Psychiatric Comorbidities May Emerge Before Cancer Diagnosis

Being diagnosed and living with cancer can cause significant psychological stress. As a result, patients with cancer may be at a heightened risk of psychiatric comorbidities, such as depression, anxiety, and substance use disorder. A 2011 meta-analysis estimated that up to 40 percent of cancer patients in hospital settings are believed to have some type of mood disorder.

While numerous studies have examined the short- and long-term impact of a cancer diagnosis on mental health, less is known of the impact of diagnostic testing leading to the diagnosis. A study in the April 28 JAMA Oncology suggests that the risk of a psychiatric comorbidity can become heightened nearly a year before an official cancer diagnosis.

These findings arose from a nationwide analysis of over 300,000 cancer patients in Sweden and more than 3 million cancer-free individuals selected as controls. The researchers, led by a group at Sweden’s Karolinska Institutet, compared the rates of five disorders between these groups: depression, anxiety, substance use, somatic/conversion disorder, and stress/adjustment disorder.

The relative rate for all of the examined mental disorders started to become elevated about 10 months before the diagnosis. While these risks were low at first—the average risk increase was only 1.1 times greater—it continued to rise as time progressed, eventually peaking at 6.7 times increased risk one week after the cancer diagnosis. Although the rate increase dropped rapidly after this point, it remained elevated for up to 10 years following the diagnosis.

Study author Fang Fang, M.D., Ph.D., an assistant professor of medical epidemiology and biostatistics at Karolinska, noted that the workup period after a patient is referred to a cancer specialist ranges from a couple of weeks to a couple of months, so the first risks of a psychiatric issue may coincide with the initial onset of cancer-related symptoms.

Fang and her colleagues also examined eight of the most common individual cancer types and found that the pre- and postdiagnosis risks of a mental disorder were greater for cancers that have a poorer prognosis, such as colorectal cancer, than those that are viewed as more benign.

When looking at specific mental disorders, the authors found that the risk for each one was roughly similar prior to a diagnosis, but immediately after diagnosis the highest risk was for stress/adjustment disorder, followed by depression, anxiety, somatic/conversion disorder, and substance use disorder.

Groups such as the Institute of Medicine and the National Comprehensive Cancer Network have previously issued recommendations that psychological and social care be integrated into cancer care. As Fang and colleagues noted, the findings of the JAMA Oncology paper support these guidelines “and call for extended vigilance for multiple mental disorders starting from the time of cancer diagnostic workup.”

Jesse Fann, M.D., M.P.H., a professor of psychiatry and behavioral sciences at the University of Washington and the director of psychiatry and psychology services at the Seattle Cancer Care Alliance, said that collaborative care either in the primary care or oncology setting may be the best fit for providing cancer patients behavioral health services.

Specifically, Fann noted the potential value of models that use a stepped approach, in which the degree of behavioral care is matched to the complexity of the condition.

“Because some patients will improve spontaneously while others will progress to more chronic mental health conditions, the priority following identification of new distress should be close follow-up and intensifying treatment if symptoms do not improve,” he told Psychiatric News.

This study was supported by grants from the Swedish Cancer Society and the Swedish Research Council for Health, Working Life, and Welfare. ■