AN EXPLOR TORY STUDY OF DEPRESSIVE DISORDER IN PATIENTS WITH GASTROINTESTINAL CARCINOMA ; dr c p sedain

AN EXPLOR TORY STUDY OF
DEPRESSIVE DISORDER IN PATIENTS
WITH GASTROINTESTINAL
CARCINOMA

THESIS
SUBMITTED TO
THE DEPARTMENT OF PSYCHIATRY AND
MENTAL HEALTH, MAHARAJGUNJ CAMPUS,
INSTITUTE OF MEDICINE, TRIBHUVAN
UNIVERSITY, KATHMANDU
AS A PARTIAL FULFILMENT OF THE
REQUIREMENT FOR DEGREE OF DOCTOR
OF MEDICINE (PSYCHIATRY)
KATHMANDU, NEPAL
DR. CHANDRA PRASAD SEDAIN
DECEMBER 2002



AN EXPLORATOI Y STUDY OF DEPRESSIVE
ISORDER IN PATIENTS WITH GASTROINTESTINAL
CARCINOMA
THESIS
SUBMITTED TO
THE DEPARTMENT OF PSYCHIATRY AND MENTAL HEALTH,
MAHARAJGUNJ CAMPUS, INSTITUTE OF MEDICINE, TRIBHUVAN
UNIVERSITY, KATHMANDU
GUIDE
Prof. Dr. Mahendra Kumar Nepal, MD
Head, Department of Psychiatry and Mental Health,
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
Co- GUIDES
Dr. K.P. Singh ,MS
Associate professor
Department of Surgery
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
Dr. Shishir Kumar Regmi, FCPS
Associate professor
Department of Psychiatry and Mental Health,
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
Dr. Naba Raj Koirala ,FCPS
Lecturer
Department of Psychiatry and Mental Health,
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
CANDIDATE
Chandra Prasad Sedain,
Resident, MD Psychiatry



Certificate

This is to certify that this work submitted by Chandra Prasad Sedain, student of MD
Psychiatry Institute of Medicine as a thesis in partial fulfilment of the requirement for the
degree of Doctor of medicine (Psychiatry). This work is a record of the candidate's
personal effort,
Guidehe
Prof. Dr. Mahendra Kumar Nepak MD
Head Department of Psychiatry and Mental Health,
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
Co- Guidę
Dr. K.P. Singh, MS
Associate professor
Department of Surgery
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
in
Sel
Co-Guide
Dr. Shishir Kimar Regmi, FCPS
Associate professor
Department of Psychiatry and Mental Health,
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu
Co-Guide
Dr. Naba Raj Koirala, FCPS
Lecturer
Department of Psychiatry and Mental Health,
Maharajgunj Campus, Institute of Medicine,
Tribhuvan University, Kathmandu


Acknowledgement

I am deeply indebted and grateful to Prof. Dr. M.K. Nepal. I offer my sincere respect for
bis invaluable guidance and constant inspiration through out the course of current work. I
acknowledge my gratitude to Associate Prof. Dr. K.P. Singh who gave me unstained
support providing expert guidance throughout the study period.
This current work gives the opportunity of acknowledging gratefully the debt I owe to my
respected teacher Associate Prof Dr. Shishir K. Regmi. This work would not have been
accomplished without his kind guidance and constant supervision.
Word has been scanty to describe the role of Dr. N.R. Koirala to formulate the protocols
as well as to go through the work from the beginning. I am deeply indebted to him for
his inspiration and guidance.
Special acknowledgements are owed to Associate Prof. Dr. V.D. Sharma, a constant
source of encouragement; Dr. Saroj P. Ojha who inspired me with his invaluable
suggestion in several arcas of difficulties; and Dr. Udaya K Sinha and Dr. Prachi for
invaluable help during the difficult time in course of current work. Likewise, I am
grateful to my teacher Mr. Chitra Kumar Gurung for help in statistical analysis, Prof.
M.P. Regmi, Mrs. Mita Rana, Mrs Jamuna Sangraula, Mr. Pashupati Mahat for helping
me through sorne difficult times on course of the study.
All of my colleagues have added luster to this work by providing help and emotional
support. Dr.Mohan Raj Shrestha, Dr.Ghana Shyam Chapagain, Dr.Anupam Pokharel, Dr.
Shudarson Pradhan, Dr.Lumeshawor Acharya, Dr.Sailendra Adhikari, Dr.Sharad Man
Tamrakar, Dr.Binu CB, Dr.Manisa Chapagain, Dr.Namrata Rawal, Mr SubashChandra
Sharma, Rekha Jalan, Mrs.Jamuna Pandey, Mr. Junga Bahadur Hanjan all of them
deserve recoganization for their role in one way or others.
I would like to thank nursing staff of Psychiatric ward and Deaddiction ward, and staff of
department of surgery for their kind co-operation, without which this work was almost
impossible to accomplish smoothly. I would like to thank Mr. Rammani Banjara who
helped me on computer work. I would like to acknowledge my regards and gratitude to
all the patients and their guardians for their co-operation and patience.
Finally, I express my gratefulness to my respected parents, a constant source of
encouragement in my life to whom the current work is dedicated; I sincerely thank Shova
my wife for her help and emotional support at many very difficult times during the
accomplishment of this thesis.
Dr. Chandra Prasad Sedain
December 2002



INTRODUCTION

Estimates of the prevalence of moderate to severe depression in hospitalized cancer
patients range trom 17%-25% (Pettey &. Noyese, 1981). The risk of suicide in patients
with cancer is double as compare with general population. History of prior depression,
inadequately controlled pain, an advanced stage of illness and disease at certain sites such as the pancreas are the factors that put the individual at high risk for depressive disorder
(Holland & Korzun, 1986).
Though the exact estimation of both new and old cases of cancer in Nepal is difficult to
obtain due to many reasons, it has been estimated that there are about one and half
million cases of cancer in the country at any given point of time with about half a million
new cancer cases being added every year (Shrestha et al, 1997; Shrestha et al,1988).
More than 60 per cent of these affected patients are in the prime of their life between the
ages of 35 and 65 years (Shrestha et al, 1997).
The majority of these cancer patients who present themselves for treatment at the various
institutions are in an advanced stage of the disease and therefore only palliative treatment
is possible. The facilities for treatment are largely restricted to urban centers and are too
meager to cater for the existing needs, which makes almost impossible, the estimation of
exact incidence and prevalence of cancer in the country. Conservative estimates (hospital
based data only) report that gastric cancer is the most leading form of cancer in Nepal
(Shrestha et al, 1997). Lung cancer in Nepal is occupying the top most rank amongst the list of cancers in Nepal (Shrestha et al, 1997) and cancer is the tenth leading cause of death in Nepal, accounting for 0.8% of the total death (WHO, 2002a).
Hospital based study revealed that almost half of the cancer patients were diagnosed as
having psychiatric disorder. Most of these patients had adjustment disorders, major
depression or delirium (Derogatis et al., 1983). Cancer of all forms causes about 12% of

death throughout the world. When global figure of death is broken-down, out of
estimated 51.3 million deaths during 1996 in the world, more than 7.1 million are
attributed to cancer (WHO, 1997),
Patients with cancer are no more depressed than other physically ill patients, and majority
do not experience long term distress unless the disorder progress or unless they are
particularly vulnerable to stress (Harrison & Raguire, 1994). The psychological distress
and depression that are prevalent in some patients with cancer represents complex, social,
psychological and medical factors. Psychological distress is to be expected in individual
with cancer because of possible death, pain or other disability, disfiguring and changes in
function, which endanger his or her relationship to others.
the body and loss
Psychological consequences of cancer are similar to those of any serious physical illness
Some patients delay seeking medical help because they fear or deny symptom
Knowledge of the diagnosis of cancer, which may cause shock, anger, disbelief as well as anxiety and depression, will further delay the process. Depressed mood is particular"
likely at the time of diagnosis and following relapse but is usually transient. Maj-
depression occurs throughout the course of cancer, affecting 10-20% of patients
appears to be more prevalent in those suffering from pain (Noyes & Kathol, 1986). Bc
the progression and the recurrence of cancer are often associated with increas
psychiatric disturbances, which may result from worsening of physical symptoms such
pain and nausea, or fear of dying or organic psychiatric symptoms (Holland & Rowls
(6861
Clinical profile of depression following cancer may be different than depression wi:
any co morbidity (Gale, 1971), therefore, the diagnosis of depression when assoc
with cancer can not be depended upon on vegetative signs, such as lack of ener
anorexia but rests on a constellation of psychological symptoms like dysphoric c
mood, feelings of helplessness and hopelessness, loss of self-esteem and feelir
worthlessness, guilt and wish to die (Plumb & Holland, 1977). Although cancer p-
usually maintain self-esteem, recurrent thoughts of death are common in them, b-
do not have the characteristic morbid intensity and desire as seen in depressed patients

The diagnosis of cancer

creates a crisis that requires patients to adapt quickly to
catastrophic news. Majority of cancer causes fear of death, dependency, disfigurement,
disability, and abandonment as well as disruption in reiationship, role function and
financial status.
Patients' responses are modulated by medical, psychological and
interpersonal factors. Medical factors include site of disease, symptom and predicted
course; psychological factors include pre-existing character style, coping ability, ego
strength, developmental stage of life and impact and meaning of career at that stage.
Interpersonal factors refer to family and social support and input from the health care
team (Lederberg and Holland, 1999).
In recent years, considerable research has been conducted concerning the diagnosis and
management of depression in patients with cancer. A major obstacle to study of
depression in patients with cancer has been the difficulty distinguishing the depressive
symptoms that are associated with syndromal depression from the symptoms that are
caused by patient's medical illness. All cancer patients with depression have strong
reactive component and are quite responsive to treatment. Unfortunately they are often
undiagnosed and untreated (Plumb & Holland, 1977).
The lack of recognition of depression in patients with cancer has been well documented.
General physicians have been found to recognize depression in only one fourth to one
half of their depressed medical outpatients (Plumb & Holland, 1977). Recognition =
these patients is important because depressive disorder may adversely affect survival,
length of hospital stay, compliance with therapy, the ability to care for oneself and qual
of life. Unfortunately, in Nepal also there are plenty of studies in Nepal which suge
that the recognition of depression both with or without comorbid condition is very p
(Wright et al,1989) therefore a large bulk of these people who required mental he
services do not get adequate treatment and are either poorly served or underser
Considering this issue in mind, the present study is carried out to study
sociodemographic and clinical correlation between depression and gastrointes
carcinoma amongst patients who had received the diagnosis of carcinom
gastrointestinal tract form Surgical Out-patient or In-patient Department of Tribhuvan University Teaching Hospital. This study is an attempt to throw light in this area, which
can be helpful in Nepal because of the paucity of available literature.



MATERIALS AND METHODS
AIM OF STUDY

To study depression in patient with gastrointestinal (G.1) carcinoma

Objectives:

To identify depression in patient with gastrointestinal (G.I) carcinoma
(1
To detect severity of depression
To compare the clinical feature of depression in patients with gastrointestinal
(G.I) carcinoma with those without any comorbidity.

Design:

It was a prospective cross sectional study in which matched control group design was
followed. The cases comprised diagnosed case of G.I. carcinoma.

Sample:

The sample comprised 50 consecutive diagnosed case of G.I. carcinoma was taken from
surgical department (OPD/Ward and endoscopy unit), of TUTH, Kathmandu. The
* sample was selected according to inclusion and exclusion criteria. A control group of 50
diagnosed cases of depression without any comorbidity was taken from psychiatry
department.

Inclusion Criteria:

Sample comprised of 50 consecutive diagnosed cases of G.I. Carcinoma who was
attending the surgical department OPD/Ward of TUTH.
The control group was taken the patients from psychiatry department those diagnosed
as depression without any comorbidity.

Exclusion Criteria:

Those patients who cannot communicate in verbal and non-verbal means.
The patient who do not give consent.
Those with G.I. carcinoma as a result of metastasis
Tools:
Self-designed semi Structured Performa:
(1
Self-designed semi structured Performa was prepared to obtain the socio-
demographic characteristics of the patient. Which contained name, age, sex, caste,
address, education, marital status, occupation, religion and other information.
Appropriate question was formed to get the relevant information.
ICD - 10 DCR:
(7
The Diagnosis was done on the basis of L.C.D. 10 diagnostic research criteria
(WHO, 1992).
Hamilton's Depression Rating Scale (HDRS)
This scale was developed by Maxwell Hamilton in 1967. This scale is designed
to measure the severity of illness of patient alrcady classified as suffering from
depressive illness.
As far as possible the scale should be use in manner of clinical interview. The
scale consists of 21 items, the scores of which are summed to give total score.
The last four items are excluded from total score because they occur infrequently.
They are useful for other purposes. The method of assessment is simple. For
some symptoms it is difficult to clicit such information as will permit of full
quantification, if present, score 2, if absent score 0, and if doubtful scorel. For
those symptoms for which more detail information can be obtained, the score of 2
are expanded into 2 for mild, 3 for moderate and 4 for severe. Maximum score is
48. Total score is used for grading as mild, moderate or sever. This scale is use
in many clinical and researches purposes. The validity has been demonstrated in a number of studies in which rating were compared in-group of patient with different severity of illness and studies where rating was compared with global
severity. The reliability of scale has been consistently high across number of
studies (Hamilton, 1967).
Beck's Depression Inventory (BDI):
(b
This is also for detection of severity of depression. It is developed by Beck et al.(
1961). This is subjective test. It consists of 21 items each statement has 4 grades.
Depending upon severity of symptoms each item graded as O to 3 score,
maximum total score is 63. The total score is categorized into mild, moderate,
and severe depression. BDI is used many clinical and research purpose has
adequate reliability and validity. The patien: ticks the best one and the total score
is calculated. The total score is used for grading. A number of studies have found
that BDI correlate reasonably well with HDRS. It is probably the best-known self-
rating scale for depression (Beck et al, 1951).
Implication:
This study will be helpful for future Research Purpose by setting precedence
regarding similar incentive in future.
This study will be helpful to explore cinica! features of depression in cancer patient
and patients suffering from depressive illness without comorbidity that may be useful
for public awareness for purpose.
Esthetical Issue:
The permission was taken from department head on surgical dept. of TUTH.
• The diagnosed case of depression was informed and request for psychiatri
consultation.



Data analysis:

Data were analyzed by 7.5 versions for window and report was prepared.
Procedure:
The cases were selected 50 diagnosed cases of Gastrointestinal (G.1.) carcinoma that
attended surgical department of TUTH. Maharajgunj, Kathmandu. Cases were collected
from (OPD, Ward and Endoscopic Unit). Total numbers of cases were 50, which were
taken as consecutive basis. The study was started first November 2000 and completed
31" June 20001. Total duration was about 8 months. Before starting the study the
permission was taken from department head of Surgical Department. Every case was
taken with consent from patient or patient relatives. One case was excluded due to verbal
communication from patient was not possible. The rapport was established with the
patient to get enough information. The semi structured Performa was filled with adequate
information The Performa composed of Name, Age, Sex, Marital Status, Address,
Religion, Caste, Education, Occupation, Type of family, Socioeconomic Status, Family
Income and Total number of family members. Question related with complaints of the
patient was taken which include chief complaints, History of present illness, past history,
family history and premorbid personality. The examination of the patient was done detail
manner, which include General examination, systemic examination and mental state
examination.
Two rating scales were used to make result accurate, which were Hamilton's Depression
Rating Scale (HDRS) and Beck Depressions Inventory (BDI). HDRS was filled during
interview, which gives objective result and BDI was given to the patient to fill up, which
gives subjective results. The report of physical investigation was also collected for detail
evaluation. The diagnosis was made on the basis of ICD-10 diagnostic criteria for
Rescarch (ICD-10, DCR). For diagnosis the guidance of the psychiatrist was taken. The
diagnosis include as follows:
G.I. Carcinoma with no depression.
( !
G.I. Carcinoma with mild depression.

32
G.I. Carcinoma with moderate depression.
(!!!
G.I. Carcinoma with severe depression.
(A!
The control group was taken from psychiatric department (ward and OPD), that was
diagnosed as depression but without any co morbidity. The total participant on control
group was also 50, which were selected on the basis of consecutive manner. As the cases
all the information were taken from the patient filling with semi structured Performa,
HDRS or BDI also calculated. The diagnosis was made same manner as on the cases,
which include as follows.
Mild depressive episode
Moderate depressive episode
(!!
Severe depressive episode
(III
Finally the demographic profile and clinical features of cases were compared with the
control group by using suitable statistical tools.


Results

This study shows that among 50 cases of gastrointestinal (Gl) carcinoma 22 (44%)
were depressed by using 1.C.D.-10 DCR. Among them, miid depression was very high 14
(28%), moderate depression was in 6 (12%) and severe depression was in 2 (4%) cases.
Data showed pancreatic (71.43%) and oesophagus (66.66%) cancers had highest rates of
depression. The clinical features of patients with G.I. carcinoma with depression were
sadness (86.36%), low mood (72.72%) fatiguability (54.54%), decreased self-confidence
(86.36%), suicidal idea (13.64%), guilt feeling (31.18%), decreased concentration
(54.54%), headache (18.18%) helplessness (9.09%), wceping (13.60%) Biological
symptoms were decreased appetite (27.27%), decreased weight (72.72%), decreased
(68.19%),disturbed sleep (81.81%). Anxiety symptoms w ere anxiesy
sexual desire
(40.90%), dry mouth
iration (36.36%). Other symptoms were auditory hallucination (13.64%), pain
(36.36%), psychomotor retardation
(9.09%), psychomotor
ahdomen (90.90%), nausea and vomiting (98.19%)
fever (18.18%), jaundice (
15 45%), abdominal lump (13.64%) , black stool (50%) , anaemia (77.77%) and
difficulty on swallowing (18.18%).
The control group differ in having less symptoms of decreased weight, pain abdomen,
nausea vomiting, fever, jaundice, abdominal lump, anaemia, passing black stool and
difficulty on swallowing. Hamilton Depression Rating Scale (HDRS) showed 50%
depressive symptoms and Beck Depression Inventory (BDI) showed 46% depressive
symptoms in patient with G.I. carcinoma.



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