ASSOCIATION BETWEEN SELF-ESTEEM AND DEPRESSION AMONG PATIENTS WITH HEAD AND NECK CANCER: A PILOT STUDY

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1 ORIGINAL ARTICLE ASSOCIATION BETWEEN SELF-ESTEEM AND DEPRESSION AMONG PATIENTS WITH HEAD AND NECK CANCER: A PILOT STUDY Mika Kobayashi, MA, 1 Taro Sugimoto, MD, 2 Ayako Matsuda, MA, 1 Eisuke Matsushima, MD, PhD, 1 Seiji Kishimoto, MD, PhD 3 1 Department of Comprehensive Diagnosis and Therapeutics, Section Division of Liaison Psychiatry and Palliative Medicine, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan. em.lppm@tmd.ac.jp 2 Department of Otorhinolaryngology, Tokyo Medical and Dental University, Tokyo, Japan 3 Department of Head and Neck Reconstruction, Section of Head and Neck Surgery, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan Accepted 29 February 2008 Published online 18 July 2008 in Wiley InterScience ( DOI: /hed Abstract: Background. We examined the psychological distress in patients with head and neck cancer and investigated how preoperative self-esteem influenced psychological distress during treatment. Methods. Fifty-eight patients who were scheduled for surgery for head and neck cancer participated. The Japanese version of hospital anxiety and depression scale (HADS) was administered preoperatively, after surgery, and 6 months postoperatively, and Rosenberg self-esteem scale was administered preoperatively and 6 months postoperatively. Results. There were significant differences among the 3 examination periods for psychological distress; the course of anxiety and depression differed between the high self-esteem group (HSEG) and the low self-esteem group (LSEG). In all examination periods, anxiety and depression scores for HSEG were significantly better than for LSEG. As for depression, scores did not change significantly over time in HSEG, whereas the scores went from bad to worse in LSEG. Correspondence to: E. Matsushima This study was presented at the 8th World Congress of Psycho-Oncology meeting, Italy, October VC 2008 Wiley Periodicals, Inc. Conclusions. Patients with cancer undergoing surgery, especially patients with low self-esteem, need preoperative and ongoing intervention. VC 2008 Wiley Periodicals, Inc. Head Neck 30: , 2008 Keywords: head and neck cancer; self-esteem; depression; anxiety; quality of life When a person is faced with a diagnosis of cancer, he or she experiences fear of disease and threats to self-image, confidence, and identity. 1 In particular, for patients with head and neck cancer, essential daily functions such as speech, eating, and respiration are altered and treatment causes multiple functional and psychosocial difficulties, 2 quality of life (QOL) is seriously disrupted in comparison with other cancer sites. 3 Previous studies have also reported the high incidence of psychiatric problems, including depression and anxiety. Studies using structured psychiatric interviews reported major depression (3.7% to 39.6%) in patients with head and neck Self-Esteem and Psychological Distress in Head and Neck Cancer HEAD & NECK DOI /hed October

2 cancer Additionally, in studies with selfreport questionnaires, depression and anxiety are identified quite frequently. Although participants and study methods differ, earlier studies have indicated that psychological distress in patients with head and neck cancer was higher than it was in those of other cancer sites. 13 Multiple factors are given as risk factors for depression: diagnosis of cancer, treatment, pain, change of body image, lack of social support, history of alcohol/smoking, and anamnesis of mental disease. 15 In addition to these risk factors, progression of cancer, single status, solitary living situation, and inadequate coping style are also emphasized as important factors for depression. 16,17 The head and neck region is considered to be the most important site in relation to psychosocial aspects because it is closely related with expression of feelings and communication. Breitbart 1 stated that for patients with head and neck cancer, changes and impairments followed by cancer treatments have negative influences on selfesteem and confidence. Besides the external factors of treatment and social support, the internal resources such as self-esteem can promote or detract from the patient s well being. 18 However, very few studies have focused on self-esteem in patients with cancer. Katz et al 19 examined selfesteem for patients with cancer and found that 20% to 50% had lowered self-esteem. In the head and neck cancer population, there are no longitudinal studies which focus on patients self-esteem. Moreover, no study has examined self-esteem as a factor for predicting the course of depression and anxiety during and after the treatment of head and neck cancer. The aim of this pilot study was to examine the changes of psychological distress, such as depression and anxiety, in patients with head and neck cancer who were scheduled to undergo surgery. We also investigated the relationship between patients self esteem and psychological distress. We hypothesized that preoperative self-esteem may affect subsequent psychological distress. Thus, patients with head and neck cancer with higher self-esteem would show greater psychological adjustment compared with patients with lower self-esteem. MATERIALS AND METHODS This is a prospective study that longitudinally followed 58 patients during and after treatments for head and neck cancer. Questionnaires were administered preoperatively (time 1), 7 to 10 days after surgery (time 2), and 6 months postoperatively (time 3). For Time 3, the questionnaires were mailed with a stamped envelope to patients or administered while patients were visiting their doctor. Medical information and demographic data were taken from medical records and patient reports. Tokyo Medical and Dental University Hospital research review board approved the study and granted formal access to the patients. All patients were informed of the nature, risks, and benefits of participation, and written consent was obtained. Participants. Inclusion criteria included: (1) age 20 years or older; (2) aware of cancer diagnosis; (3) diagnosis of head and neck cancer with scheduled surgery; (4) able to complete the questionnaire and participate in the study; (5) no severe mental disorder or dementia; and (6) able to give informed consent. During the recruitment phase (September 2005 May 2007), 82 patients met the inclusion criteria. Because of the time limitation between hospitalization and surgery, it was not possible to meet everyone. A total of 70 were approached, 12 were excluded, and 58 were eligible. The reasons for exclusion were as follows: 10 had incomplete data, 1 had an alcoholic disorder, 1 was not aware of the cancer diagnosis, and 1 refused to participate in the study. Demographic and medical variables are summarized in Tables 1 and 2. The mean age was 62.0 years (range, years). Men made up Table 1. Patient characteristics: demographic variables (n 5 58). No. of patients (%) Mean SD Sex Male 45 (77.6) Female 13 (22.4) Age, y Marital status Married 42 (72.4) Single 10 (17.2) Divorced/separated 1 (1.7) Widowed 3 (5.2) Unknown 2 (3.4) Education, y Occupation Employed full-time 18 (31.0) Employed part-time 2 (3.4) Unemployed 10 (17.2) Retired 26 (44.8) Unknown 2 (3.4) 1304 Self-Esteem and Psychological Distress in Head and Neck Cancer HEAD & NECK DOI /hed October 2008

3 Table 2. Description of sample (n 5 58). Variable Frequency % Disease/treatment variables Stage I II III IV No classification T classification x Site Oral cavity Sinus Parotid Pharynx Larynx Thyroid Ear Other Diagnose Newly diagnosed Recurrence % of the sample, mean length of education was 13.1 years, and 72.4% of the participants were married. The tumor sites included the pharynx (43.1%), oral cavity (13.8%), larynx (12.1%), thyroid (12.1%), and ear (8.6%). Of patients whose disease could be staged (10.3% were Tx), 37.9% had T3 or T4 disease. Fifteen patients had disease with stage III (25.9%) and 25 patients had disease with stage IV (43.1%). Thirty-eight patients (65.5%) were newly diagnosed with head and neck cancer and 20 patients (34.5%) were diagnosed with recurrent cancer. Method and Questionnaires Rosenberg Self-Esteem Scale. Self-esteem was measured with the Japanese version of the Rosenberg self-esteem (RSE) scale, a widely used, reliable and valid measure. 20 The RSE measures the overall sense of being capable and feeling worthwhile, and competent. The questionnaire consists of 10 items, measured on a 5-point scale. The maximum score of 50 reflects the best possible self-esteem whereas the minimal score of 10 reflects the least possible self-esteem. The questionnaire was completed by the participants time 1 and time 3. Hospital Anxiety and Depression Scale. The hospital anxiety and depression scale (HADS) is a selfrating type questionnaire with 14 items which measures anxiety (HADS-A) and depression (HADS-D). 21 The Japanese version of HADS was back-translated by Kitamura, 22 and the reliability and the validity of the Japanese version of HADS was confirmed by Kugaya et al. 23 Each item used a 4-point scale, and the possible scores ranged from 0 to 21 for anxiety and 0 to 21 for depression 24 ; the higher the score, the higher the level of symptoms. The cut-off points for HADS were 8 or 11 points. A score of 8 points meant suspected depression and a score 11 points or higher indicated depression. 25,26 The questionnaire was administered time 1, time 2, and time 3. Statistical Analyses. Data were analyzed using the Statistical Package for the Social Sciences, version 15.0 (SPSS, Cary, NC). We compiled descriptive statistics on psychological distress, selfesteem, and clinical and demographic measures. Then, participants were divided into a higherscore group (n 5 38; scores were higher than average for all participants) and a lower-score group (n 5 20; scores were lower than average) by their preoperative RSE. We selected this cutoff because there was no cutoff for the original Japanese version of the RSE for the cancer population, and the scores were distributed binomially at the border of the average. Two factor repeated-measures analysis of variance (ANOVA) between group factors with post hoc comparisons (Scheffe F test; 95% significance) was conducted to determine whether the psychological state and postoperative self-esteem depended on the participants preoperative self-esteem. For additional evaluation, chi-square tests and t tests were conducted to see differences for all of the variables between the 2 groups. For disease sites, 3 categories, (1) larynx, (2) pharynx, and (3) oral and all others, were created to examine the differences between the 2 groups. Also, for disease stages, stages I and II were categorized into an early-stage group, and stages III and IV were categorized into an advanced-stage group. For employment, a category of employment and a category of all others was evaluated to identify the differences between the 2 groups. RESULTS Two-way ANOVA with repeated measures was used to examine whether the course of psychological distress (anxiety/depression) changed between the Self-Esteem and Psychological Distress in Head and Neck Cancer HEAD & NECK DOI /hed October

4 Table 3. Variables in the low and high self-esteem groups (n 5 58). Variable LSEG (n 5 20) HSEG (n 5 38) p value Sex Male Female 3 10 Age, y Marital status Married All other 5 11 Disease stage Early Advanced Employment Employed All other Education, y Disease site Larynx Pharynx All other 5 21 Diagnosis First time Recurrence 7 13 Time 1 Depression <.0001 Time 1 Anxiety Time 1 Self-esteem <.0001 Time 2 Depression <.0001 Time 2 Anxiety <.0001 Time 3 Depression <.0001 Time 3 Anxiety <.0001 Time 3 Self-esteem <.0001 Abbreviations: LSEG, low self-esteem group; HSEG, high self-esteem group. Note: For depression and anxiety, the higher the score, the higher the level of symptoms; for self-esteem, the higher the score, the higher the level of self-esteem; for disease stage, 5 patients with no classification were excluded. higher self-esteem group (HSEG) and the lower self-esteem group (LSEG). The results are summarized in Table 3 and Figures 1 and 2. Comparison of anxiety between the 2 groups across the 3 examination periods showed significant differences (HADS-A: F , d.f. 5 1,2, p <.0001). The anxiety scores for the HSEG were significantly better than those for the LSEG at all examination periods (p <.0001). Comparison of depression between the 2 groups across the 3 time periods showed significant differences (HADS-D: F , d.f. 5 1,2, p <.0001). The depression scores for the HSEG were significantly better than those for the LSEG at all examination periods (p <.0001). Changes in HADS-A and HADS-D scores across the 3 time periods for the 2 groups were compared. There was a significant difference in both anxiety and depression scores taken at different periods (HADS-A: F , d.f. 5 1,2, FIGURE 1. Mean hospital anxiety and depression scale-anxiety (HADS-A) scores in the high self-esteem (HSEG) and low selfesteem (LSEG) groups. ^: high self-esteem group; n: low selfesteem group. A higher score indicates a higher level of symptoms. [Color figure can be viewed in the online issue, which is available at p <.0001; HADS-D: F , d.f. 5 1,2, p <.0001). For anxiety, the scores between time 1 and time 3, and time 2 and 3 were significantly different (p <.01). For depression, significant differences were found between time 1 and 2, time 1 and 3, and time 2 and 3 (p <.01). Furthermore, for depression, there was a significant interaction between the 2 factors. Whether the course of self-esteem scores changed between the HSEG and the LSEG was examined by 2-way ANOVA with repeated measures (Table 3). The scores of self-esteem in the HSEG were significantly higher than the LSEG for both time 1 and time 3 (F , d.f. 5 1,2, p <.0001). Furthermore, in the HSEG, the selfesteem scores at time 1 remained constant at Time 3. On the other hand, in the LSEG, the selfesteem score at time 1 significantly declined at Time 3 (p <.0001). We used chi-square tests and t tests to examine if other variables influenced patients FIGURE 2. Mean hospital anxiety and depression scaledepression (HADS-D) scores in the high self-esteem (HSEG) and low self-esteem (LSEG) groups. ^: high self-esteem group; n: low self-esteem group. A higher score indicates a higher level of symptoms. [Color figure can be viewed in the online issue, which is available at Self-Esteem and Psychological Distress in Head and Neck Cancer HEAD & NECK DOI /hed October 2008

5 self-esteem (Table 3). The variables were sex, age, marital status, disease stage, employment, education, disease sites, and diagnosis. There were no significant differences for these variables between the 2 groups except disease sites and employment. DISCUSSION This pilot study demonstrated how the participants preoperative self-esteem influences psychological distress during the course of treatment. Self-Esteem and Psychological Distress. Interestingly, the HSEG followed totally different paths from the LSEG. In fact, anxiety scores recovered steadily over time in the HSEG. The scores temporarily worsened after surgery and then improved 6 months postoperatively. Moreover, the HSEG showed lower anxiety levels than the LSEG at all examination periods. As for depression, the scores subsequently remained at lower levels over time in the HSEG whereas the scores went from bad to worse in the LSEG. It is noteworthy that the patients in the LSEG had clinical or borderline levels of depression immediately after surgery and 6 months postoperatively. The HSEG presented lower depression levels than the LSEG at all times. The presence of depressive symptoms contributes to a lower QOL, an increased risk for suicide, an increased psychological burden for the family, a lower compliance to cancer treatment and a lengthening of hospital stay. Therefore, it is extremely important to design interventions for patients who are confronted with depression A few studies have focused on self-esteem in patients with cancer. As explained in the beginning of this article, Katz et al 19 examined selfesteem for patients with cancer, and the study showed that self-esteem was lowered in 20% to 50% of the patients. This study supports our results, which show that scores of self-esteem at 6 months postoperatively were significantly lower than the preoperative self-esteem scores. Moreover, in the HSEG, the self-esteem scores subsequently remained at high levels over time. Conversely, the scores of self-esteem at 6 months postoperatively were significantly lower than the preoperative self-esteem score in the LSEG. Bertero 30 examined self-esteem and QOL and suggested that lowered self-esteem was recognized in 73.3% of patients with breast cancer. Also, lowered self-esteem was associated with psychosocial perspectives including negative affections, anger, hostility, absurdity, and low satisfaction with life. Tuinman et al 18 studied the predictive effects of self-esteem and social support on mental health in 3 groups of testicular cancer survivors. They concluded that self-esteem and mental health differed between single survivors of testicular cancer, survivors with a continuing relationship since diagnosis, and survivors who met their partner after treatment completion. The results showed that men who are single when they are diagnosed with testicular cancer and remain single are a vulnerable group in relation to selfesteem and mental health. The disease sites and employment were significantly different between HSEG and LSEG. As shown in Table 3, there are more patients with laryngeal cancer and other sites of cancer in the HSEG. The other site group has cancers such as ear cancer and oral cavity cancer, which are not very invasive in terms of treatment. By contrast, laryngeal cancers may get more invasive procedures than other sites of head and neck cancer. Because there were disease-site differences between the 2 groups, this factor may be contributing to the differences in the outcomes for the 2 groups. As with employment, the HSEG had more employed people than LSEG. A previous study explained that work status is known to have an impact on self-esteem. 31 Furthermore, selfesteem is shown to be associated positively with job satisfaction. 32 Therefore, employment may be contributing to the better outcomes for the HSEG than the LSEG. Because the sample size was small, it is difficult to discuss the influence of these variables on the patients self-esteem, and further investigation is necessary. There are no studies about the patients selfesteem as a factor to predict the course of psychological distress in cancer treatment. Patients who have high self-esteem tend to think positively about difficult situations, whereas patients who have low self-esteem tend to feel negatively. Moreover, patients with high self-esteem may assign greater value to themselves regardless of presence or absence of adversity. Moadel et al 33 indicated that the head and neck area plays a role in identity and self-expression, and so head and neck cancer can impose a direct challenge to a patient s sense of self. As the cancer and the treatment visibly alter aspects of the patient s head and face, self-image and selfesteem often suffer as well. 33 Psychotherapeutic measures should be designed to reduce stress, enhance coping with stress that cannot be Self-Esteem and Psychological Distress in Head and Neck Cancer HEAD & NECK DOI /hed October

6 reduced, and establish support systems to maximize adaptation. 33 Psychotherapy, medical crisis counseling, crisis intervention, family therapy, group therapy, cognitive behavioral therapy, or interpersonal therapy can be used to help the patient to express fears, anxieties, rage, helplessness, and hopelessness related to stressors. 34 This study had some limitations. We used a convenient sample, which limits the generalizability of the findings to other patients with head and neck cancer. In addition, a longitudinal study with a larger sample size would be useful to examine other related variables. Another limitation is that because the sample size was small, we were unable to control any covariates including demographics such as employment status, clinical characteristics including disease sites, and differences in treatment modalities. However, the influence of these covariates on psychological distress is worthy of additional research. Nevertheless, our results strongly highlighted the importance of patient s self-esteem as a determinant of psychological adjustment in head and neck cancer. CONCLUSIONS Our findings indicate that psychosocial assessment and support is necessary in the pretreatment period to prevent psychological distress of patients with head and neck cancer throughout and beyond the treatment. Generally speaking, anxiety prevention would be especially important in the pretreatment period, and prevention of depression is necessary in the posttreatment period. Our results indicate the participants preoperative self-esteem influences posttreatment anxiety and depression. Psychosocial intervention should start as early as possible and be individually designed with consideration of baseline selfesteem. Psychological distress in patients with head and neck cancer can be alleviated by effective and well-timed interventions. Acknowledgments. 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