Minnesota Multiphasic Personality Inventory-rated depression and the incidence of breast cancer

The Risk and The Course of Cancer Among People with Severe Mental Illness

The paucity of data regarding patients with Serious Mental Illness (SMI) and cancer is alarming given the fact that people with SMI, especially schizophrenia, bipolar disorders and severe depressive disorders, have in general poorer access to physical health care and higher morbidity and mortality because of physical illnesses. The aims of this review were to examine the current evidence from existing literature on the risk of developing cancer and its course among people with SMI. Equivocal results emerge regarding the risk of developing some kind of cancer among people with SMI, with contrasting data on a possible higher, similar or lower risk in comparison with the general population. In contrast, a series of studies have pointed out that patients with SMI who develop cancer are less likely to receive standard levels of cancer care, both in terms of screening, diagnosis and treatment. Also, the mortality for cancer has been confirmed to be higher than the general population. A global sensitization about these problems is mandatory in an era in which community psychiatry has been developed in all countries and that policies of prevention, treatment, follow up, and palliative care should regard all the segments of the population, including people with SMI, through an interdisciplinary approach.

Depressive symptomology and cancer incidence in men and women: Longitudinal evidence from the HUNT study

BACKGROUND

Depressive symptoms and mood disorders are associated with a host of physical conditions. However, it is inconclusive whether depressive symptoms are also associated with cancer onset. The aim of this study was to investigate whether depressive symptoms are associated with cancer incidence in a large population-based sample of men and women.

METHODS

This study examined data from waves two (HUNT 2, 1995-97) and three (HUNT 3, 2006-08) of the Trøndelag Health Study (HUNT). Depressive symptoms were ascertained using the Hospital Anxiety and Depression Scale (HADS-D ≥ 8), cancer onset was identified via linkage with the Cancer Registry of Norway, death records by the national Cause of Death Register (CDR), and information on lifestyle and demographic factors was self-reported. Cox-proportional hazard regression models were used to test associations. Unadjusted, age-adjusted and multivariable best models accounting for smoking, education, marital status and current employment are presented.

RESULTS

Men and women (n = 61,985; 46.0 % men) were followed from baseline over a period of 778,802 person-years. During the 20-year study period, there were 6856 (11.1 %) individuals with incident cancers and 12,480 (20.1 %) deaths (n = 2498 attributed to cancer). For men with depressive symptoms, 505 (15.3 %) developed incident cancer during the follow-up period, whereas among those without depressive symptoms, 3164 (12.5 %) developed incident cancer. Following adjustment for age, depressive symptomology was not significantly associated with risk of overall cancer onset, nor among prostate, colon or melanoma subtypes. Depressive symptoms were associated with an increased risk of bronchus and lung cancer both before (HR 1.90, 95 % CI 1.43-2.50, p ≤0.001) and after adjustment for age (HR 1.38, 95 % CI 1.04-1.80, p = 0.025). However, further adjustment for additional possible confounders explained this association. For women with depressive symptoms, 384 (11.2 %) developed incident cancer during the follow-up period, whereas among those with no depressive symptomology, 2803 (9.3 %) developed incident cancer. After accounting for age, depressive symptomology was not associated with risk of overall cancer onset, nor among breast, colon, lung and bronchus, or melanoma subtypes. Additional analyses evaluating relationship of depression symptom severity and cancer onset did not alter findings for men or women.

LIMITATIONS

This report is limited by the post-hoc study design and subsequent non-randomised nature. Future prospective studies are required.

CONCLUSION

These results suggest that depressive symptoms are not associated with an increased risk of overall or site-specific cancer onset in these men and women. Given the increased co-occurrence of other medical conditions such as cardiovascular disease, diabetes, stroke and musculoskeletal disorders in people with depression, the role of clinically diagnosed depression and other psychiatric disorders in association with cancer onset necessitates further consideration.

DNA Methylation Markers and Prediction Model for Depression and Their Contribution for Breast Cancer Risk

Background

Major depressive disorder (MDD) has become a leading cause of disability worldwide. However, the diagnosis of the disorder is dependent on clinical experience and inventory. At present, there are no reliable biomarkers to help with diagnosis and treatment. DNA methylation patterns may be a promising approach for elucidating the etiology of MDD and predicting patient susceptibility. Our overarching aim was to identify biomarkers based on DNA methylation, and then use it to propose a methylation prediction score for MDD, which we hope will help us evaluate the risk of breast cancer.

Methods

Methylation data from 533 samples were extracted from the Gene Expression Omnibus (GEO) database, of which, 324 individuals were diagnosed with MDD. Statistical difference of DNA Methylation between Promoter and Other body region (SIMPO) score for each gene was calculated based on the DNA methylation data. Based on SIMPO scores, we selected the top genes that showed a correlation with MDD in random resampling, then proposed a methylation-derived Depression Index (mDI) by combining the SIMPO of the selected genes to predict MDD. A validation analysis was then performed using additional DNA methylation data from 194 samples extracted from the GEO database. Furthermore, we applied the mDI to construct a prediction model for the risk of breast cancer using stepwise regression and random forest methods.

Results

The optimal mDI was derived from 426 genes, which included 245 positive and 181 negative correlations. It was constructed to predict MDD with high predictive power (AUC of 0.88) in the discovery dataset. In addition, we observed moderate power for mDI in the validation dataset with an OR of 1.79. Biological function assessment of the 426 genes showed that they were functionally enriched in Eph Ephrin signaling and beta-catenin Wnt signaling pathways. The mDI was then used to construct a predictive model for breast cancer that had an AUC ranging from 0.70 to 0.67.

Conclusion

Our results indicated that DNA methylation could help to explain the pathogenesis of MDD and assist with its diagnosis.

Prognostic Value of Negative Emotions on the Incidence of Breast Cancer: A Systematic Review and Meta-Analysis of 129,621 Patients with Breast Cancer

Breast cancer (BC) is one of the common malignant tumors in women and affects 1.6 million new cases globally each year. Investigators have recently found that negative emotions (NEs) and their impacts have greatly influenced the incidence and risk of BC. The present study aims to provide an association between NEs and the incidence of BC with possible risk factors. A total of 9343 studies were screened; nine studies met all inclusion criteria that were considered for the meta-analysis. The qualitative studies were measured by the Newcastle-Ottawa Scale; the observational studies were included with relative risks (RR) and corresponding 95% confidence intervals (CI). Besides the NEs and BC, the possible risk factors were evaluated. We analyzed data from 129,621 women diagnosed with NEs of which 2080 women were diagnosed with BC and their follow-up year ranges were from 4–24 years. NEs were significantly (p < 0.0001) associated with a higher incidence of BC with RR = 1.59, 95% CI:1.15–2.19, with other high-risk factors including, geographical distribution, emotion types, standard diagnosis of NEs, and follow-up duration. This study suggests that NEs significantly increase the risk for the incidence of BC, which can be supportive of the prognosis of the disease.

Influence of Psychological Factors in Breast and Lung Cancer Risk - A Systematic Review

Introduction: In 2020, according to the Global Cancer Observatory, nearly 10 million people died of cancer. Amongst all cancers, breast cancer had the highest number of new cases and lung cancer had the highest number of deaths. Even though the literatures suggest a possible connection between psychological factors and cancer risk, their association throughout studies remains inconclusive. The present systematic review studied the connection between psychological factors and the risk of breast and lung cancer, prior to a cancer diagnosis. The psychological factors of trauma, grief, and depression were studied. Methods: The current systematic review was carried out across multiple databases in two phases, an initial exploratory research in June 2020, refined with a second electronic research in December 2020. The inclusion criteria included studies describing the association between trauma, posttraumatic stress disorder (PTSD), grief, and depression with breast and lung cancer risk. The psychological data collection must have been carried out prior to a confirmed breast or lung cancer diagnosis, and accessed through self-report measures, questionnaires, clinical interviews, or clinical diagnoses. Study reports had to contain information about the incidence of cancer and effect size. The exclusion criteria were studies in which psychological factors were collected after cancer diagnosis. Results and Conclusion: A total of 26 studies were included. Although non-consensual, the findings from the present systematic review suggest that, in addition to the known risk factors, psychological factors may play an important role in the etiology of both breast and lung cancer. To include psychological factors as a variable that affects cancer development may be fundamental to opening new avenues for prevention and intervention. Systematic Review Registration: [www.ClinicalTrials.gov], identifier [CRD42020209161].

Mood disorder and cancer onset: evidence from a population-based sample of Australian women

OBJECTIVE

The role of mood disorders in cancer onset is unclear. The aim of this study was to investigate the association between mood disorder and incident cancer in a population-based sample of women.

METHODS

Data were derived from women aged 28-94 years participating in the Geelong Osteoporosis Study. Mood disorder was identified via Clinical Interview (SCID-I/NP). Cancer data was obtained following linkage with the Victorian Cancer Registry. Demographic and lifestyle factors were self-reported. Nested case-control and retrospective study designs were utilized.

RESULTS

In the case-control study (n=807), mood disorder was documented for 18 of the 75 (9.3%) cancer cases and among 288 controls (24.0% vs. 39.3%, p = 0.009). Prior exposure to mood disorder was associated with reduced cancer incidence (OR 0.49, 95%CI 0.28-0.84); this was sustained following adjustment for confounders (ORadj 0.52, 95%CI 0.30-0.90). In the retrospective cohort study (n=655), among 154 women with a history of mood disorder at baseline, 13 (8.5%) developed incident cancer during follow-up, whereas among 501 women with no history of mood disorder, 54 (10.8%) developed incident cancer. Exposure to mood disorder was not associated with incident cancer over the follow-up period (HR 0.58, 95%CI 0.31-1.08, p = 0.09).

CONCLUSION

Mood disorder was associated with reduced odds of cancer onset. However, this finding was not supported in the retrospective cohort study. Larger studies able to investigate specific cancers and mood disorders as well as underlying mechanisms in both men and women are warranted.

Association of lipoproteins and thyroid hormones with cognitive dysfunction in patients with systemic lupus erythematosus

Background

Neuropsychiatric manifestations occur in up to 75% of adult systemic lupus erythematosus (SLE) patients and are one of the major causes of death in SLE patients. Cognitive dysfunction is a typical clinical feature of neuropsychiatric SLE (NPSLE), which seriously affects the quality of life of patients. Dyslipidaemia and thyroid symptoms, which are prevalent in SLE patients, have both been related to neuropsychiatric disturbances, including significant psychiatric and cognitive disturbances. This study aimed to investigate whether cognitive dysfunction in patients with SLE was related to the expression of serum thyroid hormone and lipoprotein levels.

Methods

A total of 121 patients with SLE and 65 healthy controls (HCs) at Nanjing Drum Tower Hospital completed a cognitive function test, and 81 SLE patients were divided into a high-cognition (n = 33) group and a low-cognition group (n = 48). The clinical and laboratory characteristics of the patients were compared; moreover, correlations between serum HDL-C, LDL-C, F-T3 and F-T4 levels and cognitive function were analysed. Serum levels of APOE, APOA1, IGF-1, and IGFBP7 in 81 patients were detected by ELISA, and the correlation between these four proteins and cognition was analysed separately.

Results

The patients with SLE with abnormal cognitive function were less educated than the HCs. For low-cognition patients, the levels of albumin, F-T3 (P <  0.05) and F-T4 decreased, while D-dimer, anti-dsDNA antibody, and IgM levels increased. Serum F-T3 and F-T4 levels positively correlated with cognition. Furthermore, serum protein levels of APOE and APOA1 showed no difference between the high- and low-cognition groups. However, the serum APOE levels were negatively correlated with line orientation scores, and APOA1 levels were positively correlated with coding scores.

Conclusions

Serum F-T3 and F-T4 levels were both positively correlated with four indexes of cognition (language was the exception), while serum APOE levels were negatively correlated with line orientation scores, APOA1 levels were positively correlated with coding scores, and IGFBP7 levels were negatively correlated with figure copy scores. These results demonstrated that F-T3 and F-T4 might be clinical biomarkers of cognitive dysfunction in SLE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00190-7.

The prognostic role of depression as a predictor of chronic somatic diseases manifestation

The negative impact of depression on the course and outcome of somatic disorders is well-known and has a solid theoretical basis. The analyses of prospective studies confirm the role of depression as an independent and significant risk factor for widespread chronic somatic disorders including such severe and life-threatening conditions as cardiovascular diseases, diabetes and oncological pathology. The majority of somatic disorders and depression are the part of the big class of hereditary diseases with multifactorial character and polygenic nature. It is likely, that the genetic risk diversity of these diseases in population is close. There is also a high probability of genetic risks levels overlap (or of common «cluster») of two or more diseases in one individual, with one disorder being major depression. In that case such diseases could be considered «genetically comorbid» and manifestation of one disease could alter the risks of other. Precise and informative diagnostic tools could detect subsyndromal depression that could be the prognostic sign of the high risk and rapid manifestation of somatic diseases. Thus, patients with depressive disorder could be considered as a group with high risks of diverse range of somatic pathology. The coalescence of fundamental biomedical scientists and internists (psychiatrists and other physicians) could lead to the elaboration of specific complex preventative measures including social ones.

Defense mechanisms in cancer patients: a systematic review

The importance of defense mechanisms in cancer progression and adaptation have been largely observed. However, few studies referred to the generally accepted hierarchical organization of defenses and used validated measurements for defensive assessment. In this systematic review, we investigated the whole hierarchy of defense mechanisms and how they associate with various psychological aspects in cancer patients. A literature search was conducted using electronic databases. Among 1570 records published from 1990 to date, only 15 articles met inclusion criteria. Findings related to cancer patients' defensive functioning and its relations with other physical and psychological variables were extracted. A general consistency emerges on the role of defense mechanisms in cancer progression and recovery. Following the hierarchical organization of defenses, higher physical and emotional functioning emerged as being associated with High-adaptive defenses, while Mental Inhibition defenses, in particular repression, promote psychosomatic symptoms, passive decisional preferences and worse physical and emotional health. Disavowal defenses foster lower anxiety and higher emotional functioning by denying anxiety about death. Image distortion defenses, including both Minor and Major image-distorting defenses, were more frequent in cancer patients than in control groups and finally, Action defenses predicted sleep disturbance and lower survival probability. The early detection of maladaptive defensive functioning may foster appropriate psychotherapeutic intervention and prevent worsening of the illness. Further investigations are required to replicate these findings and highlight associations between defense mechanisms and various aspects of mental functioning in cancer patients.

Cognitive dysfunction improves in systemic lupus erythematosus: Results of a 10 years prospective study

OBJECTIVE

Cognitive impairment (CI) has been described in 3-80% of Systemic lupus erythematosus (SLE) patients but only short-term studies evaluated its over-time changes, suggesting that CI is usually a stable finding. We aimed at evaluating the changes of SLE-related CI in a 10-years prospective single center cohort study.

METHODS

We evaluated 43 patients (M/F 5/38; mean age = 45.7±10.1 years; mean disease duration = 230.8±74.3 months) at baseline (T0) and after 10 years (T1). A test battery designed to detect fronto-subcortical dysfunction across five domains (memory, attention, abstract reasoning, executive and visuospatial function) was administered. A global cognitive dysfunction score (GCD) was obtained and associated with clinical and laboratory features.

RESULTS

Prevalence of CI was 20.9% at T0 and 13.9% at T1 (P = NS). This impairment was prevalently mild at T0 (55.5%) and mild or moderate at T1 (36.3% for both degrees). After 10 years, CI improved in 50% of patients, while 10% worsened. Impaired memory (P = 0.02), executive functions (P = 0.02) and abstract reasoning (P = 0.03) were associated with dyslipidemia at T0. Worsening of visuospatial functions was significantly associated with dyslipidemia and Lupus Anticoagulant (P = 0.04 for both parameters). Finally, GCD significantly correlated with chronic damage measured by SLICC/damage index at T0 (r = 0.3; P = 0.04) and T1 (r = 0.3; P = 0.03).

CONCLUSIONS

For the first time, we assessed CI changes over 10-years in SLE. CI improved in the majority of the patients. Furthermore, we observed an improvement of the overall cognitive functions. These results could suggest that an appropriate management of the disease during the follow-up could be able to control SLE-related CI.

Depression, Antidepressant Use, and Breast Cancer Risk in Pre- and Postmenopausal Women: A Prospective Cohort Study

Background: Depression and antidepressant use is highly prevalent among U.S. women and may be related to increased breast cancer risk. However, prior studies are not in agreement regarding an increase in risk.Methods: We conducted a prospective cohort study within the Nurses' Health Study (NHS) and NHSII among females age 25 and older. Over more than 10 years of follow-up in each cohort, 4,014 incident invasive breast cancers were diagnosed. We used Cox proportional hazards regressions with updating of exposures and covariates throughout follow-up to estimate HRs and 95% confidence intervals (CIs) for associations between clinical depression and antidepressant use with invasive breast cancer risk. Analyses were repeated separately for in situ disease, as well as stratified by estrogen receptor (ER) subtype and menopausal status at diagnosis.Results: No statistically significant associations were observed between clinical depression (HR for reporting ≥3 times vs. 0, 1.13; 95% CI, 0.85-1.49) or antidepressant use (HR for reporting ≥3 times vs. 0, 0.92; 95% CI, 0.80-1.05) and invasive breast cancer risk in multivariable analyses. Likewise, we observed no significant associations between clinical depression or antidepressant use and risk of in situ, ER⁺, ER^-, premenopausal, or postmenopausal breast cancer.Conclusions: In the largest prospective study to date, we find no evidence that either depression or antidepressant use increase risk of breast cancer.Impact: The results of this study are reassuring in that neither depression nor antidepressant use appear to be related to subsequent breast cancer risk. Cancer Epidemiol Biomarkers Prev; 27(3); 306-14. ©2017 AACR.

Depression and cancer risk: a systematic review and meta-analysis

OBJECTIVE

To assess the associations between depression and incident cancer risk.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The Cochrane Library, Web of Science, MEDLINE, and PubMed databases were searched to identify studies. The quality of included studies was assessed using the Newcastle Ottawa Scale. Risk ratios (RRs) were used to measure effect size. A random-effects model was applied to synthesize the associations between depression and cancer risk. A forest plot was produced to visually assess RRs and 95% confidence intervals (CIs). Heterogeneity across studies was assessed using the I-squared statistic. A funnel plot was generated to assess potential publication bias, and Egger's regression was applied to test the symmetry of the funnel plot.

RESULTS

In total, 1,469,179 participants and 89,716 incident cases of cancer from 25 studies were included. Depression was significantly associated with overall cancer risk (RR = 1.15, 95% CI: 1.09-1.22) and with liver cancer (RR = 1.20, 95% CI: 1.01-1.43) and lung cancer (RR = 1.33, 95% CI: 1.04-1.72). Subgroup analysis of studies in North America resulted in a significant summary relative risk (RR = 1.30, 95% CI: 1.15-1.48). No significant associations were found for breast, prostate, or colorectal/colon cancer. The average Newcastle Ottawa score was 7.56 for all included studies.

CONCLUSION

Our findings showed a small and positive association between depression and the overall occurrence risk of cancer, as well as liver cancer and lung cancer risks. However, multinational and larger sample studies are required to further research and support these associations. Moreover, confounding factors such as cigarette smoking and alcohol use/abuse should be considered in future studies.

Depression, Antidepressant Use, and Postmenopausal Breast Cancer Risk

BACKGROUND

Whether depression and antidepressant (AD) use might influence breast cancer risk is unclear, and these exposures have not been evaluated together in a single, prospective cohort study of breast cancer risk.

METHODS

Among 71,439 postmenopausal women in the Women's Health Initiative Observational Study (WHI-OS), we estimated multivariable-adjusted HRs for the independent and joint effects of depressive symptoms and AD use on breast cancer risk using Cox proportional hazards regression.

RESULTS

When analyzed separately, neither depressive symptoms nor AD use at baseline were associated with a significantly increased risk of total breast cancer (HR = 0.96, 95% CI, 0.85-1.08; HR = 1.04, 95% CI, 0.92-1.20, respectively) or invasive breast cancer (HR = 0.98, 95% CI, 0.86-1.12; HR = 1.00, 95% CI, 0.86-1.16, respectively). Current AD use was associated with a borderline-significant increase of in situ breast cancer (HR = 1.30, 95% CI, 0.99-1.75) after adjustment for depressive symptoms; however, this relationship was attenuated after adjustment for mammographic screening (HR = 1.08, 95% CI, 0.76-1.51). No significant variation in total breast cancer risk was observed when the separate and joint effects of depressive symptoms and AD use were explored (P for interaction = 0.14).

CONCLUSION

We found no evidence that either depression or AD use influences breast cancer risk. An elevated risk of in situ disease among AD users could not be ruled out, though is likely due to increased screening in this subgroup.

IMPACT

Given the high prevalence of these exposures, these results may provide reassurance to the millions of women who are depressed and/or use ADs each year.

Depression and risk of epithelial ovarian cancer: Results from two large prospective cohort studies

OBJECTIVES

While emerging evidence supports a possible link between depression and ovarian cancer progression, no prospective studies have explored the association with ovarian cancer risk.

METHODS

We prospectively followed 77,451 women from the Nurses' Health Study (1992-2010) and 106,452 women from the Nurses' Health Study II (1993-2011). Depression was defined as having one or more of the following: a 5-item Mental Health Index (MHI-5) score≤52, antidepressant use, or physician-diagnosed depression. Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between depression and incident ovarian cancer.

RESULTS

We documented 698 incident cases of epithelial ovarian cancer during follow-up. In multivariable analyses, depression assessed 2-4years before cancer diagnosis was associated with a modestly higher incidence of ovarian cancer (HR=1.30, 95% CI 1.05-1.60). Compared to women with persistent negative depression status, the adjusted HRs were 1.34 (95% CI 1.01-1.76) for women with persistent positive depression status and 1.28 (95% CI 0.88-1.85) for women with worsening depression status over follow-up. The association did not appear to vary by ovarian cancer risk factors or tumor characteristics.

CONCLUSIONS

Our findings suggest that depression may be associated with a modestly increased risk of ovarian cancer. Given the relatively high prevalence of depression in women, future work in larger prospective human studies is needed to confirm our results.

Personality and breast cancer risk and survival: the Miyagi cohort study

It has long been hypothesized that personality is associated with breast cancer risk and survival. The present population-based prospective cohort study in Japan tested this hypothesis. To investigate the association of personality with breast cancer risk, a total of 15,107 women aged 40-64 years who completed the Eysenck Personality Questionnaire-Revised (EPQ-R) Short Form were followed from 1990 to 2007. To assess the association of personality with survival after breast cancer, 250 identified cases were further followed up from the date of diagnosis to 2008, and 45 all-cause deaths were documented. Study subjects were categorized into four groups based on the quartile points of scores ranging between 0 and 12 on each EPQ-R subscale (extraversion, neuroticism, psychoticism, and lie), and the hazard ratio (HR) for each category was computed using the lowest category as reference. Multivariate analysis revealed no association between any of the four personality subscales and the risk of breast cancer. In the analysis on survival, no significant association was found between any of these subscales and the risk of death, although breast cancer cases with a higher score of extraversion tended to have a lower risk of death (P for trend = 0.07; HR for highest score level = 0.38). Exclusion of 32 cases diagnosed in the first 3 years of follow-up did not largely change the results with regard to either breast cancer risk or survival. The present findings suggest that personality does not impact significantly on the development and progression of breast cancer.

Life Stressors, Emotional Avoidance and Breast Cancer

Two groups of women were assessed in psychological aspects considered by some authors of interest for personal well-being. The sample consisted of 118 women, 58 diagnosed with breast cancer and 60 healthy women, of similar ages and personal circumstances. The purpose of the study was: (a) to explore the existence of stressful life events in the women's history and their degree of subjective distress and (b) to determine whether or not there is an emotional avoidance style in the group of women with breast cancer. The following assessment instruments were employed: the “Cuestionario de Formas de Afrontamiento” (CEA), the Five-Factor Inventory NEO-PI-R, and the State-Trait Anger Inventory (STAXI). The results revealed more stressful vital events in the last two years in the group of women with breast cancer and significant differences in the degree of current distress. They also obtained higher scores in current anger, resignation, and neuroticism.

Depression and the risk of cancer: a 15-year follow-up study of the GAZEL cohort

Depression has long been hypothesized to be associated with cancer incidence. However, there is evidence for a positive publication bias in this field. In the present study, we examined the association between various measures of depression and cancer incidence at several sites. A total of 14,203 members of the French GAZEL (Gaz et Electricité) cohort (10,506 men, 3,697 women) were followed up for diagnoses of primary cancers from January 1, 1994, to December 31, 2009. All medically certified sickness absences for depression recorded between January 1, 1990, and December 31, 1993, were compiled. Depressive symptoms were self-reported in 1993, 1996, and 1999 with the Center for Epidemiologic Studies Depression Scale. During a mean follow-up period of 15.2 years, 1,119 participants received a cancer diagnosis, excluding nonmelanoma skin cancer and in situ neoplasms. Considering 6 cancer sites (prostate, breast, colorectal, smoking-related, lymphoid and hematopoietic tissues, other sites) and 4 measures of depression, we found 1 positive association and 1 negative association. Overall, there was no compelling evidence for an association between depression and cancer incidence. Such null results should be considered when addressing concerns of cancer patients and their relatives about the role of depression in cancer onset.

Antidepressants and testicular cancer

PURPOSE

Re-examine association of fluoxetine and paroxetine with risk of testicular cancer noted in drug screening, with 4 years more follow-up and expanded study of these and other antidepressant drugs.

METHODS

In the Kaiser Permanente Medical Care Program in Northern California, 906 men with testicular cancer diagnosed August 1996-December 2010 were compared with 38,253 matched controls with race/ethnicity recorded regarding receipt of antidepressant drugs at least 2 years before diagnosis or control index date. Analyses emphasized duration of use and histological subgroups.

RESULTS

With control for race/ethnicity and use of other antidepressant drugs, odds ratios (OR) and 95 % confidence intervals (CI) for associations with testicular cancer were as follows: fluoxetine 1.22 (0.88-1.71), paroxetine 1.19 (0.78-1.83), and 1.21 (0.92-1.58) for all serotonin reuptake inhibitors. There was no statistically significant association with risk of all testicular cancers or their histological subtypes for any individual drug or for tricyclics or all antidepressants combined except for citalopram with all testicular cancers 2.55 (1.43-4.52) and those of mixed histology 4.36 (1.50-12.68) and nefazodone with embryonal cancers 9.79 (1.85-51.81). These could readily be chance findings in the context of the many analyses that were performed. Duration of use was not associated with risk of the drugs and drug groups with sufficient numbers of exposed cases for analysis.

CONCLUSIONS

We found little evidence to support a testicular carcinogenic effect of fluoxetine, paroxetine, or other antidepressant drugs, but a weakly positive association is not ruled out. The signals in prior screening may have been due to chance and/or uncontrolled confounding.

Personality and the risk of cancer: a 16-year follow-up study of the GAZEL cohort

OBJECTIVE

Large-scale prospective studies do not support an association between neuroticism and extroversion with cancer incidence. However, research on other personality constructs is inconclusive. This longitudinal study examined the associations between four personality measures, Type 1, "suppressed emotional expression"; Type 5, "rational/antiemotional"; hostility; and Type A with cancer incidence.

METHODS

Personality measures were available for 13,768 members in the GAZEL cohort study (baseline assessment in 1993). Follow-up for diagnoses of primary cancers was obtained from January 1, 1994 to December 31, 2009. Associations between personality and cancer incidence were evaluated using Cox proportional hazards analyses and adjusted for potential confounders.

RESULTS

During a median follow-up of 16.0 years (range, 9 days-16 years), 1139 participants were diagnosed as having a primary cancer. The mean duration between baseline and cancer diagnosis was 9.3 years. Type 1 personality was associated with a decreased risk of breast cancer (hazard ratio per standard deviation = 0.81, 95% confidence interval = 0.68-0.97, p = .02). Type 5 personality was not associated with prostate, breast, colorectal, or smoking-related cancers, but was associated with other cancers (hazard ratio per standard deviation = 1.17, 95% confidence interval = 1.04-1.31, p = .01). Hostility was associated with an increased risk of smoking-related cancers, which was explained by smoking habits, and Type A was not associated with any of the cancer endpoints.

CONCLUSIONS

Several personality measures were prospectively associated with the incidence of selected cancers. These links may warrant further epidemiological studies and investigations about potential biobehavioral mechanisms.

Depressive symptoms and oxidative DNA damage in Japanese municipal employees

We sought to explore the relationship between depressive symptoms and urinary 8-hydroxydeoxyguanine (8-OHdG), a biomarker of systemic oxidative DNA damage and repair, among 301 men and 210 women aged 21-67 years working in two municipal offices. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression scale (CES-D). The geometric mean and its 95% confidence interval (CI) of urinary 8-OHdG concentrations were calculated according to the quartile of CES-D score. The prevalence of depressive symptoms, defined as having CES_D of ≥16, was 35.9% in men and 35.2% in women. There was no significant difference in geometric mean of urinary 8-OHdG concentrations according to the levels of depressive symptoms. In men, the multivariable-adjusted geometric mean of urinary 8-OHdG concentrations (95% CIs) in the first, second, third, and fourth category of depressive symptoms was 1.09 (1.02-1.16), 1.16 (1.08-1.24), 1.15 (1.07-1.24), and 1.10 (1.02-1.18), respectively (p for trend=0.86). Similarly, no significant association was found in the analyses among women, nonsmoking men, and smoking men. The lack of association between depressive symptoms and urinary 8-OHdG concentrations may indicate the absence or more complex interactions between milder forms of depression and systemic oxidative DNA damage and repair in well-functioning population.

Personality of outpatients with malignant tumors: a cross-sectional study

Background

There have been scarce large-scale studies investigating the personality of patients with malignant tumors. The purpose of this study is to determine the characteristic personality in malignant tumors outpatients.

Methods

Three thousand and three among 5013 consecutive outpatients who consented to answer the Japanese Maudsley Personality Inventory questionnaires were divided into two groups. 603 outpatients diagnosed with malignant tumors (M group) and the other 2400 outpatients (non-M group) were enrolled in this study. We determined three scores such as introversion/extroversion (E-score), neuroticism (N-score), and lie detection (L-score). All data were used to compare the two groups.

Results

Average E-score was slightly higher, and average N-score was slightly lower in M group than that in non-M group, and no significant differences between the two groups. However, the average L-score in M group was significant higher than that in non-M group (p < 0.01).

Conclusion

Outpatients with malignant tumors showed a significantly higher L-score on MPI when compared with patients with non-malignant tumors. These results stress the importance of taking the mentality of patients with cancer into consideration when conducting treatment and care.

Neurocognitive dysfunction in systemic lupus erythematosus: association with antiphospholipid antibodies, disease activity and chronic damage

INTRODUCTION

Systemic lupus erythematosus (SLE) is characterized by frequent neuropsychiatric involvement, which includes cognitive impairment (CI). We aimed at assessing CI in a cohort of Italian SLE patients by using a wide range of neurocognitive tests specifically designed to evaluate the fronto-subcortical dysfunction. Furthermore, we aimed at testing whether CI in SLE is associated with serum autoantibodies, disease activity and chronic damage.

METHODS

Fifty-eight consecutive patients were enrolled. Study protocol included data collection, evaluation of serum levels of ANA, anti-dsDNA, anti-cardiolipin, anti-β(2)-glycoprotein I, anti-P ribosomal, anti-endothelial cell, and anti-Nedd5 antibodies. SLEDAI-2000 and SLICC were used to assess disease activity and chronic damage. Patients were administered a test battery specifically designed to detect fronto-subcortical dysfunction across five domains: memory, attention, abstract reasoning, executive function and visuospatial function. For each patient, the raw scores from each test were compared with published norms, then transformed into Z scores (deviation from normal mean), and finally summed in the Global Cognitive Dysfunction score (GCDs).

RESULTS

Nineteen percent of patients had mild GCDs impairment (GCDs 2-3), 7% moderate (GCDs 4-5) and 5% severe (GCDs≥6). The visuospatial domain was the most compromised (MDZs = -0.89±1.23). Anti-cardiolipin IgM levels were associated with visuospatial domain impairment (r = 0.331, P = 0.005). SLEDAI correlated with GCDs, and attentional and executive domains; SLICC correlated with GCDs, and with visuospatial and attentional domains impairment.

CONCLUSIONS

Anti-phospholipids, disease activity, and chronic damage are associated with cognitive dysfunction in SLE. The use of a wide spectrum of tests allowed for a better selection of the relevant factors involved in SLE cognitive dysfunction, and standardized neuropsychological testing methods should be used for routine assessment of SLE patients.

Self-reported psychological stress and the risk of breast cancer: a case-control study

The aim of this study was to examine the relationship between severe life events and breast cancer risk. This study was based on a case-control examination of 858 Polish invasive breast cancer cases and 1085 controls matched for age and place of residence. Data on life events, sociodemographic characteristic, reproductive factors, family history of breast cancer, current weight and height, and lifestyle habits were collected between January 2003 and May 2007 using a self-administered questionnaire. Odds ratios with 95% confidence intervals were estimated as the measure of the relationship between life event stress and breast cancer risk using unconditional logistic regression analyses. After adjustment for potential breast cancer risk factors, women with four to six individual major life events had 5.33 times higher risk for breast cancer, compared with those in the lowest quartile. Similarly, women with a lifetime life change score greater than 210 had about 5 times higher risk compared to women with corresponding scores in the range 0-70. Several life events (death of a close family member, personal injury or illness, imprisonment/trouble with the law, retirement) were significantly associated with breast cancer risk. These findings suggest that major life events can play an important role in the etiology of breast cancer.

A prospective association between quality of life and risk for cancer

AIM

The contributions of social and especially of psychological factors to cancer development have been questioned. The goal of this study was to investigate, in a longitudinal setting, the prospective associations between self-reported measures of social relations, subjective health (physical and mental) and quality of life and the risk for cancer.

METHODS

In 1993, 4493 people in the Copenhagen Perinatal Cohort were asked to rate their social relations, their physical and mental health and their quality of life. The study population was followed until the end of 2006 for registration of cancer in the Danish Hospital Discharge Register.

RESULTS

During the follow-up period, cancer was diagnosed in 102 people. When compared with people with very good quality of life, those who rated their quality of life as poor had a hazard ratio of 1.90 (95% confidence interval [CI], 1.1-3.4) for cancer, and those who rated their quality of life as good had a hazard ratio of 1.31 (95% CI, 0.8-2.2), after adjustment for age, sex, income, lifestyle factors and number of health problems. Self-rated physical and mental health were significantly associated with the risk for cancer, but the estimates became non-significant after adjustment for confounding factors. Social relations were not associated with the risk for cancer.

CONCLUSION

Broad assessment of general well-being, self-rated as global quality of life, appears to be a better predictor of cancer risk than more specific information on social relations and health.

Increased risk of cancer subsequent to severe depression--a nationwide population-based study

BACKGROUND

Empirical findings on the association between a history of depression and subsequent cancer incidence are mixed and inconclusive. A link between depression and cancer would gain greater credence if it can be sustained across cultures. This nationwide, population-based study aimed to prospectively examine the relationship between a psychiatric diagnosis of depression in an inpatient setting and the risk of developing cancer in the following five years in Taiwan.

METHOD

This study used data from the Taiwan National Health Insurance Research Database. A total of 778 patients hospitalized for depression from 1998 to 2003 were recruited, together with 3890 matched non-depressive enrollees as a comparison cohort. Each patient was tracked five years to identify the occurrence of any type of cancer. The Cox proportional hazards models were carried out to compute the risk of cancer between study and comparison cohorts, following adjustment for residence and socio-demographic characteristics.

RESULTS

We found that during a five-year follow-up, 61 severely depressed patients (7.8%) and 212 patients in the non-depressed comparison cohort (5.5%) received cancer diagnoses. For adults age 18 and older, having been hospitalized with a diagnosis of depressive disorder was independently associated with a 1.62-fold (95% CI: 1.12, 2.34) overall increased risk of subsequent cancer during five years of follow-up, after adjusting for residence and socio-demographic characteristics.

CONCLUSION

Our results suggest depression is significantly associated with increased risk of cancer in a rather short follow-up time. Our results call attention to the immediate health impacts of severe depression on patients.

[Should psychological events be considered cancer risk factors?]

BACKGROUND

The possibility that life events, personality or depression can be considered risk factors for cancer has been of great interest among the lay public and doctors.

METHODS

A critical review of different publications of meta-analyses, case-control studies and cohort studies investigating a possible relation between the onset of cancer and life events, personality disorders or depression is presented. Many studies have methodological limitations with possible bias, which may explain controversial results. We selected 32 studies from which conclusions can be drawn with the least amount of bias.

RESULTS

Eighteen out of 32 publications whose methodology permits unbiased interpretation show no link between psychological factors and the risk of cancer. Six publications show a significant link only in one or several subgroups and four surveys, three of which were published by the same author, show an inverse relation in gynecological cancers. As for life events and breast cancer, the results are slightly in favor of a positive relation in four studies; four others showed no relation and one argues in favor of an inverse risk, which means a protective effect for this cancer. For life events and other cancers, studies show no relation, with the possible exception of cancers in women where endogenous estrogens can play a role (colon and endometrial cancers), where there is an inverse relation. No studies showed a significant relation between personality features and the risk of cancer. The studies of a possible relation between depression and cancer are controversial and no conclusion can be drawn.

CONCLUSION

It cannot be confidently concluded that life events, personality features or depression play a role in the onset of cancer.

Personality factors associated with psychological distress in testicular cancer survivors

The aim of this study was to investigate symptoms of anxiety and depression in testicular cancer survivors (TCSs) and to identify personality traits associated with psychological distress in these patients by means of the MMPI (Hathaway & McKinley, 1943). A total of 50 TCSs and 50 age-adjusted healthy men participated in the study, and we used the following self-report instruments: Montgomery-Asberg Depression Rating Scale (Montgomery & Asberg, 1979), Hamilton Anxiety Rating Scale (Hamilton, 1959, 1969), Spielberger's State-Trait Anxiety Inventory (Spielberger, 1970, 2005), and the MMPI. TCSs displayed higher rates on all psychopathology scales studied compared to controls, but the majority of the patients' scores were within the "normal range," indicating rather mild psychological distress. TCSs' MMPI profiles showed higher rates on Scales 1, 3, 6, and 9 compared to controls; and within the TCSs sample, symptoms of depression were most closely associated with Scales 3 and 5. Similarly, anxiety symptoms were mainly associated with Scale 3. These findings indicate that TCSs present mild symptoms of psychological distress, mainly anxiety and depressive symptoms, suggesting that careful assessment and consultation in TC patients is essential to help them deal with distress after treatment and to minimize possible risk factors.

Behavioral genetics of the depression/cancer correlation: a look at the Ras oncogene family and the 'cerebral diabetes paradigm'

This study investigates the causes of the observed linkage between depression and later onset of cancer. The prevailing view is that cancer in depressed patients results from a weakened immune system. However, molecular biologists have recognized that dysregulation of the ras proto-oncogene results in impaired serotonin and dopamine synthesis manifesting as major depression. A qualitative review of the literature showed that (1) studies using the Minnesota Multiphasic Personality Inventory showed a greater correlation between depression and later cancer onset than those employing other measures and (2) the more related the cancer type was to the Ras oncogene family, the greater the correlation between depression and later cancer onset. These results support the hypothesis that the ras proto-oncogene plays a role in the etiology of depression and could be the common denominator in long-observed depression/cancer linkages. Previous depression/cancer linkage studies are confounded in that they failed to analyze cancer type and accurately diagnose depression.

A meta-analysis on depression and subsequent cancer risk

BACKGROUND

The authors tested the hypothesis that depression is a possible factor influencing the course of cancer by reviewing prospective epidemiological studies and calculating summary relative risks.

METHODS

Studies were identified by computerized searches of Medline, Embase and PsycINFO. as well as manual searches of reference lists of selected publications. Inclusion criteria were cohort design, population-based sample, structured measurement of depression and outcome of cancer known for depressed and non-depressed subjects

RESULTS

Thirteen eligible studies were identified. Based on eight studies with complete crude data on overall cancer, our summary relative risk (95% confidence interval) was 1.19 (1.06-1.32). After adjustment for confounders we pooled a summary relative risk of 1.12 (0.99-1.26).No significant association was found between depression and subsequent breast cancer risk, based on seven heterogeneous studies, with or without adjustment for possible confounders. Subgroup analysis of studies with a follow-up of ten years or more, however, resulted in a statistically significant summary relative risk of 2.50 (1.06-5.91).No significant associations were found for lung, colon or prostate cancer.

CONCLUSION

This review suggests a tendency towards a small and marginally significant association between depression and subsequent overall cancer risk and towards a stronger increase of breast cancer risk emerging many years after a previous depression.

Is cancer risk associated with anger control and negative affect? Findings from a prospective cohort study

OBJECTIVE

To examine the associations between anger control and negative affect and the risk of five common cancers and total cancers. Possible associations between emotional states and the risk of cancer have long been postulated.

METHODS

Prospective cohort study with average follow-up of 9 years. A total of 19,730 adults (99% aged between 40 and 69 years) answered questions on negative affect and anger control at baseline. A total of 1952 cancers were diagnosed, including 352 breast cancers, 318 prostate cancers, 88 lung cancers, 280 colorectal cancers, and 261 melanomas.

RESULTS

After adjustment for potential confounders, there was no significant association between anger control or negative affect and risk of breast cancer, melanoma, or total cancers. Weak associations were identified between anger control and prostate cancer, hazards ratio (HR) 1.17 (1.04-1.30) for a 1-unit increase in the standardized scale, negative affect, and lung cancer, HR 1.24 (1.01-1.52) and colorectal cancer, HR 1.14 (1.01-1.28). There was no evidence of an interaction effect between anger control and negative affect.

CONCLUSIONS

Results suggest that anger control and negative affect are not associated with breast cancer, melanoma, or total cancer risk, although they may have a small role in risk of prostate, colorectal, and lung cancer. Although more research is needed to confirm these latter associations, the results suggest that if affective states are associated with cancer development, the association may differ for different cancers and argue against the use of total cancer as an outcome measure for studies in this area.

Depressive symptoms and prospective incidence of colorectal cancer in women

The authors examined depressive symptoms and prospective incidence of colorectal cancer and distal colorectal adenomas in 81,612 women without prior cancer from the Nurses' Health Study; 400 cases of colorectal cancer and 680 distal colorectal adenomas accrued between 1992 and the year 2000. Depressive symptoms were assessed in 1992 and 1996 with the five-question Mental Health Index (MHI-5), a subscale of the Short-Form 36 health status survey. Scores ranged from 0 to 100, and women with scores between 0 and 52 were defined as having significant depressive symptomatology. The authors also created four categories across the range of Mental Health Index scores: 0-52, 53-75, 76-85, and 86-100 (referent). Cox proportional hazards models were used to analyze the extent of depressive symptoms and colorectal events. Analyses were stratified by body mass index. In multivariate analyses with updated exposure, women with the highest levels of depressive symptoms had an elevated risk of incident colorectal cancer (hazard ratio = 1.43, 95% confidence interval: 0.97, 2.11) compared with women with the lowest levels of symptoms (p(trend) = 0.04). Associations appeared stronger in overweight women. However, depressive symptoms were unrelated to risk of colorectal adenomas. Associations are consistent with a possible role in late promotion of the disease.

Depression and possible cancer risk due to oxidative DNA damage

The potential link between depression and cancer is an important unsolved question. To clarify this, we compared a cancer-related oxidative DNA damage, 8-hydroxydeoxyguanosine (8-OH-dG), in peripheral leukocytes between 30 patients with depression and 60 age- and gender-matched healthy controls, and examined the 8-OH-dG-related factors. The degree of depression was assessed by the scores of the Center for Epidemiologic Studies Depression scale (CES-D) and the Profile of Mood States (POMS). The patients showed significantly higher 8-OH-dG levels than the controls. There was a significant positive correlation between the CES-D scores and the 8-OH-dG levels in depressive, particularly female, patients. Multiple regression analysis indicated that whether the subjects were patients or controls was a significant predictor of the 8-OH-dG levels in male and total subjects, as was the CES-D score or the Depression-Rejection score of the POMS in female subjects. This study suggests that clinical depression is a risk factor for cancer initiation in view of oxidative DNA damage.

Harmony seeking and the risk of prostate cancer: a prebioptic study

OBJECTIVE

This semiprospective case-control study was performed to investigate the relationship between harmony-seeking personality and the occurrence of prostate cancer.

METHODS

Out of 217 consecutive participants admitted to hospital for biopsy, 86 and 81 were classified into the case and control groups, respectively, based on their initial diagnosis and eligibility criteria. The participants answered several questionnaires after admission. The logistic regression model was used for multivariate analyses to assess the association.

RESULTS

"Harmony-seeking personality" was selected as the only psychological variable significantly contributing to the model, while "family history of prostate cancer" as the only somatic variable. "Harmony-seeking" maintained a significant contribution to the model, also including "family history" and even to the model adjusted by "patient prediction of cancer diagnosis" and "prostate-specific antigen" (PSA), probably related to the consequences of the disease.

CONCLUSION

The harmony-seeking personality could differentiate between groups of men with and without prostate cancer.

The role of mast cells in migraine pathophysiology

Mast cells are critical players in allergic reactions, but they have also been shown to be important in immunity and recently also in inflammatory diseases, especially asthma. Migraines are episodic, typically unilateral, throbbing headaches that occur more frequently in patients with allergy and asthma implying involvement of meningeal and/or brain mast cells. These mast cells are located perivascularly, in close association with neurons especially in the dura, where they can be activated following trigeminal nerve, as well as cervical or sphenopalatine ganglion stimulation. Neuropeptides such as calcitonin gene-related peptide (CGRP), hemokinin A, neurotensin (NT), pituitary adenylate cyclase activating peptide (PACAP), and substance P (SP) activate mast cells leading to secretion of vasoactive, pro-inflammatory, and neurosensitizing mediators, thereby contributing to migraine pathogenesis. Brain mast cells can also secrete pro-inflammatory and vasodilatory molecules such as interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF), selectively in response to corticotropin-releasing hormone (CRH), a mediator of stress which is known to precipitate or exacerbate migraines. A better understanding of brain mast cell activation in migraines would be useful and could lead to several points of prophylactic intervention.

Breast cancer risk in a large cohort of female antidepressant medication users

Paroxetine in particular has been speculated to increase the risk of breast cancer. The aim of this study was to determine if breast cancer risk is elevated among women who used paroxetine relative to those who used other antidepressants. We conducted a retrospective cohort study of 109,004 female health plan members who used various antidepressants between 1995 and 2000 to evaluate breast cancer risk. The age-adjusted relative risk comparing ever users of paroxetine to those who used other antidepressants was 1.12 (95% CI 0.96-1.31). Women who used paroxetine 2 or more years did not have a greater risk of breast cancer compared to women who used the medication for a shorter period.

Meta-analysis of the effects of psychosocial interventions on survival time in cancer patients

OBJECTIVE

To provide a quantitative summary of effects of psychosocial interventions on cancer survival, and to present an overview of methodological and reporting aspects of the studies.

METHOD

Electronic searches and manual searches of reference lists from review articles and retrieved papers. Two coders independently coded study, participant, treatment, and outcome characteristics of the studies meeting selection criteria.

RESULTS

Thirteen journal articles published between 1989 and 2003 reporting results from 14 controlled intervention studies were included. Results are based on data obtained from 2626 subjects. Effect sizes [hazard ratios (HR)] were heterogeneous and random effects models were used in the analyses. The total mean inverse-variance-weighted HR was 0.85 (95% CI: 0.65-1.11). Randomized studies (n=8) showed no overall treatment effect (HR: 0.77, 95% CI: 0.56-1.06), neither did the nonrandomized studies (HR: 1.00, 95% CI: 0.61-1.62). Interventions using individual treatment (n=3) were, however, found to be effective (HR: 0.55, 95% CI: 0.43-0.70) but interventions using group treatment (n=9) were ineffective (HR: 0.97, 95% CI: 0.73-1.27). Group treatments of breast cancer (n=6) were ineffective (HR: 0.95, 95% CI: 0.69-1.31).

CONCLUSION

A definite conclusion about whether psychosocial interventions prolong cancer survival seems premature. Future studies should use randomization to avoid self-selection of patients with poor prognosis. Interventions should focus on a single diagnosis, take into account known risk factors, and describe their interventions thoroughly.

Psychological factors and cancer development: Evidence after 30 years of research

The question whether psychological factors affect cancer development has intrigued both researchers and patients. This review critically summarizes the findings of studies that have tried to answer this question in the past 30 years. Earlier reviews, including meta-analyses, covered only a limited number of studies, and included studies with a questionable design (group-comparison, cross-sectional or semiprospective design). This review comprises only longitudinal, truly prospective studies (N=70). It was concluded that there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies. Only in terms of 'an influence that cannot be totally dismissed,' some factors emerged as 'most promising': helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis. Some, but even less convincing evidence, was found that having experienced loss events, a low level of social support, and chronic depression predict an unfavorable prognosis. The influences of life events (other than loss events), negative emotional states, fighting spirit, stoic acceptance/fatalism, active coping, personality factors, and locus of control are minor or absent. A methodological shortcoming is not to have investigated the interactive effect of psychological factors, demographic, and biomedical risk factors.