DEPRESSION IN CANCER PATIENTS DURING COVID-19 PANDEMIC

Otroshchenko Petr1, Otroshchenko Natalia2, Otroshchenko Iryna3 1 Doctor of the municipal non-profit enterprise «Clinical Hospital» PSYCHIATRIA « 2 Candidate of Medical Sciences, Associate Professor of the Department of Psychiatry and Narcology of the Bogomolets National Medical University 3 Doctor of the Department of Clinical Radiation Oncology with Brachytherapy Unit at the National Cancer Institute


Objective.
To increase the level of medical aid to patients with depression with post-cancer syndrome in cervical cancer and uterine cancer utilizing development of programs of diagnostics and treatment of depression during COVID-19 pandemic in the mentioned patients.
Materials and methods. The study covered 62 women aged 24-65, 23 (37.1%) with cervical cancer, and 39 (62.9%) uterine cancer women of the I, II, and III stages who applied for medical care after the oncological diagnosis was made.
Prior to the use of radial therapy (RT), 32 women in the main group with depressed cervical cancer 10 (31.3 %) and uterine cancer 22 (68.8 %) had laboratory-confirmed coronavirus disease during the 2019-2021 pandemic. In 30 control women, 7 (23.3%) individuals were diagnosed with cervical cancer depression and 23 (76.7 %) with uterine cancer before the start of the pandemic, during the remainder of 2018. The patients were examined by an oncogynecologist, infectious disease specialist, mammologist, urologist, proctologist, internist, joint surgeon, endocrinologist, neurologist, psychiatrist, and prognostic therapist using clinical, clinical-psychopathological, pathopsychological (using diagnostic criteria of ICD-10, Hamilton scale (НАМ-D), Spielberger-Наnіn scale and Schmischek's methods, 10word recall test, Schulte table, corrective test), clinical and statistical methods, laboratory investigations, including results of PCR test, Determination of M and G immunoglobulins, based on the Clinical Radiation Oncology Department of the National Cancer Institute, the Department of Psychiatry and Narcology of the Bogomolets National Medical University, Kyiv non-profit company «Clinical Hospital «PSYCHIATRY», other laboratory-diagnostic institutions of Kyiv. The criteria for selecting patients for the diagnostic and treatment program was the formation of depressive disorders of the non-psychotic level after the establishment of the oncological diagnosis and COVID-19. Patients were divided into therapeutic groups that underwent diagnostic and treatment programs with biological and social therapeutic components, according to the variant of depression, with the use of psychopharmacotherapy and psychotherapy. The follow-up was conducted from 2 months to 2 years. The study was conducted according to the principles of the Declaration of Helsinki. Statistical analysis was carried out using Excel for Windows and IBM SPSS Statistics using parametric and nonparametric statistical methods. The normality of the distribution of quantitative indicators was estimated using the Kolmogorov-Smirnov criterion. Quantitative parameters with a distribution law different from the normal one were represented as Median Me and Median Abbreviation m (patients' age). To estimate the significance of differences depending on the influence of the risk factor in the diagnosed variants of depression, we used Xi-square criterion, Xi-square criterion with Yates correction, Fisher's exact criterion, φ criterion, Cramer's V criterion, Chuprov's K criterion, Pearson's conjugacy coefficient (C), and the normative value of Pearson's coefficient (C ').
Results. The mean age of the patients in the main group was 47.8 ± 1.57 years old. Up to 30 years old -1 (3.1%) observation, 31 to 40 years old -7 (21, 9%), 41 to 50 years old -10 (31.3%) cases, 51 to 60 years old -11 (34.4%) cases, over 60 years old -3 (9.4%) cases. Depression (F43.1;F43.20;F43.22;F43.28) with the prevalence of astheno-depressive and anxiety-depressive disorders was found in the patients, more rarely depressed with hypochondriacal, obsessive-phobic symptoms. These illnesses were defined by non-psychotic nosogenic depression due to the establishment of oncological diagnosis (ICD-10: C53, C54), and experienced COVID-19 of high, moderate, and mild degree. Mental status is characterized by hypotymia with weakness, fatigue, exhaustion, anxiety, anxiety, anxiety, hypochondria, phobias, obsessions, sleep disturbances, lack of appetite, headaches, oppression of emotions, and hopelessness due to inability to fight the effects of the disease independently. In the ideational sphere, there are ideas of own impossibility, ineffectiveness, and pessimistic perception of perspective that are connected with the nosogenic influence. At the same time, the depressive reaction does not meet the criteria of depressive epizootic due to the indirect connection with the facts of cancer diagnosis and infection with coronavirus infection, the presence of psychogenic (nosogenic) disorder in the clinical picture, as well as the absence of vital disorders. Thus, the main group consisted most often of the asthenic (n=17; 53,1%) and anxiety-inducing (n=9; 28,1%) depressions, followed by hypochondriacal (n=4; 12,5%), obsessive-phobic (n=2; 6,3%) variants. The asthenic variant of depression was characterized by low mood, weakness, increased mental and physical fatigue, exhaustion, dragging, emotional lability, decreased memory, unsteadiness of attention, headaches, sleep disturbances, vegetative disorders. In the case of anxiety type of depression, anxiety with psychic and somatic manifestations, indifference, hopelessness, cognitive disorders, vegetative disorders came to the foreground. The hypochondriacal variant of depression was characterized by increased respect for one's health status, diligent adherence to the examination and treatment regimen, indiscriminate requests for additional examinations and consultations, distrust of formal medicine, giving preference to unconventional and paramedical methods. In the obsessive-phobic variant, a mood of depression was combined with disturbing thoughts, fears, actions, and rituals. Patients understood the insensitivity of these disorders, which occurred behind their will, tried to fight them, but could not confront them. Variants of depression in the examined patients differed in certain clinical and paraclinical features, which determined the algorithm of diagnostics, differential diagnosis, differentiated approaches to treatment programs, prevention, and medical and social rehabilitation. For these patients, treatment programs were developed and conducted with psychopharmacotherapy, which consisted of antidepressants, anxiolytics, mood stabilizers, nootropics, multivitamins, and other drugs. At the same time, psychotherapy was conducted to reduce and eliminate depressive, asthenic, hypochondriacal, obsessive-phobic disorders, actively form positive life attitudes, and mobilize the patients' reserve capacities. At this stage, rational psychotherapy with elements of suggestion, relaxation techniques, and auto-training prevailed. Phytotherapy, homeopathic drugs, probiotics, enzyme preparations, reflexology, and therapeutic physical training were also recognized. Thirty control women of the same age group had non-psychotic psychogenic depression (F43.1, F43.20, F43.22, F43. 28) in C53 and C54 stages I, II, and III, the anxiety-depression variant (n = 13; 43.3%) prevailed, whereas the asthenic (n = 8; 26.7%), hypochondriacal (n = 5; 16.7%) and obsessive-phobic (n = 4; 13.3%) variants were diagnosed more rarely. The occurrence of these disorders was associated with the psychologically traumatic influence of information about the cancer diagnosis, fears of recurrence and the occurrence of metastases, the need for prolonged RT and its adverse effects, intermittent illness, pain syndrome, and lethal consequences. Main group patients had an average Hamilton depression score of 21.6; Spielberger-Наnіn scale, elevated situational anxiety, had an average score of 46; in a memory test of 10 words, patients retained an average of 6 words; 19 (59.4%) of the patients tested with Schulte Tables and Correctional Tests had impaired sensorimotor activity, tempo, visibility, most of them of the hyposthenic type, and decreased active attention functions; the Shmіshek method indicated that 18 (56.3%) patients had normal features, 6 (18.8%) exhibited mild accentuations, 5 (15.6%) exhibited manifest personality disharmony, and 3 (9.4%) exhibited psychopathic disharmony. All the patients were confirmed to have a high prevalence of depressive and asthenic symptoms and maladaptive behavior. The control group had an average Hamilton Depression Scale score of 19.4; Spielberger-Наnіn Scale, mean anxiety score of 47; and a 10-word recall test, in which the patients averaged 7 words; 17 (56.7%) of the patients tested were normal features, 8 (26.7%) had minor accentuations, 3 (10%) had noticeable personal- ity disharmony, and 2 (6.7%) had psychopathic features. Almost half of the patients were confirmed by the presence of depression and anxiety symptoms (43.3%), maladaptive behavior. In the control group of depressed patients with cervical cancer and uterine cancer, examined before the beginning of the pandemic, there was a higher incidence of depression and anxiety disorders (p < 0.05). Astheno-depressive, depressive-hypochondriacally and obsessive-phobic disorders occur less frequently. Thus, after the established oncological diagnosis and COVID-19 in patients with depression Таб. 3. Criteria for assessing the significance of the differences depending on the influence of the risk factor* in the hypochondriacal variant of depression with post-cancer symptoms in cervical cancer and uterine cancer of the main group, Compared to the control group of depressed patients with cervical cancer and uterine cancer (Table 1), examined before the beginning of the pandemic, astheno-depressive disorders prevail (p < 0,05). There are also anxiety-depressive, depressive-hypochondriacally and obsessive-phobic disorders ( Table 2, 3, 4).

Discussion.
Patients who underwent COVID-19 underwent clinical and psychopathological, pathopsychological, and laboratory examinations that revealed corresponding changes in mental, psychological, and somato-neurological state. In particular, mental health and well-being (McCracken L.M., et al., 2020) is impaired: asthenic, emotional, anxious, hypochondriacally, anankastic, cognitive (Woo M.S., et al., 2020) disorders, sleep disorders. These findings can be explained by the effects of pandemic stress (Kujawa A, et al., 2020;Al Omari O, et al., 2020), the presence of other predictors of depression, anxiety, and stress (Al Omari O, et al, 2020), pathophysiological aspects of the effects of SARS-CoV-2 infection on the brain, both acute and long term (Kumar S., et al., 2021), post-stress factors affecting a significant proportion of COVID-19 survivors (Einvik G., et al., 2021). Distress in patients with cancer is associated with the establishment of the diagnosis of oncological disease (Arnaboldy P., et al., 2016). Our study differs in material, methods, goals, and other parameters. At the same time, the conclusions with the confirmation of the hypothesis about the consequences for mental, psychological, neurological, and somatic health of COVID-19 in cancer patients, about the commonality of cooperation of medical organizations with different institutions, use of psychological and psychiatric support and development of appropriate programs to improve the mental health of patients, in line with our findings. According to our research, cervical cancer and uterine cancer patients who overdosed on COVID-19 developed polietiological non-psychotic nosogenic depression with an excess of astheno-depressive disorders, More rare are anxiety-depressive, depressive-hypochondriacally, obsessive-phobic disorders that complicate somatic state, prognosis, and treatment of oncologic disease. For a complete reduction or reduction of the intensity of depressive disorders in these patients at all stages, it is necessary to carry out comprehensive diagnostic and treatment measures that include medical and social-psychological warehouses. Currently recognizing and treating depression with modern antidepressants, mood stabilizers, anxiolytics, nootropics, neurotropic medications, phototherapy, enzyme drugs, Probiotics in conjunction with psychotherapy, reflexology, contributed to achieving a qualitative remedy, increasing resistance to psychological trauma and infectious factors, and improving the quality of life of the patients. The use of such programs should be done on a case-by-case basis, taking into account clinical manifestations of depressive disorders, before conducting RT. The occurrence of these disorders in patients with cervical cancer and uterine cancer is caused by psychotraumatic influence of oncological diagnosis, suffered COVID-19, the need for suspending and preparing for RT, fear of the adverse effects of radiotherapy, pain syndrome, and perceptions of the fatal end of the disease. To increase the efficiency of medical, psychological, and psychiatric aid to patients with cervical cancer and uterine cancer, it is necessary to involve psychiatrists and psychotherapists in their examination and treatment, Include in the training programs of physicians involved in the provision of medical care, knowledge about the use of modern psychopharmacotherapeutic and psychotherapeutic approaches in practice. It is necessary to create on a national level medical measures for protection against coronavirus disease in oncologic patients, including patients who have had cancer, diseases, and diseases that cause disruption of the immune system (Tian, Y., et al., 2021).
Thus, the hypothesis that depression in cervical cancer and uterine cancer patients who had coronavirus disease during the pandemic occurs predominantly in the asthenic (p<0.05), as well as in the anxious, hypochondriacally, and obsessive-phobic variants is confirmed. The above requires the development and implementation of diagnostic and treatment programs that are carried out taking into account the clinical manifestations of depression and prevent it from becoming chronic, complications, the emergence of suicidal behavior, contribute to the reduction of these disorders, increase the level of medical, psychological and psychiatric care for these patients. This article does not provide data on the correlation between the clinical picture and the course of depression, the degree of severity of coronary heart disease, the stage of oncologic disease. Therefore, in the future, we plan to analyze in patients the dependence of the depth and clinical manifestations of depression on the stage of cervical cancer and uterine cancer and the degree of importance of the COVID-19. It would also be interesting to conduct a comparative characterization of the efficacy of the suggested treatment and rehabilitation programs in patients with depression with post-current symptoms and those with the mentioned disorders who are enrolled in traditional programs of diagnosis, treatment, and rehabilitation.
Conclusions. Depression in cervical and uteri cancer patients who had coronavirus disease during the pandemic occurs in the asthenic, anxious, hypochondriacal, and obsessive-phobic variants, but the asthenic variant is dominant (p<0.05). The proposed diagnostic and treatment programs are carried out taking into account clinical manifestations of depression and prevent it from becoming chronic, complications, the emergence of suicidal behavior, contribute to the reduction of these disorders, and raise the level of medical and psychiatric care for these patients.
Conflict of Interest. Conflicts of Interest of any kind concerning commercial, financial, and authorial relations; relations with organizations or persons who in any way can be connected with the research; interactions of the authors of this article P.O. Otroshchenko, N.P. Otroshchenko, I.P. Otroshchenko «DEPRESSION IN PATIENTS WITH CANCER DURING THE PANDEMIC OF COVID-19», are absent.
Funding. This study was not funded. Information about the contribution of each author.
Dr. Otroshchenko N.P., Associate Professor of Psychiatry and Narcology of the Bogomolets National Medical University, Candidate of Medical Sciences -concept and design of the study, collection and processing of material, clinical examinations, analysis of the obtained data, text writing, formulation of conclusions.
Dr. Otroshchenko I.P., physician at the Clinical Radiation Oncology Department with the Brachytherapy Unit at the National Cancer Institute -clinical and instrumental examinations, collection and processing of patient data, analysis of the data, text writing.
Dr. Otroshchenko P. O., physician of the Kyiv non-profit organization «Clinical Hospital «PSY-CHLATRY» -collection and treatment of the material, clinical examinations, analysis of the obtained data, writing the text.