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Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 72-77

Relationship between resilience, social support as well as anxiety/depression of lung cancer patients: A cross-sectional observation study

Department of Geriatrics, Xiangya Hospital of Central South University, Changsha, Hunan Province, China

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. Bixiu He
Department of Geriatrics, Xiangya Hospital of Central South University, 87 Xiangya Rood, Changsha 410008, Hunan Province
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_849_17

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 > Abstract 

Objective: The mood of patients with lung carcinoma would be greatly influenced by the diagnosing and treating processes. This study was aimed to explore the effects of resilience between social assistance and anxiety/depression of patients with lung cancer, which may assist in clinical intervention.
Design and Methods: A cross-sectional pilot study was conducted on lung cancer patients at Xiangya Hospital of Central South University, China. A total of 289 patients aged 25–81 years were included in this study.
Results: Correlational analyses revealed that anxiety/depression was negatively associated with psychological resilience and each dimension of social assistance, including subjective support, objective support along with the supports utilization (P < 0.01). Furthermore, psychological resilience was positively related to subjective support (P < 0.01), support utilization (P < 0.01) along with objective support (P < 0.05). Mediational analyses showed that, on the one hand, resilience could partially mediate the relation between anxiety and subjective support and totally mediate the relationship between support utilization and anxiety. On the other hand, resilience could totally mediate the relation between depression and subjective support and partially mediate the relation between support utilization and depression. However, resilience did not play an intermediary role between anxiety/depression and objective support.
Conclusion: Lower psychological anxiety and depression would be experienced by lung cancer patients with higher resilience and social support. The level of anxiety and depression would be indirectly affected by social support through the mediation of resilience.

Keywords: Anxiety, depression, lung cancer, resilience, social support

How to cite this article:
Hu T, Xiao J, Peng J, Kuang X, He B. Relationship between resilience, social support as well as anxiety/depression of lung cancer patients: A cross-sectional observation study. J Can Res Ther 2018;14:72-7

How to cite this URL:
Hu T, Xiao J, Peng J, Kuang X, He B. Relationship between resilience, social support as well as anxiety/depression of lung cancer patients: A cross-sectional observation study. J Can Res Ther [serial online] 2018 [cited 2021 Jun 24];14:72-7. Available from: https://www.cancerjournal.net/text.asp?2018/14/1/72/226768

 > Introduction Top

Lung cancer is a major disease which seriously endangers human health. Lung cancer has contributed to more than one-quarter (27%) of cancer deaths.[1] The diagnosis and treatment of cancer could lead to many negative emotions, generally included anxiety and depression.[2],[3] High prevalence of depression and anxiety has been usually observed in patients with malignant diseases, especially lung cancer.[4] Studies showed that anxiety, depression, and other emotional distress could make severe effects on the life quality of patients with lung cancer, and even on their survival.[5]

Social support is a multiple-faceted concept which described the assistance received from others in plight.[6] A substantial number of studies have focused on the association between psychologically healthy condition and social assistance. Most of the researches showed that social support was closely related to mental health.[7] The previous study has demonstrated that subjective support of cancer patients was negatively related to depression, as well as predicting the mental health of patients.[8]

Resilience is defined as a series of abilities and traits of individuals, which help patients to quickly recover from a disaster and pressure through dynamic interaction.[9] Similar to social support, resilience is also closely related to mental health, and it is a protective factor for psychological distress. Generally speaking, resilience has been a research hotspot in the field of psychology, and the researches carried out on resilience have gradually concentrated on malignant or incurable disease.[10],[11]

There is an internal connection between social support and resilience. The development of resilience would be promoted with social support.[12] Studies showed that both social support and resilience played a protective role to the individual's emotional disorder.[13],[14] Existing evidences suggested that resilience could be served as a mediator between social support and the generation of negative emotions.[15],[16],[17] However, the researches on mediating effects of psychological resilience between social support and psychological distress among cancer patients have been still rare.

Both cancer patients and clinician have always focused on cancer treatment, without paying attention to the psychiatric comorbidity. The related factors of anxious and depressive conditions of lung cancer sufferers should be explored. During the treatment of these patients, clinicians, and nurses should take care of their psychological state. Thus, the life quality of patients could be improved, as well as prolonging their lives. This study investigated the relationship among anxiety/depression, social support, and psychological resilience in patients with lung cancer. It aimed to provide clinical evidence for the intervention on anxiety/depression of lung cancer sufferers.

 > Design and Methods Top


In this study, 289 individuals were in-patients with lung carcinoma from the Department of respiration, geriatrics, and oncology at Xiangya Hospital of Central South University, China. The inclusion criteria were as follows:

  1. Diagnosis of lung cancer was confirmed by pathological or cytological examination
  2. There was no history of mental or psychotic disease before the diagnosis of lung cancer, without taking psychotropic drugs recently, neither alcohol and other drugs dependence
  3. No other serious physical diseases
  4. The participation of the study was voluntary.


Each participant completed a cross-sectional survey with the help of trained graduate students. The questionnaires have taken about half-an-hour to complete, including basic demographic information and psychosocial state.


The following instruments were applied: Social Assistance Rating Scale, Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), and Connor-Davidson resilience scale.

Self-rating depression scale and self-rating anxiety scale

Both Zung SDS [18] and Zung SAS [19],[20] containing 20 items were applied to measure anxious and depressive symptoms of the participants. The Chinese version has been previously validated among Chinese populations and proved to be reliable.[21],[22] Each item was evaluated with a four-point Likert scale ranged from one (never or occasionally) to four (most of the time). A higher score meant more frequent anxiety or depression symptoms. The internal consistency (alpha) was 0.82 for SDS and 0.84 for SAS.

Social Support Rating Scale

The Chinese version of the Social Support Rating Scale designed by Xiao [23] was applied in the present study. The scale was composed of three dimensions, including ten items: subjective support (item 1, 3, 4, and 5), objective support (item 2, 6, and 7), and support utilization (item 8, 9, and 10). Superior degree of social assistance was indicated by elevated score. The questionnaire has been widely applied with good reliability and validity.[24] The internal consistency (alpha) of SSRS was 0.79.

Connor-davidson resilience scale

Connor-Davidson Resilience Scale (CD-RISC)[25],[26] in Chinese was composed of 25 items. Each item was accessed by participants according to their feelings during the preceding month. The scale consisted of 0–4 points, in which zero referred to complete inconformity, and four referred to almost complete conformity. Superior resilience was indicated by elevated score. This scale was valid and reliable for Chinese population.[26] The internal consistency (alpha) of CD-RISC in this study was 0.82.

Statistical analysis

All statistical data were analyzed with SPSS 20.0 software for Windows (IBM Inc., Chicago, IL, United States). First, descriptive statistics were applied to summarize the demographic and psychosocial characteristics of participants. And then, Pearson Correlation Analyses were adopted to examine the bivariate correlations between the variable quantities. After confirming the existence of a significant correlation between the variables, the mediating effect test procedure proposed by Wen et al.[27] was applied to test the mediation role of resilience between social support and emotional distress.

 > Results Top

A total of 289 lung cancer patients were included in the study. Their characteristics of demographic information were presented in [Table 1]. These patients were aged from 25 to 81 years (mean age = 56.53 and standard deviation = 9.22), including 213 (73.7%) males and 76 (26.3%) females. Approximately half (49.2%) received middle school education or above, and most of them were unemployed after diagnose (85.1%).
Table 1: Characteristics of the patient's demographic information

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Bivariate correlations were applied for analyzing the relations among main variables [Table 2]. The anxiety and economic conditions were negatively correlated (r = −0.124, P < 0.05). The depressive degree was significantly and negatively related to economic conditions (r = −0.137, P < 0.05) and occupational conditions (r = −0.155, P < 0.01). Social support was significantly bound up with age (r = −.198, P < 0.01) in a negative manner, however, it was correlated with economic conditions (r = 0.276, P < 0.01), education background (r = 0.410, P < 0.01), occupational status (r = 0.197, P < 0.01) in a positive manner. Resilience was positively related to economic conditions (r = 0.152, P < 0.01), education background (r = 0.122, P < 0.05), and occupational conditions (r = 0.176, P < 0.01).
Table 2: Bivariate correlative values among main variables

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In addition, the bivariate correlations of other involved variables were shown in [Table 3]. Resilience was positively correlated with social support (r = 0.324, P < 0.01), as well as its three dimensions – subjective support (r = 0.142, P < 0.05), objective support (r = 0.210, P < 0.01), and support utilization (r = 0.500, P < 0.01). Anxiety was negatively bound up with social support (r = −0.309, P < 0.01), subjective support (r = −0.280, P < 0.01) and support utilization (r = −0.372, P < 0.01) with significance. Similar to the results of anxiety, depression was also significantly negatively related to subjective support (r = −0.174, P < 0.01), social support (r = −0.269, P < 0.01), and support utilization (r = −0.488, P < 0.01). Moreover, resilience was strongly and negatively related to both anxiety (r = −0.723, P < 0.01) and depression (r = −0.790, P < 0.01).
Table 3: Descriptive statistics and bivariate correlations among anxiety, depression, social support, and resilience

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Structural equation model (SEM) was involved to analyze mediating effects. Neither anxiety nor depression was correlated to objective support, so objective support was excluded from the SEM models. We estimated whether the relationship between the other two dimensions of social support and anxious/depressive degree could be regulated by resilience. Anxiety would be indirectly influenced by social support through resilience, and the results were presented [Figure 1] and the upper row of [Table 4]. The findings revealed resilience made total mediating effect between support utilization and anxiety (standard error = 0.25, P > 0.05), and partial mediation between subjective support and anxiety (standard error = 0.10, P < 0.01). The relationship between depression regulated through resilience and social support was exhibited [Figure 2] and the lower row of [Table 4]. Resilience made total mediating effects between subjective support and depression (standard error = 0.11, P > 0.05), and partial mediation between support utilization and depression (standard error = 0.27, P < 0.05).
Figure 1: Mediating effects from resilience on the relation between anxiety and social support (n = 289). Note: values are standardized path coefficient values. **P < 0.01, ***P < 0.001

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Table 4: The mediating effects of resilience on the correlation between anxiety/depression and each dimension of social supports including subjective support and utilizing of supports (n=289)

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Figure 2: Mediating effects from resilience on the relation between depression and social support (n = 289). Note: values are standard path coefficient values. **P < 0.01, ***P < 0.001

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 > Discussion Top

Consistent with the findings of other cancers, the results of this study have confirmed that resilience was strongly correlated with depressive and anxious emotions of lung cancer patients in a negative manner.[9],[28] Meanwhile, social support has proved to be a significant protective factor for anxiety and depression, which was confirmed to the results in other studies.[29],[30],[31] It indicated that patients with less social support and lower ability of resilience would be more prone to suffer from anxiety and depression.

This study has tried to clarify whether the influence by social support on anxiety and depression was mediated by resilience in patients with lung cancer. Our results showed a positive correlation between resilience and each dimension of social support for lung cancer population. Meanwhile, depressive and anxious emotions were negatively related to subjective support and supports utilization, but not significantly related to objective support. It implied that social support utilization and subjective support made greater effects on anxiety/depression, compared to that of objective support. The SEM models demonstrated that, for the individuals in our study, resilience totally mediated support utilization and anxiety; it partially mediated subjective support and anxiety (the proportion of mediating effects was 45.8%). Conversely, resilience totally mediated subjective support and depression; it partially mediated support utilization and depression (the proportion of mediating effects was 74.9%). It means that only the subjective support and utilization of support could make indirect effects on anxiety and depression through resilience for lung cancer patients.

For the participants in our study, neither gender nor age was significantly related to anxiety and depression, as well as resilience. In other cancer studies, the results were varied. Both gender and age were associated with mental disorders in some studies, while they were not related in other studies.[32],[33] There may be uneven distribution of sex and age in our study, leading to the varied results from other studies. Anxiety and depression were both negatively correlated with economic conditions. This finding was consistent with the results from other studies, in which the level of anxiety and depression was relatively high in lung patients with poor economic situations.[34] Absolutely, the financial burden of disease was one of the most disturbed problems that patients suffered, which could be relieved under superior economic conditions. Better resilience may be observed in patients with better financial conditions, which was less likely to be anxious and depressed. Economic conditions were also positively related to social support, resilience, and education background. In addition, employed patients were not prone to fall into depression in our study. In addition, they received more social support with better resilience. It may contribute to more social activities in a job and the attentions of patients could be distracted from the disease.

According to the existing researches, there was a study involving 162 community-dwelling Chinese older adults in Singapore. It revealed an indirect and remarkable influence from social support on geriatric depression via resilience.[15] A longitudinal study in multiple sclerosis demonstrated that the relation between psychologically healthy outcomes and social support would be significantly mediated with resilience.[17] Another study from Chinese mainland suggested a complete mediating influence from resilience on depressive conditions and social support in 195 children whose parents suffered from HIV.[16] These researches indicated that resilience could play a mediation role between social support and emotional distress in different groups. Our findings were also generally consistent with that of in other studies, which demonstrated the mediating effects of resilience on social support and anxiety/depression in lung cancer patients.

However, there were many studies reported different results. A study performed on infertile women in China showed that anxiety and depression were negatively correlated to objective and subjective supports, as well as support utilizing extent.[35] The depression scores of pregnant women who undergone earthquake were significantly correlated with all dimensions of social support.[36] Some of our findings were inconsistent with that of in these studies, such as objective support was not significantly associated with anxiety and depression in our individuals. The reason may be different physical symptoms of lung cancer and the pains from multiple treatments, which make lung cancer patients concern more about their subjective feelings. Another reason was that our research was a cross-sectional study on hospitalized population, who rarely contacted with others during hospitalization.

 > Conclusion Top

The present study revealed that lung cancer patients with higher resilience and social support experienced lower psychological anxiety and depression. The level of anxiety and depression was indirectly affected by social support through the mediation of resilience. Therefore, improving social support for lung cancer patients may help enhance their psychological resilience, and mitigate the generation of anxiety and depression. Further longitudinal study would be necessary to verify this point. The practical implication for clinical work was that when family members or medical professionals would like to provide support to patients with lung cancer, they should pay more attention to subjective support and focus on the extent of support utilization.

Financial support and sponsorship

This study was supported by the Health special fund from Health Care Commission of Hunan Province (No. B2015-01).

Conflicts of interest

There are no conflicts of interest.

 > References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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