Wu YP, Xu G, Wang Z. Correlation between anxiety, depression, sense of coherence, and post-traumatic growth in patients who underwent intertrochanteric femoral fracture surgery. World J Psychiatry 2025; 15(9): 106196 [DOI: 10.5498/wjp.v15.i9.106196]
Corresponding Author of This Article
Zhen Wang, Department of Hand and Foot Surgery, Dongying People’s Hospital, No. 317 Dongcheng South Frist Road, Dongying 257091, Shandong Province, China. zkk1869@126.com
Research Domain of This Article
Psychology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Psychiatry. Sep 19, 2025; 15(9): 106196 Published online Sep 19, 2025. doi: 10.5498/wjp.v15.i9.106196
Correlation between anxiety, depression, sense of coherence, and post-traumatic growth in patients who underwent intertrochanteric femoral fracture surgery
Author contributions: Wu YP designed and performed the research; Wu YP and Xu G contributed equally to this article, they are the co-first authors of this manuscript; Wu YP and Wang Z designed the research and supervised the report; Wu YP, Xu G, and Wang Z collected and analyzed data; and all authors approved the final manuscript.
Institutional review board statement: This study was approved by the Medical Ethics Committee of Dongying People’s Hospital, approval No. 2025-029.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zhen Wang, Department of Hand and Foot Surgery, Dongying People’s Hospital, No. 317 Dongcheng South Frist Road, Dongying 257091, Shandong Province, China. zkk1869@126.com
Received: April 18, 2025 Revised: May 18, 2025 Accepted: July 11, 2025 Published online: September 19, 2025 Processing time: 130 Days and 1.7 Hours
Abstract
BACKGROUND
Postoperative anxiety, depression, irritability, and even fear in patients with intertrochanteric femoral fractures may hinder recovery, compromise treatment efficacy, and impede rehabilitation.
AIM
To investigate the correlations among anxiety, depression, sense of coherence (SOC), and post-traumatic growth (PTG) in patients who underwent intertrochanteric femoral fracture surgery to improve clinical management strategies and outcomes.
METHODS
This study carefully selected 211 patients who received surgical treatment for intertrochanteric femoral fractures and were admitted to Dongying People’s Hospital from March 2022 to March 2024. Anxiety and depression in these patients were assessed with the anxiety and depression subscales of the Hospital Anxiety and Depression Scale (HADS), respectively. SOC was evaluated using the 13-item SOC scale (SOC-13), which encompasses three key dimensions: Comprehensibility, manageability, and meaningfulness. PTG was assessed with the Chinese version of PTG Inventory (CPTGI), covering five distinct dimensions: Personal strength, appreciation of life, relating to others, new possibilities, and spiritual change. The Pearson correlation coefficient was used to meticulously analyze the associations among HADS-Anxiety, HADS-Depression, SOC-13, and CPTGI. Further, univariate and multivariate analyses were conducted to identify factors that affect PTG in patients who underwent intertrochanteric femoral fracture surgery.
RESULTS
The collected data demonstrated that 67.30% and 60.66% of the 211 patients experienced anxiety and depression, respectively, with overall anxiety levels ranging from mild to moderate and depression levels being mild. The mean SOC-13 score was 55.73 ± 8.81 points, indicating a generally low SOC level. The average CPTGI score was 54.93 ± 9.92 points, demonstrating a relatively low PTG level. Notably, both HADS-Anxiety and HADS-Depression scores were significantly negatively correlated with CPTGI, whereas SOC-13 scores were significantly positively correlated with CPTGI. Univariate and multivariate analyses identified the presence of comorbidities [odds ratio (OR) = 2.747, P = 0.003], monthly household income (OR = 3.292, P < 0.001), and exercise habits (OR = 4.651, P < 0.001) as independent predictors of PTG in patients.
CONCLUSION
The results of this study indicate a significant negative correlation of anxiety and depression with PTG in patients after intertrochanteric femoral fracture surgery, whereas a significant positive association exists between SOC and PTG. This study helps more comprehensively understand the psychological status and recovery processes of such patients, thereby potentially providing valuable information for clinical practice and psychological interventions.
Core Tip: By conducting a comprehensive analysis of clinical data, this study reveals an inverse correlation between post-traumatic growth levels and anxiety/depression in patients who underwent intertrochanteric femoral fracture surgery, while revealing a positive association with sense of coherence. Notably, patients with higher socioeconomic status (including greater income), absence of comorbidities, and regular exercise habits demonstrated more pronounced post-traumatic growth. These results highlight the importance of routine psychological assessment in clinical practice and indicate that targeted psychological interventions combined with rehabilitation guidance could effectively mitigate negative emotions and optimize overall recovery.
Citation: Wu YP, Xu G, Wang Z. Correlation between anxiety, depression, sense of coherence, and post-traumatic growth in patients who underwent intertrochanteric femoral fracture surgery. World J Psychiatry 2025; 15(9): 106196
Intertrochanteric femoral fractures, which are a subset of proximal femoral fractures, occur in the extracapsular region that spans from the base of the femoral neck to the area along the lesser trochanter, adjacent to the origin of the medullary canal[1]. This condition predominantly afflicts the elderly population, with minor falls being the most prevalent cause[2]. The global incidence of hip fractures is predicted to reach approximately 6.3 million cases in 2050, reflecting an increasing trend in their risk[3]. Intertrochanteric femoral fractures constitute 50% of all peri-hip fractures in the elderly, among which 35%-40% are classified as unstable[4,5]. Surgical intervention, including intramedullary and extramedullary fixation, is the standard treatment for these fractures. Patients who do not receive prompt treatment may demonstrate up to fourfold higher mortality risk than those who undergo timely surgical management[6-8]. Further, patients recovering from intertrochanteric femoral fractures frequently grapple with negative emotional states, such as anxiety, depression, irritability, and fear, originating from disease-related adverse symptoms and uncertainties associated with surgical outcomes. Such psychological distress significantly impedes the amelioration of the patient’s condition, diminishes the efficacy of the treatment, and obstructs a smooth and successful postoperative recovery[9,10].
Sense of coherence (SOC) is the stability and positivity of an individual’s mental core when confronted with stressful events. Fundamentally, it is a constructive self-protective psychological mechanism that empowers individuals to fend off negative emotions amidst stress, thereby fostering a more resilient and optimistic method to overcoming challenges and adversity[11]. Hikichi et al[12] identified a significant inverse association between SOC and psychological distress among elderly survivors of natural disasters. This finding indicates that increased SOC levels potentially mitigate emotional disturbances, including anxiety and depression. Conversely, post-traumatic growth (PTG) denotes the positive psychological transformation that individuals undergo after traumatic experiences. Such growth is instrumental in improving psychological resilience, which enables individuals to recalibrate their mental state with greater positivity and adaptability[13,14].
Currently, the body of research investigating the correlations among anxiety, depression, SOC, and PTG in patients who underwent intertrochanteric femoral fracture surgery is rather scarce. A thorough investigation into these aspects, along with identifying the factors affecting PTG, is crucial for optimizing clinical practices for this patient population. Healthcare providers can effectively reduce the risk of anxiety and depression by implementing targeted and evidence-based interventions, thereby promoting the overall mental and physical well-being of these patients.
MATERIALS AND METHODS
General information
This study enrolled 211 patients who underwent surgery for intertrochanteric femoral fractures at Dongying People’s Hospital from March 2022 to March 2024.
Inclusion criteria: (1) Diagnosis of intertrochanteric femoral fractures confirmed with computed tomography imaging[15]; (2) Surgical treatment for the fracture; (3) Age ≥ 18 years; and (4) Availability of complete clinical records.
Exclusion criteria: (1) Concurrent fractures in other anatomical regions; (2) History of old or non-acute fractures; (3) Pre-existing limb dysfunction or hemiplegia before the fracture; (4) Pathological fractures; (5) Aphasia, visual impairment, or significant communication barriers despite external assistance; and (6) Comorbidities that contraindicate physical activity.
Assessment measures
Anxiety and depression assessment: The Hospital Anxiety and Depression Scale (HADS)[16] was used to comprehensively assess the anxiety and depression states of patients. Comprising a total of 14 items, this scale is divided into the anxiety (with 7 items dedicated to assessing anxiety) and depression (with 7 items for evaluating depression) subscales. Each subscale is scored out of 21, with a cutoff of 8 points. Scores of 0-7 points indicate the absence of anxiety or depression symptoms, whereas 8-10, 11-14, and 15-21 points denote mild, moderate, and severe anxiety or depression symptoms, respectively.
SOC analysis: The SOC was assessed using the 13-item SOC scale (SOC-13)[17], which measures comprehensibility, manageability, and meaningfulness dimensions. The scale employs a 7-point Likert scoring system, with total scores ranging from 13 to 91. A higher score on this scale strongly indicates a more robust SOC within the individual, signifying better psychological adaptability and resilience. SOC scores were classified into low (13-63 points), moderate (64-79 points), and high (80-91 points).
PTG evaluation: The Chinese version of PTG Inventory (CPTGI)[18] was implemented to precisely assess the PTG experienced by the patients. This inventory is structured around five key dimensions: Personal strength, appreciation of life, relating to others, new possibilities, and spiritual change. A 6-point Likert scale (from 0 indicating “no change at all” to 5 denoting “extremely significant change”) was adopted for scoring, with a maximum total score of 100 points. The magnitude of the score is directly proportional to the extent of PTG. Similarly, PTG levels were categorized into three corresponding grades: Low (< 60 points), moderate (60-65 points), and high (> 65 points).
Statistical analysis
Statistical Package for the Social Sciences version 26.0 software was used for data analysis. Continuous variables were expressed as mean ± SD, whereas categorical variables were presented as frequencies and percentages [n (%)]. Between-group comparisons for categorical variables were conducted with the χ2 test. Pearson correlation analysis was performed to investigate the associations among anxiety, depression, SOC, and PTG. The factors affecting patients’ PTG were investigated through univariate and binary logistic multivariate regression analyses. P < 0.05 indicated statistical significance.
RESULTS
Anxiety and depression status in patients after intertrochanteric femoral fracture surgery
Among the 211 patients assessed, 142 (67.30%) demonstrated anxiety symptoms [HADS-Anxiety (HADS-A) ≥ 8], including 38 (18.01%) mild, 42 (19.91%) moderate, and 62 (29.38%) severe cases. The mean HADS-A score was 10.67 ± 5.16, indicating an overall mild-to-moderate anxiety level. Similarly, 128 (60.66%) patients exhibited depressive symptoms [HADS-Depression (HADS-D) ≥ 8], comprising 53 (25.12%) mild, 46 (21.80%) moderate, and 29 (13.74%) severe cases. The mean HADS-D score was 9.11 ± 4.56, indicating a generally mild depression level (Table 1).
Table 1 Anxiety and depression status of patients after intertrochanteric femoral fracture surgery, mean ± SD/n (%).
Indicators
< 8
≥ 8
Mild
Moderate
Severe
HADS-A (score)
69 (32.70)
142 (67.30)
38 (18.01)
42 (19.91)
62 (29.38)
4.99 ± 1.85
13.44 ± 3.81
-
-
-
10.67 ± 5.16
HADS-D (score)
83 (39.34)
128 (60.66)
53 (25.12)
46 (21.80)
29 (13.74)
4.73 ± 1.85
11.95 ± 3.4
-
-
-
9.11 ± 4.56
SOC in patients post-intertrochanteric femoral fracture surgery
The mean scores for comprehensibility, controllability, and meaningfulness dimensions were 20.64 ± 4.79, 17.69 ± 4.68, and 17.40 ± 4.68, respectively, in the sample of 211 patients who had undergone surgical treatment for intertrochanteric femoral fractures. The overall score on the SOC-13 scale, which aggregates these dimensions, was 55.73 ± 8.81, indicating an overall low SOC level. Further, among the patients, 80.57% (n = 170), 18.96% (n = 40), and 0.47% (n = 1) demonstrated low, high, and moderate SOC levels, respectively (Table 2).
Table 2 Sense of coherence in patients after intertrochanteric femoral fracture surgery, mean ± SD.
Indicators
Score range
Score
Comprehensibility
5-35
20.64 ± 4.79
Controllability
4-28
17.69 ± 4.68
Meaningfulness
4-28
17.40 ± 4.68
SOC-13 (score)
13-91
55.73 ± 8.81
Low level, n (%)
13-63
170 (80.57)
Moderate level, n (%)
64-79
40 (18.96)
High level, n (%)
80-91
1 (0.47)
PTG in patients after intertrochanteric femoral fracture surgery
Among the 211 patients who underwent intertrochanteric femoral fracture surgery, the PTG scores were 8.32 ± 3.26, 16.39 ± 6.18, 8.19 ± 3.27, 11.27 ± 3.73, and 10.75 ± 3.94 for personal strength, appreciation of life, relating to others, new possibilities, and spiritual change, respectively. The total CPTGI score was 54.93 ± 9.92, indicating an overall low PTG level. When further categorized, 64.45% (n = 136), 22.75% (n = 48), and 12.80% (n = 27) were classified as low, moderate, and high levels, respectively (Table 3).
Table 3 Post-traumatic growth in patients after intertrochanteric femoral fracture surgery, mean ± SD.
Indicators
Score range
Score
Personal strength
0-15
8.32 ± 3.26
Appreciation of life
0-30
16.39 ± 6.18
Relating to others
0-15
8.19 ± 3.27
New possibilities
0-20
11.27 ± 3.73
Spiritual change
0-20
10.75 ± 3.94
CPTGI (score)
0-100
54.93 ± 9.92
Low level, n (%)
0-59
136 (64.45)
Moderate level, n (%)
60-65
48 (22.75)
High level, n (%)
66-100
27 (12.80)
Correlation among anxiety, depression, and PTG
The analysis revealed a significant negative correlation between HADS-A and CPTGI scores (r = -0.321, P < 0.001) in patients after intertrochanteric femoral fracture surgery. Similarly, a significant negative correlation was found between HADS-D and CPTGI scores (r = -0.261, P < 0.001). Figure 1 graphically presents these findings.
Figure 1 Correlation between anxiety, depression, and post-traumatic growth.
A: Correlation between Hospital Anxiety and Depression Scale-Anxiety and Chinese version of Post-Traumatic Growth Inventory; B: Correlation between Hospital Anxiety and Depression Scale-Depression and Chinese version of Post-Traumatic Growth Inventory. HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression.
Correlation between SOC and PTG
The analysis revealed significant positive correlations between SOC dimensions and CPTGI scores in patients after intertrochanteric femoral fracture surgery. Specifically, comprehensibility (r = 0.314, P < 0.001), manageability (r = 0.387, P < 0.001), meaningfulness (r = 0.339, P < 0.001), and the total SOC-13 score (r = 0.301, P < 0.001) exhibited significant positive associations with CPTGI scores. Figure 2 visually presents these correlations.
Figure 2 Correlation between sense of coherence and post-traumatic growth.
A: Correlation between comprehensibility and Chinese version of Post-Traumatic Growth Inventory (CPTGI); B: Correlation between manageability and CPTGI; C: Correlation between meaningfulness and CPTGI; D: Correlation between 13-item sense of coherence scale and CPTGI. SOC-13: 13-item sense of coherence scale; CPTGI: Chinese version of Post-Traumatic Growth Inventory.
Influencing factors of PTG in patients after intertrochanteric femoral fracture surgery
Univariate analysis revealed that factors, such as age, gender, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification and Orthopaedic Trauma Association classification, and marital status, exhibited no significant associations with PTG in patients who had undergone intertrochanteric femoral fracture surgery (P > 0.05). Conversely, the presence of comorbidities, educational attainment, monthly family income, and exercise habits was closely associated with PTG in these patients (P < 0.05) (Table 4).
Table 4 Univariate analysis of influencing factors of post-traumatic growth in patients after intertrochanteric femoral fracture surgery, n (%).
Indicators
Low-level group (n = 136)
Moderate-level group (n = 75)
χ2
P value
Age (year)
3.242
0.072
< 65
64 (47.06)
45 (60.00)
≥ 65
72 (52.94)
30 (40.00)
Gender
1.984
0.159
Male
79 (58.09)
36 (48.00)
Female
57 (41.91)
39 (52.00)
AO/OTA classification
1.161
0.281
Stable
62 (45.59)
40 (53.33)
Unstable
74 (54.41)
35 (46.67)
Presence of comorbidities
11.580
< 0.001
No
28 (20.59)
32 (42.67)
Yes
108 (79.41)
43 (57.33)
Educational attainment
6.048
0.014
Below senior high school
82 (60.29)
38 (50.67)
Senior high school or above
54 (39.71)
37 (49.33)
Marital status
0.148
0.700
Married
103 (75.74)
55 (73.33)
Unmarried
33 (24.26)
20 (26.67)
Monthly family income (yuan)
16.689
< 0.001
< 3500
87 (63.97)
26 (34.67)
≥ 3500
49 (36.03)
49 (65.33)
Exercise habits
13.662
< 0.001
None
123 (90.44)
53 (70.67)
Yes
13 (9.56)
22 (29.33)
Furthermore, we performed a multivariate analysis using binary logistic regression, which revealed that the presence of comorbidities [odds ratio (OR) = 2.747, P = 0.003], monthly household income (OR: 3.292, P < 0.001), and exercise habits (OR: 4.651, P < 0.001) were independent predictors of PTG in this patient population. Table 5 presents the detailed data from the multivariate analysis.
Table 5 Multivariate analysis of influencing factors of post-traumatic growth in patients after intertrochanteric femoral fracture surgery.
Indicators
B
SE
WALD
P value
OR
95%CI
Presence of comorbidities
1.011
0.343
8.706
0.003
2.747
1.404-5.376
Educational attainment
0.420
0.325
1.668
0.196
1.522
0.805-2.879
Monthly family income (Yuan)
1.192
0.325
13.479
< 0.001
3.292
1.743-6.220
Exercise habits
1.537
0.425
13.100
< 0.001
4.651
2.023-10.692
DISCUSSION
This study revealed an anxiety rate of 67.30%, indicating an overall mild to moderate level of anxiety, and a depression rate of 60.66%, reflecting an overall mild level of depression, among the 211 patients who had undergone surgical procedures for intertrochanteric femoral fractures. The underlying mechanism may involve disease- and surgery-induced hypothalamic–pituitary–adrenal axis overactivation, causing sustained cortisol level elevation, which impairs hippocampal neurogenesis and subsequently exacerbates anxiety and depressive symptoms[19]. Several previous investigations have revealed that patients with orthopedic-related trauma are highly susceptible to mental illnesses. The presence of such mental health issues can significantly intensify patients’ perception of pain, causing suboptimal surgical outcomes and a compromised quality of life for this patient population[20,21]. For instance, Wang et al[22] demonstrated that young patients with thoracolumbar fractures presented relatively increased anxiety and depression rates, reaching 49.0% and 39.0%, respectively.
Furthermore, SOC assessment in these 211 patients who underwent intertrochanteric femoral fracture surgery revealed an SOC-13 score of 55.73 ± 8.81, indicating a low SOC level. Similarly, the CPTGI score was 54.93 ± 9.92, reflecting a relatively low PTG level. Correlation analysis revealed that HADS-A and HADS-D in patients who underwent intertrochanteric femoral fracture surgery were significantly negatively correlated with CPTGI, indicating a significant negative association between anxiety, depression, and PTG in these patients. This may be attributed to the substantial psychological stress experienced by patients after intertrochanteric femoral fracture surgery, including concerns about postoperative recovery, fear of pain, and anxiety over the length of hospitalization. These psychological distresses result in a series of adverse effects. They may delay the patients’ recovery process, exacerbate the pain level they experience, and exhaust their emotional resources. Hence, patients find it arduous to respond proactively to the challenges emerging after the trauma, thereby impeding PTG[23,24]. From a neuropsychological perspective, these results may reflect dysregulation in the prefrontal-amygdala neural circuitry secondary to severe anxiety and depressive symptoms. Such neural circuit imbalance may compromise patients’ sense of comprehensibility and controllability while simultaneously hindering the cognitive restructuring ability required for PTG[25]. A significant positive correlation was observed between SOC-13 and CPTGI in patients after intertrochanteric femoral fracture surgery, indicating the association of stronger SOC with improved PTG in this population. Patients with a higher SOC level demonstrated greater psychological resilience and are more likely to receive robust social support. Collectively, these factors help them better manage post-traumatic psychological stress, thereby fostering their PTG[26].
Univariate and multivariate analyses firmly revealed that multiple factors, including the presence of comorbidities, monthly family income, and exercise habits, were significantly correlated with PTG in patients who underwent intertrochanteric femoral fracture surgery. The existence of comorbidities is a major factor with far-reaching impacts among these patients. Not only does it impose heavier physical and psychological burdens on the patients, but it also substantially prolongs the postoperative recovery period. This extended recovery process can disrupt the patients’ psychological equilibrium, ultimately causing a relatively low PTG level[27]. Regarding economic factors, a relatively high monthly family income endows patients with greater access to premium medical resources and top-notch rehabilitation services. Further, the reduced financial strain alleviates their psychological stress, enabling them to concentrate wholeheartedly on the rehabilitation journey. This financial advantage plays a positive role in promoting PTG[28]. Finally, regular exercise habits demonstrate a profound impact on patients’ physical and mental well-being. These habits not only strengthen cardiopulmonary function and improve immune capabilities but also have a positive influence on mood regulation. Thus, patients with good exercise habits are more likely to maintain an optimistic and positive mindset when confronted with the trauma, thereby significantly facilitating their PTG[29].
CONCLUSION
In summary, a significant correlation between anxiety, depression, SOC, and PTG was found in patients who underwent intertrochanteric femoral fracture surgery. Specifically, patients with less severe anxiety and depression symptoms are more likely to demonstrate a higher degree of PTG. Similarly, those with a more robust sense of psychological coherence tend to achieve a greater PTG level. Moreover, patients without comorbidities, substantial monthly family income, and consistent exercise habits typically demonstrate a remarkably increased PTG level. These results indicate that a multi-faceted approach can be adopted. This includes implementing preventive management measures for potential complications, providing financial assistance in the form of medical subsidies, and facilitating the establishment of healthy exercise routines. Such strategies are crucial for optimizing the PTG of patients who underwent intertrochanteric femoral fracture surgery. Our research not only furnishes highly targeted intervention guidelines for the clinical management of these patients but also serves as a guiding light, enabling patients to obtain a higher PTG level.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade C, Grade C
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade B, Grade B
P-Reviewer: Chou KR; Del Rosario C S-Editor: Bai Y L-Editor: A P-Editor: Zhang XD
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