In this report, the prevalence of depression using the GDS-SF15, a commonly used depression survey, was consistent with reports from some cancer patients but higher than that of others. The number (n = 77, 27.2%) of individuals with GDS-SF15 scores above the cutoff of 5, indicative of depression, also exceeded that in research with other cancer populations.31–33
Other studies found prevalence rates in cancer patients ranging from 18% to 24%.32–34
However, the participants in these studies were primarily older (>65 years) white sample with late-stage or advanced cancer. What is known about depression in African Americans comes from studies examining mental health issues among community-dwelling populations and populations with other chronic illnesses. Within the general African American population, there is a similar lack of literature examining depression using the GDS-SF15 survey. Studies have reported that, in general, African Americans tend to have a lower prevalence rate of depression than other racial groups in the United States.35,36
However, depression is frequently misdiagnosed in African Americans, a result of the stigma attached to accessing mental health services within the African American community.37
Therefore, although there is no appropriate comparison for this study, we conclude that depression is prevalent among older African American cancer patients.
Several demographic factors in African American cancer patients were found to be highly associated with a high depression score. In concurrence with other studies, we found that younger-aged (<65 years) cancer patients were more at risk of depression than were older patients.14,16,18
Several explanations have been proposed for this age-related trend. A cancer diagnosis may have a more devastating effect on younger patients because they are less likely to expect the experience of chronic illness. There is also the possibility of thoughts of unfinished goals associated with the threat of an early death.14
Cancer may also affect the daily lifestyles of younger patients because of job concerns and the devastation on their families.14,16
Younger patients are known to have more cancer-related thoughts such as the cause of cancer and “Why me?”38
These types of thoughts can lead to a poorer psychological adjustment for cancer patients and increase the anxiety and depression experienced by them. In addition, it is possible that differences in cancer pathologies that occur among adults of different ages may predispose younger cancer patients to a greater risk of depression than older cancer patients. For example, in a review of age differences in psychosocial effects of breast cancer, younger premenopausal women were found to have more aggressive cancers and a higher rate of recurrence than postmenopausal women.39,40
In addition, younger women received stronger treatments and reported a greater number of adverse effects to treatment.39,40
Another explanation for the effect of age on depression is methodological: younger patients may have received their cancer diagnosis more recently than older patients and have had less time to adjust to the disease at the time of data collection.41
Although methodological issues may contribute to the observed age trend in depression among cancer patients, there still exists a significant association, and efforts must be made to identify depression in younger cancer patients.
The economic and social impacts of not being able to hold a job can have serious psychological effects. Consistent with other studies, we found that African American cancer patients who lost their jobs because of their health had more than 3 times greater risk of depression than patients who were employed at the time of the study. Studies have found that job loss and the inability to work cause higher rates of emotional distress and depression in cancer patients.41,42
Because of symptoms and adverse effects related to cancer disease and treatment such as pain and fatigue, many patients are unable to continue working because of absenteeism and the time needed for treatment.42
Job loss can impact the daily routine, relationships with friends and family, and financial status.43
Therefore, it is particularly distressing for patients who have been the breadwinner of the home because they have to cope with the disruption of their identity.43
An association was also observed between lack of health insurance and depression among these older African American cancer patients. Although lack of insurance was not significantly associated with depression after controlling for other variables such as employment status, lack of insurance plays an important role in the onset of depression in cancer patients. Lack of insurance typically closes doors for healthcare, mental or otherwise, and can cause exceptional burden on cancer patients who are receiving treatment. Anxiety over where to get healthcare and how to pay for it can result in depression for these patients.
Living in proximity to family can be a protective factor from depression for cancer patients. Families including spouses are said to provide 85% of the social support received by cancer patients.44
Although recent research has not yet explored the relationship between proximity to family and depression among cancer patients, we can infer from literature that unmarried patients and patients without large social networks are more likely to be depressed.44–46
We found that 39% of our sample lived alone. Using living alone as an indicator for proximity to family, we found that those who lived alone had 2 times greater chance of having depressive symptoms than those patients who lived with someone. Not having someone at home to care and support the cancer patient can increase the worries and anxiety that the patient experiences. In elderly patients, it can also increase the burden of daily living. It is interesting to note, however, that no association was found between marital status and depression.
The only illness-related factor that was found to be significantly associated with depression was having symptoms from cancer. Many previous studies have also noted that having physical symptoms of cancer is strongly associated with depression in cancer patients.6,12,18,47,48
However, these studies are also focused on a primarily well-educated, middle-class white sample, much unlike our sample of relatively low-income African American sample. Although we do not have data on the specific symptoms experienced by older African American cancer patients in this study, we found that merely the presence of any symptom led to a 2.62 greater odds of depression. The most prevalent symptoms that are associated with depression are fatigue, pain, and insomnia.48
Experiencing symptoms brings the disease to the forefront of the patients’ minds as it impacts behaviors, cognition, and relationships.49
This study has several limitations. One weak point in the study is the cross-sectional study design that limits the analysis to only 1 snapshot of depression in the patients. Because depression is known to be variable over time, to assess the complexities associated with depression, longitudinal studies are greatly needed. Another limitation was that depression was measured by a self-report survey and not assessed by a trained professional. However, because depression is so often under-diagnosed particularly in the African American population, the survey was the best option available to get a preliminary assessment of depression in the patients. Moreover, many studies use a self-report survey because of the occurrence of mis-diagnosis of depression. Another limitation in this study is the lack of comparability with other studies examining depression among other demographically similar cancer patients. This study is the first to examine the risk factors of depression in older African American cancer patients and will serve as a reference point for future studies exploring this understudied population.