Original Article

Evaluating depression in a sample of children

and adolescents with cancer in Greece
V. Matziou1 RN, PhD, P. Perdikaris2 RN, PhD, P. Galanis3 RN, PhD,
E. Dousis4 RN, PhD & K. Tzoumakas5 MD, PhD
1 Assistant Professor, 3 Nurse, 5 Assistant Professor, Faculty of Nursing, National & Kapodistrian University of Athens,
Athens, Greece, 2 Nurse, Department of Paediatric Oncology, General Children’s Hospital of Athens ‘Panagiotis & Aglaia
Kiriakou’, Athens, Greece, 4 Nurse, Educational Office, General Children’s Hospital of Athens ‘Aghia Sofia’, Athens, Greece

MATZIOU V., PERDIKARIS P., GALANIS P., DOUSIS E. & TZOUMAKAS K. (2008) Evaluating depression in
a sample of children and adolescents with cancer in Greece. International Nursing Review 55, 314–319

Background: Several studies have found that serious illness increases the risk of depression. One of the most
common psychiatric disorders related to the diagnosis and treatment of cancer is depression.
Aim: The aim of the present study was to investigate the rate of depression in children with cancer compared
with that in healthy children.
Patients and methods: The present study is an ongoing prospective study. The research group consisted of
80 children with cancer followed up by an oncology inpatient clinic of a Greek Children’s hospital. The
control group consisted of 84 healthy children. After parental consent was obtained, data were collected using
the Children’s Depression Inventory (CDI) and a socio-demographic data form.
Results: At the time that this study was carried out, neither the research group nor the control group suffered
from depression. In particular, there was no statistically significant difference between the two groups with
respect to symptoms of depression (X̄ = 5.88 for children with cancer vs. X̄ = 7.23 for healthy children,
U = 3013, P = 0.25).
Conclusions: Our findings suggest that the children in this study with malignancies did not have higher
depression scores than their healthy peers, although many previous surveys confirm that children with cancer
are at high risk for depression.

Keywords: Adolescents, Cancer, Children, Children’s Depression Inventory, Depression, Malignancies

Introduction population in Greece. The prognosis for children and adoles-

The incidence of cancer in children is lower than that in adults.
It is estimated that the overall incidence in children between 0
and 14 years was 14.8 per 100 000 of child population for the
year 2004 in the USA (Miller et al. 1995; SEER 2007), whereas
the annual incidence is about 15.05–18.06 per 100 000 of child
Correspondence address: Vasiliki Matziou, 123 Papadiamantopoulou Street,
GR 115 27, Athens, Greece. Tel: 30-210-6014785; Fax: 30-210-7461476;
E-mail: vmatziou@nurs.uoa.gr.
cents with cancer has improved significantly over the last few
years. The survival rates of young patients with cancer
increased from 58.1% between 1975 and 1977 to 77.3%
between 1993 and 1995, according to scientific and epidemio-
logical data from the National Institute of Cancer (Ries et al.
1998; SEER 2007). The efficacy of treatment for the various
types of paediatric cancer has contributed to the recovery of
about 70% of patients (Boring et al. 1994). The aim of the
treatment is not only the cure but also the maintenance of the
quality of life and the psychological and psychosocial health of
the young patient (Von Essen et al. 2000).

© 2008 The Authors. Journal compilation © 2008 International Council of Nurses 314
Evaluating depression in children and adolescents
Review of the literature
Depression is reported to be one of the most common psychiat-
ric disorders of paediatric cancer (Chao et al. 2003; Goldman
et al. 2006; Valante & Saunders 1997). It is caused by the loss of
the sense of normality owing to the disease and the side effects of
the long-term treatment. Depression in children with cancer is
often expressed as a feeling of sorrow and less often as anorexia
and decrease in the mood for activities (Cavusoglu 2001; Lovejoy
& Matteis 1997; Von Essen et al. 2000).
Many studies that concern the psychological parameters of
paediatric cancer have determined rates of depression (Cavuso-
glu 2001; Greenberg et al. 1989; Von Essen et al. 2000; Yavas et al.
1994). The results of the studies are contradictory, as many
researchers did not find significant differences in depression
scores between children with cancer and healthy peers, whereas
some found that children with cancer had higher scores of
depression than healthy children.
Armstrong et al. (1982) suggested a higher score of depression
and stress in children and adolescents with cancer in comparison
with healthy peers. Lansky et al. (1986) and Zeltzer (1993) found
that children with cancer had higher rates of depression than
healthy children. Recently, Cavusoglu (2001), having studied 50
children with cancer and 50 healthy school-aged children, found
a significant difference in depression scores between the healthy
children and the children with cancer.
However, there are many studies which did not show signifi-
cant differences in depression scores between healthy children
and children suffering from cancer (Greenberg et al. 1989;
Yavas et al. 1994). Worchel et al. (1988) and Canning et al. (1992)
found that children and adolescents with cancer had lower levels
of depression in comparison with the control group. Similarly,
Allen et al. (1997) and Neville (1996) found that adolescents with
cancer did not demonstrate more stress and depression than did
healthy peers. Noll et al. (1993, 1999) found in two different
studies that the children who were receiving treatment for pae-
diatric cancer had the same level of depression, stress and self-
esteem as did healthy peers.
Sawyer et al. (1995) studied self-reports from children who
were suffering from cancer, and their mothers’ reports, and
found that stress/depression scores were lower than those
reported for healthy children. Last & van Veldhuizen (1995)
found that when children with cancer were informed about the
disease and its treatment, the possibility of depression was
decreased. Finally, Von Essen et al. (2000) studied 16 children
and adolescents who received treatment for a malignant disease
and found no significant difference relating to self-esteem,
stress and depression in comparison with children and
adolescents who were off-treatment, as well as with healthy
peers.
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
315
Aim of study
The aim of this study was to compare depression scores between
children and adolescents suffering from cancer and healthy chil-
dren of the same ages.
Methods
Sample
The study group consisted of 80 children and adolescents with
cancer followed up by the paediatric oncology ward of the
General Children’s Hospital ‘Panagiotis & Aglaia Kiriakou’ in
Athens, Greece. Children were eligible to participate in the study
if they met the following criteria: (i) had a cancer diagnosis
(confirmed by histological biopsy and excluding brain tumours
as these patients have special problems), (ii) were between the
ages of 6 and 16 years (for the study purposes, adolescents were
defined as the 12–17 years age group), (iii) were undergoing at
least two schemes of cancer therapy, (iv) were receiving cancer
treatment involving chemotherapy and/or radiation, and (v)
were Greek-speaking. The survey was performed between
October 2002 and December 2005.
The control group consisted of 84 healthy children deter-
mined from lists of primary and high schools in the municipality
of Athens, obtained from the Hellenic Ministry of Education.
Three primary schools and two high schools were selected by
random sampling. The control group consisted of students who
were selected using simple random sampling. The Educational
Institute of the Hellenic Ministry of Education gave permission
for the study. The participants of the control group were all free
of cancer, nor ever had paediatric cancer. This information was
obtained by asking their parents.
Ethics
Permission was obtained from the Ethics Committee of the hos-
pital for the ethical acceptance of the study. Informed consent
was obtained from each participant and the parent before
administering the CDI-27. Similarly, permission was asked and
obtained by the Educational Institute of the Hellenic Ministry
of Education. Every healthy child and adolescent participated in
the study after informing his/her parent and obtaining his/her
consent. Before collecting the data from patients’ medical
records, permission was asked and provided by the chief doctor
and the Ethics Committee of the hospital.
Instrument
The Children’s Depression Inventory (CDI) and socio-
demographic data form were given to both groups. A coordinat-
ing nurse collected additional data from the patients’ medical
316 V. Matziou et al.

records. The socio-demographic data form included questions Table 1 Demographic characteristics of participants
about the child’s age, gender, school class, parents’ age and
marital status, education and occupation of parents, the exist- Children with cancer Healthy children
ence and the number of siblings, and where the family lived.
There were questions about the child’s diagnosis, the stage of the Mean age 11.2 ⫾ 2.8 11.4 ⫾ 1.4
illness (treatment, remission) and changes in body image. This Gender
part of the demographic data form was filled in by the parents, Male 45 (56.3%) 38 (45.2%)
Female 35 (43.8%) 46 (54.8%)
except for some information about the disease, which was
Siblings
obtained from the medical record of each child.
Yes 40 (50%) 44 (52.4%)
The CDI-27 is a 27-item self-report symptom scale designed No 40 (50%) 40 (47.6%)
to assess depression in children and adolescents aged 8–15 years Stage of illness
and was developed by Kovac (1985, 1992). The data obtained Treatment 69 (86.3%)
from the self-report symptom scale were used to determine chil- Relapse 11 (13.7%)
dren at risk of depression. The inventory assesses commonly Disease
accepted symptoms of depression that the children had experi- Leukaemia 31 (38.8%)
Solid tumour 22 (27.5%)
enced in the previous 2 weeks. For each item there are three Other 27 (33.7%)
sentences and the children choose the one that best matches their
feelings. Each item is rated on a scale of 0–3, in terms of severity
of symptoms. Total scores range from 0 to 54 and the cut-off
Table 2 The mean scores of Children’s Depression Inventory and the
point for depression is 19. In this study the children completed stage of illness
the inventory by themselves. It was found that the reliability of
CDI-27 in Greek children population was high (Cronbach’s
Stage of illness n X̄ SD U P-value
alpha = 0.833).
Treatment 69 5.7 4.9 311 0.4
Statistics Relapse 11 7.1 5
The Statistical Package for Social Sciences (spss) program,
version 13.0 was used for statistical analysis. Continuous data X̄, mean; SD, standard deviation.
were expressed as means (⫾standard deviation), while categori-
cal or dichotomous variables were expressed as percentages of Table 3 The distribution of Children’s Depression Inventory (CDI)
the groups. A one-sided P-value of less than 0.05 was considered scores among groups
statistically significant. The Mann–Whitney test was used to
compare values in the two groups. CDI scores Children with Healthy Total
cancer children
Findings
n % n % n %
The demographic characteristics of participants are shown
in Table 1. The mean age of children with cancer was
0–5 44 55 44 52.4 88 53.7
11.2 ⫾ 2.8 years and the mean age of healthy children was 6–10 22 27.5 17 20.2 39 23.8
11.4 ⫾ 1.4 years. Forty (50%) children with cancer had siblings, 11–15 8 10 13 15.5 21 12.8
compared with 44 (52.4%) healthy children. There were more 16–20 6 7.5 7 8.3 13 7.9
males in the cancer group. The majority of the fathers in both 21–25 0 0 1 1.2 1 0.6
26–31 0 0 2 2.4 2 1.2
groups had university level education. The majority of mothers Total 80 100 84 100 164 100
in the cancer group had high school education, while in the
healthy group most mothers had university level education.
The children with malignant conditions had leukaemia, lym-
phoma and solid tumours. The majority of children with cancer The distribution of depression scores among children with
were in a treatment phase and the mean CDI scores of children in cancer and healthy children is shown in Table 3. The majority
relapse were higher than those of children in the treatment stage of the children in both groups had scores between 0 and 5.
but this difference was not significant (Table 2). Three (3.6%) healthy children had scores of 19 or higher in the

© 2008 The Authors. Journal compilation © 2008 International Council of Nurses

Evaluating depression in children and adolescents
Table 4 The mean scores of Children’s Depression Inventory among
groups
Groups n X̄ SD U P-value
Children with cancer 80 5.88 4.87 3013 0.25
Healthy children 84 7.23 6.26
X̄, mean; SD, standard deviation.
depression scale, while only one (1.2%) child with cancer had a
score of 19. The children according to their age were divided into
two categories: 7–12 and 13–17 years. Healthy children had
higher depression scores than children with cancer, although the
differences were not significant (Table 4). The mean depression
scores of children aged between 7 and 12 years and children aged
between 13 and 16 years are shown in Table 5 in terms of health
status. Adolescents with cancer had higher mean depression
score than children with cancer, but the difference was not sta-
tistically significant (U = 600.5, P = 0.069). Healthy children
aged between 13 and 16 years had higher depression scores than
children with cancer (U = 170, P = 0.05).
The statistical analysis of children with cancer and healthy
children in terms of gender shows that the mean depression score
of males (7 ⫾ 6.3) was higher than females (6.2 ⫾ 4.9), but this
difference was not statistically significant (U = 3233, P = 0.67).
In the healthy group, males had higher depression scores than
females, but this difference was not statistically significant, and
in children with cancer, females had higher depression score
than males. The mean depression score of females with cancer
was 6.2 ⫾ 5, while of healthy females was 6.1 ⫾ 4.8 (U = 796,
P = 0.93). Moreover, healthy males had higher depression score
(8.6 ⫾ 7.4) than males with cancer (5.6 ⫾ 4.8), but this differ-
ence was not statistically significant (U = 673, P = 0.1). Finally,
socio-demographic factors such as the number of siblings, type
of family, occupation and education level of parents did not
show any significant difference in CDI scores.
Discussion
Cancer during childhood and adolescence is a life-threatening
disease which is accompanied by stress, emotional instability,
fear, depression, changes in lifestyle and uncertainty for the
future (Hassel 1996; Lamarine 1995). Children and adolescents
with cancer are said to be at high risk for depression owing to the
disease and its treatment. However, the results of our study have
shown that children with cancer did not have higher depression
scores than did their healthy peers.
Depression in our study was evaluated after the completion of
the second chemotherapy or radiotherapy scheme, a time period
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
317
that is relatively close to the time of initial diagnosis. Children’s
reactions to the disease and its treatment depend significantly
on their cognitive level and age (Cavusoglu 2001). The level of
depression may be low at this time, because they had not suffered
the effects of the continuous schemes and the consecutive side
effects of the treatment. The mean age of the sample was
11.2 years and this may be a protective mechanism, as the expe-
riences from the disease had not yet been strong (Cavusoglu
2001; Greenberg et al. 1989).
Children tend to worry about the feelings of their parents.
They, often, want ‘to protect’ their loved ones, by hiding facts,
situations or feelings which may be painful or stressful. Canning
et al. (1992) suggest that the absence or the attenuated awareness
of emotional distress could explain such factors, whereas
Worchel et al. (1988) suggested that children denied the
acknowledgement of emotional distress, using refusal as a pro-
tective mechanism. It seems that children with cancer may
develop conscious, preconscious and unconscious mechanisms
in order to gain a sense of security and hope, which is essential
for their psychological survival (Von Essen et al. 2000).
Besides the initial shock, cancer diagnosis in a child or in an
adolescent is usually accompanied by the development of a pro-
tective background by the family in Greek culture. Within this
background of ‘overprotection’, the parents offer affection and
love in an attempt to escape from the threat of cancer. At the
same time, the children develop their own defences, thus they
may not feel depressed at the time after the diagnosis, when our
study was performed.
Our findings suggest that there is no significant difference in
depression score between males and females with cancer. This
result is comparable with others and strengthens the conclusion
that gender does not influence depression levels in the preado-
lescent period (Cavusoglu 2001; Moreau 1990). In our study,
girls with cancer did not have significantly higher depression
score than the boys did, although changes in body image
influence mostly girls (Anholt et al. 1993; Madan-Swain et al.
1994).
The results from our study were comparable with those of
previous surveys using the same tool (Noll et al. 1999; Von Essen
et al. 2000). On the other hand, they were lower than that of
Cavusoglu (2001) who found that children with cancer had
higher depression score than their healthy peers. Our results
suggest that adolescents (age of 12–17 years) had higher depres-
sion scores than children, although this difference was not sta-
tistically significant. This finding strengthens the conviction that
cognitive level and age influence depression levels of children
with cancer, and older children may better understand the
disease, the treatment, its side effects and the changes in their
lives (Cavusoglu 2001).
318 V. Matziou et al.
Table 5 The mean scores of Children’s Depression Inventory among age categories and groups
Group Children aged between 7 and 12 years
n X̄ SD
Children with cancer 45 5.1 4.6
Healthy children 69 6.4 5.6
X̄, mean; SD, standard deviation.
The children with relapse had higher depression scores than
the children with an initial cancer diagnosis, although the differ-
ence was not significant. Only one child (1.2%) passed the cut-
off point of depression in our study. No other demographics
(number of siblings, type of family, parental occupation and level
of education) were found to be of influence.
The findings suggest that the care given to these children may
have significant effects on depression. We found two reasons
which could account for these findings: (a) factors that were
related to the children’s health care, and (b) the time of data
collection. Holistic nursing care, appropriate information-giving
for children and parents, the interventions of a specialized child
psychologist, the trust between ill children, parents and staff, and
the child-orientated and family-orientated patterns of care may
have resulted in the children having positive feelings despite their
disease. We also considered that the time of data collection
occurred soon after initial cancer diagnosis, so the children may
not have had many painful procedures or experiences owing to
their cancer. Only one child had suffered depression, but his
mother had died during his hospital stay, so his emotional status
had been jeopardized.
Limitations
This study was performed in one paediatric oncology clinic. In
Athens, there are two major paediatric hospitals, which have
paediatric oncology units, but they use different treatment pro-
tocols. We preferred to include in our study children who were
treated with the same protocols in order to avoid other poten-
tially confounding factors, although in consequence our sample
was smaller. In the hospital where we performed the study, 80
new cases of paediatric cancer are diagnosed every year. Only
20–25% of them met our inclusion criteria. Moreover, we did not
create categories of ill children and adolescents depending on
their type of malignancy, thus we could not differentiate the
specific change in depression scores for each type of cancer. We
suggest that depression should be assessed in each type of cancer
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
Children aged between 13 and 17 years
U P-value n X̄ SD U P-value
1370 0.29 35 6.9 5 170 0.05
15 11.1 7.7
separately, but such surveys need a wider sample and a consid-
erable time period.
Nursing implications
In our study, there was no statistically significant difference in
depression scores between the young patients with cancer and
the control group. This finding may reflect the good work of
the scientific team, in which the nurses’ role is very important.
Paediatric oncology nurses should target two specific groups:
(a) young patients with cancer, and (b) their parents-proxies.
Nurses should spend time listening to children’s fears and
worries and identifying signs and symptoms of depression.
Moreover, nurses need to teach parents, who are responsible for
the care of their ill children especially in chronic diseases, to
report changes in their children’s behaviour, which may show
depression.
Future studies should focus on the comparison of depression
scores in young patients who are undergoing treatment and then
become survivors of childhood cancer in order to establish dif-
ferences in depression scores in on- and off-treatment paediatric
cancer populations. Further, it will be of great interest to
compare survivors’ depression scores with those of control
groups in order to understand the patterns of depression in
paediatric cancer more widely.
Conclusions
Our findings suggest that children with malignancies had no
higher depression scores than their healthy peers, although many
other studies confirm that children with cancer are at high risk of
depression. Paediatric oncology nurses have the responsibility to
recognize signs and symptoms of depression in children with
cancer. The application of valid and reliable tools in clinical
practice helps nurses to recognize and evaluate children with
malignancies who suffer from psychological disorders as early as
possible.
Evaluating depression in children and adolescents
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