783
British Journal of Health Psychology (2014), 19, 783–794 © 2013 The British Psychological Society www.wileyonlinelibrary.com
The impact of diagnosis and trait anxiety on psychological distress in women with early stage breast cancer: A prospective study Claudia M. G. Keyzer-Dekker1,2, Jolanda de Vries3,4, Marlies C. Mertens3,5, Jan A. Roukema3,6 and Alida F. W. van der Steeg1,3,6* 1
Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital AMC and VU University Medical Centre, Amsterdam, The Netherlands 2 Department of Paediatric Surgery, Beatrix Children’s Hospital, University Medical Centre Groningen, The Netherlands 3 Centre of Research on Psychology in Somatic Disease (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands 4 Department of Medical Psychology, St Elisabeth Hospital, Tilburg, The Netherlands 5 Department of Medical Psychology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands 6 Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands Objectives. High trait anxiety (HTA) determines depressive symptoms and state anxiety in women with breast cancer (BC) or benign breast disease (BBD). Before implementing screening for psychological counselling in these women, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by HTA. Therefore, we compared women with a lump in the breast with women with gallstone disease (GD). Methods. Women diagnosed with BC (n = 152), BBD (n = 205), and GD (n = 128) were included in a prospective longitudinal study. Questionnaires concerning trait anxiety (baseline), state anxiety, and depressive symptoms were completed before diagnosis was known (BC and BBD) or the laparoscopic cholecystectomy and 6 months later. Results. Pre-diagnosis BC patients scored higher on state anxiety (p = .001) and depressive symptoms (p < .001) compared with GD. At 6 months, scores on depressive symptoms in BC remained higher than GD (p = .005). In women with HTA, before being diagnosed with BC or BBD, scores on state anxiety were higher compared with HTA women with GD (p < .001, p = .040). State anxiety and depressive symptoms at 6 months were predicted by baseline depressive symptoms in women with BC.
*Correspondence should be addressed to Alida F. W. van der Steeg, Department of Paediatric Surgery, Emma Children’s Hospital AMC and VU University Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands (email: a.f.vandersteeg@amc. uva.nl). DOI:10.1111/bjhp.12076
784
Claudia M. G. Keyzer-Dekker et al. Conclusions. The severity of diagnosis (BC) in combination with HTA determined the level of state anxiety and depressive symptoms. Therefore, we recommend identifying women with HTA and offering them a tailor-made follow-up protocol during and after the diagnostic process for BBD or BC.
Statement of contribution What is already known on this subject? Women diagnosed with BC or BBD experience high levels of anxiety and distress during the diagnostic process. These adverse psychological effects are strengthened by the personality characteristic trait anxiety. Before implementing screening for psychological counselling in women with high trait anixety, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by HTA. What does this study add? To our knowledge, this is the first study comparing women who are confronted with the possibility of having a life-threatening disease, that is, BC, with women who were not suspected of having a life-threatening disease, that is, GD. This study reveals that the severity of diagnosis (BC) in combination with HTA determined the level of state anxiety and depressive symptoms. Therefore, we recommend identifying women with HTA and offering them a tailor-made follow-up protocol during and after the diagnostic process for BC or BBD.
Breast cancer (BC) is the most common type of cancer among women. One in eight women in the Western world will be diagnosed with BC (Integral Cancer Centre Netherlands (IKCN), 2013; National Cancer Institute (NCI), 2013). In addition, the majority of women visiting a surgical outpatient clinic with breast problems are diagnosed with benign breast disease (BBD; Van Esch, Den Oudsten, & De Vries, 2011). Up to 50% of these women with BBD, like women with BC, experience high levels of distress, that is, anxiety and depressive symptoms, during the diagnostic process (Ando et al., 2011; Montgomery & McCrone, 2010; Van der Steeg, Keyzer-Dekker, De Vries, & Roukema, 2011; Witek-Janusek, Gabram, & Mathews, 2007; Woodward & Webb, 2001). In women with BC, the prevalence of depressive symptoms is up to 46% (Massie, 2004). Before being diagnosed with BC, 28% of the women experience high levels of state anxiety in combination with depressive symptoms (Van Esch, Roukema, Ernst, Nieuwenhuijzen, & De Vries, 2012). This combination of high state anxiety and depressive symptoms appears to be a major predictor of quality of life (QoL) in women with BC (Van Esch et al., 2012). The adverse psychological effects are strengthened by personality, that is, women with a high score on trait anxiety (HTA) report more state anxiety or depressive symptoms during and after the diagnostic process for BC or BBD (Ando et al., 2011; De Vries, Van der Steeg, & Roukema, 2009; Keyzer-Dekker, De Vries, et al., 2012; Montgomery & McCrone, 2010; van der Steeg et al., 2011). State anxiety is a momentary emotional condition characterized by subjective feeling of apprehension and tension (Spielberger, Gorsuch, & Lushene, 1970).Trait anxiety is a personality characteristic that refers to a relatively stable individual difference in anxiety proneness; thus, it concerns differences in individuals in the disposition to respond to stressful situations with varying amounts of stress (Spielberger et al., 1970). It can also be considered as a part of the neuroticism domain. Neuroticism is part of the worldwide-acknowledged five-factor model to describe personality. This model consists of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness (McCrae & John, 1992). Neuroticism weighs
The impact of diagnosis on distress
785
emotional instability against emotional stability, that is, the tendency to experience no distressing emotions such as fear, guilt, and frustration (McCrae & John, 1992) In previous studies, we have found an important influence of neuroticism on distress in women with BC or BBD, but in particular, HTA predicts women’s state anxiety and depressive symptoms (Keyzer-Dekker, De Vries, et al., 2012; Van Esch et al., 2012). Moreover, we have found that women scoring high on trait anxiety are also scoring high on neuroticism (Keyzer-Dekker, De Vries, et al., 2012). Therefore, in this study, the personality factor trait anxiety and its impact on state anxiety and depressive symptoms were the main focus. Thus, high state anxiety and depressive symptoms are important problems in women during and after the diagnostic process for breast disease, especially in women with HTA (Ando et al., 2011; De Vries et al., 2009; Keyzer-Dekker, De Vries, et al., 2012; Montgomery & McCrone, 2010; Van der Steeg et al., 2011). Therefore, we intend to implement screening for HTA in order to refer patients for psychological counselling. Before implementing this tailored approach, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by the personality characteristic HTA, in other words, whether women with HTA experience high levels of state anxiety and depressive symptoms, regardless of the disease that these women have. Previously, it was found that trait anxiety determines impairment in QoL in women with breast disease, regardless of the diagnosis being BC or BBD (Van der Steeg, De Vries, & Roukema, 2004). We hypothesized that in addition to the personality characteristic trait anxiety, the severity of diagnosis, that is, the suspicion of malignant disease, would also be an important predictor of state anxiety and depressive symptoms. Therefore, in this study, we compared women confronted with the possible life-threatening disease, BC, with women with a non-life-threatening disease, that is, GD, undergoing an elective laparoscopic cholecystectomy (GD). The GD group was chosen because it was previously found that HTA has a negative impact on QoL and persisting biliary symptoms after the operation in this group (Mertens, Roukema, Scholtes, & De Vries, 2009, 2010). In this prospective longitudinal study, the predictive value of trait anxiety and diagnosis was examined for state anxiety and depressive symptoms at baseline and after 6 months.
Patients and methods Participants Women analysed for this study were recruited for two different studies in the Netherlands. The first study analysed the role of psychological factors on QoL and recovery after surgery for symptomatic GD. Between March 2006 and January 2008, all consecutive patients with GD in one teaching hospital awaiting an elective laparoscopic cholecystectomy were asked to participate. For this study, we have only used the data of the women with GD. Exclusion criteria were severe comorbidity (ASA III or more), known pregnancy, undergoing an emergency procedure or intended open cholecystectomy, complicated GD or liver disease, history of abdominal malignancy, and previous upper abdominal surgery. Women with an inability to read and write in Dutch or (previous) psychiatric illness (self-reported or by medical record) were excluded. The first set of questionnaires was given to the patients in the outpatient clinic and was completed before admission for the cholecystectomy. This set could be returned by mail or delivered to the nurses at the
786
Claudia M. G. Keyzer-Dekker et al.
surgical ward. Follow-up questionnaires were posted to the participants and were returned by mail. The second study concerned personality and QoL in women with early stage BC or BBD. Between September 2002 and June 2007, all consecutive women who were referred to one of the three teaching hospitals with an abnormality on a screening mammogram or with a palpable lump in the breast were invited to participate. During the first visit to the outpatient clinic, women completed the first set of questionnaires before any diagnostic procedures were carried out, thus before the diagnosis was known. Exclusion criteria were recurrent (benign) breast disease, inability to read and write in Dutch, or a (history of) psychiatric disease (self-reported or by medical record). Follow-up questionnaires were sent to the participants and were returned by post. The Medical Ethical Board of the primary research hospital approved both study protocols. All participants gave written informed consent.
Questionnaires Questionnaires were completed at baseline and at 6 months. The questionnaires assessed anxiety as personality characteristic at baseline State-Trait Anxiety Inventory (STAI-trait) and experienced momentary anxiety (STAI-state) and depressive symptoms (CES-D) at baseline and at 6 months. The Dutch version of the Spielberger STAI measures trait and state anxiety (Spielberger et al., 1970; Van der Ploeg, Defares, & Spielberger, 1980). It is a widely used 20-item questionnaire with good reliability and validity (Spielberger et al., 1970; Van der Ploeg et al., 1980). The response scale is from 1 to 4 for each item, and scores can range from 20 to 80 of both questionnaires. High state anxiety was defined as a score >38 and HTA with a score >41 (Van der Ploeg et al., 1980). In this study, the Cronbach’s alpha was for STAI-state .96 and for STAI-trait .94. The Centre for Epidemiological Studies-Depression Scale (CES-D) was used to assess depressive symptoms. It measures both the presence and the degree of depressive symptoms. The CES-D questionnaire includes six components of depressive symptoms: depressed mood, feelings of guilt and worthlessness, feelings of hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance. The psychometric properties are good (Hann, Winter, & Jacobsen, 1999; Schroevers, Sanderman, van Sonderen, & Ranchor, 2000). In this study, the 16-item version was used with a response scale from 0 to 3 for each item, and the total score can range from 0 to 48. A high score on depressive symptoms was defined as a score >12. In this study, the Cronbach’s alpha was for the CES-D .90. At baseline, women were also asked to complete a questionnaire concerning demographic characteristics such as age, paid work, marital status, and education level. The medical data concerning patient, diagnostic, and treatment characteristics were obtained from the medical records.
Statistical procedures Women who did not complete all questionnaires at 6 months were considered as dropouts and excluded from further analysis. For examining differences concerning baseline characteristics between the dropout and non-dropout groups and between the three groups based on diagnosis (GD, BBD, and BC), chi-square tests (discrete variables) and one-way ANOVA (continuous variables) were used. Differences in
The impact of diagnosis on distress
787
demographic characteristics at baseline were used as covariables in the subsequent analyses. A repeated-measures general linear model (GLM) was used to examine scores on state anxiety and depressive symptoms across time (1) in the three groups GD, BBD, and BC and (2) in patients with HTA or not-high score on trait anxiety (NHTA) in the GD, BBD, and BC groups. When differences were found in the GLM between groups, one-way ANOVA (Bonferroni method) was used to examine differences between groups at one particular measurement time. When differences were found in the GLM within one group concerning the scores at baseline compared with 6 months, paired t-tests were applied. The predictors of state anxiety and depressive symptoms (dependent variables) at 6 months were found using the diagnosis and demographic characteristics (block 1), scores on state anxiety and depressive symptoms at baseline (block 2), and trait anxiety (block 3) as independent variables in a multivariate linear regression analysis. It is known, also from clinical practice, that anxiety and depressive symptoms are related and that anxiety may predict a subsequent increase in depressive symptoms. In turn, depressive symptoms may elicit anxiety. For this reason, when depressive symptoms at 6 months as a dependent variable was analysed, also state anxiety at baseline was used as the independent variable and vice versa. Each regression analysis was performed twice, that is, the first analysis with trait anxiety as dichotomous variable (HTA and NHTA) and the second analysis with trait anxiety as a continuous variable. A p-value < .050 was considered statistically significant. Statistical analyses were performed with SPSSâ version 18 (SPSS, Chicago, IL, USA).
Results During the study period, in total 740 women were included. At 6 months, 255 women did not complete both questionnaires and were excluded from further analysis. Women in the dropout group were older (p = .040) and were more often diagnosed with BC or BBD compared with women who remained in the analysis (p < .001). In total 485 women were included in the analysis: 128 women awaiting laparoscopic cholecystectomy for GD, 205 women were diagnosed with BBD, and 152 women with BC. At baseline, there were significant differences between groups regarding demographic characteristics, but no differences were found concerning high scores on trait anxiety (Table 1). Before diagnosis was known, mean state anxiety scores at baseline were significantly higher in the BC group compared with BBD and GD (p < .001, Table 1). At 6 months, the state anxiety scores were significantly diminished in all three groups compared with the baseline scores (p < .001), and no significant differences were found between the three diagnosis groups. Concerning depressive symptoms, women with BC or BBD scored higher at baseline compared with GD (p = .024, p < .001, Table 1). At 6 months, depressive symptom scores were decreased in all three groups (p < .001); however, scores in BC were still significantly higher compared with GD (p = .005, Table 1). Subsequently, women were divided in six groups based on diagnosis (BC, BBD, or GD) combined with the score on trait anxiety (HTA or NHTA). For each diagnosis group, women with HTA scored higher on state anxiety and depressive symptoms compared with women with NHTA at all time points (p < .001, Table 2).
783
British Journal of Health Psychology (2014), 19, 783–794 © 2013 The British Psychological Society www.wileyonlinelibrary.com
The impact of diagnosis and trait anxiety on psychological distress in women with early stage breast cancer: A prospective study Claudia M. G. Keyzer-Dekker1,2, Jolanda de Vries3,4, Marlies C. Mertens3,5, Jan A. Roukema3,6 and Alida F. W. van der Steeg1,3,6* 1
Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital AMC and VU University Medical Centre, Amsterdam, The Netherlands 2 Department of Paediatric Surgery, Beatrix Children’s Hospital, University Medical Centre Groningen, The Netherlands 3 Centre of Research on Psychology in Somatic Disease (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands 4 Department of Medical Psychology, St Elisabeth Hospital, Tilburg, The Netherlands 5 Department of Medical Psychology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands 6 Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands Objectives. High trait anxiety (HTA) determines depressive symptoms and state anxiety in women with breast cancer (BC) or benign breast disease (BBD). Before implementing screening for psychological counselling in these women, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by HTA. Therefore, we compared women with a lump in the breast with women with gallstone disease (GD). Methods. Women diagnosed with BC (n = 152), BBD (n = 205), and GD (n = 128) were included in a prospective longitudinal study. Questionnaires concerning trait anxiety (baseline), state anxiety, and depressive symptoms were completed before diagnosis was known (BC and BBD) or the laparoscopic cholecystectomy and 6 months later. Results. Pre-diagnosis BC patients scored higher on state anxiety (p = .001) and depressive symptoms (p < .001) compared with GD. At 6 months, scores on depressive symptoms in BC remained higher than GD (p = .005). In women with HTA, before being diagnosed with BC or BBD, scores on state anxiety were higher compared with HTA women with GD (p < .001, p = .040). State anxiety and depressive symptoms at 6 months were predicted by baseline depressive symptoms in women with BC.
*Correspondence should be addressed to Alida F. W. van der Steeg, Department of Paediatric Surgery, Emma Children’s Hospital AMC and VU University Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands (email: a.f.vandersteeg@amc. uva.nl). DOI:10.1111/bjhp.12076
The impact of diagnosis on distress
789
Figure 1. State anxiety (general mean scores) at baseline and at 6 months per diagnosis and per score on trait anxiety. NHTA = not-high trait anxiety; GD = gallstone disease; BBD = benign breast disease; BC = breast cancer; HTA = high trait anxiety.
Figure 2. Depressive symptoms (general mean scores) at baseline and at 6 months per diagnosis and per score on trait anxiety. NHTA = not-high trait anxiety; GD = gallstone disease; BBD = benign breast disease; BC = breast cancer; HTA = high trait anxiety.
790
Claudia M. G. Keyzer-Dekker et al.
Table 3. Regression analyses for state anxiety and depressive symptoms at 6 months per diagnosis: gallstone disease (GD), benign breast disease (BBD), and breast cancer (BC) Dependent factor
Diagnosis
Independent factor
R2
State anxiety
GD
State anxiety Trait anxiety Education State anxiety Trait anxiety Depressive symptoms Trait anxiety Depressive symptoms Trait anxiety Work Depressive symptoms Trait anxiety Depressive symptoms Trait anxiety
.296 .106 .049 .260 .109 .265 .089 .216 .098 .045 .186 .099 .275 .105
BBD BC Depressive symptoms
GD
BBD BC
b
p-value .386 .364 .156 .242 .425 .235 .371 .303 .354 .197 .244 .367 .341 .372
British Journal of Health Psychology (2014), 19, 783–794 © 2013 The British Psychological Society www.wileyonlinelibrary.com
The impact of diagnosis and trait anxiety on psychological distress in women with early stage breast cancer: A prospective study Claudia M. G. Keyzer-Dekker1,2, Jolanda de Vries3,4, Marlies C. Mertens3,5, Jan A. Roukema3,6 and Alida F. W. van der Steeg1,3,6* 1
Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital AMC and VU University Medical Centre, Amsterdam, The Netherlands 2 Department of Paediatric Surgery, Beatrix Children’s Hospital, University Medical Centre Groningen, The Netherlands 3 Centre of Research on Psychology in Somatic Disease (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands 4 Department of Medical Psychology, St Elisabeth Hospital, Tilburg, The Netherlands 5 Department of Medical Psychology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands 6 Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands Objectives. High trait anxiety (HTA) determines depressive symptoms and state anxiety in women with breast cancer (BC) or benign breast disease (BBD). Before implementing screening for psychological counselling in these women, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by HTA. Therefore, we compared women with a lump in the breast with women with gallstone disease (GD). Methods. Women diagnosed with BC (n = 152), BBD (n = 205), and GD (n = 128) were included in a prospective longitudinal study. Questionnaires concerning trait anxiety (baseline), state anxiety, and depressive symptoms were completed before diagnosis was known (BC and BBD) or the laparoscopic cholecystectomy and 6 months later. Results. Pre-diagnosis BC patients scored higher on state anxiety (p = .001) and depressive symptoms (p < .001) compared with GD. At 6 months, scores on depressive symptoms in BC remained higher than GD (p = .005). In women with HTA, before being diagnosed with BC or BBD, scores on state anxiety were higher compared with HTA women with GD (p < .001, p = .040). State anxiety and depressive symptoms at 6 months were predicted by baseline depressive symptoms in women with BC.
*Correspondence should be addressed to Alida F. W. van der Steeg, Department of Paediatric Surgery, Emma Children’s Hospital AMC and VU University Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands (email: a.f.vandersteeg@amc. uva.nl). DOI:10.1111/bjhp.12076
784
Claudia M. G. Keyzer-Dekker et al. Conclusions. The severity of diagnosis (BC) in combination with HTA determined the level of state anxiety and depressive symptoms. Therefore, we recommend identifying women with HTA and offering them a tailor-made follow-up protocol during and after the diagnostic process for BBD or BC.
Statement of contribution What is already known on this subject? Women diagnosed with BC or BBD experience high levels of anxiety and distress during the diagnostic process. These adverse psychological effects are strengthened by the personality characteristic trait anxiety. Before implementing screening for psychological counselling in women with high trait anixety, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by HTA. What does this study add? To our knowledge, this is the first study comparing women who are confronted with the possibility of having a life-threatening disease, that is, BC, with women who were not suspected of having a life-threatening disease, that is, GD. This study reveals that the severity of diagnosis (BC) in combination with HTA determined the level of state anxiety and depressive symptoms. Therefore, we recommend identifying women with HTA and offering them a tailor-made follow-up protocol during and after the diagnostic process for BC or BBD.
Breast cancer (BC) is the most common type of cancer among women. One in eight women in the Western world will be diagnosed with BC (Integral Cancer Centre Netherlands (IKCN), 2013; National Cancer Institute (NCI), 2013). In addition, the majority of women visiting a surgical outpatient clinic with breast problems are diagnosed with benign breast disease (BBD; Van Esch, Den Oudsten, & De Vries, 2011). Up to 50% of these women with BBD, like women with BC, experience high levels of distress, that is, anxiety and depressive symptoms, during the diagnostic process (Ando et al., 2011; Montgomery & McCrone, 2010; Van der Steeg, Keyzer-Dekker, De Vries, & Roukema, 2011; Witek-Janusek, Gabram, & Mathews, 2007; Woodward & Webb, 2001). In women with BC, the prevalence of depressive symptoms is up to 46% (Massie, 2004). Before being diagnosed with BC, 28% of the women experience high levels of state anxiety in combination with depressive symptoms (Van Esch, Roukema, Ernst, Nieuwenhuijzen, & De Vries, 2012). This combination of high state anxiety and depressive symptoms appears to be a major predictor of quality of life (QoL) in women with BC (Van Esch et al., 2012). The adverse psychological effects are strengthened by personality, that is, women with a high score on trait anxiety (HTA) report more state anxiety or depressive symptoms during and after the diagnostic process for BC or BBD (Ando et al., 2011; De Vries, Van der Steeg, & Roukema, 2009; Keyzer-Dekker, De Vries, et al., 2012; Montgomery & McCrone, 2010; van der Steeg et al., 2011). State anxiety is a momentary emotional condition characterized by subjective feeling of apprehension and tension (Spielberger, Gorsuch, & Lushene, 1970).Trait anxiety is a personality characteristic that refers to a relatively stable individual difference in anxiety proneness; thus, it concerns differences in individuals in the disposition to respond to stressful situations with varying amounts of stress (Spielberger et al., 1970). It can also be considered as a part of the neuroticism domain. Neuroticism is part of the worldwide-acknowledged five-factor model to describe personality. This model consists of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness (McCrae & John, 1992). Neuroticism weighs
The impact of diagnosis on distress
785
emotional instability against emotional stability, that is, the tendency to experience no distressing emotions such as fear, guilt, and frustration (McCrae & John, 1992) In previous studies, we have found an important influence of neuroticism on distress in women with BC or BBD, but in particular, HTA predicts women’s state anxiety and depressive symptoms (Keyzer-Dekker, De Vries, et al., 2012; Van Esch et al., 2012). Moreover, we have found that women scoring high on trait anxiety are also scoring high on neuroticism (Keyzer-Dekker, De Vries, et al., 2012). Therefore, in this study, the personality factor trait anxiety and its impact on state anxiety and depressive symptoms were the main focus. Thus, high state anxiety and depressive symptoms are important problems in women during and after the diagnostic process for breast disease, especially in women with HTA (Ando et al., 2011; De Vries et al., 2009; Keyzer-Dekker, De Vries, et al., 2012; Montgomery & McCrone, 2010; Van der Steeg et al., 2011). Therefore, we intend to implement screening for HTA in order to refer patients for psychological counselling. Before implementing this tailored approach, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by the personality characteristic HTA, in other words, whether women with HTA experience high levels of state anxiety and depressive symptoms, regardless of the disease that these women have. Previously, it was found that trait anxiety determines impairment in QoL in women with breast disease, regardless of the diagnosis being BC or BBD (Van der Steeg, De Vries, & Roukema, 2004). We hypothesized that in addition to the personality characteristic trait anxiety, the severity of diagnosis, that is, the suspicion of malignant disease, would also be an important predictor of state anxiety and depressive symptoms. Therefore, in this study, we compared women confronted with the possible life-threatening disease, BC, with women with a non-life-threatening disease, that is, GD, undergoing an elective laparoscopic cholecystectomy (GD). The GD group was chosen because it was previously found that HTA has a negative impact on QoL and persisting biliary symptoms after the operation in this group (Mertens, Roukema, Scholtes, & De Vries, 2009, 2010). In this prospective longitudinal study, the predictive value of trait anxiety and diagnosis was examined for state anxiety and depressive symptoms at baseline and after 6 months.
Patients and methods Participants Women analysed for this study were recruited for two different studies in the Netherlands. The first study analysed the role of psychological factors on QoL and recovery after surgery for symptomatic GD. Between March 2006 and January 2008, all consecutive patients with GD in one teaching hospital awaiting an elective laparoscopic cholecystectomy were asked to participate. For this study, we have only used the data of the women with GD. Exclusion criteria were severe comorbidity (ASA III or more), known pregnancy, undergoing an emergency procedure or intended open cholecystectomy, complicated GD or liver disease, history of abdominal malignancy, and previous upper abdominal surgery. Women with an inability to read and write in Dutch or (previous) psychiatric illness (self-reported or by medical record) were excluded. The first set of questionnaires was given to the patients in the outpatient clinic and was completed before admission for the cholecystectomy. This set could be returned by mail or delivered to the nurses at the
786
Claudia M. G. Keyzer-Dekker et al.
surgical ward. Follow-up questionnaires were posted to the participants and were returned by mail. The second study concerned personality and QoL in women with early stage BC or BBD. Between September 2002 and June 2007, all consecutive women who were referred to one of the three teaching hospitals with an abnormality on a screening mammogram or with a palpable lump in the breast were invited to participate. During the first visit to the outpatient clinic, women completed the first set of questionnaires before any diagnostic procedures were carried out, thus before the diagnosis was known. Exclusion criteria were recurrent (benign) breast disease, inability to read and write in Dutch, or a (history of) psychiatric disease (self-reported or by medical record). Follow-up questionnaires were sent to the participants and were returned by post. The Medical Ethical Board of the primary research hospital approved both study protocols. All participants gave written informed consent.
Questionnaires Questionnaires were completed at baseline and at 6 months. The questionnaires assessed anxiety as personality characteristic at baseline State-Trait Anxiety Inventory (STAI-trait) and experienced momentary anxiety (STAI-state) and depressive symptoms (CES-D) at baseline and at 6 months. The Dutch version of the Spielberger STAI measures trait and state anxiety (Spielberger et al., 1970; Van der Ploeg, Defares, & Spielberger, 1980). It is a widely used 20-item questionnaire with good reliability and validity (Spielberger et al., 1970; Van der Ploeg et al., 1980). The response scale is from 1 to 4 for each item, and scores can range from 20 to 80 of both questionnaires. High state anxiety was defined as a score >38 and HTA with a score >41 (Van der Ploeg et al., 1980). In this study, the Cronbach’s alpha was for STAI-state .96 and for STAI-trait .94. The Centre for Epidemiological Studies-Depression Scale (CES-D) was used to assess depressive symptoms. It measures both the presence and the degree of depressive symptoms. The CES-D questionnaire includes six components of depressive symptoms: depressed mood, feelings of guilt and worthlessness, feelings of hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance. The psychometric properties are good (Hann, Winter, & Jacobsen, 1999; Schroevers, Sanderman, van Sonderen, & Ranchor, 2000). In this study, the 16-item version was used with a response scale from 0 to 3 for each item, and the total score can range from 0 to 48. A high score on depressive symptoms was defined as a score >12. In this study, the Cronbach’s alpha was for the CES-D .90. At baseline, women were also asked to complete a questionnaire concerning demographic characteristics such as age, paid work, marital status, and education level. The medical data concerning patient, diagnostic, and treatment characteristics were obtained from the medical records.
Statistical procedures Women who did not complete all questionnaires at 6 months were considered as dropouts and excluded from further analysis. For examining differences concerning baseline characteristics between the dropout and non-dropout groups and between the three groups based on diagnosis (GD, BBD, and BC), chi-square tests (discrete variables) and one-way ANOVA (continuous variables) were used. Differences in
The impact of diagnosis on distress
787
demographic characteristics at baseline were used as covariables in the subsequent analyses. A repeated-measures general linear model (GLM) was used to examine scores on state anxiety and depressive symptoms across time (1) in the three groups GD, BBD, and BC and (2) in patients with HTA or not-high score on trait anxiety (NHTA) in the GD, BBD, and BC groups. When differences were found in the GLM between groups, one-way ANOVA (Bonferroni method) was used to examine differences between groups at one particular measurement time. When differences were found in the GLM within one group concerning the scores at baseline compared with 6 months, paired t-tests were applied. The predictors of state anxiety and depressive symptoms (dependent variables) at 6 months were found using the diagnosis and demographic characteristics (block 1), scores on state anxiety and depressive symptoms at baseline (block 2), and trait anxiety (block 3) as independent variables in a multivariate linear regression analysis. It is known, also from clinical practice, that anxiety and depressive symptoms are related and that anxiety may predict a subsequent increase in depressive symptoms. In turn, depressive symptoms may elicit anxiety. For this reason, when depressive symptoms at 6 months as a dependent variable was analysed, also state anxiety at baseline was used as the independent variable and vice versa. Each regression analysis was performed twice, that is, the first analysis with trait anxiety as dichotomous variable (HTA and NHTA) and the second analysis with trait anxiety as a continuous variable. A p-value < .050 was considered statistically significant. Statistical analyses were performed with SPSSâ version 18 (SPSS, Chicago, IL, USA).
Results During the study period, in total 740 women were included. At 6 months, 255 women did not complete both questionnaires and were excluded from further analysis. Women in the dropout group were older (p = .040) and were more often diagnosed with BC or BBD compared with women who remained in the analysis (p < .001). In total 485 women were included in the analysis: 128 women awaiting laparoscopic cholecystectomy for GD, 205 women were diagnosed with BBD, and 152 women with BC. At baseline, there were significant differences between groups regarding demographic characteristics, but no differences were found concerning high scores on trait anxiety (Table 1). Before diagnosis was known, mean state anxiety scores at baseline were significantly higher in the BC group compared with BBD and GD (p < .001, Table 1). At 6 months, the state anxiety scores were significantly diminished in all three groups compared with the baseline scores (p < .001), and no significant differences were found between the three diagnosis groups. Concerning depressive symptoms, women with BC or BBD scored higher at baseline compared with GD (p = .024, p < .001, Table 1). At 6 months, depressive symptom scores were decreased in all three groups (p < .001); however, scores in BC were still significantly higher compared with GD (p = .005, Table 1). Subsequently, women were divided in six groups based on diagnosis (BC, BBD, or GD) combined with the score on trait anxiety (HTA or NHTA). For each diagnosis group, women with HTA scored higher on state anxiety and depressive symptoms compared with women with NHTA at all time points (p < .001, Table 2).
783
British Journal of Health Psychology (2014), 19, 783–794 © 2013 The British Psychological Society www.wileyonlinelibrary.com
The impact of diagnosis and trait anxiety on psychological distress in women with early stage breast cancer: A prospective study Claudia M. G. Keyzer-Dekker1,2, Jolanda de Vries3,4, Marlies C. Mertens3,5, Jan A. Roukema3,6 and Alida F. W. van der Steeg1,3,6* 1
Department of Paediatric Surgery, Paediatric Surgical Centre of Amsterdam, Emma Children’s Hospital AMC and VU University Medical Centre, Amsterdam, The Netherlands 2 Department of Paediatric Surgery, Beatrix Children’s Hospital, University Medical Centre Groningen, The Netherlands 3 Centre of Research on Psychology in Somatic Disease (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands 4 Department of Medical Psychology, St Elisabeth Hospital, Tilburg, The Netherlands 5 Department of Medical Psychology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands 6 Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands Objectives. High trait anxiety (HTA) determines depressive symptoms and state anxiety in women with breast cancer (BC) or benign breast disease (BBD). Before implementing screening for psychological counselling in these women, it is important to evaluate whether high state anxiety and depressive symptoms are determined by (the threat of) having BC or solely by HTA. Therefore, we compared women with a lump in the breast with women with gallstone disease (GD). Methods. Women diagnosed with BC (n = 152), BBD (n = 205), and GD (n = 128) were included in a prospective longitudinal study. Questionnaires concerning trait anxiety (baseline), state anxiety, and depressive symptoms were completed before diagnosis was known (BC and BBD) or the laparoscopic cholecystectomy and 6 months later. Results. Pre-diagnosis BC patients scored higher on state anxiety (p = .001) and depressive symptoms (p < .001) compared with GD. At 6 months, scores on depressive symptoms in BC remained higher than GD (p = .005). In women with HTA, before being diagnosed with BC or BBD, scores on state anxiety were higher compared with HTA women with GD (p < .001, p = .040). State anxiety and depressive symptoms at 6 months were predicted by baseline depressive symptoms in women with BC.
*Correspondence should be addressed to Alida F. W. van der Steeg, Department of Paediatric Surgery, Emma Children’s Hospital AMC and VU University Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands (email: a.f.vandersteeg@amc. uva.nl). DOI:10.1111/bjhp.12076
The impact of diagnosis on distress
789
Figure 1. State anxiety (general mean scores) at baseline and at 6 months per diagnosis and per score on trait anxiety. NHTA = not-high trait anxiety; GD = gallstone disease; BBD = benign breast disease; BC = breast cancer; HTA = high trait anxiety.
Figure 2. Depressive symptoms (general mean scores) at baseline and at 6 months per diagnosis and per score on trait anxiety. NHTA = not-high trait anxiety; GD = gallstone disease; BBD = benign breast disease; BC = breast cancer; HTA = high trait anxiety.
790
Claudia M. G. Keyzer-Dekker et al.
Table 3. Regression analyses for state anxiety and depressive symptoms at 6 months per diagnosis: gallstone disease (GD), benign breast disease (BBD), and breast cancer (BC) Dependent factor
Diagnosis
Independent factor
R2
State anxiety
GD
State anxiety Trait anxiety Education State anxiety Trait anxiety Depressive symptoms Trait anxiety Depressive symptoms Trait anxiety Work Depressive symptoms Trait anxiety Depressive symptoms Trait anxiety
.296 .106 .049 .260 .109 .265 .089 .216 .098 .045 .186 .099 .275 .105
BBD BC Depressive symptoms
GD
BBD BC
b
p-value .386 .364 .156 .242 .425 .235 .371 .303 .354 .197 .244 .367 .341 .372
