Introduction
Cancer is a serious health problem that leads to death in a short time when it is not diagnosed and treated early. While it constitutes 25% of deaths in developed countries, in the entire world, it comes second in terms of causes of death following ischemic heart disease (Bray et al., Reference Bray, Ferlay and Soerjomataram2018). In addition to causing high numbers of deaths, cancer also increases the risk of the formation of psychiatric disorders (Planas et al., Reference Planas, Álvarez-Hernández and León-Sanz2016). Knowing about the mental conditions that may affect the physical severity, course, and treatment response of the disease affects the patient's quality of life, care, and treatment compliance (Choi and Ryu, Reference Choi and Ryu2018). As a result of medical development, several diseases which used to be deadly can now be treated. However, despite such developments, cancer is still among the most frequent causes of death. This is why the society and many patients consider cancer and death synonymously. Knowing that the possibility of death may happen in a very short time is a main source of stress for the patient. “Disruption of morale or being out of spirits” is considered inevitable in cancer patients by the people around them, including the healthcare team (Pitman et al., Reference Pitman, Suleman and Hyde2018; Zhu et al., Reference Zhu, Wang and Gao2018).
Studies have determined that more major depression is seen in cancer patients than not only in the general population but also in the psychiatric patient population (Pitman et al., Reference Pitman, Suleman and Hyde2018). Depression may be seen as a psychological reaction of the oncological disease in some patients or a physiological outcome of the physical disease in some others. In these patients, it is highly difficult to distinguish whether depression is actually an emerging symptom of a psychiatric disease, or it consists of physical symptoms in relation to the diagnosis of cancer (Li et al., Reference Li, Kennedy and Byrne2017). While depression is seen at all stages of cancer, it is seen more frequently and on more severe levels by the advancement of the disease (Ostuzzi et al., Reference Ostuzzi, Matcham and Dauchy2018).
The prevalence of psychiatric disorders in cancer patients is reported in the range of 30–40%, and it is stated that the most frequently observed psychopathology is major depression (Caruso et al., Reference Caruso, Nanni and Riba2017). In cancer, main risk factors for depression are a history of psychiatric disease, low self-respect, emotional stress or insufficient social support at diagnosis, low functional capacity, poor physical conditions, and loss of spouse of close relatives (Okuyama et al., Reference Okuyama, Akechi and Mackenzie2017). Other risk factors include alcohol addiction, advanced cancer, inadequate pain management, comorbid physical disease, and use of chemotherapeutics with a side effect of depression (Hinz et al., Reference Hinz, Herzberg and Lordick2019). In the study by Massie (Reference Massie2004) on the prevalence of major depression and depressive symptoms in cancer patients, the prevalence of major depression was reported as 38%, while the prevalence of depressive symptoms was 58%. A strong relationship was found between the tumor-related reduced chance of survival and depression in patients (Sharif et al., Reference Sharif, Lehto and Nia2018; Mohammadzadeh and Najafi, Reference Mohammadzadeh and Najafi2020).
Sufficient and balance nutrition of a cancer patient is highly important for them to feel physiologically and psychologically strong and content before, during, and after treatment. Some gastrointestinal symptoms such as pain while eating, wounds in the oral mucosa, diarrhea, nausea, and vomiting may lead to a disruption in nutritional status, and a picture of inadequate nutrition that could reach up to malnutrition may develop in patients (Fearon et al., Reference Fearon, Strasser and Anker2011; Arends et al., Reference Arends, Bachmann and Baracos2017). Malnutrition, which develops in 39% of cancer patient, may affect the duration of hospitalization by even more negatively affecting the course of the disease and the status of the patient; it may lower the quality of life by reducing the capacity of the immune system even more and increase the risk of death (Gyan et al., Reference Gyan, Raynard and Durand2018; Pinho et al., Reference Pinho, Martucci and Rodrigues2019). Also, the incidence of malnutrition also differs according to the type of cancer. Its frequency has been recently reported to be as high as 48% in the gastric and colorectal cancer population. It is an independent risk factor for mortality and morbidity, and for the anorexia–cachexia syndrome, owing to profound metabolic alterations. Patients with upper gastrointestinal cancers (GICs) are particularly prone to malnutrition, owing to malabsorption, obstructive symptoms, and diarrhea. GIC patients were not included in this study, as these patients may develop malnutrition due to the nature of the disease and due to the need for separate evaluation of GIC patients (Attar et al., Reference Attar, Malka and Sabate2012).
Evaluation of nutritional status is made by a specialist dietitian at the beginning of the treatment and once a week or once every two weeks during the treatment in the institution participating in this study. Accordingly, 24-h nutritional history, body mass index (BMI total = weight/height2), weight (kg) change compared to the last 3 months at the beginning of the treatment, and the previous week during the treatment are noted in each evaluation. The patient's caloric needs are calculated as 30 kcal/kg/day and protein needs are calculated as 1–1.2 g/kg/day.
The presence of depression is shown among psychological causes in the development of malnutrition. Due to the destructive effects of severe malnutrition on mental health in addition to its negative effects on bodily health, the effects of nutrition on mental health have gained significance. In cancer patients, severe weight loss varies between 7% and 57%, and this may lead to an increase in complication rates (Langius et al., Reference Langius, Twisk and Kampman2016; Zhu et al., Reference Zhu, Wang and Gao2018).
Thiamine (vitamin B1) deficiency, which is present in 45% of cancer patients, has been reported to cause neuropsychiatric disorders. Thiamine (vitamin B1) deficiency is more common especially in advanced cancer patients due to anorexia, vomiting, malabsorption, and malnutrition (Isenberg-Grzeda et al., Reference Isenberg-Grzeda, Rahane and DeRosa2016). Thiamine (vitamin B1) deficiency has been proven to be the cause of delirium in cancer patients (Isenberg-Grzeda et al., Reference Isenberg-Grzeda, Hsu and Hatzoglou2015; Onishi et al., Reference Onishi, Sato and Uchida2021). Therefore, mental status change, early diagnosis, and treatment of thiamine (vitamin B1) deficiency in cancer patients are important issues to prevent severe brain damage, delirium, and protect the patient's quality of life (Isenberg-Grzeda et al., Reference Isenberg-Grzeda, Rahane and DeRosa2016).
Depression affects the cancer patient's quality of life, self-care, coping strength, treatment compliance, nutritional status, and in time, the severity and progress of the disease, and it may also lead to serious problems such as suicide (Arends et al., Reference Arends, Bachmann and Baracos2017; Bortolato et al., Reference Bortolato, Hyphantis and Valpione2017; Chabowski et al., Reference Chabowski, Polański and Jankowska-Polańska2018; Pinho et al., Reference Pinho, Martucci and Rodrigues2019). Nutrition problems may be stemming from psychological health problems, too, and thus, malnutrition and depression symptoms overlap, but very few studies in the literature have focused on the relationship between the two (Ma et al., Reference Ma, Poulin and Feldstain2013; Zhu et al., Reference Zhu, Wang and Gao2018).
It is vitally important to reveal the relationship between depression and malnutrition in advanced stage cancer patients with studies and to increase the awareness of nurses who have significant roles in the presentation of holistic healthcare on this issue. Based on all these data, in this study, it was aimed to determine the depression and malnutrition levels of advanced stage cancer patients and investigate the relationship between depression and malnutrition.
Research questions are
• What are the depression levels and prevalence in advanced stage cancer patients?
• What are the malnutrition levels and prevalence in advanced stage cancer patients?
• Is there a relationship between depression and malnutrition developing in advanced stage cancer patients?
Methods
Design
This descriptive and correlational study aimed to determine the depression and malnutrition levels in advanced stage cancer patients and the relationship between depression and malnutrition.
Sample and setting
This study was conducted at the internal medicine and oncology clinics of a university hospital between August and November 2020. The population of the study consisted of cancer patients receiving treatment at the internal medicine and oncology services of a university hospital. The sample of the study included 245 advanced stage cancer patients who met the inclusion criteria. The sample was selected with the purposive sampling method, and the patient who met the inclusion criteria was included. The inclusion criteria were (a) being 18 years or older and voluntary to participate in the study, (b) having the capacity to understand and interpret the questions, and (c) having a diagnosis of Stage III or IV cancer.
Kendall's sample size calculation principle yields sample sizes 5–10 times the number of variables (Lewis, Reference Lewis2009). In our research, there were 14 variables (11 related to socio-demographic information, 1 related to pain levels, 1 related to the nutrition status, and 1 related to the characteristics of depression). Considering a 20% dropout rate, the sample size in this study was set at 84–168 [14 × 5 × (1 + 0.2) = 84−14 × 10 × (1 + 0.2) = 168].
Ethical aspect of the study
For the study to be conducted, written ethics board approval numbered 2020/08 (20292139-050.01.04) was obtained from the Istanbul Sabahattin Zaim University Ethics Board. Additionally, after informing the participants about the objective and method of the study, their verbal and written consent was received. This study was conducted following the principles of the Declaration of Helsinki.
Data collection tools
In the study, an Information Form, the Visual Analog Scale (VAS), the NRS-2002-Nutritional Risk Score, and the Beck Depression Inventory were used as the data collection instruments.
Information form
It included questions to determine the participants’ sex, age (years), body weight (kg), height (cm), and BMI (kg/m2).
The controlling nutritional status (CONUT) score was calculated using the serum albumin concentration, peripheral lymphocyte counts, and total cholesterol concentration. All patients scores are divided into four levels, namely normal [0–1], mild [2–4], moderate [5–8], and severe [9–12] (De Ulíbarri et al., Reference De Ulíbarri, González-Madroño and de Villar2005).
NRS-2002 Nutritional Risk Score
In assessment of the nutritional statuses of the inpatients, the NRS-2002 form recommended by the European Society of Parenteral Enteral Nutrition (ESPEN) was utilized. This system, developed by Kondrup et al., aims to determine insufficient nutrition and malnutrition risk and detect patients who may benefit from nutritional support. NRS-2002 ≥3 shows a risk of malnutrition (Kondrup et al., Reference Kondrup, Allison and Elia2003; Bolayır, Reference Bolayır2014).
Beck Depression Inventory
The scale that was developed by Beck et al. (Reference Beck, Steer and Carbin1988) was tested for validity and reliability in Turkish by Hisli. It is a depression classification scale consisting of a total of 21 questions each of which are score between 0 and 3. The scores of the scale are grouped as: 1–10 points, normal; 11–16 points, moderate mood disorder; 17–20 points, clinical depression; 21–30 points, moderate depression; 31–40 points, substantial depression; and 41–63 points, severe depression (Beck et al., Reference Beck, Steer and Carbin1988; Hisli, Reference Hisli1988). In this study, Cronbach's alpha value of the Inventory was found as 0.86.
Visual Analog Scale
The VAS was used to evaluate the pain severity level which was composed of a 10-cm-long line, which had subjective descriptive expressions on both sides (0 cm: no pain and 10 cm: unbearable pain). The participants were asked to place a sign on the line that matched their level of pain, and the numerical values were recorded by the researcher.
Data collection
In the study, the Information Form, the NRS-2002 Nutritional Risk Score, and the Beck Depression Inventory were used as the data collection instruments. The data were collected between August and November 2020. According to the responses given to the questions read by the researchers, the forms and scales were filled out by face-to-face interviews with the cancer patients who were receiving treatment at the internal medicine and oncology services of a university hospital. Each interview last 15–20 min on average.
Data analysis
The data were analyzed using the SPSS 26.0 package software. The descriptive data are presented as frequencies, percentages, and means. The Shapiro–Wilk test was used to analyze the data for normal distribution. The data were analyzed by correlation analysis and independent-samples t-test. All results were considered significant at p < 0.05 and in a confidence interval of 95%.
Results
The study analyzed the data of 245 advanced stage cancer patients including 119 women and 126 men. The mean age of the patients was 60.34 (SD: 14.93; range 20–90) years. Among the patients, 36.7% (n = 90) had lung cancer, 18% (n = 44) had breast cancer, and 13.1% (n = 32) had genitourinary system cancer. It was determined that the incomes of 60% (n = 147) of the patients did not cover their expenses (Table 1).
Socio-demographic characteristics
VAS, Visual Analog Scale.
The malnutrition status of the patients was determined by NRS-2002. The mean NRS-2002 score of the patients was 2.22 (0–8), and considering the cutoff value of 3, it was determined that 96 patients (39.2%) had malnutrition. The depression levels of the patients were determined by using the Beck Depression Inventory, their mean score was 35.06 (2–61, SD: 10.14), and they had substantial depression. It was determined that 96.4% (n = 236) of the patients received a score of higher than 10 in the Beck Depression Inventory and experienced depression. According to the Beck Depression Inventory, 3.6% (n = 9) of the patients were normal, 5.4% (n = 13) had moderate mood disorders, 2% (n = 5) had clinical depression, 8.6% (n = 21) had moderate depression, 63.7% (n = 156) had substantial depression, and 16.7% (n = 41) had severe depression.
There was a positive relationship between the NRS-2002 scores and the Beck Depression Inventory scores of the patients (r = 0.409; p < 0.001). Also when the relationships of the depression levels of the patients with other factors were examined, it was found that there was a significant positive relationship between age and the Beck Depression Inventory scores (r = 0.351, p < 0.01). When the relationships of the nutritional levels of the patients with other factors were examined, it was found that there was a significant positive relationship between age and the NRS-2002 score (r = 0.230, p < 0.01), (Table 2).
Relationship between depression levels and nutritional statuses
NRS-2002, Nutritional Risk Screening 2002, Spearman's correlation test.
The mean Beck Depression Inventory score of the women (38.05 ± 8.47) was significantly higher than that of the men (32.22 ± 10.79) (p < 0.01). Additionally, the mean Beck Depression Inventory score of those with a pain score of ≥4 (37.97 ± 9.64) was significantly higher than that of those with a pain score of <4 (34.43 ± 10.16) (p = 0.037). Also, the mean Beck Depression Inventory score of patients with cancer stage IV was statistically significantly higher than patients with cancer stage III. On the other hand, there was no significant difference in the mean Beck Depression Inventory scores of the patients based on their marital status, educational status and income status, nutrition status, and diet restriction (p > 0.05).
The mean NRS-2002 score of the women (2.53 ± 1.41) was significantly higher than that of the men (1.92 ± 1.25) (p < 0.01). Additionally, the mean NRS-2002 score of those who had a pain score of ≥4 (3.02 ± 1.70) was significantly higher than that of those who had a pain score of <4 (2.05 ± 1.22) (p < 0.01). Also, the mean Nutritional Status NRS-2002 of patients with cancer stage IV was statistically significantly higher than patients with cancer stage III. On the other hand, there was no significant difference in the mean NRS-2002 scores of the patients based on their marital status, educational status and income status, nutrition status, and diet restriction (p > 0.05) (Table 3).
Analyses demonstrating the relationship between different basic situations and the Beck Depression Inventory and NRS-2002
1 T test.
2 Kruskall–Wallis.
3 Mann–Whitney U test.
* TNM, tumour–lymph node–metastasis. Tumour stages are based on seventh edition of the Union for International Cancer Control TNM classification.
According to the classification of the patients using the CONUT score, it was determined that the mean Beck Depression Inventory score of the patients with severe level was statistically higher than the other groups. On the other hand, there was no statistically significant difference between the mean scores of the Beck Depression Inventory according to the cachexia classification (Table 4).
Comparison of Beck Depression Inventory scores based on nutritional statuses of patients
1 Independent-samples t-test.
2 Kruskal–Wallis test.
Discussion
In this correlational and cross-sectional study, it was determined that 96.4% of the advanced stage cancer patients received a score of higher than 10 in the Beck Depression Inventory and experienced depression. In addition, the distribution of the cancer patients according to the Beck Depression Inventory was as follows: 3.6% (n = 9) of the patients were normal, 5.4% (n = 13) had moderate mood disorders, 2% (n = 5) had clinical depression, 8.6% (n = 21) had moderate depression, 63.7% (n = 156) had substantial depression, and 16.7% (n = 41) had severe depression. Moreover, it was found that 39.2% of the patients had malnutrition. The correlation analysis showed that nutritional status was positively and strongly related to psychological disorder levels (p < 0.001). Looking at the factors related to depression and malnutrition in the advanced stage cancer patients, it was found that the female sex, advanced age, and pain were significantly effective.
Various studies have determined that depression, which is one of the most frequently experienced mood disorders among cancer patients, has destructive effects of the dimensions of the disease and the quality of life of the patient. A high prevalence of depression has been predicted at all stages of cancer, but it is frequently present at advanced stages (Caruso et al., Reference Caruso, Nanni and Riba2017). At further stages of the disease, adverse effects caused by treatments (alopecia, mucositis, peripheral neuropathy, etc.), dysfunctional thoughts, and death anxiety are reported as main factors contributing to depression and hopelessness (Parpa et al., Reference Parpa, Tsilika and Galanos2019). In our findings, it was observed that almost all advanced stage cancer patients experienced depression, and this finding supported the literature. Other studies have also reported that cancer patients experienced depression. In a study conducted with breast cancer patients, it was stated that the depression level measured with the Beck Depression Inventory was 25.1 ± 7.7, 27.7% of the patients had moderate depression, and 19.5% had severe depression (Bener et al., Reference Bener, Alsulaiman and Doodson2017). Considering depression levels measured with the Beck Depression Inventory in advanced stage cancer patients, the mean score was found to be 16.99 ± 10.24, and this corresponded to clinical depression (Parpa et al., Reference Parpa, Tsilika and Galanos2019). Another study conducted with cancer patients reported that 29.1% of patients experienced moderate depression, while 18.2% experienced severe depression (Alacacıoglu et al., Reference Alacacioglu, Tarhan and Alacacioglu2013).
A finding worth noting in this study was the role of depression in malnutrition. It was determined that, in a way compatible and consistent with previous studies, depression affected insufficient nutrition. Previously, a few studies have reported similar results in breast, lung, and head and neck cancer patients (Prevost et al., Reference Prevost, Joubert and Heutte2014; Saxton et al., Reference Saxton, Scott and Daley2014; Chabowski et al., Reference Chabowski, Polański and Jankowska-Polańska2018), especially in those receiving radiotherapy (Hong et al., Reference Hong, Wu and Su2016). However, the causality between these two factors has not been clarified yet. Previous studies have reported that proinflammatory cytokines including IL-1, IL-6, TNF-α, and INF-γ were associated with depressive symptoms in cancer patients. Depression, fatigue, and cognitive disorders are the systemic effects of these cytokines, and they may affect the quality of life of patients before, during, and after treatment (Caruso et al., Reference Caruso, Nanni and Riba2017; Zhu et al., Reference Zhu, Wang and Gao2018). Some researchers proposed that psychological factors have an important role in the development of poor nutrition in cancer (Britton et al., Reference Britton, Baker and Clover2017; Gosak et al., Reference Gosak, Gradišar and Kozjek2020). Depression may affect the self-care behaviors of patients, and appetite changes may emerge as a prevalent sign of depression (Hong et al., Reference Hong, Wu and Su2016). Psychological factors such as the acceptance of the gravity of their disease by the cancer patient and any behavioral change accompanying this may contribute to the relationship between these two syndromes. More studies are needed to clarify these problems. We found a strong relationship between depression and malnutrition status in advanced stage cancer patients. Our results supported the claim that depression predicts malnutrition in advanced stage cancer patients and emphasized the importance of depression screening.
Furthermore, age, sex, and pain may affect Beck Depression Inventory and NRS-2002 scores. Various studies have reported that age, sex, and pain have independent correlations with depression scores (Hong et al., Reference Hong, Wu and Su2016; Pitman et al., Reference Pitman, Suleman and Hyde2018; Zhu et al., Reference Zhu, Wang and Gao2018). This is compatible with our study. NRS-2002 is a nutrition scale that is widely accepted in clinical practice as a nutritional assessment and a malnutrition screening instrument. Studies conducted using this scale have found that nutritional status may be affected by age, sex, and pain in cancer patients (Bossola, Reference Bossola2015; Dos Santos et al., Reference Dos Santos, Rosa and Ribeiro2015; Orell-Kotikangas et al., Reference Orell-Kotikangas, Österlund and Saarilahti2015). Our finding in this study was compatible with the literature. This is one of the few studies showing that malnutrition in advanced stage cancer patients is affected by advanced age, the female sex, and increased pain (Planas et al., Reference Planas, Álvarez-Hernández and León-Sanz2016). Particularly few studies have mentioned the effects of pain on malnutrition seen in cancer patients (Zhu et al., Reference Zhu, Wang and Gao2018). It is worth noting that our study showed that deterioration in the nutritional status in advanced stage cancer patients is associated with a significant worsening effect in terms of depression and pain. For this reason, these factors should definitely be kept in mind in the assessment of malnutrition in advanced stage cancer patients. Moreover, the results showed that it is necessity to assess the nutritional and psychological statuses of patients beginning with the very first day of cancer diagnosis to put mental health and interventions toward the improvement of perceived support in use as early as possible.
Our study had some limitations. First of all, this was a cross-sectional study, and it had the capacity to only show the relationship between these two factors. It is not known whether malnutrition causes depression or depression causes malnutrition, and this issue needs confirmation in detail with a long-term follow-up study. Second of all, our study included various cancer types, and we did not examine the relationship of these factors with each type of cancer. Finally, although we collected data on several potential risk factors for malnutrition and depression, we might have overlooked some important and currently unknown cancer-related factors. Longer-term studies are needed to explain the relationship between malnutrition and depression in detail along with their causes.
Conclusions
The Beck Depression Inventory scores of most of the advanced stage cancer patients were higher than 10. Moreover, 39.2% of the patients had malnutrition. Furthermore, there was a strong relationship between depression and malnutrition. It was also determined that the factors of old age, the female sex, and pain influenced both the Beck Depression Inventory and the NRS-2002 scores. Our article emphasizes the need for an interdisciplinary collaboration plan involving doctors, nurses, dieticians, social services specialists, and psychologists to maintain an acceptable quality of life and improve the clinical outcomes of patients.
According to the results of this study, malnutrition was closely related to depression in the advanced stage cancer patients, and this showed that there is a need for nutrition-based interventions to improve the psychological statuses of advanced stage cancer patients. It is highly important to increase the awareness of nurses who have significant roles in provision of holistic healthcare on this issue. Nurses may provide counselling regarding the psychosocial problems of advanced stage cancer patients and help in discussion of these problems. Our study is one of the few studies showing that malnutrition is influenced by advanced age, increased pain, and the female sex in advanced stage cancer patients. It was shown that deterioration in the nutritional status of the advanced stage cancer patients was associated with a significant worsening effect in terms of depression and pain. For this reason, these factors should definitely be kept in mind in assessing malnutrition in advanced stage cancer patients. Moreover, our results showed that there is a need to assess the nutritional and psychological statuses of patients starting with the first diagnosis of cancer to implement interventions toward the improvement of nutritional status and mental health as early as possible.
Acknowledgments
The author thank all the participants who took part in this study.
Funding
The author has no funding sources to declare.
Conflict of interest
The author reports no actual or potential conflicts of interest.
