Depression in cancer patients: a critical review

Massimo Pasquini, Massimo Biondi, Massimo Pasquini, Massimo Biondi

Abstract

Cancer patients experience several stressors and emotional upheavals. Fear of death, interruption of life plans, changes in body image and self-esteem, changes in social role and lifestyle are all important issues to be faced. Moreover, Depressive Disorders may impact the course of the disease and compliance. The cost and prevalence, the impairment caused, and the diagnostic and therapeutic uncertainty surrounding depressive symptoms among cancer patients make these conditions a priority for research. In this article we discuss recent data, focusing on detection of Depressive Disorders, biological correlates, treatments and unmet needs of depressed cancer patients.

References

    1. US Mortality Public Use Data Tape 2001, National Center for Health Statistics, Centers for Disease Control and Prevention. 2003.
    1. WHO International Consortium in Psychiatric Epidemiology. Cross-national comparisons of prevalences and correlates of mental disorders. Bulletin of World Health Organization. 2000;78:413–26.
    1. Üstün TB. The global Burden of mental health disorders. American Journal of Public Health. 1999;89:1315–1318.
    1. Grassi L, Rosti G. Psychiatric and psychosocial concomitants of abnormal illness behaviour in patients with cancer. Psychother Psychosom. 1999;65:246–252.
    1. Sharpe M, Strong V, Allen K, Rush R, Postma K, Tulloh A, Maguire P, House A, Ramirez A, Cull A. Major depression in outpatients attending a regional cancer centre: screening and unmet treatment needs. Br J Cancer. 2004;90(2):314–20. doi: 10.1038/sj.bjc.6601578.
    1. Prieto JM, Atala J, Blanch J, Carreras E, Rovira M, Cirera E, Espinal A, Gasto C. Role of Depression as a predictor of mortality among cancer patients after stem-cell transplantation. J Clin Oncol. 2005;23:6063–6071. doi: 10.1200/JCO.2005.05.751.
    1. Coyne JC, Palmer SC, Shapiro PJ, Thompson R, De ichele A. Distress, psychiatric morbidity, and prescriptions for psychotropic medication in breast cancer waiting room sample. Gen Hosp Psychiatry. 2004;26:121–128. doi: 10.1016/j.genhosppsych.2003.08.012.
    1. Ell K, Sanchez K, Vourlekis B, Lee PJ, Dwight-Johnson M, Lagomasino I, Muderspach L, Russell C. Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol. 2005;23:3052–3060. doi: 10.1200/JCO.2005.08.041.
    1. Okamura M, Yamawaki S, Akechi T, Taniguchi K, Uchitomi Y. Psychiatric disorders following breast cancer recurrence: prevalence, associated factors and relationship to quality of life. Jpn J Clin Oncol. 2002;35(6):302–309. doi: 10.1093/jjco/hyi097.
    1. 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;330:702–707. doi: 10.1136/bmj.38343.670868.D3.
    1. Zabora J, Blanchard CG, Smith ED. Prevalence of psychological distress among cancer patients across the disease continuum. J Psychosoc Oncol. 1997;15:73–87. doi: 10.1300/J077V15N02_05.
    1. Kadan-Lottick NS, Vanderwerker LC, Block SD, Zhang B, Prigerson HG. Psychiatric disorders and mental health service use in patients with advanced cancer. Cancer. 2005;104(12):2872–81. doi: 10.1002/cncr.21532.
    1. Korfage IJ, Essink-Bot ML, Janssens AC, Schroder FH, de Koning HJ. Anxiety and depression after prostate cancer diagnosis and treatment: 5-year follow-up. Br J Cancer. 2006;94(8):1093–8. doi: 10.1038/sj.bjc.6603057.
    1. Bardwell WA, Natarajan L, Dimsdale JE, Rock CL, Mortimer JE, Hollenbach K, Pierce JP. Objective cancer-related variables are not associated with depressive symptoms in women treated for early-stage breast cancer. J Clin Oncol. 2006;24(16):2420–7. doi: 10.1200/JCO.2005.02.0081.
    1. Berard RMF. Depression and anxiety in oncology: The Psychiatrist's perspective. J Clin Psychiatry. 2001;62(8):58–61.
    1. Ashbury FD, Madlensky L, Raich P, Thompson M, Whitney G, Hotz K, Kralj B, Edell WS. Antidepressant prescribing in community cancer care. Support Care Cancer. 2003;11:278–285.
    1. Bailey RK, Geyen DJ, Scott-Gurnell K, Hipolito MMS, Bailey TA, Beal JM. Understanding and treating depression among cancer patients. Int J Gynecol Cancer. 2005;15:203–208. doi: 10.1111/j.1525-1438.2005.15204.x.
    1. Derogatis LR, Melisaraatos N. The Brief Symptom inventory (BSI): An introductory report. Psychol Med. 1983;13:595–606.
    1. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361–70.
    1. Radloff LS. The CES-D: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;3:385–401.
    1. Beck AT, Ward C. Reliability of psychiatric diagnoses. A study of clinical judgements and ratings. Am J Psychiatry. 1962;19:351–356.
    1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4. Washington DC: American Psychiatric Association; 1994.
    1. Raison C, Miller A. Depression in cancer: new developments regarding diagnosis and treatment. Biol Psychiatry. 2003;54:283–294. doi: 10.1016/S0006-3223(03)00413-X.
    1. Keller M, Sommerfeldt S, Fischer C, Knight L, Riesbeck M, Lowe B, Herfarth C, Lehnert T. Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach. Annals of Oncology. 2004;15:1243–1249. doi: 10.1093/annonc/mdh318.
    1. Costantini M, Musso M, Viterbori P, Bonci F, Del Mastro L, Garrone O, Venturini M, Morasso G. Detecting psychological distress in cancer patients: validity of the Italian version of the Hospital Anxiety and Depression Scale. Support Care Cancer. 1999;7:121–127. doi: 10.1007/s005200050241.
    1. Biondi M, Picardi A, Pasquini M, Gaetano P, Pancheri P. Dimensional psychopathology of depression: detection of an "activation" dimension in unipolar depressed oupatients. Journal of Affective Disorders. 2005;84:133–139. doi: 10.1016/S0165-0327(02)00103-9.
    1. Pasquini M, Picardi A, Biondi M, Gaetano P, Morosini P. Relevance of Anger and Irritability in Outpatients with Major Depressive Disorder. Psychopathology. 2004;37:155–160. doi: 10.1159/000079418.
    1. Feinstein AR. An additional science for clinical medicine. The development of clinimetrics. Ann Intern Med. 1983;99:843–848.
    1. Fava GA, Ruini C, Rafanelli C. Psychometric Theory Is an Obstacle to the Progress of Clinical Research. Psychother Psychosom. 2004;73:145–148. doi: 10.1159/000076451.
    1. Brennan J. Adjustment to cancer-coping or personal transition? Psycho-Oncology. 2001;10:1–18. doi: 10.1002/1099-1611(200101/02)10:1<1::AID-PON484>;2-T.
    1. Servaes P, Verhagen C, Bleijenberg G. Fatigue in cancer patients and after treatment: Prevalence, correlates and interventions. Eur J Cancer. 2002;38:27–43. doi: 10.1016/S0959-8049(01)00332-X.
    1. Portenoy RK, Itri LM. Cancer-related fatigue: guidelines for evaluation and management. Oncologist. 1999;4:1–10.
    1. Stone P, Richards M, A'Hern R, Hardy J. A study to investigate the prevalence, severity, and correlates of fatigue among patients with cancer in comparison with a control group of volunteers without cancer. Ann Oncol. 2000;11:561–567. doi: 10.1023/A:1008331230608.
    1. Morrow GR, Hickok JT, Roscoe JA, Raubertas RF, Andrews PL, Flynn PJ, Hynes HE, Banerjee TK, Kirshner JJ, King DK. University of Rochester Cancer Center Community Clinical Oncology Program. Differential effects of paroxetine on fatigue and depression: a randomized, double-blind trial from the University of Rochester Cancer Center Community Clinical Oncology Program. J Clin Oncol. 2003;21:4635–41. doi: 10.1200/JCO.2003.04.070.
    1. Bower JE, Ganz PA, Dickerson SS, Petersen L, Aziz N, Fahey JL. Diurnal cortisol rhythm and fatigue in breast cancer survivors. Psychoneuroendocrinology. 2005;30:92–100. doi: 10.1016/j.psyneuen.2004.06.003.
    1. Dantzer R. Somatization: A psychoneuroimmune perspective. Psychoneuroendocrinology. 2005;30:947–952. doi: 10.1016/j.psyneuen.2005.03.011.
    1. Surveillance, Epidemiology, and End Results Program, 1975–2000, Division of Cancer Control and Population Sciences, National Cancer Institute. 2003.
    1. Touitou Y, Levi F, Bogdan A, Benavides M, Bailleul F, Misset JL. Rhythm alteration in patients with metastatic breast cancer and poor prognostic factors. J Cancer Res Clin Oncol. 1995;121:181–188. doi: 10.1007/BF01198101.
    1. Touitou Y, Bogdan A, Levi F, Benavides M, Auzeby A. Disruption of the circadian patterns of serum cortisol in breast and ovarian cancer patients: relationships with tumour marker antigens. Br J Cancer. 1996;74:248–1252.
    1. Porter LS, Mishel M, Neelon V, Belyea M, Pisano E, Soo MS. Cortisol levels and responses to mammography screening in breast cancer survivors: a pilot study. Psychosom Med. 2003;65(5):842–848. doi: 10.1097/01.PSY.0000088595.91705.C5.
    1. Abercrombie HC, Janine Giese-Davi J, Sephton S, Epel ES, Turner-Cobb JM, Spiegel D. Flattened cortisol rhythms in metastatic breast cancer patients. Psychoneuroendocrinology. 2004;29:1082–1092. doi: 10.1016/j.psyneuen.2003.11.003.
    1. Sephton S, Sapolsky R, Kraemer H, Spiegel D. Diurnal cortisol rhythm as a predictor of breast cancer survival. J Natl Cancer Inst. 2000;92:994–1000. doi: 10.1093/jnci/92.12.994.
    1. Osborne RH, Sali A, Aaronson NK, Elsworth GR, Mdzewski B, Sinclair AJ. Immune function and adjustment style: do they predict survival in breast cancer? Psycho-Oncology. 2004;13:199–210. doi: 10.1002/pon.723.
    1. Vedhara K, Stra JT, Miles JN, Sanderman R, Ranchor AV. Psychosocial factors associated with indices of cortisol production in women with breast cancer and controls. Psychoneuroendocrinology. 2006;31(3):299–311. doi: 10.1016/j.psyneuen.2005.08.006.
    1. Turner-Cobb JM, Sephton SE, Koopman C, Blake-Mortimer J, Spiegel D. Social support and salivary cortisol in women with metastatic breast cancer. Psychosom Med. 2000;2:337–345.
    1. Kobayakawa M, Yamawaki S, Hamazaki K, Akechi T, Inagaki M, Uchitomi Y. Levels of omega-3 fatty acid in serum phospholipids and depression in patients with lung cancer. Br J Cancer. 2005;93(12):1329–33. doi: 10.1038/sj.bjc.6602877.
    1. Adler A, Stein JA, Ben-Efraim S. Immunocompetence, immunosuppression, and human breast cancer. III. Prognostic significance of initial level of immunocompetence in early and advanced disease. Cancer. 1980;45:2074–2083. doi: 10.1002/1097-0142(19800415)45:8<2074::AID-CNCR2820450814>;2-K.
    1. Levy SM, Herberman RB, Lippman M, D'Angelo T, Lee J. Immunological and psychosocial predictors of disease recurrence in patients with early stage breast cancer. Behav Med. 1991;17:67–75.
    1. Reiche EM, Morimoto HK, Nunes SM. Stress and depression-induced immune dysfunction: implications for the development and progression of cancer. Int Rev Psychiatry. 2005. pp. 515–27.
    1. Reiche EM, Nunes SO, Morimoto HK. Stress, depression, the immune system, and cancer. Lancet Oncol. 2004;5(10):617–625. doi: 10.1016/S1470-2045(04)01597-9.
    1. Andersen BL, Farrar WB, Golden-Kreutz D, Kutz LA, MacCallum R, Courtney ME, Glaser R. Stress and immune response after surgical treatment for regional breast cancer. J Natl Cancer Inst. 1998;90:30–36. doi: 10.1093/jnci/90.1.30.
    1. Penedo FJ, Dahn JR, Kinsinger D, Antoni MH, Molton I, Gonzalez JS, Fletcher MA, Roos B, Carver CS, Schneiderman N. Anger suppression mediates the relationship between optimism and natural killer cell cytotoxicity in men treated for localized prostate cancer. J Psychosom Res. 2006;60(4):423–7. doi: 10.1016/j.jpsychores.2005.08.001.
    1. Fawzy FI, Kemeny ME, Fawzy NW, Elashoff R, Morton D, Cousins N, Fahey JL. A structured psychiatric intervention for cancer patients, II: changes over time in immunological measures. Arch Gen Psychiatry. 1990;47:729–735.
    1. Musselman DL, Miller AH, Porter MR, Manatunga A, Gao F, Penna S, Pearce BD, Landry J, Glover S, McDaniel JS, Nemeroff CB. Higher than normal plasma interleukin-6 concentrations in cancer patients with depression: Preliminary findings. Am J Psychiatry. 2001;158:1252–1257. doi: 10.1176/appi.ajp.158.8.1252.
    1. Jehn CF, Kuehnhardt D, Bartholomae A, Pfeiffer S, Krebs M, Regierer AC, Schmid P, Possinger K, Flath BC. Biomarkers of depression in cancer patients. Cancer. 2006. in press .
    1. Costanzo ES, Lutgendorf SK, Sood AK, Anderson B, Sorosky J, Lubaroff DM. Psychosocial factors and interleukin-6 among women with advanced ovarian cancer. Cancer. 2005;15, 104(2):305–13. doi: 10.1002/cncr.21147.
    1. Raison CL, Miller AH. Depression in Cancer: New Developments Regarding Diagnosis and Treatment. Biol Psychiatry. 2003;54:283–294. doi: 10.1016/S0006-3223(03)00413-X.
    1. Hammacher A, Thompson EW, Williams ED. Interleukin-6 is a potent inducer of S100P, which is up-regulated in androgen-refractory and metastatic prostate cancer. Int J Biochem Cell Biol. 2005;37(2):442–50. doi: 10.1016/j.biocel.2004.07.011.
    1. George DJ, Halabi S, Shepard TF, Sanford B, Vogelzang NJ, Small EJ, Kantoff PW. The prognostic significance of plasma interleukin-6 levels in patients with metastatic hormone-refractory prostate cancer: results from cancer and leukemia group B 9480. Clin Cancer Res. 2005;11(5):1815–20. doi: 10.1158/1078-0432.CCR-04-1560.
    1. Jee SH, Chu CY, Chiu HC, Huang YL, Tsai WL, Liao YH, Kuo ML. Interleukin-6 induced basic fibroblast growth factor-dependent angiogenesis in basal cell carcinoma cell line via JAK/STAT3 and PI3-kinase/Akt pathways. Invest Dermatol. 2004;123(6):1169–75. doi: 10.1111/j.0022-202X.2004.23497.x.
    1. Cools-Lartigue J, Marshall JC, Caissie AL, Saraiva VS, Burnier MN Jr. Secretion of interleukin-6 and prostaglandin E2 during uveal melanoma-monocyte in vitro interactions. Exp Eye Res. 2004;79(4):451–4. doi: 10.1016/j.exer.2004.05.015.
    1. Berger FG. The interleukin-6 gene: a susceptibility factor that may contribute to racial and ethnic disparities in breast cancer mortality. Breast Cancer Res Treat. 2004;88(3):281–5. doi: 10.1007/s10549-004-0726-0.
    1. Savard J, Simard S, Ivers H, Morin CM. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: Sleep and psychological effects. J Clin Oncol. 2005;1;23(25):6083–96. doi: 10.1200/JCO.2005.09.548.
    1. Matsuoka Y, Yamawaki S, Inagaki M, Akechi T, Uchitomi Y. A Volumetric Study of Amygdala in Cancer Survivors with Intrusive Recollections. Biol Psychiatry. 2003;54:736–743. doi: 10.1016/S0006-3223(02)01907-8.
    1. Yoshikawa E, Matsuoka Y, Yamasue H, Inagaki M, Nakano T, Akechi T, Kobayakawa M, Fujimori M, Nakaya N, Akizuki N, Imoto S, Murakami K, Kasai K, Uchitomi Y. Prefrontal cortex and amygdala volume in first minor or major depressive episode after cancer diagnosis. Biol Psychiatry. 2006;59(8):707–12. doi: 10.1016/j.biopsych.2005.08.018.
    1. Inagaki M, Yoshikawa E, Kobayakawa M, Matsuoka Y, Sugawara Y, Nakano T, Akizuki N, Fujimori M, Akechi T, Kinoshita T, Furuse J, Murakami K, Uchitomi Y. Regional cerebral glucose metabolism in patients with secondary depressive episodes after fatal pancreatic cancer diagnosis. J Affect Disord. 2006, Sep 19.
    1. Kumano H, Ida I, Oshima A, Takahashi K, Yuuki N, Amanuma M, Oriuchi N, Endo K, Matsuda H, Mikuni M. Brain metabolic changes associated with predispotion to onset of major depressive disorder and adjustment disorder in cancer patients. A preliminary PET study. J Psychiatr Res. 2006, May 8.
    1. Watson M, Homewood J, Haviland J, Bliss JM. Influence of psychological response on breast cancer survival: 10-year follow-up of a population-based cohort. Eur J Cancer. 2005;41(12):1710–4. doi: 10.1016/j.ejca.2005.01.012.
    1. 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(5):396–402. doi: 10.1016/j.genhosppsych.2006.05.006.
    1. Faller H, Bülzebruck H, Drings P, Lang H. Coping, distress and survival among patients with lung cancer. Arch Gen psychiatry. 1999;56:756–762. doi: 10.1001/archpsyc.56.8.756.
    1. Butow PN, Coates AS, Dunn SM. Psychosocial predictors of survival in metastatic melanoma. J Clin Oncol. 1999;17:2256–2263.
    1. Butow PN, Coates AS, Dunn SM. Psychosocial predictors of survival: metastatic breast cancer. Ann Oncol. 2000;11:469–474. doi: 10.1023/A:1008396330433.
    1. Spiegel D, Giese-Davis J. Depression and cancer: mechanisms and disease progression. Biol Psychiatry. 2003;54:269–282. doi: 10.1016/S0006-3223(03)00566-3.
    1. Fawzy FI, Canada AL, Fawzy NW. Malignant melanoma: Effects of a brief, structured psychiatric intervention on survival and recurrence at 10-year follow-up. Arch Gen Psychiatry. 2003;60:100–103.
    1. Palmer SC, Coyne JC. Examining the Evidence that Psychotherapy Improves the Survival of Cancer Patients. Biol Psychiatry. 2004;56:61–64. doi: 10.1016/j.biopsych.2004.02.028.
    1. Dwight-Johnson M, Ell K, Lee PJ. Can collaborative care address the needs of low-income Latinas with comorbid depression and cancer? Results from a randomized pilot study. Psychosomatics. 2005;46(3):224–32. doi: 10.1176/appi.psy.46.3.224.
    1. Peveler R, House A. In: Liaison Psychiatry. Planning Services for Specialist Settings. Peveler R, Feldman E, Friedman T, editor. Glasgow; Gaskell; 2000. Developing services in liaison psychiatry: making the case of need; pp. 1–14.
    1. Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer. pp. 372–90. 2006 Feb 13.
    1. Fisch M. Treatment of Depression in Cancer. Journal of the National Cancer Institute Monographs. 2004;32:105–111. doi: 10.1093/jncimonographs/lgh011.
    1. Loprinzi CL, Pisansky TM, Fonseca R, Sloan JA, Zahasky KM, Quella SK, Novotny PJ, Rummans TA, Dumesic DA, Perez EA. Pilot evaluation of venlafaxine hydrochloride for the therapy of hot flashes in cancer survivors. J Clin Oncol. 1998;16(7):2377–2381.
    1. Tasmut T, Hartel B, Kalso E. Venlafaxine in neuropathic pain following treatment of breast cancer. Eur J Pain. 2002;6:17–24. doi: 10.1053/eujp.2001.0266.
    1. Kimmick GG, Lovato J, McQuellon R, Robinson E, Muss HB. Randomized, double-blind, placebo-controlled, crossover study of sertraline (Zoloft) for the treatment of hot flashes in women with early stage breast cancer taking tamoxifen. Breast J. 2006;12(2):114–22. doi: 10.1111/j.1075-122X.2006.00218.x.
    1. Durand JP, Brezault C, Goldwasser F. Protection against oxaliplatin acute neurosensory toxicity by venlafaxine. Anticancer Drugs. 2003;14(6):423–425. doi: 10.1097/00001813-200307000-00006.
    1. Razavi D, Allilaire J, Smith M, Salimpour A, Verra M, Desclaux B, Saltel P, Piollet I, Gauvain-Piquard A, Trichard C, Cordier B, Fresco R, Guillibert E, Sechter D, Orth JP, Bouhassira M, Mesters P, Blin P. The effect of fluoxetine on anxiety and depression symptoms in cancer patients. Acta Psychiatr Scand. 1996;94:205–210.
    1. Theobald DE, Kirsh KL, Holtsclaw E, Donaghy K, Passik SD. An Open-Label, Crossover Trial of Mirtazapine (15 and 30 mg) in Cancer Patients with Pain and Other Distressing Symptoms. J Pain Symptom Manage. 2002;23(5):442–7. doi: 10.1016/S0885-3924(02)00381-0.
    1. Richards S, Umbreit JN, Fanucchi MP, Giblin J, Khuri F. Selective serotonin reuptake inhibitor-induced rhabdomyolysis associated with irinotecan. South Med Journal. 2003;96(10):1031–3. doi: 10.1097/01.SMJ.0000084311.35864.D6.
    1. Thompson DS. Mirtazapine for the treatment of depression and nausea in breast and gynecological oncology. Psychosomatics. 2000;41(4):356–9. doi: 10.1176/appi.psy.41.4.356.
    1. Davis MP, Khawam E, Pozuelo L, Lagman R. Management of symptoms associated with advanced cancer: olanzapine and mirtazapine a World Health Organization project. Expert Rev Anticancer Ther. 2002;2(4):365–376. doi: 10.1586/14737140.2.4.365.
    1. Pasquini M, Biondi M, Costantini A, Cairoli F, Ferrarese G, Picardi A, Sternberg C. Detection and treatment of depressive and anxiety disorders among cancer patients: feasibility and preliminary findings from a liaison service in an Oncology Division'. Depression and Anxiety. 2006;16:1–8.
    1. Stiefel F, Die Trill M, Berney A, Nunez Olatre JM, Razavi D. Depression in palliative care: a pragmatic report from the Expert working Group of The European Association for Palliative Care. Support Care Cancer. 2001;9:477–488. doi: 10.1007/s005200100244.
    1. Newell SA, Sanson-Fisher RW, Savolainen NJ. Systematic review of psychological therapies for cancer patients: overview and recommendations for the future. J Natl Cancer Inst. 2002;94:558–584.
    1. Sheard T, Maguire P. The effect of psychological interventions on anxiety and depression in cancer patients results of two meta-analyses. British Journal of Cancer. 1999;80(11):1770–1780. doi: 10.1038/sj.bjc.6690596.
    1. Meyer TJ, Mark MM. Effect of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychology. 1995;14(2):101–108. doi: 10.1037/0278-6133.14.2.101.
    1. Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Egerton S. Oncologist's recognition of depression in their patients with cancer. J Clin Oncol. 1998;16:1594–1600.
    1. Boscaglia N, Clarke DM, Jobling TW, Quinn MA. The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer. Int J Gynecol Cancer. 2005;15(5):755–61. doi: 10.1111/j.1525-1438.2005.00248.x.

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