Anxiety, depression, psychological resilience, and illness uncertainty in lung cancer patients undergoing thoracoscopic surgery: Correlations and associated factors

Abstract

BACKGROUND

Patients with lung cancer (LC) undergoing thoracoscopic surgery, or video-assisted thoracic surgery (VATS), may experience different degrees of anxiety or depression, which are not conducive to clinical management or smooth postoperative recovery.

AIM

To explore the correlations of anxiety and depression with psychological resilience and illness uncertainty in VATS-treated patients with LC and to analyze their influencing factors.

METHODS

A total of 297 patients with LC undergoing VATS were enrolled from January 2022-October 2025. Data on the Self-Rating Anxiety/Depression Scale (SAS/SDS), Connor-Davidson Resilience Scale (CD-RISC), Mishel Uncertainty in Illness Scale (MUIS), and clinical characteristics were collected. Pearson’s correlation analysis was used to assess the associations of SAS and SDS scores with CD-RISC and MUIS scores. Determinants associated with anxiety and depression were also investigated.

RESULTS

Among the cohort, 39.06% and 42.09% of the patients experienced anxiety and depression, respectively, mostly with mild symptoms. The mean CD-RISC score was 46.67 ± 8.11, and the MUIS score was 83.98 ± 9.45. Correlation analysis showed that anxiety and depression in VATS-treated LC patients correlated negatively with psychological resilience but positively with illness uncertainty, while psychological resilience correlated negatively with illness uncertainty. Univariate and multivariate analyses identified preoperative forced expiratory volume in one second as a percentage of the predicted value (FEV1%), clinical staging, educational level, monthly household income (MHI), psychological resilience, and illness uncertainty as independent correlates of anxiety or depression in patients with LC undergoing VATS.

CONCLUSION

Patients with LC undergoing VATS commonly experience preoperative anxiety and depression. These psychological states are significantly associated with levels of resilience and illness uncertainty. In addition, preoperative FEV1%, clinical staging, educational level, MHI, psychological resilience, and illness uncertainty are independent predictors of anxiety or depression in these patients.

Key Words: Thoracoscopic surgery (video-assisted thoracic surgery) for lung cancer; Anxiety; Depression; Psychological resilience; Illness uncertainty

Core Tip: This study included 297 patients undergoing thoracoscopic surgery for lung cancer and investigated the correlations of anxiety and depression with psychological resilience and illness uncertainty while identifying influencing factors. Analyses of clinical data revealed that preoperative anxiety and depression correlated negatively with psychological resilience and positively with illness uncertainty. Forced expiratory volume in one second as a percentage of the predicted value < 70%, clinical staging, educational level, monthly household income, psychological resilience, and illness uncertainty independently influenced anxiety or depression development. Clinically, psychological interventions should be provided preoperatively for patients with these factors to enhance psychological resilience, reduce illness uncertainty, and relieve adverse emotional states.

INTRODUCTION

Globally, lung cancer (LC) ranks among malignancies with the highest incidence and fatality rates. Although its incidence has declined in some regions, LC remains a prime reason for cancer-related deaths[1]. Its risk determinants include smoking, genetic susceptibility, immunodeficiencies, professional risks, air pollution, chronic lung illnesses, etc.[2]. Thoracoscopic surgery, or video-assisted thoracic surgery (VATS), is preferred for managing LC due to reduced trauma and faster postoperative recovery compared with traditional thoracotomy[3]. Treatment optimization for enhancing LC patients’ survival outcomes is required, despite continuously improved therapeutic strategies[4]. Beyond pain, fatigue, and dyspnea, common symptoms in LC patients, psychological distress (e.g., anxiety, depression, worry, and fear) triggered by inadequately addressed needs during postoperative recovery is also prevalent[5]. Being common adverse moods, anxiety and depression often lead to quality of life declines and increased mortality risk. Timely identifying and managing such conditions is therefore essential for improving overall clinical outcomes[6,7]. Resilience, a dynamic resource that psychologically enables active handling and adaptation to adverse events (trauma, stress, difficulties, etc.), help maintain psychological well-being[8]. In oncological practice, high-level resilience generally suggests great capacity in regulating emotions and alleviating psychological distress, as well as improved compliance[9]. Illness uncertainty is a cognitive state in which individuals feel that they can not control the illness. The common manifestations are difficulties in understanding or predicting the meanings, outcomes, and significance of illness-related events[10]. Cancer patients are often predisposed to a strong sense of illness uncertainty and thus develop a heavy psychological burden due to the difficulty in early disease detection and control caused by relatively hidden progression of the lesion[11].

However, how anxiety and depression correlate with resilience and illness uncertainty in VATS-treated LC patients need further elucidation. By exploring and validating these associations, this study offers novel perspectives for enhancing LC patients’ physical and psychological health.

MATERIALS AND METHODS

Case selection

To be included, patients need to meet all of the following criteria: (1) Being 18-80 years old; (2) Undergoing VATS at our institution (January 2022-October 2025); (3) Confirmed LC by postoperative histopathological examination[12]; and (4) Clinical data completeness. Meeting any of the criteria below means exclusion: (1) Severe organ failure; (2) Other malignancies; (3) Pregnancy or lactation; and (4) History of depression/anxiety or other mental illnesses. 297 VATS-treated LC patients (January 2022-October 2025) were enrolled. Figure 1 shows the patient selection process.

Figure 1  Flowchart of patient selection.

Survey methods

An anonymous questionnaire survey method was adopted. Before surveying, the survey purpose and questionnaire filling requirements were explained. The patients were required to complete the questionnaire independently the day before surgery. Assistance was provided by the investigators for those suffering from dyslexia. Following about 45 minutes of filling, questionnaire checking and on-site recovery were conducted. All survey questionnaires were collected on the same day.

Data collection and outcome measures

We gathered the participants’ clinical data through the hospital’s electronic medical record system.

General demographics: Sex, age, education level (senior high school or below vs junior college or above), and monthly household income (MHI in RMB; < 15000 vs ≥ 15000) were collected. A higher education background, as indicated by the Chinese education system standards and commonly used grouping methods in health literacy research, referred to having a college degree or above. The cut-off for of 15000 RMB was used for MHI to stratify patients into high- vs middle-low income groups.

Clinical data: Preoperative hospitalization, surgical technique (thoracoscopic wedge resection, thoracoscopic segmentectomy, or thoracoscopic lobectomy/pneumonectomy), tumor TNM staging (0-I vs II/above), and preoperative forced expiratory volume in one second as a percentage of the predicted value (FEV1%) were assessed.

Anxiety and depression: The assessments were conducted using the Self-Rating Anxiety/Depression Scale (SAS/SDS)[13], both with 20 items. By first summing all item scores to obtain a raw score and then multiplying it by 1.25, the standard score was computed, and the integer part was used (0-100 scale). The scores of both tools are proportional to symptom severity. The SAS score interpretation is < 50 for none, 50-59 for mild, 60-69 for moderate, and ≥ 70 for severe anxiety. Corresponding SDS (depression) cutoffs are < 53, 53-62, 63-72, and ≥ 73. The Chinese-version scales (Cronbach’s α = 0.87 for SAS and 0.86 for SDS) exhibit good reliability and validity in the Chinese population.

Psychological resilience: Preoperatively (day-1), patients were assessed for tenacity (13 items), strength (8 items), and optimism (4 items) using the 25-item Connor–Davidson Resilience Scale (CD-RISC)[14], each rated on 5-point Likert scale ranging from 0 (“never”) to 4 (“almost always”). Stronger resilience is reflected in higher total scores (maximum 100; < 56 weak resilience; 57-70, normal resilience; > 70 strong resilience). The Chinese-version tool is widely used in domestic patient populations due to its sound reliability and validity (coefficient α = 0.91).

Illness uncertainty: The assessment was conducted from ambiguity (13 items), complexity (8 items), inconsistency (7 items), and unpredictability (5 items) dimensions with the Mishel Uncertainty in Illness Scale (MUIS). Given that the 15^th item is used for calibration, it is excluded from scoring. With the remaining 32 items (1-5 points each), the total score ranges from 32 to 160. The score is positively related to the illness uncertainty level, which is classified as low (32-74.7), moderate (74.8-117.4), or high (117.5-160.0). The good reliability and validity of the Chinese-version MUIS is demonstrated by a Cronbach’s α of 0.87.

Statistical analysis

For measurement data, normality testing with the Shapiro-Wilk test was performed first. The mean ± SD was used for statistical description and the independent-samples t-tests for between-group comparisons for variables of Gaussian distribution; when normal distribution was violated, data were shown as the median (interquartile range) and underwent Mann-Whitney U testing.

For categorical variables presented as n (%), comparative assessments were performed using χ² tests. SPSS (v27.0) was the tool utilized for statistical data analyses. SAS/SDS-CD-RISC/MUIS associations were examined using Pearson’s r. Anxiety/depression-associated predictors were explored using univariate and multivariate analyses (binary logistic regression). Preceding multivariate analysis, collinearity diagnostics assessed multicollinearity among independent variables. All variables exhibited no significant multicollinearity, evidenced by a variance inflation factor (VIF) below 10. Model calibration assessment (goodness of fit) used the Hosmer–Lemeshow test, with good fitting indicated by P values > 0.05 between model-predicted probabilities and observed outcomes. Finally, receiver operating characteristic plotting and area under the curve (AUC) calculation were carried out for model discrimination evaluation. The resultant AUC was > 0.7, indicating acceptable model discrimination. A two-sided P value < 0.05 was considered statistically significant.

RESULTS

Anxiety and depression prevalence among VATS-treated LC patients

Evaluation of 297 VATS-treated LC patients using the SAS (anxiety) and SDS (depression) showed mean scores of 47.49 ± 7.86 and 50.49 ± 8.51 points, respectively. Among them, 181 patients were classified as non-anxious and 172 as depression-free, while those affected by either condition mostly experienced mild symptoms. Overall, 62.96% of the cohort experienced either condition, whereas 18.18% suffered from both (Figure 2 and Table 1).

Figure 2 Anxiety and depression distribution in surgically-treated lung cancer patients. A: Percentage of lung cancer surgery patients with different anxiety levels; B: Proportional distribution of different depression levels.

Table 1 Psychological symptom severity in lung cancer surgery patients.

Indicators	n (%)
Anxiety	116 (39.06)
Depression	125 (42.09)
Anxiety or depression	187 (62.96)
Anxiety + depression	54 (18.18)

Psychological resilience of the patient cohort

The CD-RISC-based evaluation of psychological resilience in VATS-treated LC patients is presented in Table 2. The cohort’s overall resilience score averaged 46.67 ± 8.11 points, with domain scores of 30.00 (26.50-35.00) points for tenacity, 9.00 (6.00-11.00) points for strength, and 8.00 (6.00-10.00) points for optimism.

Table 2 Psychological resilience of lung cancer surgery patients, mean ± SD/median (interquartile range).

Indicators	Score
Tenacity (points)	30.00 (26.50-35.00)
Strength (points)	9.00 (6.00-11.00)
Optimism (points)	8.00 (6.00-10.00)
CD-RISC (points)	46.67 ± 8.11

CD-RISC: Connor-Davidson Resilience Scale.

Illness uncertainty among VATS-treated LC patients

Illness uncertainty was assessed using the MUIS (Table 3). The total score averaged 83.98 ± 9.45 points. Dimension scores were as follows: Ambiguity (35.40 ± 6.18) points, complexity (19.09 ± 4.45) points, inconsistency 16.00 (14.00-19.00) points, and unpredictability 13.00 (10.00-16.00) points.

Table 3 Mishel Uncertainty in Illness Scale domain scores for illness uncertainty, mean ± SD/median (interquartile range).

Indicators	Score
Ambiguity (points)	35.40 ± 6.18
Complexity (points)	19.09 ± 4.45
Inconsistency (points)	16.00 (14.00-19.00)
Unpredictability (points)	13.00 (10.00-16.00)
MUIS (points)	83.98 ± 9.45

MUIS: Mishel Uncertainty in Illness Scale.

Anxiety/depression correlations with psychological resilience and illness uncertainty

To examine the potential relationships between anxiety, depression, psychological resilience, and illness uncertainty in VATS-treated LC patients, Pearson correlation analysis was conducted (Figure 3 and Table 4). SAS and SDS scores correlated negatively with CD-RISC scores (P < 0.001) but positively with MUIS scores (P < 0.001). Additionally, CD-RISC and MUIS scores were negatively correlated (P < 0.001).

Figure 3 Correlation analysis of anxiety and depression with psychological resilience and illness uncertainty. A: Self-Rating Anxiety Scale (SAS)-Connor-Davidson Resilience Scale correlation (CD-RISC); B: Self-Rating Depression Scale (SDS)-CD-RISC; C: SAS-Connor-Davidson-Mishel Uncertainty in Illness Scale (MUIS) correlation; D: SDS-Connor-Davidson-MUIS correlation; E: CD-RISC-MUIS correlation. Pearson correlation coefficients are used for correlation analyses. SAS/SDS: Self-Rating Anxiety/Depression Scale; CD-RISC: Connor-Davidson Resilience Scale; MUIS: Mishel Uncertainty in Illness Scale.

Table 4 Correlations among anxiety, depression, psychological resilience, and illness uncertainty.

Indicators	r	P value
SAS (points) vs CD-RISC (points)	-0.334	< 0.001
SDS (points) vs CD-RISC (points)	-0.435	< 0.001
SAS (points) vs MUIS (points)	0.457	< 0.001
SDS (points) vs MUIS (points)	0.394	< 0.001
CD-RISC (points) vs MUIS (points)	-0.321	< 0.001

Correlations are evaluated by Pearson correlation coefficients. SAS/SDS: Self-Rating Anxiety/Depression Scale; CD-RISC: Connor-Davidson Resilience Scale; MUIS: Mishel Uncertainty in Illness Scale.

Predictors of anxiety or depression in VATS-treated LC patients

Univariate analysis showed that sex, age, preoperative hospitalization, and surgical technique has limited effects on anxiety or depression in VATS-treated LC patients (P > 0.05). Conversely, preoperative FEV1% < 70%, tumor staging, educational level, MHI, CD-RISC score, and MUIS score were significant correlates (P < 0.05). Further multivariate analysis indicated that educational level, MHI, and CD-RISC score served as protective factors for anxiety or depression, whereas preoperative FEV1% < 70%, tumor staging, and MUIS score were risk factors.

Multicollinearity diagnostics showed that VIF values for all independent variables was 1.006-1.013, indicating no serious multicollinearity. The Hosmer-Lemeshow test yielded a χ² value of 4.295 (degree of freedom = 7, P = 0.745), demonstrating good model fit. Furthermore, the binary logistic regression model showed an AUC of 0.704 (P < 0.001), suggesting significant and acceptable discrimination ability (Tables 5 and 6).

Table 5 Preliminary screening of anxiety or depression-associated factors using univariate analysis, n (%)/median (interquartile range).

Indicators	Anxiety/depression (n = 187)	Non-anxiety/depression (n = 110)	χ2/Z	P value
Sex			0.046	0.830
Male	84 (44.92)	48 (43.64)
Female	103 (55.08)	62 (56.36)
Age (years)	54.00 (45.00-63.00)	52.00 (43.00-64.25)	-0.351	0.725
Preoperative hospital stay (day)	5.00 (4.00-5.00)	5.00 (4.00-6.00)	-0.547	0.584
Surgical technique			2.970	0.227
Thoracoscopic wedge resection	81 (43.32)	59 (53.64)
Thoracoscopic segmentectomy	57 (30.48)	27 (24.55)
Thoracoscopic lobectomy or pneumonectomy	49 (26.20)	24 (21.82)
Preoperative FEV1% < 70%	51 (27.27)	15 (13.64)	7.451	0.006
Tumor staging			4.548	0.033
0-I	115 (61.50)	81 (73.64)
II or above	72 (38.50)	29 (26.36)
Educational level			10.273	0.001
Senior high school or below	142 (75.94)	64 (58.18)
Junior college or above	45 (24.06)	46 (41.82)
Monthly household income (RMB)			6.032	0.014
< 15000	127 (67.91)	59 (53.64)
≥ 15000	60 (32.09)	51 (46.36)
CD-RISC (points)			6.621	0.010
< 47	102 (54.55)	43 (39.09)
≥ 47	85 (45.45)	67 (60.91)
MUIS (points)			4.994	0.025
< 84	82 (43.85)	63 (57.25)
≥ 84	105 (56.15)	47 (42.73)

FEV1%: The preoperative forced expiratory volume in one second as a percentage of the predicted value; CD-RISC: Connor-Davidson Resilience Scale; MUIS: Mishel Uncertainty in Illness Scale.

Table 6 Multivariate analysis of independent predictors of anxiety or depression.

Indicators	B	Standard error	Wald	P value	Exp (B)	95%CI for EXP (B)
Preoperative FEV1% < 70%	0.855	0.337	6.420	0.011	2.351	1.214-4.556
Tumor staging	0.567	0.280	4.111	0.043	1.763	1.019-3.050
Educational level (senior high school or below = 0, junior college or above = 1)	-0.935	0.276	11.519	0.001	0.392	0.229-0.674
Monthly household income (RMB; < 15000 = 0, ≥ 15000 = 1)	-0.591	0.262	5.082	0.024	0.554	0.331-0.926
CD-RISC (points; < 47 = 0, ≥ 47 = 1)	-0.588	0.260	5.130	0.024	0.555	0.334-0.924
MUIS (points; < 84 = 0, ≥ 84 = 1)	0.623	0.261	5.695	0.017	1.864	1.118-3.109

FEV1%: The preoperative forced expiratory volume in one second as a percentage of the predicted value; CD-RISC: Connor-Davidson Resilience Scale; MUIS: Mishel Uncertainty in Illness Scale.

DISCUSSION

Although many VATS-treated LC patients benefit from surgery, they may still experience declines in physical function, deterioration in quality of life, treatment-related adverse reactions, and increased negative emotions[15,16]. Therefore, continued optimization of patient management remains necessary. This study was conducted to explore this issue and provide relevant findings.

In this study, the mean SAS score among the 297 patients undergoing VATS for LC was 47.49 ± 7.86 points, and the mean SDS score was 50.49 ± 8.51 points. The prevalence of anxiety and depression was 39.06% and 42.09%, respectively. Moreover, comorbid anxiety and depression were observed in 18.18% of the cohort, accounting for 28.88% of all patients with emotional disorders. This finding suggest that more than one-quarter of patients with emotional disorders experience anxiety–depression comorbidity, potentially predisposing them to more severe dysfunction and poorer treatment compliance[17]. Consequently, screening for comorbidity should be incorporated into routine preoperative evaluation, and intensive psychological interventions, such as cognitive behavioral therapy or mindfulness training, may help support postoperative recovery. Previous studies have reported a 30.00%-50.00% risk of anxiety or depression among post-surgical NSCLC patients, corroborating our findings[18]. Thi Ngoc Han et al[19] reported a depression incidence of 44.50% and an anxiety prevalence of 38.00% among chemotherapy-treated LC patients, similar to our results. In surgically treated LC patients, these adverse emotional states may be influenced by disease progression, aggravated pain, treatment complications, and reduced psychological resilience[20,21].

Subsequent resilience assessment showed an overall CD-RISC score of 46.67 ± 8.11 points, which was lower than the predefined threshold for weak psychological resilience, indicating insufficient overall psychological resources in this cohort. VATS-treated LC patients often face multiple stressors, including diagnosis-related trauma, surgical stress, and prognostic uncertainty, resulting in obvious exhaustion of their psychological resources. Consequently, early identification and the provision of psychological and social support are therefore essential to prevent further deterioration. This systematic depletion of psychological resources was reflected in the imbalance across the three resilience dimensions: The strength dimension was the most affected, with a score rate of only 28.1%, indicating markedly reduced self-efficacy in coping with illness-related stress. The optimism dimension, with a score rate of 50.0%, also showed severe damage, suggesting generally pessimistic expectations regarding prognosis and surgical outcomes. In contrast, the tenacity dimension was relatively preserved (57.7%), indicating that although patients continued to struggle and persist, they might still be prone to collapse instantly when confronted with postoperative pain or complications. Given these observations, targeted and individualized psychological empowerment should be incorporated into preoperative psychological interventions. Patients with insufficient strength may benefit from strategies aimed at rebuilding self-efficacy, such as sharing successful treatment experiences and providing immediate feedback during respiratory function training. For those with diminished optimism, approaches such as cognitive restructuring or hope-based therapy can be adopted. For individuals with low tenacity scores, strengthening goal-setting and sense-of-control training may be helpful. The resilience score observed in this study is lower than the postoperative value of 57.18 ± 8.55 points reported by Chen et al[22] in NSCLC patients. This difference is possibly because the present study evaluated the preoperative CD-RISC score rather than the postoperative value. Patients undergoing LC surgery often experience greater psychological distress preoperatively than postoperatively, largely due to the fear of uncertain outcomes. These findings also suggest that appropriate psychological counseling should be provided preoperatively to alleviate negative emotions[23]. Although the improvement of psychological resilience generally requires long-term efforts, short-term intensive psychological interventions may still effectively stimulate and support resilience in patients facing acute stress events such as LC surgery[24]. Regarding illness uncertainty, the total MUIS score was 83.98 ± 9.45, suggesting a moderate level of illness uncertainty among the VATS-treated LC patients included in this study. Wongkalasin et al[25] similarly reported a moderate level of illness uncertainty among patients with advanced LC (total MUIS score: 83.73 ± 15.25 points), consistent with this study’s findings. This may be related to the complexity of treatment and prognostic unpredictability of LC, which lead to moderate levels of illness uncertainty in patients.

Conversely, anxiety and depression correlated negatively with psychological resilience but positively with illness uncertainty, while psychological resilience and illness uncertainty correlated negatively. Song et al[26] studied patients with gastroenteropancreatic neuroendocrine tumors and reported a negative relationship between psychological distress and resilience, consistent with our observations. Similarly, an evident inverse relationship between depression and resilience has been reported in cancer patients both pre- and post-intervention[27]. Rambod et al[28] indicated that psychological resilience mediates the relationship among anxiety, depression, and stress in children with cancer, supporting the core role of psychological resilience in emotion regulation. Additional evidence suggests a potential negative association between psychological resilience and illness uncertainty in LC surgery patients, as improved disease understanding and perceived control help boost resilience[29]. Wang et al[30] further reported that illness uncertainty can mediate the influence of perceived social support on anxiety and depression in patients with LC, which partly explains the potential relationship between illness uncertainty and emotional distress in VATS-treated LC patients. Our final analysis confirmed preoperative FEV1% < 70%, clinical staging, educational level, MHI, psychological resilience, and illness uncertainty as independent determinants of anxiety or depression, whereas sex, age, hospitalization, and surgical techniques were not significant predictors. Therefore, preoperative FEV1% < 70% and lower educational level should be regarded as high-risk indicators requiring special attention and prompt psychological support. In contrast, interventions aimed at boosting psychological resilience and reducing illness uncertainty may be key to alleviating psychological distress in these patients. Moreover, the model was systematically verified through multicollinearity diagnostics, goodness-of-fit test, and discriminant ability evaluation, which ensures the robustness of statistical conclusions. Masaeli et al[31] reported that advanced age, inadequate education, rural residence, and a longer disease course were risk factors for anxiety, depression, and reduced quality of life in patients undergoing LC surgery. These findings are consistent with and complementary to our findings. The potential mechanisms underlying these associations may be explained as follows: Preoperative pulmonary dysfunction (FEV1% < 70%) and advanced clinical stages may increase surgical risk and simultaneously aggravate patients’ psychological burden from a physiological perspective. Patients with higher education levels have relatively stronger abilities to obtain and understand health information, enabling a greater sense of disease control and more confident and proactive coping with disease-related stress. Patients with higher MHI often have broader access to social resources, enabling them to receive more adequate informational support and emotional comfort when facing diseases, which may help reduce psychological pressure. Individuals with stronger psychological resilience typically possess more abundant positive psychological resources-such as optimism, tenacity, and strength-and more mature cognition. This enables them to correctly understand the disease and seek coping strategies rather than remaining in persistent negative emotional states. Conversely, lower illness uncertainty often indicates that such patients have developed a stronger sense of control over their condition and greater self-efficacy, which helps mitigate fear of the unknown.

Based on these findings, several psychological and cognitive interventions may be considered for patients with LC undergoing VATS. First, preoperative psychological counseling should prioritize strengthening the dimensions of tenacity and strength. Through cognitive restructuring and empowerment-based education, patients should be assisted in perceiving surgery as a controllable challenge and to master essential self-care skills. Second, standardized health education manuals should be provided to all patients, especially those with lower educational levels. Surgical procedures, expected discomfort, and rehabilitation pathways should be explained systematically using plain language to help reduce illness uncertainty. Finally, during the implementation of the above intervention processes, medical staff should adopt a gradual approach. By delivering key information in stages and repetitively, patients may better understand and absorb the information, thereby improving their sense of security and control[27,32].

This study has several limitations. First, the single-center design and relatively limited sample size may restrict representativeness; future studies should include participants from multiple regions to result generalizability. Second, the cross-sectional design does not allow the determination of causal relationships among psychological resilience, illness uncertainty, and psychological distress (anxiety and depression), and longitudinal studies are therefore required to clarify causal pathways. Third, although multivariate analysis was performed, potential unmeasured confounders, such as social support, personality traits, and other comorbid mental disorders, may simultaneously affect anxiety, depression, psychological resilience, and illness uncertainty. Future studies should prospectively incorporate these variables to more accurately identify the independent effects of each factor. The present research will be further refined based on these directions.

CONCLUSION

In conclusion, this study identified close associations between anxiety and depression and both psychological resilience and illness uncertainty among VATS-treated LC patients. Preoperative FEV1%, clinical staging, educational level, MHI, psychological resilience, and illness uncertainty independently influenced anxiety and depression in these patients. Providing targeted psychological interventions that improve psychological resilience and reduce illness uncertainty may help alleviate negative emotional states in VATS-treated LC patients.