Shi HJ, Huang SC, Wang BW. Analysis the incidence and related risk factors of depression in patients with esophageal cancer combined with bone metastasis. World J Psychiatry 2026; 16(1): 110875 [DOI: 10.5498/wjp.v16.i1.110875]
Corresponding Author of This Article
Shi-Chao Huang, Chief Physician, Department of Orthopedics, People’s Hospital of Tongshan District, No. 267 Huaihai West Road, Quanshan District, Xuzhou 221100, Jiangsu Province, China. hxx20180817@163.com
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Psychiatry
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Retrospective Study
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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/
Jan 19, 2026 (publication date) through Dec 31, 2025
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World Journal of Psychiatry
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Shi HJ, Huang SC, Wang BW. Analysis the incidence and related risk factors of depression in patients with esophageal cancer combined with bone metastasis. World J Psychiatry 2026; 16(1): 110875 [DOI: 10.5498/wjp.v16.i1.110875]
Hao-Jie Shi, Department of Thoracic Surgery, The Fifth People’s Hospital of Huai’an, Huai’an 223300, Jiangsu Province, China
Shi-Chao Huang, Department of Orthopedics, People’s Hospital of Tongshan District, Xuzhou 221100, Jiangsu Province, China
Bing-Wu Wang, Department of Medical Oncology, The General Hospital of XZCMG (The Affiliated No. 2 Hospital of XZMC), Xuzhou 221000, Jiangsu Province, China
Author contributions: Shi HJ performed the research and wrote the manuscript; Huang SC conceived the research and provided guidance; Wang BW analyzed the data; and all authors reviewed and approved the final manuscript.
Institutional review board statement: This study was approved by the Medical Ethics Committee of the Fifth People’s Hospital of Huai’an, approval No. (2022)-001.
Informed consent statement: All study participants and their legal guardians provided written informed consent before recruitment.
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: Shi-Chao Huang, Chief Physician, Department of Orthopedics, People’s Hospital of Tongshan District, No. 267 Huaihai West Road, Quanshan District, Xuzhou 221100, Jiangsu Province, China. hxx20180817@163.com
Received: July 15, 2025 Revised: August 15, 2025 Accepted: October 21, 2025 Published online: January 19, 2026 Processing time: 168 Days and 16.9 Hours
Abstract
BACKGROUND
Esophageal cancer is highly malignant and frequently metastasizes to bones. Concomitant depression worsens prognosis; however, its incidence and determinants in this specific population remain poorly defined.
AIM
To determine the incidence of depression and its independent risk factors in patients with esophageal cancer and bone metastasis.
METHODS
A total of 100 consecutive eligible patients admitted between March 2022 and March 2025 were recruited. Depression was assessed with the Beck Depression Inventory-II; scores > 4 defined the depression group (n = 42) and scores ≤ 4 the non-depression group (n = 58). Demographic, clinical, and laboratory variables were compared between the groups. Multivariate logistic regression was used to identify independent risk factors.
RESULTS
Depression prevalence was 42.0% (42/100). Univariate analysis demonstrated significant differences in monthly per-capita household income, education level, social support, sleep disorders, and serum high-sensitivity C-reactive protein (all P < 0.05); no differences were observed in sex, age, tumor characteristics, or other laboratory indices (all P > 0.05). Multivariable analysis revealed the following independent risk factors for depression: Low income [odds ratio (OR) = 2.66, 95% confidence interval (CI): 1.17-6.03], low education (OR = 2.46, 95%CI: 1.08-5.61), low social support (OR = 5.10, 95%CI: 1.81-14.39), sleep disorders (OR = 2.79, 95%CI: 1.23-6.35), and elevated high-sensitivity C-reactive protein (OR = 1.31 per unit increase, 95%CI: 1.18-1.46).
CONCLUSION
Depression is common among patients with esophageal cancer and bone metastasis. Low socioeconomic status, limited education, insufficient social support, sleep disturbances, and systemic inflammation were independent predictors. Interventions that address these modifiable factors may reduce depression risk in this population.
Core Tip: This retrospective study recruited 100 patients with esophageal cancer and bone metastasis, finding 42% had depression (assessed via Beck Depression Inventory-II). Multivariate logistic regression identified five independent risk factors: low monthly per capital household income [odds ratio (OR) = 2.66], low education (OR = 2.46), low social support (OR = 5.10), sleep disorders (OR = 2.79), and elevated high-sensitivity C-reactive protein (OR = 1.31 per unit increase). Targeted interventions for these factors may lower depression risk in this population.
Citation: Shi HJ, Huang SC, Wang BW. Analysis the incidence and related risk factors of depression in patients with esophageal cancer combined with bone metastasis. World J Psychiatry 2026; 16(1): 110875
Esophageal cancer is a common malignant tumor of the digestive system, characterized by a high degree of malignancy, as well as high morbidity and mortality rates. According to statistics from 2020, the cumulative incidence and mortality risks of esophageal cancer in the age group of 0-74 years were 0.78% and 0.68%, respectively[1], and the incidence and mortality rates of esophageal cancer in China account for > 50% of the global total[2]. Bone metastasis is a common metastatic mode of esophageal cancer, which not only causes difficulties in the treatment of patients, but also makes patients more prone to depression due to the high-risk and traumatic nature of esophageal cancer[3]. Depression is common in cancer patients which can increase their physical and mental pain, reduce treatment compliance, and prolong the length of hospitalization[4]. Some studies have pointed out that the occurrence, development, and prognosis of esophageal cancer are closely related to psychological conditions and that the two interact with each other[5]. Therefore, it is necessary to identify the risk factors for depression in patients with esophageal cancer and bone metastases. Previous studies have explored the risk factors for depression in patients with breast and liver cancer[6-8]. However, the relevant factors sought are not effective in guiding the development of relevant interventions for patients with esophageal cancer and bone metastasis, and other risk factors need to be sought. Based on this, the present study aimed to focus on observing the incidence of depression and related risk factors in patients with esophageal cancer combined with bone metastasis to guide the development of clinically relevant interventions and to reduce the incidence of depression in patients with esophageal cancer combined with bone metastasis.
MATERIALS AND METHODS
General information
According to the calculation formula, where the P-value is 0.12, significance level α = 0.05 (two-tailed), Z2α/2 = 1.96, and tolerance error δ = 0.05, the total sample size was obtained to be 85 cases. Considering the shedding rate of 5%-15% and the impact of manpower and material resources, 100 cases of patients with esophageal cancer combined with bone metastasis admitted into the hospital from March 2022 to March 2025 were selected as the study subjects for the study, which was approved by the Hospital Ethics Committee for implementation. Depression was assessed with the Beck Depression Inventory-II (BDI-II); scores > 4 defined the depression group (n = 42) and scores ≤ 4 the non-depression group (n = 58). Patients were included if they met the diagnostic criteria of esophageal cancer in the Guidelines for Standardized Diagnosis and Treatment of Esophageal Cancer (2nd edition)[9] and were confirmed by pathological examination; had bone metastases diagnosed by magnetic resonance imaging, computed tomography (CT), positron-emission tomography/CT, emission CT, or other examinations; signed an informed consent form; and could cooperate with the investigation. The exclusion criteria were primary tumors in other parts of the body, comorbid psychiatric disease or cognitive dysfunction, physical disability, genetic disease, or psychological intervention in the last 1 month; those who had received antidepressant and anxiolytic treatment in the last 1 month; extensive metastasis, such as liver and brain metastases; and those who withdrew from the study in the middle, those who did not complete the scale assessment, or those who could not cooperate to complete the psychological assessment.
Depression assessment
Depression was assessed using the BDI-II[10], with a Cronbach’s alpha coefficient of 0.940. It includes three dimensions (cognitive, emotional, and somatic symptoms) with a total of 21 items. Each item has four options scored from 0 to 3, with a total score ranging from 0 to 63. Higher scores indicate more severe depression. A score > 4 indicates depressive symptoms and a score of 0-4 indicates no depressive symptoms.
The BDI-II offers several advantages compared with the Self-Rating Depression Scale. First, the BDI-II is more sensitive and specific in detecting mild to moderate depression, with scoring items closely aligned with the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, enabling better consistency with current psychiatric diagnostic standards. Second, the BDI-II comprehensively evaluates the emotional, cognitive, and somatic dimensions of depression, whereas the Self-Rating Depression Scale places relatively less emphasis on the cognitive aspects. Third, the wider score range of the BDI-II (0-63) allows for finer discrimination and facilitates dynamic tracking of symptom changes before and after intervention, making it especially suitable for clinical trials assessing rehabilitation outcomes. Furthermore, the BDI-II has undergone extensive cross-cultural validation and is widely used internationally in oncology, surgery, and rehabilitation settings, ensuring greater comparability of results across studies.
Baseline data statistics
A baseline data questionnaire was designed to collect detailed baseline data from the two groups.
General data: Sex, age, monthly per capital household income (≥ 5000 yuan, < 5000 yuan), place of residence (urban, rural), comorbid hypertension (based on relevant diagnostic criteria[11]), marital status (married, unmarried/divorced/widowed), comorbid diabetes (based on relevant diagnostic criteria[12]), drinking history (yes/no), smoking history (yes/no), social support [assessed using the Social Support Rating Scale[13], with a Cronbach’s alpha of 0.890, including three dimensions: Subjective support (four items, 8-32 points), objective support (three items, 1-22 points), utilization of support (three items, 3-12 points), totaling 10 items. Total score ranges from 12-66, with low, medium, and high social support levels defined as < 24, 24-32, and > 32 points, respectively, education level (high school and above, junior high school and below), and sleep disorders (assessed using the Pittsburgh Sleep Quality Index)[14], with a Cronbach’s alpha coefficient of 0.840. It includes seven aspects (sleep efficiency, daytime function, sleep duration, sleep quality, use of hypnotics, etc.), each scored 0-3 (total score 0-21), with scores ≥ 7 indicating sleep disorders].
Disease data: Tumor location (upper, middle, lower), tumor type (squamous carcinoma, adenocarcinoma), surgical treatment (yes/no), number of bone metastases (> 3, ≤ 3), site of bone metastases [axial bones (pelvis, spine), peripheral bones (other bones)], degree of differentiation (poorly differentiated, moderately to well differentiated), skeletal-related events (yes/no; spinal cord compression and pathological fractures caused by bone metastases), clinical stage (stage I-II, stage III-IV).
Laboratory indicators: Fasting venous blood (5 mL) was collected from both groups and centrifuged at 3000 rpm for 10 minutes with a centrifuge radius of 15 cm. The supernatants were collected. High-sensitivity C-reactive protein (hs-CRP) levels were measured using enzyme-linked immunosorbent assay. white blood cell count and albumin and total protein levels were measured using a Beckman Coulter DxH900 automatic hematology analyzer (Beckman Coulter, Brea, CA, United States).
Quality control
All questionnaires (questionnaires and scales) in the study were investigated after obtaining the consent of patients with esophageal cancer combined with bone metastases, and the evaluation of the patients’ questionnaires was completed by two professional investigators (with standardized training) The questionnaires were filled in by the patients themselves, and if it was difficult to understand, explanations were given; if it was difficult to understand in physical conditions, the patients relayed the questionnaires to family members to write on their behalf, and the questionnaires were filled in by specialists for auditing, double-entry of data, and proofreading to ensure the reliability of the data. If the answers to the questionnaire showed obvious regularity or the number of answers did not reach two-thirds of the total number of questions, it was considered an invalid survey. All questionnaires in this study were effectively recovered with a recovery rate of 95.5%.
Statistical analysis
SPSS 27.0 (IBM, Armonk, NY, United States) was used for data processing. The normality of the measurement data was tested using the Shapiro-Wilk test. Normally distributed data were expressed as means and standard deviations and were compared using the t-test. Count data were expressed as frequency (%) and compared using the χ2 test. The Bonferroni method was used for multiple-group comparison (test level α = original α level/number of comparisons, i.e., 0.05/3 = 0.017). Dummy variables were transformed for multicategorical variables, and the influencing factors for the occurrence of depression in patients with esophageal cancer combined with bone metastases were tested by logistic regression analysis. Statistical significance was established at P < 0.05.
RESULTS
Depression status
There were 42 cases (42/100) of depression in 100 patients with bone metastasis of esophageal cancer.
General information
There were significant differences in monthly per capital income, social support, sleep disorders, and cultural level between patients in the groups with and without occurrence (P < 0.05), but no significant differences in sex, age, hypertension, hyperglycemia, residence, marital status, smoking history, or drinking history were observed between the groups (P > 0.05) (Table 1).
Table 1 Comparison of general information between the two groups, n (%).
There were no significant differences between groups in terms of tumor location, surgical treatment, tumor type, bone metastasis site, number of bone metastases, bone-related events, or clinical staging (P > 0.05) (Table 2).
Table 2 Comparison of disease data between the two groups, n (%).
The hs-CRP level of the affected group was higher than that of the unaffected group (P < 0.001), but there were no significant differences in albumin, total protein, or white blood cell levels between the groups (P > 0.05) (Table 3, Figure 1).
Figure 1 Bar chart comparing laboratory indicators between groups with and without depression.
WBC: White blood cell; hs-CRP: High-sensitivity C-reactive protein.
Table 3 Comparison of laboratory indicators between the two groups, mean ± SD.
Logistic regression analysis of the influencing factors of depression in patients with esophageal cancer and bone metastasis
Depression in patients with esophageal cancer and bone metastasis was used as the dependent variable (1: Occurring; 0: Not occurring). Variables with significant differences in the baseline data were selected as independent variables and included in a single logistic regression analysis. The P-value threshold was then relaxed to < 0.2, and all eligible variables were included as independent variables (Table 4). A multivariate regression model was then established. The results indicated that high hs-CRP, low educational attainment, low social support, sleep disorders, and low per capital monthly household income were risk factors for depression in patients with esophageal cancer and bone metastasis (odds ratio > 1, P < 0.05) (Table 5, Figure 2).
Figure 2 Forest map of risk factors for depression in patients with esophageal cancer combined with bone metastasis.
hs-CRP: High-sensitivity C-reactive protein; OR: Odds ratio.
Incidence of depression in patients with esophageal cancer and bone metastases
Depression is one of the most common psychological disorders among patients with cancer. Currently, research on the relationship between malignancy and depression mostly focuses on epidemiological studies. Studies have indicated that the incidence of depression is significantly higher in patients with cancer than in non-cancer populations[15]. Depression can affect the psychological state of patients with cancer, leading to persistent anxiety, reduced treatment compliance, and impaired treatment decision-making, thereby affecting patient prognosis[16]. In this study, 42 (of the 100 patients with esophageal cancer and bone metastases developed depression. This is comparable to the overall detection rate of depression (42.10%) in Chinese female patients with breast cancer reported by Rice et al[17], suggesting that patients with esophageal cancer and bone metastases are also at a high risk of developing depression. Therefore, identifying risk factors for depression in these patients is essential. This study found significant differences between the occurrence and non-occurrence groups in terms of monthly per capital household income, social support, sleep disorders, hs-CRP levels, and educational levels. Logistic regression analysis revealed that low education level, high hs-CRP level, low social support, sleep disorders, and low monthly per capital household income were risk factors for depression in patients with esophageal cancer and bone metastases.
Impact of monthly per capital household income
Esophageal cancer has a long course, complex treatment options, and high treatment costs. However, long-term treatment can impose significant financial burdens. Patients with a low monthly per capital household income often experience significant psychological stress due to concerns about missing optimal treatment opportunities and modalities. The financial burden of the disease treatment may lead to feelings of guilt and stress. These patients are more sensitive to financial issues and may refuse or neglect psychological interventions due to economic concerns, thereby exacerbating psychological distress and increasing the risk of depression[18,19]. Conversely, patients with higher income can access more medical and social resources to cope with the challenges brought about by the disease, alleviate economic stress, and reduce the risk of depression[20]. Therefore, attention should be paid to the economic status of patients with esophageal cancer and bone metastases. Necessary support and assistance should be provided to patients from financially disadvantaged families. Families should be guided in seeking social support. A comprehensive treatment plan should be selected based on the patient's condition and economic status along with strengthened psychological support to reduce the risk of depression.
Impact of education level
A low level of education among patients with esophageal cancer and bone metastases indicates that they may have difficulty acquiring disease-related knowledge through various channels. They mainly rely on verbal education from medical staff, resulting in a poor understanding of the disease and treatment, more doubts, and a higher likelihood of misperceptions, leading to uncertainty and greater psychological burden[21]. In contrast, patients with higher educational levels can access disease and treatment information through multiple channels. They tend to have a clearer and more objective understanding of their condition, possess stronger self-regulation abilities, and are more likely to maintain a positive and optimistic attitude when facing disease and treatment challenges, thereby reducing the risk of depression[22,23]. Therefore, health education for patients with esophageal cancer and bone metastases should be strengthened. For patients with lower educational levels, diverse health education methods such as video explanations and multimedia presentations should be adopted to improve disease and treatment awareness. Sharing experiences with other patients can also help build treatment confidence and reduce the risk of depression.
Impact of social support
Social support refers to various forms of assistance, support, and recognition provided by friends, family, colleagues, and social organizations. High levels of social support can provide individuals with psychological and material assistance, helping them improve physical and mental health and actively cope with adversity[24,25]. Patients with esophageal cancer and bone metastases who receive low social support receive less help from friends and family, making them more prone to feelings of loneliness, helplessness, and despair when facing the disease and treatment. This reduces treatment confidence and results in negative emotions. Furthermore, due to a lack of social support, patients experiencing negative emotions may not receive emotional relief and comfort, leading to a vicious cycle and an increased risk of depression[26]. In contrast, patients with high levels of social support can access more material and psychological assistance during treatment, meet both physical and psychological needs, reduce the impact of the disease, and lower the risk of depression[27]. Therefore, cognitive should be provided to patients with low social support to help them identify and correct their negative thoughts. Community resources such as volunteer accompaniments and financial aid can be integrated to address practical difficulties. Families should be guided to accompany and encourage patients, help them actively seek help, and improve their use of social resources to reduce their risk of depression.
Impact of sleep disorders
Sleep disorders are common among patients with cancer. Long-term sleep disturbance can reduce natural killer cell activity, weaken immune surveillance, accelerate tumor progression, and trigger feelings of helplessness. In addition, sleep disorders can reduce serotonin secretion, thereby directly promoting the onset of depression. Disruption of the biological clock can suppress melatonin secretion, affecting hormone metabolism related to tumors, and aggravating negative emotions in patients with esophageal cancer and bone metastases[28]. Moreover, sleep disorders can lead to increased daytime fatigue and impaired daytime functioning, further exacerbating negative emotions. Night-time awakening can intensify feelings of shame and increase the risk of depression[29]. Therefore, sleep guidance should be provided for these patients. Measures include using blackout curtains at night, maintaining a constant room temperature of 22-24 °C, soaking feet in warm water before bed to promote sleep, limiting nap time to ≤ 30 minutes, and minimizing the impact of sleep disorders. Individualized psychological counseling should also be implemented to alleviate negative emotions and reduce the risk of depression.
Impact of hs-CRP levels
Studies have shown that inflammatory cytokines can influence the onset, progression, and outcome of depression by affecting neurotransmitters, regulating neuroendocrine functions, altering neural plasticity, and ultimately affecting emotional regulation[30]. hs-CRP is a non-specific inflammatory marker in the plasma. Elevated hs-CRP levels can promote the release of inflammatory cytokines, inhibit serotonin synthesis in the hippocampus, and induce depressive behaviors. Chronic inflammation may also excessively activate the hypothalamic-pituitary-adrenal axis, increase cortisol levels, and worsen depressive symptoms[31]. Furthermore, inflammation may damage synaptic plasticity through the blood-brain barrier, impair executive function and attention, and trigger death anxiety due to worsening infection symptoms, thereby increasing the risk of depression[32]. Therefore, hs-CRP levels in patients with esophageal cancer and bone metastases should be monitored. Active anti-inflammatory treatments should be implemented, along with cognitive restructuring training, to alleviate negative emotions and reduce the risk of depression.
CONCLUSION
Low education levels, high hs-CRP levels, low social support, sleep disorders, and low monthly per capital household income are risk factors for depression in patients with esophageal cancer and bone metastases. Targeted interventions based on these factors should be implemented to reduce the risk of depression in this population. However, this study has certain limitations, such as a lack of evidence on the effectiveness of the proposed interventions. Further studies are needed to validate these measures and provide reference data for clinical intervention strategies to reduce the risk of depression in patients with esophageal cancer and bone metastases.
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 B, Grade C
Creativity or Innovation: Grade B, Grade C
Scientific Significance: Grade B, Grade C
P-Reviewer: Funkhouser CJ, Associate Professor, United States; Justinski C, PhD, Germany S-Editor: Bai Y L-Editor: A P-Editor: Lei YY
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