Breast Cancer Research and Treatment

, Volume 113, Issue 2, pp 339–355 | Cite as

Prevalence and risk of depressive symptoms 3–4 months post-surgery in a nationwide cohort study of Danish women treated for early stage breast-cancer

  • Søren Christensen
  • Robert Zachariae
  • Anders Bonde Jensen
  • Michael Væth
  • Susanne Møller
  • Joan Ravnsbæk
  • Hans von der Maase


Background Elevated levels of depressive symptoms are generally found among cancer patients, but results from existing studies vary considerably with respect to prevalence and proposed risk factors. Purpose To study the prevalence of depressive symptoms and major depression 3–4 months following surgery for breast cancer, and to identify clinical risk factors while adjusting for pre-cancer sociodemographic factors, comorbidity, and psychiatric history. Patients and methods The study cohort consists of 4917 Danish women, aged 18–70 years, receiving standardized treatment for early stage invasive breast cancer during the 2 1/2 year study period. Of these, 3343 women (68%) participated in a questionnaire study 12–16 weeks following surgery. Depressive symptoms (Beck’s Depression Inventory II) and health-related behaviors were assessed by questionnaire. The Danish Breast Cancer Cooperative Group (DBCG) and the surgical departments provided disease-, treatment-, and comorbidity data for the study cohort. Information concerning sociodemographics and psychiatric history were obtained from national longitudinal registries. Results The results indicated an increased prevalence of depressive symptoms and major depression (13.7%) compared to population-based samples. The pre-cancer variables: Social status, net-wealth, ethnicity, comorbidity, psychiatric history, and age were all independent risk factors for depressive symptoms. Of the clinical variables, only nodal status carried additional prognostic information. Physical functioning, smoking, alcohol use, and BMI were also independently associated with depressive symptoms. Conclusion Risk factors for depressive symptoms were primarily restricted to pre-cancer conditions rather than disease-specific conditions. Special attention should be given to socio-economically deprived women with a history of somatic- and psychiatric disease and poor health behaviors.


Age Alcohol consumption Body-mass index Breast-cancer Breast neoplasms psychology Chemotherapy Cohort studies Comorbidity Depression Epidemiology Health behavior Major mastectomy Neoplasms psychology Physical function Prevalence Prospective studies Psychiatry Psychosocial Radiotherapy Risk-factors Smoking Socioeconomic factors Stage 


  1. 1.
    Massie NJ, Popkin MK (1998) Depressive disorders. In: Holland J (ed) Psycho-oncology. Oxford University Press, New YorkGoogle Scholar
  2. 2.
    Al Ghazal SK, Sully L, Fallowfield L et al (2000) The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol 26:17–19PubMedCrossRefGoogle Scholar
  3. 3.
    Maraste R, Brandt L, Olsson H et al (1992) Anxiety and depression in breast-cancer patients at start of adjuvant radiotherapy—relations to age and type of surgery. Acta Oncol 31:641–643PubMedCrossRefGoogle Scholar
  4. 4.
    Gaston-Johansson F, Fall-Dickson JM, Bakos AB et al (1999) Fatigue, pain, and depression in pre-autotransplant breast cancer patients. Cancer Pract 7:240–247PubMedCrossRefGoogle Scholar
  5. 5.
    Gross JJ, Carstensen LL, Pasupathi M et al (1997) Emotion and aging: experience, expression, and control. Psychol Aging 12:590–599PubMedCrossRefGoogle Scholar
  6. 6.
    Charles ST, Reynolds CA, Gatz M (2001) Age-related differences and change in positive and negative affect over 23 years. J Pers Soc Psychol 80:136–151PubMedCrossRefGoogle Scholar
  7. 7.
    Mosher CE, Danoff-Burg S (2005) A review of age differences in psychological adjustment to breast cancer. J Psychosoc Oncol 23:101–114PubMedCrossRefGoogle Scholar
  8. 8.
    Dean C (1987) Psychiatric morbidity following mastectomy—preoperative predictors and types of illness. J Psychosom Res 31:385–392PubMedCrossRefGoogle Scholar
  9. 9.
    Bloom JR (1982) Social support, accommodation to stress and adjustment to breast-cancer. Soc Sci Med 16:1329–1338PubMedCrossRefGoogle Scholar
  10. 10.
    Deshields T, Tibbs T, Fan MY et al (2006) Differences in patterns of depression after treatment for breast cancer. Psychooncology 15:398–406PubMedCrossRefGoogle Scholar
  11. 11.
    Pinder KL, Ramirez AJ, Black ME et al (1993) Psychiatric-disorder in patients with advanced breast-cancer—prevalence and associated factors. Eur J Cancer 29A:524–527PubMedGoogle Scholar
  12. 12.
    Spitzer RL, Williams JBW, Gibbon M et al (1992) The structured clinical interview for Dsm-Iii-R (Scid).1. History, rationale, and description. Arch Gen Psychiatry 49:624–629PubMedGoogle Scholar
  13. 13.
    First MB, Gibbon M, Spitzer RL (1996) Structured clinical interview for DSM-IV (IP). New York, Biometrics research department, New York State Psychiatric Institute.Google Scholar
  14. 14.
    Radlof LS (1977) The CES-D Scale: A self-report depression scale for research in the general population. J Applied Psychol Meas 1:385–401CrossRefGoogle Scholar
  15. 15.
    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370PubMedCrossRefGoogle Scholar
  16. 16.
    Beck AT, Erbaugh J, Ward CH et al (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571PubMedGoogle Scholar
  17. 17.
    Beck AT, Steer RA, Brown GK (1996) Manual: Beck depression inventory, 2nd edn. The Psychological Corp Hartcourt & Brace, San Antonio, TXGoogle Scholar
  18. 18.
    Wilcox H, Field T (1998) Correlations between the BDI and CES-D in a sample of adolescent mothers. Adolescence 33:565–574PubMedGoogle Scholar
  19. 19.
    Berard RMF, Boermeester F, Viljoen G (1998) Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management. Psychooncology 7:112–120PubMedCrossRefGoogle Scholar
  20. 20.
    Hann D, Winter K, Jacobsen P (1999) Measurement of depressive symptoms in cancer patients: Evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res 46:437–443PubMedCrossRefGoogle Scholar
  21. 21.
    Hall A, A’Hern R, Fallowfield L (1999) Are we using appropriate self-report questionnaires for detecting anxiety and depression in women with early breast cancer?. Eur J Cancer 35:79–85PubMedCrossRefGoogle Scholar
  22. 22.
    Groenvold M, Fayers PM, Sprangers MAG et al (1999) Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: A valid comparison? J Clin Epidemiol 52:523–530PubMedCrossRefGoogle Scholar
  23. 23.
    Love AW, Grabsch B, Clarke DM et al (2004) Screening for depression in women with metastatic breast cancer: a comparison of the Beck depression inventory short form and the hospital anxiety and depression scale. Aust N Z J Psychiatry 38:526–531PubMedCrossRefGoogle Scholar
  24. 24.
    Love AW, Kissane DW, Bloch S et al (2002) Diagnostic efficiency of the Hospital Anxiety and Depression Scale in women with early stage breast cancer. Aust N Z J Psychiatry 36:246–250PubMedCrossRefGoogle Scholar
  25. 25.
    Farragher B (1998) Psychiatric morbidity following the diagnosis and treatment of early breast cancer. Ir J Med Sci 167:166–169PubMedCrossRefGoogle Scholar
  26. 26.
    Pasacreta JV (1997) Depressive phenomena, physical symptom distress, and functional status among women with breast cancer. Nurs Res 46:214–221PubMedCrossRefGoogle Scholar
  27. 27.
    Al Ghazal SK, Fallowfield L, Blamey RW (2000) Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 36:1938–1943PubMedCrossRefGoogle Scholar
  28. 28.
    Cordova MJ, Cunningham LLC, Carlson CR et al (2001) Posttraumatic growth following breast cancer: a controlled comparison study. Health Psychol 20:176–185PubMedCrossRefGoogle Scholar
  29. 29.
    Yeter K, Rock CL, Pakiz B et al (2006) Depressive symptoms, eating psychopathology, and physical activity in obese breast cancer survivors. Psychooncology 15:453–462PubMedCrossRefGoogle Scholar
  30. 30.
    Burgess C, Cornelius V, Love S et al (2005) Depression and anxiety in women with early breast cancer: five year observational cohort study. Br Med J 330:702–705CrossRefGoogle Scholar
  31. 31.
    Goldberg JA, Scott RN, Davidson PM et al (1992) Psychological morbidity in the 1st year after breast surgery. Eur J Surg Oncol 18:327–331PubMedGoogle Scholar
  32. 32.
    Rijken M, de Kruif AT, Komproe IH et al (1995) Depressive symptomatology of post-menopausal breast cancer patients: a comparison of women recently treated by mastectomy or by breast-conserving therapy. Eur J Surg Oncol 21:498–503PubMedCrossRefGoogle Scholar
  33. 33.
    Andersen BL, Kiecoltglaser JK, Glaser R (1994) A Biobehavioral Model of Cancer Stress and Disease Course. Am Psychol 49:389–404PubMedCrossRefGoogle Scholar
  34. 34.
    Andersen BL, Shapiro CL, Farrar WB et al (2005) Psychological responses to cancer recurrence—a controlled prospective study. Cancer 104:1540–1547PubMedCrossRefGoogle Scholar
  35. 35.
    Antoni MH, Lehman JM, Kilbourn KM et al (2001) Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 20:20–32PubMedCrossRefGoogle Scholar
  36. 36.
    Green BL, Krupnick JL, Rowland JH et al (2000) Trauma history as a predictor of psychologic symptoms in women with breast cancer. J Clin Oncol 18:1084–1093PubMedGoogle Scholar
  37. 37.
    Hopwood P, Howell A, Maguire P (1991) Psychiatric morbidity in patients with advanced cancer of the breast—prevalence measured by 2 self-rating questionnaires. Br J Cancer 64:349–352PubMedGoogle Scholar
  38. 38.
    vantSpijker A, Trijsburg RW, Duivenvoorden HJ (1997) Psychological sequelae of cancer diagnosis: a meta-analytical review of 58 studies after 1980. Psychosom Med 59:280–293Google Scholar
  39. 39.
    Aragona M, Muscatello MRA, Mesiti M (1997) Depressive mood disorders in patients with operable breast cancer. J Exp Clin Canc Res 16:111–118Google Scholar
  40. 40.
    Ell K, Sanchez K, Vourlekis B, Lee PJ et al (2005) Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol 23:3052–3060PubMedCrossRefGoogle Scholar
  41. 41.
    Bardwell WA, Natarajan L, Dimsdale JE et al (2006) Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. J Clin Oncol 24:2420–2427PubMedCrossRefGoogle Scholar
  42. 42.
    Kissane DW, Clarke DM, Ikin J et al (1998) Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey. Med J Aust 169:192–196PubMedGoogle Scholar
  43. 43.
    Aukst-Margetic B, Jakovljevic M, Margetic B et al (2005) Religiosity, depression and pain in patients with breast cancer. Gen Hosp Psychiatry 27:250–255PubMedCrossRefGoogle Scholar
  44. 44.
    Fallowfield LJ, Hall A, Maguire GP et al (1990) Psychological outcomes of different treatment policies in women with early breast-cancer outside a clinical-trial. Br Med J 301:575–580Google Scholar
  45. 45.
    Lasry JCM, Margolese RG, Poisson R et al (1987) Depression and body-image following mastectomy and lumpectomy. J Chronic Dis 40:529–534PubMedCrossRefGoogle Scholar
  46. 46.
    Duffy LS, Greenberg DB, Younger J et al (1999) Iatrogenic acute estrogen deficiency and psychiatric syndromes in breast cancer patients. Psychosomatics 40:304–308PubMedGoogle Scholar
  47. 47.
    Cathcart CK, Jones SE, Pumroy CS et al (1993) Clinical recognition and management of depression in node-negative breast-cancer patients treated with Tamoxifen. Breast Cancer Res Treat 27:277–281PubMedCrossRefGoogle Scholar
  48. 48.
    Kissane DW, Grabsch B, Love A et al (2004) Psychiatric disorder in women with early stage and advanced breast cancer: a comparative analysis. Aust N Z J Psychiatry 38:320–326PubMedCrossRefGoogle Scholar
  49. 49.
    Day R, Ganz PA, Costantino JP (2001) Tamoxifen and depression: More evidence from the National Surgical Adjuvant Breast and Bowel Project’s Breast Cancer Prevention (P-1) randomized study. J Natl Cancer Inst 93:1615–1623PubMedCrossRefGoogle Scholar
  50. 50.
    Lee KC, Ray GT, Hunkeler EM et al (2007) Tamoxifen treatment and new-onset depression in breast cancer patients. Psychosomatics 48:205–210PubMedCrossRefGoogle Scholar
  51. 51.
    Tjemsland L, Soreide JA, Malt UF (1995) Psychosocial factors in women with operable breast-cancer—an association to estrogen-receptor status. J Psychosom Res 39:875–881PubMedCrossRefGoogle Scholar
  52. 52.
    Stommel M, Kurtz ME, Kurtz JC et al (2004) A longitudinal analysis of the course of depressive symptomatology in geriatric patients with cancer of the breast, colon, lung, or prostate. Health Psychol 23:564–573PubMedCrossRefGoogle Scholar
  53. 53.
    Krishnan L, Stanton AL, Collins CA et al (2001) Form or function? Part 2. Objective cosmetic and functional correlates of quality of life in women treated with breast-conserving surgical procedures and radiotherapy. Cancer 91:2282–2287Google Scholar
  54. 54.
    Werrij MQ, Mulkens S, Hospers HJ et al (2006) Overweight and obesity: the significance of a depressed mood. Patient Educ Couns 62:126–131PubMedCrossRefGoogle Scholar
  55. 55.
    Extermann M (2000) Measurement and impact of comorbidity in older cancer patients. Crit Rev Oncol Hematol 35:181–200PubMedCrossRefGoogle Scholar
  56. 56.
    Janssen-Heijnen MLG, Houterman S, Lemmens VEPP et al (2005) Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approach. Crit Rev Oncol Hematol 55:231–240PubMedCrossRefGoogle Scholar
  57. 57.
    Evans DL, Charney DS, Lewis L et al (2005) Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry 58:175–189PubMedCrossRefGoogle Scholar
  58. 58.
    Krishnan KRR, Delong M, Kraemer H et al (2002) Comorbidity of depression with other medical diseases in the elderly. Biol Psychiatry 52:559–588PubMedCrossRefGoogle Scholar
  59. 59.
    Louwman WJ, Janssen-Heijnen MLG, Houterman S et al (2005) Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based study. Eur J Cancer 41:779–785PubMedCrossRefGoogle Scholar
  60. 60.
    Singletary SE, Allred C, Ashley P et al (2002) Revision of the American joint committee on cancer staging system for breast cancer. J Clin Oncol 20:3628–3636PubMedCrossRefGoogle Scholar
  61. 61.
    Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383PubMedCrossRefGoogle Scholar
  62. 62.
    Bjørner JB, Damsgaard MT, Watt T et al (1997) Dansk manual for SF-36 (Danish manual for the SF-36), Lægemiddelindustriforeningen, Copenhagen.Google Scholar
  63. 63.
    Ware JE, Sherbourne CD (1992) The Mos 36-item short-form health survey (Sf-36) .1. Conceptual-Framework and Item Selection. Med Care 30:473–483PubMedCrossRefGoogle Scholar
  64. 64.
    World Health Organization (2000) Obesity. Preventing and managing the global endemic. Technical report series no 894, WHO, Geneva.Google Scholar
  65. 65.
    Extermann M (2000) Measuring comorbidity in older cancer patients. Eur J Cancer 36:453–471PubMedCrossRefGoogle Scholar
  66. 66.
    Rostgaard K, Holst H, Mouridsen HT et al (2000) Do clinical databases render population-based cancer registers obsolete? The example of breast cancer in Denmark. Cancer Causes Control 11:669–674PubMedCrossRefGoogle Scholar
  67. 67.
    Statistics Denmark (2005). Statistics Denmark. Numbers on time. Cited 23 nov 2007
  68. 68.
    UNESCO (2006) ISCED 1997. International standard classification of education, Re-edition. Cited 11 oct 2007.
  69. 69.
    Munk-Jorgensen P, Mortensen PB (1997) The Danish Psychiatric Central Register. Dan Med Bull 44:82–84PubMedGoogle Scholar
  70. 70.
    Schafer JL, Graham JW (2002) Missing data: our view of the state of the art. Psychol Methods 7:147–177PubMedCrossRefGoogle Scholar
  71. 71.
    Zachariae R, Zachariae C, Ibsen HHW et al (2004) Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients. Acta Derm Venereol 84:205–212PubMedCrossRefGoogle Scholar
  72. 72.
    Thomsen DK, Mehlsen MY, Viidik A et al (2005) Age and gender differences in negative affect—Is there a role for emotion regulation? Personality and Individual Differences 38:1935–1946CrossRefGoogle Scholar
  73. 73.
    Olsen LR, Mortensen EL, Bech P (2004) Prevalence of major depression and stress indicators in the Danish general population. Acta Psychiatr Scand 109:96–103PubMedCrossRefGoogle Scholar
  74. 74.
    Kessler RC, Berglund P, Demler O et al (2003) The Epidemiology of Major Depressive Disorder: Results From the National Comorbidity Survey Replication (NCS-R). JAMA 289:3095–3105PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2008

Authors and Affiliations

  • Søren Christensen
    • 1
  • Robert Zachariae
    • 1
  • Anders Bonde Jensen
    • 2
  • Michael Væth
    • 3
  • Susanne Møller
    • 4
  • Joan Ravnsbæk
    • 5
  • Hans von der Maase
    • 6
  1. 1.Psychooncology Reseach UnitAarhus University HospitalAarhus CDenmark
  2. 2.Department of OncologyAarhus University HospitalAarhusDenmark
  3. 3.Department of BiostatisticsAarhus UniversityAarhusDenmark
  4. 4.Danish Breast Cancer Cooperative Group (DBCG), RigshospitaletCopenhagen University HospitalCopenhagenDenmark
  5. 5.Aarhus Breast Care ClinicAarhusDenmark
  6. 6.Department of Oncology, RigshospitaletCopenhagen University HospitalCopenhagenDenmark

Personalised recommendations