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Systematic review
Prevalence of depression in patients with cancer in Iran: a systematic review and meta-analysis
  1. Aidin Aryankhesal1,2,
  2. Ahmad Ghashghaee1,3,
  3. Elnaz Sardari3,
  4. Sara Mahmoudi3,
  5. Samira Alihosseini1,
  6. Afsaneh Dehnad4,
  7. Mahshid Roohravan Benis3 and
  8. Dorsa Gharagozlou5
  1. 1 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
  2. 2 Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
  3. 3 Student Research Committee, Faculty of Health Management and Information Sciences Branch, Iran University of Medical Sciences, Tehran, Iran
  4. 4 Department of Foreign Languages, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
  5. 5 Department of Biology, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
  1. Correspondence to Mr Ahmad Ghashghaee; ahmad.ghashghaee1996{at}gmail.com

Abstract

Introduction It is generally accepted that depression, affecting the quality of life, is a serious and common complication in patients with cancer. Given that there is no integrated study on this topic in Iran, the present study sought to investigate the prevalence of depression in patients with cancer by a systematic review and meta-analysis.

Methods To meet the study objectives, all English and Persian papers published from 2000 to January 2018 were systematically collected and the data were extracted for analysis.

Results There were 14 studies which were selected on the basis of the inclusion and exclusion criteria. A total number of 2831 patients with cancer had participated in the studies. The prevalence of depression among Iranian patients with cancer was 35% (95% CI 16% to 70%) based on random effects model. Among various types of cancer, the highest prevalence of depression appeared to patients suffering from breast cancer.

Conclusion The prevalence of depression among patients with cancer in Iran was higher than the developed countries. As depression affects the quality of life of patients with cancer, the results can help policymakers and service providers in planning to reduce the prevalence of depression.

  • depression
  • neoplasms
  • cancer
  • multimorbidity
  • Iran

https://doi.org/10.1136/bmjspcare-2018-001724

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    Introduction

    Depression as the most common mental disorder is increasingly a serious concern of health systems worldwide.1 According to the WHO, about 300 million people suffer from depression and it is the main cause of disability which adds to the overall burden of diseases worldwide.2 This is added to the high cost of treatment which often increases annually in different countries.3 It has significant economic and social consequences; thus, preventive measures should be taken into consideration to maintain the resources of the health sector.4

    It is said that depression will become the second leading cause of diseases in the world by 2030,5 and will pose a great impact on individuals’ performance.6 Close relatives’ deaths, and social, familial and occupational conditions are often the main causes of depression.7 8 It causes serious problems in performing familial and social activities such as their jobs. Unfortunately, individuals suffering from depression may commit suicide in severe cases.9

    Cancer and its treatment procedure are also reported to be important factors that can cause physical, psychological and behavioural complications and multimorbidities.10 11 Patients with cancer are among the high-risk groups who are prone to mental complications such as depression.12

    Several studies have examined the prevalence of depression in patients with cancer. In particular, two studies conducted in Iran have reported the prevalence of depression to be 69.4% in women with breast cancer.13 However, in a review study, this was about 23%14 which indicates a controversy across study results.

    Therefore, the present study aimed to provide information on the prevalence of depression in patients with cancer by a systematic review and meta-analysis in order to help policymakers to have proper planning for the prevention and control of depression in this group of patients.

    Methodology

    Electronic search

    International electronic databases, including: PsycInfo, Embase, Web of Science, Scopus and PubMed, along with Iranian databases, SID, Irandoc and Magiran were searched. The target studies were searched using MeSH standardisation and the determined keywords (see table 1). This review study was conducted on English and Persian papers published from 2000 to January 2018 as well as international conferences, references and relevant case reports. After the electronic search, 333 academic papers were found. The reason why we included published articles from 2000 was that we decided to survey the prevalence of depression in patients with cancer in Iran in the current century. The included papers were then imported into EndNote software and the duplicate ones were removed.

    View this table:
    Table 1

    Search strategy in different databases

    Study selection

    The selection of papers was done in two stages. First, two authors independently reviewed the papers. In the initial screening stage, we studied the titles and abstracts, and removed irrelevant studies on the basis of inclusion and exclusion criteria. Therefore, 40 potentially relevant papers remained. In the second stage, the full texts of papers were independently studied in order to determine the eligibility of papers. Ultimately, 14 papers were selected as eligible (figure 1).

    Figure 1
    Figure 1

    Flow diagram of our review process (PRISMA).

    Inclusion criteria

    1. English and Persian language papers.

    2. Studies between 2000 and 2018 original research.

    3. Studies with available full text.

    4. Observational studies (cross-sectional, cohort, and case–control, descriptive, prospective studies).

    5. Studies that reported a figure of depression in patients with cancer, or the possibility of calculating a figure on the basis of the data reported by the authors.

    6. Studies carried out in Iran.

    Exclusion criteria

    1. Studies written in other languages except in English and Persian.

    2. Studies before year 2000.

    3. Review studies, letters to editors, editorials, commentaries, expert opinions, case studies, case series, books, book chapters, brief reports, randomised controlled trials and thesis.

    4. Studies related to treatment, follow-up, medication and overall clinical decision-making process.

    5. Studies that did not allow the calculation of the prevalence.

    6. Studies not carried out in Iran.

    Quality of studies

    At this stage, the Mixed Methods Appraisal Tool (MMAT), introduced by Pluye et al, was used to evaluate the quality of selected studies.15 MMAT is a very comprehensive tool for assessing qualitative, quantitative and mixed studies. The overall quality score for each selected study was calculated using the MMAT.15–17 Therefore, the quality of these studies was independently evaluated by two reviewers, and any disagreement about the quality of the studies was resolved by a third reviewer through discussion, if necessary.

    Data extraction

    A preliminary data extraction form was prepared at this stage. Data including general information (author, year of publication, city, type of publication, name and purpose of publication) and specific information (sample size, prevalence of depression, type of cancer, number of men, number of women, education level, marital status, age, research city and type of questionnaire) were extracted from each paper (table 2).

    View this table:
    Table 2

    The main characteristics of the included studies based on the prevalence of depression among patients with cancer across Iran

    Statistical analysis

    The prevalence rate was measured using the DerSimonian-Laird model showing results on a forest plot at a confidence level of 95%. The I2 test of heterogeneity was performed along with a meta-regression analysis based on the year of publication and sizes of samples. The sensitivity analysis was then performed in order to ensure the stability of the results. Next, sample size, geographical place, year of publication, gender, research type and quality of study were used for performing a subgroup analysis. Moreover, a cumulative meta-analysis was performed on the basis of the publication year and sample size. The publication bias was analysed using the Egger’s test; and data were analysed in Stata V.14 software.

    Findings

    Search results

    The characteristics of selected studies are summarised in table 2. Figure 1 shows the results of the present study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The selected studies were published from 2000 to 2017; and 2831 patients with cancer had participated in the studies. The largest study included 400 patients while the smallest had a sample size of 60.

    Systematic review

    Montazeri et al 18 conducted a prospective study on 316 patients with cancer with depression within a period of 1 year. According to the findings of this study, 18% of patients were depressed and there was a significant relationship between the stage of disease and level of depression (p=0.04), that is, patients at the advanced stage of cancer had a higher level of depression.18 In a cross-sectional study on 243 patients with cancer, Montazeri et al noticed that 16% of patients with cancer suffered from depression; there was no significant relationship between depression and other relevant variables (p˂0.05).12 In a prospective study on 400 patients with cancer, Mashhadi et al 19 found that 26.5% of research participants had depression. The findings of their study indicated that the depression level of patients with breast cancer was higher than others (p˂0.0001), and there was a significant relationship between depression and education and marital status. They observed that depression in single patients was commonly higher than that of married patients (p˂0.0001) and that was more common among those with higher education (p˂0.0001).19 In a cross-sectional study on 380 patients with cancer, Goudarzian et al found that 31.3% of patients with cancer suffered from depression and there was a significant negative relationship between depression and self-care (r=−0.134, p<0.05).9 In a cross-sectional study on 60 participants, Didehdar Ardebil et al found that 50% of subjects suffered from depression and there was a significant relationship between depression and financial status (p≤0.001), that is, patients with lower financial status had higher chance of depression.20 Bemana21 conducted a quantitative study on 105 patients with cancer and found that 15% of them had depression, and there was a significant relationship between level of depression and marital status (p˂0.05). In other words, level of depression was significantly higher among those who lived alone.21 According to a research on 180 patients with cancer by Amirmohamadi et al,22 17.22% of them suffered from depression and there was a significant negative relationship between depression and mental health (r=−0.54, p<0.001).22 Aminisani et al 7 conducted a cross-sectional study on 157 patients with cancer and found that 40.4% of them had depression.22 In a descriptive study on 98 patients with cancer, Shakeri et al 23 found that 69.4% of subjects suffered from depression and there was a negative significant relationship between depression and quality of life (r=−0.78, p≤0.001).23 In a cross-sectional study on 150 patients with cancer, Nikbakhsh et al 24 found that 48% of them suffered from depression and there was a significant relationship between the type of cancer (p≤0.001) and type of treatment (p<0.05); for example, patients receiving chemotherapy were generally more depressed than those undergoing surgery. There was also a positive significant correlation between depression and age (p≤0.004).24 Saeedi-Saedi et al 25 conducted a quantitative study on 82 patients with cancer and found that 43.9% of them had depression, and there was a significant relationship between depression and emotional distress (p<0.001).25 In another study on 256 subjects, Saedi et al reported the prevalence of depression was 51.6%, and found a significant relationship between depression and marital status in which single patients were noticeably more depressed (p<0.001).26 In a cross-sectional study on 142 patients with cancer, Tavoli et al 27 reported that the rate of depression was 38.2% in these patients with cancer and indicated that there was no significant relationship between patients’ rates of depression and their demographic information.27 Tabrizi28 conducted a research on 262 patients with cancer and reported a rate of depression of 55.9% in the study population and found a significant relationship between individuals’ depression and health-promoting lifestyles (p<0.05).28

    Meta-analysis

    Given the significant statistical heterogeneity (I2=96.2% with p≤0.001), the random effects model was used. Based on this model, the overall prevalence of depression was equal to 35% (95% CI 27% to 44%) in patients with cancer across Iran (figure 2). A sensitivity test was performed to ensure the stability of the results. Results before and after the sensitivity analysis were not changed (figure 3). Table 3 presents the results of subgroup analysis based on the place, quality, type of study and the diagnostic questionnaire for depression in patients with cancer.

    Figure 2
    Figure 2

    The overall prevalence of depression in cancer patients in Iran

    Figure 3
    Figure 3

    The sensitivity analysis of depression prevalence in cancer patients in Iran

    Figure 4
    Figure 4

    The graphs of meta-regressions based on the year of publication and sample size of studies.

    View this table:
    Table 3

    The results of subgroup analysis

    The regression process was performed on the basis of the year of publication and sample size (figure 4) to investigate the heterogeneous sources. Figure 4 and table 4 present our results.

    View this table:
    Table 4

    The result of meta-regressions

    Figure 5 shows results of publication irregularities based on Egger test; hence, P-value was obtained equal to 0.108, and thus there was no bias.

    Figure 5
    Figure 5

    Egger's regression test to assess publication bias.

    Discussion

    The present study aimed to investigate depression among Iranian patients with cancer. It is the first systematic and meta-analytic study on this topic in Iran, providing comprehensive analyses such as the subgroup analysis, sensitivity analysis and meta-analysis as its strengths and distinction from other studies. The findings indicated that the prevalence of depression was 35% in the Iranian patients with cancer. In similar studies in other countries, a review study on 31 reports from 1950 to 2010 indicated that the rate of depression was 10.8% (996/9248).29 Another review on 211 studies reported a rate of 14% (95% CI 11% to 17%).30 The prevalence of depression in both studies was reported less than that reported in the present study.

    The findings of the studies conducted in other countries show diverse results. A cross-sectional study on 206 patients with cancer in Singapore indicated that about 27%–38% of them suffered from depression,31 and it was approximately equal to the result of our study. Another study in British Columbia reported the prevalence of depression was equal to 12.9% (−15% to 13%),32 which was much lower than that of the present study. While in a study on 534 patients in India, the rate of this type of depression was reported to be 46.4% (n=248).33 Another study in 300 patients in Pakistan showed an incidence of depression of 48.7%.34 Both studies had higher prevalence rates than the present study.

    It seems that the prevalence of depression was much higher in patients with cancer of low/middle-income countries than developed countries, and this might be due to various factors including economic, social, cultural and health factors. For instance, patients with cancer are less worried about their healthcare costs in countries with better economic status; thus, they suffer less stress and depression. On the other hand, economic pressure of lower income societies can be a cause of depression which significantly affects mental health and prevalence of depression in these patients.35 Patients with cancer should be supported by the healthcare system because they may suffer from depression due to medical conditions and increased economic costs. Therefore, a sufficient insurance coverage can help reduce the burden of the disease. Given that Iran is a low/middle-income country, there are economic constraints in the health sector, and the optimal aim can be achieved by providing health services coverage to patients with cancer.

    Limitations

    The main limitation of this study was that there was no study on the rate of depression among patients with cancer in many Iranian provinces. Furthermore, there is a high heterogeneity in the available studies that can have effect on results. This can be due to different diagnosis methods (most studies were cross sectional and some of them used convenience sampling, while others applied cluster sampling methods). Another limitation of the present study was that some variables such as gender of depressed participants were not reported in the selected studies, and the researchers could not perform a full subgroup analysis.

    Conclusion

    Depression prevalence among Iranian patients with cancer was higher than that of developed countries. This can be a significant point for policymakers in this field because depression can lead to other multimorbidities and negative outcomes such as lack of motivation for treatment, prolonged treatment period and burden of additional costs. Since there are few preliminary studies in Iran, this area of research needs further high-quality studies to improve decision-making, and planning for the delivery of better care and services.

    Ethics statements

    Patient consent for publication

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    Footnotes

    • Correction notice This article has been updated since it was first published. The article type has been changed to Systematic review.

    • Contributors Conception and design of study: AG, AA. Acquisition of data: AG, ES, SM, DG. Analysis and/or interpretation of data: AA, SA, MRB. Drafting the manuscript: AG, AA. Revising the manuscript critically for important intellectual content: AA, AD. Approval of the version of the manuscript to be published: AG, AA, ES, SM, DG, SA, MRB.

    • Funding This research was supported by the Iran University of Medical Sciences and Student Research Committee of Faculty of Health Management and Information Sciences Branch that provided expertise that greatly assisted the research.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.