Review Article - (2018) Volume 8, Issue 4

Trajectories and Predictors of Post-Treatment Depression in Patients with Head and Neck Cancer

Corresponding Author:
Yasunori Adachi
Department of Palliative Care, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo 446-8602, Japan
Tel: +81-566-75-2111
Fax: +81-566-75-4335


Head and neck cancer (HNC) is considered one of the most traumatic and distressing types of cancer and is often associated with high rates of depression and suicide. Depression has a negative effect on HNC treatment outcomes, such as quality of life and mortality. However, depression is frequently underdiagnosed and consequently undertreated. Therefore, it is important to understand the trajectories of HNC-associated depression to be able to predict which patients will develop post-treatment depression. This article reviews the literature on the prevalence and trajectories of depressive symptoms and identifies predictors of post-treatment depression in patients with HNC. Many studies have reported persistent depressive symptoms after treatment. The level of pretreatment depressive symptoms could be a useful predictor of the level of pretreatment depression, although the findings of the studies reviewed here are inconsistent.


Head and neck cancer, Depression, Prediction of post-treatment depression


Head and neck cancer (HNC) is an epithelial malignancy of the upper aerodigestive tract, which includes the oral cavity, paranasal cavity, pharynx, and larynx. HNC is estimated to account for nearly one million incident cases of cancer and approximately 400,000 deaths annually and is the seventh most frequently diagnosed cancer worldwide [1,2]. HNC is considered one of the most traumatic types of cancer. HNC can be particularly distressing because it may affect patients’ communication and functioning, and surgical treatment may cause severe facial disfigurement. Because the emotional burden of HNC can be exhausting, it is often associated with a high suicide rate and high prevalence of depression [3,4]. Misono et al. reported that, of patients with cancer, those with cancer of the oral cavity and pharynx, and those with cancer of the larynx, show the third and fourth highest suicide risks, respectively [5].

Depression has a negative effect on cancer treatment outcomes, and can substantially compromise quality of life, length of hospital stay, ability to care for oneself, and survival time, and can lead to complications with therapy [6]. Compared with cancer patients who are not depressed, those who are depressed are less likely to participate in treatment decisions and to seek out social support and are more likely to experience decline in physical function during treatment, to drop out of treatment, and to have shorter survival times. A meta-analysis conducted by Satin et al. presented reasonable evidence that depression predicts mortality in mixed cancer patients [7]. Barber et al. systematically reviewed the relationship between depression and survival in HNC patients, and reported that two of three studies demonstrated a statistically significant difference in survival for depressed HNC patients compared with non-depressed HNC patients [8].

Although the risk of depression is high in HNC patients, depression is frequently underdiagnosed and subsequently undertreated [6]. Therefore, it is important to understand the trajectories of depression in HNC patients and to predict which patients will develop post-treatment depression.

Trajectories of Depression

The prevalence of depression has been estimated as 15–50% in patients with HNC [3,9]. Inconsistent estimates might be a result of the inclusion of studies of varying methodological quality. As recent systematic reviews and meta-analyses have revealed, the prevalence of depression among patients with HNC may be lower than previously assumed if a rigorous and explicit definition of major depressive disorder diagnosis is applied [10,11]. A recent population-based study showed that 10.6% of HNC patients had been diagnosed with depression prior to HNC diagnosis and an additional 8.9% developed depression in the year following diagnosis [12].

Hemmerlid et al. examined changes in Hospital Anxiety and Depression Scale (HADS) scores before and after treatment in 357 HNC patients. The percentages of patients scoring 8 or more on the depression subscale were 36%, 34%, 30%, and 26%, respectively, at the following time points: at diagnosis, and at 3, 6, and 12 months after treatment [9]. We also investigated the time course of depressive symptoms and reported that the percentages of patients with a HADS total score of 15 or more were 21.6%, 30.6%, 20.3%, and 30.8%, respectively, at baseline, and at the 3rd, 6th, and 12th postoperative month [13]. Karnell et al. investigated percentages of HNC patients with persistently high scores (above the cut-off) on the Beck Depression Inventory for 6 months or more during their first post-treatment year. They found that 25.0% of patients persistently scored above 10 or more (possible depression) and 7.4% of patients persistently scored 18 or more (probable depression) [14]. Although many other studies of patients with HNC have found persistent depressive symptoms after treatment, Neilson et al. showed that the prevalence of probable cases of depression increased from baseline (15%) to 3 weeks after radiotherapy (29%) and decreased at 18-month follow-up (8%), and depression scores significantly increased from baseline to 3 weeks post-treatment and decreased at 18-month follow-up [15].

Predictors of Depression

Studies have been conducted to identify predictors of depression in patients with various type of cancer, including lung, breast, and colorectal, gastrointestinal, and mixed cancers. A systematic review by Cook et al. found no consistent evidence that demographic, clinical, or social factors reliably predict longer-term distress [16]. They concluded that baseline distress and neuroticism predicted longer-term distress in cancer patients.

We previously reported the results of a prospective study to identify predictors of postoperative levels of depression in patients with HNC who had undergone surgery [13]. Our results were similar to those of Cook et al. in that the baseline level of depression predicted depression levels at follow-up. We found that the preoperative depression level was a significant predictor of the postoperative depression level at the 3rd, 6th, and 12th postoperative months. Furthermore, at the 6th postoperative month, negative adjustment to cancer at baseline was also a significant predictor of postoperative depression levels. De Graeff et al. found that pretreatment depressive symptoms can be used to predict post-treatment depression and those they accounted for 18–32% of posttreatment scores on the Center for Epidemiologic Studies Depression scale [17]. Karnell et al. also identified pretreatment depressive symptoms as the strongest predictor of persistent posttreatment depressive symptoms [14]. Similarly, Hammerlid reported that the only predictor of developing psychiatric morbidity at 12 months post-diagnosis was probable and/or possible anxiety or depression at diagnosis in 357 HNC patients [9].

In contrast to the above-mentioned results, several studies have reported that the baseline level of depression did not predict the level of depression at follow-up. Aastrad et al. concluded that sense of humor, but not depression levels at diagnosis, predicted depression levels at followup [18]. Neilson et al. reported that the severity of physical symptoms associated with HNC tumors and treatment was the only significant predictor of depression scores, although they did not include the baseline depression score as an independent variable [15].

Approach to Depression

The American Society of Clinical Oncology has recommended the following algorithmic approach to screening and treatment initiation for depression in cancer patients [19,20]. Symptoms of depression and anxiety should be routinely evaluated using validated measures, such as the nine-item Personal Health Questionnaire, at periods throughout the care trajectory. Different treatment pathways are recommended according to symptom levels. A detailed psychiatric interview is conducted to identify pertinent history and risk factors of depression. Then, tailored treatment strategies are used according to the severity of depression, from nurse-led psychosocial interventions to referral for psychiatric assessment and initiation of pharmacologic treatment or psychotherapy. However, one recent review did not support the effectiveness of psychosocial interventions for patients with HNC [21].


Recent studies show that post-treatment depressive symptoms can be persistent in patients with HNC. Levels of pretreatment depressive symptoms may be useful in predicting which patients will experience high levels of depressive symptoms after treatment. However, previous research findings are inconsistent because of methodological differences. Therefore, it is necessary that the search method, criteria of inclusion and exclusion, quality of observational studies and qualitative assessment of each article are undertaken. Furthermore, future research efforts will need to use more sophisticated longitudinal designs and statistical methodology.

Competing Interests

The authors declared that they had no competing interests.


This work was supported by a Health Labor Science Research Grant [H23-seishin-ippan-003] from the Japanese Ministry of Health, Labor and Welfare and a Grant-in-Aid for Science Research [245911703, 16K10249] from the Japanese Ministry of Education, Culture, Sports, Science and Technology. All authors have no conflict of interest to report.