Cancer is a major global public health challenge and a leading cause of morbidity and mortality. Improvements in screening, diagnosis, and treatment have increased survival for many cancers; however, the growing number of people living with cancer has also increased the demand for comprehensive supportive care. The Global Burden of Disease Cancer Collaboration documented substantial increases in cancer incidence and cancer-related disability across many countries, demonstrating that the consequences of cancer extend far beyond mortality alone. ¹ Although oncology services traditionally emphasize tumor control and physical symptoms, cancer also has profound psychological, social, occupational, and financial consequences for patients and their families. A cancer diagnosis is frequently experienced as a major life crisis. Patients may confront uncertainty about treatment, fear of disease progression, altered body image, loss of independence, disruption of family and occupational roles, and concerns about pain and death. Sadness, anxiety, anticipatory grief, and emotional distress may represent understandable reactions to these circumstances. Nevertheless, persistent or severe symptoms can develop into clinically important psychiatric conditions requiring assessment and treatment. Early psycho-oncology research emphasized the need to distinguish normal emotional reactions from psychiatric disorders that impair functioning, treatment participation, and quality of life. ² Depression is among the most clinically important psychological problems encountered during cancer care and may occur at diagnosis, during active treatment, after recurrence, or in advanced and palliative stages of illness. Depression in patients with cancer is difficult to recognize because several depressive symptoms overlap with manifestations of cancer and treatment-related toxicity. Fatigue, sleep disturbance, reduced appetite, weight change, impaired concentration, psychomotor slowing, and loss of energy may result from depression, cancer, chemotherapy, radiotherapy, pain, anemia, infection, or other medical complications. Consequently, clinicians may attribute psychological symptoms entirely to the underlying malignancy. Pirl noted that variation in definitions, assessment instruments, diagnostic thresholds, and clinical settings substantially affects reported estimates of depression in cancer populations. ³ Screening instruments are therefore useful for identifying patients who require further assessment, but a positive questionnaire result should not automatically be interpreted as a confirmed depressive disorder. Reported frequencies of depressive symptoms among patients with cancer vary widely across countries and clinical settings. A cross-sectional study among Thai patients with cancer demonstrated that depression was common and was associated with relevant clinical and psychosocial characteristics. ⁴ Higher estimates are often observed in tertiary hospitals, inpatient units, and palliative-care settings, where patients may have advanced disease, greater symptom burden, or more intensive treatment. Research involving patients with advanced cancer has also shown that affective disorders can be difficult to assess reliably when physical deterioration and psychological distress occur simultaneously.⁵ Among hospitalized patients with cancer, depression has been associated with functional impairment and increased medical and psychosocial needs.⁶ These findings indicate that prevalence estimates must be interpreted according to the measurement method, cancer population, stage of illness, and healthcare setting.

The risk of depression may also differ according to the primary cancer site and the biological and symptomatic burden of disease. Patients with cancers associated with severe pain, poor prognosis, metabolic disturbance, or intensive treatment may experience particularly high psychological distress. Depression has been extensively documented among patients with pancreatic cancer, illustrating how disease-related biological factors, symptom burden, and awareness of prognosis may interact. ⁷ However, differences between cancer types should be interpreted cautiously because demographic factors, disease stage, treatment exposure, and access to supportive care may confound these relationships.   Untreated depression can have serious clinical consequences. It may reduce motivation, impair communication with healthcare professionals, interfere with adherence to anticancer treatment, worsen perceived symptom severity, and diminish social functioning and quality of life. A meta-analysis found that depression was associated with increased mortality among patients with cancer, although the underlying pathways may involve behavioral, clinical, and biological mechanisms. ⁸ Depression may also contribute to hopelessness, suicidal thoughts, and a desire for hastened death, particularly among patients experiencing uncontrolled pain or advanced illness. A longitudinal study demonstrated important relationships among depression, cancer pain, and the desire for hastened death, emphasizing the need for timely psychological and safety assessment. ⁹

Depression in cancer is treatable. Psychotherapeutic interventions, pharmacological treatment, collaborative care, symptom management, and structured psychosocial support may reduce depressive symptoms and improve quality of life. Jacobsen and Jim reviewed substantial progress in psychosocial interventions for anxiety and depression among adults with cancer while also identifying challenges related to implementation, patient access, and integration into routine oncology practice. ¹⁰ Despite the availability of effective interventions, depression has historically remained under-recognized and undertreated. Prescription studies have shown that only a small proportion of patients with cancer received psychotropic treatment, indicating a considerable gap between psychological need and clinical care. ¹¹ Screening must therefore be connected to confirmatory assessment, appropriate referral, evidence-based treatment, and follow-up rather than functioning as an isolated administrative activity. Evidence concerning depressive symptoms among Pakistani patients with cancer remains limited. Patients may face additional pressures related to treatment costs, travel to tertiary hospitals, limited psycho-oncology services, mental-health stigma, and dependence on family support. Locally generated evidence is necessary to estimate service needs and identify groups that may benefit from targeted assessment. Therefore, this study aimed to determine the frequency of clinically relevant depressive symptoms among adults with cancer attending Ayub Teaching Hospital, Abbottabad, and to examine their associations with selected demographic and socioeconomic characteristics.

Study design and setting This descriptive cross-sectional study in the Oncology and Psychiatry departments of Ayub Teaching Hospital, Abbottabad, Pakistan, from November 1, 2022, through April 30, 2023. Reporting was structured using the STROBE recommendations for cross-sectional studies.6 Participants and sampling Patients with a confirmed cancer diagnosis who consented to participate were enrolled by nonprobability convenience sampling. The source protocol states an eligible age range of 18-70 years; however, the supplied results report observed ages of 19-88 years. The eligibility criterion and source data must therefore be reconciled before submission. Exclusion criteria in the source draft were a new cancer diagnosis at the index visit, language or hearing impairment, incomplete medical records, or ongoing psychological treatment. Sample size The planned sample size was 115, calculated with WHO sample-size software using 95% confidence, 10% absolute precision, and an expected prevalence of 53%. The source citation and exact calculation module require author confirmation. Variables and measurement An interviewer-assisted form captured age, gender, marital status, education, employment, household income, physical activity, smoking, cancer region, time since diagnosis, treatment modality, and surgical history. Depressive symptoms were assessed using a 21-item Beck Depression Inventory scored from 0 to 63. The analysis dichotomized scores as 20 or lower versus greater than 20. The source draft does not identify whether the original BDI or BDI-II, or which language/validated translation, was administered; these details require confirmation. Because the measure was used as a symptom screen, we use “positive screen” rather than a clinical diagnosis throughout. Statistical analysis Continuous variables are summarized as mean, standard deviation, minimum, and maximum; categorical variables as frequency and percentage. The positive-screen proportion is presented with a 95% Wilson confidence interval. Pearson chi-square tests were recalculated from the reported contingency-table counts to examine unadjusted associations. Two-sided P<.05 was considered statistically significant. P values smaller than .001 are reported as P<.001, not P=.000. Sparse and zero cells in the household-income analysis may violate chi-square assumptions; an exact test or category consolidation should be considered with access to participant-level data. No multivariable adjustment was possible from the aggregate source tables. Analyses in the original study were performed using SPSS version 23.0.

Participant characteristics

The analysis included 115 participants. Mean age was 45.87 years (SD, 13.66; reported range, 19-88), and 64 (55.7%) were women. Hematologic malignancies were the largest category (34.8%), followed by breast cancer (23.5%). Eighty-two participants (71.3%) were receiving chemotherapy.

Table 1. Participant demographic and clinical characteristics (N=115)

Depressive-symptom screening

The mean Beck Depression Inventory score was 25.37 (SD, 8.75; range, 9-43). Seventy-nine participants screened positive, corresponding to 68.7% (95% CI, 59.7%-76.5%).

Figure 1. Frequency of positive depressive-symptom screens

Bivariate associations

Positive-screen proportions differed by age group, education, and household-income category. Gender and marital status were not associated with screening status. These comparisons are unadjusted and should not be interpreted as independent predictors or causal effects.

Table 2. Unadjusted associations with positive depressive-symptom screening

Figure 2. Positive-screen frequency across prespecified sociodemographic groups

This single-center cross-sectional study found that approximately two thirds of participating adults with cancer screened positive for clinically relevant depressive symptoms. The observed frequency of 68.7% is higher than estimates commonly reported in studies using structured diagnostic interviews. However, studies relying on self-report symptom scales often produce higher estimates because these instruments identify symptom burden rather than confirmed depressive disorders. Research among hospitalized cancer populations has similarly demonstrated substantial psychiatric symptomatology, particularly among patients experiencing intensive treatment and physical deterioration.¹² Differences in cancer type, disease severity, clinical setting, measurement instrument, threshold, and sociocultural context make direct comparisons between studies difficult.¹³ Consequently, the present estimate should be interpreted as the frequency of positive depressive-symptom screening in a selected tertiary-care sample rather than the population prevalence of clinically diagnosed depression among Pakistani patients with cancer. The relatively high frequency may partly reflect the characteristics of the study setting. Tertiary hospitals generally receive patients with complicated malignancies, prolonged illness, treatment toxicity, and greater functional impairment. Studies involving patients with advanced cancer have reported particularly high levels of self-reported depressive symptoms. ¹⁴ In the present study, more than two thirds of participants had lived with cancer for at least six months, and most were receiving chemotherapy. Persistent symptoms, uncertainty about treatment response, disruption of employment, and repeated hospital visits may collectively increase psychological distress. Depression is also clinically important because severe hopelessness, uncontrolled symptoms, and perceived burden may contribute to suicidal thinking or a desire for hastened death. ¹⁵ The frequency observed here is substantially greater than estimates reported for depressive disorders in general community populations. ¹⁶ This difference is clinically plausible because patients with cancer face threats to survival, physical functioning, family responsibilities, employment, and financial security. Nevertheless, the screening instrument includes somatic symptoms that can also result from cancer or its treatment. Fatigue, appetite disturbance, sleep disruption, reduced activity, and impaired concentration may therefore increase total scores even when they are not caused primarily by depression. This overlap reinforces the need for clinical assessment after a positive screen rather than automatic assignment of a psychiatric diagnosis. Limited clinician training and the tendency to consider distress an inevitable consequence of cancer may further contribute to under-recognition and undertreatment. ¹⁷ Early psychological testing studies also demonstrated considerable variation in the emotional responses of patients with cancer, supporting individualized rather than assumption-based assessment. ¹⁸ Older age was significantly associated with positive screening status. Patients aged 40 years or older had a higher positive-screen frequency than younger participants. Older adults may experience greater physical disability, comorbidity, treatment toxicity, dependency, and reduced occupational or social functioning. However, age should not be treated as an independent predictor because the analysis was unadjusted. Cancer type, disease stage, pain, treatment exposure, and socioeconomic circumstances could partly explain this association. Previous literature has likewise shown that psychological responses vary across age groups and clinical contexts.¹⁹ No statistically significant association was identified between gender and screening status. Although depression is generally reported more frequently among women, evidence from oncology populations is inconsistent. Reviews of gender differences in cancer-related depression suggest that disease severity, cancer site, treatment burden, and social circumstances may modify or outweigh general-population gender patterns.²⁰ Psychological distress may also differ across cancer sites; for example, early research reported different psychiatric experiences among patients with pancreatic and gastric cancers.²¹ Biological treatment mechanisms may further influence symptoms, as inflammatory therapies such as interferon and interleukin treatment have been associated with the emergence of depressive symptoms.²² Because the present study grouped heterogeneous cancers and treatments together, it could not evaluate these potentially important clinical differences. Educational attainment and household-income category were significantly associated with screening status. Limited education may reduce access to understandable medical information, complicate navigation of cancer services, and restrict knowledge of available psychological support. Financial pressures may intensify distress through treatment costs, transportation expenses, lost earnings, and dependence on relatives. Patients at risk of major psychiatric complications require active identification and appropriate intervention rather than reliance on spontaneous disclosure.²³ Comprehensive cancer care frameworks accordingly recommend integrating psychosocial assessment with medical treatment and addressing practical, social, and emotional needs.²⁴ The household-income finding requires particular caution because all 30 participants in the intermediate-income category screened positive. This zero cell may violate the assumptions of the Pearson chi-square test and may reflect sampling variation, category construction, or data-entry error. Diagnostic classification can also vary according to the criteria and instruments applied.²⁵ Studies of medically ill inpatients have long demonstrated the methodological difficulty of separating depressive syndromes from emotional and somatic consequences of physical illness.²⁶ Participant-level verification and an exact statistical test should therefore be completed before the income association is emphasized. Pain and inadequate symptom control may represent additional unmeasured confounders. Cancer pain can substantially impair sleep, mobility, independence, and quality of life and may contribute to depressive symptoms.²⁷ The Beck Depression Inventory provides a standardized measure of symptom severity,²⁸ but it does not replace a diagnostic interview. Other instruments developed for older populations may reduce emphasis on somatic symptoms, although their appropriateness depends on the population and study objective.²⁹ Instrument selection must therefore be justified rather than based solely on availability, because evidence from unrelated psychiatric populations cannot automatically be generalized to oncology.³⁰ Clinically, screening should be connected to a defined response pathway. Programs require confirmatory assessment, suicide-risk evaluation when indicated, referral capacity, evidence-based psychological or pharmacological care, and follow-up. Multidisciplinary collaboration among oncology, psychiatry, psychology, nursing, and social-work services may improve continuity and reduce unmet needs. Current oncology guidance supports systematic assessment and management of depressive symptoms rather than isolated questionnaire administration.³¹ Strengths and Limitations This study contributes locally relevant psycho-oncology evidence from a major tertiary hospital and provides a transparent numerator and denominator for the primary outcome. Its limitations include convenience sampling, a single-center design, modest sample size, heterogeneous cancers and treatments, cross-sectional measurement, use of a symptom questionnaire rather than diagnostic interviews, unadjusted analyses, and incomplete information about disease stage, pain, performance status, prognosis, social support, treatment toxicity, nonparticipants, and missing data. The reported upper-age eligibility limit of 70 years conflicts with the observed maximum age of 88 years. In addition, several originally reported chi-square statistics do not match recalculations from the displayed counts. These discrepancies must be reconciled against participant-level records before journal submission.

Clinically relevant depressive symptoms were common among adults receiving cancer care in this tertiary-hospital sample. The findings justify evaluation of integrated screening and response pathways, while underscoring the need for multicenter studies with validated local-language instruments, diagnostic confirmation, complete cancer-stage data, and multivariable analysis. The current results support association and service-planning inferences, not causal claims.

AUTHOR CONTRIBUTIONS

¹Najma Ishtiaq (design), 

²Aamer Mumtaz (literature), 

³Aminur Rashid (experiments),

 ⁴Waqas Ahmed (statistics), 

⁵Sunila Munir (manuscript),

 ⁶Imran Ullah (supervision).Correspondence  Author

.All authors read and approved the final version.