Older adults with cancer at higher risk for depression during COVID-19 pandemic
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The COVID-19 pandemic became a stressful, disruptive experience for people of all ages and health statuses around the world.
Older adults living with cancer found the pandemic a uniquely frightening, alienating experience. A study published in Cancer Management & Research revealed increased levels of depression among older Canadian patients with cancer.
“The pandemic was a struggle for everyone, but we were really interested in people with chronic illness, who are typically more vulnerable to depression anyway,” Esme Fuller-Thomson, PhD, MSW, professor at University of Toronto’s Factor-Inwentash Faculty of Social Work and director of Institute for Life Course & Aging, told Healio. “Those with a history of depression did quite poorly, not surprisingly, because this was such a hit emotionally and to their lifestyles. Even quite a few of the people who had been free of depression before the pandemic developed depression for the first time, because it was so hard on them.”
Investigators assessed data from a sample of 2,486 adults aged 50 years and older with a history of cancer who participated in the Canadian Longitudinal Study on Aging. Fuller-Thomson spoke with Healio about the factors that added to the likelihood of depression in this population and discussed how oncologists can better address the mental health challenges of patients with cancer.
Healio: How did you conduct this study?
Fuller-Thomson: We were fortunate enough to have access to a dataset from a longitudinal study that had been going on since 2011. We knew quite a bit about these individuals before the pandemic started. Most people in our study, despite having cancer, had never reached levels of clinical depression. Our study was done early in the pandemic when everything was particularly challenging. People were locked down — they couldn’t get to hospitals. People with cancer had been warned to be particularly careful and vigilant about minimizing contact because we were worried that outcomes would be worse for people with chronic disease. It was a time of heightened concern and fear.
Healio: What did you find in terms of the 786 individuals who already had a history of depression?
Fuller-Thomson: About half of these patients were depressed at the beginning of the pandemic. This isn’t too surprising because these individuals were already more vulnerable to depression. The pandemic was just so emotionally demanding; there were so many unknowns. These were patients with cancer who could not get to their doctor, and they can’t do their regular screening. For people who were already vulnerable to depression, it isn’t very surprising that so many of them struggled.
Healio: What did you find regarding patients who had no history of depression?
Fuller-Thomson: We wanted to specifically look at people who had not been depressed prior to the shutdown to see what effect the pandemic had. Most research has been unable to differentiate between people with a history of depression and those without, but we were fortunate enough to have access to this prospective data.
Most people in our study, despite having cancer, had never reached levels of clinical depression. Yet, when you put cancer and the pandemic together, one in eight people succumbed to depression. This doesn’t mean they stayed depressed forever, but we only studied the beginning of the pandemic.
Healio: What did your study reveal about the role family conflicts played in heightening the risk for depression?
Fuller-Thomson: Yes, that can be a major issue. Normally, if there are tensions in your family, you still have your work, your friends, and your outside interests and activities. In this way, individuals can perhaps minimize interaction and conflict within the family. However, during the pandemic, we were all in a Petri dish locked in small spaces together. There weren’t as many ways to avoid or manage family conflict. Not surprisingly, being locked in a small space during a family conflict is not good for well-being.
Healio: What did the results show about the impact of gender differences in your study population?
Fuller-Thomson: In general, in the absence of cancer and a pandemic, women are more vulnerable to depression. The combination of cancer and the lockdown had more of an effect on women than men with respect to new-onset depression. It’s valuable to remember that men and women sometimes present differently with stress, and we could not examine these other coping strategies. For example, men who are upset may drink more, while women have more internalized feelings of depression. We just looked at depression as quantified by mood. This doesn’t necessarily mean that men weren’t doing unhealthy things to help cope with the difficult times.
Healio: Do you think the depression you observed had an impact on the delivery of cancer care to these patients?
Fuller-Thomson: My guess is that this association might go in the opposite direction — that not being able to access health care may have resulted in a person with cancer becoming anxious and depressed. This would seem especially true for people who could not access regular care related to the monitoring and assessment of their cancer — cancer treatment is not something patients want to postpone.
Our study found that if patients had problems getting access to health care, they were more likely to become depressed, whether they had a history of depression or not. If a patient can’t get in to see their doctor or if their regular cancer screenings are delayed, then it can produce a lot of anxiety, especially among people with a history of cancer who want to be up to date on check-ups and monitoring for potential reoccurrence of their cancer.
Healio: What can oncologists do to support patients during especially stressful times like the pandemic?
Fuller-Thomson: Oncologists are often focused on the absolutely essential, physical aspects of health care, but I would love to see them screen their patients more regularly for depression. It’s not their responsibility to provide this mental health support themselves, but it would be very helpful to refer patients with depression for mental health treatment. There are people who continue to be depressed, even multiple years into the pandemic. The pandemic was so disruptive, and we don’t yet have the longitudinal data. It certainly would be relatively simple to do a standardized depression screening when patients are in the waiting room. Those patients who are struggling with depression can be referred for effective treatment.
One treatment that has shown to be very helpful is cognitive behavioral therapy. It can be done individually or in a group — an hour a week for 12 weeks — and it enables many people to recover from depression who might not recover otherwise. It is a relatively inexpensive and easy form of talk therapy that is evidence based. I would love to see oncologists, who are the first line of defense for patients with cancer, start to think a bit more about the mental health side of their patients. They might be reluctant to bring up the topic of their depression. They wouldn’t necessarily flag their own mental health problems and seek out psychiatric or social work support. However, if their oncologists says, “Hey, it’s normal to be struggling with this, but there are some really good tools out there that might help,” that gives it a level of legitimacy that makes therapy less intimidating.
Oncologists are exactly the people I would like to hear about this, because they are the health professionals who have the complete confidence of their patients. If oncologists have it on their radar screen to screen for depression and refer those who are struggling to therapy, their patients will benefit from it.
Reference:
Esme Fuller-Thomson, PhD, MSW, can be reached at Institute for Life Course and Aging, University of Toronto, 246 Bloor St. West, Room 214, Toronto, Ontario M5S, 1V4; email: esme.fuller.thomson@utoronto.ca.
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