Clinical Context

Depression is a common comorbid illness with a number of different significant somatic disease states, and one of the most important of these is cancer. A previous meta-analysis by Krebber and colleagues evaluated the prevalence of depression in the setting of cancer, using both diagnostic interviews and patient self-rating tools. Their study was published in the September 16, 2013, issue of Psycho-Oncology.^[1]

The prevalence of depression among patients with cancer during or after treatment was between 8% and 24%. Just 3% of patients with lung cancer were found to have depression following diagnostic interviews compared with 31% of patients with cancers of the digestive tract. Depression was most common during cancer treatment, and there was a slight reduction in the prevalence of cancer after a year had passed since the cancer diagnosis.

Although depression among patients with cancer has been well-researched, there is much less information regarding the effects of cancer on the mental health of spouses. The current study addresses this issue.

Study Synopsis and Perspective

A cancer diagnosis can take a heavy emotional toll on a patient’s spouse, even years after the diagnosis, new research shows.

In a study of more than 3 million Danes and Swedes, spouses of patients with cancer faced an increased risk of developing a psychiatric disorder, including substance abuse, depression, anxiety, and stress-related conditions, compared with peers whose spouse did not have cancer. The risk was higher for male spouses, for those with preexisting psychiatric conditions, and in the first year after a spouse’s cancer diagnosis.

“The bottom line is that psychiatric illness is exacerbated by a spouse’s diagnosis of cancer,” said Holly G. Prigerson, PhD, director of the Cornell Center for Research on End-of-Life Care, Weill Cornell Medical College, New York City, who was not involved in the study.

The study was published online January 5 in JAMA Network Open.^[2]

Previous research has shown that spouses of patients with cancer had a higher risk for depression, anxiety, and other psychiatric conditions, but few population-based studies in this group exist. The study authors, led by Kejia Hu, MD, from the Karolinska Institute in Stockholm, wanted to understand the spectrum of psychiatric disorders and risk factors that may exist on a population level.

The findings are based on 546,321 spouses of patients with cancer in Denmark and Sweden, who were followed for a median of 8.4 years, and roughly 2.7 million spouses of individuals without cancer, who were followed for a median of 7.6 years. The authors identified first clinical diagnoses of psychiatric disorders requiring inpatient or outpatient care in these populations, using the Danish National Patient Registry, the Danish Psychiatric Central Research Register, the Swedish National Patient Register, and other registries.

During the study period, the authors reported 37,830 cases (6.9%) of first-onset psychiatric disorders among spouses of patients with cancer, for an incidence rate of 6.8 per 1000 person-years, compared with 153,607 cases (5.6%) among spouses of cancer-free individuals (incidence rate of 5.9 per 1000 person-years).

Although the between-group difference (6.9% vs 5.6%) appears “small, these results are actually quite striking,” said Dr Prigerson. The reason, she added, is that these rates reflect new-onset cases excluding those with preexisting mental illness and cases extreme enough to result in psychiatric hospitalization or outpatient psychiatric treatment.

In the first year after a cancer diagnosis, the study investigators found that the risk for first-onset psychiatric disorders among spouses increased by 30% (adjusted hazard ratio [aHR], 1.30), especially depression (aHR, 1.38) and stress-related disorders (aHR, 2.04).

During the entire follow-up period, the risk for first-onset psychiatric disorders increased by 14% overall, with similar rates observed for diagnoses of substance abuse, depression, and stress-related disorders.

The risk for new psychiatric illness was most prominent (aHR, 1.41) among spouses of patients diagnosed with cancer of the lung, esophagus, pancreas, liver, or biliary passages, as these cancers carry a poor prognosis. Risk for new psychiatric illness was also greater for spouses of patients with an advanced tumor (aHR, 1.31) and after the death of the patient (aHR, 1.29).

Men and individuals aged 40 to 79 years had a slightly higher risk for first-onset psychiatric disorders compared with women and individuals in other age groups. Spouses with a lower household income also appeared to be more vulnerable to psychiatric disorders after cancer diagnosis.

In a secondary analysis of spouses with preexisting psychiatry illness, the risk for first-onset or recurrent psychiatric disorders increased by 23%.

Had the study been performed in the United States, which does not have universal healthcare, these “numbers would probably be much higher,” said Asher Aladjem, MD, medical director of psychosocial services, Perlmutter Cancer Center, New York City, who was not associated with this research. In the US, patients and their spouses deal with issues around insurance coverage and a fragmented healthcare system, which is a “big burden on any chronic or life-threatening illness,” he explained.

Dr Prigerson added that her own research has shown that the mental health of patients and spousal caregivers can also undermine the end-of-life experience of the patient.

“Stress responses trigger avoidance of end-of-life discussions, advance care planning, and signing of Do Not Resuscitate orders, which result in family members witnessing the horrors of life-prolonging care that, itself, may prove psychologically traumatizing,” Dr Prigerson said.

To address this “all too common” situation, Dr Prigerson and colleagues have developed psychological approaches to target experiential avoidance and reduce the grief and psychological trauma of spouses of patients with terminal cancer receiving critical care.

“We are finding that addressing the grief and trauma of spouses results not only in better care of dying cancer patients, but also fewer regrets and better mental health among the surviving spouses,” Dr Prigerson said.

Support for the study was provided by the Swedish Cancer Society; Karolinska Institute; the Swedish Research Council for Health, Working Life and Welfare; the China Scholarship Council; the Novo Nordisk Foundation; the Independent Research Fund Denmark; the Nordic Cancer Union; and the Karen Elise Jensens Fund. Dr Hu, Dr Prigerson, and Dr Aladjem have disclosed no relevant financial relationships.

JAMA Netw Open. Published online January 5, 2023.

Clinical Implications

• In a previous meta-analysis, the prevalence of depression among patients with cancer during or after treatment was between 8% and 24%. Just 3% of patients with lung cancer were found to have depression after diagnostic interviews compared with 31% of patients with cancers of the digestive tract. Depression was most common during cancer treatment, and there was a slight reduction in the prevalence of cancer after a year had passed since the cancer diagnosis.
• The current study demonstrates a significant increase in the risk for a number of psychiatric illnesses among the spouses of adults with cancer. This risk was greatest in the year after cancer diagnosis but remained elevated for at least 10 years. Variables associated with a particularly higher risk for depression among spouses of adults with cancer included being a man, lower household income, and diagnosis of cancer at an advanced stage.
• Implications for the healthcare team: The healthcare team should inquire into the well-being of significant others of patients with cancer, particularly with regard to mental health.

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