Depression, Somatic Distress and Anxiety in Adult Long-Term Survivors of Hematopoietic Cell Transplantation (HCT): A Report from the Bone Marrow Transplant Survivor Study.
Authors: Francisco Liton , Baker K. S. , Carter Andrea , Forman Stephen J. , Gurney James G. , Grant Marcia , Robison Leslie L. , Weisdorf Daniel J. , Bhatia Smita 
Published: October 2019

Abstract
We assessed prevalence of adverse psychological symptoms in a retrospective cohort of 865 patients who had undergone HCT between 1974 and 1998 for hematological malignancies (CML: n=214; AML: n=233; NHL: n=198; HD: n=84; ALL: n=96) and severe aplastic anemia (n=47), at City of Hope Cancer Center or the University of Minnesota. Participants were at least 21 years of age at interview, and had survived at least two years post-HCT. A cohort of 317 nearest-age siblings of survivors served as a comparison group. Related donor HCT was performed in 416 patients (48.1%), unrelated donor HCT in 97 patients (11.2%), and autologous HCT in 352 patients (40.7%). The median age at HCT was 33.9 years (range, 1.7 to 69.7 years), and the median length of follow-up was 7.4 years (2.0 to 27.8 years). The median age at the time of study was 43 years (18–72) for the survivors and 44 years (19 to 79 years) for the siblings. Psychological health status was evaluated via a series of 5-point Likert scale items (n=18), from the Brief Symptom Inventory, exploring the degree to which particular problems distressed the respondent during the past 7 days, allowing assessment of symptoms associated with depression, somatic distress, and anxiety. Twenty-one percent of survivors and 8% of siblings reported having at least one prevalent adverse mental health symptom. Survivors were significantly more likely to report symptoms of depression [Prevalence Odds Ratio (OR), 1.84, 95% CI, 0.99–3.42] and somatic distress (OR, 4.34, 95% CI, 2.23–8.46), when compared with siblings. There was a significant association between low household income (<$20,000/year compared with >$60,000/year) and adverse symptoms across all domains of mental health that was independent of survivor/sibling respondent status (Depression: OR=4.78, 95% CI, 2.59–8.82; Somatic distress: OR=2.43, 95% CI, 1.41–4.21, Anxiety: OR=2.80, 95% CI, 1.09–7.20). Independent of survivor/sibling respondent status, females were significantly less likely to report depression when compared with males (OR=0.61, 95% CI, 0.39–0.95). Among the patients, factors associated with reporting at least one prevalent symptom of psychological distress included therapeutic exposure to etoposide as a preparative regimen (OR=1.79, 95% CI, 1.2–2.68), prophylactic use of prednisone for graft versus host disease (GVHD) prevention (OR=1.42, 95% CI, 0.91–2.21), presence of chronic GVHD (OR=1.62, 95% CI, 1.06–2.49), and low household income (OR=3.0, 95% CI, 1.82–4.95). Age at HCT, time since HCT, marital status, race/ethnicity, primary diagnosis, and type of transplant, were not associated with symptomatic scores for depression, somatic distress, or anxiety. This large, sibling-controlled study of long-term survivors of HCT demonstrates that HCT survivors are at significantly increased risk of reporting symptoms of depression and somatic distress, and that low household income is associated with this risk, necessitating careful follow-up of this vulnerable population.