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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 126-131

Stress, anxiety, depression, and resilience in cancer patients on chemotherapy

1 Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Center, Dr D Y Patil University, Pune, Maharashtra, India
2 Department of Psychiatry, Rural Medical College, PIMS (DU), Loni, Maharashtra, India
3 Department of Psychiatry, AFMC, Pune, Maharashtra, India
4 Department of Radiotherapy, Rural Medical College, PIMS (DU), Loni, Maharashtra, India

Date of Submission08-Dec-2020
Date of Decision19-Apr-2021
Date of Acceptance03-May-2021
Date of Web Publication28-Oct-2021

Correspondence Address:
Dr. Suprakash Chaudhury
Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Center, Dr D Y Patil University, Pimpri, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_138_20

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Background: Cancer chemotherapy is an intense and cyclic treatment that is associated with a number of distressing side effects that may affect the person's psyche. Aim: The aim of the study is to evaluate stress, anxiety, depression, and resilience in cancer patients undergoing chemotherapy. Materials and Methods: Consecutive cancer patients undergoing chemotherapy at a tertiary care rural medical college hospital were included in the study with their consent. Patients having comorbid medical or psychiatric disorders were excluded. Demographic and clinical characteristics of the patients were recorded. The Depression Anxiety Stress Scale and Abbreviated Connor-Davidson Resilience Scale were administered and scored as per the test manual. The data were analyzed using the SPSS software with t-test, Chi-square test, Mann–Whitney U-test, Spearman's correlation, and multiple regression analysis. Results: The study included 32 male and 68 female cancer patients on chemotherapy. Depression was found in 33 patients, anxiety was observed in ten patients while stress was present in three patients. Stress was positively correlated to anxiety and depression, while resilience was negatively correlated to depression. There were no gender differences in stress, anxiety, depression, or resilience. A multiple regression was run to predict depression from stress, anxiety, and resilience. These variables statistically significantly predicted depression, F (3,96) =55.075, P < 0.0001, R2 = 0.632. All three variables added statistically significantly to the prediction (P < 0.05). Conclusion: One-third of cancer patients on chemotherapy suffer from depression which is negatively correlated with resilience. Significant predictors of depression in these patients were stress, anxiety, and resilience. Psychiatric management in addition to reducing depression, stress, and anxiety should also aim to increase resilience in these patients.

Keywords: Anxiety, depression, malignancy, pain, resilience, stress, tertiary care hospital

How to cite this article:
Chaudhury S, Jagtap B, Shailaja B, Mungase M, Saini RK, Jain V. Stress, anxiety, depression, and resilience in cancer patients on chemotherapy. Ann Indian Psychiatry 2021;5:126-31

How to cite this URL:
Chaudhury S, Jagtap B, Shailaja B, Mungase M, Saini RK, Jain V. Stress, anxiety, depression, and resilience in cancer patients on chemotherapy. Ann Indian Psychiatry [serial online] 2021 [cited 2023 Mar 25];5:126-31. Available from: https://www.anip.co.in/text.asp?2021/5/2/126/329428

  Introduction Top

To many laypersons, the diagnosis of cancer is akin to a death sentence. A diagnosis of cancer produces greater sense of distress than nonmalignant diseases with poorer prognoses Sustained high levels of distress for prolonged periods in cancer patients may lead to anxiety, depression, or both. Depression adversely affects the quality of life and is associated with poorer patient outcomes.[1],[2],[3] Despite tremendous advances in cancer treatment, it remains the second most common cause of death in India, exceeded only by heart disease.[2] At present, malignant diseases are treated by surgery, radiotherapy, and chemotherapy. In cancer chemotherapy drugs are administered which destroy the cancer cells in the body, but unfortunately, they also affect some normal cells. As a result cancer chemotherapy has numerous, troublesome and embarrassing side effects including nausea, vomiting, diarrhea, hair loss, fatigue, and risk for infection that add to the distress felt by the patient. Prolonged treatment, repeated hospitalizations apart from the knowledge of having cancer a highly stigmatizing illness, can all affect the psyche of the patient.[4]

Psychiatric comorbidity in cancer patients is fairly high; almost one-half exhibit emotional difficulties in the form of adjustment disorder, depressed mood, anxiety, reduced life satisfaction, or loss of self-esteem.[5],[6],[7] A recent review reported that in patients treated for cancer, the prevalence of depression was 13%, and anxiety was 15%.[8] As compared to the above prevalence figures, the estimated prevalence of depression (4.4%) and anxiety (3.6%) in general population is much lower.[9] Thus, a number of studies attest to the presence of adverse psychological consequences of cancer. Few studies also indicate that some psychosocial factors may reduce emotional distress in these patients. These factors include social support, adaptive coping strategies, optimism, positive emotion, self-coherence, and spirituality. However, which of the above named factors is most influential in modifying the emotional distress in cancer patients is not known.[10],[11]

To encompass the protective individual qualities in the adaptation to cancer, the concept of resilience was introduced.[12] Resilience is a person's ability to retain or rebuild relatively stable psychological functioning when facing a stressful life event and adversity. Studies in cancer patients have shown that resilience may independently contribute to low emotional distress in these patients.[11] There is a paucity of local studies that have assessed the levels of anxiety, depression, stress, and resilience in cancer patients being treated with chemotherapy. Keeping this in view, the above study was undertaken to assess the levels of anxiety, depression, stress, and resilience in cancer patients undergoing chemotherapy.

  Materials and Methods Top

This was a prospective cross-sectional analytical study undertaken at Rural Medical College, Loni, by the Department of Psychiatry in collaboration with oncology department. The study was approved by the Institutional Ethical Committee. Ethical clearance was obtained from Institutional Ethical Committee of Pravara Institute of Medical Sciences (Deemed University) vide letter no. PIMS/RMC/IEC-UG-PG/2019/219 dated 24.06.2017. All the participants gave written informed consent.


The sample of the study consisted of 100 consecutive cancer patients on chemotherapy treatment at Oncology department, Rural Medical College, Loni.

Inclusion criteria

  1. Patients with confirmed diagnosis of Cancer undergoing chemotherapy treatment in Pravara Rural Hospital
  2. Patients are stable, communicative, and willing to give their consent.

Exclusion criteria

  1. Patients suffering from chronic psychiatric disorder
  2. Patients with a history of mental illness
  3. Patients with previous or current use of sleep medications.

Tools used in the study

Demographic and clinical questionnaire

This self-made questionnaire included questions about various demographic variables such as sex, age, education, religion, occupation, number of children, marital status, and details of the illness.

Depression, Anxiety, Stress Scale

The Depression, Anxiety, Stress Scale (DASS) is a 21-item self-report inventory that gives the levels of depression, anxiety, and stress in the participant. The scale has adequate reliability. Test-retest reliability is also considered adequate with 71 for depression, 79 for anxiety, and 81 for stress. Exploratory and confirmatory factor analyses have supported the presence of the three factors (P < 0.05). Concurrent validity is also established. The DASS Depression scale correlates 0.74 with the Beck Depression Inventory while the DASS anxiety scale correlates 0.81 with the Beck Anxiety Inventory.[13],[14]

Connor-Davidson Resilience Scale

The Connor-Davidson Resilience Scale (CD-RISC2) is an abbreviated version of the CD-RISC consisting of 2-items. It is a self-report scale. Each item is scored 0–4 and total score ranges from 0 to 8. Studies indicate that it has adequate internal consistency, test-retest reliability, convergent validity, and divergent validity as well as correlation with full Connor-Davidson Resilience scale.[15]


Consecutive cancer patients registered in Oncology department for undergoing chemotherapy were requested to participate in the study. None of the patients refused to participate in the study. After explaining the purpose of the study to the patient and relatives, a written informed consent was taken. After that, the sociodemographic and clinical details of the participants were recorded in the case record form. Thereafter, the DASS and CD-RISC2 were administered individually to the patients. The scales were scored as per the test manual.

Statistical analysis

The collected data were entered in the computer and analyzed using SPSS 16 software (SPSS, IBM Corp., Chicago, IL, USA) using appropriate statistical tests. Statistical analysis was carried out using t-test, Chi-square test, Mann–Whitney U-test, and Spearman's correlation as appropriate.

  Results Top

The study included 100 consecutive patients undergoing chemotherapy. Mean (± Standard deviation [SD]) age of the patients was 53.06 (±8.67) years. Majority of the patients were female, married, Hindu, and farmers [Table 1]. Most common site of cancer was breast followed by head and neck and cervix [Table 1]. Family history of cancer was present in 17% patients. None of the patients had a past or family history of psychiatric disorders. Six percent patients had diabetes mellitus, 7% had hypertension, and 6% patients had undergone cataract surgery. Mean (±SD) (range) of scores of depression, anxiety, stress, and resilience were 6.85 (±4.85) (0–19), 3.94 (±2.23) (0–11), 7.15 (±3.22) (2–15), and 4.11(±1.67) (1–7), respectively [Figure 1]. Applying the cut-off scores of the DASS, it was found that, in patients on chemotherapy, 3%, 10%, and 33% patients had higher than normal levels of stress, anxiety, and depression, respectively [Figure 2]. The distribution of scores on depression, anxiety, and stress in the various groups of cancer patients is shown in [Table 2]. In patients undergoing chemotherapy, stress was positively correlated to anxiety and depression, while only depression was negatively correlated to resilience [Table 3]. Further analysis revealed that there were no gender differences in anxiety, depression, stress, and resilience in patients undergoing chemotherapy [Table 4].
Table 1: Demographic and clinical characteristics of the cancer patients on chemotherapy (n=100)

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Table 2: Distribution of scores obtained by different types of cancer patients on the Depression Anxiety Stress Scale

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Table 3: Correlations of stress, anxiety, depression, and resilience in cancer patients on chemotherapy (Spearman's rho)

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Table 4: Characteristics of male and female cancer patients on chemotherapy

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Figure 1: Mean values of resilience, depression, anxiety and stress in cancer patients on chemotherapy

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Figure 2: Severity of anxiety, depression and stress in cancer patients on chemotherapy

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A multiple regression was applied which showed that stress, resilience, and anxiety are useful to predict depression. It is evident from [Table 5] that the multiple linear regression model summary shows that the adjusted R2 of our model is 0.636 and the R2 =0.647. This indicates that the linear regression explains 64.7% of the variance in the data. The Durbin–Watson (d = 2.046) lies between the two critical values of 1.5 < d <2.5. Therefore, we can conclude that there is no first-order linear autocorrelation in our multiple linear regression data [Table 5].
Table 5: Multiple regression analysis by stepwise method Model summaryd

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Further, the linear regression's F-test is highly significant which tells us that the model explains a significant amount of the variance in depression rate [Table 6]. From [Table 7], it is obvious that out of the predictor variables stress, resilience and anxiety are significant predictors of depression. We can also assume that stress has a higher impact than anxiety by comparing the standardized coefficients (β =0.540 vs. β =0.258).
Table 6: Multiple regression analysis by stepwise method ANOVAa

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Table 7: Multiple regression analysis by step-wise method: Coefficientsa

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  Discussion Top

A major finding of the present study was the finding of higher than “normal” levels of depression, anxiety, and stress in 33%, 10%, and 3% of the cancer patients undergoing chemotherapy all of whom hailed from rural areas. This trend is in agreement but lower than number of studies. In 50 patients with cancer, anxiety and depression were found in 44% of patients.[1] In another study, mild and symptomatic depression was seen in 26.7% and 21.3% patients, respectively, while 29.3% patients had mild anxiety and 16.7% had symptomatic anxiety. Anxiety and depression were more frequent in older ages. Breast and stomach cancer patients had the highest prevalence of anxiety and depression, especially in the patients who received chemotherapy as the only treatment.[16]

In our study, 33% of cancer patients on treatment with chemotherapy had depression.

Similarly, in another study, 117 patients undergoing chemotherapy were evaluated using distress inventory for cancer (DIC2) and hospital anxiety and depression scale (HADS). The mean distress score was 24, 18 (15.38%) were found to have anxiety while 19 (16.23%) had depression. In this study, female gender was the only factor found to influence depression.[5] In our study, depression was most frequent in patients with cancer cervix followed by gastrointestinal cancer and breast cancer. This is partly in agreement with the finding that depression most frequently affects patients with lung cancer, followed by gynecological cancers, and breast cancer.[17]

On the other hand, our findings are somewhat in disagreement with few studies. A study of 111 cancer patients on chemotherapy reported somewhat higher figures with 21.8% having mild depressive symptoms and 24.3% having moderate depressive symptoms. The level of depression was not related to gender, age, and chemotherapy's cycle.[18]

In a study from north Bengal, 55% of 174 cancer patients on chemotherapy were found to be depressed. Depression was higher in male patients more than 50 years of age, non-Hindus, those who received higher education, had monthly family income ≥5000 rupees, and were involved in moderate or heavy work. Nearly 70.6% of blood cancer patients, 64.3% of those who had been receiving chemotherapy for ≥6 months and 56.9% of those in their 4th or less cycle of chemotherapy were found to be depressed.[7]

In the current study, anxiety was found in only 10% of cancer patients undergoing chemotherapy treatment. This finding is lower than the findings of a recent review which reported mean 15% prevalence of anxiety in patients being treated for cancer.[9] In our study, anxiety was not associated with age or gender. This finding is in agreement with the observation that unlike in the general population, anxiety disorders in cancer are not associated with age, gender, or socioeconomic status.[9] In our study, anxiety was most frequent in patients with cancer cervix followed by head and neck. This is partly in agreement with the finding that the highest levels of anxiety were observed in lung, gynecological, and hematological cancers.[19]

Another important finding of our study was that in the cancer patients on chemotherapy, stress, anxiety, and depression are positively correlated to each other. However, resilience is negatively correlated to depression. Our findings are in agreement with a recent study in which 152 cancer patients completed questionnaires on demographic variables, the HADS, the Connor–Davidson Resilience Scale (CD-RISC), and the Duke–University of North Carolina Functional Social Support Questionnaire (FSSQ).

The prevalence of emotional distress (HADS score ≥13) was 54.6% in the cancer patients. Psychological stress was positively related to depressive and anxiety symptoms, while resilience was negatively related to these symptoms. Resilience partially mediated the relations of psychological stress with depressive and anxiety symptoms. There were no significant differences between the distressed and nondistressed cancer groups with regard to age, gender, education, socioeconomic status, occupation, religion, marital status, having children, psychiatric history, medical comorbidity, time since cancer diagnosis, and experience of cancer-related treatments. Nondistressed cancer patients had significantly higher mean total scores on the FSSQ and the CD-RISC compared to distressed cancer patients. Psychological resilience was negatively associated with emotional distress in cancer patients and even in the subgroup with metastatic cancer.[11] On the other hand, contrary findings were reported by another study which assessed 198 ovarian cancer patients with HADS, Perceived Stress Scale-10, the Herth Hope Scale, and the resilience scale. The prevalence of depression and anxiety was 47.0% and 51.5%, respectively. Perceived stress correlated significantly with symptoms of depression and anxiety. The association between perceived stress with depression and anxiety was partly mediated by hope. However, resilience did not mediate the association between perceived stress and symptoms of depression or anxiety.[20] A review of 154 studies on resilience in cancer patients concluded that resilience has an important protective role against psychological distress and therefore is closely related to mental health. Factors that contribute to the cancer patient's resilience include biological factors (gene–environment), personality factors (e.g. optimism, hope, and sense of coherence), and social factors (e.g. social support). Improving resilience leads to improved quality of life, favorable psychological, and treatment-related outcomes. It has been observed that targeted interventions (e.g. stress management and resilience training) enhance resilience and well-being, relieve symptoms of distress and anxiety, and promote positive adaptations to cancer. These interventions have been found to be useful in cancer survivors as they improve health outcomes by strengthening personal and social resources and enabling effective coping strategies.[12]


The present study has certain limitations including modest sample size and limited number of patients in different cancer groups. Anxiety, depression, stress, and resilience were assessed using screening instruments, and a formal psychiatric interview or structured clinical interview was not conducted. Apart from resilience, age, and gender, other clinical and psychosocial factors including time since diagnosis, level of disability due to illness and treatment, social support, and coping may influence depression and anxiety were not evaluated. Factors such as stage of the disease, palliative chemotherapy patients, relapse cases, and type of cancer might have some relation with anxiety, stress, and depression which were not studied. These factors should be included in future studies.

  Conclusion Top

Psychiatric morbidity in the form of depression and anxiety is not uncommon among patients with cancer undergoing chemotherapy. Stress, anxiety, and depression are significantly positively correlated to each other, while depression is significantly negatively correlated to resilience in cancer patients undergoing chemotherapy.

In addition to reducing depressive and anxiety symptoms, resilience development should be included in depression and anxiety prevention and treatment strategies accordingly; there is a need for close liaison between oncologists and psychiatrists to improve the outcome of patients with various malignancies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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