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Theory of mind deficit in women with breast cancer and depression: A comparative study

1 Psychologist, Netaji Subhas Chandra Bose Cancer Research Institute, Kolkata, West Bengal, India
2 Department of Psychiatry, The Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
3 Department of Applied Psychology, Calcutta University, Kolkata, West Bengal, India
4 Associate Professor, Saroj Gupta Cancer Centre & Research Institute, Kolkata, Consultant Oncologist, The Advanced Medical Research Institute Hospitals, Kolkata, West Bengal, India

Date of Submission02-Dec-2019
Date of Decision01-Feb-2020
Date of Acceptance17-May-2020
Date of Web Publication11-May-2021

Correspondence Address:
Prathama Guha,
Department of Psychiatry, The Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_1022_19

PMID: 34380823


Background: Studies have established that Theory of Mind (ToM) is impaired in patients with depression, but few studies have investigated the status of ToM in breast cancer patients who often suffer from depression. Our objective was to compare the ToM deficits in women with breast cancer with and without depression with a control group.
Methods: The study was conducted at the Oncology department of a multi-speciality hospital in Kolkata. It was a cross sectional matched control study. We compared the ToM performance of women with breast cancer and depression (N=39), breast cancer without depression (N=63) and a healthy control group (N=34) using the widely used ToM task, Reading the Mind in the Eyes test (Eyes Test). Depression was diagnosed using Mini - International Neuropsychiatric Interview following International Classification of Diseases - 10th edition guidelines. Chi-square and one-way analysis of variances was done.
Results: Both groups of patients had greater impairment in ToM compared to healthy controls (p<0.05). Among breast cancer patients, presence of depression predicted even greater impairment of ToM (p<0.05). Lower income, less education and not being in any occupation other than homemaking were associated with greater ToM impairment across all groups (p<0.05).
Conclusion: Breast cancer patients suffering from depression may have an additional burden of impaired social cognition, which may reduce their ability to shore up social support when it is most required. This needs to be addressed urgently to ensure better quality of life.

Keywords: Breast cancer, depression, theory of mind
Key Message
Theory of mind deficit is significant in breast cancer and it worsens with the presence of depression. it is important to address this issue to ensure better quality of living.

How to cite this URL:
Datta A, Guha P, Rathi M, Chaudhuri T. Theory of mind deficit in women with breast cancer and depression: A comparative study. Indian J Cancer [Epub ahead of print] [cited 2022 Nov 29]. Available from:

  Introduction Top

Breast cancer is the commonest cancer in women in Kolkata.[1] The five-year cumulative mortality due to breast cancer in urban Indian women still remains alarmingly high at 50%, mostly due to late-stage presentation.[2] Depression is often underestimated in patients with breast cancer, with a reported prevalence between 10% and 25%.[3],[4] Indian studies have reported anxiety and depression in about 38% patients of breast cancer,[5] which is not surprising, given the fact that Indian women have to bear the additional burden of social isolation and family sanctions on account of their inability to look after household chores, physical disfigurement, and restricted sexual intimacy.[6]

Theory of mind is an aspect of social cognition, which involves understanding the mental state of others in the context of everyday social interactions. It is now an established fact that there is theory of mind deficits in patients with depression.[7],[8] As a result, depressed individuals have dysfunctional interaction patterns[7] and problems in interpreting interpersonal information like emotions and their expressions.[9] The deficit in social interactions of depressed patients has a major role in the onset and maintenance of depression,[4],[7] thus setting up a vicious cycle.

In recent years, the social cognitive impairment caused by depression and its potential cognitive neuropsychological mechanisms has become a research hotspot. However, there is a dearth of literature on the social cognitive abilities of cancer patients who frequently suffer from depression. The few studies that have looked into social and cognitive deficits in patients with cancer and comorbid depression report significant impairment in social role functioning compared to healthy controls.[10] Cancer patients often suffer social isolation in the context of both family and community, particularly in developing countries like India where the disease is still associated with significant stigma and discrimination.[11] Additional risk factors involve financial difficulties, restricted access to treatment, and for women, fear of disfigurement, and subsequent spousal rejection.[12] Recent studies reveal distressing facts about Indian women suffering from breast cancer where 90% women are reported to suffer from social embarrassment, something that could be explained by the fact that Indian women across age, education, and domicile seem to define their social acceptance in terms of physical appearance and their role as providers of the family.[13] The burden of social isolation increases when the cancer sufferer is unable to negotiate her social interactions efficiently, on account of depression-related ToM deficits.

We conducted this study to assess the degree of ToM impairment of depressed breast cancer patients compared to their nondepressed counterparts. We also wanted to know if their ToM deficits were any different from a matched control group.

  Materials and Methods Top

Study design

It was a cross-sectional comparative study using validated tools and structured face-to-face interviews.

Sample selection

This study was conducted at the oncology department of a multispeciality hospital in Kolkata, situated in eastern India, between April 2017 to August 2018. Early nonmetastatic breast cancer women participants between age group of 30 and 60 years, who had at least ten years of formal education and could understand English language were included, after applying specific inclusion and exclusion criteria. The Mini-International Neuropsychiatric Interview (MINI) was administered by an experienced psychiatrist to assess the presence of depression.

Group 1

Healthy age and education-matched women were chosen from the local community. Fifty women were approached, of whom 38 agreed to participate in the study. Four were excluded on account of their inability to understand English language. The presence of psychiatric morbidity was ruled out using the General Health Questionnaire (GHQ-12). Reading the mind in the eyes test was also applied to them.

Inclusion criteria for Group 1 were being aged between 30 and 60 years, having no history of past or present comorbid medical illness or psychiatric disorder, and having a formal education of a minimum ten years. Those who were not willing to participate or were not able to read or understand English language or were suffering from severe depression were excluded.

Group 2 and 3

The researchers had approached 436 nonmetastatic breast cancer patients undergoing chemotherapy; 286 (65.56%) agreed to participate in the study. Among them, women who had a previous history suggestive of psychiatric disorders (N = 28), those who had severe depression (N = 20), recurrence of cancer (N = 85), or who were unable to give information and/or could not understand/read English, a language taught in all schools in this part of India (N = 51) were excluded from the study, resulting in a total of 102 study participants.

These patients were screened using the MINI and those with the diagnosis of first episode depression (mild or moderate severity) as per International Classification of Diseases – 10th edition (ICD 10) criteria, as confirmed by an experienced psychiatrist and clinical psychologist were included in Group 3 (N = 39). The rest were included in Group 2 (breast cancer patients without depression; N = 63). Those patients who received a diagnosis other than depression (N = 11) were excluded from the study. The Beck Depression Inventory (BDI 2) was then used for patients with depression to determine the severity of depression (mild/moderate). All patients were given the Reading the Mind in the Eyes Test (RMT), a well-known ToM task.

Thus, diagnosed patients with early nonmetastatic breast cancer aged between 30 and 60 years undergoing neoadjuvant chemotherapy, who were willing to participate in the study, and had at least ten years of formal education were included. Those with a history of past mental illness were excluded from the study.

Data collection

Demographic data were collected from all the groups of the study population, followed by the administration of tests in a single interview.


Semi-structured proforma: A semi-structured proforma was developed to assess the sociodemographic and clinical details of the study subjects.

MINI is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association - IVth Edition) and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it is easy to administer.[14]

The BDI is a 21-item, self-report rating inventory that measures depression. It is a widely used psychometric instrument with high internal consistency (mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric patients). The concurrent validity of BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) are also high. (mean correlations for psychiatric patients: 0.72 and 0.73, respectively.)[15]

Reading the Mind in the Eyes Test (RMT): This test, which is meant to evaluate mind-reading ability, was developed by Baron-Cohen, et al. in 2001. The revised form of this test includes photographs from eye region (from eyebrows to halfway down the bridge of the nose) of actors in 36 different forms. For each photograph, four words describing mental states with similar emotional capacity are presented. Respondents are asked to pick the word that best describes the mental state of the person in the photograph. The maximum score achievable for choosing the right words in the test is 36 and the minimum is zero. In the scoring stage, each correct answer is worth one point and overall scores range from zero to 36. Overall scores between 22 and 30 demonstrate a medium theory of mind; scores lower than 22 show a low theory of mind, and scores higher than 30 indicate a high theory of mind.[16] Social cognition research is still in its early stages in India, hence there are not many culturally adapted tools for its measurement. India being a multilingual and multicultural country, there cannot be a single “Indian adaptation” to meet the needs of her entire population. Tools like the Social Cognition Rating Tools in Indian Setting (SOCRATIS), for example, do not address the needs of the eastern parts of the country, where the majority speak Bengali.[17] The eyes test is easy and fast to administer tool, and more importantly, a validated Bengali version has been used in West Bengal in patients with autism.[18] Hence, we chose this instrument to assess ToM in our subjects.

General Health Questionnaire (GHQ)- 12 is a measure of current mental health. Since its development by Goldberg in the 1970s, it has been extensively used in different settings and cultures as a screening tool to determine whether an individual is at risk of developing a psychiatric disorder. The GHQ comes in four versions. GHQ-12 is a short version and commonly used as a screening tool in a public setting. A score of 3 determines “caseness” in GHQ-12. Its reliability coefficient varies from 0.78 to 0.95.[19]

Consent form: Informed consent was obtained from all participants in writing according to the format laid down by the Indian Council for Medical Research (ICMR), the apex body governing research in India.[20]


Written informed consent was obtained from all participants. The study protocol was approved by ethics committee of the institute. Demographic data were collected via interviews using the semi-structured proforma. After assessing psychiatric state using MINI by psychiatrist and clinical psychologist, they were given the BDI and the RMT. The presence of psychiatric disorder in the control group was ruled out using the GHQ-12.

Statistical analysis

SPSS program version 21 was used for compilation and analysis of data. Descriptive statistics were calculated as the mean (M) ± standard deviation (SD) deviation of age and frequency of demographic factors was tabulated according to education, occupation, and family income. Chi-square was used to see a significant difference, if any in socio-demographic variables among the three groups. One-way analysis of variances (ANOVA) was done to see the significant difference in RMT score within the test variables under study.

  Results Top

Demographic information

From [Table 1], it can be seen that all the three groups match in terms of socio-demographic variables. No significant difference is found in terms of any of the observed socio-demographic variables in the current study for the three groups, namely control, breast cancer without depression, and breast cancer with depression.
Table 1: Summary of Chi-square for social variables

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In group 2 (breast cancer without depression), 54 (85.7%) were living with their spouse. Twenty six (41.3%) received only 10 years of formal education and 55 (87.3%) of women were homemakers. The majority belonged to low socioeconomic status.

In case of group 3 (breast cancer with depression), the majority were living with a spouse 36 (92.3%). Sixteen (41%) received only 10 years of formal education and most of them were homemakers 29 (74.4%). In this group too, a large majority belonged to a low socioeconomic status.

In group 1, which comprises healthy controls, 26 (76.5%) were living with their spouses, majority 14(41.8%) had received just 10 years of formal education, and 25(73.5%) were homemakers.

The mean age of Group 2 was 46.83 ± 0.18 (range: 31 - 58) years while it was 44.12 ± 0.21 (range: 30 - 60) years in Group 3 and 45.12 ± 0.01 (range: 39 - 59) years in the control group. All groups were comparable in terms of sociodemographic variables.

Reading the Mind in the Eyes Test (RMT) score

The RMT scores for each group are shown in [Table 2]. All groups performed poorly compared to normal healthy controls (27.8 ± 3.8). Scores of breast cancer patients with depression (17.9 ± 4.3) were significantly lower than their nondepressed counterparts (20.92 ± 5.9).
Table 2: Descriptive statistics for Reading the Mind in the Eyes test scores for all study variables

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Table 3: ANOVA for Reading the Mind in the Eyes Test score

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ANOVA showed that the effect of diagnosis was significant, F (2, 133) = 37.170, P = 0.000. Posthoc analysis using Bonferroni correction indicated that RMT score in control group with no pathology (M = 27.85, SD = 3.807) was significantly higher than women with breast cancer without depression (M = 20.92, SD = 5.911), F (2, 133) =.37.170, P = 0.001 Further, RMT score of women with breast cancer without depression was significantly higher than women with breast cancer with depression (M = 17.90, SD =4.394), P = 0.011.

ANOVA showed that the effect of education was significant, F (2, 133) = 31.068, P = 0.000. Posthoc analysis using Bonferroni correction indicated that RMT score in graduate individuals (M = 26.53, SD = 6.033) was significantly higher than women with secondary level of education (M = 17.68, SD = 4.882), F (2, 133) =.31.068, P = 0.002. The pairwise comparison did not indicate any significant difference in women who were graduate and those with high school education or between secondary and high school educated women.

ANOVA showed that the effect of income was significant, F(2, 133) = 7.495, P = 0.000. Posthoc analysis using Bonferroni correction indicated that RMT score in individuals with income >3000 (M = 25.44, SD = 5.989) was significantly higher than women with income less than <500 (M = 19.22, SD = 6.238), F (2, 133) =. 7.495, P = 0.000. The pairwise comparison did not indicate any significant difference in women in other income categories.

ANOVA showed that the effect of occupation was significant, F (2, 133) = 4.796, P = 0.030. RMT scores of working women (M = 24.11, SD = 6.594) was significantly higher than homemakers (M = 21.21, SD = 6.051).

  Discussion Top

ToM is the ability to understand others' mental states. It is an essential component of social cognition, considered to be very important in helping people maintain their social network and support. Depression is known to adversely affect ToM, preventing people from activating social support, which could have helped them cope with their own illness, thus setting up a vicious cycle. The additional contribution of the present study is to assess ToM in a group of breast cancer patients who are suffering from depression to evaluate whether the diagnosis and subsequent stigma/isolation of cancer magnify the impact of depression on one's theory of mind.

The results show that impairment in theory of mind exists in all patients of breast cancer (depressed or not) compared to a control group. This confirms our assumption that breast cancer patients' social cognition is an important area of deficit, which, if unaddressed, will make her lose her valuable social support and cause her to develop further depression with subsequent nonadherence and other adverse treatment-related issues. The findings are consistent with that of previous researchers who have proposed that social constraints inhibit cognitive processing of the cancer experience, leading to poorer adjustment and well being.[21],[22]

That depression causes ToM deficit is a well-established fact, and it is an expected finding that breast cancer patients with depression will have deficits too. But our finding that ToM impairment was greater for all breast cancer patients compared to the control group is surprising and calls for in-depth analysis. This seems to imply that the ToM impairment in breast cancer patients cannot be explained by the presence of associated depression alone. Some other mechanism appears to be working here, which requires further probing in subsequent studies. The burden of a long, tiring journey from diagnosis to treatment of cancer, the stigma and isolation that a patient faces on her way, in addition to any other factor that we may have overlooked, seems to play a major role in affecting her social cognitive ability. Since most of our patients belonged to low socioeconomic status; poverty could have played an additional role in causing ToM impairment. In breast cancer patients, compromised social cognition becomes worse if there is an associated diagnosis of depression, as found in our study.

ToM was better, across all groups, in women who had higher levels of education and more per capita family income. Those engaged in any occupation other than homemaking also had higher ToM scores. This is not surprising, since studies that have explored environmental factors affecting ToM have found that socioeconomic factors play a key role in its development and maintenance.[23]

Previous studies have explored the relationship between intelligence, education and ToM with varying results.[24],[25] Some have found a positive association between ToM and intelligence level (IQ), even reading habits (reading literary fiction), the latter being a likely correlate of educational level.[26]

Economic hardship has been consistently and strongly associated with poor physical, psychological, and cognitive functioning.[27] Since social cognitive abilities are often considered a reflection of general cognitive abilities, though not fully accounted for by the latter, it may be inversely related to economic status, or per capita income, as found in our study.

We found no study exploring the relationship between occupation and ToM. The finding that women who pursue an occupation other than homemaking have a better theory of mind could possibly be explained by the fact that working outside the confines of home necessitate more social interaction, endowing these women with more exposure and better social skills.

Many theories have been proposed to explain the state-related ToM deficit in depression. Some presume that depression tends to turn the mind inward and direct attention towards self rumination. This may result in a lesser understanding or awareness of other people's states of mind.[28] We interviewed some of our breast cancer study participants on a second sitting about their major concerns in life. Common causes of concern as stated by breast cancer patients were: 1. They think cancer is a cause of their “bad karma” and feel guilty about it; 2. They feel that they are a burden for their family members because of their physical deterioration due to cancer, and treatment-related expenses; 3. They feel that their friends and family cannot accept them because they think cancer is an infectious disease; 4. During social events or gatherings, they feel that others consider them “different” because of their physical and facial changes; and 5. During the period of chemotherapy and its side effects, they feel helpless and attribute all this to their misgivings in this life or an earlier one. All of these cognitive antecedents make them turn away from social interactions, fearing rejection and humiliation in the hands of people they love.

This deprives them of some of the key positive resources to cope with life's crises — strong social support, good family relationships, and adaptive problem or conflict solving styles, all considered important in the overall quality of life of breast cancer patients.[29]

The study has been carried out in West Bengal, a state in eastern India, and mostly addressed women belonging to a low to middle socioeconomic status. The burden of cancer here is often plagued by an associated nihilism (”Death is knocking at your door”). It is almost a ritual in this part of the country for streams of relatives to visit a patient diagnosed with cancer, not so much to offer support as to proffer pity. At the other end of the spectrum are the fear of death and even contamination (ulcerative lesions are often considered infectious) and rejection by other members in the patients' social circuit. One needs strong ToM skills and a consistent supportive confidante to negotiate all these challenging social circumstances. This is vital for the patients' prognosis, as studies have shown that social isolation results in 66% higher chance of death by all causes in breast cancer patients.[30]

Many studies have emphasized the need for structured psychotherapy to increase the quality of life of cancer patients in general and breast cancer patients in particular.[31] Psychotherapy is not a blanket term and needs to be individualized according to the needs of the patient. The finding of significantly impaired ToM deficits in depressed women with breast cancer should spur mental health professionals to include elements of culturally adapted integrated psychosocial therapy focusing on social cognition for best outcomes. Similar studies have been carried out successfully in different patient populations in India.[32]

Limitations of the study

This study has its limitations. It was conducted on a relatively small sample size. Most patients belonged to low to middle socioeconomic strata and had a lesser number of years in terms of formal education, hence it cannot be said to be representative of all Indian women. No follow-up was carried out except for a single sitting with breast cancer patients to look into their major concerns of life.

  Conclusion Top

According to our study, a significant number of breast cancer patients (38.2%) suffer from depression. Breast cancer patients have compromised theory of mind compared to healthy controls. The presence of depression worsens the ToM of breast cancer patients, but depression alone cannot fully explain their ToM deficits. Other factors, including social constraints and poverty need to be investigated in future studies. ToM skills are most affected in patients who come from lower socioeconomic status, have less formal education, and are not engaged in any occupation other than homemaking. As social support is an important component of overall survival of breast cancer patients and better ToM is likely to translate into better social adjustment and support, one needs to devise ways to improve depression and ToM in breast cancer patients as a priorit

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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