Investigation of depressive symptoms after thyroid cancer surgery: Logistic regression analysis and adjustment strategy

Abstract

BACKGROUND

Post-thyroidectomy patients frequently experience depressive symptoms triggered by surgical trauma, fluctuating thyroid hormone levels, and the psychological burden of long-term surveillance; however, large-scale multivariable-adjusted risk-factor data remain scarce.

AIM

To determine the prevalence and predictors of postoperative depression, and propose tailored mitigation strategies.

METHODS

We enrolled 108 consecutive patients who underwent thyroidectomies at The First Affiliated Hospital of Hebei North University between January 2023 and January 2025. Depression was assessed using the Self-Rating Depression Scale (SDS), while coping styles and social support were evaluated using the Medical Coping Modes Questionnaire and Perceived Social Support Scale. Logistic regression was used to identify independent risk and protective factors.

RESULTS

The mean SDS score was 52.58 ± 10.20; 62 patients (57.4%) met the criteria for depression (mild 32.4%, moderate 15.7%, severe 9.3%). Univariate analyses revealed higher depression rates among patients aged ≥ 60 years, those with ≤ high-school education, monthly family income < 3000 yuan, ¹³¹I therapy, and avoidance/surrender coping; and lower social support (P < 0.05). Multivariate regression showed income < 3000 yuan (OR = 5.26, 95%CI: 1.89-14.60), ¹³¹I therapy (OR = 5.70, 95%CI: 1.91-17.01), and avoidance/surrender coping (OR = 4.77, 95%CI: 1.51-15.11) as independent risk factors, whereas higher social support was protective (OR = 0.22, 95%CI: 0.09-0.54).

CONCLUSION

Depression is common after thyroidectomy, and is driven by socioeconomic, treatment-related, and psychosocial factors. Targeted interventions that address coping skills and bolster social support should be integrated into postoperative care.

Key Words: Thyroid cancer; Surgery; Depression; Related factors; Countermeasures

Core Tip: This study revealed a 57.4% prevalence of depression in post-thyroidectomy patients, with key risk factors including low family income (< 3000 yuan/month, OR = 5.26), ¹³¹I therapy (OR = 5.70), and avoidant coping style (OR = 4.77). Strong social support had a significant protective effect (OR = 0.22). These findings highlight the critical need for routine depression screening and targeted psychosocial interventions, particularly in patients undergoing ¹³¹I treatment or exhibiting maladaptive coping behaviors. The identification of modifiable risk factors (coping styles) and protective factors (social support) provides actionable targets for improving mental health outcomes in thyroid cancer survivors.

INTRODUCTION

Thyroid cancer is the most rapidly increasing malignancy worldwide with an average annual incidence of 7.7%[1,2]. In China, the age-standardized incidence has doubled within the past decade, and the age of onset is trending downward[3]. Paralleling this epidemiological shift, accumulating evidence indicates that thyroid cancer survivors face a disproportionate burden of psychological morbidity, particularly depression, which may exceed that observed in other common malignancies[4-6].

Despite the well-documented efficacy of thyroidectomy in improving oncological outcomes, the procedure itself-along with subsequent levothyroxine withdrawal or ¹³¹I ablation-can precipitate acute and chronic hypothyroidism, postsurgical pain, and body-image alteration. These physiological and psychosocial stressors synergistically increase the risk of depressive symptoms[7,8]. Nevertheless, existing studies have predominantly focused on long-term recurrence and survival, leaving the prevalence, trajectory, and determinants of post-thyroidectomy depression largely unknown.

Moreover, existing investigations are limited by small sample sizes, lack of multivariable adjustment, and absence of theoretically grounded coping or social support measures, thereby impeding the identification of modifiable risk and protective factors. Clarifying these knowledge gaps is imperative for designing targeted psychosocial interventions and optimizing holistic survivorship care. Therefore, the present study aimed to delineate the prevalence and independent predictors of depressive symptoms after thyroidectomy while proposing evidence-based adjustment strategies.

MATERIALS AND METHODS

General data

A total of 108 patients who underwent thyroid cancer surgery in the First Affiliated Hospital of Hebei North University from January 2023 to January 2025 were selected, including 46 male and 62 female participants, aged 42-78 years, (average age of 60.16 ± 4.08 years); tumor types: 83 cases of papillary carcinoma and 25 cases of follicular carcinoma; surgical methods: 73 cases of total thyroidectomy and 35 cases of partial thyroidectomy.

Inclusion and exclusion criteria

Inclusion criteria: (1) They met the diagnostic criteria of the “Guidelines for the Diagnosis and Treatment of Adult Thyroid Nodules and Differentiated Thyroid Cancer”[7]; (2) Underwent a smooth thyroidectomy surgery; (3) Had independent communication and comprehension abilities; and (4) Volunteered to participate in this study.

Exclusion criteria: (1) Unstable vital signs after surgery; (2) Severe immune or hematological diseases; (3) Recent major traumatic events; (4) Mental or cognitive dysfunction; or (5) Inability to understand the content of this study.

Research tools

General information questionnaire: Designed by the researchers, the survey content included the following: (1) Demographic data: Sex, age, residence, marital status, educational background, and family monthly per capita income; and (2) Disease data: Family history of tumors, tumor type, surgical method, and ¹³¹I treatment.

Self-Rating Depression Scale: Compiled by Zung[8], it includes 20 items reflecting subjective feelings of depression using a 4-point scoring method (1-4 points). The raw score was 1.25 equals to the standard score, with a cut-off value of 50 points. A total score < 53 indicates no depressive symptoms, 53-62 indicates mild depression, 63-72 indicates moderate depression, and ≥ 73 indicates severe depression. The Cronbach's α coefficient of this scale is 0.806.

Medical Coping Modes Questionnaire: Compiled by Folkman et al[9], it includes three dimensions: Facing, avoidance, and yielding, with eight, seven, and four items, respectively, using a 4-point scoring method (1-4 points). The dimension with the highest score indicated the coping style that the patient tended to adopt. The Cronbach's α coefficients of each dimension of this scale are 0.69, 0.60, and 0.76, respectively.

Perceived Social support Scale: Compiled by Scholar Zimet et al[10], it includes three dimensions: Family support, friend support, and other support, each consisting of four items. The total score ranges from 12 to 84 points; a total score > 36 is defined as having social support and < 36 as having no social support. The Cronbach's α coefficient of this scale is 0.896.

Research methods

Two otolaryngology head and neck surgeons who underwent unified systematic training conducted a questionnaire survey. Before the survey, simple and clear language was used to avoid excessive medical terms, and the purpose, method, and significance of the survey were explained to the patients in detail. On-site uniform distribution, filling, and recycling methods were adopted. A total of 112 questionnaires were distributed. After excluding incomplete and logically inconsistent questionnaires, 108 valid questionnaires were returned. The collected data were stored by a dedicated person, double-checked, and entered. The effective recovery rate was 96.43%.

Statistical analysis

SPSS 26.0 statistical software was used for the analysis. Enumeration data were expressed as [n (%)] and analyzed by χ² test; measurement data conforming to normal distribution were expressed as mean ± SD; logistic regression analysis was used for related factors affecting depression after thyroid cancer surgery; P < 0.05 was considered statistically significant.

RESULTS

Current status of depression after thyroid cancer surgery

The Self-Rating Depression Scale (SDS) score of the included 108 patients after thyroid cancer surgery was 52.58 ± 10.20 points. A total of 62 cases had depressive symptoms, with a detection rate of 57.41%, including mild depression, moderate depression, and severe depression with detection rates of 32.41% (35/108), 15.74% (17/108), and 9.26% (10/108), respectively. The remaining 46 patients (42.59%) exhibited no signs of depression.

Univariate analysis of factors affecting depression after thyroid cancer surgery

Univariate analysis showed that the proportions of age ≥ 60 years, education below high school, family monthly per capita income < 3000 yuan, ¹³¹I treatment, and avoidance/yielding in the depression group were higher than those in the non-depression group, while the proportion of social support was lower than that in the non-depression group, with statistically significant differences (P < 0.05). As shown in Table 1, no statistically significant differences were noted in sex, residence, marital status, family history of tumors, tumor type, or surgical method between the two groups (P > 0.05).

Table 1 Univariate analysis of the factors affecting postoperative depression in thyroid cancer, n (%).

Correlative factor	No. of cases	Non-depressed group (n = 46)	Depressed group (n = 62)	χ2	P value
Sex
Male	46	18 (39.13)	28 (45.16)	0.393	0.531
Female	62	28 (60.87)	34 (54.84)
Age (years)
≥ 60	60	20 (43.48)	40 (64.52)	4.734	0.030
< 60	48	26 (56.52)	22 (35.48)
Domicile
Rural area	63	30 (65.22)	33 (53.23)	1.562	0.211
Town	45	16 (34.78)	29 (46.77)
Matrimonial res
Married	87	41 (89.13)	46 (74.19)	5.320	0.070
Unmarried	7	3 (6.52)	4 (6.45)
Divorced	14	2 (4.35)	12 (19.36)
Educational background
Below high school	59	19 (41.30)	40 (64.52)	5.740	0.017
High school or above	49	27 (58.70)	22 (35.48)
Per capita monthly Household income (yuan)
< 3000	52	12 (26.08)	40 (64.52)	23.152	< 0.001
3000-5000	36	17 (36.96)	19 (30.65)
> 5000	20	17 (36.96)	3 (4.83)
Family history of cancer
Yes	21	5 (10.87)	16 (25.81)	3.761	0.052
No	87	41 (89.13)	46 (74.19)
Type of tumor
Papillary carcinoma	83	38 (82.61)	45 (72.58)	1.493	0.222
Carcinoma of the follicle	25	8 (17.39)	17 (27.42)
Modus operandi
Total thyroidectomy	73	33 (71.74)	40 (64.52)	0.629	0.428
Partial thyroidectomy	35	13 (28.26)	22 (35.48)
131I treatment
Yes	40	8 (17.39)	32 (51.61)	13.262	< 0.001
No	68	38 (82.61)	30 (48.39)
Coping style
Face	66	40 (86.96)	26 (41.94)	22.522	< 0.001
Avoidance	42	6 (13.04)	36 (58.06)
Social support
Yes	70	38 (82.61)	32 (51.61)	11.125	0.001
No	38	8 (17.39)	30 (48.39)

Multivariate analysis of factors affecting depression after thyroid cancer surgery

We considered whether depressive symptoms occurred after thyroid cancer surgery as the dependent variable (no = 0, yes = 1), and selected the indicators with P < 0.05, in the univariate analysis, as independent variables for multivariate logistic regression analysis. The specific coding is presented in Table 2. The results showed that a family monthly per capita income < 3000 yuan, ¹³¹I treatment, and avoidance/yielding were risk factors for depression after thyroid cancer surgery, whereas social support was a protective factor (Table 3).

Table 2 Factors affecting depression after surgery for thyroid cancer.

Variable name	Influencing factor	Variable assignment
X1	Age (years)	< 60 = 0, ≥ 60 = 1
X2	Record of formal schooling	High school and above = 0, high school below = 1
X3	Per capita monthly household income (yuan)	> 5000 = 0, 3000-5000 = 1, < 3000 = 2
X4	131I treatment	No = 0, yes = 1
X5	Coping style	Facing = 0, avoidance/surrender = 1
X6	Social support	No = 0, yes = 1
Y	Depression symptoms	No = 0, yes = 1

Table 3 Multivariate analysis of factors affecting postoperative depression in patients with thyroid cancer.

Factor	β	SE	Wald χ2	P value	OR	95%CI
Age > 60 years	1.280	0.658	3.784	0.052	3.597	0.990-13.062
Less than high school education	1.332	0.721	3.413	0.065	3.789	0.922-15.567
Per capita monthly income of the family is less than 3000 yuan	1.660	0.521	10.152	0.001	5.259	1.894-14.602
131I treatment	1.740	0.558	9.724	0.002	5.697	1.909-17.008
Avoidance/submission	1.563	0.588	7.066	0.008	4.773	1.508-15.112
social support	-1.508	0.450	11.230	0.001	0.221	0.092-0.535

DISCUSSION

Current status of depressive symptoms after thyroid cancer surgery

The Integrative Oncology Nursing Guidelines for Anxiety and Depression Symptoms in Adult Cancer Patients[11] jointly published by the American Society of Integrative Oncology and the American Society of Clinical Oncology in 2023, indicate that cancer patients are prone to mental health problems at all treatment stages, with depressive symptoms being the most common. These symptoms often have adverse effects on treatment efficacy and prognosis. This study used the SDS to evaluate the current status of depression after thyroid cancer surgery. The results showed that the SDS score of 108 patients after thyroid cancer surgery was 52.58 ± 10.20 points, and the detection rate of depressive symptoms was 57.41%, which was lower than the 76.6% incidence of depressive symptoms in cancer patients belonging to the Chinese community[12]. The differences in the research results may be related to variations in the basic data of the surveyed population, tumor types, tumor stages, and the popularization of medical science. Survey subjects were patients who had undergone thyroid cancer surgery. The risk of recurrent laryngeal nerve injury during surgery, combined with a traumatic stress response, fear of cancer recurrence, and physical image damage caused by neck incision scars, may significantly affect patients' psychological states, making them prone to depressive symptoms[13,14]. Therefore, after thyroid cancer surgery, clinicians should not only strengthen disease management but also focus on patients' mental health status.

Influencing factors depression and intervention strategies after thyroid cancer surgery

Family monthly per-capita income: The results of this study showed that a monthly family per capita income of < 3000 yuan was a risk factor for depression after thyroid cancer surgery, which is similar to the findings of Doege et al[15] in their survey on anxiety and depression among cancer patients and survivors against the background of exposure and tumor treatment restrictions during the coronavirus disease 2019 pandemic. Thyroid cancer is a malignant tumor, and patients need regular follow-ups and long-term endocrine suppression therapy after surgery, causing them to bear the pain of the tumor itself, while they and their families need to shoulder high treatment or examination costs. Especially for patients with a lower family monthly per capita income, the huge economic burden more easily leads to psychological problems such as anxiety and guilt, thus causing depressive symptoms. Therefore, clinical medical workers should choose cost-effective treatment plans according to the specific conditions of patients and national medical insurance reimbursement policies to minimize the economic burden on patients, thereby improving their confidence in treatment and effectively relieving their depressive emotions.

¹³¹I treatment

¹³¹I treatment is the most widely used and effective treatment method for differentiated thyroid cancer after surgery and can maximize the removal of residual or metastatic cancer foci after surgery, thereby prolonging the survival period of patients[16-18]. However, with the deepening of clinical practice, some studies have reported that thyroid cancer patients who receive ¹³¹I treatment after surgery are more prone to mental health problems, such as anxiety and depression, than those who only receive surgical treatment[19,20]. The results of this study showed that ¹³¹I treatment is a risk factor for depression after thyroid cancer surgery. On the one hand, ¹³¹I treatment can cause varying degrees of radiation damage to normal tissues around the thyroid, leading to a series of discomfort symptoms such as neck pain and swelling, prompting patients to generate negative psychology. On the other hand, during ¹³¹I treatment, patients experience decreased thyroid hormone secretion levels, and the uncertainty about the treatment effect and fear of tumor recurrence/metastasis often cause patients to produce pessimistic, fearful, and other negative emotions, easily losing confidence and purpose in their future lives, leading to the occurrence of depressive symptoms. Authoritative standards and guidelines formulated by organizations such as the American Thyroid Association[7] and Society of Nuclear Medicine and Molecular Imaging[21] indicate that detailed communication of the risks and benefits of ¹³¹I treatment can improve patients' treatment tolerance and compliance. Moncayo et al[22] conducted a longitudinal coordination service for nuclear medicine physicians and found that risk communication education and high-quality management of ¹³¹I-treated patients with thyroid cancer during follow-up can greatly improve psychological problems such as anxiety and depression. Medical workers need to pay attention to the psychological state of patients after thyroid surgery who receive ¹³¹I treatment, and help patients correctly understand the importance of the disease and ¹³¹I treatment through various means such as actively carrying out “health education activities”, patient mutual assistance activities, and “model power inspiration”, and carry out positive psychological construction, thereby reducing the risk of depressive symptoms.

Coping styles

After thyroid cancer surgery, patients face multiple pressures caused by the disease and are prone to a series of adverse psychological reactions, such as self-defense and negative emotions. Coping style refers to the strategies or behaviors adopted by individuals in stressful situations. As an important psychological reaction and behavioral performance, it plays an important role in promoting the mental health of patients[23,24]. The results of this study showed that the adoption of avoidance/yielding coping styles was a risk factor for depression after thyroid cancer surgery. Studies on the neural mechanisms of psychological resilience have shown that when facing stress, individuals who adopt positive coping styles hyperpolarize glutamatergic neurons in the medial geniculate body, which can activate the medial prefrontal cortex of the brain, promote an increase in cortisol secretion in the hypothalamic-pituitary-adrenal axis, and further enhance the function of the thalamocortical circuit, thereby promoting mental health[25]. Therefore, medical workers should strengthen communication with patients, fully understand their living characteristics and emotional expression methods, put themselves in the patients' shoes and show appropriate empathy on the basis of respecting patients' feelings and emotions, reducing patients' anxiety, depression, and other emotions through micro-expressions such as eye contact and smiling, or by guiding patients to perform deep breathing, music therapy guided by the disease psychological resilience model, mindfulness-based cognitive therapy, etc., and establish a trusting relationship. At the same time, they should provide timely and appropriate feedback to patients' emotional needs, guide them to use their internal positive forces to manage the disease, and effectively relieve depressive symptoms. In addition, lifestyle adjustments during the clinical treatment stage are important for patients undergoing thyroid cancer surgery. Therefore, doctors need to have a comprehensive understanding, formulate scientific work and rest time for patients, instruct patients not to stay up late, and provide sleep-aiding drugs when necessary; in daily life, in order to better distract patients' attention, doctors can suggest that family members accompany patients to carry out aerobic exercise, thereby effectively regulating the hormone level in the body. In terms of personal diet, strongly stimulating foods should not be ingested, and the intake ratio of foods rich in high-quality proteins and vitamins should be appropriately increased to improve patients' physical and coping abilities.

Social support

An individual’s degree of cognition of the negative consequences of tumors is related to psychological distress, including anxiety and depression. Identifying psychosocial factors that buffer the impact of tumor cognition on distress can provide intervention targets for improving patients' mental health. Social support can reflect the degree of close connection between individuals and society and is considered an important factor in preventing anxiety and depression. Studies have indicated that good social support can significantly improve individual psychological resilience and promote the development of physical and mental health[26,27]. Another study showed that actively mobilizing the relevant social support system for patients and helping them effectively use social resources can significantly improve their ability to bear and adapt to the disease[28]. The results of this study showed that social support is a protective factor against depression after thyroid cancer surgery. Salafia et al[29] reported in their study that in cancer survivors, social support is a long-term protective factor that can prevent disease cognition from causing psychological distress and reduce psychological pain, which supports the findings of this study. Therefore, medical staff should help patients establish a support system with family and friends, encourage family members to actively participate in the patients' disease health management, and provide family emotional support and practical help; at the same time, guide patients to actively participate in cancer patient support groups, mutual assistance groups, etc., and use the "Internet+" platform to formulate corresponding management plans for patients to help them return to family and society as soon as possible.

Drug treatment

Depressive symptoms are a common psychological problem after thyroid cancer surgery, and severe cases can lead to a poor patient prognosis. Therefore, clinicians need to attach great importance to it, maintain a professional and empathetic attitude in communicating with patients, guide patients to express themselves bravely, and comprehensively analyze them to understand the root cause of patients' depressive symptoms. In the clinical treatment stage, in addition to life management, doctors can prescribe antidepressant drugs for such patients, such as fluoxetine, escitalopram, and instruct patients to take them strictly according to the corresponding dose, and not to change them privately to avoid serious consequences. In addition, during drug treatment, due to individual differences in patients after thyroid cancer surgery and the influence of other factors, patients may experience a series of adverse reactions. Clinicians should inform patients in advance to avoid disputes; during the treatment period, doctors can adjust the drug dosage according to the patient's recovery situation to ensure the effectiveness and safety of treatment.

CONCLUSION

Depressive symptoms are relatively common after thyroid cancer surgery and can cause a high degree of harm. During the clinical treatment stage, the attending doctors of patients need to comprehensively investigate and analyze the root causes of the occurrence of depressive symptoms, and consequently cultivate patients' positive coping styles from a psychological perspective, emphasize the importance of social support, and, at the same time, correct the living behavioral habits of patients after thyroid cancer surgery, provide antidepressant drugs for patients when necessary, and guide patients to take them correctly to improve their physical and mental health. In addition, this study has certain limitations such as a small sample size, no follow-up investigation on the long-term psychological state of patients after surgery, and no multicenter research design, which may cause deviations in the research results. Therefore, follow-up studies should actively carry out multicenter, large-sample prospective cohort studies should be conducted to provide important references for subsequent treatments.

This single-center study enrolled 108 consecutive patients; although the sample size was modest, it provided sufficient power for the observed effect sizes. Nevertheless, multicenter validation is warranted to enhance generalizability. Due to the cross-sectional design, causal inferences between depressive symptoms and identified predictors cannot be drawn, and a longitudinal follow-up is planned to clarify the temporal relationships. Importantly, as serum TSH, free T₄, and free T₃ levels were not collected, the direct contribution of biochemical hypothyroidism to depression remains to be elucidated. Finally, while well-validated instruments were used, self-reported data may have been subject to social desirability bias. Despite these constraints, our findings provide timely and actionable evidence for the integration of routine psychological screening and targeted support into post-thyroidectomy care pathways.