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Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

ASEAN-Turkey ASLI (Annual Serial Landmark International) Conferences on Quality of Life 2016
AMER International Conference on Quality of Life, AicQoL2016Medan
25 – 27 February 2016, Medan, Indonesia

Depressive Symptoms among Cancer Patients Undergoing

Chemotherapy
Suzana Yusofa*, Fatin Nadzirah Zakariab, Nina Keterina Hashimb, Razif Dasimanb
a
Department of Nursing, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia
b
Department of Basic Science, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia

Abstract

Objective: To investigate the level of depressive symptoms among cancer patients undergoing chemotherapy and its association
with sociodemographic data. A cross-sectional study was conducted among cancer patient in General Hospital Kuala Lumpur.
One hundred eleven (111) cancer patients undergoing chemotherapy were evaluated, and their participation was on a voluntary
basis. A well-constructed and validated questionnaire was used to assess the depressive symptom including their demographic
and sociographic data. The results of the present investigation revealed that the level of depressive symptom in cancer patients
did not affect between gender, ages and chemotherapy’s cycle as there showed no significant difference. However, the result
showed a significant difference between marital statuses. This finding would be useful and beneficial to healthcare services
which might improve in management and intervention on psychological of patient undergoing chemotherapy. Other factors that
contributed to depression among cancer patient also need to be investigated.
© 2015 The Authors. Published by Elsevier Ltd.
© 2016 The Authors.
Peer-review Published by Elsevier
under responsibility of AMER Ltd. This is an open
(Association access article
of Malaysian under the CC BY-NC-ND
Environment-Behaviour license
Researchers) and cE-Bs (Centre
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
for Environment-Behaviour Studies, Faculty of Architecture, Planning & Surveying, Universiti Teknologi
Peer-review under responsibility of the Association of Malaysian Environment-Behavior Researchers, AMER (ABRA MARA, Malaysia.
malaysia)

Keywords: Depression; cancer patient; chemotherapy

* Corresponding author. Tel.: +603-3258-4350; fax: +603-32584599.

E-mail address: suzanay@salam.uitm.edu.my

1877-0428 © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the Association of Malaysian Environment-Behavior Researchers, AMER (ABRA malaysia)
doi:10.1016/j.sbspro.2016.10.233
186 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

1. Introduction

Cancer is the second leading cause of death (Polikandrioti et al., 2008). The risk factors that lead to cancer
include chemical carcinogens, age, lifestyle factors, radiation, infection and immune system. Surgery, chemotherapy,
and radiotherapy are the most common treatment of cancer to cure or control from spreading throughout the body
(Tim, 2012). Patient diagnosed with cancer commonly having depressive symptoms (Kim et al., 2006). About 15-
25% of cancer patients are affected by depression reports by The National Cancer Institute (2008) (Bayer, 2009).
Chemotherapy is a type of cancer treatment that uses drugs to destroy the cancer cells. The cancer patient receiving
chemotherapy may lead to depressive symptoms and worsening during chemotherapy (Polikandrioti et al., 2008).
According to National Cancer Registry (2011), the symptoms of depression were included sadness, loss of interest,
changes in eating and sleeping habits, nervousness, slow physical and mental responses, feeling guilty, unable to
focus and frequent thoughts of death or suicide. In diagnosing depression, physical and mental state assessment, as
well as laboratory investigations, were commonly evaluated.
Apart from genetic factor, nutritional intakes and family history, the demographic factors were also contributed to
depressive symptoms in cancer patients who undergone chemotherapy. The previous study had been shown that
women have the higher prevalence of depressive symptoms than male. On the other hand, depression level decreases
inversely with increases of age (Miaskowski, 2004). Other study conducted by Beyer (2009) claimed that young
unmarried women have the higher risk of developing depression. This finding was parallel with Hann et al. (2002)
who stated that high social support from family member results in reducing the depression symptoms. However,
there were limited finding on the association between the level of depressive symptoms and demographic factors
such as age, gender, marital status as well as chemotherapy’s cycle. Hence, these findings can provide a baseline
information that may potentially be important for the healthcare provider in providing accurate and efficient
management, especially in the cancer patient.

2. Materials and methods

2.1. Sampling

One hundred eleven (111) respondents of the cancer patient who was undergoing chemotherapy at General
Hospital Kuala Lumpur were evaluated. The researchers have explained the purpose of conducting the research to
the respondents before data collection. All experiments were conducted according to the guideline proved by Ethic
Committee of UiTM Puncak Alam (UiTM 600-FSK (PT. 5/2)), the director of Kuala Lumpur Hospital, Head of
Department of Oncology Unit and National Medical Research (reference number 15333). All data collection were
kept confidentially and only been used for academic purposes.

2.2. Selection criteria

Some criteria must be included to form a sample population.

Inclusion Criteria
x 18 years of age and above
x Cancer patient undergoing chemotherapy
x Conscious patient

Exclusion Criteria
x Cancer patient undergoing radiotherapy

2.3. Questionnaire

The researcher used the survey as the instrument for data collection. The level of the depressive symptom of
respondents was scored using the Center for Epidemiologic Studies Depression Scale (CESD) tool. The
questionnaire consists of three parts. Part A includes the question related to sociodemographic data such as gender,
 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192 187

age, marital status, chemotherapy's cycle, stages and type of cancer. Part B includes the question regarding on the
level of depression symptoms whereas Part C includes the respondent's feeling to depression. All respondents have
fulfilled the questionnaire within 15 minutes and were scored according to the scoring system as indicated below:

x Score less than 15 : not appear to be experiencing high levels of depressive symptom
x Score 15-21 : mild to moderate depressive symptom
x Score more than 21 : high level of depressive symptom

2.4. Statistical data analysis

Statistical Package for Social Science (SPSS) software was used in this study. Data was analyzed by using
descriptive analysis followed by Spearman’s Rank Correlation Test to identify the relationship between variables.
P< 0.10 was considered as significant differences.

3. Results

From a total of 111 respondents in the study, there were 67 (60.4%) male patients and 44 (39.6%) female
patients. Sixty-one (55%) of the patients involved in this study were above 50 years of age, followed by 34 (36.6%)
of 30-49 years old and 16 (14.4%) of 18-29 years old. About marital status, 13 (11.7%) were unmarried, 92 (82.9%)
married and 6 (5.4%) were divorced. Based on data of chemotherapy cycle during the study, 9.0% was in the first
cycle, 16.2% was in the second cycle, 20.7% was in the third cycle, and 54.1% was in the forth cycle and above (See
Table 1).

Table 1. Sociodemographic data

Characteristic n %
Gender Male 7 60.4
Female 44 39.6

Age 18-29 16 14.4

30-49 34 36.6
Above 50 61 55

Marital status Single 13 11.7

Married 92 82.9
Divorced 6 5.4

Chemotherapy 1st 10 9.0

cycles 2nd 18 16.2
3rd 23 20.7
4th and above 60 54.1
188 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

Table 2. Level of depressive symptoms of cancer patients undergoing chemotherapy

Depressive symptoms n %

No experiencing depressive symptoms 60 54.1

Mild to moderate depressive symptoms 24 21.8
Possibility of major depressive symptoms 27 24.3

For the level of the depressive symptom of the total sample in the study, there was 54.1% ) for the total of no
depressive symptom which, (21.8 [n=24]) was the total of mild to depressive symptom level. The high-level
depressive symptom associated with major depression is much higher compare to moderate depressive symptom
level with total (24.3% [n= 27]). In regard to gender, from 111 of cancer patient undergoing chemotherapy, for
males, (53.7% [n=36) having no depressive symptom, (22.4% [n=15]) was mild to moderate of depressive symptom
and (23.9% [n=16]) was high level of depressive symptom associated with major depressive symptom. While
female gender, (54.5% [n=24]) was no depressive symptom, (20.5% [n=9]) was mild to moderate of depressive
symptom and (25% [n=11]) was a high level of the depressive symptom associated with the major depressive
symptom.
Regarding age category, for 18-29 years old, (62.5% [n=10) having no depressive symptom, (18.75% [n=3]) was
mild to moderate of depressive symptom and (18.75% [n=3]) was the high level of depressive symptom associated
with major depressive symptom. While 30 – 49 years old, (53% [n=18]) was no having depressive symptom, (29.4%
[n=10]) was mild to moderate of depressive symptom and (17.6% [n=6]) was the high level of the depressive
symptom associated with the major depressive symptom. For 50 years old and above, (52.5% [n=32) having no
depressive symptom, (18% [n=11]) was mild to moderate of depressive symptom and (29.5% [n=18]) was high
level of depressive symptom associated with major depressive symptom.
Regarding marital status of participants, for single, (69.2% [n=9) having no depressive symptom, (7.7% [n=1])
was mild to moderate of depressive symptom and (23% [n=3]) was high level of depressive symptom associated
with major depressive symptom. While for married, (55.4% [n=51]) was no having depressive symptom, (20.7%
[n=19]) was mild to moderate of depressive symptom and (23.9% [n=22) was the high level of the depressive
symptom associated with the major depressive symptom. For divorced, (0% [n=0) having no depressive symptom,
(66.7% [n=4]) was mild to moderate of depressive symptom and (33.3% [n=2]) was high level of depressive
symptom associated with major depressive symptom (See Table 3).

Table 3. Sociodemographic data and level of depressive symptoms

Level of depressive symptoms

Characteristics
No depressive symptoms
n %
Mild to moderate of High level of depressive
depressive symptoms symptom associated with
major depressive symptoms
n % n %

Gender Male 3 18.75 10 29.4 11 18

Female 3 18.75 6 17.6 18 29.5

Age 18-29 10 62.5 3 18.75 3 18.75

30-49 18 53 10 29.4 6 17.6
Above 50 32 52.5 11 18 18 29.5
 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192 189

Marital status Single 9 69.2 1 7.7 3 23

Married 51 55.4 19 20.7 22 23.9
Divorced 0 0 4 23.9 2 33.3

Chemotherapy 1st 7 70 0 0 3 30
cycle
2nd 7 38.9 5 27.8 6 33.3
3rd 12 55.2 8 34.8 3 13
4th and above 34 56.7 11 18.3 15 25

This study was used nonparametric test Spearman Rank correlation to identify the association between variables
which met the objective 2 and 3. The statistical analysis showed no correlation between the level of depressive
symptom and gender, p=0.992. The statistical analysis also showed no correlation between the level of depressive
symptom and the age of participant during the study, p=0.380. According to marital status, the statistical analysis
showed the correlation between the level of depressive symptom and marital status, p=0.064 with the confidence
interval of 90%. Regarding the current chemotherapy cycle during the study, the statistical analysis also showed no
correlation between the level of depressive symptom and the current chemotherapy’s cycle during the study,
p=0.682. (see Table 4)

Table 4. Association between gender, age, marital status, current chemotherapy cycle and the
levels of the depressive symptom (90% of confidence interval)

Variables p-value
Gender p=0.992
Age p=0.380
Marital status p=0.064
Current chemotherapy cycle p=0.682

4. Discussion

Based on (Inaba, et al., 2005), the most of the cross study stated that woman, unmarried person, lower education
person, low income, or occupational prestige have the higher risk for depressive disorder than man, the married, and
higher advantaged socioeconomic status (SES) position. In this study, the number of samples according to gender
differences also had been observed where the majority of the samples are the man than the woman, the similar
finding with another study (Lavdaniti, 2012). The statistical result showed that 54.1% did not have depressive
symptom, 21.6% experienced mild to the moderate depressive symptom, and 24.3% had high-level depressive
symptom associated with major depression. There was no significant difference found between age, sex, marital
status, and educational level in the study conducted by Rezaei, and Adib-hajbaghery (2008).

4.1. Gender

From the result analysis of the present study on gender differences, there is no statistically significant from
gender differences as per the previous study conducted by Polikandrioti et al., (2008) that showed women
experienced higher depression than man but no significant statistics. The finding of the current research is parallel
with the research finding by Farooqi, & Ahsan, (2009), Hann, et al., (2002), Linden, W. et al., (2012), Inaba, et al.,
(2005).
The result of Farooqi, & Ahsan, (2009)'s study also supported the result of this study. The cross-sectional study
was carried on gender differences in anxiety and depression among Pakistani cancer patients using HADS. 100
190 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

patients (male = 50, female = 50) were taken as samples, and the result shows that there were no significant
differences between gender and depression.
The study conducted by Lavdaniti, (2012) revealed that there was no statistically significant difference in the
relationship between depression and gender. Lavdaniti, (2012) believed that the depression level affects men and
women equally. Linden, et al., (2012) suggested that gender differences influenced in their willingness to express
depression and women tend to apply emotional approach coping skills.
Newport, & Nemeroff, (1998) stated that depression was a common clinical entity with the lifetime risk of Major
depressive disorder (MDD) had been 20% to 25% of women and 7% to 12% for men where the point of prevalence
is 5% to 9% for women and 2% to 3% for men. The Cross-National Collaborative Group found higher lifetime and
12-month rates of major depressive disorder among women compared to men across all ten nations, including
Taiwan, South Korea, urban women in Seoul and women in Taiwan.

4.2. Age

In the term of age in this study, younger patients are less depressed than older patients. (Fann, et al., 2008) In his
study stated that younger patients have the higher risk of depression especially the first year after diagnosis of
having breast cancer. However, no significant difference was found between level of depression and age in this
study which is similar to Polikandrioti et al., (2008) who mentioned that his study does not show a direct association
between depression level and age. The result of Lavdaniti, (2012) also showed there was no statistically significant
between depression and age. In the meta-analysis of the study conducted by (Chang-quan, et al., 2010) showed there
was no significant difference between old age cancer patient and depression.
However, the study by Linden, et al., (2012) mentioned that there were higher prevalence rate of depression level
among younger age cancer patients than lower prevalence rate of depression level in older age cancer patients
(Linden, et al., (2012) (Kim, et al., 2006). The researchers believed that higher prevalence rate of depression level
among younger age due to more disruption in daily life while the older age already had physical function
impairments and they had prepared cognitively and emotionally in accepting the illness (Linden, et al., 2012)
(Polikandrioti et al., 2008). Hopwood, (2000) found that there was a slight trend for lower depression level in older
patients, but the variable did not achieve statistical significance (p = .058).
In the literature review of Trask, (2004), using HADS tool as a unitary scale with 11 as a threshold level, it was
found that a significant of 70% in identifying psychiatric disorder and this varied by the age of the women.
However, < women 50 years of age showed 90% sensitive and 40% false positive rate using 11 as a threshold level,
but in > women 50 years of age, the sensitive was 57%, and the false positive rate was 3%.
Study conducted by Miaskowski, (2004) showed that there was interaction between age and gender on the
depression level using Center for Epidemiological Studies-Depression scale (CES-D) where if age increased by 1
year for men, depression level reduced by 0.33 units; while as age increased by 1 year in women, depression raised
by 0.16 units. According to Ahles, & Saykin, (2002), there was speculation that older adult might be exposed to the
chemotherapy’s side effect to cognitive function. So, the age at treatment can be a predictor of the level of
chemotherapy-induced cognitive changes.

4.3. Marital status

Marital distress and depression always occur especially among women (Rehman, et al., 2008). The interesting
finding in this research is about the marital status where in this study, there are statistically significant differences
between depression level and marital status. It found that divorced patients faced more depression than married
patients. This present study finding matched with the previous research conducted by Lavdaniti, (2012). The Cross-
National Collaborative Group cater across all ten nations including Taiwan and South Korea found that separated
and divorced individuals showed higher major depression prevalence compared to the married person (Inaba, et al.,
2005). The possible explanation for this is because divorced patients did not have moral support from the family
members than the married patients that had moral support from the family members (Lavdaniti, 2012). Similar to
other study by Pasquini, Biondi, (2007) mentioned that social support also played an important role alleviating
depression among cancer patients and family counseling should be implemented to educate the family members
 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192 191

about depression among cancer patients (Pasquini, & Biondi, (2007) (Hann, et al., 2002). Hann, et al., (2002) also
shared the same confirmed result that increasing in social support were linked with the low level of depression
among cancer patients. Hann, et al., (2002) also stated that having larger social support significantly associated with
low depression level for women but not significant for men. In a study conducted by (Inaba, et al., 2005) it was
stated that unmarried and formerly-married individual exhibit higher depression level scores than the married.

4.4. Chemotherapy cycle

In the present study, there is no significant difference between depression and chemotherapy cycles. This finding
is consistent with Khudhair, (2009) who mentioned that there were no significant differences found between
depression level and chemotherapy cycle. The study conducted by Beyer, (2009) showed there were no significant
differences in the number of depressed patients before and after treatment, and levels of depression were not
significantly different for either type of cancers. Pandey, et al., (2006) also mentioned there was no relationship
between chemotherapy cycle and depression. However, research conducted by Polikandrioti et al., (2008) showed
that those undergoing chemotherapy with no response felt more depressed than those who had responded after
chemotherapy treatment.( Polikandrioti et al., 2008) (Pandey, et al., 2006)
The study conducted by Jim, et al., (2011) stated that there were significant differences on the main effect of
chemotherapy cycle and depression where the depression was found on the infusion day with the higher level of
depression than the later infusion. (Fann, et al., 2008) also showed the same result where women who received
chemotherapy reported more psychological distress and depression compared to those who did not receive
chemotherapy.
Although cancer diagnosis was a marked stressor, there were other psychological and biological stressors that
accompany cancer and developing the depressive syndrome. Chemotherapeutic agents, surgical procedures, and
radiotherapy were the biological stressors experienced by cancer patients that include the effect of treatment as well
as the consequences of paraneoplastic syndromes (Newport, & Nemeroff, 1998).
The result of Cantor, et al., (2003) study showed that 70 years and over cancer patients were treated at one
academic tertiary cancer center, faced deteriorations in emotional and functional after chemotherapy treatment. This
deterioration was higher in patients who faced severe side effects from chemotherapy treatment than those who did
not, and among tumor progression patients than those with partial or complete treatment.
The study conducted by Pandey, et al., (2006) showed that side effect symptoms appearance among cancer
patients receiving chemotherapy. The symptoms are like tiredness, loss of appetite, dryness of mouth, nausea, and
sleep disturbances. For breast cancer patients undergoing chemotherapy, the chemotherapy adverse effect involved
are of fertility, sexuality and menopause-associated health problems (e.g., osteoporosis and cardiovascular disease)
that can lead to high distress level (Fann, et al., 2008). Khudhair, (2009) stated that the relationship between
depression level and the physical symptoms among cancer patients was limited. This result showed that the
depression symptoms among cancer patients undergoing chemotherapy may arise from the disease itself.

5. Conclusion

In conclusion, there was no association between the level of the depressive symptom with age, gender and
chemotherapy's cycle, indicating that the depression was caused by the disease itself. However, there was a
significant difference between marital statuses on depression indicating that moral support from the family member
can minimize the depression level among cancer patient who was undergoing chemotherapy. This finding may be
useful for the health care provider to identify the potential depression patient. Other factors that contributed to
depression among cancer patient also need to be investigated.

Conflict of Interest

We declare that we have no conflict of interest.

192 Suzana Yusof et al. / Procedia - Social and Behavioral Sciences 234 (2016) 185 – 192

Acknowledgement

The authors are grateful to Head of Oncology Department, General Hospital Kuala Lumpur, nurses, student
nurses and staff for their cooperation and providing necessary research facilities.

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