cancers

Article
Mental Health Challenges in Cancer Patients: A Cross-Sectional
Analysis of Depression and Anxiety
Walid Shalata 1, *,† , Itamar Gothelf 2,† , Tomer Bernstine 3 , Regina Michlin 1 , Lena Tourkey 1 , Sondos Shalata 4
and Alexander Yakobson 1

1 The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center, Ben-Gurion
University, Beer-Sheva 84105, Israel
2 Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev,
Beer-Sheva 84105, Israel
3 The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 13115, Israel
4 Nutrition Unit, Galilee Medical Center, Nahariya 22000, Israel
* Correspondence: [email protected]
† These authors contributed equally to this work.

Simple Summary: This research is suggested to address the significant psychological distress that
cancer patients often experience during diagnosis and treatment, which can adversely affect their out-
comes and care. Despite advancements in cancer treatments extending survival rates, the emergence
of depression and anxiety as common comorbidities underscores the need for targeted interventions
to improve patient well-being. The study aims to investigate the prevalence of depression and anxiety
among cancer patients and identify some of the associated risk factors.

Abstract: Advancements in cancer treatment and early detection have extended survival rates,
transforming many cancers into chronic conditions. However, cancer diagnosis and treatment
can trigger significant psychological distress, including depression and anxiety, impacting patient
outcomes and care. This study aimed to examine the prevalence of and identify the risk factors for
depression and anxiety among cancer patients. A cross-sectional study was conducted, including
Citation: Shalata, W.; Gothelf, I.;
patients under the care of the oncology department at a tertiary medical center between June 2021
Bernstine, T.; Michlin, R.; Tourkey, L.;
and October 2023. Depression and anxiety were assessed using the Patient-Reported Outcomes
Shalata, S.; Yakobson, A. Mental
Measurement Information System (PROMIS) short forms. Logistic regression analysis identified
Health Challenges in Cancer Patients:
A Cross-Sectional Analysis of
risk factors for depression and anxiety. The study population included 159 patients, with 40.3%
Depression and Anxiety. Cancers 2024, reporting worsening mental health, but only about half of them received therapy. Among the study
16, 2827. https://doi.org/10.3390/ participants, 22.6% experienced symptoms of depression and 30.2% experienced symptoms of anxiety.
cancers16162827 Single-cancer patients and those with metastases were at increased risk for depression, while those
with a disease duration of more than a year and patients with female-specific cancer were more likely
Academic Editors: Richard Crevenna
to experience anxiety. Given the high prevalence of mental health deterioration in cancer patients,
and Thomas Licht
closer monitoring and validated assessment tools are essential to improve depression and anxiety
Received: 30 July 2024 diagnosis and facilitate early interventions.
Revised: 4 August 2024
Accepted: 7 August 2024 Keywords: cancer; depression; anxiety; mental health; patient-reported outcomes; psycho-oncology;
Published: 12 August 2024
metastasis

Copyright: © 2024 by the authors.

1. Introduction
Licensee MDPI, Basel, Switzerland.
This article is an open access article Cancer diagnosis and treatment are life-changing experiences that demoralize cancer
distributed under the terms and patients [1]. Recent advancements in cancer treatment represent the forefront of biomedical
conditions of the Creative Commons therapy, encompassing modalities such as chemotherapy, immunotherapy, targeted therapy,
Attribution (CC BY) license (https:// and radiotherapy. These approaches signify significant progress in improving patients’
creativecommons.org/licenses/by/ quality of life and extending their survival rates [2,3]. Furthermore, enhancements in
4.0/). early cancer detection have contributed to an extended lifespan for individuals living with

Cancers 2024, 16, 2827. https://doi.org/10.3390/cancers16162827 https://www.mdpi.com/journal/cancers

Cancers 2024, 16, 2827 2 of 14

cancer, presenting a considerable global healthcare challenge. These advancements in the

cancer field have resulted in a noteworthy outcome, wherein approximately fifty percent
of individuals newly diagnosed with cancer can anticipate a minimum 10-year survival
period [4]. This shift characterizes numerous cancer types as chronic conditions, thereby
emphasizing the need for comprehensive, long-term management strategies.
In addition to the physical challenges posed by cancer and its treatments, receiving a
cancer diagnosis is a profoundly stressful event and can be life-changing for the patient.
The psychological response to this diagnosis can potentially trigger a range of serious
health consequences, including the development of psychiatric disorders [5]. Among
the most prevalent comorbid mental disorders are adjustment disorders (13%), followed
by depression (11%) and anxiety disorders (10%) [6]. However, the relationship between
mental health status and cancer-related complications is bidirectional. Over the past decade,
there has been a rapid accumulation of evidence regarding the influence of mental disorders
on tumor progression and cancer-related mortality [7]. Studies have found that psychiatric
disorders adversely impact patient management and control, quality of life, duration of
hospitalization, treatment compliance, and associated treatment expenses [8,9].
Prior research assessing psychological distress in cancer patients has revealed diverse
prevalence rates, which varied between 5.0% and 49.0% depending on the disease stage,
clinical setting, and treatment phase [10]. Another study found that approximately half
of cancer patients report experiencing clinical levels of distress [11]. Variations across
medical centers regarding the diagnosis and management of psychological distress within
cancer care settings indicate a potential gap in awareness or recognition of these mental
health issues [12]. Progress has been made in addressing the psychological needs of cancer
patients. Oncologists are now receiving enhanced communication skills training to discuss
psychological concerns with patients more effectively [13,14]. Additionally, screening
systems have been developed to identify individuals experiencing depression and anxiety,
taking into account various social factors [15,16]. However, to effectively implement these
advances, oncology teams need to gain more exposure to these skills and screening systems
and better understand the prevalence of depression and anxiety among their patients.
Evaluating depression and anxiety among cancer patients is vital to identifying those
requiring support, additional evaluation, and follow-up interventions. One method of iden-
tifying such patients is through the administration of validated screening tests, as recom-
mended by the National Comprehensive Cancer Network (NCCN) [17,18]. These screening
tests use various questionnaires to detect patients with elevated levels of depression and
anxiety symptoms, thereby indicating the potential need for additional psychological or
psycho-oncological assistance and interventions [19]. Among these, the Patient-Reported
Outcomes Measurement Information System (PROMIS) depression and anxiety short forms
have gained increasing importance. These tools were designed to assess the severity of
depression and anxiety symptoms through the patient’s self-reported experiences, aligning
with psychological diagnostic methods rather than biomedical diagnostic criteria outlined
in the DSM-5 [20].
Despite numerous research publications, the prevalence of depression and anxiety
among clinically relevant cancer subgroups remains ambiguous, with varying estimates
that are difficult to apply in clinical practice. Additionally, the association between cancer
patients’ sociodemographic, oncologic, and psychiatric characteristics and their risk of de-
veloping depression and anxiety has not been adequately studied and remains unclear. We
hypothesize that specific characteristics within these categories (e.g., marital status and gen-
der) are associated with an increased risk of depression and anxiety among cancer patients.
Therefore, the objectives of this study are: (1) to evaluate the prevalence of depression and
anxiety among cancer patients in Israel; and (2) to explore the relationships between various
sociodemographic, oncologic, and psychiatric characteristics and the risk of depression
and anxiety. Addressing this knowledge gap is essential for raising awareness of these
mental health issues and facilitating early identification and personalized interventions.
Cancers 2024, 16, 2827 3 of 14

This approach can promote holistic disease management, improve the overall quality of
life, and reduce mortality for cancer patients.

2. Materials and Methods

2.1. Study Design
This is a cross-sectional study conducted at the Soroka University Medical Center
(SUMC) in Beer-Sheva, Israel, between June 2021 and October 2023. SUMC serves as the
principal hospital and the sole specialized tertiary care facility in Israel’s southern region,
an area that encompasses approximately 60% of the nation’s territory [21]. It delivers a full
spectrum of clinical management and oncological services, addressing the needs of both
adult and pediatric patients within Beer-Sheva and its adjacent areas.

2.2. Sample Characteristics

From June 2021 through October 2023, all cancer patients under the care of the oncol-
ogy department at SUMC were invited by their physicians to participate in a cross-sectional
study. Patients who consented to participate in the study were provided with a comprehen-
sive explanation of its content and purposes. Participants were notified that their assent
to engage in the study would be acknowledged with their written consent. Subsequently,
they were requested to complete a detailed questionnaire as part of the study protocol.
The inclusion criteria for the study were: (a) cancer patients under the care of the oncol-
ogy department at SUMC undergoing treatment modalities (immunotherapy, chemother-
apy, chemo-immunotherapy, or radiotherapy); (b) patients capable of reading in Hebrew,
Arabic, English, and Russian and willing to provide informed consent; (c) patients aged
18 years or older.

2.3. Assessment
Patients completed self-administered, anonymous written questionnaires. The re-
sponses were securely stored in a locked facility at SUMC. Subsequently, a separate research
member processed the questionnaire data using a computerized system. The questionnaires
were composed of five modules: (a) Sociodemographic characteristics included age, gender,
ethnicity, marital status. (b) Oncologic characteristics included cancer metastasis (yes/no),
disease duration, cancer therapy and family history of malignancy (yes/no). (c) Psychi-
atric characteristics included past mental health disorder, past anti-depressant treatment
(yes/no), type of treatment, family history of diagnosed mental health disorder (yes/no),
is the patient feeling mental health worsening (yes/no), currently using pharmacology
therapy (yes/no), and current psychiatric/psychologic support (yes/no). (d) The evalua-
tion of anxiety was performed using the seven-question version of the PROMIS Emotional
Distress–Anxiety short form, translated into Hebrew, Arabic, English, and Russian. This val-
idated assessment tool is a widely recognized self-administered instrument formulated by
the National Institutes of Health for quantifying anxiety symptoms [22,23]. Each question
was rated from 1, indicating ‘never’, to 5, signifying ‘always’ [24,25]. (e) Depression was
assessed using the eight-question version of the PROMIS Emotional Distress–Depression
short form, a version specifically designed to screen for depression. This form was also
translated into Hebrew, Arabic, English, and Russian. Similarly, each question rated on a
scale from 1 (‘never’) to 5 (‘always’), following a consistent rating pattern [26].

2.4. Methods
The PROMIS depression form included 8 items, each scored from 1 to 5. The scores
were summed to obtain a raw score ranging from 8 to 40, which was then converted into a
T-score ranging from 37.1 to 81.1. Similarly, the PROMIS anxiety form included 7 items,
each scored from 1 to 5, resulting in a raw score ranging from 7 to 35 [27]. This raw score
was converted into a T-score ranging from 36.3 to 82.7. For both forms, a T-score of less
than 55 indicated no to slight depression or anxiety, 55–59.9 indicated mild depression or
Cancers 2024, 16, 2827 4 of 14

anxiety, 60–69.9 indicated moderate depression or anxiety, and 70 or above indicated severe
depression or anxiety.

2.5. Statistical Analysis

Descriptive statistics were employed to summarize the patients’ sociodemographic,
oncologic, and psychiatric characteristics. Continuous data were presented as mean ± stan-
dard deviation (SD), while categorical variables were reported as frequencies (percentages).
Logistic regression was utilized to evaluate the primary hypotheses that certain sociodemo-
graphic, oncologic, and psychiatric factors are associated with the presence of depression
and anxiety. The variables included in the regression model were selected based on their es-
tablished relevance to depression and anxiety as documented in the existing literature. This
method estimated odds ratios (ORs) and 95% confidence intervals (CIs) for these associa-
tions. Logistic regression was preferred for its ability to handle binary dependent variables
and adjust for multiple confounders, providing a distinct advantage when addressing
categorical outcomes. The cut-off points for depression and anxiety were determined
according to DSM-level 2 criteria, as detailed in the Section 2.4. For both depression and
anxiety, a T-score of 55 and above was used as the threshold, reflecting the standard crite-
rion commonly used to indicate clinically significant symptoms. Statistical analysis was
performed using SPSS software (version 29). A two-sided p-value of less than 0.05 was
considered statistically significant.

3. Results
During the recruitment period from June 2021 and October 2023, 159 patients provided
their consent to participate in the study. Table 1 presents the background characteristics of
the study participants, whose median age was 67.0 with an interquartile range (IQR) of
11. The majority of the participants were males (62.3%, with a median age of 69 and an
IQR of 8), whereas the female participants had a mean age of 64.65 ± 10.57 years. Table 2
provides a detailed analysis of these descriptive statistics. In total, 57.2% identified as
Jewish, 19.5% as Arab, and 23.3% as of European descent, with 66% of the participants
being married. Among the participants, 69.8% (n = 111) reported having metastatic cancer,
with most treated either with chemotherapy alone (n = 69, 43.4%) or a combination of
immunotherapy and chemotherapy (n = 47, 29.6%). Approximately half of the patients
(n = 81, 50.9%) had a disease duration of more than one year, and 45.3% (n = 72) reported a
family history of malignancy.

Table 1. The baseline characteristics of the study population (n = 159).

Characteristics Median (Interquartile Range)

Age (years) 67.0 (11)
Gender
Male 69.0 (8)
Mean ± SD (range)
Female 64.65 ± 10.57 (44–87)
Frequencies (percentage)
Female 60 (37.7)
Male 99 (62.3)
Ethnicity
Jewish 91 (57.2)
Arab 31 (19.5)
European descent 37 (23.3)
Marital status
Married 105 (66.0)
Divorced 25 (15.7)
Widowed 14 (8.8)
Single 11 (6.9)
In relationship 4 (2.5)
Cancers 2024, 16, 2827 5 of 14

Table 1. Cont.

Characteristics Median (Interquartile Range)

Cancer metastasis
Yes 111 (69.8)
No 48 (30.2)
Disease duration
<1 month 3 (1.9)
1–3 month 19 (11.9)
3–6 month 29 (18.2)
6–9 month 18 (11.3)
9–12 month 9 (5.7)
>1 year 81 (50.9)
Cancer therapy
Immunotherapy 38 (23.9)
Chemotherapy 69 (43.4)
Combination of immunotherapy and
47 (29.6)
chemotherapy
Radiotherapy 5 (3.1)
Family history of malignancy
Yes 72 (45.3)
No 87 (54.7)
Past mental health disorder
Yes 7 (4.4)
No 152 (95.6)
Past antidepressant treatment
Yes 16 (10.1)
No 143 (89.9)
Type of antidepressant treatment
Psychotherapy 2 (1.3)
Medications 10 (6.3)
Combination 4 (2.5)
Family history of diagnosed mental health disorder
Yes 6 (3.8)
No 153 (96.2)
Are you feeling mental health worsening?
Yes 64 (40.3)
No 95 (59.7)
Currently using pharmacology therapy
Yes 10 (6.3)
No 149 (93.7)
Current psychiatric/psychological support
Yes 30 (18.9)
No 129 (81.1)

Table 2. Descriptive statistics of age by gender.

N Mean Median Standard Deviation Variance Skewness Coefficient

Age (Total) 159 65.75 67 10.99 120.72 −1.180
Female 60 64.65 64.0 10.57 111.62 0.210
Male 99 66.41 69.0 11.24 126.25 −1.918

Among the 159 patients, 10.1% (n = 16) reported having received past mental health
treatment, primarily medications (n = 10, 6.3%). Additionally, 3.8% (n = 6) mentioned a
family history of diagnosed mental health disorders. Notably, 40.3% (n = 64) of all partici-
pants reported a subjective deterioration of their mental status, but only 6.3% (n = 10) were
currently undergoing medical therapy, whereas 18.9% (n = 30) were receiving psychiatric
or psychological support.
Table 3 below provides a breakdown of the prevalence of anxiety and depressive
symptoms among patients, categorized by severity. Anxiety symptoms, as assessed using
the PROMIS Emotional Distress–Anxiety short form, were identified in 30.2% (n = 48) of
Cancers 2024, 16, 2827 6 of 14

the patients. Among these, 15.1% (n = 24) reported mild anxiety, 13.2% (n = 21) reported
moderate anxiety, and 1.9% (n = 3) reported severe anxiety. By comparison, depressive
symptoms, evaluated using the PROMIS Emotional Distress–Depression short form, were
less prevalent, affecting 22.6% (n = 36) of the patients. Within this group, 13.2% (n = 21)
experienced mild depression, 7.5% (n = 12) experienced moderate depression, and 1.9%
(n = 3) experienced severe depression. Table 4 provides further descriptive statistics related
to the PROMIS form.

Table 3. Prevalence of depression and anxiety among the patients, stratified by severity (n = 159).

Severity of Depression Prevalence (Percentage)

Normal 123 (77.4)
Mild depression 21 (13.2)
Moderate depression 12 (7.5)
Severe depression 3 (1.9)
Severity of anxiety Prevalence (percentage)
Normal 111 (69.8)
Mild anxiety 24 (15.1)
Moderate anxiety 21 (13.2)
Severe anxiety 3 (1.9)

Table 4. Descriptive statistics of PROMIS T-score.

PROMIS T-Score N Mean Median Standard Deviation Variance Skewness Coefficient

Depression 159 46.56 46.20 9.16 83.90 0.61
Anxiety 159 48.64 48.40 9.99 99.88 0.26

The prevalences of depression and anxiety, stratified by the type and severity of
cancer, are presented in Table 5. Lung cancer was the most prevalent type of cancer among
the patients, accounting for 23.3% (n = 37) of cases. Within this subgroup, 27% (n = 10)
of patients experienced anxiety symptoms, while 21.6% (n = 8) exhibited symptoms of
depression. Similarly, colorectal cancer was diagnosed in 17.0% (n = 27) of the participants,
with 18.5% (n = 5) of these patients describing anxiety and 29.6% (n = 8) reporting depression.
Furthermore, skin and breast cancers constituted 15.7% (n = 25) and 13.2% (n = 21) of the
cases, respectively. Notably, 38.9% (n = 8) of breast cancer patients and 28% (n = 7) of skin
cancer patients reported anxiety symptoms.
The multivariable logistic regression analysis, as detailed in Table 6, examined various
characteristics that could impact the diagnosis of anxiety and depression based on the
PROMIS questionnaires. The findings indicate that patients who were single (OR = 10.89,
p = 0.002, 95% CI 2.44–48.64), those with metastatic disease (OR = 3.66, p = 0.033, 95%
CI 1.11–12.01), and those with past mental treatment history (OR = 4.30, p = 0.033, 95%
CI 1.12–16.48) faced a significantly increased risk of reporting depression. Additionally, the
multivariable logistic regression analysis for anxiety revealed that patients with a disease
duration of more than one year had a significantly increased risk of reporting anxiety
symptoms (OR = 2.65, p = 0.022, 95% CI 1.15–6.08), while patients with female-specific
types of cancer (OR = 7.78, p = 0.045, 95% CI 1.05–57.96) were at a significantly heightened
risk for reporting anxiety symptoms and marginally significantly more at risk for reporting
symptoms of depression (OR = 8.53, p = 0.071, 95% CI 0.83–87.41). Supplementary S1
illustrates depression/anxiety among cancer patients across various demographic and
clinical characteristics.
Cancers 2024, 16, 2827 7 of 14

Table 5. Prevalence of depression and anxiety stratified by type of cancer and severity.

Liver Renal Pancreas Brain Skin Sarcoma Prostate Neck Colorectal Stomach Uterine Lung Breast Ovarian Bladder
Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer Cancer
Depression
severity
Normal 5 (100.0) 3 (60.0) 3 (42.9) 0 22 (88.0) 3 (50.0) 6 (85.7) 0 22 (81.5) 7 (87.5) 0 29 (78.4) 16 (76.2) 5 (100.0) 2 (100.0)
Mild depression 0 1 (20.0) 2 (28.6) 1 (100.0) 1 (4.0) 1 (16.7) 1 (14.3) 1 (50.0) 3 (11.1) 0 0 7 (18.9) 3 (14.3) 0 0
Moderate
0 1 (20.0) 2 (28.6) 0 2 (8.0) 1 (16.7) 0 1 (50.0) 2 (7.4) 0 1 (100.0) 1 (2.7) 1 (4.8) 0 0
depression
Severe
0 0 0 0 0 1 (16.7) 0 0 0 1 (12.5) 0 0 1 (4.8) 0 0
depression
Total 5 (3.1) 5 (3.1) 7 (4.4) 1 (0.6) 25 (15.7) 6 (3.8) 7 (4.4) 2 (1.3) 27 (17.0) 8 (5.0) 1 (0.6) 37 (23.3) 21 (13.2) 5 (3.1) 2 (1.3)
Anxiety
severity
Normal 5 (100.0) 4 (80.0) 4 (57.1) 0 18 (72.0) 3 (50.0) 6 (85.7) 0 19 (70.4) 6 (75.0) 0 27 (73.0) 13 (61.9) 4 (80.0) 2 (100.0)
Mild anxiety 0 0 1 (14.3) 1 (100.0) 3 (12.0) 1 (16.7) 1 (14.3) 2 (100.0) 4 (14.8) 0 0 7 (18.9) 3 (14.3) 1 (20.0) 0
Moderate
0 1 (20.0) 2 (28.6) 0 3 (12.0) 1 (16.7) 0 0 4 (14.8) 2 (25.0) 1 (100.0) 3 (8.1) 4 (19.0) 0 0
anxiety
Severe anxiety 0 0 0 0 1 (4.0) 1 (16.7) 0 0 0 0 0 0 1 (4.8) 0 0
Total 5 (3.1) 5 (3.1) 7 (4.4) 1 (0.6) 25 (15.7) 6 (3.8) 7 (4.4) 2 (1.3) 27 (17.0) 8 (5.0) 1 (0.6) 37 (23.3) 21 (13.2) 5 (3.1) 2 (1.3)
Cancers 2024, 16, 2827 8 of 14

Table 6. Multivariable logistic regression analysis of sociodemographic, oncologic, and psychiatric

characteristics and their associations with the risk of developing depression and anxiety.

Odds ratio for

Odds Ratio for p-Value p-Value
Variable Anxiety; CI 95%,
Depression; CI 95% for Depression for Anxiety
p-Value
Gender
Female (reference) 1 1
Male 1.56; 0.48–5.05 0.462 2.55; 0.86–7.59 0.093
Marital status
Married (reference) 1 1
Divorced 1.28; 0.39–4.20 0.688 1.97; 0.71–5.48 0.195
Widowed 0.88; 0.16–4.94 0.881 0.25; 0.03–2.23 0.214
Single 10.89; 2.44–48.64 0.002 2.89; 0.71–11.71 0.137
In relationship 0; 0.999 1.51; 0.13–17.37 0.740
Duration of disease
<1 year (reference) 1 1
>1 year 1.41; 0.56–3.54 0.464 2.65; 1.15–6.08 0.022
Metastasis
No (reference) 1 1
Yes 3.66; 1.11–12.01 0.033 1.17; 0.49–2.79 0.722
Cancer therapy
Immunotherapy (reference) 1 1
Chemotherapy 1.27; 0.31–5.26 0.742 0.46; 0.12–1.67 0.236
Combination of immunotherapy
0.54; 0.11–2.51 0.428 0.26; 0.06–1.03 0.056
and chemotherapy
Radiotherapy 2.80; 0.26–29.75 0.394 1.06; 0.11–9.91 0.962
Ethnicity
Jewish (reference) 1 1
Arab 1.30; 0.44–3.85 0.634 1.75; 0.63–4.88 0.284
European descent 0.88; 0.27–2.87 0.834 1.12; 0.42–2.97 0.819
Age
Less than 65 (reference) 1 1
65 years and above 0.75; 0.30–1.90 0.549 0.47; 0.20–1.07 0.072
Type of cancer
Skin (reference) 1 1
Colon 3.10; 0.38–25.69 0.294 3.21; 0.57–17.78 0.182
Lung 5.0; 0.72–34.92 0.104 2.71; 0.59–12.52 0.202
Female-specific (breast, ovarian,
8.53; 0.83–87.41 0.071 7.78; 1.05–57.96 0.045
uterine)
Other 6.40; 0.94–43.72 0.058 2.69; 0.56–12.88 0.217
Past mental treatment
No (reference) 1 1
Yes 4.30; 1.12–16.48 0.033 2.10; 0.61–7.25 0.239

4. Discussion
This study aimed to investigate the prevalence of mental health conditions, specifically
depression and anxiety, across clinically relevant cancer subgroups and to identify the
risk factors associated with these conditions. An assessment of depression and anxiety
symptoms was conducted using the PROMIS self-report questionnaires. Patients scoring
above the threshold (T-score of 55 or higher) were considered within the clinical range for
symptoms. Clinical symptoms of depression and anxiety stem from a variety of factors,
including medical, psychological, and cultural. The study was composed of several key
sections: (a) characterization of the patient population; (b) the prevalence and severity of
depression and anxiety symptoms, stratified by multiple cancer types; and (c) examina-
tion of various risk factors contributing to the development of depression and anxiety in
cancer patients.
In this study, 22.6% of cancer patients experienced depression symptoms, while
30.2% experienced anxiety. A comparable study conducted in Alabama, USA, utilizing
Cancers 2024, 16, 2827 9 of 14

the PROMIS depression form reported a depression prevalence of 25.9% [28]. Another
study conducted in California, USA, reported markedly higher rates than those commonly
observed in the literature [29], with 47% of cancer patients experiencing symptoms of
depression and 45% experiencing symptoms of anxiety [30]. It is important to note that these
studies evaluated the prevalence of depression and anxiety using the PROMIS questionnaire
among specific cancer subtypes, while PROMIS data regarding a wider range of cancer
subtypes remain limited. Our study examined individuals at risk for mental health issues
and assessed whether they received appropriate treatment. Among the 40.3% of cancer
patients who reported a deterioration in their mental status, only 6.3% were currently
taking anti-depressant medications. The alarmingly low rates of patients receiving anti-
depressant medications highlight a significant and concerning issue, suggesting that cancer
patients may not be receiving the necessary therapy, which could adversely impact their
quality of life. This finding aligns with a US study that revealed that only 12% of those
diagnosed with depression received antidepressant medications, and a mere 5% reached a
mental health counsellor [31]. This discrepancy may stem from insufficient mental health
evaluations. Following a cancer diagnosis, patients must receive multidisciplinary support,
including mental health care, to monitor and address potential symptoms of anxiety and
depression [32,33]. Another factor contributing to the under-diagnosis of depression and
anxiety is that oncologists diagnose mild to moderate depressive and anxiety symptoms
in only one-third of patients who exhibit these symptoms and tend to underestimate the
severity of these symptoms compared to patients who are more severely affected [34]. It
should also be considered that once medical therapy is initiated, close follow-up is essential
to evaluate the effectiveness of the treatment, monitor patient compliance, and assess for
potential side effects and drug interactions [35].
Our study found different risk factors for depression and anxiety. The results indicated
that single patients were more prone to depression compared to their married counterparts.
This finding is consistent with a study by Aizer et al. that reported similar outcomes [36].
Our results indicate that single individuals that were diagnosed with cancer exhibited
significantly higher levels of depression and anxiety compared to those in other relationship
statuses. We hypothesize that this may be due to increased concerns about rejection and
difficulties in forming new relationships. Extended periods of singlehood can lead to
heightened caution when interacting with potential partners, which may adversely affect
mental health. Long-term singlehood can foster feelings of loneliness, isolation, and
social exclusion, potentially contributing to depression and anxiety. Additionally, societal
pressures and personal beliefs about relationships might diminish self-esteem or self-worth.
Prolonged singlehood may also undermine confidence in dating, further exacerbating
social anxiety. Thus, the increased susceptibility to depression among single individuals
may reflect broader issues related to social support and societal structures especially after a
diagnosis of cancer. Married individuals often benefit from emotional and practical support
from their partners, which can buffer against the psychological stress of cancer diagnosis
and treatment. In contrast, single patients may lack immediate access to such support,
potentially leading to higher emotional burdens and mental health challenges. This aligns
with the understanding that social support networks are critical to mental health outcomes.
Additionally, single patients demonstrate poorer adherence to the various and demanding
treatments compared to their married counterparts throughout the disease progression [37].
This discrepancy may arise from the absence of a supportive partner who can assist in
managing the logistical and emotional aspects of treatment adherence. The relationship
between therapy adherence and depression has been explored in various studies, indicating
that a lack of support can lead to higher depression rates [38,39]. Therefore, oncologists
and mental health providers should adopt a holistic approach to assessing cancer patients
for depression and anxiety, considering both individual circumstances and broader social
contexts, ultimately improving patients’ well-being and quality of life.
In addition to marital status, metastasis was also found to be associated with an
increased risk of depression in our study. This association is supported by the literature
Cancers 2024, 16, 2827 10 of 14

and can be attributed to several factors [40,41]. Metastatic disease is often linked with
a poorer prognosis and lower survival rates, which can lead to heightened feelings of
hopelessness, despair, and depression. Moreover, metastatic cancer is associated with an
increased symptom burden, chronic pain, and severe physical limitations, all of which are
known risk factors for depression [42]. The aggressive treatments required for metastatic
cancer usually result in severe side effects that contribute to both physical discomfort and
emotional distress, further exacerbating the risk of depression in these patients.
Furthermore, our data showed that patients with a history of antidepressant use are
at an increased risk of depression following a cancer diagnosis. This finding is plausible,
as these patients likely have a history of depression and a predisposition to depressive
episodes. The emotional and physical burdens of a cancer diagnosis and treatment can
disrupt previously stable remission of depressive symptoms, leading to psychological
imbalance. This disruption can reactivate underlying depressive tendencies, exacerbating
the patient’s mental health condition [43].
A disease duration of more than a year was linked in our study to an increased risk of
anxiety, contrary to the findings of Krebber et al. [44]. This discrepancy may be due to the
relatively high proportion of patients (96.2%) in our study who were still undergoing cancer
therapy, with almost 70% receiving chemotherapy. Prolonged cancer therapy, particularly
chemotherapy, can lead to long-term emotional exhaustion and overwhelm the patient’s
coping mechanisms. Additionally, as cancer progresses, the physical symptoms and side
effects of treatments can become more severe, resulting in increased physical pain and
discomfort, further contributing to the heightened risk of anxiety [45].
Our study also found that the type of cancer impacts the development of anxiety.
Specifically, we found that patients with female-specific cancers, predominantly breast
cancer, had a higher probability of reporting anxiety symptoms compared to those with
other types of cancer, and also a trend for higher probability of reporting symptoms of
depression. Although some types of cancer may require more intensive treatments than
breast cancer, this does not appear to be the predominant factor influencing anxiety levels.
Factors such as coping strategies, social support, and social reintegration play crucial roles
in the development of depression and anxiety [46]. A possible explanation for this finding
may be that the emotional and psychological burden of a breast cancer diagnosis, along
with concerns about body image, both contribute to heightened depression and anxiety
levels in these patients [47].
Another explanation for this finding, supported by the existing literature [48,49], may
be that women often employ emotion-focused coping strategies [50]. These strategies make
them more acutely aware of their condition and personal distress. In contrast, men tend to
adopt more restrained and self-contained attitudes, leading to fewer complaints and less
emotional sharing. While the psychological challenges and coping mechanisms utilized
by women with female-specific cancers are not yet fully understood and warrant further
research, it is essential to evaluate sub-groups of patients, particularly women, for mental
health conditions, specifically depression and anxiety. Following this evaluation, patients
should receive appropriate psychological support and medical treatment.
In this study, we compared the prevalence of depression and anxiety among three
ethnic groups: Jewish, Arabs, and European descent women. Interestingly, our findings did
not reveal significant differences in the incidence of these mental health issues among the
groups, suggesting that the overall burden of these mental health morbidities is similarly
distributed despite their diverse backgrounds. In an 18-center meta-analysis in the USA,
Hispanic cancer patients reported higher levels of depression compared to other ethnici-
ties [51]. However, the prevalence of depression and anxiety among Jewish and Arab cancer
patients has not yet been studied. The Arabs are a traditionally nomadic Muslim ethnic
group characterized by a distinct cultural heritage and lifestyle [52]. Despite facing unique
socio-economic challenges, such as limited access to healthcare and lower socio-economic
status, the incidence of these mental health morbidities did not significantly differ from
Cancers 2024, 16, 2827 11 of 14

other groups. These findings highlight the need for further study of these factors and a
deeper examination of the varied characteristics among different ethnicities.
Indeed, we did not find significant gender differences in our study in the rates of
anxiety and depression symptoms. A recent meta-analysis found that, overall, female
cancer patients reported significantly higher levels of depression compared to their male
counterparts, while males reported significantly greater levels of anxiety than females [53].
Yet, the findings were inconsistent among studies. Thus, further research is needed in order
to conclude whether there are indeed gender differences in the rates of depression and
anxiety in cancer patients.
To our knowledge, this is the first study to utilize the PROMIS anxiety and depression
questionnaires, well-established and validated assessment tools, to evaluate the prevalence
and severity of anxiety and depression across various types of cancer in a diverse ethnic
population. Additionally, this study aimed to identify risk factors associated with anxiety
and depression in a varied cancer patient population, without restrictions on age, ethnicity,
gender, family status, type of treatment, or type of cancer.
However, this study has several limitations. First and foremost, the relatively small
sample size of our study may limit the generalizability of our findings, potentially limiting
our ability to adequately represent the broader population of cancer patients. Specifically,
the heterogeneity of the study population and the limited numbers within certain cancer
type subgroups hinder our ability to detect significant associations and draw robust con-
clusions. Yet, to our knowledge, this is the first study from Israel reporting on the rates of
depression and anxiety in adults with various types of cancers. Additionally, due to the
cross-sectional design, it is not possible to establish causality between the different variables;
it can only demonstrate associations between them. Furthermore, the study lacks measures
of anxiety and depression at different time points, which could help to evaluate the mental
health status throughout disease progression. Such a follow-up could also aid in detecting
patients who are not receiving proper therapy or any therapy at all. Moreover, anxiety
and depression were assessed using the PROMIS questionnaire, which may not provide a
comprehensive assessment of the patient’s full mental status, thus limiting our ability to
determine a patient-tailored intervention based on the study outcomes. In addition, the
questionnaire used in this study did not account for the number of divorces within the
marital status category of participants, nor did it inquire about the specific generation of
family history of malignancy, thereby limiting our ability to ascertain the extent of familial
malignancy history. Finally, self-filled questionnaires can be a limitation due to potential
biases such as self-reporting bias and recall bias, which can affect the accuracy of the
data. Future studies should aim to include larger sample sizes and incorporate continuous
follow-up with multiple evaluation points.

5. Conclusions
This study highlights the high prevalence of mental health deterioration among cancer
patients and identifies key risk factors for depression and anxiety. The findings sug-
gest that closer monitoring of mental health and the use of validated assessment tools in
cancer patients can lead to better diagnosis and, as a result, timely and effective interven-
tions. It is important for clinicians to be aware of these outcomes and provide suitable
psycho-oncologic support for their patients. Future research should focus on large-scale
longitudinal studies to better understand the course of mental health symptoms in cancer
patients and to identify the most critical periods for intervention. Additionally, there is a
need to explore the impact of tailored mental health interventions and support systems on
improving patient outcomes. Physicians should consider routinely using short self-report
mental health questionnaires, such as the PROMIS, for screening anxiety and depression
symptoms in patients with cancer. By prioritizing mental health, clinicians can significantly
enhance the overall well-being and quality of life of their patients.
Cancers 2024, 16, 2827 12 of 14

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/cancers16162827/s1, Supplementary S1: Depression and Anxiety
Among Cancer Patients by Various Demographic and Clinical Factors.
Author Contributions: Conceptualization, W.S. and A.Y.; methodology, W.S.; software, W.S.; vali-
dation, W.S., I.G., T.B., R.M., L.T., S.S. and A.Y.; formal analysis, W.S., I.G., T.B., L.T., S.S., R.M. and
A.Y.; investigation, W.S., I.G., T.B., R.M., L.T., S.S. and A.Y.; resources, W.S.; data curation, W.S.;
writing—original draft preparation, W.S., I.G., T.B., R.M., L.T., S.S. and A.Y.; writing—review and
editing, W.S., I.G., T.B., L.T., S.S., R.M. and A.Y.; visualization, W.S.; supervision, W.S.; project admin-
istration, W.S.; funding acquisition, W.S. All authors have read and agreed to the published version
of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional Review Board of Soroka Medical Center as
“Tests of depression and anxiety symptoms among oncology patients”. The study was approved by
the Institutional Review Board of Soroka Medical Center (approval no. 50-21; on 23 June 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data either reside within the article itself or can be obtained from
the authors upon making a reasonable request.
Acknowledgments: The authors express their gratitude to the patients and their families for their un-
wavering cooperation throughout the treatment process and for generously sharing their experiences
to raise awareness among other patients and medical professionals. Furthermore, the authors extend
their thanks to the dedicated medical and non-medical staff, encompassing oncologists, radiologists,
nurses, and secretaries, for their tireless efforts and contributions.
Conflicts of Interest: The authors declare no conflicts of interest.

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