ORIGINAL RESEARCH

published: 12 January 2021

doi: 10.3389/fpsyt.2020.584907

Anxiety and Depression

Comorbidities in Moroccan Patients
With Breast Cancer
Ouassil El kherchi 1 , Amina Aquil 1 , Noureddine El khoudri 1 , Mustapha Mouallif 1 ,
Mohamed Daghi 1 , Maroua Guerroumi 1 , El madani Saad 1 , Abdellatif Benider 2 ,
Arumugam R. Jayakumar 3*† and Abdeljalil Elgot 1*†
1
Epidemiology and Biomedical Unit, Laboratory of Sciences and Health Technologies, Higher Institute of Health Sciences,
Hassan First University of Settat, Settat, Morocco, 2 Mohammed VI Center for the Treatment of Cancers, Ibn Rochd
University Hospital Center Casablanca, Casablanca, Morocco, 3 Neuropathology Research Unit, Miami VA Medical Center
Edited by: and Department of Obstetrics, Gynecology and Reproductive Sciences University of Miami Miller School of Medicine, Miami,
Yuan-Pang Wang, FL, United States
University of São Paulo, Brazil
Reviewed by:
Marilene Filbet,
Background: Breast cancer is the leading cause of cancer death in women worldwide
Hospices Civils de Lyon, France with more than 1. 7 million new cases annually. Major advances have been made in the
Majdouline Obtel, therapeutic management of this condition in many countries. However, neuropsychiatric
Mohammed V University, Morocco
disorders in patients with breast cancer constitute a significant concern due to their
*Correspondence:
Arumugam R. Jayakumar negative impact on patient’s life and on the success of therapy itself.
ajayakumar@med.miami.edu
Methodology: In this study we aimed to evaluate psychological disorders in a
Abdeljalil Elgot
abdeljalil.elgot@uhp.ac.ma population of 212 Moroccan women treated for breast cancer within the Mohammed VI
† These
Center for the Treatment of Cancers of Casablanca. A questionnaire was designed to this
authors have contributed
equally to this work end on the basis of different validated scales, including the Hospital Anxiety Depression
Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI), and the Body Image Scale (BIS).
Specialty section:
This article was submitted to Results: Data analysis has shown that 69.3% of participants had significant sleep
Mood and Anxiety Disorders, disorders; 87% suffer from an anxiety-depressive syndrome (ADS), and 83.0% had
a section of the journal
Frontiers in Psychiatry
significant body image dissatisfaction. A positive correlation was shown between ADS
Received: 25 July 2020
and both patients’ national health insurance coverage and patients or husbands’
Accepted: 25 November 2020 education. Analysis further revealed that anxiety and depression were negatively
Published: 12 January 2021 correlated with different types of treatment. Similarly, both BIS and PSQI scores were
Citation: positively associated with anxiety and depression disorders.
El kherchi O, Aquil A, El khoudri N,
Mouallif M, Daghi M, Guerroumi M, Conclusion: The present investigation highlights the need to generalize and strengthen
Saad Em, Benider A, Jayakumar AR
the psychological approach of patients treated for breast cancer in Morocco. We
and Elgot A (2021) Anxiety and
Depression Comorbidities in anticipate that such a strategy will alleviate suffering and promote therapy success in
Moroccan Patients With Breast these patients and will diminish or prevent conjugal and familial impacts of the illness.
Cancer. Front. Psychiatry 11:584907.
doi: 10.3389/fpsyt.2020.584907 Keywords: breast cancer, anxiety, depression, sleep quality, body image, Morocco, survey

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El kherchi et al. Anxiodepressive Disorders in Breast Cancer Patients

INTRODUCTION including types of treatment, sleep disturbance, and body

image dissatisfaction.
Breast cancer is considered to be one of the most common public
health issues in the world. It’s the leading cause of mortality due
to cancer in women in the world, with more than 1.7 million new METHODS AND MATERIALS
cases and ∼521,900 deaths each year (1). Various investigations Study Design and Sample
have shown a negative impact of this pathology on the quality The present descriptive and cross-sectional analysis was carried
of life of patients, due to its chronicity and malignancy (2). In out between February 2018 and May 2019 in the Mohammed
addition, although the various healing forms—chemotherapy, VI Center for the Treatment of Cancers, Ibn Rochd University
radiotherapy, and surgery—allowed better management of Hospital of Casablanca, Morocco. Casablanca is the largest city
patients suffering from this pathology, they affect the mental in Morocco and the economic capital of the country. During this
health of patients and cause significant mood disorders (3, 4). study, 212 breast cancer patients were randomly chosen among
According to a recent epidemiological study published by a patients coming for follow-up at the Oncology Department. The
German research team, 32% of people with cancer in general inclusion criteria were the following: women with confirmed
and 42% of those with breast cancer in particular, have a high diagnosis of breast cancer, those agreeing to participate in this
level of mental disorders and emotional distress (5). These study with written consent (for unschooled patients, verbal
disorders are the main criteria for the Diagnostic and Statistical consent followed by a fingerprint was used as proof of consent),
Manual of mental disorders (DSM-IV), which include, among patients with no previous follow-up of any psychiatric and mental
others, anxiety, and depression. Indeed, new studies suggest that disorders, and the ability to understand and speak the Moroccan
depression is a common comorbidity in cancer patients, who dialect. The latter was to ensure efficient and easy communication
exhibit poor quality of life, more functional disorders, higher during the completion of the questionnaire.
levels of suicidal ideation, and significant death rates (6).
In this setting, depression disorders consist of a combination
of major depressive disorders, persistent depressive disorders—
Questionnaire Validation
Before proceeding with data collection using the Hospital
also known as dysthymic disorders—and a mixed form of
Anxiety and Depression Scale (HADS), the Pittsburgh Sleep
both depression and anxiety disorders (7). In addition, women
Quality Index (PSQI), and the Body Image Scale (BIS), two
with breast cancer show anxiety, including post-traumatic stress
translators translated the questionnaire from English into
syndrome and generalized anxiety disorders characterized by
dialectal Arabic, and then another team made up of two other
persistent and excessive worries about numerous events (8).
translators performed a back translation of the questionnaire.
In Morocco, breast cancer is the leading cancer in terms of
The two versions of the questionnaire were studied by a team
incidence and mortality (9). The quality of life and psychiatric
of experts (translators, a nurse, a psychiatrist, an epidemiologist,
health care of people with this pathology is gaining more
and an oncologist) to produce a pre-final version. Finally,
and more interest but has still not reached desirable levels.
a pilot study was carried out on 30 cancer patients to test
Hence, in Morocco, very few data are available on this subject.
comprehension of the items. The reliability test calculation
The few published data on Moroccan patients claim that
(Cronbach α) indicates good validity for the three scales (HADS,
radical mastectomy should be avoided “as far as possible” in
BIS, and PSQI).
young women suffering from breast cancer, as it engenders in
them more anxiety and more depression disorders, whereas
conservative surgery should be practiced whenever possible for Assessment of Anxiety and Depression
young patients to cope with psychological distress related to Disorders
mastectomy (10). In this study we used a questionnaire that provided participants’
The same Moroccan team working at the Moroccan National socio-demographic data and the Hospital Anxiety and
Institute of Oncology at Rabat, the capital, suggested many Depression Scale (HADS). The HADS, developed by Zidmond
interventions that should be done in order to protect patients and Snaith (13), assesses the dimensions of anxiety and
living with breast cancer against psychological distress, among depression in non-psychiatric populations and largely used in
them, social family support and both emotional and financial psycho-oncology research. In addition, it offers the advantage of
facilities (11). eliminating, at the same time, the physical symptoms that can
However, a study published by Haddou Rahou and his be bias factors. The HADS consists of two subscales of seven
collaborators highlighted a lack of studies on the quality of life items each, which give two scores, the first measuring anxiety
of women with breast cancer in different Muslim and Arab (HAD-A) and the second, depression (HAD-D). The anxiety
countries, including Morocco. Hence the need to conduct a and depression subscales have three levels: 0–7, absence of
comprehensive investigation (12). anxiety or depressive disorders; from 8 to 10, suspected anxiety
The aim of this study was to evaluate both anxiety and or depressive disorders; and from 11 to 21, proven anxiety or
depression disorders in a population of Moroccan breast depressive disorders. The total HADS-T scale ranges from 0 to
cancer patients within the region of Casablanca, the largest 14 (absence of anxio-depressive disorders) and from 15 to 42
Moroccan city, and to identify the anxio-depressive impacts of (existence of anxio-depressive disorders). The Cronbach α for
some socio-demographic parameters and some clinical variables the HADS scale used in this study is 0.76, showing good validity.

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El kherchi et al. Anxiodepressive Disorders in Breast Cancer Patients

Assessment of Sleep Quality Disorders study is 0.85 which demonstrated a very a good reliability of the
The Pittsburgh Sleep Quality Index (PSQI) used in the used questionnaire.
questionnaire has 19 items grouped into seven components,
including: (i) subjective sleep quality, (ii) sleep latency, (iii) Statistical Analysis
duration of sleep, (iv) habitual sleep efficiency, (v) sleep The descriptive analysis consisted of calculating absolute and
disturbances, (vii) sleep medication use, and (vii) daytime relative frequencies for qualitative variables, in addition to
dysfunction due to lack of sleep. Each component score ranges positioning and dispersion parameters for quantitative variables
from 0 to 3, where 3 refers to a severe sleep disturbance. The (average, standard deviation).
summation of the PSQI scores yields a total score ranging from 0 The normal distribution of the variables was examined
to 21. A total score >8 indicates a patient with a significant sleep with the Kolmogorov-Smirnov test. In bivariate analysis, the
disorder and poor sleep quality. The Cronbach α for the PSQI in continuous variable comparison involved the Student t-test, the
this study is 0.67; this value is strong and approaches one of the Mann-Whitney test, ANOVA, and the Friedman test.
original validations (14). The significance level was set at p < 0.05. The statistical
analysis was carried out using SPSS software version 19.0.
Assessment of Body Image Dissatisfaction
In the current study, body image dissatisfaction regarding RESULTS
breast cancer patients was assessed using the body image
scale (BIS) (15). This scale includes 10 items developed to Socio-Demographic Characteristics
evaluate briefly and consistently the affective, behavioral, and The present study was based on data from a random sample
cognitive aspects of the body image in cancer patients who are of Moroccan woman with breast cancer. The age range was
undergoing appearance changes. It also reflects the impact of from 22 to 82 years (n = 212), with a mean age of 49.66
cancer treatment, including surgery, on the body image of breast (SD = 12.50). About half of the participants (49.53%) and
cancer patients. The BIS components score ranges from 0 (not their husbands (56.60%) were unschooled and exhibited a low
at all) to 3 (very much), and the BIS final score (the sum of the educational level, and about 52% were of low socioeconomic
10 items subscales) ranges from 0 (body image satisfaction) to status. As for insurance coverage, the vast majority of our study
30 (strong body image dissatisfaction). The Cronbach α for this population (93.4%) had RAMED, which is a national health

TABLE 1 | Demographic and clinicopathological characteristics of the breast cancer sample.

Characteristics Study population (n = 212)

n %

Women’s age (Years) <35 21 9.91

35–49 103 48.58
>50 88 41.51
Education’s level Unschooled 105 49.53
Elementary 44 20.75
High school and university 63 29.72
Socioeconomic status Low 109 51.42
Average and high 103 48.58
Health insurance coverage CNPS CNSS 14 6.60
RAMED 198 93.40
Residential typologies Rural 54 25.47
Urban 158 74.53
Husduand’s education Unschooled 120 56.60
Elementary 44 20.75
High school and university 48 22.64
Types of treatments (Two) surgery, chemotherapy 69 32.55
(Three) surgery, chemotherapy, hormone therapy 131 61.79
(Four) surgery, radiotherapy, chemotherapy, and 12 5.66
hormone therapy or immunotherapy
BODY Image Scale (BIS)- total score BIS-S 36 16.98
BIS-D 176 83.02
Pittsburgh Sleep Quality Index (PSQI-T) PSQI-T < 8 65 30.66
PSQI-T >8 147 69.34

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El kherchi et al. Anxiodepressive Disorders in Breast Cancer Patients

TABLE 2 | Comparison between the Hospital Anxiety and Depression scale components (HADS-A, HADS-D, HADS-T) and both demographic and clinicopathological
characteristics.

Characteristics HADS-A HADS-D HADS-T

Mean ± SD P-value Mean ± SD P-value Mean ± SD P-value

Women’s age (Years) <35 12.67 ± 4.041 0.29 10.38 ± 4.353 0.35 23.05 ± 7.194 0.31
35–49 13.96 ± 3.559 10.99 ± 3.974 25.05 ± 6.82
>50 13.88 ± 3.293 11.56 ± 3.328 25.43 ± 5.669
Educational levels Unschooled 14.54 ± 3.337 0.0001*** 11.95 ± 3.341 0.0001*** 26.5 ± 5.696 0.0001***
Elementary 14.18 ± 2.326 11.7 ±0.764 25.89 ± 5.226
High school and university 12.29 ± 4.002 9.48 ± 3.926 21.92 ± 7.247
Socioeconomic status Low 14.08 ± 3.588 0.22 11.72 ± 4.028 0.028* 25.8 ± 6.8 0.065
Average and high 13.05 ± 3.407 10.58 ± 3.377 24.17 ± 5.89
Health insurance coverage CNPS CNSS 15.71 ± 2.4 0.034* 11.36 ± 2.341 0.84 27.07 ± 2.674 0.014*
RAMED 13.66 ± 3.535 11.15 ± 3.844 24.86 ± 6.575
Residential typologies Rural 14.28 ± 3.153 0.24 11.91 ± 3.338 0.093 26.19 ± 5.624 0.12
Urban 13.63 ± 3.612 10.91 ± 3.871 24.61 ± 6.627
Husband’s education Unschooled 14.61 ± 2.979 0.097 11.89 ± 3.198 0.05* 26.5 ± 5.168 0.05*
Elementary 13.36 ± 3.807 10.4 ± 5.058 23.76 ± 8.243
High school and university 13.3 ± 3.941 10.2 ± 3.624 23.83 ± 6.953
Types of treatments Two 14.29 ± 3.01 0.008** 11.42 ± 3.371 0.005** 25.71 ± 5.196 0.002**
Three 13.8 ± 3.535 11.34 ± 3.843 25.22 ± 6.582
Four 10.92 ± 4.621 7.75 ± 3.596 18.67 ± 7.866
Body Image Scale (BIS)- total score BIS-S 12.08 ± 3.667 0.001** 9.19 ± 4.341 0.004** 21.28 ± 6.606 0.0001***
BIS-D 14.15 ± 3.376 11.57 ± 3.905 25.77 ± 6.114
Pittsburgh Sleep Quality IndeX (PSQI-T) PSQI-T<8 12.82 ± 3.863 0.007** 10.54 ± 3.657 0.64 23.28 ± 6.677 0.009**
PSQI-T>8 14.22 ± 3.258 11.48 ± 3.773 25.78 ± 6.159

*p < 0.05, **p < 0.001, ***p < 0.0001.

insurance program intended to allow low-income Moroccan Correlation Between the HADS
citizens access to health facilities (Table 1). Components and Both Socio-Demographic
and Clinical Characteristics
In this study, three components of the HADS scale were used:
Clinical and Neuropsychiatric HADS-A, for anxiety; HADS-D, for depression; and HADS-T, for
Characteristics anxio-depressive syndrome. The three components allowed the
After analyses of patients’ medical history, several treatments assessment of the presence or absence of these neuropsychiatric
were administered to our breast cancer patients. Thus, almost disorders, which usually occur in women with breast cancer
two thirds of our sample (61.79%) received surgery and/or (Table 2).
chemotherapy or hormone therapy. In all, 32.55% of patients Throughout the present study, we noticed that our general
received only surgery and chemotherapy. A minority of our population showed suspected or well-proven anxiety and/or
participants (5.66%) had surgery, radiotherapy, chemotherapy, depression. The suspected anxiety or depression is assessed
and hormone therapy together (Table 1). from a HADS-A or HADS-D score from 8 to 10. Anxiety or
As for the assessment of sleep quality, the total score of the depressive disorders are proven by HADS-A or HADS-D scores
Pittsburgh Sleep Quality Index (PSQI-T) revealed that more than ranging from 11 to 21. Data also indicate the presence of anxio-
two thirds of our breast cancer patients (69.34%) had significant depressive syndrome (ADS) for the whole of our breast cancer
sleep disorders and exhibited poor sleep quality (Table 1). population (total score, HADS-T >15) (Table 2). According to
The monitoring of neuropsychiatric parameters revealed our results, anxiety and depressive disorders could affect any
that our population sample exhibited severe psychiatric age range without any distinction (p > 0.05). However, a strong
comorbidities. In fact, the HADS and the BIS data analysis correlation was found between educational levels and the onset
showed that 86.67% of our breast cancer patients suffered of both anxiety and depression in our sample (p = 0.0001). This
from an anxiety-depressive syndrome (ADS). Results further correlation was also seen between the husband’s education levels
showed that almost 83% our population suffered from not and both depression and ADS (p = 0.05).
being attractive and then expressed significant body image Furthermore, data indicate no association between the
dissatisfaction (BIS-D) (Table 1). aforementioned neuropsychiatric and socioeconomic status

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El kherchi et al. Anxiodepressive Disorders in Breast Cancer Patients

(p > 0.05), whereas our results showed a noticeable association leading to cancer progression and reducing patients’ lifespan
between national health insurance coverage (RAMED) and both (19, 20).
anxiety disorder (p = 0.034) and ADS (p = 0.014) (Table 2). In our breast cancer sample, it seems that anxiety and
As for the effect of other health factors on the mental depression comorbidities are strongly correlated to patients’
health of our breast cancer population study, results showed body image dissatisfaction. The latter comes from visible body
a strong association between the number of treatments, sleep modification, such as breast and hair losses, and stems also
quality (PSQI-T score), and body image dissatisfaction (BIS-D from perceptible manifestations such as hot flashes. Our finding
score). In light of this, different types of treatments received is in agreement with recent studies showing that persistent
by our patients, including surgery, chemotherapy, radiotherapy, body image distress is closely linked to psychological distress,
hormone therapy, and immunotherapy, had a negative effect on such as anxio-depressive syndrome (21, 22). Other studies
the mental health of our study population, which exhibited a confirm that 33% of breast cancer survivors experiencing body
strong association with anxiety disease (p = 0.0008), depression image dissatisfaction still have this feeling for up to 9 years
(p = 0.0005) and ADS (p = 0.0002) (Table 2). post-surgery (23, 24). From this point of view, it is well-
In terms of the impact of sleep quality on the mental health of known that depression is a serious mental disease that can
patients with breast cancer, our data indicate a strong correlation cause severe feelings of sadness and hopelessness that could
between the Pittsburgh index (PSQI-T ≥ 8) and both anxiety lead breast cancer patients to criticize themselves after breast
disease (p = 0.0007) and ADS (p = 0.0009) (Table 2). loss, which leads to high levels of body image dissatisfaction.
Our results show also that the psychological disturbances To deal with this, self-compassion and hope-focused therapy
revealed in this study are strongly related to the side effects may be useful to relieve body image dissatisfaction of patients
of the surgery seen on patients’ bodies. Thus, the assessment with breast cancer (25). Further, many others suggestions
of body image dissatisfaction (BIS-D) exhibits solid association could be brilliants alternatives. Thus, the focus on couples
with anxiety (p = 0.001), depression (p = 0.004), and ADS or groups within clinic and psychological settings seems to
(p = 0.0001). be promising (23), even though such interventions could
have limited effectiveness for younger breast cancer patients
(22) and require more health professionals and financially
DISCUSSION expensive treatment (26). In our context, such an approach
needs incentives and subsidies granted by the Ministry of
Anxiety and depression are the main mental health disorders Health, since the majority of breast cancer patients attending
directly or indirectly induced either by breast cancer, its the public hospitals are from low-income backgrounds. In our
treatment, or only its disclosure during the first diagnosis. The population study, more than half of the patients had a low
psychological distress is the term generally adopted in oncology socioeconomic status and did not have the ability to enter
and cancer care to refer to these two mental disorders, which private health care. Moreover, the majority of our sample had
affect more than one third of breast cancer patients (16). In RAMED, which is a national health insurance. To cope with
Morocco as well as in other developing countries, few studies this socioeconomic issue and in order to correct the body
have focused on the evaluation of the psychological component image dissatisfaction of breast cancer patients experiencing
of patients with breast cancer. From this point of view, efforts psychological distress, new strategies are being used in oncology
should be made to improve adapted health care against anxiety (27). One of them consists of unstructured writing activities
and depression for breast cancer. To the best of our knowledge, (23), which aim to enhance the confidence and self-appreciation
this study is the first to examine the possible link between for mastectomy patients. Along these lines, psychologists from
the anxio-depressive syndrome, sleep disturbance, and body Macquarie University of Sydney have developed a program
image dissatisfaction in a population of Moroccan patients with called “My Changed Body,” which is a web platform containing
breast cancer. writing exercises intended to encourage self-compassion and
In this study, all breast cancer patients received several to lower anxiety and depression related to the body image
treatments, but chemotherapy and surgery were the first dissatisfaction (28).
to be practiced. According to our results, these medical The extrapolation of this strategy to our sample appears
interventions induced anxiety, depression, and ADS. Our infeasible because of the high level of illiteracy. In another
findings are in agreement with data from the literature context, our results displayed a significant impact of sleep quality
showing that cancer treatments worsen the quality life of breast disturbance on the mental health of our population study. Thus,
cancer patients and lead to the deterioration of their mental a strong correlation between the Pittsburgh index and both
health, mainly manifesting itself as anxiety and symptoms anxiety disorder and ADS was found. We can confirm that
of depression (3, 4, 17). Moreover, another study suggested our results are in agreement with those published by other
that anxiety remains persistent during treatment, which researchers (29). Moreover, it has been shown not only in breast
could likely be related to misunderstanding the efficiency cancer but in other types of cancer that sleep disturbance is
of therapeutic approaches used in breast cancer treatment accompanied usually by noticeable fatigue, depressive symptoms,
(18). Furthermore, it has been shown that depression and anxiety disorders (30–32). Those previous findings show a
decreases the incentive for chemotherapy and lowers the strong association between sleep disturbance and both fatigue
compliance with both chemotherapy and radiotherapy, and depression (33, 34). In light of this, Fiorentino and

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El kherchi et al. Anxiodepressive Disorders in Breast Cancer Patients

Ancoli-Israel claim that breast cancer patients usually complain psychological care teams for breast cancer patients and consider
of sleep disorders with a percentage ranging between 20 and establishing mobile psychological health care units in order to
70% (17). Moreover, sleep disturbance rates are found to be visit patients in their homes, especially those living in isolated
higher in women with breast cancer than in people with areas or with low socioeconomic status.
other types of cancer as well as in people with non-cancerous This study has some limitations. On the one hand, our
conditions (35). From the analysis of our results and comparisons sample may not be representative of the general population of
of them with others, it appears that sleep disturbance in Moroccan women with breast cancer, due to the recruitment of a
breast cancer patients is highly correlated with most types of limited sample in a single counter hospital. On the other hand,
treatments especially surgery, chemotherapy, and radiotherapy our work is conducted only at the university hospital center,
(32). The pathophysiological mechanism by which chemotherapy which welcomes patients coming from both urban and rural
induces sleep disturbance remains unclear, but some researchers areas of the Casablanca-Settat region, the country’s economic
have suggested that proinflammatory cytokines and circadian capital. For future studies, we plan to initiate a multicentric study
rhythm perturbation could be the basis for the sleeplessness which would include other hospital universities and also the
observed in breast cancer patients undergoing chemotherapy private sector.
(32). Additionally, breast cancer patients who have completed
chemotherapy treatment exhibit less sleep depth, less Rapid Eye DATA AVAILABILITY STATEMENT
Movement sleep (REM), and less sleep effectiveness compared
with people without cancer (36). The original contributions presented in the study are included
Concerning the most useful interventions for the relief of in the article/supplementary materials, further inquiries can be
sleep disturbances and fatigue in patients with breast cancer directed to the corresponding author/s.
undergoing radiotherapy treatment, Mock and collaborators
assessed the impact of home-based walking exercise (4–5 ETHICS STATEMENT
days/week, 20–30 min/day over 6 weeks). The results show a
significant improvement of sleep quality as well as in relief of The studies involving human participants were reviewed
anxiety and fatigue (37). and approved by Mohammed VI Center for the Treatment
of Cancers, Ibn Rochd University Hospital Center
CONCLUSION Casablanca, Morocco approved the study presented here.
The patients/participants provided their written informed
Overall, breast cancer is known to be an alarming disease consent to participate in this study.
that causes women both physical and psychological suffering.
In this study we have demonstrated that our population AUTHOR CONTRIBUTIONS
exhibited severe psychiatric comorbidities, especially anxiety
and depression. Besides low socioeconomic status and low OE, AA, and AE: conception and design of the study. MD, AA,
educational level, we found that most types of treatments, and MG: data collection. NE, AA, OE, and ES: acquisition and
sleep disorders, and body image dissatisfaction encountered data analysis. AB: recruitment of patients. OE, MM, AJ, and AE:
by women with breast cancer exacerbate both anxiety and interpretation of data. OE and AA drafting of the work. MM, AB,
depression levels inducing in patients a worse psychological AJ, and AE: revising the manuscript critically and final approval
health status. of the manuscript. All authors: approved the final version of the
From this study, it seems that the pathological triad of manuscript to be submitted.
anxio-depressive syndrome, sleep disorders, and body image
dissatisfaction forms a kind of vicious circle and that each of ACKNOWLEDGMENTS
them potentiates the effects of the others. When these three
comorbidities are associated in the same breast cancer patients, Authors gratefully acknowledge the support offered by the
the patients’ survival rates decrease. medical and the nursing staff of Mohammed VI Center for
Given the results of this study, we recommend that health care the treatment of cancers, Ibn Rochd University Hospital Center
providers and decision-makers in the field of health strengthen Casablanca, Morocco.

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21. Galiano-Castillo N, Ariza-García A, Cantarero-Villanueva I, Fernández- absence of any commercial or financial relationships that could be construed as a
Lao C, Díaz-Rodríguez L, Arroyo-Morales M. Depressed mood in potential conflict of interest.
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