Wang FZ, Xu JS, Sun H, Wang XL, Huang Y. Association between illness perception and depression in colorectal cancer patients: Chain mediating effects of self-efficacy and post-traumatic growth. World J Psychiatry 2026; 16(6): 119401 [DOI: 10.5498/wjp.v16.i6.119401]
Corresponding Author of This Article
Ye Huang, FRCS, Deputy Director, Department of General Surgery, The First Affiliated Hospital of Jinzhou Medical University, No. 2 Section 5 Renmin Street, Guta District, Jinzhou 121000, Liaoning Province, China. huangy1@jzmu.edu.cn
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Wang FZ, Xu JS, Sun H, Wang XL, Huang Y. Association between illness perception and depression in colorectal cancer patients: Chain mediating effects of self-efficacy and post-traumatic growth. World J Psychiatry 2026; 16(6): 119401 [DOI: 10.5498/wjp.v16.i6.119401]
World J Psychiatry. Jun 19, 2026; 16(6): 119401 Published online Jun 19, 2026. doi: 10.5498/wjp.v16.i6.119401
Association between illness perception and depression in colorectal cancer patients: Chain mediating effects of self-efficacy and post-traumatic growth
Fu-Zhuo Wang, Ye Huang, Department of General Surgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou 121000, Liaoning Province, China
Jia-Shuang Xu, Department of Nursing, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
Hong Sun, Department of Nursing, Liaoning Cancer Hospital and Institute, Shenyang 110801, Liaoning Province, China
Xiu-Li Wang, Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou 121000, Liaoning Province, China
Author contributions: Wang FZ and Xu JS conceived and designed the research, and they are the co-first authors of this manuscript; Wang FZ wrote the paper; Wang FZ and Xu JS analyzed the data; Wang FZ, Xu JS, Sun H, Wang XL, and Huang Y revised the paper; all authors have read and approved the final manuscript.
Institutional review board statement: The study was reviewed and approved by the College of Nursing’s Research Committee at Jinzhou Medical University Institutional Review Board (approval No. JZMULL2023029), and all research methods strictly adhered to the principles of the Declaration of Helsinki.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at E-mail address: huangy1@jzmu.edu.cn.
Corresponding author: Ye Huang, FRCS, Deputy Director, Department of General Surgery, The First Affiliated Hospital of Jinzhou Medical University, No. 2 Section 5 Renmin Street, Guta District, Jinzhou 121000, Liaoning Province, China. huangy1@jzmu.edu.cn
Received: January 29, 2026 Revised: March 7, 2026 Accepted: April 10, 2026 Published online: June 19, 2026 Processing time: 122 Days and 2.3 Hours
Abstract
BACKGROUND
Illness perception is a known correlate of depression in cancer patients, yet the mechanisms explaining this association remain incompletely understood. Self-efficacy and post-traumatic growth represent two psychological resources that may explain the association between illness perceptions and depressive symptoms. Understanding these pathways could inform targeted interventions for colorectal cancer patients.
AIM
To investigate the mediating roles of self-efficacy and post-traumatic growth in the relationship between illness perception and depression among colorectal cancer patients.
METHODS
A cross-sectional study was conducted from May to November 2024 in two tertiary hospitals in Liaoning Province, China. A total of 290 colorectal cancer patients were recruited using multistage stratified sampling. Data were collected via questionnaires assessing demographic characteristics, illness perception (Brief Illness Perception Questionnaire), self-efficacy (General Self-Efficacy Scale), post-traumatic growth (Post-Traumatic Growth Inventory), and depression (Patient Health Questionnaire-9). Mediation analysis was performed using the PROCESS macro (model 6) with 5000 bootstrap samples.
RESULTS
Illness perception was positively associated with depression [β = 0.2575, 95% confidence interval (CI): 0.1827-0.3323]. Three significant mediating pathways were identified: (1) Via self-efficacy alone (β = 0.1099, 95%CI: 0.0700-0.1599), accounting for 27.47% of the total effect; (2) Via post-traumatic growth alone (β = 0.0275, 95%CI: 0.0014-0.0537), accounting for 6.80%; and (3) Via the sequential pathway of self-efficacy and post-traumatic growth (β = 0.0051, 95%CI: 0.0001-0.0122), accounting for 1.28%. The total indirect effect explained 35.63% of the variance.
CONCLUSION
Self-efficacy and post-traumatic growth mediate the relationship between illness perception and depression. Interventions targeting both cognitive appraisal and positive psychological growth may help mitigate depressive symptoms in this population.
Core Tip: This study reveals that self-efficacy and post-traumatic growth play a significant chain mediating role in the relationship between illness perception and depression among colorectal cancer patients. By enhancing patients’ self-efficacy and fostering post-traumatic growth, healthcare providers can effectively mitigate depressive symptoms, offering a dual-target intervention strategy that combines cognitive restructuring with psychological resource development.
Citation: Wang FZ, Xu JS, Sun H, Wang XL, Huang Y. Association between illness perception and depression in colorectal cancer patients: Chain mediating effects of self-efficacy and post-traumatic growth. World J Psychiatry 2026; 16(6): 119401
Colorectal cancer is one of the most prevalent and deadly malignant tumors globally, posing a serious threat to human health[1]. Although advances in medical technology have significantly improved survival rates for colorectal cancer patients, the disease and its treatment often present various challenges, including physical discomfort, functional impairment, and changes in appearance[2,3]. These challenges are related not only to patients’ physical health but also to their psychological well-being. Among the psychological difficulties reported by colorectal cancer patients, depression is particularly common[4,5]. Depression is a mood disorder characterized by persistent low mood[6], which has been linked to cognitive decline, increased risk of dementia, disability, and, in severe cases, suicide and death[7]. Therefore, understanding the factors associated with depression in colorectal cancer patients and their underlying mechanisms is of considerable importance.
Illness perception refers to how individuals assess and interpret their symptoms based on past experiences and knowledge when facing health threats, forming a personalized understanding of their condition[8]. This subjective cognition has been associated with how patients understand and respond to their illness, and has been identified as a factor related to self-management behaviors and depression in colorectal cancer patients[9]. Studies have found that positive illness perception is correlated with better treatment adherence and lower levels of depression[10,11]. In contrast, negative illness perception has been linked to poorer treatment adherence and higher levels of depression. Thus, illness perception may be a relevant factor in understanding depression among colorectal cancer patients.
Self-efficacy describes an individual's belief in their ability to perform a specific behavior, representing their cognitive assessment and evaluation of their behavioral capacity[12]. Omran and Mcmillan[13] reported that low self-efficacy is closely associated with the emergence of depression. Fisher et al[14] observed that individuals with low self-efficacy tend to exaggerate difficulties and adopt negative coping strategies, which have been linked to difficulty in achieving goals and depression. Phillips and McAuley[15] demonstrated that lower self-efficacy correlates with more severe depression. Furthermore, Alhofaian et al[16] found that illness perception among colorectal cancer patients serves as a risk factor for self-efficacy, exhibiting a negative correlation. Thus, self-efficacy may mediate the relationship between illness perception and depression in colorectal cancer patients.
Post-traumatic growth refers to positive psychological changes that may occur as individuals reflect on and process traumatic events[17]. Arefian and Asgari-Mobarakeh[18] reported that higher levels of post-traumatic growth are associated with reduced emotional inhibition, lower anxiety, and fewer depressive symptoms. Li et al[19] found that post-traumatic growth is related to psychological resilience and has been linked to better coping with disease-related stress. Conversely, Peng et al[20] observed that lower levels of post-traumatic growth are correlated with diminished meaning in life and more severe anxiety and depression. Furthermore, Bayraktar and Ozkan[21] reported that negative illness perception is associated with lower levels of post-traumatic growth. These findings suggest a close relationship among post-traumatic growth, illness perception, and depression in colorectal cancer patients. However, research examining whether post-traumatic growth mediates the relationship between illness perception and depression in colorectal cancer patients remains relatively limited.
Furthermore, according to social cognitive theory, self-efficacy plays an important role in how individuals cope with traumatic events and adapt psychologically[22]. Individuals with higher self-efficacy tend to manage disease symptoms more effectively and adapt to lifestyle changes, and have been found to report higher levels of post-traumatic growth[23]. In contrast, individuals with low self-efficacy may lack confidence in overcoming challenges and have been shown to report lower levels of post-traumatic growth[24]. Patients with lower levels of post-traumatic growth may be more likely to interpret disease-related events as purely negative, which has been associated with depressive symptoms[25]. Furthermore, Shim et al’s research indicated that illness perception is associated with self-efficacy[26].
Based on the above analysis, self-efficacy and post-traumatic growth may have a chain mediating effect on the relationship between illness perception and depression in colorectal cancer patients. Therefore, we proposed three hypotheses to construct the research model (Figure 1). First, we hypothesized that self-efficacy mediates the relationship between illness perception and depression (H1). Second, we hypothesized that post-traumatic growth mediates the relationship between illness perception and depression (H2). Third, we hypothesized that self-efficacy and post-traumatic growth have a chain mediating effect on the relationship between illness perception and depression (H3).
This study employed a cross-sectional design with a multistage stratified sampling method. The sampling procedure was as follows: Stage 1: A list of tertiary grade A hospitals in Liaoning Province was reviewed. Based on hospital size, oncology specialization, and patient volume, two hospitals were randomly selected: Jinzhou Medical University Affiliated Hospital and Dalian University of Technology Affiliated Cancer Hospital; Stage 2: Within each selected hospital, all departments involved in colorectal cancer diagnosis and treatment were identified. These departments were stratified by clinical focus and patient volume, and then randomly selected from each stratum; Stage 3: Colorectal cancer patients were randomly selected from each participating department. The sample size was calculated using GPower 3.1 software[27]. Based on the hypothesized chain mediation model, a total of 11 predictor variables were included (eight demographic variables, illness perception, self-efficacy, and post-traumatic growth). Following Cohen’s criteria[28], a medium effect size (f2 = 0.15) was specified, with a significance level of α = 0.05 and a target power of 0.95. The analysis indicated that a minimum of 178 participants was required. To account for an anticipated attrition rate of 10%-15%, the target sample size was increased to approximately 300 participants. A total of 319 questionnaires were distributed, and 290 valid responses were obtained (159 from the Affiliated Cancer Hospital of Dalian University of Technology and 131 from the Affiliated Hospital of Jinzhou Medical University), yielding a response rate of 90.91%. The final sample size substantially exceeded the minimum requirement, ensuring adequate statistical power and robustness of the results. The inclusion criteria were: (1) Clinically and pathologically confirmed colorectal cancer; (2) Willingness to participate with informed consent; (3) Clear consciousness and adequate communication skills; and (4) Age ≥ 18 years. The exclusion criteria were: (1) Severe illness preventing participation; (2) Expected survival < 6 months; (3) Cognitive impairment or psychiatric disorders; (4) Prior psychological interventions that could influence the results; and (5) Patients unaware of their diagnosis.
Before data collection, all investigators received standardized training on the use of assessment scales and communication techniques. Questionnaires were then administered to eligible colorectal cancer patients at the two participating hospitals. Researchers explained the purpose, procedures, and significance of the study to patients and their families, provided instructions for completing the questionnaire, and obtained informed consent. Participants completed the questionnaires independently. For those with limited literacy or writing difficulties, researchers assisted with verbal communication. Upon completion, the questionnaires were reviewed immediately for completeness and accuracy, and any necessary clarifications were made with the participants. The average time to complete the questionnaire was 9-16 minutes. All procedures were conducted in accordance with the principles of the Declaration of Helsinki.
Instruments
General information questionnaire: Sociodemographic information collected included age, gender, smoking status, drinking status, economic situation, primary caregiver, religious beliefs, and household registration.
Illness Perception Scale: The Illness Perception Scale was developed by Broadbent et al[29] in 2006. It consists of nine items across three dimensions: Illness cognition (items 1-5), affect (items 6 and 8), and comprehension (item 7). Item 9 is an open-ended question about perceived causes of the illness and is not included in the total score. The first eight items are rated on an 11-point scale ranging from 0 to 10, with items 3, 4, and 7 reverse-scored. Total scores range from 0 to 80, with higher scores indicating more negative illness perceptions, greater symptom burden, and a higher perceived threat to personal health. In the present study, the scale demonstrated a Cronbach’s α of 0.752 and a Kaiser-Meyer-Olkin (KMO) value of 0.713.
Self-Efficacy Scale: The Self-Efficacy Scale was developed by Gandoy-Crego et al[30] in 1992 and has been widely used across different cultural contexts. The scale consists of 10 items measuring a single dimension of general self-efficacy. Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with total scores ranging from 10 to 50. Higher scores indicate greater self-efficacy, with scores < 25 suggesting low self-efficacy, 25-37 moderate self-efficacy, and > 37 high self-efficacy. In the present study, the scale demonstrated a Cronbach’s α of 0.935 and a KMO value of 0.936.
Post-Traumatic Growth Inventory: The Post-Traumatic Growth Inventory was developed by Tedeschi and Calhoun[31] in 1996 and is a widely used instrument for assessing positive psychological changes following traumatic events. The scale consists of 20 items across five domains: Appreciation of life (items 2, 5, 11, 13, 15, and 19), personal strength (items 10, 12, and 18), new possibilities (items 9, 14, 16, and 17), relating to others (items 6, 8, and 20), and spiritual change (items 1, 3, 4, and 7). Each item is rated on a 6-point Likert scale ranging from 0 (not at all) to 5 (to a great extent). Total scores range from 0 to 100, with higher scores reflecting greater post-traumatic growth. In the present study, the scale demonstrated a Cronbach’s α of 0.859 and a KMO value of 0.820.
Depression Scale: The Patient Health Questionnaire-9, developed by Kroenke et al[32] in 2001, was used to assess depressive symptoms. The measure consists of nine items rated on a 4-point scale, with scores for each item ranging from 0 (never) to 3 (nearly every day). Total scores range from 0 to 27, with higher scores indicating greater depression severity. Based on the total score, depressive severity is categorized as follows: 0-4, no depression; 5-9, mild depression; 10-14, moderate depression; and 15 or higher, severe depression. In the present study, the scale demonstrated a Cronbach’s α of 0.875 and a KMO value of 0.891.
Statistical analysis
Data were analyzed using IBM SPSS Statistics (version 25.0) and the PROCESS macro (version 3.5) for mediation analysis. First, descriptive statistics (frequencies, percentages, means, and standard deviations) were calculated for all study variables. Second, independent samples t-tests and one-way analysis of variance were conducted to examine differences in depression scores across demographic subgroups. Third, Pearson correlation coefficients were computed to assess bivariate associations among the main study variables. Finally, mediation analysis was performed using PROCESS model 6 with 5000 bootstrap samples to generate 95% bias-corrected confidence intervals (CIs). A mediation effect was considered statistically significant if the 95%CI did not include zero. All statistical tests were two-tailed, with a significance level set at α = 0.05.
RESULTS
Characteristics of participants
Table 1 presents the demographic characteristics of the sample and the results of univariate analyses of depression scores across subgroups. The study sample consisted of 290 colorectal cancer patients, including 149 males (51.4%) and 141 females (48.6%). Participants’ ages ranged from 19 years to 90 years, with a mean age of 59.58 ± 13.09 years. Of the participants, 28.3% were smokers and 29.3% were drinkers. Depression scores differed significantly by age, gender, and primary caregiver. To ensure analytical accuracy, these variables were controlled for as potential confounders in subsequent mediation analyses.
Table 1 Participant characteristics and univariate analysis of depression (n = 290).
Pearson’s correlation analysis revealed that illness perception was negatively correlated with both self-efficacy and post-traumatic growth, and positively correlated with depression (P < 0.01). Additionally, self-efficacy was positively correlated with post-traumatic growth and negatively correlated with depression, and post-traumatic growth was negatively correlated with depression (P < 0.01; Table 2).
As shown in Table 3, after controlling for confounding factors such as age, gender, and primary caregiver, model 6 of the PROCESS macro (Hayes) was used to examine the mediating effects of self-efficacy and post-traumatic growth on the relationship between illness perception and depression. Results revealed that illness perception was positively associated with depression (B = 0.257, P < 0.001). After incorporating self-efficacy and post-traumatic growth as mediating variables into the model, the direct association between illness perception and depression remained significant (B = 0.400, P < 0.001). Further path analysis revealed that illness perception was negatively associated with both self-efficacy (B = -0.450, P < 0.001) and post-traumatic growth (B = -0.578, P < 0.001), while being positively associated with depression (B = 0.257, P < 0.001). Self-efficacy was positively associated with post-traumatic growth (B = 0.235, P < 0.01) and negatively associated with depression (B = -0.243, P < 0.01); post-traumatic growth was negatively associated with depression (B = -0.047,P < 0.05).
Table 3 Regression analysis of the mediation model.
Bootstrap sampling with 5000 resamples was used to test the mediating effects and calculate 95%CIs (Figure 2 and Table 4). The results were as follows: (1) Mediating effect of self-efficacy: The 95%CI did not include zero, indicating a significant mediating effect. The indirect effect was 0.1099, accounting for 27.47% of the total effect. Hypothesis 1 was supported; (2) Mediating effect of post-traumatic growth: The 95%CI did not include zero, indicating a significant mediating effect. The indirect effect was 0.0275, accounting for 6.80% of the total effect. Hypothesis 2 was supported; and (3) Serial mediation via self-efficacy and post-traumatic growth: The 95%CI did not include zero, confirming a significant serial mediating effect. The indirect effect was 0.0051, accounting for 1.28% of the total effect. Hypothesis 3 was supported.
This study revealed a significant positive correlation between illness perception and depression among colorectal cancer patients (B = 0.257, P < 0.001), which is consistent with previous studies[33]. Colorectal cancer patients with negative illness perceptions viewing their disease as uncontrollable, highly threatening, or severe were more likely to report depressive symptoms[34,35]. This finding suggests that illness perception may serve as an important psychological assessment indicator in the clinical care of colorectal cancer patients. Early identification of maladaptive illness perceptions, coupled with targeted psychological support and health education, may be beneficial in addressing depressive symptoms in this population.
Self-efficacy partially mediated the relationship between illness perception and depression (indirect effect = 0.1099, 95%CI: 0.0700-0.1599), accounting for 27.47% of the total effect. Colorectal cancer and its treatment are often accompanied by symptoms such as abdominal pain, changes in bowel habits, bloody stools, weight loss, and fatigue. These persistent physical discomforts were closely associated with patients’ negative illness perceptions[36]. Negative perceptions were positively correlated with feelings of helplessness when patients faced treatment-related challenges such as nausea, vomiting, pain, fatigue, and stoma care. This was related to lower levels of self-efficacy[37], with reduced self-efficacy associated with diminished treatment motivation and decreased disease management ability. These factors were further linked to increased risks of tumor recurrence and postoperative complications, and may interact with negative cognitions in relation to depressive symptoms[38]. Therefore, psychological interventions for colorectal cancer patients should consider both illness perception and self-efficacy enhancement.
Post-traumatic growth also played a significant mediating role in the relationship between illness perception and depression (indirect effect = 0.0275, 95%CI: 0.0014-0.0537), explaining 6.80% of the total effect. Nearly all colorectal cancer patients in this sample reported some degree of negative illness perception[39]. Patients who perceived their disease as highly threatening found it more difficult to derive positive meaning from their illness experience, which was associated with lower levels of post-traumatic growth[40-42]. Patients with lower levels of post-traumatic growth often experienced difficulty engaging in effective cognitive restructuring and meaning construction, making it harder for them to draw strength from disease-related challenges. This was associated with depressive symptoms such as pessimism, anhedonia, and feelings of worthlessness[43]. Therefore, promoting post-traumatic growth may be a valuable component of psychological interventions for colorectal cancer patients. Approaches such as meaning therapy and narrative nursing may help patients reconstruct life meaning from their illness experience.
Furthermore, this study identified a significant chain mediating effect of self-efficacy and post-traumatic growth in the relationship between illness perception and depression among colorectal cancer patients (indirect effect = 0.0051, 95%CI: 0.0001-0.0122), accounting for 1.28% of the total effect. This finding is consistent with Lazarus and Folkman’s Transactional Model of Stress and Coping[44]. Within this theoretical framework, illness perception represents an individual’s primary appraisal of stress, determining whether the disease is perceived as a threat, challenge, or loss. Self-efficacy constitutes a secondary appraisal, reflecting an individual’s judgment of their coping abilities and is associated with the selection and implementation of coping strategies. Post-traumatic growth represents a positive psychological transformation that may emerge following successful coping with stress, while depression reflects a negative emotional response that may occur when individuals persistently appraise stress as threatening and perceive their coping resources as insufficient. Specifically, patients with negative illness perception in this study tended to report higher psychological stress and lower self-efficacy[45]. This state was associated with lower levels of post-traumatic growth[46]. Patients with lower levels of post-traumatic growth appeared more vulnerable to being overwhelmed by the negative impacts of their disease, showing a significant association with depression[47,48].
Limitations
Several limitations of this study should be noted. First, the cross-sectional design precludes causal inferences regarding the associations among illness perception, self-efficacy, post-traumatic growth, and depression. Although mediation analysis was conducted based on theoretical assumptions, longitudinal or interventional studies are needed to confirm the temporal relationships among these variables. Second, all data were collected via self-report questionnaires, which may be subject to recall bias. Future research could incorporate clinician-rated assessments or objective measures to enhance data validity. Third, this study did not assess clinical characteristics potentially related to depression, such as pathological stage, treatment type (surgery, chemotherapy, and radiotherapy), time since diagnosis or surgery, and stoma status. The absence of these factors may, to some extent, limit the comprehensiveness of our findings. Therefore, future studies should incorporate these clinical variables to further explore their potential role in the observed associations.
Implications
This study offers preliminary insights into the factors associated with illness perception and depression in colorectal cancer patients, providing both theoretical and practical implications. Based on these findings, several strategies may be considered in clinical practice. First, customized disease cognition and psychological adjustment programs including counseling and psychoeducation may be useful for patients in understanding and coping with psychological stress and emotional fluctuations during treatment. Such approaches have been linked to modifications in negative or catastrophic perceptions of the disease and may be associated with more adaptive illness perceptions[49]. Second, comprehensive psychological interventions such as cognitive behavioral therapy, narrative therapy, or positive psychology interventions are related to the development of self-efficacy and post-traumatic growth[50,51]. Additionally, encouraging patients to engage in social activities, strengthen interactions with family and friends, and establish supportive networks may be associated with an enhanced sense of belonging and coping capacity, which has been linked to more adaptive illness perceptions[52]. Such integrated interventions may be related to reduced negative illness perception, enhanced self-efficacy and post-traumatic growth, and improved depression among colorectal cancer patients.
CONCLUSION
This study examined the associations among illness perception, self-efficacy, post-traumatic growth, and depression in colorectal cancer patients. Illness perception was positively associated with depression, partially accounted for by self-efficacy and post-traumatic growth, with a total indirect effect of 35.63%. Given the prevalence of depressive symptoms, multidimensional psychosocial approaches may be considered. Self-efficacy and post-traumatic growth were related to the illness perception-depression link. Healthcare providers may consider assessing these factors and developing targeted support strategies for patients with low self-efficacy and limited post-traumatic growth.
ACKNOWLEDGEMENTS
We express our great gratitude to the participants in the study.
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