Incidence and risk factors of post-traumatic stress disorder in patients after endoscopic submucosal dissection for early gastric cancer

Table 1 Analysis of general data of patients in the post-traumatic stress disorder group and the non-post-traumatic stress disorder group, n (%)

Item	Category/unit	PTSD group (n = 56)	Non-PTSD group (n = 160)	Test statistic	P value
Gender	Male	33 (58.9)	105 (65.6)	χ2 = 0.838	0.36
	Female	23 (41.1)	55 (34.4)
Age (years)1	M (P25, P75)	63.0 (58.0, 68.0)	59.0 (54.0, 65.0)	Z = -2.456	0.014
Education level	Illiterate/primary	18 (32.1)	28 (17.5)	χ2 = 7.624	0.054
	Junior high	22 (39.3)	58 (36.3)
	High school/technical	12 (21.4)	48 (30.0)
	College and above	4 (7.1)	26 (16.3)
Marital status	Married	42 (75.0)	142 (88.8)	χ2 = 6.589	0.01
	Unmarried/divorced/widowed	14 (25.0)	18 (11.3)
Occupation	Employed	18 (32.1)	72 (45.0)	χ2 = 5.893	0.053
	Retired	28 (50.0)	68 (42.5)
	Unemployed	10 (17.9)	20 (12.5)
Lesion location	Fundus/body	12 (21.4)	42 (26.3)	χ2 = 0.556	0.456
	Antrum/angle	44 (78.6)	118 (73.8)
Lesion size (cm)	M (P25, P75)	2.2 (1.5, 3.0)	1.8 (1.2, 2.5)	Z = -2.867	0.004
Pathological type	Differentiated adenocarcinoma	48 (85.7)	143 (89.4)	χ2 = 0.581	0.446
	Undifferentiated adenocarcinoma	8 (14.3)	17 (10.6)
Depth of invasion	Mucosal layer M	38 (67.9)	118 (73.8)	χ2 = 0.748	0.387
	Submucosal layer SM	18 (32.1)	42 (26.3)
Combined with ulcer	Yes	26 (46.4)	48 (30.0)	χ2 = 5.312	0.021
	No	30 (53.6)	112 (70.0)
Lymphovascular invasion	Yes	12 (21.4)	18 (11.3)	χ2 = 3.611	0.057
	No	44 (78.6)	142 (88.8)
En bloc resection	Yes	52 (92.9)	152 (95.0)	Fisher	0.719
	No	4 (7.1)	8 (5.0)
Complete resection	Yes	48 (85.7)	144 (90.0)	χ2 = 0.753	0.386
	No	8 (14.3)	16 (10.0)
Past medical history	Yes	34 (60.7)	88 (55.0)	χ2 = 0.580	0.446
	No	22 (39.3)	72 (45.0)
Family tumor history	Yes	22 (39.3)	42 (26.3)	χ2 = 3.578	0.059
	No	34 (60.7)	118 (73.8)

¹Age and lesion size are non-normally distributed data, expressed as median (interquartile range) [M (P25, P75)].

PTSD: Post-traumatic stress disorder; M: Mucosa; SM: Submucosa.

Table 2 Comparison of psychological assessment indicators between post-traumatic stress disorder group and non-post-traumatic stress disorder group (mean ± SD, points)

Scale	Time point	PTSD group (n = 56)	Non-PTSD group (n = 160)	t value	P value
SAS	Preoperative	48.6 ± 8.2	42.3 ± 7.5	5.198	< 0.001
	3 months postoperative	51.2 ± 9.4	38.5 ± 6.8	10.632	< 0.001
SDS	Preoperative	52.3 ± 9.6	45.8 ± 8.2	4.751	< 0.001
	3 months postoperative	56.8 ± 10.5	40.2 ± 7.3	12.486	< 0.001
SSRS	Preoperative	32.4 ± 5.8	38.6 ± 6.2	-6.563	< 0.001
	3 months postoperative	28.7 ± 6.3	40.1 ± 5.9	-11.982	< 0.001

PTSD: Post-traumatic stress disorder; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SSRS: Social Support Rating Scale.

Table 3 Comparison of Social Support Rating Scale dimension scores between post-traumatic stress disorder group and non- post-traumatic stress disorder group (mean ± SD, points)

Dimension	Time point	PTSD group (n = 56)	Non-PTSD group (n = 160)	t value	P value
Objective support1	Preoperative	7.8 ± 1.9	8.9 ± 2.0	-3.565	< 0.001
	3 months postoperative	6.9 ± 2.1	9.2 ± 1.9	-7.323	< 0.001
Subjective support2	Preoperative	13.5 ± 2.6	16.2 ± 2.8	-6.304	< 0.001
	3 months postoperative	11.8 ± 2.8	17.3 ± 2.7	-12.739	< 0.001
Utilization of social support3	Preoperative	11.1 ± 2.1	13.5 ± 2.2	-7.094	< 0.001
	3 months postoperative	10.0 ± 2.3	13.6 ± 2.1	-10.489	< 0.001

¹Objective support score range 3-11 points.

²Subjective support score range 4-20 points.

³Utilization of social support score range 3-12 points.

PTSD: Post-traumatic stress disorder.

Table 4 Multivariate logistic regression analysis of post-traumatic stress disorder occurrence in patients after endoscopic submucosal dissection for early gastric cancer

Variable	B	SE	Wald χ2	P value	OR	95%CI
Age (per 1-year increase)	0.058	0.023	6.281	0.012	1.06	1.013-1.109
Marital status (unmarried/divorced/widowed vs married)	1.124	0.456	6.079	0.014	3.077	1.259-7.516
Lesion size (per 1-cm increase)	0.485	0.186	6.796	0.009	1.624	1.129-2.336
Combined with ulcer (yes vs no)	0.892	0.382	5.455	0.02	2.44	1.154-5.161
Preoperative SDS score (per 1-point increase)	0.062	0.021	8.722	0.003	1.064	1.021-1.109
Preoperative SSRS score (per 1-point increase)	-0.098	0.034	8.291	0.004	0.907	0.848-0.970
Constant	-9.824	2.145	20.963	< 0.001	< 0.001	-

B: Regression coefficient; SE: Standard error; OR: Odds ratio; CI: Confidence interval; SDS: Self-Rating Depression Scale; SSRS: Social Support Rating Scale.

Table 5 Receiver operating characteristic curve analysis results of the post-traumatic stress disorder prediction model and individual factors

Predictive factor	AUC	95%CI	Sensitivity (%)	Specificity (%)	Youden index	Cut-off value1
Combined prediction model	0.856	0.801-0.910	78.6	85	0.636	Predicted probability ≥ 0.31
Age	0.617	0.531-0.703	64.3	60.6	0.249	62 years
Marital status	0.594	0.512-0.676	25	88.8	0.138	Unmarried/divorced/widowed
Lesion size	0.652	0.571-0.733	58.9	68.8	0.277	2.0 cm
Combined with ulcer	0.582	0.500-0.664	46.4	70	0.164	Yes
Preoperative SDS score	0.681	0.602-0.759	62.5	70	0.325	50 points
Preoperative SSRS score	0.745	0.674-0.816	71.4	71.3	0.427	35 points

¹Cut-off value for the combined prediction model determined based on maximum Youden index principle.

AUC: Area under the curve; CI: Confidence interval; SDS: Self-Rating Depression Scale; SSRS: Social Support Rating Scale.

Table 6 Comparison of patient characteristics between the clinical post-traumatic stress disorder group and the mild-to-moderate post-traumatic stress disorder group

Item	Category/unit	Clinical PTSD group (n = 18)	Mild-to-moderate PTSD group (n = 38)	Test statistic	P value
Gender	Male	10 (55.6)	23 (60.5)	χ2 = 0.137	0.711
	Female	8 (44.4)	15 (39.5)
Age (years)		64.8 ± 7.3	59.6 ± 8.5	t = 2.239	0.029
3-month postoperative SAS score (points)		58.3 ± 8.6	48.2 ± 7.9	t = 4.392	< 0.001
3-month postoperative SDS score (points)		64.7 ± 9.2	53.5 ± 8.4	t = 4.635	< 0.001
3-month postoperative SSRS score (points)		24.1 ± 5.2	30.8 ± 5.7	t = -4.242	< 0.001
Combined with ulcer	Yes	11 (61.1)	15 (39.5)	χ2 = 2.546	0.111
	No	7 (38.9)	23 (60.5)

Clinical post-traumatic stress disorder (PTSD) group defined as PTSD Checklist-Civilian Version total score ≥ 50, Mild-to-moderate PTSD group defined as PTSD Checklist-Civilian Version total score 38-49. SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; SSRS: Social Support Rating Scale; PTSD: Post-traumatic stress disorder.