Correlation of resilience with anxiety and depression in patients with prostate cancer and analysis of influencing factors

Abstract

BACKGROUND

The development of prostate cancer (PC) frequently intensifies negative emotional states, such as anxiety and depression, which compromise the effectiveness of radical surgery and reduce treatment adherence. In this study, we hypothesized that psychological resilience plays a crucial role in this process and explored its impact.

AIM

To investigate the association of resilience with anxiety and depression in patients with PC and to analyze the influencing factors.

METHODS

We selected 147 patients with PC who visited Qingdao Traditional Chinese Medicine Hospital from January 2022 to June 2024. The resilience scores of patients with PC were assessed using the Connor-Davidson Resilience Scale (CD-RISC) from the tenacity, self-improvement, and optimism dimensions. Based on the total CD-RISC score, patients were categorized into groups A (total CD-RISC score > 63 points, n = 69) and B (total CD-RISC score ≤ 63 points, n = 78) for comparative analysis of anxiety [Hamilton Anxiety Rating Scale (HAMA)], depression [Hamilton Depression Rating Scale (HAMD)], sexual function [International Index of Erectile Function-5 (IIEF-5) and Sexual Life Quality Questionnaire-Quality of Life (SLQQ-QOL)], and quality of life [the EORTC Core Quality of Life Questionnaire (QLQ-C30)]. The association between CD-RISC and the above indicators was analyzed with Spearman correlation coefficients, and the influencing factors of resilience in patients with PC were identified with binary logistic regression.

RESULTS

Group A demonstrated statistically lower HAMA and HAMD scores and markedly higher scores of IIEF-5, SLQQ-QOL, and various QLQ-C30 aspects. Correlation analysis revealed that CD-RISC was significantly negatively correlated with HAMA and HAMD scores and significantly positively correlated with IIEF-5, SLQQ-QOL, and QLQ-C30 total scores. Binary logistic regression analysis revealed educational and per capita monthly household income levels as significant influencing factors of resilience in patients with PC.

CONCLUSION

Our results indicate a significant correlation of resilience with anxiety and depression in patients with PC. The milder the anxiety and depression emotions in patients, the higher their resilience. Further, assisting patients with PC to improve their educational and per capita monthly household income levels will help their resilience to some extent.

Key Words: Prostate cancer; Resilience; Anxiety; Depression; Analysis of influencing factors

Core Tip: Psychological resilience is an individual’s capacity to adapt to stressors and counteract the detrimental effects of future adverse events. In patients with prostate cancer, resilience acts as a protective buffer, facilitating effective emotional regulation and alleviating emotional distress. Despite its importance, research that examined the association between psychological resilience and anxiety or depression in patients with prostate cancer as well as the factors influencing this association remains limited. Our study reveals that higher psychological resilience levels are strongly associated with reduced anxiety and depression, improved sexual function, and enhanced overall quality of life. Furthermore, factors, such as higher educational attainment and greater monthly household income per capita positively contribute to the development of psychological resilience in these patients.

INTRODUCTION

Prostate cancer (PC) constitutes 13.5% of all male-related tumors, and the global cumulative lifetime risk of men developing this disease is 3.7%[1]. Relevant data statistics reported approximately 1.3 million patients with PC globally in 2018, with approximately 29.3 patients with PC per 100000 men[2,3]. Factors, such as race, genetic factors, obesity, smoking, and excessive dairy intake, all predispose to PC and further increase the risk of men developing PC[4]. The occurrence of PC causes adverse clinical manifestations, such as sexual dysfunction, upper urinary tract damage, and even urinary incontinence, in men[5]. This not only strongly affects patients’ physical and mental health and exacerbates their negative emotions, such as anxiety, depression, fear, and helplessness, but also compromises the therapeutic effect of radical surgery and treatment compliance, thereby posing a serious threat to their quality of life[6,7]. Detailed data indicated that over 16.0% of patients with PC experience significant depressive symptoms with a 6.5 times higher risk of suicide within the first 6 months of developing the disease than that of the general population, in addition to an increased risk of sleep disorders[8-10]. Resilience is an individual’s ability to cope with stressors and resist the harmful effects of future negative events, which buffer stress-related depression and, to a certain extent, help patients with PC reduce distress[11,12]. Groarke et al[13] revealed resilience as a protective factor that helps patients with PC to buffer pressure, realize effective emotional regulation, and effectively reduce emotional distress. Further, resilience assists individuals in restoring optimism and tranquility when confronted with events such as chronic pain, the aging process, and terrorist attacks[14-16]. Research on the correlation of resilience with anxiety and depression in patients with PC and the investigation of influencing factors is currently limited. This study fills the crucial gaps by conducting relevant analysis and is committed to improving the physical and mental health of patients with PC.

MATERIALS AND METHODS

General information

Participants consisted of 147 patients with PC admitted to Qingdao Traditional Chinese Medicine Hospital from January 2022 to June 2024. They were categorized based on the total score of the Connor-Davidson Resilience Scale (CD-RISC). Group A consisted of patients with a total CD-RISC score of > 63 (n = 69), whereas group B included those with a total CD-RISC score of ≤ 63 (n = 78). The research flow chart is shown in Figure 1.

Figure 1 Research flow chart. PC: Prostate cancer; CD-RISC: Connor-Davidson Resilience Scale.

Inclusion criteria: (1) PC diagnosis based on imaging and pathological specimens; (2) Ability to normal reading comprehension and independently completing the scale survey; (3) Meeting the surgical indications for laparoscopic radical prostatectomy; and (4) Intact clinical data.

Exclusion criteria: (1) Unstable or rapidly deteriorating condition; (2) Other malignant tumors; (3) Alcohol and drug dependence; and (4) Coagulation dysfunction and autoimmune system deficiencies.

Detection indicators

Resilience: The CD-RISC scale compiled by Connor and Davidson was used for resilience assessment. The 25-item instrument consists of three dimensions (tenacity, self-improvement, and optimism with 13, 8, and 4 items, respectively) and uses a 5-point Likert scale.

Psychological state: The Hamilton Anxiety Rating Scale (HAMA) and the Hamilton Depression Rating Scale (HAMD) were employed to assess patients’ anxiety and depression, consisting of 14 items and 17 items with a cut-off value of 14 points and 17 points, respectively. Both scales are rated on a 5-point scale (0-4 points), with higher scores indicating more severe anxiety or depression.

Sexual function: The International Index of Erectile Function-5 (IIEF-5) and the Sexual Life Quality Questionnaire-Quality of Life (SLQQ-QOL) were used for sexual function assessment. IIEF-5 consists of 5 items with a total score of 25 points, whereas SLQQ-QOL consists of 10 items, each scored on a 4-point scale. A higher score on either scale indicates better sexual function.

Quality of life: The EORTC Core Quality of Life Questionnaire (QLQ-C30) was used for assessment. This scale comprises five functional dimensions: Physical, role, emotional, cognitive, and social functions. A higher score indicates a better quality of life.

Scale survey environment and investigator qualifications

The scale surveys were performed in a controlled and private setting, with patients seated in either independent consultation rooms or hospital wards to ensure a quiet, well-lit, and distraction-free environment. Privacy curtains or separate partitions were utilized to prevent any external observation. Encrypted tablets were used for electronic data collection, whereas paper questionnaires were securely sealed by patients in confidential envelopes. To minimize fatigue-induced response bias, the survey duration for each patient was carefully maintained within 20-30 minutes. Two physicians, who had received standardized training, administered the surveys. The training program included instruction on consistent scale interpretation, the use of neutral language, and strategies for providing emotional reassurance to patients. Crucially, these investigators were not involved in the clinical treatment of participants and were blinded to the study hypotheses, thereby reducing the potential for subjective bias or undue influence on patient responses.

Statistical analysis

Statistical Package for the Social Sciences version 22.0 statistical software was used for data analysis in this study. Measurement data were statistically described as mean ± SEM. The t-test was used for comparing measurement data between groups. Count data were statistically described by frequency (percentage). The χ² test was conducted to compare count data between the two groups. Binary logistic regression was applied to analyze the influencing factors of resilience in patients with PC. A P value of < 0.05 indicated a statistically significant difference. For binary logistic regression analysis, the sample size is recommended to be at least 10 times the number of predictor variables. A minimum of 50 samples was required in this study, which included five predictor variables. This study significantly exceeded the minimum sample size requirement by enrolling 147 cases, thereby ensuring robust statistical power for the analysis.

RESULTS

Anxiety and depression levels between the two groups

Group A demonstrated reduced HAMA and HAMD scores compared with group B, with statistically significant differences (P < 0.01) (Figure 2).

Figure 2 Anxiety and depression levels of two groups. A: The Hamilton Anxiety Rating Scale levels of two groups; B: The Hamilton Depression Rating Scale levels of two groups. The Hamilton Anxiety Rating Scale was utilized to measure anxiety levels, and the Hamilton Depression Rating Scale was employed to assess depressive symptoms. Intergroup comparisons for these measures were conducted using independent t-tests. ^bP < 0.01 compared to group A. HAMA: Hamilton Anxiety Rating Scale; HAMD: Hamilton Depression Rating Scale.

Sexual function between two groups

The sexual function assessment of the two groups using the IIEF-5 and SLQQ-QOL scales revealed that group A demonstrated significantly higher IIEF-5 and SLQQ-QOL scores than group B (P < 0.01) (Figure 3).

Figure 3 Sexual function of two groups. A: The International Index of Erectile Function-5 Levels of two groups; B: The Sexual Life Quality Questionnaire-Quality of Life levels of two groups. Erectile function was evaluated using the International Index of Erectile Function-5, while sexual quality of life was measured with the Sexual Life Quality Questionnaire-Quality of Life. Comparisons between the two groups for these outcomes were also performed using independent t-tests. ^bP < 0.01 compared to group A. IIEF-5: International Index of Erectile Function-5; SLQQ-QOL: Sexual Life Quality Questionnaire-Quality of Life.

Quality of life between the two groups

The QLQ-C30 scale was used to assess the quality of life levels between the two groups in terms of physical, role, emotional, cognitive, and social function aspects as well as overall health status. The data indicated that group A exhibited significantly higher QLQ-C30 scores in each of the above dimensions compared to group B (P < 0.05) (Figure 4).

Figure 4 Quality of life of two groups. A: The EORTC Core Quality of Life Questionnaire (QLQ-C30) scores of the two groups in terms of physical function; B: QLQ-C30 role function dimension scores in both groups; C: QLQ-C30 emotional function dimension scores in both groups; D: QLQ-C30 cognitive function dimension scores in both groups; E: QLQ-C30 social function dimension scores in both groups; F: QLQ-C30 overall health status dimension scores in both groups. All the aforementioned domains of the EORTC Core Quality of Life Questionnaire were used to evaluate quality of life, and intergroup comparisons were analyzed using independent t-tests. ^aP < 0.05, compared to group A; ^bP < 0.01, compared to group A. SLQQ-QOL: Core Quality of Life Questionnaire.

Correlation analysis of resilience with anxiety and depression

Spearman correlation coefficients were used to analyze the correlation between resilience and various indicators. Resilience demonstrated a significant inverse correlation with anxiety and depression (r = -0.544, P < 0.001; r = -0.619, P < 0.001) and a significant positive association with the two sexual function scales (r = 0.396, P < 0.001; r = 0.390, P < 0.001) as well as the quality of life (r = 0.460, P < 0.001) (Table 1).

Table 1 Correlation analysis between resilience and anxiety, depression, and other indicators.

Variable	r	P value
HAMA	-0.544	< 0.001
HAMD	-0.619	< 0.001
IIEF-5	0.396	< 0.001
SLQQ-QOL	0.390	< 0.001
General health status of QLQ-C30	0.460	< 0.001

HAMA: Hamilton Anxiety Rating Scale; HAMD: Hamilton Depression Rating Scale; IIEF-5: International Index of Erectile Function-5; SLQQ-QOL: Sexual Life Quality Questionnaire-Quality of Life; QLQ-C30: Core Quality of Life Questionnaire.

Analysis of factors influencing resilience in patients with PC

We conducted univariate and multivariate analyses of factors influencing resilience in patients with PC. Both analyses revealed educational and per capita monthly household income levels as significant factors affecting the resilience of patients with PC (P < 0.05) (Tables 2 and 3).

Table 2 Univariate analysis of resilience in prostate cancer patients, n (%).

Variable	Group A (n = 69)	Group B (n = 78)	χ2	P value
Age (years)			0.080	0.777
< 60	32 (46.38)	38 (48.72)
≥ 60	37 (53.62)	40 (51.28)
Marital status			0.162	0.687
Married	49 (71.01)	53 (67.95)
Single	20 (28.99)	25 (32.05)
Children			0.210	0.646
Have	51 (73.91)	55 (70.51)
Don’t have	18 (26.09)	23 (29.49)
Education level			4.561	0.033
Below senior high school	34 (49.28)	52 (66.67)
Senior high school or above	35 (50.72)	26 (33.33)
Per capita monthly household income (CNY)			4.871	0.027
< 5000	29 (42.03)	47 (60.26)
≥ 5000	40 (57.97)	31 (39.74)

Table 3 Multivariate analysis of resilience in prostate cancer patients.

Factor	β	SE	Wald	P value	OR	95%CI
Age (years)	-0.127	0.345	0.137	0.711	0.880	0.448-1.730
Marital status	0.084	0.375	0.050	0.822	1.088	0.521-2.271
Children	0.131	0.385	0.116	0.733	1.140	0.537-2.423
Education level	0.761	0.348	4.793	0.029	2.141	1.083-4.234
Per capita monthly household income (CNY)	0.764	0.346	4.882	0.027	2.147	1.090-4.230

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

PC is a male-related malignancy that causes a relatively high mortality risk, which is associated with the fact that patients are frequently in an advanced disease stage when diagnosed[17]. Currently, several relevant studies focus on the resilience of patients with PC; however, the majority of them focus on the potential associations or interactions between resilience and cancer treatment, psychosocial outcomes, sleep deterioration-related depression, family functioning, and self-efficacy[18-21]. Further investigations are warranted to assess the correlation of resilience with anxiety and depression in patients with PC and the influencing factors.

In this investigation, group A is considered a cohort with relatively increased resilience, whereas group B is a group with comparatively decreased resilience. Our data indicate that the group with higher resilience not only demonstrates significantly lower HAMA and HAMD scores but also exhibits significantly higher IIEF-5, SLQQ-QOL, and QLQ-C30 scores across various dimensions. The aforementioned data indicate that patients with PC demonstrating greater resilience appeared to bear milder negative emotions or psychological distress and possess relatively higher sexual function and quality of life levels. Sharpley et al[22] revealed that patients with PC exhibiting higher resilience demonstrated significantly lower anxiety and depression levels than those with low resilience, which is congruent with the results of our study. Patients with PC frequently have a relatively high risk of developing depression. Perceived social support, hope, and resilience are helpful to their active struggle against depression symptoms, particularly via strengthening support from families[23]. Another study highlights that measuring the resilience of patients with PC helps to screen out those at high risk of depression, thereby enabling the provision of targeted resilience training to assist them improve resilience[24].

Subsequently, the correlation analysis has robustly revealed the presence of a marked inverse association of resilience with anxiety and depression in patients with PC as well as a significant positive association with the two sexual function scales and quality of life. This indicates that resilience is not only closely associated with negative emotions but may also influence patients’ sexual function and quality of life levels. A 5-year study has further substantiated that resilience in patients with PC not only demonstrates a significant negative correlation with depression but also exhibits a significant protective effect against depression that varies over time, peaking at 6 months, 24 months, and 60 months[25]. Martin et al[26] reported a significant negative correlation between resilience and anxiety (r = -0.45, P < 0.001) as well as depression (r = -0.54, P < 0.001) in patients with PC, similar to our results. Generally, the anxiety and depression of patients with PC primarily originate from concerns about treatment side effects, such as urinary incontinence and erectile dysfunction, along with the threat of tumor metastasis and death[27]. Patients with higher resilience typically carry less psychological burden and can more relatively face various possible stress events, with a positive and optimistic attitude and a relatively higher hope level[28].

Finally, we verified the factors influencing resilience in patients with PC. Both univariate and multivariate analyses reveal educational and per capita monthly household income levels as independent factors associated with resilience in patients with PC. Chien et al[29] revealed that psychological resilience in patients with PC has been significantly influenced by cancer-specific self-efficacy, with increased self-efficacy contributing to improved resilience. Furthermore, other studies have determined high perceived stress as a crucial predictor of psychological resilience in patients with PC, demonstrating a strong correlation with worsened emotional states and diminished quality of life[13].

This study has several limitations that warrant further refinement in future investigations. First, the cohort comprised only 147 PC patients from a single institution, lacking diversity in terms of geographic distribution, socioeconomic status, or disease phases (e.g., initial diagnosis vs recurrent/metastatic disease), potentially limiting the generalizability of the findings. Second, the cross-sectional nature of the study design only demonstrates an association between resilience and anxiety/depression, precluding causal inferences. Lastly, critical factors such as clinical variables (e.g., tumor stage, treatment modalities like surgery or endocrine therapy) and social support systems (e.g., family dynamics, physician-patient communication) were not comprehensively assessed for their influence on resilience, possibly resulting in overlooked confounders in the regression model. Future directions will involve expanding the study population to ensure heterogeneity, implementing longitudinal designs, and rigorously controlling for key confounding variables to enhance the robustness of this research.

CONCLUSION

In summary, a relatively high resilience in patients with PC is typically closely associated with relatively milder anxiety and depression as well as relatively higher sexual function and quality of life. Conversely, educational and per capita monthly household income levels may, to a certain extent, influence the resilience of patients with PC. Specifically, patients with PC with higher educational and per capita monthly household income levels demonstrated greater resilience.