Anxiety, depression, and sleep quality among breast cancer patients in North China: Mediating roles of hope and medical social support

A cross-sectional study was conducted at the Breast Surgery Department of Shanxi Baiqiuen Hospital, a tertiary hospital in Shanxi, China, from October 2021 to February 2022.

The inclusion criteria for participants were as follows: (1) age ≥ 18 years; (2) female; (3) initial diagnosis of breast cancer and awareness of the disease; (4) ability to communicate verbally and read independently; (5) absence of neurological and psychiatric disorders. The exclusion criteria were: (1) prior diagnosis of a sleep disorder; (2) use of glucocorticoids or sedatives during the study period; (3) refusal to participate in the study. The study was approved by the Shanxi Baiqiuen Hospital Ethics Committee, and written informed consent was obtained from all patients.

Participants were selected using convenience sampling. Before administering the questionnaire, the study purpose was explained to the participants, and their informed consent was obtained. Two trained researchers conducted the study in the breast surgery ward. Participants received instructions on questionnaire completion and safety procedures, and they completed a paper-based Chinese questionnaire. The survey took approximately 20 to 30 min, and all questionnaires were collected on-site, checked for completeness, and any missing items were promptly addressed. In cases where medical records were unavailable, patients provided self-reported demographic and illness information. The collected information was double-checked and entered anonymously to ensure patient confidentiality. A third investigator reviewed 10% of the surveys for error correction.

A total of 330 questionnaires were distributed in this study, out of which 315 were deemed valid, resulting in a valid return rate of 95.5%. Twelve patients did not meet the exclusion criteria, and three surveys were found to be faulty. The age range of the 315 breast cancer patients was 25–72 years, with a mean age of 49.76 ± 10.26 years.

According to the findings of this study, 82 respondents (26.0%) reported anxiety scores ≥ 8, and 68 (21.6%) had depression scores ≥ 8. Furthermore, 137 respondents (43.5%) experienced sleep disturbance. Among the participants, 197 (62.5%) breast cancer patients exhibited a high level of hope. As there was no specific scoring system for the MOS-SSS scale, and the scores followed a normal distribution, they were presented as mean ± standard deviation values, the mean score of the total medical social support score was 67.53(SD = 16.18, range = 0 to 95).

The results of Pearson correlation analysis revealed a significant positive correlation between sleep quality and anxiety (r = 0.429, p < 0.01), as well as between sleep quality and depression (r = 0.349, p < 0.01). Sleep quality demonstrated a significant negative correlation with hope (r = -0.288, p < 0.01) and with medical social support (r = -0.256, p < 0.01). Additionally, we examined the correlation between demographic characteristics and sleep quality, according to our analysis, only age exhibited a significant association with sleep quality and the results are provided in Supplementary Material (Stable 1). In subsequent mediation analysis, we further included age as a covariate in the model.

After controlling for age, which was significantly associated with the study variables in bivariate analyses,the fitness indicators for the anxiety-hope-medical social support-sleep quality model were as follows: RMSEA = 0.095, TLI = 0.786, CFI = 0.914. For the depression-hope-medical social support-sleep quality model, the indicators were: RMSEA = 0.066, TLI = 0.904, CFI = 0.961. The coefficients for all paths are shown in Fig. 1.

The results show that the 95% confidence intervals (CIs) for the total, direct, and indirect effects of the model did not include 0, indicating that the mediating effect is significant.Path analysis revealed that the direct effect of anxiety on sleep quality was 0.331, while the total indirect effect value was 0.108, and the total effect value was 0.439. Similarly, the direct effect of depression on sleep quality was 0.235, and the total indirect effect value was 0.143, and the total effect value was 0.379.

The finding that 46.6% of breast cancer patients in this study had a Pittsburgh Sleep Quality Index (PSQI) score ≥ 8 suggests that this population experiences sleep problems, highlighting the need for sleep management in breast cancer chemotherapy patients. Sleep disturbances can lead to various medical and mental illnesses, resulting in cognitive decline, decreased appetite, and weakened immunity [24]. Sleep problems not only impact patients' quality of life but also affect the metabolism of substances like glycogen storage [33]. This study found a positive correlation between anxiety, depression, and sleep quality in breast cancer patients. Specifically, lower levels of anxiety and depression were associated with a reduced likelihood of sleep disturbance, consistent with the findings of Carreira [10].Miloseva L [34] also reported a negative correlation between anxiety, depression, and sleep quality in 152 preoperative breast cancer patients. Since patients often experience anxiety and depression concurrently [35], it is crucial to detect early signs of psychological distress in clinical treatment and provide guidance and support, such as Cognitive-Behavioral Therapy, to improve sleep quality and enhance patients' resilience.

The study clearly indicates that medical social support plays a significant mediating role between anxiety, depression, and sleep quality. Social support acts as a stress buffer between negative events (e.g., illness) and anxiety-depression, making it a significant predictor [36]. The buffering model suggests that social support protects individuals from the potentially harmful effects of stressful events [35], a concept supported by additional research [37]. The positive impact of social support is influenced by personal perception. Perceived social support [34] refers to the subjective assessment of how individuals perceive the availability of economic, emotional, and general assistance from relatives and close friends. Individual perceptions determine the positive influence of social support. Perceived social support has been found to be negatively correlated with psychological discomfort and suicidal thoughts [13], and the ability to perceive social support is diminished in patients with anxiety and depression [38]. A previous study [39] demonstrated that social support can provide diverse information sources and increase the availability of information that encourages health-related behaviors, including maintaining healthy sleep patterns. Medical social support can provide a secure sleeping environment, reducing vigilance and alertness, thereby facilitating adequate rest.

The mediation model reveals that hope has a significant indirect effect on sleep quality, both independently and through the mediating role of medical social support. With the emergence of positive psychology, researchers have focused more on the impact of positive psychological factors on health. Hope [40] is a positive psychological construct and a powerful force that motivates patients to transcend the realities of their life circumstances and find meaning in their lives. According to Kaleta et al. [28], hope can assist cancer patients in coping with their condition and promote positive behaviors that alleviate depression. Studies [40] indicate that breast cancer patients with high levels of hope possess greater disease knowledge and engage in more informed medical decision-making than those with low levels of hope. Patients with high levels of hope also exhibit positive psychological changes following a cancer diagnosis, such as finding new purpose, deepening their spirituality, and engaging in positive activities. Hope [41] not only leads to a significantly stronger immune system but also improves overall quality of life and health. Hope can be a vital component in the treatment process for cancer patients, as it significantly alleviates pain, helps overcome obstacles, improves mood, and enhances sleep quality.

Path analysis revealed that the effects of anxiety and depression on sleep quality remained significant even after considering the influence of medical social support and hope, indicating that anxiety and depression indirectly affect sleep quality through the mediating effects of medical social support and hope. The levels of medical social support and hope mediate the relationship between anxiety, depression, and sleep quality. Within the framework of resilience theory, Fergus and Zimmerman [40] proposed a protective-protective model to describe the mechanisms of influence between two protective variables. They suggest that these protective variables interact with each other to produce results. Building on this theoretical framework, hope and social support may interact with each other concerning sleep quality in breast cancer patients. For example, Snyder's study [26] demonstrated that hope levels can be enhanced by building and strengthening social support resources. Consistent with Chen's findings [25], the present study reveals that the depression-medical social support-hope-sleep quality pathway demonstrates how social support and hope collectively influence sleep quality as coping factors. Sufficient social support can promote positive psychological resources, such as hope. Hope represents an internal positive component, while social support serves as an external positive factor. Medical social support, as an external positive factor, is more amenable to change, providing a valuable clue for clinical care. In our clinical practice, assessing patients' social support and providing appropriate assistance based on the results can lead to improved health outcomes. However, the moderating role of medical social support and hope is not fully understood, and further research is needed to explore the association between anxiety, depression, sleep treatment, and other influential factors in breast cancer patients.

This research has several limitations. Firstly, the cross-sectional design used in this study does not establish a direct causal relationship between the four factors. All four variables are dynamic and subject to change over time. However, the cross-sectional approach only captures the current situation, which limits the reliability of the study's model. Furthermore, convenience sampling was employed, which lacks sample representativeness and restricts the generalizability of the model. Future research should consider longitudinal studies and random sampling to address these limitations. Secondly, the sole source of information was the participants themselves, which may introduce information bias. Other cognitive factors and biological parameters, such as consciousness, pain perception, and functional capacity, may potentially influence the mediating effects of the model. However, these factors were not considered in this study. Incorporating these variables into future research would be beneficial.