Examining the relationship between social support, depression, and cancer in Latin America through research collaborations
A team of medical students from the University of Michigan and Universidad San Francisco de Quito is seeking to better understand the influence of social support systems in helping individuals cope with cancer, particularly how one’s close relationships may affect the development of depression symptoms during the cancer treatment process.
The project is part of an ongoing partnership between researchers at U-M, USFQ, and the Sociedad de Lucha Contra el Cáncer (SOLCA), which operates a large comprehensive cancer care facility in Quito, Ecuador.
While the connection between perceived social support and rates of depression has been well documented in cancer populations in the U.S. and Canada, less is known about this relationship in Latin America, a part of the world where family ties tend to be robust, but stigma around mental illness remains stubborn.
The student researchers in front of the SOLCA clinic.
The project is comparing rates of depression among cancer patients to the rates established in primary care, with the hypothesis that the burden of depression will be higher among those with cancer. To assess rates of depression among the SOLCA clinic’s cancer patients, the team used the validated PHQ-9 screening tool. [A research project completed in 2012 by David Schrock, a U-M medical student, along with with USFQ medical students Eric Fabara and Gabriela Jimenez, documented rates of depression in a primary care setting in Quito, reaffirming the utility of the PHQ-9 in Ecuador.]
As a way to provide a brief but broad assessment of patients’ concerns and need for assistance during their cancer treatment, the team also used an instrument called the Distress Thermometer, commonly used in cancer clinics in Europe and the U.S. This instrument identifies anxiety, depression, and anger in patients with cancer, providing a simple measure of current “distress.”
In addition, the students used the Experiences in Close Relationships scale to examine how people interact with their romantic partners during the cancer treatment process (if they don’t have a romantic partner, a shortened version refers to close friends).
Patients completed the instruments in clinic waiting areas on tablet computers with touch screens. The captured data is stored on the tablet and later synced centrally with a wireless connection, which represents a significant advance in data gathering techniques in global health research.
“We’re looking to see if there’s a relationship between how people do on the Distress Thermometer and the PHQ-9, with how their personal life is,” says Erica Prochaska, one of the project researchers and a second-year medical student at U-M. “We want to see if the people who have closer relationships and feel comfortable talking with their partner are doing better emotionally during their cancer treatment.”
Although the team has yet to formally analyze their data (fieldwork wrapped up in July 2013), they have already seen strong evidence that the level of social support may be a better predictor of a cancer patient’s emotional functioning than their cancer prognosis. “Even patients who have a terminal diagnosis but have great family support behind them will say, ‘you know, I’m doing pretty well,’” Paula Goldman, another team researcher and second-year U-M medical student, says.
Conversely, people who may have felt isolated or “abandoned” in their experience with cancer diagnosis and treatment have generally appeared to be more prone to depression symptoms, with that perceived lack of social support seeming to weigh as heavily on them as (if not more than) the challenges that may lie ahead in their cancer journey.
“This makes a lot of sense to me,” Goldman says. “When I think about many of the people we spoke with, they really considered strong mental health to be derived from family and relationships, rather than intrinsically derived.”
Better knowledge about the role of social support in improving well-being among those living with cancer may prove especially valuable in a part of the world where family ties are notoriously strong – particularly around a loved one dealing with illness. “In Ecuador, if someone is sick, the whole extended family comes together to support and visit them,” explains project team member Ignacio Stacey, who is completing his final year of medical school at USFQ.
In the long term, the research team hopes their work will also help document the need for expanded mental health services as well as more integrated mental health care that leverages novel technologies to help strengthen services in a region where psychiatric care has typically been fragmented or absent. For example, SOLCA’s Quito clinic, the largest cancer center in Quito and one of the largest in Ecuador, has just one psychiatrist and one psychiatry resident to serve the entire hospital.
For many individuals the students have had the chance to interact with on the project, there’s been more immediate benefit. Until they talked with the research team, a number of patients who were in distress were unaware of the psychiatric services available at all in the clinic, and the students were able to help them make appointments quickly and address some of their urgent needs.
In small but meaningful ways, the team believes, this project has helped further normalize the experience of talking about mental health as a medical issue in the setting of cancer care.
“There is still a lot of taboo here in Ecuador towards mental health,” Stacey explains. “Many times when we were talking to the patients and asked if they wanted for us to do some follow up with a mental health doctor, there were negative responses – that they didn’t need it since they were not ‘crazy.’”
“If we took the approach of calling the doctors ‘specialists in mood disorders,’ however, patients were more willing to accept help,” he says.
Goldman adds that “mental health and spiritual health seemed to be considered to be strongly intertwined, which can lead to stigma when depression is viewed as a failure of faith.”
For the U.S.-based students, the experience afforded the opportunity to build their skills as physicians and researchers through cross-cultural partnerships and networks.
“Having a multicultural team of both students and physician mentors was incredible. The fact that we were able to collaborate so successfully gave me a whole new level of confidence in the power of international research and medicine,” Goldman says. “I may also never again have an unlimited amount of time to listen to each patient, so I was so glad to have this chance.”
This project and similar research in other parts of the world, by establishing a clearer picture of the interplay between personal relationships and health status in various cultural settings, are contributing to the knowledge base about the potential for social support to improve outcomes for both cancer and depression. As long-lasting and sustainable outcomes, this project directly suggests effective ways to integrate and supplement the available mental health services for cancer patients.
In addition to the U-M and USFQ medical students, the research team includes SOLCA researchers José Mosquera, M.D., and Ivonne de la Vega, M.D. Student mentorship was provided jointly by Depression Center Associate Director Melvin McInnis, M.D., Sofia Merajver, M.D., Ph.D., Scientific Director of the Breast Oncology Program of the U-M Comprehensive Cancer Center, and Michelle Grunauer, M.D., Dean of the School of Medicine at USFQ. Aimee Miller, LCSW, provided project coordination and management in Quito.
This work is part of “The Quito Project,” a medical student initiative founded a decade ago by Bina Valsangkar, who was then an undergraduate student headed for medical school at U-M. The U-M project students were supported in part by the U-M Student Biomedical Research Program (Goldman) and the U-M International Institute (Prochaska). Additional financial and data analyses support was provided by the U-M Depression Center and Comprehensive Cancer Center.