Psycho-Oncology

Psycho-Oncology (2016)
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.4073

Does knowledge of diagnosis really affect rates of depression

in cancer patients?
Éva Kállay1, Sebastian Pintea1 and Csaba L. Dégi2*
1
Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania
2
Faculty of Sociology and Social Work, Babes-Bolyai University, Cluj-Napoca, Romania
*Correspondence to: Abstract
Faculty of Sociology and Social
Work, Babes-Bolyai University, Significant levels of distress usually accompany the entire cancer experience, affecting the patients’
B-dul 21 Dec. 28, Cluj-Napoca general functioning and adaptation to illness.
400604, Romania. E-mail: Objective: The major objective of the present study was to investigate potential demographic and
csabadegi@gmail.com intrapersonal moderators of the relationship between knowing the cancer diagnosis and the level of
depression experienced.
Method: The present research has a transversal comparative repeated cross-sectional design (2006–2014),
sampling following the proportional quota method. Research was conducted in the four major oncological
institutes in Romania, obtaining a national sample of cancer patients, maintaining gender and ethnic rates,
and permitting the investigation of the stability of the results from one assessment to the other.
Results: Results indicate that in the Romanian context, knowing the diagnosis is associated with a
lower level of depression than not knowing the diagnosis, the results being similar in both assessments
(2006–2014). Furthermore, from the explored demographic factors (gender, residence, age, and
education), only age has a main effect upon depression (depression increasing with age), while educa-
tion is the only factor from those analyzed, which has a moderator effect. Regarding the analyzed
intra-individual variables, only dysfunctional attitudes, emotion-focused coping, and lack of emotional
support from the family (loneliness) have main effects upon the level of depression (i.e., higher levels of
dysfunctional attitudes, emotion-focused coping, and loneliness are associated with higher levels of
depression), while neither of them has a moderator effect on the relationship between knowing the
diagnosis and depression.
Received: 3 September 2015 Conclusion: These results are important in the improvement of the doctor–patient relationship, the
Revised: 14 December 2015 management of cancer-related distress, and implicitly for the course of illness.
Accepted: 15 December 2015 Copyright © 2016 John Wiley & Sons, Ltd.

Worldwide, over one-quarter of deaths are attributable to care [1]. Considering the negative effects of cancer-
different forms of oncological diseases, and the next related emotional distress [10], the salience of the timely
decade is expected to record an over 50% increase in assessment and management of emotional complications
cancer-related illnesses [1]. These results become extremely have been repeatedly underscored [11]. Thus, the inves-
relevant from two points of view: (i) the diagnosis and treat- tigation of factors affecting the cancer patients’ psycho-
ment of cancer affect all levels of the patients’ functioning logical functioning and their interaction becomes
[2,3], and (ii) because of improvements in detection and critical [12].
treatment methods, more than two-thirds of the adult cancer One of the subtlest turning points in the cancer experience
patients may be expected to survive more than 5 years [4]. is the communication of the diagnosis. The direct communi-
Thus, the number of patients who will have to receive med- cation of the diagnosis, prognosis, treatment, and their psy-
ical and psychosocial care will also considerably increase. chosocial implications are strongly related to the emotional
Patients diagnosed with cancer present significantly distress experienced by the patient [2,13] – those who know
more mental health problems than the healthy population their diagnosis gradually experience lower distress [14,15].
[5,6]. Cancer-related emotional distress may have a signif- Since 2003, the communication of the tumoral diagnosis is
icant impact on the course of illness via poorer pain compulsory in Romania. Nevertheless, a considerable
control, lower levels of compliance to treatment, and de- number of physicians are still reluctant to directly inform
creased involvement in different forms of therapy [7–9]. the patient, continuing to communicate with his or her
The psychosocial adaptation to the diagnosis, treatment, family [16].
and changed life conditions depends not only on the abilities Besides knowing or not the diagnosis, demographic and
of the patients’ to adjust to illness, social and emotional sup- intrapersonal factors significantly contribute to the depres-
port, and so on but also on the medical and psychosocial sion experienced by cancer patients [17,18]. Age, gender,

Copyright © 2016 John Wiley & Sons, Ltd.

 É. Kállay et al.

and education contribute to the unfolding of depressive the four major oncological institutes in Romania (Bucharest,
symptomatology [19]. Cluj-Napoca, Iasi, and Oradea), obtaining a national sample
Intrapersonal variables as functional/dysfunctional atti- of cancer patients, maintaining gender and ethnic rates. This
tudes and coping strategies also influence the levels of kind of design offers us the possibility to replicate the results
depression [20]. Dysfunctional attitudes usually reflect from one sample to the other, which permits the investigation
negative maladaptive cognitive biases, where the impor- of the stability of the results from one assessment to the other
tance of negatively valenced information is exaggerated (2006–2014).
[21]. Emotion-focused and problem-focused coping strat-
egies are actions and thoughts individuals refer to in Participants
highly stressful conditions [22]. Emotion-focused coping
A sample of 798 oncology patients was screened in 2014
is directed towards managing emotional distress associ-
and 416 in 2006. The mean age of the 2014 sample was
ated with the stressor, while problem-focused coping aims
56.38 years (min = 18 and max = 82 years, standard devia-
to solve/alter the source of the stress and its implications.
tion (SD) = 10.82), 337 male and 461 female patients. The
Most stressors elicit both types of coping strategies, the
mean age of the 2006 sample was 51.95 years (min = 17
use of each type depending on the major characteristics
and max = 89 years, SD = 14.24), 179 male and 237 female
of the event [23]. Furthermore, different forms of social
participants, with different cancer localizations. All
support also have a significant role in the unfolding of
patients were assessed after agreeing to participate in the
highly stressful encounters (e.g., cancer) [24]. Most of
study, by researchers certified in protecting human
the social support is available within a caring family,
research participants, by The National Institutes of Health
who could appease the experienced distress, help rebuild
Office of Extramural Research.
a healthy self-image, and motivate the patient to strive
towards recovery [25]. Those patients who do not obtain
Measures
such assistance may become lonely and less involved in
recovery [26]. Demographic variables are age, gender, and level of
Taking into consideration the intricate relationship be- education.
tween demographic, intrapersonal variables, cancer-related Depression was measured with the Beck Depression In-
distress, and knowing/not knowing the diagnosis, it is ventory (BDI) [29]. The BDI is a 21-item, multiple-choice
extremely important to investigate not only if knowledge format inventory, measuring the presence of depression in
of the diagnostic significantly lowers the emotional distress adults and adolescents. Each of the 21 items assesses a
but also the degree to which this relationship is moderated symptom or attitude specific to depression, inquiring its
by demographic and intrapersonal variables. In other words, somatic, cognitive, and behavioral aspects, occurring in
it is important to investigate if it is always better to know the the last week (Cronbach’s α = .90).
diagnostic and which are those patients who would benefit Emotional support was measured with the Social and
most of this knowledge. This information has crucial impor- Emotional Loneliness Scale for Adults (SELSA) [30]. The
tance in the improvement of the doctor–patient relationship, SELSA is a 37-item, multidimensional measure of loneli-
for the management of the emotional consequences of ness, assessing romantic, family, and social loneliness. In
cancer-related distress and implicitly for the course of illness. this study, we used the 10-item family loneliness subscale,
items being rated on a 7-point Likert scale (1 – strongly
Study disagree to 7 – strongly agree). High scores obtained on
SELSA indicate high levels of family-related emotional
Objective loneliness (Cronbach’s α = .87–.90 [31]).
The major objective of the present study is to investigate Dysfunctional attitudes were assessed with Dysfunctional
potential demographic and intrapersonal (coping strategies, Attitudes Scale [32], a self-report inventory designed to
dysfunctional attitudes, and emotional support) moderators measure attitudes that can prone a person to depression
of the relationship between knowing the cancer diagnosis [29]. Participants rate items on a 7-point Likert scale, ranging
and the level of depression experienced. from totally agree (1) to totally disagree (7). Higher scores in-
dicate greater levels of negative beliefs (Cronbach’s α = .74).
In this study, we used the shortened, 8-item version of the
Methods
original scale.
APSCO – Assessment of Psycho-Social and Communication Problem-focused and emotion-focused copings were
needs in Oncology – is the first extensive questionnaire-based assessed with the Ways of Coping Questionnaire [22],
multicenter study in Romania on psychosocial aspects of measuring a wide array of thoughts and acts people use
cancer. The present research has a transversal comparative to deal with stressful encounters. The items of the 22-item
repeated cross-sectional design [27], sampling following the variant of the Ways of Coping Questionnaire may be
proportional quota method [28]. Research was conducted in grouped in two major factors: emotion-focused and

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology (2016)

DOI: 10.1002/pon
Demographic and psychosocial moderators of diagnosis and depression

problem-focused copings. Items are rated on a 4-point β = 0.10, t(758) = 2.77, p < .01 for knowing the diag-
Likert scale (0 = does not apply and/or not used; 3 = used nosis and, β = 0.08, t(758) = 2.22, p < .05 for age. In the
a great deal) (Cronbach’s α = .72–.73). second step, the interaction factor between knowing the
diagnosis and age was entered. It did not significantly
Results add to the amount of variance in the criterion accounted
for, R2change = .002, Fchange(1, 757) = 1.19, p > .05,
The analysis of social and demographic factors
β = 0.21, t(758) = 1.09, p > .05. This result confirms
Firstly, we investigated the moderator effect of gender on that age does not moderate the relationship between
the relationship between knowing the diagnosis with can- knowing the diagnosis and the level of depression, mean-
cer and depression. ing that knowing the diagnosis is related to a lower level
The two-way independent analysis of variance performed of depression irrespective of age.
on the data from 2006 demonstrated that the main effect of Next, we investigated the moderator effect of education
knowing the diagnosis was significant, F(1, 409) = 15.77, on the relationship between knowing the cancer diagnostic
p < .001, partial η2 = .037, while the main effect of gender and depression.
was not significant, F(1, 409) = 0.61, p > .05, partial The two-way independent analysis of variance performed
η2 = .002. The interaction between knowing the diagnosis on the data from 2006 demonstrated that the main effect of
and gender was not significant, F(1, 409) = 0.01, p > .05, knowing the diagnosis was significant, F(1, 409) = 14.85,
partial η2 = .001. p < .001, partial η2 = .035, while the main effect of educa-
The same type of analysis performed on the data from tion was not significant, F(2, 409) = 0.62, p > .05, partial
2014 proved that the main effect of knowing the diagnosis η2 = .003. The interaction between knowing the diagnosis
was significant, F(1, 762) = 9.94, p < .01, partial η2 = .013. and education was not significant, F(2, 409) = 1.47,
The main effect of gender was not significant, F(1, 762) p > .05, partial η2 = .007. Even if the interaction effect is
= 1.88, p > .05, partial η2 = .002. The interaction between not significant, the graphical representation of the effects
knowing the diagnosis and gender was not significant, shows a slight tendency of knowing the diagnosis to make
F(1, 762) = 0.81, p > .05, partial η2 = .001. a greater difference in the level of depression, as the level
Results indicate that knowing the diagnosis is associ- of education increases (Figure 1).
ated with a lower level of depression than not knowing The same type of analysis performed on the data from
the diagnosis, irrespective of the patients’ gender. The 2014 proved that the main effect of knowing the diagnosis
reliability of this result is proved by its stability in both was significant, F(1, 762) = 12.70, p < .001, partial
samples (2006–2014). η2 = .017. The main effect of education was not signifi-
We also investigated the moderator effect of age on the cant, F(1, 762) = 0.27, p > .05, partial η2 = .001. The inter-
relationship between knowing the diagnosis and depression. action between knowing the diagnosis and education was
Thus, a hierarchical multiple regression analysis was con- this time significant, F(1, 762) = 4.40, p < .001, partial
ducted for both 2006 and 2014 data. On the 2006 sample, η2 = .011. The graphical representation of the effects con-
in the first step, two variables were introduced in the model: firms the tendency of knowing the diagnosis to make a
age and knowing the diagnosis (coded as a dummy variable greater difference in the level of depression, as the level
with 1 = diagnosis known and 0 = diagnosis unknown). In of education increases (Figure 2).
the 2006 sample, these variables accounted for a significant Knowing the diagnosis has a greater influence in reduc-
amount of variance in the BDI scores, R2 = .065, F(2, 405) ing depression as the level of education increases, while
= 14.01, p < .001, where both knowing the diagnosis and
age were significant predictors, with β = 0.16, t(403)
= 3.41, p < .01 for knowing the diagnosis and, β = 0.17, 30.00
t(403) = 3.50, p < .01 for age. In the second step, the in- 28.00
Education categories
teraction factor between knowing the diagnosis and age Lower than high school
Depression meanscore

26.00 High school

was entered. It did not significantly add to the amount Higher education
of variance in the criterion accounted for, 24.00
R2change = .003, Fchange(1, 402) = 1.18, p > .05, 22.00
β = 0.18, t(402) = 1.08, p > .05. This result suggests that
20.00
age does not moderate the relationship between knowing
the diagnosis and the level of depression. 18.00
The same analysis was replicated on the 2014 data. In 16.00
the first step, knowing the diagnosis and age accounted
Diagnosis not known Diagnosis known
for a significant amount of variance in the BDI scores,
R2 = .019, F(2, 758) = 7.20, p < .001, where both knowing Figure 1. The relationship between knowledge of the diagnostic
the diagnosis and age were significant predictors, with and depression as a function of education (2006)

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology (2016)

DOI: 10.1002/pon
 É. Kállay et al.

Education categories
30.00 Lower than high school regression. The analysis conducted for the 2006 sample
High school proved that the knowledge of diagnosis and dysfunctional at-
Higher education
titudes accounted for a significant amount of variance in the
Depression mean score

25.00
BDI scores, R2 = .068, F(2, 403) = 14.69, p < .001, where
both knowing the diagnosis and dysfunctional attitudes were
20.00 significant predictors, with β = 0.19, t(403) = 4.12,
p < .001 for knowing the diagnosis and β = 0.16, t(403) = 3.46,
p < .01 for dysfunctional attitudes. The interaction factor
15.00 between knowing the diagnosis and dysfunctional attitudes did
not significantly add to the amount of variance in the criterion
accounted for, R2change = .001, Fchange(1, 402) = 0.58,
Diagnosis not known Diagnosis known
p > .05, β = 0.13, t(402) = .76, p> .05. Dysfunctional attitudes
Figure 2. The relationship between knowledge of the diagnostic do not moderate the relationship between knowing the diagnosis
and depression as a function of education (2014) and the level of depression.
The same analysis performed on the 2014 data confirmed
for the patients with a level of education lower than high the results. Knowing the diagnosis and dysfunctional attitudes
school, the level of depression is the same irrespective of accounted for a significant amount of variance in the BDI
knowing or not the diagnosis. scores, R2 = .050, F(2, 760) = 20.17, p < .001, where both
knowing the diagnosis and dysfunctional attitudes were sig-
nificant predictors, with β = 0.10, t(758) = 3.00, p < .01
The analysis of psychological factors
for knowing the diagnosis and β = 0.19, t(758) = 5.57,
The social support perceived from the family (loneliness) p < .001 for dysfunctional attitudes. The interaction factor be-
was also tested as potential moderator of the relationship be- tween knowing the diagnosis and dysfunctional attitudes did
tween knowing the diagnosis and level of depression. For not significantly add to the amount of variance in the criterion
the 2006 data, the hierarchical regression analysis proved accounted for, R2change < 0.001, Fchange(1, 759) = .01,
in the first step that knowing the diagnosis and loneliness p > .05, β = 0.05, t(758) = 0.031, p > .05. Dysfunctional atti-
accounted for a significant amount of variance in the BDI tudes do not moderate the relationship between knowing the
scores, R2 = .084, F(2, 402) = 18.52, p < .001, where both diagnosis and the level of depression, which means that
knowing the diagnosis and loneliness were significant pre- knowing the diagnosis is related to a lower level of depression
dictors, with β = 0.18, t(402) = 3.77, p < .001 for know- irrespective of dysfunctional attitudes.
ing the diagnosis and β = 0.21, t(402) = 4.49, p < .001 for Another psychological factor tested as a potential mod-
loneliness. In the second step, the interaction factor between erator was the problem-focused coping style. Analysis on
knowing the diagnosis and loneliness was entered. It did not the 2006 data showed that the knowledge of diagnosis
significantly add to the amount of variance in the criterion and problem-focused coping accounted for a significant
accounted for, R2change = .002, Fchange(1, 401) = 0.92, amount of variance in the BDI scores, R2 = .045, F(2,
p > .05, β = 0.13, t(401) = 0.961, p > .05. This result sug- 404) = 9.53, p < .001, where knowing the diagnosis was
gests that loneliness does not moderate the relationship be- a significant predictor, β = 0.20, t(404) = 4.17,
tween knowing the diagnosis and the level of depression. p < .001, and problem-focused coping was not a signifi-
The data from the 2014 sample confirmed these results. cant predictor, β = 0.09, t(403) = 1.90, p > .05. The inter-
Thus, the first step of the analysis demonstrated that action factor did not significantly add to the amount of
knowing the diagnosis and loneliness accounted for a sig- variance in the criterion accounted for, R2change = .01,
nificant amount of variance in the BDI scores, R2 = .090, Fchange(1, 403) = 0.18, p > .05, β = 0.06, t(402) = 0.42,
F(2, 760) = 37.41, p < .001, where both knowing the diag- p > .05. Thus, problem-focused coping styles do not
nosis and loneliness were significant predictors, with moderate the relationship between knowing the diagnosis
β = 0.09, t(760) = 2.85, p < .01 for knowing the diag- and the level of depression.
nosis and β = 0.27, t(760) = 8.06, p < .001 for loneliness. The analysis performed on the 2014 data confirmed
In the second step, the interaction factor between knowing these results. Knowing the diagnosis and problem-
the diagnosis and loneliness was entered. It did not signif- focused coping accounted for a significant amount of var-
icantly add to the amount of variance in the criterion iance in the BDI scores, R2 = .016, F(2, 760) = 6.22,
accounted for, R2change = .002, Fchange(1, 759) = 2.08, p < .01. Knowing the diagnosis was a significant predic-
p > .05, β = 0.18, t(401) = 1.44, p > .05. In this case, lone- tor, β = 0.09, t(758) = 2.63, p < .01, while problem-
liness does not moderate the relationship between know- focused coping proved not to be a significant predictor,
ing the diagnosis and the level of depression. β = 0.06, t(758) = 1.85, p > .05. The interaction factor
Dysfunctional attitudes of the patients were the next did not significantly add to the amount of variance in the
potential moderator tested with the hierarchical multiple criterion accounted for, R2change = 0.002, Fchange(1,

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology (2016)

DOI: 10.1002/pon
Demographic and psychosocial moderators of diagnosis and depression

759) = 1.33, p > .05, β = 0.19, t(758) = 1.15, p > .05. specific to the last decade, which facilitates even more
This result confirms that the problem-focused coping the access to information (quadrupled from 2007 to
style does not moderate the relationship between knowing 2014) [32].
the diagnosis and the level of depression. From the analyzed intra-individual variables, only dys-
Another potential moderator tested was the emotion- functional attitudes, emotion-focused coping, and lack of
focused coping style. Data from 2006 showed that knowl- emotional support from the family (loneliness) have main ef-
edge of diagnosis and emotion-focused coping accounted fects upon the level of depression (positive relationship,
for a significant amount of variance in the BDI scores, meaning that higher levels of dysfunctional attitudes,
R2 = .19, F(2, 404) = 49.91, p < .001. Knowing the diagno- emotion-focused coping, and loneliness are associated with
sis and emotion-focused coping were both significant higher levels of depression), while neither of them has a
predictors, with β = 0.19, t(404) = 4.38, p < .001 for moderator effect on the relationship between knowing the
knowledge of diagnosis and β = 0.39, t(403) = 8.92, diagnosis and depression. These results indicate that dys-
p < .001 for emotion-focused coping. The interaction factor functional attitudes generally bias the perceived information
did not significantly add to the amount of variance in the crite- in a negative, maladaptive direction. Moreover, those pa-
rion accounted for, R2change = .002, Fchange(1, 403) = 1.10, tients who tend to reside excessively on emotion-focused
p > .05, β = 0.15, t(402) = 1.05, p > .05. This result suggests coping strategies, while eluding the use of problem solving
that the emotion-focused coping style do not moderate the strategies, experience significantly higher levels of depres-
relationship between knowing the diagnosis and the level of sion. The lack of emotional support that is expected to be
depression. offered by the core of the social net (the family) may further
The 2014 results confirmed this conclusion. Knowing aggravate the levels of experienced depression.
the diagnosis and emotion-focused coping accounted for a
significant amount of variance in the BDI scores, Study limitations
R2 = .073, F(2, 760) = 30.00, p < .01. Both knowing the
diagnosis and emotion-focused coping were significant pre- Because of the study design, no causal relationship between
dictors, with β = 0.11, t(758) = 3.33, p < .001 for knowl- investigated variables can be established. Additionally,
edge of diagnosis and β = 0.36, t(758) = 3.07, p < .01 for caution is needed in generalizing results to all cancer
emotion-focused coping. The interaction factor did not sig- patients in Romania because the influence of other factors,
nificantly add to the amount of variance in the criterion such as access to health and mental health services, may
accounted for, R2change = 0.001, Fchange(1, 759) = 1.07, modify the extent of significant associations that were not
p > .05, β = 0.16, t(758) = 1.03, p > .05. This result assessed in this study.
confirms that the emotion-focused coping style does not
moderate the relationship between knowing the diagnosis Clinical implications
and the level of depression, which means that knowing
An extremely relevant aspect of the cancer experience is
the diagnosis is related to a lower level of depression
represented by the communication of the diagnosis and
irrespective of the emotion-focused coping.
its implications. Even if in Romania, it has become a com-
Conclusions pulsory procedure since 2003 [33], some of the physicians
are often reluctant to communicate directly with the pa-
The first major finding of this study is that in the Romanian tient, delegating the responsibility to the patients’ families.
context, knowing the diagnosis is associated with a vlower Besides the way the diagnosis is communicated (empathy,
level of depression than not knowing the diagnosis, the re- understanding, and caring on behalf of the curing doctor
sults being similar in both assessments (2006–2014). being essential), it is also extremely important to know
Our second major finding is that from the explored de- as exactly as possible which categories of patients would
mographic factors (gender, age, and education), only age benefit most of this information. Without reducing the im-
has a main effect upon depression, while education has a portance of the subjective, individualized nature of the
moderator effect. In other words, as the level of educa- way each cancer patient reacts to the diagnosis, the results
tion increases, patients benefit emotionally more from obtained in this study could facilitate the improvement of
knowing the diagnosis. These findings may suggest that the doctor–patient relationship, for the management of the
through education, individuals acquire a larger number emotional consequences of cancer-related distress and im-
of mechanisms that can mitigate the negative affect of plicitly for the course of illness.
the cancer experience. While this effect was only a ten-
dency in 2006, it became a pregnant effect in the 2014 Acknowledgements
sample. This accentuation of the initial tendency into sta- This work was supported by a grant from the Romanian National
ble effect (from 2006 to 2014) might be attributable to Authority for Scientific Research, CNCS – UEFISCDI, project
the dramatic development of information technology number PN-II-RU-TE-2012-3-0011.

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology (2016)

DOI: 10.1002/pon
 É. Kállay et al.

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DOI: 10.1002/pon