Prevalence and Predictors of Anxiety and Depressive Symptoms among Patients Diagnosed with Oral Cancer in China: A cross-sectional study

Prevalence and Predictors of Anxiety and Depressive Symptoms among Patients Diagnosed with Oral Cancer in China: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Prevalence and Predictors of Anxiety and Depressive Symptoms among Patients Diagnosed with Oral Cancer in China: A cross-sectional study Lulu Yuan, Bochen Pan, Weiren Wang, Lie Wang, Xujie Zhang, Yuqin Gao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-15838/v4 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Aug, 2020 Read the published version in BMC Psychiatry → Version 4 posted 4 You are reading this latest preprint version Show more versions Abstract Background Anxiety and depression are common mental health problems among patients with cancer. While many psychological variables have been proven to influence anxiety and depressive symptoms, the variables are not mutually exclusive and their integrated effects on patients with oral cancer are yet unknown. The present study aims to explore the prevalence of anxiety and depressive symptoms among patients with oral cancer, to find out key potentially predictive factors associated with anxiety and depressive symptoms. Method A cross-sectional study was carried out for Chinese patients with oral cancer between May 2016 and October 2017 in two Grade-A Tertiary Hospitals in Shenyang, China. 230 patients with oral cancer were interviewed with questionnaires on demographic variables, Zung Self-Rating Anxiety Scale (SAS), Center for Epidemiologic Studies Depression Scale (CES-D), Herth Hope Index (HHI), Social Impact Scale, Multidimensional Scale of Perceived Social Support (MSPSS), Revised Life Orientation Test (LOT-R), Perceived Stress Scale-10 (PSS-10), and General Perceived Self-efficacy Scale(GSE). Chi-square test, nonparametric test, t-test and logistic regression analyses were conducted where appropriate to explore predictive factors of anxiety symptoms and depressive symptoms. Result The prevalence of anxiety symptoms and depressive symptoms in the sample population was 36.96% (85/230) and 65.21% (150/230), respectively. Social isolation dimension of stigma (β=0.436, OR=1.547, CI:1.211~1.975), optimism (β=-0.276, OR=0.759, CI:0.624~0.922), and perceived stress (β=0.217, OR=1.243, CI:1.092~1.414) were predictors of anxiety symptoms. Marriage (β=1.648, OR=5.198, CI:1.427~18.924), positive readiness and expectancy dimension of hope (β=-0.505, OR=0.604, CI:0.395~0.923), social isolation dimension of stigma (β=0.314, OR=1.368, CI:1.054~1.776) and perceived stress (β=0.273, OR=1.314, CI:1.134~1.524) were predictors of depressive symptoms among oral cancer patients. Conclusion The prevalence of anxiety symptoms and depressive symptoms was high among oral cancer patients in China. The communal predictors of anxiety and depressive symptoms in patients with oral cancer were levels of perceived stress and social isolation of stigma. In addition, optimism was a predictor of anxiety symptoms and hope was a predictor of depressive symptoms. Psychiatry Psychology oral cancer anxiety symptoms depressive symptoms Full Text Due to technical limitations, full-text HTML conversion of this manuscript could not be completed. However, the manuscript can be downloaded and accessed as a PDF. Supplementary Files STROBEoralcancer.docx Cite Share Download PDF Status: Published Journal Publication published 05 Aug, 2020 Read the published version in BMC Psychiatry → Version 4 posted Editorial decision: Accept 25 Jul, 2020 Editor assigned by journal 12 Jul, 2020 Submission checks completed at journal 11 Jul, 2020 Editor invited by journal 11 Jul, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-15838","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":809618,"identity":"6dafbc10-6b1e-437a-bb94-bdaccdba2511","order_by":0,"name":"Lulu Yuan","email":"","orcid":"","institution":"School and Hospital of Stomatology,China Medical University,Liaoning Provincial Key Laboratory of Oral Disease","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lulu","middleName":"","lastName":"Yuan","suffix":""},{"id":809619,"identity":"250e5c37-1890-43fd-ae76-0483ce3cb248","order_by":1,"name":"Bochen Pan","email":"","orcid":"","institution":"Shengjing Hospital,China Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bochen","middleName":"","lastName":"Pan","suffix":""},{"id":809620,"identity":"5c6ccaee-7250-40ee-93ec-749a217ec5e6","order_by":2,"name":"Weiren Wang","email":"","orcid":"","institution":"School and Hospital of Stomatology,China Medical University,Liaoning Provincial Key Laboratory of Oral Disease","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Weiren","middleName":"","lastName":"Wang","suffix":""},{"id":809621,"identity":"1f4c02f3-ff58-420e-bfa7-cdb637868293","order_by":3,"name":"Lie Wang","email":"","orcid":"","institution":"school of public health,China Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lie","middleName":"","lastName":"Wang","suffix":""},{"id":809622,"identity":"cdea970e-6f54-470f-afd8-4675c90e90b3","order_by":4,"name":"Xujie Zhang","email":"","orcid":"","institution":"School and Hospital of Stomatology,China Medical University,Liaoning Provincial Laboratory of Oral Disease","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xujie","middleName":"","lastName":"Zhang","suffix":""},{"id":809623,"identity":"4b25e88a-55d4-43b0-9ab0-2117ebed01f2","order_by":5,"name":"Yuqin Gao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACfvnz3z8kVNTU87M3EKlFcgaDGcOHM8cSJHsOEKnF4AaDGePMNuYEgxsJxGq53ZD2mOcMW57kzMcbbzDU2EQTdtidA8eNeSpkivml04otGI6l5TYQ0sJ3ILFBGmgL48zZOWYSjA2HCWthOJDMIM3bxsy44eYZIrUI3EhjkwR6P3HDDR4itUj2nGE2AAaysWQP0C8JxPiFn72H8QEwKuX42Q9vvPGhxoYIvyABA4kEUpRDtJCqYxSMglEwCkYGAAAwzEPk/+ak/gAAAABJRU5ErkJggg==","orcid":"","institution":"School and Hospital of Stomatology,China Medical University,Liaoning Provincial Key Laboratory Of Oral Disease","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yuqin","middleName":"","lastName":"Gao","suffix":""}],"badges":[],"createdAt":"2020-02-28 12:30:51","currentVersionCode":4,"declarations":"","doi":"10.21203/rs.3.rs-15838/v4","doiUrl":"https://doi.org/10.21203/rs.3.rs-15838/v4","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-020-02796-6","type":"published","date":"2020-08-05T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":13515440,"identity":"5290c822-12ec-4dde-9ef0-64711374ea46","added_by":"auto","created_at":"2021-09-17 00:07:53","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":427325,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptoralcancer0711.pdf","url":"https://assets-eu.researchsquare.com/files/rs-15838/v4_covered.pdf"},{"id":13512726,"identity":"814c4165-4716-4f4e-9fd8-4677c2f3e00c","added_by":"auto","created_at":"2021-09-16 23:56:53","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":334946,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptoralcancer0627.pdf","url":"https://assets-eu.researchsquare.com/files/rs-15838/v3_covered.pdf"},{"id":1555872,"identity":"c92028a9-e14a-425d-8b0e-b873f2b744b8","added_by":"auto","created_at":"2020-07-14 18:04:33","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":301383,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptoralcancer0711.pdf","url":"https://assets-eu.researchsquare.com/files/rs-15838/v4_stamped.pdf"},{"id":1555870,"identity":"ec8a2660-3bc3-4d81-b75c-71c6db32f208","added_by":"auto","created_at":"2020-07-14 18:04:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":269989,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptoralcancer0711.pdf","url":"https://assets-eu.researchsquare.com/files/rs-15838/v4/manuscriptoralcancer0711.pdf"},{"id":1555871,"identity":"73966acb-e6a4-44f0-a68f-c29a64b724b1","added_by":"auto","created_at":"2020-07-14 18:04:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33396,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEoralcancer.docx","url":"https://assets-eu.researchsquare.com/files/rs-15838/v4/STROBEoralcancer.docx"}],"financialInterests":"","formattedTitle":"Prevalence and Predictors of Anxiety and Depressive Symptoms among Patients Diagnosed with Oral Cancer in China: A cross-sectional study","fulltext":[{"header":"Full Text","content":" \u003cp\u003eDue to technical limitations, full-text HTML conversion of this manuscript could not be completed. However, the manuscript can be downloaded and accessed as a PDF.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"oral cancer, anxiety symptoms, depressive symptoms","lastPublishedDoi":"10.21203/rs.3.rs-15838/v4","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-15838/v4","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground Anxiety and depression are common mental health problems among patients with cancer. While many psychological variables have been proven to influence anxiety and depressive symptoms, the variables are not mutually exclusive and their integrated effects on patients with oral cancer are yet unknown. The present study aims to explore the prevalence of anxiety and depressive symptoms among patients with oral cancer, to find out key potentially predictive factors associated with anxiety and depressive symptoms. \u003c/p\u003e\u003cp\u003eMethod A cross-sectional study was carried out for Chinese patients with oral cancer between May 2016 and October 2017 in two Grade-A Tertiary Hospitals in Shenyang, China. 230 patients with oral cancer were interviewed with questionnaires on demographic variables, Zung Self-Rating Anxiety Scale (SAS), Center for Epidemiologic Studies Depression Scale (CES-D), Herth Hope Index (HHI), Social Impact Scale, Multidimensional Scale of Perceived Social Support (MSPSS), Revised Life Orientation Test (LOT-R), Perceived Stress Scale-10 (PSS-10), and General Perceived Self-efficacy Scale(GSE). Chi-square test, nonparametric test, t-test and logistic regression analyses were conducted where appropriate to explore predictive factors of anxiety symptoms and depressive symptoms. \u003c/p\u003e\u003cp\u003eResult The prevalence of anxiety symptoms and depressive symptoms in the sample population was 36.96% (85/230) and 65.21% (150/230), respectively. Social isolation dimension of stigma (β=0.436, OR=1.547, CI:1.211~1.975), optimism (β=-0.276, OR=0.759, CI:0.624~0.922), and perceived stress (β=0.217, OR=1.243, CI:1.092~1.414) were predictors of anxiety symptoms. Marriage (β=1.648, OR=5.198, CI:1.427~18.924), positive readiness and expectancy dimension of hope (β=-0.505, OR=0.604, CI:0.395~0.923), social isolation dimension of stigma (β=0.314, OR=1.368, CI:1.054~1.776) and perceived stress (β=0.273, OR=1.314, CI:1.134~1.524) were predictors of depressive symptoms among oral cancer patients. \u003c/p\u003e\u003cp\u003eConclusion\u0026nbsp;The prevalence of anxiety symptoms and depressive symptoms was high among oral cancer patients in China.\u0026nbsp;The communal predictors of anxiety and depressive symptoms in patients with oral cancer were levels of perceived stress and social isolation of stigma. In addition, optimism was a predictor of anxiety symptoms and hope was a predictor of depressive symptoms.\u003c/p\u003e","manuscriptTitle":"Prevalence and Predictors of Anxiety and Depressive Symptoms among Patients Diagnosed with Oral Cancer in China: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":4,"date":"2020-07-14 18:04:30","doi":"10.21203/rs.3.rs-15838/v4","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-07-25T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-07-12T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-07-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-07-11T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":3,"date":"2020-06-30 15:19:01","doi":"10.21203/rs.3.rs-15838/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-06-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-28T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-06-27T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-06-27T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-05-01 15:13:53","doi":"10.21203/rs.3.rs-15838/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-05-28T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-05-22T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThis paper is suitable for publication.* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"editorInvitedReview","content":"","date":"2020-05-17T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to re-review this manuscript. The manuscript has been improved insofar as some ambiguous sections have been clarified. However, some methodological problems remain and some of the results are still not suffiently clear:\n\nQuestion 5:\nResults\n- It appears as though men had a higher risk of suffering from anxiety than women (OR 3.1). Most studies report higher rates in women than in men. In addition, the OR appears to be quite high. Is this correct?\nAnswer 5: Yes, we totally agree with Dr. Hartung's comment on the result. It happened that in the previous manuscript, we not only put variables with statistical significance in the Chi-square test (distant metastasis), but also put two other variables (age and gender) that were reported statistically significant by other studies into the Logistic regression analysis as control variables thus resulting in such a result. Now we realize that age and gender should not have been put into the regression analysis in the first place. So, we repeated the regression analysis without input of these two variables, and the mistake has been corrected in the revised manuscript. Accordingly, the Abstract section, Statistical analyses section, Result section and Discussion section have been re-written. See Abstract section, line 24-26, page 1; Abstract section, line 1- 6, page 2; Statistical analyses section, line 18-19, page 7; Result section, line 4-7, Tab 3, page 9; Result section, line 1-3, Tab 4, page 10; Discussion section, line 14-23, page 11.\n\nRe-reply 5: In my opinion, age, gender and other sociodemographic variables should be included in the multivariable regression analyses. One of the advantages of this statistical method is precisely that one can control for sociodemographic confounders. Also, in the first version of the manuscript, age and gender did have a significant impact on the presence of anxiety symptoms.\n\nQuestion 6:\nResults\n- married patients appear to have had much higher risk of suffering from depressive symptoms (OR 4.7). Most studies find that being in a relationship / being married is a protective factor against depression. How do the authors explain this result?\nAnswer 6: Thank you for the question, which really helped us to improve the manuscript. It's indeed hard to understand. We guess that might have been caused by the sample size. The sample size of the married/cohabitation group was 204, whereas the sample size of the unmarried group was only 26 which was too small to reach a definite conclusion. Therefore, in the revised manuscript, we have added relevant comments in the Limitations section. See Discussion section, line 14-23, page 11; Limitation section, line 8-10, page 14.\n\nRe-reply 6: Sample size alone does not explain this result. If the group was too small, i.e. the analysis underpowered, the effect should be non-significant. This issue requires further discussion.\n\nQuestion 7:\nResults\n- Even though previous results on head and neck cancer are scarce, it is surprising that one third of patients suffers from severe levels of anxiety and two thirds (!) suffer from at least moderate depressive symptoms. E.g. most studies in European countries found rates of moderate to severe depressive symptoms of around 25% in patients with head and neck cancer. How do the authors explain such high prevalence rates in this study and the other cited study from China?\nAnswer 7: We are sorry for the confusion caused. We have defined the criteria for anxiety and depression in the operational definition section. The criteria were used mainly to distinguish whether the patients had symptoms of anxiety/depression, not to define the severity of anxiety/depression. Here's what it says:\"The cut-off points of SAS and CES-D were set to be the criteria to differentiate patients. According to the previous studies，patients with a 50 or above SAS standardized score were classified into the anxiety symptoms group, and patients with a CES-D score over 16 or above were defined as the depressive symptoms group.\"\nIf it happens that it is necessary to define the severity of anxiety/depression and explore the potential related factors in the revised manuscript, we will. We would be grateful if we could have your advice on this. See Methods section, line 5-6, page 7.\n\nRe-reply 7: Do the prevalence rates refer to the number of patients scoring above the cutoff scores or the number of patients reporting ANY symptoms of depression / anxiety? This needs to be made clear and clinically relevant cutoff scores should be used.\n\n\nQuestion 9:\nDiscussion\n- The association between socio-demographic variables and anxiety and depressive symptoms needs to be discussed further. In particular, the direction of these associations is not specified (see above). How do the authors explain these results which appear to be contrary to the majority of the psycho-oncological literature?\nAnswer 9: In the revised manuscript, we reset the requirements for variables to be included in the Logistic regression equation, as shown in Answer 5. See Abstract section, line 24-26, page 1; Abstract section, line 1-6, page 2; Statistical analyses section, line 18-19, page 7; Result section, line 4-7, Tab 3, page 9; Result section, line 1-3, Tab 4, page 10; Discussion section, line 14-23, page 11. After reanalysis, only marital status was associated with depressive symptoms, as explained in Answer 6. See Discussion section, line 14-23, page 11; Limitation section, line 8-10, page 14. At the same time, the data can be shared if necessary (as detailed in Answer 8. See Declarations section, line 14-15, page 15). Accordingly, in the revised manuscript, the Abstract section, Method section, Result section and Discussion section all have been re-written.\n\nRe-reply 9: Were the same cutoff scores used to do the chi-squared tests? It says on page 8 that \"Notably, most patients (204, 88.7%) were in a married or cohabited status, whose depressive symptoms were found statistically higher than those single/ divorced/ widowed (X2=9.251, p=0.002).\" Chi-squared is used for hypothesis testing of quantities, not of severity (usually a metric or ordinal variable). It is strange that these sociodemographic variables were significant in a multiple regression, which requires more statistical power, but not in a chi-squared tests which works for much smaller samples.* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **Unable to assess**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-05-01T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-05-01T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-04-24T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-04-20T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-04-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-04-19T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-03-04 04:02:03","doi":"10.21203/rs.3.rs-15838/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-03-18T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-03-05T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-03-05T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe authors conducted a cross-sectional study in 230 patients with head and neck cancer in China to assess levels of psychosocial symptom burden, personality traits and other psychosocial self-report data and the associations between these factors. They found relatively high levels of anxiety and depressive symptoms and unusual associations between sociodemographic variables and psychosocial symptomatology. At the current state of the manuscript, the reporting of the results is unprecise and those findings that appear to be contrary to the majority of the international literature are not discussed in sufficient detail. At other points the results are over-interpreted and clinical recommendations are derived from cross-sectional data that can not provide insights into causal relationships. There are a number of smaller grammatical errors, especially in the discussion section, that should be corrected by a native speaker of English.\n\nIntro\n- p2, l. 26: Why are depressive symptoms in patients with cancer compared to anxiety in the general Chinese population?\n- p2. l28: I would be careful with the term \"proved\".\n- One of the aims is \"to identify the sequence of their contributions\". However, the design is cross-sectional, which does not provide insights into the sequence of causes and effects.\n\nResults\n- The response rate is reported as 99.57%. How do the authors explain that not a single patient refused participation in the study?\n- It appears as though men had a higher risk of suffering from anxiety than women (OR 3.1). Most studies report higher rates in women than in men. In addition, the OR appears to be quite high. Is this correct?\n- married patients appear to have had much higher risk of suffering from depressive symptoms (OR 4.7). Most studies find that being in a relationship / being married is a protective factor against depression. How do the authors explain this result?\n- Even though previous results on head and neck cancer are scarce, it is surprising that one third of patients suffers from severe levels of anxiety and two thirds (!) suffer from at least moderate depressive symptoms. E.g. most studies in European countries found rates of moderate to severe depressive symptoms of around 25% in patients with head and neck cancer. How do the authors explain such high prevalence rates in this study and the other cited study from China?\n- With such unusual results the authors should consider sharing the data set so that this sample can be analysed further and statistical procedures can be reproduced by other researchers.\n\nDiscussion\n- The association between socio-demographic variables and anxiety and depressive symptoms needs to be discussed further. In particular, the direction of these associations is not specified (see above). How do the authors explain these results which appear to be contrary to the majority of the psycho-oncological literature?\n- The discussion of potentially causal relationships between psychosocial symptom burden and personality traits as well as cognitions is somewhat speculative and should be toned-down, as a causal relationship cannot be derived from the reported cross-sectional data.\n- Statements such as \"Our study provides the evidence that hope and optimism intervention may be especially worthy of use in oral cancer patients.\" are an over-interpretation of the data.* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Unable to assess**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-02-23T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe topic of this study is interesting, and it is of great importance to study the depression and anxiety in patients with oral cancer.\n1.In this study, 85 patients have anxious symptoms, and 150 patients have depressive symptoms, how many patients have both anxiety and depression? How do you deal with this factor in the logistic regression analysis of depression and anxiety？\n2. Table1, residence, there are 145 urban patients, and 84 rural patients, one is missing.\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-02-09T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-02-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-02-03T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-02T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-01-30T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a14d0a24-a9e0-44ea-b9f6-5d693fdecbff","owner":[],"postedDate":"July 14th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":156054,"name":"Psychiatry"},{"id":156055,"name":"Psychology"}],"tags":[],"updatedAt":"2020-08-09T22:36:21+00:00","versionOfRecord":{"articleIdentity":"rs-15838","link":"https://doi.org/10.1186/s12888-020-02796-6","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2020-08-05 12:00:00","publishedOnDateReadable":"August 5th, 2020"},"versionCreatedAt":"2020-07-14 18:04:30","video":"","vorDoi":"10.1186/s12888-020-02796-6","vorDoiUrl":"https://doi.org/10.1186/s12888-020-02796-6","workflowStages":[]},"version":"v4","identity":"rs-15838","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-15838","identity":"rs-15838","version":["v4"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}