gms | German Medical Science

GMS Psycho-Social-Medicine

Corporate journal of German scientific societies in psychosocial medicine

ISSN 1860-5214

Long-term course of psychiatric disorders in cancer patients: a pilot study

Langzeitverlauf psychischer Erkrankungen bei Krebspatienten: eine Pilotstudie

Research Article

GMS Psychosoc Med 2008;5:Doc03

The electronic version of this article is the complete one and can be found online at:

Published: April 17, 2008

© 2008 Bringmann et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Background: About one third of cancer patients suffer from a psychiatric disorder. However, only few studies feature long-term assessment of psychiatric disease in cancer patients, covering a broad range of diagnoses, and employing high-quality instruments.

Patients and methods: A total of 62 patients underwent assessments during a 3-year follow-up period after initial cancer diagnosis. The Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders was administered to measure psychiatric morbidity at baseline (t1) and two follow-ups (t2 and t3). Follow-up assessments took place from 6 to 18 months (t2) and from 24 to 36 months (t3) after baseline. Biomedical and psychosocial factors were evaluated to identify predictors of psychiatric disorders using univariate and multivariate analyses.

Results: At t1, at least one DSM-IV diagnosis was found in 29% of the cases. At follow-ups, the frequency of psychiatric morbidity increased to 36% at t2 and 44% at t3, respectively. New occurrence of psychiatric disease at follow-ups was 18% at t2, and 38%, at t3. Predictors of psychiatric disorders were low social support, low physical functioning, metastases, complications of disease, and loss of sportive activity.

Conclusion: Persistence and amount of newly diagnosed psychiatric disorders during three years after cancer treatment should be considered in the treatment of cancer patients, especially in individuals with accordant predictive factors.

Keywords: psychiatric morbidity, DSM-IV, cancer, clinical course, predictors


Hintergrund: Etwa ein Drittel aller Krebspatienten leidet unter einer psychischen Erkrankung. Dennoch gibt es bisher nur wenige Studien, die unter Einschluss eines breiten Diagnosespektrums die psychische Komorbität von Krebspatienten im Langzeitverlauf mit elaborierten Instrumenten erfassen.

Patienten und Methoden: Insgesamt 62 Patienten nahmen nach Krebsdiagnose am gesamten Verlauf der 3-jährigen Studie teil. Das Strukturierte Klinische Interview für DSM-IV wurde zur Erhebung psychischer Erkrankungen bei Aufnahme (t1) sowie zu zwei Nachfolgeuntersuchungen (t2 and t3) eingesetzt. Die Nachfolgeuntersuchungen fanden im Zeitraum von 6 bis 18 Monaten (t2) und 24 bis 36 Monaten (t3) nach der Aufnahmeuntersuchung statt. Biomedizinische und psychosoziale Einflussgrößen wurden ausgewertet, um Prädiktoren psychischer Erkrankungen mittels uni- und multivariater Analyse zu bestimmen.

Ergebnisse: Bei Aufnahme erhielten 29% der Patienten eine DSM-IV-Diagnose. Zu beiden Nachfolgeuntersuchungen zeigte sich ein Anstieg der Häufigkeit psychischer Erkrankungen mit 36% zu t2 und 44% zu t3. Ein Neuauftreten psychischer Erkrankungen zeigte sich bei beiden Nachfolgeuntersuchungen mit 18% zu t2 und 38% zu t3. Prädiktoren psychischer Erkrankung waren geringe soziale Unterstützung nach Krebstherapie, ein niedriges körperliches Funktionsniveau, Metastasen oder andere ernste Komplikationen sowie der Verlust sportlicher Aktivität.

Schlussfolgerung: Persistenz und Neuauftreten psychischer Krankheiten auch im späten zeitlichen Verlauf nach Krebsdiagnose sollten bei der Behandlung von Krebspatienten beachtet werden – insbesondere bei Vorhandensein von Risikofaktoren.

Schlüsselwörter: psychiatrische Erkrankung, DSM-IV, Krebs, Verlauf, Prädiktoren


Various reviews on psychological adjustment to a cancer diagnosis have demonstrated that about one third of cancer patients suffer from a psychiatric disorder [1], [2], [3], [4]. It has also been shown in particular studies that psychiatric morbidity in cancer patients may be negatively associated with the patients’ quality of life [5], [6], the duration of hospitalization [7], [8], the compliance with anti-cancer treatment [9], [10], mortality [11], and the risk of suicide [12].

Prevalences however, vary significantly depending on patient characteristics (e.g. type of cancer, stage of disease, age and sex) and methods of investigation (e.g. interview versus questionnaire). Structured interviews, based on current nosographic classifications as DSM-IV or ICD-10 are considered to be the 'gold standard' to register the criteria of a formal psychiatric diagnosis. Table 1 [Tab. 1] summarizes the results of recent studies that comply with this requirement. All of these studies are cross-sectional in design, displaying rates of mental disorders at a certain point of time since diagnosis or treatment. However, little is known about a longitudinal perspective on psychiatric symptoms. Available studies on clinical course commonly feature only short follow-up intervals (up to one year) [13], [14], [15], [16], [17] or findings were raised without using a structured interview for diagnosis [18], [19], [20], [21], [22], [23].

Yet the long-term course of psychiatric disorders in cancer patients could be vitally important for planning and reviewing psychosocial interventions: knowledge about course characteristics as progression, regression or frequent transitions between different disorders could influence the choice of interventions to be applied for addressing these problems.

To the best of our knowledge, there are only three studies that describe the course of psychiatric disorders in a prospective way during the period of at least one year, employing diagnostics based on structured interviews as mentioned above:

  • Uchitomi et al. assessed 212 non-small cell lung cancer (NSCLC) patients 1, 3, and 12 months after curative resection [24]. The prevalence of depression did not change significantly in the year after surgery (8%, 5% and 5% respectively). However, major depression decreased while minor depression stayed constant. Other disorders had not been taken into account in this report.
  • Akechi et al. investigated prevalence, predictors and change of adjustment disorders (AD), major depression (MD) and post-traumatic stress disorder (PTSD) in 85 terminally ill cancer patients [25]. At baseline, 16% of the patients showed symptoms of AD and 7% had symptoms of MD. PTSD had not been diagnosed. At follow-up, 11% were diagnosed with AD and 12% with MD. About 30% of all patients had changed in their initial diagnosis (including “none”), showing all possible transitions with an emphasis on changes from MD to AD. It may be criticized however, that time to follow-up had a wide range from 7 to 633 days and a median of only 58 days. Anxiety disorders (other than PTSD) have not been taken into account.
  • Burgess et al. evaluated prevalence and predictive factors of anxiety and depression in 170 patients with breast-cancer [26]. During a five-year period, these women were interviewed four times to cover the complete interval. Point prevalence of depression was 33% at diagnosis, 24% at three months and around 15% after 12 months and beyond. The one-year-prevalences dropped continuously from 48% in the first year to 15% in the fifth year. Unfortunately, the course of anxiety and depression had not been displayed separately in this study, as the course of anxiety levels is discussed controversially in literature with references to constant levels of anxiety even more than 12 months after cancer diagnosis [19], [21].

Associated or predictive factors of psychiatric disease include demographic [24], [26], psychosocial [18], [26] and biomedical variables [20], [27]. Psychosocial factors like social support, own children or psychiatric distress in patient's history were generally reported to have a higher impact on prediction of mental disorders in cancer patients than biomedical factors like cancer state, age or sex [18], [26]. Naturally, most of these factors have been found in relation to short term investigations and may not necessarily predict psychiatric disease several years after cancer treatment.

Summarizing, there is a lack of studies featuring long-term assessment of psychiatric disease in cancer patients, covering a broad range of diagnoses, and employing high-quality instruments.

Therefore, in our study, newly diagnosed cancer patients were followed for three years, assessing psychiatric morbidity with a structured interview based on a comprehensive range of DSM-IV diagnoses. Furthermore, factors predictive of psychiatric disease during three years after cancer diagnosis have been identified using reliable and valid instruments.

Patients and methods

Sample and design

The primary sample (n=689) was formed consecutively from individuals with a cancer diagnosis who had undergone inpatient treatment between June 2002 and July 2004 in a hospital affiliated to the University of Leipzig (visceral surgery, urology, radiotherapy and gynaecology) or the maternity clinic of the community hospital St. Georg (Leipzig). The eligibility criteria for patient recruitment in the study were: 1) age 18 years or older, 2) newly diagnosed cancer with curative therapy approach, 3) knowledge of cancer diagnosis, 4) being in acceptable physical and mental condition to complete the questionnaires and participate in an interview taking at least 45 minutes, and 5) having sufficient verbal communication skills in German language. Concerning criterion (4), eligibility was discussed by physicians and investigators on a case-by-case basis to avoid biased judgement and selection bias.

The study was approved by the local Ethics committee of the University of Leipzig and funded by The German Federal Ministry for Education and Research. Each patient was informed both verbally and in written form about the goals of the study, the voluntary nature of their participation and the confidentiality of information shared.

General demographic and clinical characteristics, including age, sex, tumour site, UICC state (Union Internationale Contre le Cancer) and type of therapy were obtained from patients' medical charts, whereas socio-demographic attributes as income, educational level, having a partner or family and religious and national affiliations were retrieved using an additional questionnaire. Then, psychological measurement using a semi-structured interview was arranged during the first three days after admission (baseline, t1).

As a result of economic limitations of the study, only n=100 patients living near the city centre of Leipzig could be included for follow-up examinations. They were selected by random, minimizing the distance of their domicile to the city centre. Thus, first follow-up examination (t2) was conducted 6 to 18 months after t1 on n=100 local residents of Leipzig and second follow-up (t3) was arranged 24 to 36 months after t1 with n=62 patients who participated both at t1 and t2. At both follow-ups a comprehensive evaluation of the patient's mental disorders had been carried out using a semi-structured interview. This interview was also used at t3 to investigate patients' history of psychiatric disorders, i.e. whether a mental disorder was present before diagnosis of cancer (lifetime). Additionally, certain aspects of quality of life (including physical functioning, pain and social well-being) were assessed using two questionnaires to gather information on potential correlations of psychiatric morbidity.

Information concerning death dates and current postal address was provided by the local census bureau. Participants were interviewed by a psychologist, interviews took place in hospital at baseline and at home during follow-up examinations.

Assessment instruments

Psychiatric morbidity

To cover a broad range of information about patients’ psychiatric disorders in a standardized way, the Structured Clinical Interview based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was administered to assess psychiatric morbidity. The variant used in the present investigation was the Structured Clinical Interview for DSM-IV, German Version [28], a translation and adaptation of the ‘Structured Clinical Interview for DSM-IV – Research Version (SCID-1, Version 2.0)’. The interview provides the diagnosis of affective disorders (including major depression and dysthymia), anxiety disorders (including panic disorder, social phobia, specific phobia, posttraumatic stress disorder and generalized anxiety disorder), stress disorders (including acute stress disorder and adjustment disorder), and screens for substance abuse (including pharmaceuticals, drugs, nicotine and alcohol). To constitute a diagnosis, certain criteria have to be met, including severity and duration of symptoms and their impact on everyday activities - taking into account that symptoms should not be direct physiological result of intoxication or general medical factors. The reliability of SCID has been reported to be satisfactory [29] and is commonly used for validation for other psychiatric diagnostic instruments [30], [31]. Cohen’s kappa was used to assess interrater reliability for 45 randomly selected interviews in this study. Interrater agreement for all current diagnoses was κ=0.95 (SD=0.12).

Demographic, biomedical and psychosocial attributes

To find potential factors associated with mental disorders, demographic (sex, age, social affiliation, marital status, number of children, nationality, membership of religious group), psychosocial and biomedical data (UICC stage, tumour localization, type of treatment, cancer recurrence, history of psychiatric treatment) were recorded in this study. While most of the biomedical and demographic data were registered during inpatient admission as described above, selected psychosocial characteristics were asked for at second follow-up, employing certain scales of two questionnaires: 1) The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), which is a questionnaire developed to assess the quality of life in cancer patients [32]. Its scales “physical functioning” and “pain” used in this investigation, take into account the physical ability to master daily-life activities and subjects’ impairment caused by pain, respectively. 2) The Functional Assessment of Cancer Therapy-General, which is the core module of the Functional Assessment of Chronic Illness Therapy-measurement system, a collection of Quality-of-Life questionnaires targeted to the management of chronic illness [33]. Its scale “Social/Family Well-Being” applied in this study, informs about the degree of social support and intimacy of relationships to other persons. Additionally, single item questions concerning patients' satisfaction with their job, their habitation, their financial situation, the extent of sportive activities and the importance of spirituality were asked.

Statistical analysis

Intergroup differences in categorical, nonparametric, and continuous variables were tested with the chi-square statistics (or Fisher's exact test if applicable), the Wilcoxon two-sample test, and the unpaired t test, respectively. Binary logistic regression analysis with forward and backward selection method was used to find the potential predictors of psychiatric morbidity after diagnosis of cancer. The model for logistic regression was tested for goodness of fit with the Hosmer and Lemeshow test. SPSS® 13.0 (SPSS Inc. Chicago, IL, USA) and G*Power® 2.0 (Faul, F. & Erdländer, E.) were used for data storage and analysis.


Sample characteristics

Of 689 patients who were interviewed during the first three days after admission (baseline), n=100 local residents of the City of Leipzig were selected (see sample and design for details) at first follow-up, which was conducted 5 to 18 months (mean 13 months) after baseline. At second follow-up (between 23 and 38 months after baseline, mean 28 months), 20 patients were excluded due to death (n=10) or insufficient physical or mental conditions (n=10). An additional 16 patients could not be contacted by mail or by telephone using updated address information from local census bureaus and 2 patients refused further participation for other reasons. Thus, the final study group consisted of 62 individuals with a complete data set of three assessments.

The mean age of participants was 59.5 years (SD=11.7, range = 34-84 years) and 66% were female. Table 2 [Tab. 2] shows the demographics for the sample. The participants were primarily German (92%), married or living with a partner (63%), having own children (79%), middle class (66%) and most were not members of a religious group (73%).

The medical characteristics are described in Table 3 [Tab. 3]. Individuals predominantly had stage II or III disease (61% of classified tumours) and were suffering from breast or urogenital cancer (66%). Most patients had undergone surgery (66%). In all mentioned biomedical and socio-demographic variables, the final sample did not differ significantly from the sample at first follow-up.

Prevalence of mental disorders

At baseline, at least one DSM-IV diagnosis was given in 29% of the cases. At both follow-ups, the frequency of psychiatric morbidity did increase (t2: 36%; t3: 44%). A detailed report of diagnoses is illustrated in Table 4 [Tab. 4]. Affective disorders remained constant over time (t1: 13%, t2: 13% and t3: 16%) but the prevalence of dysthymia increased (t1: 0%, t2: 6% and t3: 13%), whereas major depressive episodes occurred less frequently. Anxiety disorders advanced from initially 8% to 27% at both follow-ups. At t2, this class of disorders is predominated by posttraumatic stress disorder (8%), generalized anxiety disorder (10%) and panic disorder (10%). At t3, in contrast, social phobia (7%), specific phobia (10%) and generalized anxiety disorder (11%) played the major role. Stress disorders occurred only at baseline (12%) and second follow-up (8%). Considerable substance abuse was found throughout all points in time of investigation (t1: 15%, t2: 11% and t3: 13%).

Clinical course of psychiatric morbidity

In 18% of the cases, individuals not suffering from psychiatric morbidity at baseline, had a DSM-IV diagnosis at first follow-up. At second follow-up, 38% of the patients were newly diagnosed with mental illness. The rates of psychiatric disorders did not decrease during the three years after initial treatment of cancer (χ2=1.49, df=1, p=0.223, power=0.8 at an effect size=0.36. According to conventions for χ2-tests an effect size of 0.3 is regarded as medium). A history of psychiatric morbidity before the diagnosis of cancer was found in 26 (42%) individuals. During the whole period of investigation (up to 38 months after clinical assessment), a total of 39 persons (63%) were given a psychiatric diagnosis on at least one occasion. For 20 of these individuals (51%) this was the first occurrence of a psychiatric disease in lifetime. Individual changes of the patients' DSM-IV diagnoses are shown in Figure 1 [Fig. 1]. Affective disorders were found predominantly in patients with former affective disorder (5 of 8 subjects at t2), anxiety disorder (4 of 10 subjects at t3) or were newly diagnosed (4 of 10 subjects at t3). Of 17 individuals with an anxiety disorder at t2 (t3), 7 patients were suffering from a stress disorder (anxiety disorder). At both follow-ups another 7 patients with an anxiety disorder had no DSM-IV diagnosis at baseline or t1, respectively. All three patients with an acute stress disorder at second follow-up were suffering from newly diagnosed metastases (data not shown). Substance abuse was found predominantly in individuals with former substance abuse (5 of 7 subjects at t2) or former anxiety disorder (6 of 8 subjects at t3).

Predictive factors for psychiatric morbidity

During the period from baseline investigation to second follow-up, 39 patients (63%) were diagnosed with at least one DSM-IV diagnosis. In respect of demographic, biomedical and psychosocial attributes, there were several differences between patients with and without psychiatric morbidity. Variables at t3 which showed a p<0.1 in univariate analysis were used as covariates in a binary logistic regression analysis model to find the predictors of mental disorders during up to 38 months after diagnosis of cancer. By binary logistic regression analysis, the following four predictive variables could be found in both forward and backward selection (power of 0.8 at an effect size of 0.21): social support after cancer therapy (p=0.045) and good physical functioning regarding daily activities (p=0.067) were negatively correlated with psychiatric morbidity, whereas metastases or other severe complications of treatment (p=0.004) and loss of sportive activity (p=0.065) were positively correlated (Table 5 [Tab. 5]). This configuration had a Nagelkerke R2 of 0.526 in forward selection and a non-significant Hosmer-Lemeshow chi square indicating reasonable model fit (χ2=11.52, df=8, p=0.989).


The present investigation has the character of a pilot study which prospectively assesses a broad range of psychiatric diagnoses in a population of patients with cancer during a 3-year period after initial treatment and analyses predictive factors of psychiatric morbidity during this period. It was designed to retrieve data concerning a long-term clinical course using standardized diagnostic criteria with reliable and valid instruments that might be useful for future research.

Our finding showed that the rates of psychiatric disorders did not decrease during the three years after initial treatment of cancer. While the rate of psychiatric morbidity at t1 is in line with results of other studies, our findings of the follow-ups have to be discussed in more detail. In our study, prevalence of anxiety disorders increased from 8% at baseline to 27% at first follow-up and stayed constant in second follow-up. In contrast, Burgess et al. [26] found a significant decrease of depression and anxiety during the second and third year after diagnosis of breast cancer. However, a shortened version of SCID, focusing on symptoms of depression and anxiety, had been used in Burgess’ investigation and it remains unclear if dysthymia and different kinds of anxiety disorders were taken into account. Other studies reported a constant level of anxiety over time [19], [20], [21], but did not use semi-structured clinical interviews for investigation.

Another important point concerning anxiety disorders is that they were likely to arise later than one year after diagnosis of cancer: 41% of patients with an anxiety disorder at t2 or t3 had no DSM-IV diagnosis at baseline or t2, respectively (7 out of 17 in each case). A considerable part of late onsets has also been found for affective disorders and stress disorders at second follow-up, the latter being associated with the occurrence of metastases or severe complications of treatment. The de novo manifestation of psychiatric disorders at t2 and t3 shows the importance of observing psychological distress in cancer patients over years, even if they did not receive a DSM-IV diagnosis at the time of cancer occurrence.

Affective disorders remained constant over time. However, the prevalence of dysthymia increased, whereas major depressive episodes occurred less frequently. This finding is compatible with other studies [19], [24]: the severity of depressive symptoms decreases and gives way for milder, but chronic dysthymia. Noticeable, however, are rates of adjustment disorders below 5% found in this study, compared to reported rates of up to 28% [34]. This might have one of the following reasons: 1) in investigations using a limited range of diagnoses, adjustment disorders could have been used as a container diagnosis, e.g. cases that could have been diagnosed as acute stress reaction or minor depression were diagnosed as adjustment disorder with anxiety or depressed mood, respectively. 2) Adjustment disorders are clinically significant as evidenced by either “distress that is in excess of what would be expected from exposure to the stressor” or “significant impairment in social, occupational or educational functioning”, two assertions that leave a considerable range of interpretation [17].

Predictors of psychiatric morbidity during a 3-year period after cancer diagnosis were a lack of social support, occurrence of metastases or other severe complications, insufficient physical function in daily life activities and loss of sportive activity after cancer treatment. Except for the occurrence of metastases, these predictors are in line with the assertion made in the introduction, that psychosocial factors have a higher impact on prediction of mental disorders in cancer patients than biomedical factors. However, patients with recurrence have been described in the literature as experiencing a sharp increase in levels of anxiety and depression [26].

Our study has several limitations. First of all, since the sample size of individuals participating in the first follow-up had to be reduced seriously due to economic limitations of the study (n=100, 15 % of initial sample size n=689) and a drop-out of 38% was recorded at t3 (n=62, 9% of initial sample size), generalizing the results in detail may not be possible. On the other hand, our sample differed only in sex (more females) and cancer localisation (more breast cancer) from the sample of all cancer patients assessed during the period of investigation (n=689). Although the role of sex differences is discussed controversially, a review article [35] and our own findings found no sex differences in prevalence of psychiatric morbidity in cancer patients. Second, the selection of urban inhabitants at first follow-up (which was also due to economic limitations) might have led to a bias against rural populations. Third, the time span of each follow-up assessment is large (12 months), which impairs the comparability within the sample. At a given time gap of at least 6 months between follow-ups, grouping of the patients still seemed justifiable, though. Furthermore, the need of treatment of specific phobia and social phobia is discussed controversially and may put into perspective the considerable increase of these disorders at both follow-ups. However, at least social phobia in the context of impaired function and altered appearance after treatment (e.g. head and neck surgery) is a well-known indication for psychological intervention. Even specific phobia, such as agoraphobia, may have essential consequences for tomography and other techniques where the patient has to lay quietly in a narrow tube for quite a long period of time. Finally, conducting a regression analysis with a sample size of 62 may be of low significance. In our example, the analysis had a power of 0.8 at an effect size of 0.21 (according to conventions for regression analyses an effect size of 0.15 is regarded as medium).

Notwithstanding these limitations, it may be summarized that both, noticeable persistence and amount of newly diagnosed psychiatric disorders during three years after cancer treatment should be considered in the treatment of cancer patients, especially in individuals with positive predictive factors. As a matter of course, small sample size and high drop-out rate constitute the preliminary character of this study. Yet it could be shown, that psychiatric disorders may prevail or arise even years after cancer diagnosis. To learn more about the temporal patterns of psychiatric disorders in cancer patients, and to efficiently provide professional psychological support, more well-designed long-term studies with larger numbers of participants are desirable.


Conflicts of interest

None declared.


The authors are grateful to the patients who gave their time so willingly and to the physicians of the collaborating hospitals for enrolling their patients into the study. They also thank Sylke Claus, Matthias Kauschke, Heike Slesazeck, Andrea Klein and Cathleen Rösner for their research assistance. The project was partly financed with a grant from the German Federal Ministry for Education and Research (#01ZZ0106).


Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;57-71.
Kua J. The prevalence of psychological and psychiatric sequelae of cancer in the elderly - how much do we know? Ann Acad Med Singapore. 2005;34:250-6.
Pirl WF, Mello J. Psychological complications of prostate cancer. Oncology (Huntingt). 2002;16:1448-53.
Somerset W, Stout SC, Miller AH, Musselman D. Breast cancer and depression. Oncology (Huntingt). 2004;18:1021-34.
Mystakidou K, Tsilika E, Parpa E, Katsouda E, Galanos A, Vlahos L. Assessment of anxiety and depression in advanced cancer patients and their relationship with quality of life. Qual Life Res. 2005;14:1825-33.
Grassi L, Indelli M, Marzola M, Maestri A, Santini A, Piva E, Boccalon M. Depressive symptoms and quality of life in home-care-assisted cancer patients. J Pain Symptom Manage. 1996;12:300-7.
Prieto JM, Blanch J, Atala J, Carreras E, Rovira M, Cirera E, Gastó C. Psychiatric morbidity and impact on hospital length of stay among hematologic cancer patients receiving stem-cell transplantation. J Clin Oncol. 2002;20:1907-17.
Saravay SM, Lavin M. Psychiatric comorbidity and length of stay in the general hospital. A critical review of outcome studies. Psychosomatics. 1994;35:233-52.
Keller M, Sommerfeldt S, Fischer C, Knight L, Riesbeck M, Löwe B, Herfarth C, Lehnert T. Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach. Ann Oncol. 2004;15:1243-9.
DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101-7.
Onitilo AA, Nietert PJ, Egede LE. Effect of depression on all-cause mortality in adults with cancer and differential effects by cancer site. Gen Hosp Psychiatry. 2006;28:396-402.
Henriksson MM, Isometsä ET, Hietanen PS, Aro HM, Lönnqvist JK. Mental disorders in cancer suicides. J Affect Disord. 1995;36:11-20.
Bisson JI, Chubb HL, Bennett S, Mason M, Jones D, Kynaston H. The prevalence and predictors of psychological distress in patients with early localized prostate cancer. BJU Int. 2002;90:56-61.
Lam WWT, Fielding R, Ho EYY. Predicting psychological morbidity in Chinese women after surgery for breast carcinoma. Cancer. 2005;103:637-46.
Heszen-Niejodek I, Gottschalk LA, Januszek M. Anxiety and hope during the course of three different medical illnesses: a longitudinal study. Psychother Psychosom. 1999;68:304-12.
Akechi T, Okamura H, Nishiwaki Y, Uchitomi Y. Psychiatric disorders and associated and predictive factors in patients with unresectable nonsmall cell lung carcinoma: a longitudinal study. Cancer. 2001;92:2609-22.
Mehnert A, Koch U. Prevalence of acute and post-traumatic stress disorder and comorbid mental disorders in breast cancer patients during primary cancer care: a prospective study. Psychooncology. 2007;16:181-8.
Akechi T, Okuyama T, Akizuki N, Azuma H, Sagawa R, Furukawa TA, Uchitomi Y. Course of psychological distress and its predictors in advanced non-small cell lung cancer patients. Psychooncology. 2006;15:463-73.
Schou I, Ekeberg ü, Ruland CM, Sandvik L, Kåresen R. Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology. 2004;13:309-20.
Matsushita T, Matsushima E, Maruyama M. Anxiety and depression of patients with digestive cancer. Psychiatry Clin Neurosci. 2005;59:576-83.
Hack TF, Degner LF. Coping responses following breast cancer diagnosis predict psychological adjustment three years later. Psychooncology. 2004;13:235-47.
Maunsell E, Drolet M, Brisson J, Robert J, Deschênes L. Dietary change after breast cancer: extent, predictors, and relation with psychological distress. J Clin Oncol. 2002;20:1017-25.
Bleiker EM, Pouwer F, Ploeg HM, Leer JW, Adèr HJ. Psychological distress two years after diagnosis of breast cancer: frequency and prediction. Patient Educ Couns. 2000;40:209-17.
Uchitomi Y, Mikami I, Nagai K, Nishiwaki Y, Akechi T, Okamura H. Depression and psychological distress in patients during the year after curative resection of non-small-cell lung cancer. J Clin Oncol. 2003;21:69-77.
Akechi T, Okuyama T, Sugawara Y, Nakano T, Shima Y, Uchitomi Y. Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol. 2004;22:1957-65.
Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ. 2005;330:702.
Atesci FC, Ouzhanolu NK, Baltalarli B, Karada F, Ozdel O, Karagöz N. [Psychiatric disorders in cancer patients and associated factors]. Turk Psikiyatri Derg. 2003;14:145-52.
Wittchen HU, Zaudig M, Fydrich T. SKID. Strukturiertes Klinisches Interview für DSM-IV. Hogrefe; 1997.
Segal DL, Hersen M, Hasselt VBV. Reliability of the Structured Clinical Interview for DSM-III-R: an evaluative review. Compr Psychiatry. 1994;35:316-27.
Steiner JL, Tebes JK, Sledge WH, Walker ML. A comparison of the structured clinical interview for DSM-III-R and clinical diagnoses. J Nerv Ment Dis. 1995;183:365-9.
Shear MK, Greeno C, Kang J, Ludewig D, Frank E, Swartz HA, Hanekamp M. Diagnosis of nonpsychotic patients in community clinics. Am J Psychiatry. 2000;157:581-7.
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, Haes JC. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85:365-76.
Webster K, Cella D, Yost K. The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System: properties, applications, and interpretation. Health Qual Life Outcomes. 2003;1:79.
Grassi L, Sabato S, Rossi E, Biancosino B, Marmai L. Use of the diagnostic criteria for psychosomatic research in oncology. Psychother Psychosom. 2005;74:100-7.
DeFlorio M, Massi MJ. Review of depression in cancer: gender differences. Depression. 1995;3:66-80.
Singer S, Herrmann E, Welzel C, Klemm E, Heim M, Schwarz R. Comorbid mental disorders in laryngectomees. Onkologie. 2005;28:631-6.
Atesci FC, Baltalarli B, Oguzhanoglu NK, Karadag F, Ozdel O, Karagoz N. Psychiatric morbidity among cancer patients and awareness of illness. Support Care Cancer. 2004;12:161-7.
Dausch BM, Compas BE, Beckjord E, Luecken L, Anderson-Hanley C, Sherman M, Grossman C. Rates and Correlates of DSM-IV Diagnoses in Women Newly Diagnosed with Breast Cancer. J Clin Psy Med. 2004;11:159-69.
Hosaka T, Awazu H, Fukunishi I, Okuyama T, Wogan J. Disclosure of true diagnosis in Japanese cancer patients. Gen Hosp Psychiatry. 1999;21:209-13.