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03 August 2024: Database Analysis  

Psychological Impact of Bladder Cancer: Insights from 219 Patients and Caregivers in Indonesia Using DASS-21 (2019–2023)

Wahjoe Djatisoesanto ORCID logo12ABCEF*, Yufi Aulia Azmi ORCID logo123ABCDEF, Ida Bagus Gde Tirta Yoga Yatindra ORCID logo12ABCDE

DOI: 10.12659/MSM.945272

Med Sci Monit 2024; 30:e945272

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Abstract

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BACKGROUND: Bladder cancer (BC) is a common disease worldwide. Low survival rates and high recurrence lead to the risk of mental disorders. This study analyzed 219 patients with bladder cancer using the Indonesian Version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) and related factors.

MATERIAL AND METHODS: This cross-sectional study included 219 patients diagnosed with bladder cancer during 2019-2023 in a referral hospital in Indonesia. Data were collected using a questionnaire that assessed the characteristics of the patients and a DASS-21 questionnaire.

RESULTS: Some patients and caregivers experienced depression, stress, and anxiety. The percentage of caregivers who experienced anxiety was higher than for patients (47.9% vs 45.7%). Statistical analysis showed that age, income, and marital status were associated with the incidence of depression (p=0.000, p=0.001, and p=0.000, respectively), anxiety (p=0.000, p=0.012, and p=0.001, respectively), and stress (p=0.000, p=0.007, and p=0.000, respectively). Routes of patient admission (p=0.043, respectively) and employment status (p=0.005, respectively) were associated with the incidence of depression in patients (p=0.043, respectively). Employment status was also associated with stress in patients (p=0.038, respectively). Statistical analysis of caregivers found that routes of patient admission and marital status were related to the incidence of depression among caregivers (p=0.036 and p=0.007, respectively).

CONCLUSIONS: Monitoring and providing support for patients and caregivers are needed to prevent poor prognosis due to psychological problems, including paying attention to sociodemographic factors.

Keywords: Emergency Medical Services, Psychiatry, Surgery Department, Hospital, Urology

Introduction

Bladder cancer is the most common cancer, and there are about 550 000 new cases every year in the world [1]. In 2020, 573 000 new cases were recorded, and the death rate was higher in men. By 2040, the number of annual deaths is expected to have increased [2]. According to the latest GLOBOCAN data, bladder cancer contributes to 3% of global cancer diagnoses and is particularly common in developed countries [3]. There is expected to be a 73–87% increase in annual cases and deaths by 2040 globally [2].

Bladder cancer is becoming a significant burden on global healthcare services since it is one of the most expensive cancers to treat due to the prolonged treatments and follow-up resulting in expensive and invasive procedures [4]. Besides expensive treatment, the patient’s quality of life also experiences problems. Patients with bladder cancer frequently experience a lower quality of life, which may be more harmful than in other prevalent pelvic cancers [5]. Patients undergoing treatment for bladder cancer report worse Health-Related Quality of Life (HRQoL), including lower social functioning, increased fatigue, and more concerns about the future. Patients treated radically also report worse HRQoL, including problems with body image and male sexual function, compared to those undergoing transurethral resection of bladder tumor (TURBT) [6].

Complications from bladder cancer include adverse effects from treatment and symptoms. Weight loss, exhaustion, urinary tract infections, metastases, and urine blockage resulting in chronic renal failure are among the consequences associated with tumors. Urinary tract infections, bladder stones, vaginal stricture, urinary tract obstruction, and erectile dysfunction are among the adverse effects of surgical treatment. In the first 3 months following surgery, over two-thirds of patients undergoing radical cystectomies will encounter at least 1 postoperative problem, and 13% will experience a severe complication (grade 3 or above) [7].

Bladder cancer has a high probability of recurrence and progression [8]. Survival varies greatly with stage and between non-invasive and invasive cases [9]. Research in Kurdistan found that patients with bladder cancer have a relatively low survival rate [10]. Research in Malaysia also found that the survival of bladder cancer patients is lower in patients with advanced stages [11]. The psychological state of the patient is connected to this low survival rate. Older patients with muscle-invasive bladder cancer who also had a pre-existing mental illness had a lower chance of receiving therapy according to guidelines, which led to poor overall and disease-specific survival [12]. A 2018 report by Jazzar et al. found that 1870 (50.4%) of 3709 patients with a diagnosis of bladder cancer had a diagnosis of psychological problems following therapy. The overall and cancer-specific survival rates were significantly poorer when a mental illness was diagnosed [13]. Depression and anxiety were more common in women and individuals undergoing more drastic therapies [14]. Psychological distress is commonly seen in patients with health conditions and has been associated with poorer health outcomes and treatment noncompliance. Therefore, understanding the nature of psychological distress and providing timely psychological therapy is crucial for both patients and healthcare providers [15]. Urologists may gain a unique opportunity to diagnose mental health issues, encourage healthy behavior change, and successfully refer patients who may not otherwise seek proper medical/psychological care [16]. This demonstrates the importance of considering mental well-being during the follow-up period for early recognition and treatment of mental health problems. However, current evidence is mixed, so more research is needed to explore at-risk patients [17]. One way to overcome and prevent mental problems is by understanding the existing risk factors.

There is still a lack of evidence on risk factors for stress, anxiety, and depression in bladder cancer patients in Indonesia, including caregivers’ sociodemographic factors. This study analyzed data from 219 patients with bladder cancer utilizing the Indonesian Version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) to identify prevalences and related factors. This research may help inform interventions and improve mental health support in this population.

Material and Methods

ETHICS STATEMENT:

This research was approved by the hospital ethics committee from Dr Soetomo General Academic Hospital, East Java, Indonesia (ethical number 2590/109/4/XI/2023). All procedures followed the Helsinki Declaration, 2000 version. Patients voluntarily participated in the research and filled out informed consent forms upon admission to the hospital after being informed that the data would be used in research and scientific development. We did not collect any data revealing patient identity, including names.

RESEARCH TYPE:

A cross-sectional study was undertaken at a tertiary referral hospital in East Java during 2019–2023. We used data from medical records. The questionnaire administered in the hospital collected data on general patient information, clinical conditions, and psychological conditions of patients and companions. Since the patient was admitted to the hospital, various data were collected. The researchers identified medical record data based on the diagnosis of bladder cancer patients. Data extraction was conducted using CRF demographic sources and dummy table references according to the variables studied. The medical records used have limitations, such as incomplete data on certain variables. A cross-sectional research design was used because this study aimed to explore the psychological situation of patients and their caregivers in a single data collection.

STUDY PARTICIPANTS:

This study investigated the psychological situation of patients and caregivers during treatment at a referral hospital. The population of this study was patients diagnosed with bladder cancer and hospitalized at Dr Soetomo General Academic Hospital during the period 2019–2023. The study sample was patients diagnosed with bladder cancer and hospitalized at Dr Soetomo General Academic Hospital who met the inclusion and exclusion criteria. The inclusion criteria were patients aged >18 years, had bladder cancer stage 3/4 status, had caregivers, had no comorbidities or other cancers, had no cancer recurrence, had been diagnosed with bladder cancer, and had complete medical records. Patients discharged against medical advice were excluded from the study because the role of care in the hospital could not be identified. Patients who had been diagnosed with stress, anxiety, and depression in medical records and had a Holmes and Rahe stress scale score of >300 were not included in the study because it showed that the patient had experienced a mental disorder before developing cancer. The caregiver in this study was the person in charge of the patient who accompanied the patient during the hospital admission process and while in the hospital. The inclusion criterion for caregivers was complete data. Caregivers who had a history of depression, stress, and anxiety or had comorbidities were also excluded.

VARIABLES:

Independent variables were age, routes of patient admission, gender, highest education, employment status, income, marital status, caregiver age, caregiver gender, caregiver highest education, caregiver employment status, caregiver income, and caregiver marital status. The dependent variables were depression, anxiety, and stress, as measured by the DASS-21 Questionnaire. Age was calculated based on the date of birth on the patient’s identity card. The routes of patient admission were determined based on initial data collected at hospital admission, the arrival of patients through emergencies in the emergency room, or routine checks at the polyclinic. Gender was identified by the patient’s identity document. The highest education, employment status, income, and marital status were assessed through interviews with patients.

DATA COLLECTION USING DASS-21 QUESTIONNAIRE:

Informed consent was obtained from all qualifying patients. Data collection was carried out by filling out a questionnaire. The questionnaire asked about sociodemographic information such as patient age, routes of patient admission, gender, recent education, employment status, income, marital status, caregiver age, caregiver gender, caregiver last education, caregiver employment status, caregiver income, and marital caregiver status. The questionnaire also included the Indonesian version of the Depression Anxiety Scale. The DASS-21 is a self-report tool used to identify negative mental health symptoms, including a stress scale. It is composed of 21 items that evaluate 3 different components: stress, anxiety, and depressive symptoms. Each component consists of 7 questions, with a 4-point Likert scale ranging from 0 (does not apply to me at all/never) to 3 (applies very much to me/almost usually) for each topic. Each component’s final score is determined by multiplying it by 2. For every component, the lowest possible final score was 0, and the highest possible score was 42. The results were classified into 5 categories: normal, mild, moderate, severe, and extremely severe, depending on the overall score for each component, as shown in Table 1. Prior validation of the Indonesian version of the DASS-21 indicated strong internal consistency, discriminant validity, and convergence (Cronbach’s alpha of 0.895).

STATISTICAL TEST:

IBM SPSS Statistics software, version 24.0 (New York, USA), was used for statistical analysis. Descriptive analysis was utilized to explore the percentage of depression, stress, and anxiety, as well as the demographic features of patients and caregivers. In addition, mean and standard deviation were used for the age variable. The DASS-21 data in the descriptive analysis was categorized into 5 categories – normal, mild, moderate, severe, and extremely severe (Table 1). In the bivariate analysis, demographic data were converted to a nominal data scale with 2 categories to be statistically analyzed for association with risk factors. DASS-21 data in scores were converted to nominal data – yes and no. Bivariate analysis used the chi-square test to evaluate differences in depression, anxiety, and stress status based on demographic data. A value of p<0.05 indicates a statistical significance. Multivariate analysis using binary logistic regression was also conducted to examine the associations of demographic variables with depression, anxiety, and stress status simultaneously. We used a confidence interval of 95%. The confounding variable in this study was the treatment regimen.

Results

DEMOGRAPHIC DATA:

A total of 219 patients were involved in the study. The average age was 58 years. More than half of the patients were adults (63%) admitted to the hospital through the emergency department (59.4%). Most patients (80.8%) were male. More than half of patients had graduated from senior high school (59.4%) and worked (51.6%). Most had incomes ≤4 million rupiahs (79.5%) and were married (76.7%). The average age of caregivers was 46 years old, all of whom were adults. More than half of all caregivers were women (63.5%), have a senior high school education (53.9%), work (53.4%), and have an income of ≤4 million rupiahs (64.8%). Most caregivers are married (80/8%). Table 2 shows the sociodemographic characteristics of patients and caregivers.

PREVALENCE OF DEPRESSION, STRESS, AND ANXIETY AMONG BLADDER CANCER PATIENTS AND CAREGIVERS:

The results of the assessment showed that some patients and caregivers experienced depression, stress, and anxiety. Some patients experienced severe depression (1.4%) and severe anxiety (3.7%). Some caregivers experienced severe anxiety (0.9%). The results of the depression status examination in patients showed that 13.3% of patients experienced depression, including 18 patients (8.2%) with mild depression, 8 patients (3.7%) with moderate depression, and 3 patients (1.4%) with severe depression. The incidence rate of depression is higher than that of caregivers; 11.4% of caregivers were depressed. Cases of depression in caregivers showed mild depression in 22 caregivers (10%) and moderate depression in 3 caregivers (1.4%). The results of the anxiety examination in patients showed that 46.7% of patients experienced anxiety, including 38 patients (17.4%) who experienced mild anxiety, 54 patients (24.7%) who experienced moderate anxiety, and 8 patients (3.7%) who experienced severe anxiety. The incidence rate of anxiety was higher than that of caregivers, which showed that 37.9% of caregivers experienced anxiety. Among caregivers, 44 (20.1%) had mild anxiety, 37 (16.9%) had moderate anxiety, and 2 (0.9%) had severe anxiety. The results of the stress status examination showed that 21% of patients experienced stress, with 43 patients (19.6%) experiencing mild stress and 3 patients (1.4%) experiencing moderate stress. Stress was common in caregivers, with 25.5% experiencing stress. A total of 52 caregivers (23.7%) experienced mild stress, and 4 caregivers (1.8%) experienced moderate stress. Table 2 presents the results of the assessment of the prevalence of depression, stress, and anxiety.

RISK FACTORS FOR DEPRESSION, STRESS, AND ANXIETY AMONG BLADDER CANCER PATIENTS AND CAREGIVERS:

Certain variables were linked to the incidence of depression, stress, and anxiety based on age, routes of patient admission, gender, education level, employment status, income, and marital status. Among patients, age was associated with the incidence of depression (p=0.000, OR 0.790, 95% CI 0.725–0.861, respectively), anxiety (p=0.000, OR 0.667, 95% CI 0.592–0.750, respectively), and stress (p=0.000, OR 0.275, 95% CI 0.210–0.361, respectively). Income was associated with the incidence of depression (p=0.001, OR 4.012, 95% CI 1.759–9.151, respectively), anxiety (p=0.012, OR 2.333, 95% CI 1.189–4.578, respectively), and stress (p=0.007, OR 2.648, 95% CI 1.281–5.474, respectively). Marital status was associated with the incidence of depression (p=0.000, OR 0.014, 95% CI 0.002–0.117, respectively), anxiety (p=0.001, OR 2.308, 95% CI 1.977–2.694, respectively), and stress (p=0.000, OR 0.028, 95% CI 0.003–0.227, respectively). Routes of patient admission (p=0.043, OR=2.322, CI 95% 1.048–5.141, respectively) and employment status (p=0.005, OR=0.292, CI 95% 0.119–0.717, respectively) were correlated with the incidence of depression in patients. Employment status was also associated with stress (p=0.038, OR=0.492, CI 95% 0.250–0.967, respectively). Multivariate analysis showed that income (OR=6.553, 95% CI 95% 2.012–21.340) and marital status (OR=0.030 CI 95% 0.003–0.297) were associated with inpatient depression, while income also affected patient anxiety (OR=4.181, CI 95% 1.259–13.884) and marital status affected stress in the patient (OR=0.054, 95% CI 0.006–0.490) (see Table 3).

Among caregivers, routes of patient admission (p=0.036 OR 2.432, CI 95% 1.309–5.697, respectively) and marital status (p=0.007, OR=0.111, CI 95% 0.026–0.475, respectively) were associated with depression. The results of multivariate analysis of caregivers showed routes of patient admission (OR=2.545, 95% CI 1.037–6.242) and marital status (OR=0.099, 95% CI 0.022–0.450) were associated with caregiver depression, and marital status (OR=0.189, 95% CI 0.037–0.978) was associated with caregiver anxiety (see Table 4).

Discussion

Results from the present study revealed that age, income, and marital status were associated with depression, anxiety, and stress. Routes of patient admission and employment status were associated with the incidence of depression in patients. Employment status was also associated with stress in patients. Routes of patient admission and marital status were related to the incidence of depression among caregivers.

Age was associated with depression, stress, and anxiety. A 2023 study by Mohammed et al. found that bladder cancer patients experienced significant levels of depression and anxiety, and these levels were related to the patient’s age, as well as inadequate supportive care and lack of social support [18]. Other research stated that older age was protective against the development of depression [19]. Advanced age was correlated with the likelihood of developing depression. When bladder cancer was diagnosed and following radical cystectomy surgery, younger patients (less than 65 years old) were more likely than older patients to have psychological anguish [20]. This situation was also found in younger patients with muscle-invasive BC. These patients were more likely to be diagnosed with post-treatment psychiatric disorders, likely due to morbidity and mortality associated with treatment [13]. However, it differed from the results of a 2017 study by Draeger et al., which found that age was not associated with stress levels or the need for psychosocial treatment [21]. A 2016 study by Mengyao Li et al. also found that age was not associated with depression and anxiety in bladder and renal cancer patients [22].

We also found an association between patient income and stress, anxiety, and depression. Health insurance and medical costs are related to income. Bladder cancer patients are more likely to experience anxiety or depression for the first time at 6 months (for insurance patients) and 36 months (for those paying with personal funds). Compared to younger patients, personally insured patients over the age of 50 were less likely to develop clinically significant anxiety or sadness in the year following a bladder cancer diagnosis [14]. Income is inversely correlated with depression risk in cancer patients and is linked to their quality of life. Depression risk is significantly associated with low income (less than $ 30 000 annually). There are other social and demographic factors at work as well [19]. Income levels were found to differ in each group, namely the group that did not experience mental disorders, anxiety disorders, and depression, the group that only experienced depression, the group that experienced severe mental disorders, and the group that only experienced anxiety disorders. [12]. In contrast, younger patients and middle-aged patients may be forced to lose income due to their illness, resulting in devastating financial and social consequences for their entire family. The rising costs of newly diagnosed cancer make things worse and create more tremendous pressure [20]. A patient’s financial situation may play a role because increased income negatively correlates with depressive symptoms. [23]. While work status and health insurance demonstrated substantial disparities in survival among patients with bladder cancer, an analysis of 219 patients revealed no changes in patient survival depending on income [24].

Marital status is related to depression, anxiety, and stress situations among patients and is related to depression in caregivers. Married people have a comparatively more extended life expectancy and a superior quality of life in several diseases, especially cancer [25]. Due to several factors, married people feel stressful events less emotionally than single people, which helps to explain why they have lower rates of depression [26]. A 2016 study by Mengyao Li et al. found that marital status was not related to depressive and anxiety symptoms in Chinese bladder and renal cancer patients [22]. Research conducted by Oserowsky et al. in 2021 found that marriage was protective against the development of depression in elderly patients [19]. Marital status is also related to the survival status of patients [27]. In numerous aspects of cancer therapy, marital support is crucial and may be linked to improved treatment adherence and intensity. Inadequate marital support and other forms of social support may have detrimental effects, such as variations in treatment compliance, noncompliance with supportive interventions, and a decrease in the quality of life reported by patients. A multimodal approach is used to treat many cancer patients with palliative intentions, and radiotherapy is frequently part of this method [28]. Married individuals tend to have better access to emotional and financial support and more comprehensive medical care, resulting in a better prognosis [29]. Patients with upper urinary tract urothelial carcinoma (UTUC) have separate prognostic factors for both cancer-specific survival (CSS) and overall survival (OS). Compared to their never-married and widowed peers, patients with UTUC who are married report better OS and CSS [25]. Education in patients and their partners/caregivers gives good results. There was a decrease in depressive symptoms after the intervention. An intervention involving couples is the most feasible and acceptable, but more research is needed [30].

Routes of patient admission were associated with the incidence of depression in patients and caregivers. Few studies have discussed this because it focuses on the role of depression in the use of emergency departments. In the emergency unit, problems such as difficulty finding transportation, job responsibilities, embarrassment about potential illnesses, confusion with appointments, and the feeling that doctors are not responding to their concerns may be found. Worse depressive symptoms are associated with greater difficulty accessing treatment [31].

Employment status was also associated with stress and depression in patients and depression in caregivers. Regarding employment status, the total score of the Zarit Burden Inventory (ZBI) differed significantly among various conditions (p<0.001). ZBI is used to assess depression, anxiety, and caregiving burden [32]. Depression was shown to be quite prevalent in those who care for cancer patients, and it was found to be significantly correlated with the caregiver’s employment level [33]. While family support is associated with better results for cancer patients, family caregivers deal with a variety of hurdles in their responsibilities and lifestyles, such as shifting work schedules, emotional difficulties, and other issues. A lack of social support can also make parenting more challenging. Previous studies have shown that caregivers struggle to exercise and manage their roles as caregivers on top of their current responsibilities linked to parenting and job [34]. In cervical cancer, in addition to other comorbidities and prior employment status, the percentage of unemployed survivors appears to be rising. Low income and the unavailability of medical aid are also connected with unemployment. The financial standing of cervical cancer survivors needs to be secured [35]. Unemployed cancer patients who were fired from their jobs and had stage IV cancer tended to be more prone to depression, whereas patients who had completed basic education and had colon, prostate, and cervical cancer tended to be less depressed [36].

This study has some limitations. The questionnaire was only filled out once, making it impossible to conduct more in-depth research as in qualitative research on mental disorders in patients and their families. This study was also unable to examine the form of mental support from hospitals and healthcare workers to patients and caregivers. We explored bladder cancer in general and have not associated it with the treatment regimen due to inadequate data, a variable that cannot be controlled. Further research is needed to classify these factors related to the mental status of bladder cancer patients. Additional research is also required to explore the long-term effects of mental disorders and investigate the role of hospitals in providing support.

Conclusions

Some bladder cancer patients and their caregivers experience depression, anxiety, and stress. The percentage of caregivers who experienced anxiety was higher than among patients. Age, income, and marital status were associated with the incidence of anxiety, depression, and stress among patients. Routes of patient admission and employment status were correlated with the incidence of depression in patients. Employment status was also associated with stress in patients. Routes of patient admission and marital status were linked to the incidence of depression among caregivers. Monitoring and providing support for patients and caregivers are needed to prevent poor prognosis due to psychological problems, including paying attention to sociodemographic factors.

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