Cognitive behavioral intervention for depressive disorders in patients after cervical cancer surgery

Abstract

BACKGROUND

Cervical cancer is a common cancer type affecting women. Currently, surgical treatment is the primary clinical approach for cervical cancer. However, owing to various factors, patients are prone to developing depressive symptoms after surgery, which adversely affects their disease prognosis and quality of life. Therefore, the implementation of effective psychological interventions for patients in the postoperative period is critical.

AIM

To investigate the effects of cognitive behavioral intervention (CBI) on depression in post-cervical cancer surgery patients.

METHODS

In this retrospective study, clinical and follow-up data were collected from patients undergoing radical cervical cancer surgery at Shanxi Provincial People’s Hospital (2023-2025); 185 participants were enrolled via consecutive retrospective sampling and divided into observation and control groups. The observation group received postoperative 8-week standardized CBI once weekly, delivered by professionally trained nurses to alleviate postoperative negative emotions. Propensity score matching was used to balance baseline confounders. Depression incidence, symptom scores, remission rate, quality of life, and treatment compliance were compared between the groups. Multivariate logistic regression identified independent factors for postoperative depression.

RESULTS

A total of 185 patients were enrolled; the observation and control groups each comprised 84 patients after propensity score matching. Baseline data were well-balanced across the two groups after matching. At 6 months postoperatively, the observation group exhibited markedly lower depression symptom scores and a lower incidence of depressive disorders compared with the control group, while the depression symptom remission rate, quality of life score, and treatment compliance were significantly higher (6.5 ± 1.3 vs 8.9 ± 1.9, P < 0.001; 20.2% vs 41.7%, P < 0.01; 51.8% vs 4.8%, P < 0.001; 18.0 ± 3.6 vs 15.8 ± 3.4, P < 0.001; 72.6% vs 44.0%, P < 0.001). Multivariate regression analysis showed that CBI was an independent protective factor against depressive disorders in patients after cervical cancer surgery, whereas older age and postoperative chemoradiotherapy were independent risk factors (all P < 0.05).

CONCLUSION

Standardized cognitive behavioral therapy lowers depression risk, relieves symptoms, and improves remission rate for cervical cancer postoperative patients. Thus, this intervention is worthy of clinical promotion.

Key Words: Cervical cancer; Postoperative; Depressive disorder; Cognitive behavioral intervention; Retrospective study

Core Tip: This study investigated the impact of cognitive behavioral intervention (CBI) on depressive symptom severity, remission rate, and incidence of depressive disorders among patients following cervical cancer surgery. After the CBI, the observation group exhibited significantly lower depression symptom scores and incidence of depressive disorders than the control group (P < 0.05), as well as better depression symptom remission rate, quality of life score, and treatment compliance (P < 0.05). These results support the effectiveness of CBI in patients after cervical cancer surgery.

INTRODUCTION

Cervical cancer is the third most prevalent malignant tumor in women worldwide, carrying a persistently high epidemiological burden that severely threatens women’s health[1]. The incidence and mortality burden are particularly prominent in low- and middle-income countries, and the unequal allocation of medical resources further intensifies the pressure of disease prevention[2]. With the popularization of screening techniques and optimization of surgical protocols, the survival rate for patients with early-stage cervical cancer has increased significantly, and the postoperative survival period has been greatly prolonged[3]. However, postoperative psychological disorders have become increasingly prevalent, and the long-term physical and mental health management and quality of life improvement of patients have become the focus of clinical attention.

As the primary treatment for cervical cancer, surgery can effectively resect the lesion; however, the pathophysiological changes caused by surgery and the psychological stress induced by the disease itself make patients prone to negative emotions. Consequently, the incidence of depressive disorders in postoperative patients with cervical cancer is much higher than that in the general female population[4]. Multiple real-world studies and epidemiological surveys have confirmed a high incidence of depressive symptoms in patients after cervical cancer surgery. An international survey on psychiatric comorbidities in cervical cancer survivors found that the prevalence of depressive disorders after surgery reached 31%, far exceeding that of the general female population[5]. Another large-scale cohort study reported a postoperative depression incidence of 23.0%, with 6.1% comprising moderate to severe cases[6]. The impact of depressive disorders on patients is multidimensional: Directly, it reduces treatment compliance, leading to decreased cooperation in postoperative rehabilitation training and poor follow-up adherence; indirectly, it disturbs immune function, elevates the risk of tumor recurrence and metastasis, reduces both disease-free and overall survival, markedly impairs postoperative quality of life, and adds to the medical burden borne by families and society[7]. At present, clinical diagnosis and treatment of postoperative depression in cancer patients are insufficient, primarily relying on pharmacological interventions, and lacking targeted, widely applicable, and safe non-pharmacological psychological intervention programs. The available treatments fail to meet the long-term psychological rehabilitation needs of patients.

Cognitive behavioral intervention (CBI) is supported by substantial evidence in the field of psychological interventions. By correcting patients’ irrational cognitions, reshaping healthy behavioral patterns, and relieving negative emotional stress, CBI achieves effective regulation of depressive disorders and shows high application value in various mental health problems and depression comorbid with chronic diseases[8]. Multiple systematic reviews have confirmed that CBI can effectively alleviate mental illness in patients with cancer and improve psychological adjustment ability and quality of life. CBI has no adverse reactions, high patient acceptance, and long-term benefits, making it particularly suitable for long-term postoperative rehabilitation of cancer patients[9,10]. Furthermore, studies on patients with gynecological malignancies have shown that standardized CBI can precisely relieve depressive symptoms in cervical cancer patients, help them face disease and surgical trauma, and return to normal life, with a promising clinical application prospect[11].

Although the efficacy of CBI in depressive disorders and cancer-related depression has been initially confirmed, existing studies on patients after cervical cancer surgery have obvious limitations, and the reliability and practicability of the evidence need to be improved. Most existing studies are randomized controlled trials with a strict design and high internal validity. However, they have stringent inclusion criteria and are conducted in highly controllable research settings, which differ greatly from real clinical scenarios. Therefore, their findings have insufficient external validity, making it difficult to directly apply them to routine clinical nursing[12,13]. Given these limitations, including real-world clinical data allows for comprehensively evaluating the intervention effectiveness of CBI in postoperative cervical cancer patients with different disease severity, ages, and backgrounds.

Based on the high incidence and prominent clinical harm of postoperative depressive disorders in cervical cancer patients, as well as the deficiencies of existing CBI research, this study uses real-world data in a clinical setting to investigate the effects of standardized CBI on postoperative depression in cervical cancer patients. This study provides real-world evidence for non-pharmacological interventions for postoperative depressive disorders in cervical cancer patients. It also offers a scientific reference for improving patients’ psychological rehabilitation management system and enhancing long-term quality of life.

MATERIALS AND METHODS

Study population

This study retrospectively analyzed female patients who underwent radical hysterectomy ± pelvic lymphadenectomy in Shanxi Provincial People’s Hospital from January 2023 to December 2025 (Figure 1). The inclusion criteria were: (1) Confirmed primary cervical cancer by postoperative histopathology; (2) Aged 18-70 years, conscious, with basic communication and cooperation ability, and complete medical and follow-up data; (3) Completed at least 12 months of standardized follow-up postoperatively with no missing core outcome indicators; and (4) No history of depressive disorders or other mental illnesses before surgery, no use of antidepressants, and no prior psychological intervention of any form.

Figure 1 Flow diagram of this study. CBI: Cognitive behavioral intervention; PSM: Propensity score matching.

The exclusion criteria were: (1) Preoperative comorbidity with depressive disorders, schizophrenia or any other mental illnesses, or long-term use of psychotropic drugs; (2) Cervical cancer recurrence, distant metastasis, or complicated with severe cardiac, hepatic, renal failure, or other organ dysfunctions that prevent follow-up cooperation; (3) Received other systematic psychological interventions besides CBI after surgery; (4) Missing medical records, incomplete core scale data, or failure to follow-up; and (5) History of other malignant tumors. Eligible patients were split into observation and control groups depending on postoperative receipt of standardized CBI: The observation group received standardized CBI combined with routine nursing, while the control group received only routine cervical cancer nursing without any systematic psychological intervention. This study was approved by the Medical Ethics Committee of Shanxi Provincial People’s Hospital (approval No. 2026327).

Criteria for standardized cognitive behavioral intervention

Observation group: The intervention was delivered by medical staff with nationally certified psychological consultant/psychotherapist qualifications or standardized CBI training. The cumulative intervention frequency was ≥ 4 times within 6 months postoperatively; a single session lasted for ≥ 30 minutes, with complete intervention records (time, core content, and patient feedback); and the intervention was initiated within 1 month postoperatively. The first intervention includes psychological education and relaxation training. The second covers cognitive restructuring and behavioral activation. The third consists of cognitive consolidation, behavioral reinforcement, and advanced relaxation training. Finally, the fourth focuses on relapse prevention and comprehensive review.

The control group received routine cervical cancer nursing and health education after surgery only, without standardized CBI as defined above and with no records of systematic psychological intervention. Nursing care followed the Clinical Practice Guidelines for Gynecologic Oncology Nursing and the hospital’s clinical nursing pathway for post-cervical cancer surgery. Registered nurses with gynecologic oncology experience delivered all nursing services during hospitalization. Their in-hospital work included vital sign monitoring, complication prevention, basic care, diet and medication guidance, routine health education, and basic emotional support. After discharge, patients received outpatient follow-ups at 1, 3, 6, and 12 months post-surgery, plus telephone follow-ups. Nurses assessed patients’ recovery and provided instructions regarding home care, pelvic floor training, and the recognition of abnormal symptoms.

Clinical data collection

Data for all indicators were obtained retrospectively from the hospital electronic medical record system, follow-up registration system, and psychological assessment files. Assessment time points were: Within 1 week postoperatively (baseline) and 1, 3, 6, and 12 months postoperatively. Baseline data included demographic characteristics and clinical data.

Outcome measures

The primary outcome measures were the degree of depressive symptoms, assessed using the 17-item Hamilton Depression Rating Scale (HAMD-17)[14], with a total score 0-54; higher scores indicated more severe depressive symptoms. Incidence of depressive disorders: The proportion of patients meeting the Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria for major depressive episode[15] with a HAMD-17 score ≥ 8. The primary endpoint was 6 months postoperatively and the secondary was 12 months postoperatively. Remission rate of depressive symptoms: Proportion of patients with a HAMD-17 score < 7 (clinical cure) or a ≥ 50% reduction from baseline (marked response) at 6 months postoperatively.

Secondary outcome measures included quality of life, assessed at 6 months postoperatively using the Functional Assessment of Cancer Therapy-Cervix (FACT-Cx) scale and cervical cancer-specific concerns. Higher total scores indicated better quality of life[16].

Statistical analysis

Continuous data were described as mean ± SD, with between-group differences analyzed using the independent-samples t-test. Categorical data were presented as n (%), and between-group comparisons were performed using the χ² test. Survival curves for depressive disorder onset were plotted using the Kaplan-Meier method, and between-group differences were tested using the Log-rank test. Multivariate logistic regression was used to analyze the independent factors influencing depressive symptoms remission. The test level was α = 0.05 (two-sided), and P < 0.05 was considered statistically significant. Propensity score matching (PSM; 1:1 matching, caliper value 0.02) was performed to balance baseline confounding factors, including age, education level, marital status, monthly household income, International Federation of Gynecology and Obstetrics stage, postoperative adjuvant chemoradiotherapy, chronic comorbidities, and baseline HAMD-17 score as matching variables.

RESULTS

Comparison of baseline characteristics between the two groups

A total of 208 patients were initially screened. Six patients with a history of mental illness, 8 with postoperative recurrence/metastasis, and 9 who failed to follow up were excluded. Finally, 185 patients were enrolled (94 in the observation group and 91 in the control group). After propensity score matching, each group contained 84 patients, and no significant between-group differences were observed in baseline characteristics, suggesting satisfactory matching quality (Table 1).

Table 1 Baseline characteristics of patients in the two groups after propensity score matching.

Variable	Observation group	Control group	t/χ2 value	P value
Age, mean ± SD	44.5 ± 8.4	46.0 ± 8.4	-1.117	0.266
Age stratification			0.264	0.870
< 40	20	22
40-59	59	56
≥ 60	5	6
Marital status			0.000	1
Married/cohabiting	63	63
Divorced/widowed/single	21	21
Educational level			0.983	0.805
Primary school and below	17	18
Junior high school	24	27
High school/technical secondary school	24	25
College level and above	19	17
Monthly household income			1.153	0.764
< 3000 yuan	18	22
3001-6000 yuan	28	27
6001-10000 yuan	23	18
> 10000 yuan	15	17
FIGO			4.281	0.118
I	49	57
II	27	25
III	8	2
Postoperative radiotherapy and chemotherapy			0.096	0.757
Yes	38	40
No	46	44
Chronic comorbidities			0.12	0.729
Yes	22	24
No	62	60
HAMD score, mean ± SD	11.2 ± 2.1	10.7 ± 2.0	1.695	0.092

FIGO: International Federation of Gynecology and Obstetrics; HAMD: Hamilton Depression Rating Scale.

Comparison of depressive symptoms scores between the two groups

This study showed that the baseline HAMD-17 scores of the two groups were 11.2 ± 2.1 and 10.7 ± 2.0, with no statistically significant difference (P > 0.05). At 1, 3, 6, and 12 months after surgery, the HAMD-17 scores of the observation group were 8.7 ± 1.8, 7.5 ± 1.5, 6.5 ± 1.3, and 5.4 ± 1.2, respectively. These values were significantly lower than those of the control group (10.2 ± 2.0, 9.6 ± 2.1, 8.9 ± 1.9, and 8.2 ± 1.7) (P < 0.001), which indicates that CBI significantly relieved depressive symptoms (Table 2).

Table 2 Comparison of 17-item Hamilton Depression Rating Scale scores between the two groups, mean ± SD.

Variable	Observation group	Control group	t/χ2 value	P value
Baseline	11.2 ± 2.1	10.7 ± 2.0	1.695	0.092
1-month postoperative	8.7 ± 1.8	10.2 ± 2.0	-4.995	< 0.001
3-month postoperative	7.5 ± 1.5	9.6 ± 2.1	-7.337	< 0.001
6-month postoperative	6.5 ± 1.3	8.9 ± 1.9	-9.536	< 0.001
12-month postoperative	5.4 ± 1.2	8.2 ± 1.7	-12.093	< 0.001

Comparison of depression symptom remission rate between the two groups

At 6 months postoperatively, the clinical cure rate and marked response rate in the observation group were 51.8% and 12.0%, respectively, while those in the control group were 4.8% and 0%, respectively. The observation group presented markedly higher clinical cure and marked response rates compared with the control group (P < 0.001) (Table 3, Figure 2).

Figure 2 Comparison of depression symptom remission rate between the two groups. ^cP < 0.001.

Table 3 Comparison of depression symptom remission rate at 6 months postoperatively, n (%).

Variable	Observation group	Control group	t/χ2 value	P value
6-month postoperative
Clinical cure	43 (51.8)	4 (4.8)	45.143	< 0.001
Significant response	10 (12.0)	0	10.641	0.001

Comparison of the incidence of depressive disorders between the two groups

This study found that the incidence of depressive disorders in the two groups was 26.2% and 36.9% at 1 month after surgery, with no statistically significant difference (P > 0.05). At 3, 6 and 12 months postoperatively, the incidence rates of depressive disorders in the observation group were 21.4%, 20.2%, and 23.5%, respectively. All these rates were markedly lower than the corresponding rates of 41.7%, 41.7%, and 38.1% in the control group, and the differences were statistically significant (P < 0.01) (Table 4).

Table 4 Comparison of the incidence of depressive disorders between the two groups.

Variable	Observation group	Control group	t/χ2 value	P value
1-month postoperative	22 (26.2)	31 (36.9)	2.233	0.135
3-month postoperative	18 (21.4)	35 (41.7)	7.966	< 0.01
6-month postoperative	17 (20.2)	35 (41.7)	9.024	< 0.01
12-month postoperative	15 (23.5)	32 (38.1)	8.537	< 0.01

Comparison of the risk of depressive disorders between the two groups

Kaplan-Meier survival curves for postoperative depressive disorder onset were plotted using Prism software. Log-rank test showed that the observation group exhibited a markedly reduced risk of depressive disorders compared with the control group, suggesting that CBI effectively reduced the occurrence of depressive disorders after cervical cancer surgery (Log-rank χ² = 5.414, P < 0.05) (Figure 3).

Figure 3  Predictive curves of depressive disorder occurrence in the two groups.

Comparison of postoperative quality of life between the two groups

At 6 months after surgery, quality of life was evaluated using the FACT-Cx scale. The results demonstrated that the scores of all subscales of the FACT-Cx scale in the observation group were 18.0 ± 3.6, 25.6 ± 3.3, 19.6 ± 3.6, 22.1 ± 3.4, and 23.6 ± 3.1, respectively. All scores were significantly higher than those of the control group (15.8 ± 3.4, 21.5 ± 3.3, 14.7 ± 3.6, 18.1 ± 3.4, and 19.2 ± 3.4), with statistically significant differences (P < 0.001). These results suggest that CBI effectively enhanced patients’ quality of life following cervical cancer surgery (Table 5).

Table 5 Comparison of Functional Assessment of Cancer Therapy-Cervix scores at 6 months postoperatively, mean ± SD.

Variable	Observation group	Control group	t/χ2 value	P value
Physical status	18.0 ± 3.6	15.8 ± 3.4	4.158	< 0.001
Social/family status	25.6 ± 3.3	21.5 ± 3.3	8.149	< 0.001
Emotional status	19.6 ± 3.6	14.7 ± 3.6	8.921	< 0.001
Functional status	22.1 ± 3.4	18.1 ± 3.4	7.585	< 0.001
Cervical cancer-specific concerns	23.6 ± 3.1	19.2 ± 3.4	8.66	< 0.001

Comparison of treatment compliance between the two groups

Rehabilitation treatment compliance was evaluated within 6 months after surgery. The full compliance rate of the observation group was 72.6%, and the partial compliance rate was 27.4%. In the control group, the full compliance rate was 44.0% and the partial compliance rate was 51.2%. The difference between the two groups was statistically significant (P < 0.001), suggesting that CBI significantly improved adherence to rehabilitation treatment (Table 6).

Table 6 Comparison of treatment compliance between the two groups, n (%).

Variable	Observation group	Control group	t/χ2 value	P value
			15.655	< 0.001
Complete adherence	61 (72.6)	37 (44.0)
Partial adherence	23 (27.4)	43 (51.2)
Non-adherence	0	4 (4.8)

Analysis of factors influencing depressive disorders after cervical cancer surgery

Multivariate logistic regression was performed with the occurrence of depressive disorders at 6 months postoperatively as the outcome. After adjusting for baseline confounding factors, CBI, age, and postoperative chemoradiotherapy were independent influencing factors. CBI was a protective factor, while older age and postoperative chemoradiotherapy were risk factors [odds ratio (OR) = 0.296, P < 0.01; OR = 1.070, P < 0.01; OR = 2.995, P < 0.01, respectively] (Table 7).

Table 7 Multivariate logistic regression analysis for depressive disorders at 6 months postoperatively.

Variable	OR value	95%CI	P value
Age	1.070	1.021-1.122	0.005
Marital status	0.804	0.328-1.970	0.632
Educational level			0.103
Monthly household income			0.632
FIGO			0.752
Postoperative radiotherapy and chemotherapy	2.995	1.337-6.708	0.008
Chronic comorbidities	0.491	0.220-1.096	0.083
CBI	0.296	0.137-0.636	0.002

FIGO: International Federation of Gynecology and Obstetrics; CBI: Cognitive behavioral intervention; OR: Odds ratio; CI: Confidence interval.

DISCUSSION

This study indicates that targeted CBI can effectively reduce depressive symptoms, lower the incidence of postoperative depressive disorders, improve negative emotional states, and enhance treatment compliance and prognosis after cervical cancer surgery. The results suggest that CBI has both preventive and ameliorative effects on postoperative depressive disorders. After accounting for baseline confounding factors, multivariate logistic regression analysis reveals that CBI is a protective factor against postoperative depressive disorders, while older age and postoperative chemoradiotherapy are risk factors. These findings are generally consistent with previous domestic and foreign studies. Several foreign randomized controlled trials confirmed that CBI can markedly reduce anxiety and depression and boost the general quality of life in postoperative cervical cancer patients[10,11]. Domestic studies have also indicated that standardized CBI can correct irrational cognitions, relieve depressive symptoms, and improve psychological resilience and rehabilitation compliance[17,18].

Cancer and depression have a two-way interactive relationship, wherein they act as mutual predisposing factors[19]. Epidemiologically, depression significantly increases the risk of cancer, while the incidence of depressive disorders rises sharply during cancer treatment. Furthermore, depression aggravates disease progression and worsens prognosis[20,21]. Pathophysiologically, depression stimulates the hypothalamic-pituitary-adrenal axis, which triggers endocrine disorders and the massive release of pro-inflammatory cytokines, leading to systemic chronic inflammation[22-24]. These inflammatory mediators damage normal cellular DNA and promote carcinogenesis. They also exacerbate neuroinflammation and negative emotions, forming a vicious cycle[25,26]. Furthermore, depression-induced immunosuppression impairs immune surveillance, weakens the clearance of tumor cells by immune cells, and accelerates tumor progression. Conversely, cancer-related pain, inflammation, and treatment side effects further disrupt neuroendocrine function, amplifying negative emotions such as depression and hopelessness[27,28]. Therefore, relieving depressive symptoms and preventing depressive disorders are crucial for cancer patients.

CBI is a structured, short-term, goal-oriented evidence-based psychological intervention based on cognitive-behavioral interaction theory, with highly standardized procedures. Its clinical application encompasses mental disorders, psychological problems comorbid with physical diseases, and public health fields, and its effectiveness has been verified by numerous randomized controlled trials and real-world studies[29]. Its core process includes two parts: Cognitive restructuring and behavioral training. At the cognitive level, CBI blocks the generation of negative emotions at the source by guiding patients to correct erroneous thinking and rebuild rational cognitions[30]. At the behavioral level, it combines behavioral training, relaxation training to help patients relieve psychological pressure, and improve emotion regulation abilities[31]. Furthermore, CBI enhances patients’ sense of disease control and self-efficacy, reduces excessive worry about prognosis, lowers psychological stress responses, and regulates neuroendocrine function. Consequently, it can improve patients’ depressive states, helping them establish a positive rehabilitation mindset and meet physical and mental rehabilitation needs after surgery[32].

In conclusion, this study is based on real-world clinical data. It verifies that CBI can effectively relieve depressive symptoms and improve quality of life in patients after cervical cancer surgery. This intervention also markedly reduces the risk of depressive disorders. Psychological support is generally overlooked in routine gynecologic oncology practice. The findings of this study confirm the efficacy and necessity of CBI. They support integrating depression screening and CBI into routine follow-up protocols for patients with post-cervical cancer. This study also provides a reference for primary medical institutions to carry out psychological interventions.

This study has some limitations, including the inherent selection bias of a single-center retrospective design and lack of follow-up data on the long-term effects of CBI on emotional state, quality of life, and disease prognosis, making it impossible to evaluate long-term intervention benefits. Multicenter, prospective cohort studies with extended follow-up periods are needed to improve the comprehensive evaluation system of intervention benefits.

CONCLUSION

Standardized CBI can significantly reduce the risk of depressive disorders, alleviate depressive symptoms, and improve the remission rate in patients after cervical cancer surgery. The findings provide practical references for clinical psychological nursing, lay a foundation for further relevant research. This intervention is worthy of clinical application and promotion.