|Year : 2018 | Volume
| Issue : 1 | Page : 72-77
Relationship between resilience, social support as well as anxiety/depression of lung cancer patients: A cross-sectional observation study
Tingjie Hu, Jian Xiao, Juan Peng, Xiao Kuang, Bixiu He
Department of Geriatrics, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
|Date of Web Publication||8-Mar-2018|
Dr. Bixiu He
Department of Geriatrics, Xiangya Hospital of Central South University, 87 Xiangya Rood, Changsha 410008, Hunan Province
Source of Support: None, Conflict of Interest: None
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 13];14:72-7. Available from: https://www.cancerjournal.net/text.asp?2018/14/1/72/226768
| > Introduction|| |
Lung cancer is a major disease which seriously endangers human health. Lung cancer has contributed to more than one-quarter (27%) of cancer deaths. The diagnosis and treatment of cancer could lead to many negative emotions, generally included anxiety and depression., High prevalence of depression and anxiety has been usually observed in patients with malignant diseases, especially lung cancer. 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.
Social support is a multiple-faceted concept which described the assistance received from others in plight. 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. 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.
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. 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.,
There is an internal connection between social support and resilience. The development of resilience would be promoted with social support. Studies showed that both social support and resilience played a protective role to the individual's emotional disorder., Existing evidences suggested that resilience could be served as a mediator between social support and the generation of negative emotions.,, 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|| |
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:
- Diagnosis of lung cancer was confirmed by pathological or cytological examination
- 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
- No other serious physical diseases
- 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  and Zung SAS , 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., 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  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. The internal consistency (alpha) of SSRS was 0.79.
Connor-davidson resilience scale
Connor-Davidson Resilience Scale (CD-RISC), 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. The internal consistency (alpha) of CD-RISC in this study was 0.82.
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. was applied to test the mediation role of resilience between social support and emotional distress.
| > Results|| |
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%).
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).
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|| |
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., Meanwhile, social support has proved to be a significant protective factor for anxiety and depression, which was confirmed to the results in other studies.,, 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., 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. 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. A longitudinal study in multiple sclerosis demonstrated that the relation between psychologically healthy outcomes and social support would be significantly mediated with resilience. 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. 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. The depression scores of pregnant women who undergone earthquake were significantly correlated with all dimensions of social support. 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|| |
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|| |
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7-30.
Takahashi T, Hondo M, Nishimura K, Kitani A, Yamano T, Yanagita H, et al.
Evaluation of quality of life and psychological response in cancer patients treated with radiotherapy. Radiat Med 2008;26:396-401.
Thekkumpurath P, Venkateswaran C, Kumar M, Newsham A, Bennett MI. Screening for psychological distress in palliative care: Performance of touch screen questionnaires compared with semistructured psychiatric interview. J Pain Symptom Manage 2009;38:597-605.
Brintzenhofe-Szoc KM, Levin TT, Li Y, Kissane DW, Zabora JR. Mixed anxiety/depression symptoms in a large cancer cohort: Prevalence by cancer type. Psychosomatics 2009;50:383-91.
Pirl WF, Temel JS, Billings A, Dahlin C, Jackson V, Prigerson HG, et al.
Depression after diagnosis of advanced non-small cell lung cancer and survival: A pilot study. Psychosomatics 2008;49:218-24.
Paterson C, Jones M, Rattray J, Lauder W. Exploring the relationship between coping, social support and health-related quality of life for prostate cancer survivors: A review of the literature. Eur J Oncol Nurs 2013;17:750-9.
Li H, Ji Y, Chen T. The roles of different sources of social support on emotional well-being among Chinese elderly. PLoS One 2014;9:e90051.
Corey AL, Haase JE, Azzouz F, Monahan PO. Social support and symptom distress in adolescents/young adults with cancer. J Pediatr Oncol Nurs 2008;25:275-84.
Tusaie K, Dyer J. Resilience: A historical review of the construct. Holist Nurs Pract 2004;18:3-8.
Ye ZJ, Qiu HZ, Li PF, Liang MZ, Zhu YF, Zeng Z, et al.
Predicting changes in quality of life and emotional distress in Chinese patients with lung, gastric, and colon-rectal cancer diagnoses: The role of psychological resilience. Psychooncology 2017;26:829-35.
Eicher M, Matzka M, Dubey C, White K. Resilience in adult cancer care: An integrative literature review. Oncol Nurs Forum 2015;42:E3-16.
Ozbay F, Fitterling H, Charney D, Southwick S. Social support and resilience to stress across the life span: A neurobiologic framework. Curr Psychiatry Rep 2008;10:304-10.
Kroenke CH, Kubzansky LD, Schernhammer ES, Holmes MD, Kawachi I. Social networks, social support, and survival after breast cancer diagnosis. J Clin Oncol 2006;24:1105-11.
Bonanno GA. Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol 2004;59:20-8.
Li J, Theng YL, Foo S. Does psychological resilience mediate the impact of social support on geriatric depression? An exploratory study among Chinese older adults in Singapore. Asian J Psychiatr 2015;14:22-7.
Mo PK, Lau JT, Yu X, Gu J. The role of social support on resilience, posttraumatic growth, hopelessness, and depression among children of HIV-infected parents in mainland China. AIDS Care 2014;26:1526-33.
Koelmel E, Hughes AJ, Alschuler KN, Ehde DM. Resilience mediates the longitudinal relationships between social support and mental health outcomes in multiple sclerosis. Arch Phys Med Rehabil 2017;98:1139-48.
Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 1965;13:508-15.
Dai W, Kaminga AC, Tan H, Wang J, Lai Z, Wu X, et al.
Long-term psychological outcomes of flood survivors of hard-hit areas of the 1998 dongting lake flood in China: Prevalence and risk factors. PLoS One 2017;12:e0171557.
Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371-9.
Lei M, Li C, Xiao X, Qiu J, Dai Y, Zhang Q, et al.
Evaluation of the psychometric properties of the Chinese version of the resilience scale in wenchuan earthquake survivors. Compr Psychiatry 2012;53:616-22.
He L, Tang S, Yu W, Xu W, Xie Q, Wang J, et al.
The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults. Psychiatry Res 2014;219:347-52.
Xiao SY. Theoretical foundation and application of Social Support Rating Scale. J Clin Psychol Med 1994;4:98-100.
Ma X, Liu X, Hu X, Qiu C, Wang Y, Huang Y, et al.
Risk indicators for post-traumatic stress disorder in adolescents exposed to the 5.12 Wenchuan earthquake in China. Psychiatry Res 2011;189:385-91.
Zhong X, Wu D, Nie X, Xia J, Li M, Lei F, et al.
Parenting style, resilience, and mental health of community-dwelling elderly adults in China. BMC Geriatr 2016;16:135.
Yu XN, Lau JT, Mak WW, Zhang J, Lui WW, Zhang J, et al.
Factor structure and psychometric properties of the connor-davidson resilience scale among Chinese adolescents. Compr Psychiatry 2011;52:218-24.
Wen ZL, Hou JT, Zhang L. Comparison and application of moderating effect and mediating effect. Acta Psychol Sin 2005;37:268-74.
Solano JP, da Silva AG, Soares IA, Ashmawi HA, Vieira JE. Resilience and hope during advanced disease: A pilot study with metastatic colorectal cancer patients. BMC Palliat Care 2016;15:70.
Costa AL, Heitkemper MM, Alencar GP, Damiani LP, Silva RM, Jarrett ME, et al.
Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer. Cancer Nurs 2017;40:352-60.
Yeung NC, Lu Q. Perceived stress as a mediator between social support and posttraumatic growth among Chinese American breast cancer survivors. Cancer Nurs 2018;41:53-61.
Padmaja G, Vanlalhruaii C, Rana S, Nandinee D, Hariharan M. Care givers' depression, anxiety, distress, and somatization as predictors of identical symptoms in cancer patients. J Cancer Res Ther 2016;12:53-7.
Jung JY, Lee JM, Kim MS, Shim YM, Zo JI, Yun YH, et al.
Comparison of fatigue, depression, and anxiety as factors affecting posttreatment health-related quality of life in lung cancer survivors. Psychooncology 2017.
Braamse AM, van Turenhout ST, Terhaar Sive Droste JS, de Groot GH, van der Hulst RW, Klemt-Kropp M, et al.
Factors associated with anxiety and depressive symptoms in colorectal cancer survivors. Eur J Gastroenterol Hepatol 2016;28:831-5.
Scheffold K, Mehnert A, Müller V, Koch U, Härter M, Vehling S, et al.
Sources of meaning in cancer patients-influences on global meaning, anxiety and depression in a longitudinal study. Eur J Cancer Care (Engl) 2014;23:472-80.
Li H, Yan C, Zhu S, Cheng L, He G, Lei J, et al.
Correlation among coping style, social support, and negative emotion in infertile women. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2011;36:138-42.
Ren J, Jiang X, Yao J, Li X, Liu X, Pang M, et al.
Depression, social support, and coping styles among pregnant women after the Lushan Earthquake in Ya'an, China. PLoS One 2015;10:e0135809.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]