In women with early breast cancer, the prevalence of depression, anxiety, or both in the year after diagnosis is around twice that of the general female population. Thereafter, women in remission show similar levels of depression and anxiety to the general female population, but those with recurrence of disease experience a sharp increase in levels. The risk factors for depression and anxiety are related to the patient rather than to disease or treatment.
Our large cohort study is unique in that we used structured interviews and standardised diagnostic criteria to assess the point prevalence and period prevalence of clinically important depression and anxiety in women with early breast cancer in the five years after diagnosis. We also used a standardised interview method to examine the broader social context in which cancer occurred.
The point prevalence of depression, anxiety, or both in the year after diagnosis was lower than reported in previous studies,7,8
including one study carried out in the same breast unit as our study.9
The effect of diagnosis and treatment may have been reduced because of improvements in survival rates from breast cancer and better supportive care, including management of the side effects of anticancer treatments. The stigma associated with breast cancer may have decreased over time and a diagnosis may be less likely to provoke clinically important distress. Alternatively, the use of different diagnostic criteria for depression and anxiety may have contributed to the different levels recorded in our study.10
Our findings are in line with other studies, which show that factors related to the patient rather than to the disease or treatment increase the risk of clinically important depression and anxiety in women who remain free of breast cancer in the year after the disease is diagnosed.11-13
These risk factors include the main ones for depression and anxiety in the general female population5
—namely, younger age, previous psychological problems, non-cancer related difficulties, and lack of social support. The quality of social support predicts better health related quality of life generally in women who are in remission from breast cancer.2
Effective dissemination of information and the communication style of the surgeon seem to protect women against depression, anxiety, or both,11,13,14
whereas offering women choice of surgical treatment does not.8,14
The risk is not affected by clinical factors such as prognosis, type of surgery, or adjuvant radiotherapy.15-18
Adjuvant chemotherapy may increase the risk of depression, anxiety, or both during but not after treatment.7,18
Detecting breast cancer through screening rather than through self discovery does not seem to increase the risk of depression and anxiety.15,19
The increased levels of depression and anxiety around recurrence of breast cancer highlight the adverse effect of this event on women's mental health, which signals incurability and possible physical burden. Much less is known about the psychological problems experienced by women with advanced breast cancer. The improved survival of women with advanced disease from new treatments increases the need to understand better these issues.20,21
The lack of risk factors for depression and anxiety at recurrence suggest that the adverse psychological consequences are relatively independent of an individual's own vulnerability factors.22,23
These findings should be interpreted with caution, however, because of the small sample sizes.
What is already known on this topic
More women are surviving breast cancer because of early detection and improved treatment
Around twice as many of these women than the general female population have clinically important depression, anxiety, or both in the year after diagnosis
Less is known about the prevalence of, and risk factors for, clinically important depression and anxiety beyond the year after diagnosis
What this study adds
After the first year following a diagnosis of breast cancer, women in remission have levels of depression and anxiety that are comparable with those of the general female population
The risk factors for depression and anxiety in the five years after diagnosis are related to the patient rather than to the disease or its treatment
Psychological interventions for women with breast cancer should take account of the broader social context in which the cancer occurs, focusing on improved social support
We examined clinically important anxiety and depression, but this is only one dimension of the psychological consequence of survival after breast cancer is diagnosed. The absence of problems from anxiety and depression after the first year of diagnosis does not imply the absence of other psychological difficulties for women in remission from breast cancer. These include more subtle and existential concerns about loss of hope and certainty about the future.
Our findings are relevant to the implementation of the guidance for improving supportive and palliative care services for adults with cancer commissioned by the National Institute for Clinical Excellence.24
Effective psychological services are needed for women with breast cancer, especially in the year after diagnosis and around recurrence. We also found that women who are free of the disease but who are at risk of developing depression and anxiety are likely to benefit from psychological interventions that take account of the broader social context in which cancer occurs, including interventions to improve social support. Improving social support may also limit chronic depression, anxiety, or both in those women who lack an intimate confiding relationship.