Factors influencing anxiety and depression among patients with digestive tract subepithelial lesions

Abstract

BACKGROUND

Digestive tract subepithelial lesions (SELs) are relatively common, and early diagnosis and treatment are critical for improving patient quality of life and prognosis. However, diagnostic uncertainty often leads to negative psychological effects, including anxiety and depression.

AIM

To investigate the prevalence of anxiety and depressive symptoms and identify associated factors among patients with digestive tract SELs.

METHODS

This retrospective study included 296 consecutive patients diagnosed with digestive tract SELs at the Affiliated Hospital of North Sichuan Medical College Endoscopy Center between October 2024 and April 2025. Demographic and clinical data were collected through standardized questionnaires. Anxiety and depression were assessed using the Self-Rating Anxiety Scale and the Self-Rating Depression Scale, respectively, while sleep quality was evaluated using the Pittsburgh Sleep Quality Index. Participants were classified into anxiety vs non-anxiety and depression vs non-depression groups based on established cutoff scores, and potential determinants were examined.

RESULTS

Anxiety symptoms were observed in 35.8% of cases (mean Self-Rating Anxiety Scale score: 46.56 ± 9.13) and depressive symptoms in 33.1% (mean Self-Rating Depression scale score: 48.64 ± 8.30). Pittsburgh Sleep Quality Index scores were positively correlated with both anxiety and depression (P < 0.05). Univariate analysis identified age, annual income, sleep disorders, and endoscopic ultrasonography (EUS) evaluation status as significant factors (P < 0.05). Multivariable analysis revealed that low annual income (< 10000 Chinese yuan) and sleep disorders were independent risk factors, whereas undergoing EUS examination and having disease awareness were protective factors against anxiety and depression (P < 0.05).

CONCLUSION

Patients with digestive tract SELs are at increased risk for anxiety and depression, with poor sleep strongly linked to worsening psychological symptoms. Early diagnostic assessment with EUS appears to serve a protective role against the onset of these psychological disorders.

Key Words: Subepithelial lesions; Anxiety; Depressive symptoms; Sleep disorders; Endoscopic ultrasonography

Core Tip: With advancements in endoscopic technology and increasing public awareness of digestive tract endoscopy, the detection rate of digestive tract subepithelial lesions has risen. However, limited medical knowledge among patients often leads to anxiety, worry, depression, and other psychological concerns. This study aims to investigate the prevalence of anxiety and depression among patients with digestive tract subepithelial lesions, identify influencing factors, and propose targeted interventions to promote physical and mental health and improve quality of life.

INTRODUCTION

Subepithelial lesions (SELs) of the digestive tract are protrusive growths originating from the submucosal layer, muscularis mucosa, or muscularis propria, typically covered by normal-appearing mucosa. They are also referred to as subepithelial tumors and present with diverse morphological features[1,2]. While SELs may occur throughout the digestive system, they are most frequently observed in the stomach, followed by the esophagus and duodenum[3].

SELs encompass diverse pathological types and may present with complications such as hemorrhage, luminal obstruction, or metastasis, depending on their size, anatomical location, and histopathological characteristics[4]. They demonstrate marked heterogeneity in tissue origin, malignant potential, and management strategies. Pathologically, SELs are generally classified into two groups: Neoplastic lesions (including gastrointestinal stromal tumors, neuroendocrine neoplasms, leiomyomas, and lipomas[5,6]) and non-neoplastic lesions (such as pancreatic heterotopia, cystic formations, and inflammatory fibroid polyps[7,8]). Although many SELs are biologically benign, some possess malignant potential or are already malignant at the time of diagnosis. Most remain asymptomatic and are incidentally detected during endoscopic examinations. Endoscopic ultrasonography (EUS) is currently regarded as the gold standard for diagnosis, offering critical information for treatment planning and decision-making prior to endoscopic or surgical intervention[9].

With recent advancements in endoscopic techniques and growing public awareness of gastrointestinal health screening, the detection rate of SELs has increased markedly. However, diagnostic terminology such as “mucosal protrusion” or “submucosal mass” often causes undue concern among patients with limited medical knowledge, as these terms are frequently misinterpreted as “tumor” or “cancer”. Such misunderstandings may trigger significant psychological distress, including anxiety, fear, and depressive symptoms. Existing research indicates that psychological comorbidities, particularly anxiety and depression, negatively affect patients’ quality of life, which is a critical determinant of treatment outcomes in digestive tract SELs[10]. Currently, there remains a paucity of international studies examining anxiety and depression in this population, and no such research has been conducted in China.

Therefore, this study aims to: (1) Assess the prevalence of anxiety and depressive symptoms among patients with digestive tract SELs; (2) Identify potential contributing factors; and (3) Develop evidence-based interventions to optimize both physical and psychological outcomes. Ultimately, our goals are to improve overall quality of life, enhance therapeutic efficacy, and advance high-quality, patient-centered medical care with a humanistic approach.

MATERIALS AND METHODS

Study population

This study enrolled consecutive patients diagnosed with digestive tract SELs at the Affiliated Hospital of North Sichuan Medical College from October 2024 to April 2025. Eligible participants met all of the following criteria: (1) Endoscopic confirmation of SELs; (2) Age between 25 and 70 years; (3) Adequate visual and auditory function, barrier-free language communication, and literacy skills to complete questionnaires; and (4) Availability of complete medical records. Exclusion criteria were: (1) Severe comorbidities affecting vital organs or pregnancy; (2) Documented cognitive impairment, psychiatric history, or current use of psychotropic medication; (3) Other mental disturbances such as chronic alcoholism or drug dependence; (4) Medical conditions potentially influencing psychological assessment (e.g., epilepsy, thyroid dysfunction); and (5) Incomplete clinical data.

Data collection

(1) General information questionnaire: A structured questionnaire was designed to collect demographic data, including age, gender, occupation, ethnicity, marital status, educational level, annual income, place of residence, type of medical insurance, and disease-related information; (2) Sleep quality assessment: Sleep quality over the preceding month was evaluated using the Pittsburgh Sleep Quality Index (PSQI). This index assesses seven domains: Subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of hypnotic medication, and daytime dysfunction. It comprises 18 items, each scored from 0 to 3. The total score (range: 0-21) was calculated by summing the seven component scores. A total score exceeding 7 indicates clinically significant sleep disturbances, with higher scores reflecting poorer sleep quality; and (3) Psychological status: Depressive symptoms were assessed using the Self-Rating Depression Scale (SDS), which contains 20 items rated on a 4-point Likert Scale (1-4). The raw score is multiplied by 1.25 and rounded to the nearest whole number to yield a standard score. Severity categories are: Mild depression (score 53-62), moderate depression (score 63-72), and severe depression (score ≥ 73). Anxiety levels were assessed via the Self-Rating Anxiety Scale (SAS), comprising 20 items (15 positively phrased and 5 reverse-scored), each rated on a 4-point scale. Standard scores were calculated using the same method as the SDS. Severity categories are: Mild anxiety (score 50-59), moderate anxiety (score 60-69), and severe anxiety (score ≥ 70).

Data collection procedures

Two gastroenterologists collected patients’ demographic data and administered standardized scale evaluations. To ensure scoring reliability and consistency, all evaluators underwent training before the study. All evaluations were conducted in a controlled setting that was quiet, well-lit, and free of distractions. For data management, two independent researchers established a database using Excel. Double-entry verification procedures were applied to detect and correct discrepancies, thereby ensuring accuracy and consistency.

Statistical analysis

Data analyses were performed using SPSS software (version 25.0). Continuous variables were expressed as means ± SD for normally distributed data and compared using independent-samples t-tests. Non-normally distributed variables were presented as median (interquartile range) and analyzed with the Mann-Whitney U test. Categorical variables were summarized as n (%) and compared using the χ² test. Potential factors associated with anxiety and depression were identified using multivariate logistic regression analysis. Correlations among anxiety, depression, and sleep quality were assessed using Pearson’s rank correlation coefficients. A two-tailed P value less than 0.05 was considered statistically significant.

RESULTS

Sociodemographic characteristics of participants

A total of 315 questionnaires were administered, of which 296 valid responses were retained, yielding an effective response rate of 94.0%. The study population (n = 296) included 49.7% males, with a mean age of 47.48 ± 7.57 years. Regarding education, 34.1% had attained a university degree or higher. In terms of residence, 51.7% lived in urban areas, and 30.4% reported an annual income below 10000 Chinese yuan. The majority of respondents (83.1%) were married. Additional demographic characteristics are summarized in Table 1.

Table 1 Sociodemographic profile of study participants.

	Number of cases (n = 296)	Constituent ratio (%)
Gender
Male	147	49.7
Female	149	50.3
Age	47.48 ± 7.57
Body mass index	23.61 ± 3.14
Ethnicity
Han	242	81.8
Ethnic minorities	54	18.2
Educational attainment
≤ Junior high school	90	30.4
College, technical secondary school, or senior high school	105	35.5
≥ University	101	34.1
Occupation
Employed	107	36.1
Retired	94	31.8
Unemployed	95	32.1
Marital status
Unmarried	21	7.1
Married	246	83.1
Divorced or widowed	29	9.8
Place of residence
Urban	153	51.7
Rural	143	48.3
Annual income (in 10000 Chinese yuan)
≤ 1	91	30.7
1-6	112	37.8
> 6	93	31.5
Medical insurance type
Employee or resident medical insurance	124	41.9
New rural cooperative medical scheme	78	26.4
Commercial insurance	56	18.9
No medical insurance	38	12.8
Family history
Positive	113	38.2
Negative	183	61.8
Endoscopic ultrasonography
Yes	145	49.0
No	151	51.0

Sleep quality assessment

The mean PSQI score among participants with digestive tract SELs was 6.25 ± 1.85. Notably, 77 of the 296 patients (26.0%) exhibited clinically significant sleep disturbances (PSQI ≥ 7), with varying degrees of severity. Compared with established Chinese normative data[11], patients with digestive tract SELs scored statistically higher across all PSQI domains (P < 0.05), except for hypnotic medication use (Table 2).

Table 2 Sleep quality metrics: Study cohort vs Chinese norms.

	Digestive tract SEL patients (n = 296)	Chinese norms (n = 112)	t	P value
Subjective sleep quality	0.94 ± 0.60	0.67 ± 0.88	3.538	0.0004
Sleep onset latency	1.18 ± 0.72	0.70 ± 0.98	5.412	< 0.0001
Sleep duration	0.93 ± 0.81	0.46 ± 0.68	5.455	< 0.0001
Sleep efficiency	0.99 ± 0.74	0.02 ± 0.73	11.859	< 0.0001
Sleep disturbances	1.00 ± 0.71	0.83 ± 0.61	2.240	0.026
Hypnotic medication use	0.19 ± 0.39	0.18 ± 0.63	0.193	0.402
Daytime dysfunction	1.02 ± 0.65	0.79 ± 0.94	2.799	0.005
Total PSQI score	6.25 ± 1.85	3.23 ± 3.12	11.99	< 0.0001

SEL: Subepithelial lesion; PSQI: Pittsburgh Sleep Quality Index.

Anxiety and depression levels among patients

The mean anxiety score was 46.56 ± 9.13, and the mean depression score was 48.64 ± 8.30. Based on established thresholds (≥ 50 for anxiety and ≥ 53 for depression), 35.8% of patients met the criteria for anxiety symptoms, while 33.1% exhibited depressive symptoms (Table 3).

Table 3 Prevalence of anxiety and depression in the study cohort.

	Total score (n = 296)		Score
SAS score	46.56 ± 9.13	Anxiety (n = 106)	41.13 ± 6.14
		Non-anxiety (n = 190)	56.29 ± 4.17
SDS score	48.64 ± 8.30	Depression (n = 98)	44.15 ± 5.99
		Non-depression (n = 198)	57.71 ± 3.53

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Association between anxiety/depression and sleep quality

Both anxiety (SAS) and depression (SDS) scores were significantly positively correlated with overall sleep quality (PSQI total score, P < 0.05). Specifically, most PSQI subscales, excluding sleep duration, sleep disturbances, and hypnotic medication use, were positively associated with anxiety (P < 0.05). Similarly, depression scores correlated with multiple PSQI components, except for sleep efficiency, sleep disturbances, hypnotic medication use, and daytime dysfunction (P < 0.05; Table 4).

Table 4 Relationships between anxiety, depression, and sleep quality indicators.

	SAS		SDS
	r	P value	r	P value
Subjective sleep quality	0.161	0.006	0.253	< 0.0001
Sleep onset latency	0.124	0.033	0.149	0.010
Sleep duration	0.108	0.064	0.209	0.0003
Sleep efficiency	0.157	0.007	0.114	0.051
Sleep disturbances	0.048	0.406	0.094	0.107
Hypnotic medication use	0.010	0.864	0.030	0.602
Daytime dysfunction	0.212	0.0002	0.057	0.325
Total PSQI score	0.304	< 0.0001	0.338	<0.0001

SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; PSQI: Pittsburgh Sleep Quality Index.

Clinical predictors of anxiety: Univariate analysis

Of the 296 patients, 106 (35.8%) presented with anxiety symptoms. Significant differences (P < 0.05) were observed between anxious and non-anxious groups regarding age, educational level, annual income, EUS testing (yes/no), sleep disorders (yes/no), and disease cognition level (present/absent) (Table 5).

Table 5 Univariate analysis of anxiety-related factors.

	Anxiety (n = 106)	Non-anxiety (n = 190)	χ2/t	P value
Gender			0.780	0.377
Male	49	98
Female	57	92
Age	49.43 ± 7.42	46.38 ± 7.45	3.381	0.0008
Body mass index	23.27 ± 2.90	23.80 ± 3.2	1.397	0.163
Ethnicity			0.539	0.463
Han	89	153
Ethnic minorities	17	37
Educational attainment			6.038	0.049
≤ Junior high school	41	49
College, technical secondary school, or senior high school	36	69
≥ University	29	72
Occupation			3.012	0.222
Employed	42	65
Retired	27	67
Unemployed	37	58
Marital status			0.497	0.780
Unmarried	9	12
Married	87	159
Divorced or widowed	10	19
Place of residence			0.458	0.498
Urban	52	101
Rural	54	89
Annual income (in 10000 Chinese yuan)			11.462	0.003
≤ 1	46	48
1-6	36	73
> 6	24	69
Medical insurance type			0.596	0.897
Employee or resident medical insurance	48	79
New rural cooperative medical scheme	28	50
Commercial insurance	19	37
No medical insurance	11	24
Family history			1.280	0.258
Positive	45	68
Negative	61	122
Endoscopic ultrasonography			14.921	0.0001
Yes	36	109
No	70	81
Sleep disorders			31.861	<0.0001
Yes	48	29
No	58	161
Disease cognition level			14.171	0.0002
Without cognition	66	75
With cognition	40	115

Predictors for anxiety: Multivariate analysis

Multivariate logistic regression was conducted to identify independent predictors of anxiety (coded as 0 = absent, 1 = present), incorporating variables significant in the univariate analysis. As a result, low annual income (< 10000 Chinese yuan) was associated with a higher risk of anxiety compared with incomes > 60000 Chinese yuan [odds ratio (OR) = 2.061, P = 0.041]. Advancing age (OR = 1.059, P = 0.003) and the presence of sleep disorders (OR = 3.153, P < 0.0001) were also identified as risk factors. In contrast, undergoing EUS examination (OR = 0.446, P = 0.004) and having disease-related knowledge (OR = 0.561, P = 0.046) were protective factors against anxiety (Table 6).

Table 6 Multivariate logistic regression analysis of anxiety-related factors.

Variable	β	SE	Wald	P value	OR	95%CI
Constant	-3.145	0.940	11.186	0.001	0.043
Age (continuous variable)	0.057	0.019	8.934	0.003	1.059	1.020-1.099
Educational attainment (0, ≤ junior high school)			3.070	0.215
1, college, technical secondary school, or senior high school	-0.319	0.332	0.923	0.337	0.727	0.379-1.393
2, ≥ university	-0.596	0.34	3.059	0.080	0.551	0.282-1.075
Annual income (in 10000 Chinese yuan; 0, > 6)			4.539	0.103
1, 1-6	0.563	0.344	2.684	0.101	1.756	0.89-3.443
2, < 1	0.723	0.355	4.157	0.041	2.061	1.028-4.131
Sleep disorders (0 = no, 1 = yes)	1.148	0.317	13.417	0.000	3.153	1.695-5.865
Endoscopic ultrasonography (0 = no, 1 = yes)	-0.807	0.21	8.227	0.004	0.446	0.257-0.775
Disease cognition level (0 = without cognition; 1 = with cognition)	-0.569	0.285	3.91	0.046	0.561	0.324-0.989

OR: Odds ratio; CI: Confidence interval.

Univariate analysis of depression-associated clinical features

Among the 296 digestive tract SEL patients, 98 (33.1%) presented with depressive symptoms. Univariate analysis revealed statistically significant differences (P < 0.05) between depressed and non-depressed patients regarding age, marital status, annual income, EUS evaluation (yes/no), sleep disorders (yes/no) and disease cognition level (present/absent) (Table 7).

Table 7 Univariate analysis of depression-related variables, mean ± SD.

	Depression (n = 98)	Non-depression (n = 198)	χ2/t	P value
Gender			1.145	0.285
Male	53	94
Female	45	104
Age	48.93 ± 7.06	46.76 ± 7.73	2.339	0.020
Body mass index	23.58 ± 3.34	23.62 ± 3.05	0.090	0.928
Ethnicity			2.683	0.101
Han	75	167
Ethnic minorities	23	31
Educational attainment			0.168	0.920
≤ Junior high school	31	59
College, technical secondary school, or senior high school	35	70
≥ University	32	69
Occupation			2.475	0.290
Employed	33	74
Retired	37	57
Unemployed	28	67
Marital status			12.022	0.003
Unmarried	12	9
Married	71	175
Divorced or widowed	15	14
Place of residence			0.068	0.794
Urban	57	112
Rural	41	86
Annual income (in 10000 Chinese yuan)			73.682	< 0.0001
≤ 1	63	31
1-6	14	95
> 6	21	72
Medical insurance type			2.617	0.455
Employee or resident medical insurance	36	88
New rural cooperative medical scheme	28	50
Commercial insurance	18	38
No medical insurance	16	22
Family history			0.753	0.867
Positive	34	79
Negative	64	119
Endoscopic ultrasonography			17.661	< 0.0001
Yes	31	114
No	67	84
Sleep disorders			83.7511	< 0.0001
Yes	58	19
No	40	179
Disease cognition level			33.251	< 0.0001
Without cognition	70	71
With cognition	28	127

Multivariable modeling of depression predictors

Variables identified as significant in the univariate analysis were further examined using multivariate logistic regression, with depression status as the binary outcome (0 = absent, 1 = present). The analysis demonstrated that marital status significantly influenced depression risk, with married patients showing lower odds of depression compared with unmarried patients (OR = 0.166, P = 0.007). Socioeconomic status also played a notable role, as patients with annual incomes < 10000 Chinese yuan had a significantly higher risk of depression compared with those earning > 60000 Chinese yuan (OR = 10.302, P < 0.0001). Sleep disorders were independently associated with an increased likelihood of depression (OR = 7.667, P < 0.0001). Conversely, undergoing EUS examination (OR = 0.394, P = 0.010) and having disease-related knowledge (OR = 0.229, P < 0.0001) were protective factors (Table 8).

Table 8 Multivariate logistic regression analysis of depression determinants.

Variable	β	SE	Wald	P value	OR	95%CI
Constant	-0.632	1.283	0.243	0.622	0.532
Age (continuous variable)	0.027	0.023	1.395	0.238	1.027	0.983-1.074
Marital status (0 = unmarried)			10.609	0.005
1 = married	-1.794	0.660	7.384	0.007	0.166	0.046-0.606
2 = divorced or widowed	-0.627	0.809	0.601	0.438	0.534	0.109-2.607
Annual income (in 10000 Chinese yuan; 0, > 6)			45.297	0.000
1, 1-6	-0.629	0.456	1.904	0.168	0.533	0.218-1.303
2, < 1	2.332	0.445	27.454	0.000	10.302	4.305-24.649
Sleep disorders (0 = no, 1 = yes)	2.037	0.399	26.092	0.000	7.667	3.509-16.751
Endoscopic ultrasonography (0 = no, 1 = yes)	-0.930	0.363	6.551	0.010	0.394	0.193-0.804
Disease cognition level (0 = without cognition; 1 = with cognition)	-1.474	0.371	15.809	0.000	0.229	0.111-0.474

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

SELs are a common clinical finding in digestive system disorders, where timely diagnosis and appropriate management are essential for optimizing outcomes and improving quality of life. However, their indeterminate nature often makes diagnosis challenging, which in turn may lead to significant psychological distress, including anxiety and depression. Notably, a substantial proportion of patients develop clinically significant anxiety and/or depression immediately after the incidental detection of these lesions during routine endoscopic examinations. These findings highlight the importance of incorporating tailored psychological support strategies and strengthening patient-centered care in this population. In this study, 35.8% of patients exhibited anxiety symptoms, with a mean SAS score of 46.56 ± 9.13, while 33.1% demonstrated depressive symptoms, with a mean SDS score of 48.64 ± 8.30. These results indicate a notable burden of psychological distress among patients with SELs.

The brain-gut axis, a complex bidirectional system linking neuroendocrine pathways, the autonomic nervous system, and the gastrointestinal tract, has been implicated in the pathogenesis of functional gastrointestinal disorders[12] and chronic inflammatory gastrointestinal diseases characterized by recurrent and remitting courses[13]. Moreover, anxiety and depression are well-documented comorbidities in chronic diseases with strong immune or inflammatory components, such as diabetes, cancer, multiple sclerosis, rheumatoid arthritis, and inflammatory bowel disease[14]. Therefore, the anxiety and depression status of patients with SELs in the digestive tract is worthy of research and analysis.

Further analysis identified several key factors influencing anxiety and depression. An annual income below 10000 Chinese yuan and the presence of sleep disorders were significant risk factors, while undergoing EUS emerged as a protective factor. The mean patient age in this study was 47.48 ± 7.57 years, indicating a predominantly middle-aged cohort. Patients in this demographic may be particularly vulnerable to psychological distress due to disease uncertainty. The possibility of a malignant diagnosis may exacerbate financial strain, familial responsibilities, and emotional burden, thereby increasing susceptibility to anxiety and depression[15,16]. Notably, lower annual income is directly associated with perceived economic pressure, defined as the stress that arises when individuals perceive household resources as insufficient to meet familial needs[17]. Substantial evidence demonstrates that financial hardship is a strong predictor of psychological distress, including anxiety and depression[18,19].

Sleep disorders were also identified as an important risk factor. In this study, patients’ sleep quality, assessed using PSQI, showed significantly higher scores compared to the general Chinese population, indicating clinically relevant sleep disturbances. Although the underlying causes, whether illness-related distress or demographic influences, were not further investigated, existing literature strongly supports the bidirectional relationship between sleep impairment and mental health deterioration[20]. Notably, this study found no correlation between anxiety or depression scores and hypnotic drug use. This result may be due to the low rate of hypnotic drug use in our study population and the relatively small sample size, which may have introduced bias. Nevertheless, sleep impairment remains a modifiable risk factor for neuropsychiatric disorders, warranting early intervention in at-risk populations.

Our findings further revealed that patients undergoing EUS had a lower incidence of anxiety and depression. All patients who underwent EUS in this study were informed of their results. EUS, an advanced imaging modality integrating high-frequency ultrasound with endoscopy, provides real-time visualization of the gastrointestinal lumen as well as detailed cross-sectional imaging of the gastric wall and adjacent structures[21]. The digestive tract wall is visualized as five alternating hyperechoic and hypoechoic layers, corresponding histologically to the mucosa (hyperechoic), muscularis mucosae (hypoechoic), submucosa (hyperechoic), muscularis propria (hypoechoic), and serosa (hyperechoic). This high-resolution technique allows precise characterization of SELs, including their size, layer of origin, echotexture, and local invasion, facilitating an accurate preliminary EUS-based diagnosis[22]. By providing patients with clearer information about the nature of the lesions, EUS reduces anxiety related to potential malignancy, thereby improving psychological well-being. Therefore, we recommend incorporating EUS into early diagnostic pathways, as it is less costly than many advanced diagnostic modalities and can help reduce long-term medical expenses[23]. Additionally, disease cognition itself was found to be a protective factor against anxiety and depression. Patients with poor understanding of their condition tended to have higher levels of negative emotions. A lack of knowledge about the disease and its treatment fosters fear, lowers treatment expectations, and contributes to anxiety and depression.

In addition to the shared risk factors for anxiety and depression, our findings indicate that advanced age is an independent risk factor for anxiety. Older patients may be more vulnerable due to reduced physical resilience and heightened concerns about coping with severe disease outcomes. Furthermore, age-related social and psychological stressors may further contribute to emotional distress. Notably, marital status appears to play a protective role against depression, likely because spousal support provides emotional and psychological stability, thereby reducing depressive symptoms. Family culture, deeply rooted in Chinese society, also strongly influences individual behavior and family decision-making[24].

This study has several limitations. First, it was a single center, small sample size study, which limits the generalizability of the results. Inclusion of more patients from other centers in Sichuan and across China would provide a more comprehensive understanding of anxiety and depression in patients with digestive tract SELs. Second, due to its retrospective design, this study relied on observational data, preventing the establishment of definitive causal relationships. Third, the lack of long-term follow-up data made it impossible to assess changes in emotional states over time. Moreover, as no intervention measures were implemented, changes in psychological status before and after the intervention could not be evaluated. Therefore, a well-designed, multicenter, large-scale, prospective interventional study is needed to validate these findings.

CONCLUSION

Patients with digestive tract SELs are at an elevated risk of developing anxiety and depression. Poor sleep quality is significantly associated with greater susceptibility to these psychological symptoms. Performing EUS for lesion characterization not only facilitates diagnostic evaluation and guides management decisions, including surgery or follow-up, but also helps mitigate psychological distress, thereby reducing the risk of anxiety and depression. Early psychological assessment allows for tailored interventions, which can enhance quality of life, particularly in early-stage cancer cases, and potentially improve endoscopic treatment outcomes while reinforcing patient-centered care and medical humanism.