cancer patients and age [18,80], can- studies utilizing self-reports compared with clinical diagno- cer type [10,81,82], gender [83,84], income [85] and so on, sis, although not significantly difference between clinical but our meta-analysis did not provide enough information diagnoses and self-reports of depression. This discrepancy and number of studies regarding these potential moderat- may result from the same reason that these studies only fo- ing factors. Third, although we employed subgroup analysis cused on the cancer patients and ignored the control group to explore potential sources of heterogeneity including con- when different assessment methods of depression and anx- trol group, methods of depression/anxiety assessment and iety were used [20,29,70,71]. However, only five and four cancer types, the subgroup analysis could not reduce I studies with a combined population of 1010 and 650 were to 50% or less in many cases. Fourth, only five and four conducted to measure depression/anxiety using clinical studies with a combined population of 1010 and 650 Yang et al. BMC Cancer 2013, 13:393 Page 14 of 15 http://www.biomedcentral.com/1471-2407/13/393 were conducted using HRSD/HRSA to measure clinically 8. Massie MJ: Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr 2004, 32:57–71. significant anxiety and depression. Thus, depression and 9. Hotopf M, Chidgey J, Addington-Hall J, Lan Ly K: Depression in advanced anxiety in our meta-analysis more often referred to the de- disease: a systematic review. Part 1. Prevalence and case finding. Palliat pressive symptom and anxiety symptom. Fifth, we did not Med 2002, 16:81–97. 10. 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Journal

BMC CancerSpringer Journals

Published: Dec 1, 2013

Keywords: cancer research; oncology; surgical oncology; health promotion and disease prevention; biomedicine, general; medicine/public health, general

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