Abstract
Background:
Depression commonly occurs in patients with breast cancer (BC), affecting their quality of life.
Objectives:
The relationships between depression and different sociodemographic characteristics in patients with BC are under-researched. We conducted a multicenter study to determine the magnitude of depression and its association with different sociodemographic characteristics.
Design:
In this multi-institutional study, clinical data were collected, prospectively between October 2019 and January 2023 from 207 patients who were on active treatment for BC diagnosis in tertiary oncology hospitals in Georgia.
Methods:
Patients’ sociodemographic characteristics were analyzed and their association with depression was assessed, using Patient Health Questionnaire-9 (PHQ-9) for the identification of depressive symptoms. Patients were stratified using basic information.
Results:
The median age of participants was 53 years (ranging from 31 to 77). Of the participants, 63.2% were married, 44.5% were employed, and only 16.4% reported having adequate financial status. Based on pro-rated PHQ-9 scores, 42% of patients reported some level of depressive symptoms, and 14.5% met the criteria for probable depressive disorder. Women with very inadequate financial status (10/21, 47.6%) reported significantly more depressive symptoms than those with adequate financial support (3/34, 8.8%) (P = .001). Unemployed women (12/42, 28.6%) were nearly 3 times more likely to experience moderate or severe depressive symptoms compared with employed patients (8/92, 8.7%) (P = .002). A significant difference in depressive symptoms was also observed based on education level, with individuals with higher education (12/119, 10%) reporting fewer depressive symptoms compared with those with middle education (18/88, 20.4%) (P = .036). No statistically significant difference in depressive symptoms was found based on marital status or social support.
Conclusions:
Our study found a significant relationship between depression and factors such as financial status, education level, and employment. Lower household income and education level were identified as predictors of clinical depression among patients with BC. These findings can help oncologists in Georgia recognize the importance of providing psychological support to cancer patients. Early detection and prompt referral to mental health specialists can play a key role in effectively managing depression.
Introduction
Breast cancer (BC) is the most frequently diagnosed cancer among women worldwide, constituting 32% of all cancer cases. 1 Advances in early detection and treatment have improved survival rates for patients with BC. 2 Notably, more than half of all BC cases are diagnosed in low- and middle-income countries (LMICs), imposing a significant burden. 3
Georgia, an Eastern European middle-income country with a population of 3.7 million, 4 faces a high prevalence of cancers, with BC being the most common type among females, comprising 29.7% of new cases in this demographic. In 2021, in Georgia, there were 1640 new cases of BC in women registered.5,6 Patients with BC often experience elevated levels of psycho-pathological symptoms, influenced by psychological and physical factors such as reactions to mastectomy and chemotherapy side effects such as hair loss and edema. 7 The diagnosis of BC is frequently traumatic, profoundly impacting patients’ lifestyles, family dynamics, and relationships. 8 More than one-third of patients with BC suffer from psychological symptoms, predominantly anxiety and depression, which are shaped by various sociodemographic factors. 9
Depression is prevalent among patients with BC, significantly affecting their quality of life (QoL) and functional abilities. Research has explored the association between sociodemographic factors such as age, gender, marital status, income, education, employment, and social support and depression severity among patients with BC.7,8,10,11 These relationships are inadequately studied in many countries, including Georgia. Our previous study involving Georgian women indicated a prevalence of depressive symptoms ranging from 14% to 44%. 12
To address these gaps, we conducted a multicenter, prospective study aimed at analyzing the correlation between depression symptoms and sociodemographic characteristics among women undergoing active treatment for BC. Our goal is to identify high-risk patient categories susceptible to developing psychological disorders.
Methods
In this multicenter observational study conducted between October 2019 and January 2023 at 4 health care facilities (Multiprofile Hospital Consilium Medulla, Caucasus Medical Centre, Mardaleishvili Medical Centre and S.Khechinashvili University Hospital) with the highest flow of patients with BC in the country, clinical data were prospectively collected from 214 patients undergoing active treatment for BC.
The sample size was calculated using special tool: confidence level was 95%; margin error 5%; population size (possible level of depression) 20%; population size (BC incidence in 2021 by Georgian cancer registry) 1640, sample size result was -214. After the survey 7 patients withdrew from the study because of several reasons (previous contralateral BC, a history of other type of cancer, known cognitive impairment).
The study received approval from the local ethics committee of Multiprofile Hospital Consilium Medulla, and this document was acceptable to all participant hospitals. All patients provided written informed consent. The inclusion criteria for the study were women aged 18 or older who were undergoing active treatment, had a histologically confirmed diagnosis of BC, had no prior history of mental disorders or dementia, did not abuse alcohol or drugs, were proficient in the Georgian language, able to communicate effectively, and provided consent to participate. There were no restrictions based on the histological type of BC, disease stage, or demographic characteristics.
Specially trained medical personnel collected sociodemographic and clinical data from patients and administered the Patient Health Questionnaire-9 (PHQ-9) to assess depression. The PHQ-9, originally in English, was translated into Georgian and validated for use in the country, as in previous studies. 13 The sociodemographic factors considered included age, marital status, educational level, social and financial support, and employment status.
Data analysis
The data underwent manual entry, cleaning, and logic verification. Initially, depression prevalence analyses were computed using the complete PHQ-9 score. 14 Total scores range from 0 to 27, with higher scores indicating more-severe depressive symptoms. The PHQ-9 demonstrated satisfactory internal consistency (Cronbach’s alpha = .89) and good sensitivity and specificity in identifying cases of major depressive disorders. However, 3 of the 9 PHQ-9 items—related to sleep difficulties, fatigue, and appetite changes—are not specific to depression and are frequently observed in physical illnesses. Thus, they could potentially be influenced by cancer symptoms or treatments like chemotherapy, which might inflate the scores. To mitigate this risk, PHQ-9 scores were recalculated after excluding these 3 items, aiming to reduce the overestimation of depressive symptom prevalence.
The analyses were then repeated using PHQ-9 scores that were adjusted by excluding these 3 vegetative items. The excluded items were proportionally adjusted based on the remaining scores to maintain score consistency (remaining 6 PSQ item total X 1.33 = pro-rated score). Most scales demonstrated robust score stability when adjusted in this manner, using 60% or more of the scale items, with errors remaining within a 61-point scale range. 15
For all bivariate analyses χ2 test (P < .01) was used to test differences.
Depressive symptom severity was defined as mild, moderate or severe. The higher the score the more depressed the patient—PHQ-9/PR scores:
Results
The median age of the patients was 53 years (range 31 to 77), with 131 (63.2%) being married, and 92 (44.5%) employed (Table 1). Using pro-rated PHQ-9 scores, 87 patients (42%) reported some level of depressive symptoms, while 30 (14.5%) women met the criteria for moderate to severe depression.
Patients’ characteristics (n = 207).
Patients with very inadequate financial status (10/21, 47.6%) reported significantly higher levels of depressive symptoms compared with women with adequate financial status (3/34, 8.8%) (P = .001) (Figure 1). Unemployed women (12/42, 28.6%) were nearly 3 times more likely than employed patients (8/92, 8.7%) to experience moderate or severe depressive symptoms, which was statistically significant (P = .002) (Figure 2). In addition, a statistically significant difference was observed based on educational status, as women with higher education levels (12/119, 10%) reported fewer depressive symptoms compared with those with intermediate educational levels (18/88, 20.4%) (P = .036) (Figure 3).
Financial status.
Employment.
Educational status.
The study did not find a statistically significant difference in depressive symptoms based on marital status or social support.
Discussion
Our study, to our knowledge, the first of such kind in the Georgian population, revealed the correlation between depression, financial status, educational level, and employment. While numerous reports examine depression and its correlates, the relationship between sociodemographic and clinical factors and depression following a BC diagnosis remains controversial.16-19 Some studies suggest that sociodemographic factors, such as age, marital status, and socioeconomic status, are associated with depression.16,17,19-22
Our study’s findings that lower income and unemployment are associated with higher levels of depression among patients with BC align with studies from LMICs.23-25 Financial status can worsen feelings of depression, which is particularly relevant in resource-restricted countries like Georgia. Similarly, Avis et al 26 highlighted higher depression levels among lower-income and less-educated patients with BC.
Higher levels of education are typically linked to lower levels of depression. Educated patients often have better access to information, resources, and coping strategies, which can help reduce depression. McCall et al 27 stated that a lower level of education increases the risk for major depressive disorder. In addition, other studies consistent with ours have shown a correlation between depression and education.28,29
Some studies have shown both similarities and differences compared with our findings. A study from Kazakhstan 30 identified social status, household income level, reliability of social support, and the stage of BC as factors associated with depression symptoms. A Shanghai study revealed that low income, marital status, comorbidity, and low QOL scores were independent predictors of depression. 10
Our study does not support the evidence that single, divorced, or widowed patients may experience higher levels of depression. Married patients or those with partners typically have lower levels of depression, likely due to the emotional and practical support provided by their partners. Dadheech et al 31 found that marital status, along with factors such as place of residence, educational and employment status, and having an accompanying person, were significant predictors of depression risk. Similarly, Fann et al 7 identified unmarried status as a significant predictor of depression in patients with BC.
The absence of a correlation between depression and marital status in Georgia might be due to the strong social support networks from family members and friends. The study by Kissane et al 32 highlighted the protective role of social support in reducing depression among patients with BC.
We did not find a statistically significant association between social support and depression, unlike other studies.28,29,33 Evidence indicates that social support greatly reduces depression scores among patients with BC. Family and social support play a crucial protective role against depressive illness. 34
Younger patients with BC often report higher levels of depression compared with older patients, potentially due to the impact of cancer on roles like parenting or career, and concerns about body image and fertility. Burgess et al 15 found that depression was more prevalent in younger women. Our study did not support this correlation, possibly due to the small sample size of young patients. In addition, our research has limitations, as we did not evaluate other potential socioeconomic risk factors such as rural residence, minority groups, and medical insurance.
We believe that understanding and identifying these correlations can assist health care providers in designing more effective, personalized interventions to support the mental health of patients with BC. It is important to remember that patients need psychosocial support in addition to medical treatment.
Conclusion
The study found a significant correlation between depression, financial status, educational level, and employment. Lower household income and educational level predict clinical depression among patients with BC. Early identification of these sociodemographic factors may prevent the development of moderate and severe depressive symptoms. These findings can help oncologists recognize the need for psychological support for patients with BC. By detecting these factors early and making timely referrals, depression can be effectively managed, which is vital for patients with BC. In our future study, we plan to examine the effect of cognitive-behavioral therapy group therapy on patients with BC.
