A Bibliometric Review of Depression Among Cancer Patients in Low- and Middle-Income Countries

A Bibliometric Review of Depression Among Cancer Patients in Low- and Middle-Income Countries | 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 Systematic Review A Bibliometric Review of Depression Among Cancer Patients in Low- and Middle-Income Countries Tay Zar LIN, Nguyen Thi Thanh Tuyen, Fadhlin Binti Abd Hamid This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8079820/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective Depression is an important comorbidity among cancer patients, particularly in resource-limited settings. This bibliometric review aims to map and describe the scientific landscape of approaches to understanding depression among cancer patients in Low- and Middle-Income Countries (LMICs). Methods A bibliometric analysis of research on depression among cancer patients was conducted using data from Scopus. The quantitative bibliometric analysis was performed using the Bibliometrix R package and the VOSviewer platform. The bibliometric analysis analyzed the publication output, keyword co-occurrence to profile publication trends, research hotspots, leading authors, countries, institutions, and collaboration networks. Results The analysis identified 173 eligible publications. The output consistently increased after 2018. Overall, the highest number of publications were produced by India (n = 42), Ethiopia (n = 32), and the United States (n = 26). The dominant research themes included studies of breast cancer (n = 38), depression scale (n = 46), and data (n = 58). The co-authorship analysis identified distinct collaborative clusters while the keyword analysis identified four major thematic clusters: methodological aspects, clinical assessment, cancer type and treatment dimensions, and evidence synthesis & interventions. The temporal analysis revealed an evolution from predominantly basic studies of prevalence, toward increased sophistication in research on predictors and interventions. Conclusion This review highlights the growing research interest in depression among cancer patients in LMICs, while geographic and thematic gaps remain. While breast cancer dominates literature, other prevalent cancers remain understudied. Future research must focus on developing culturally adapted screening tools, implementing context-specific interventions, and increasing international collaboration to address the psycho-oncological needs of cancer patients in low-resource settings. Depression Cancer Psycho-oncology Mental health Bibliometric analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Cancer has remained a prominent contributor to morbidity and mortality globally, with a disproportionate burden increasingly shifting to Low- and Middle-Income Countries (LMICs) ( 1 ). Disorders of psychological distress often affect cancer survivors beyond the physical presentation of illnesses and treatment, making depression one of the most prevalent mental health comorbidities ( 2 ) ( 3 ). Meta-analyses estimate that between 8% and 24% of cancer patients experience depression which can be significantly higher than general population estimates ( 4 ) whereas one of the studies ( 5 )showed that severe depressive symptoms are observed in about 25% of cancer patients, and this rate increases to 77% among those with advanced disease. The distress of depression generally amplifies in LMIC settings, compounded by limited mental health resources and service, delays in diagnoses, the stigma of mental instability, and lack of psycho-oncological services ( 6 ). Despite these hurdles, the last few decades have seen increased research interest in the psychological elements of cancer care in LMICs, demonstrating more awareness of the need for a comprehensive approach to cancer management that recognizes the relative importance of both physical and human needs ( 7 ). This disparity underscores the broader challenge of integrating psycho-oncology within the global mental health agenda, as emphasized in the WHO Comprehensive Mental Health Action Plan 2013–2030, which calls for equitable inclusion of mental health in all disease care pathways, including cancer. Bibliometric analysis provides a solid methodological approach to identify the topography of scientific production in a particular domain of interest, yielding data on trends in research, landmark contributions, collaborative networks, and theme development ( 8 ). Several bibliometric analyses have been conducted in relation to cancer research ( 9 ) ( 10 ) and mental health research in these settings ( 11 ). However, no systematic bibliometric analysis has so far probed the intersection of these two subfields; the research on depression in cancer patients in LMICs. This review seeks to bridge this gap by systematically mapping and analyzing scientific literature on depression in cancer patients in LMICs from the year 2000 to April 2025 using bibliometric methods. The objectives of the study are to; Quantify trends in publication and scientific production in the field overtime Determine the most influential countries, institutions, authors, and journals contributing to this area of research Examine collaboration patterns and research networks among institutions and researchers Explore the landscape of themes and the evolution of research themes Identify literature gaps and suggest areas for further research By critical examination of the existing research on depression among cancer patients in LMICs, this review aims to inform researchers, clinicians, policymakers, and funding agencies about what is now known, what is currently trending, and what still needs to be investigated in this important yet low-priority area of psycho-oncology. Materials and methods Study Design and Data Source This bibliometric review was conducted following the established guidelines for science mapping and bibliometric analysis ( 12 ). Data were retrieved from the Scopus database, selected for its broad coverage of peer-reviewed literature and structured metadata suitable for bibliometric analysis, particularly for LMIC research outputs. Data extraction was performed on April 30, 2025, ensuring inclusion of all records published between January 1, 2000 and April 30, 2025. Although Scopus offers extensive coverage, it may underrepresent non-indexed or non-English-language journals common in LMICs. Nonetheless, it remains the most comprehensive database for large-scale, structured bibliometric data suitable for quantitative mapping. Search Strategy A comprehensive search string combined terms related to cancer, depression, prevalence/predictors, and LMICs. The Boolean search syntax was: (cancer OR neoplasm* OR tumor* OR tumour* OR oncology) AND (depression OR "depressive symptoms" OR "depressive disorder") AND (prevalence OR epidemiology OR "epidemiological study" OR "risk factor*" OR predictor* OR determinant* OR "associated factor*") AND ([list of LMICs as defined by World Bank]) The search was limited to English peer-reviewed articles. Reference lists were screened to identify additional relevant studies. Eligibility Criteria Studies were included if they: ( 1 ) focused on depression or depressive symptoms with cancer patients; ( 2 ) conducted in or focused on LMICs as defined by the World Bank; ( 3 ) focused on prevalence, predictors, risk factors, or associated factors of depression; ( 4 ) original research articles published in peer-reviewed journals; and ( 5 ) had full bibliometric metadata. Exclusion criteria included: ( 1 ) studies that did not relate to cancer or depression; ( 2 ) intervention trials without prevalence or risk factor reporting; ( 3 ) editorials, letters, protocols, case reports, and conference abstracts; ( 4 ) studies that were conducted in high-income countries; and ( 5 ) articles that did not contain full bibliometric metadata. The initial search returned 425 publications, which were reviewed initially based on titles and abstracts. Following adherence to inclusion and exclusion criteria, 173 publications were included in the final analysis as per figure (1). Data Extraction and Analysis The bibliographic data for the 173 publications was extracted from Scopus in CSV format, including Authors, title, abstract, keywords, journal, publication year, citations, affiliations, and countries. The data was cleaned and standardized to ensure consistent author names, keywords, and institutional affiliations. Quantitative bibliometric analyses were conducted using Bibliometrix (R package) ( 13 ), and a VOSviewer (version 1.6.19), a software application for building and visualizing bibliometric networks ( 14 ). The following analyses were conducted: Publication trends analysis: Examining the distribution of publications over time and across journals, countries, and institutions. Co-authorship analysis: Identifying collaboration patterns among authors, institutions, and countries. Citation analysis: Examining citation patterns to identify influential publications, authors, and journals. Keyword co-occurrence analysis: Analyzing the co-occurrence of author keywords and index keywords to identify research themes and clusters. Temporal analysis: Examining the evolution of research themes over time through overlay visualization. Thresholds were set to optimize interpretability: a minimum of 2 documents for authors, institutions, and countries, and 10 keyword occurrences for inclusion in network maps. Cluster identification was performed using the association strength algorithm in VOSviewer. Methodological Considerations The use of a single database (Scopus) may underrepresent LMIC publications from non-indexed or regional journals, potentially biasing geographic and linguistic representation. In addition, focusing exclusively on peer-reviewed journal articles excludes gray literature, Non-Governmental Organisation (NGO) reports, and national guidelines that may hold contextual relevance. The World Bank’s LMIC classification also encompasses countries with wide variability in health systems and research infrastructure, which should be considered when interpreting geographic disparities in publication output. Results Publication Trajectory A bibliometric review identified 173 papers that met the inclusion criteria between 2000 and April 2025 as shown in Fig. 2 . The trend in publications takes three periods: A formative stage (2000–2012) of intermittent publications at fewer than 3 papers yearly. A developmental stage (2013–2017) of moderate but variable growth (5–8 papers yearly); and An acceleration stage (2018–2025) of exponential growth with 22–28 papers yearly by 2022–2025. This non-linear growth pattern illustrates an inflection point beginning in late 2017, which represents a paradigm shift in research prioritization. The inflection point is coincident with several external events: publication of the Lancet Commission on Global Mental Health (2018), WHO's incorporation of mental health into the Sustainable Development Goals framework, and increased availability of funding for global psycho-oncology research from major foundations. The notable growth from 2018 onwards coincides with global policy initiatives emphasizing mental health integration into cancer care. Overall, the period between 2017 and 2023 recorded an approximately eightfold increase in annual publication volume. Subject and Journal Distribution Patterns Analysis by discipline revealed that most publications were indexed under Medicine (83.8%, n = 145), followed by Biochemistry/Genetics/Molecular Biology (13.3%, n = 23), Psychology (11.6%, n = 20), and Nursing (11.0%, n = 19). Only a small proportion appeared in the Social Sciences (1.2%) and Humanities (0.6%), suggesting limited interdisciplinary engagement. Journal-level analysis reveals a dispersed dissemination environment with 173 papers spread out in 88 journals, giving a high dispersion ratio of 0.51 (where 1.0 would signify complete dispersion). The most frequent publication outlets were PLOS One and Psycho-Oncology (each 4.6%, n = 8), followed by Asian Pacific Journal of Cancer Prevention (2.3%, n = 4). Most papers appeared in international rather than regional journals, reflecting uneven access to local publication platforms (Fig. 3 ). Geographic and Institutional Distribution Geographically, research output was dominated by a few countries. India (24.3%, n = 42), Ethiopia (18.5%, n = 32), and Pakistan (8.7%, n = 15) accounted for over half of all LMIC publications. High-income countries also contributed substantially through collaborations, with the United States (15.0%, n = 26) and United Kingdom (8.1%, n = 14) ranking among the top five contributors. Institutionally, output was concentrated among a few centers. Addis Ababa University (n = 12), University of Gondar (n = 9), and Bahir Dar University (n = 6) were the leading institutions, collectively producing 28.6% of total publications. Ethiopia’s research output appeared centralized around a few key universities, whereas India exhibited a more distributed institutional structure. Figure 4 visualizes the collaborative research efforts between countries in the study of depression among cancer patients in Low- and Middle-Income Countries. The size of the country shading indicates the volume of publications, while the thickness of the lines represents the strength of co-authorship between nations. Co-authorship Network Analysis The co-authorship network (Fig. 5 ) revealed regionally clustered collaborations with limited cross-regional integration. The largest cluster, led by Pakistani researchers (e.g., Zahid N., Ahmad K., Bhamani S.S., Asad N.), demonstrated strong internal connections but few external partnerships. Similar patterns were observed across other large clusters, indicating nationally focused collaboration. Between 2020 and 2022, newer clusters emerged with greater inter-country linkages, suggesting gradual diversification and growth of collaborative networks. However, minimal overlap existed between researchers studying epidemiological factors and those developing interventions, highlighting a gap in translational collaboration within the field. Thematic Analysis of the Keywords Keyword analysis identified four major thematic clusters (see Fig. 6 ), reflecting the conceptual structure of research on depression among cancer patients in LMICs: Cluster 1: Methodological Aspects Emphasized epidemiological and statistical studies featuring terms such as “data,” “p value,” and “confidence interval.” Research was often country-specific, particularly from Ethiopia, and primarily focused on prevalence and risk associations. Cluster 2: Clinical Assessment and Quality of Life Focused on measurement tools such as “depression scale,” “HADS,” and “HRQoL,” frequently used in studies from India. This cluster represented efforts to assess the psychological and physical dimensions of cancer-related depression. Cluster 3: Cancer Types and Treatment Dimension Highlighted disease-specific focus areas especially “breast cancer,” “cervical cancer,” and “surgery” and their associations with “depressive disorder” and “risk factors.” This cluster underscored the dominance of female cancer types in the literature. Cluster 4: Evidence Synthesis and Intervention Included terms such as “intervention,” “systematic review,” “meta-analysis,” and “mental health.” These publications reflected a more recent shift (average publication year- 2022) toward evidence-based approaches and intervention-oriented studies. Together, these clusters illustrate a transition in the field from descriptive epidemiology toward more comprehensive, evidence-informed psycho-oncology research. Discussion This bibliometric review constitutes the first total overview of research on depression in cancer patients in LMICs, and includes an overall analysis of the development, state, and directions of the field. Our data demonstrates meaningful patterns and accompanying consequences regarding the organisation of research, translation to clinical practice, and policy formulation. Research Growth and Evolution The sharp increase in publications since 2018 (850%) exhibits increasing recognition of psychosocial elements of cancer care. This may be considered analogous to the "catch-up science" observed in other areas of global health, which often involves increased research activities in neglected areas of research, more rapidly, once identified as a research priority. This increase coincides with the Lancet Commission on Global Mental Health (2018) ( 15 ), which illustrates the multifaceted interconnections between global health agenda-setting, funding priorities, and research interest. Importantly, the transition from descriptive studies of prevalence to more sophisticated analyses of predictors, quality of life, and interventions suggests a gradual shift toward applied and translational research. This evolution indicates that psycho-oncology in LMICs is maturing beyond epidemiological mapping toward generating actionable knowledge for clinical and policy implementation. Geographic Disparities The dominance of publications from a few countries particularly India, Ethiopia, and Pakistan reveals major geographic imbalances. Many LMICs with high cancer burdens and limited psychosocial support systems remain underrepresented. This pattern reflects structural inequities in research capacity, infrastructure, and funding. The relationship between national research productivity and cancer mortality-to-incidence ratios ( 16 ) suggests a paradox: countries facing the greatest cancer-related psychosocial challenges contribute the least to the evidence base ( 17 ). Addressing this imbalance requires targeted investment in research capacity, particularly in underrepresented regions such as Sub-Saharan Africa (outside Ethiopia) and Southeast Asia. Building sustainable psycho-oncology research networks will require multi-level interventions enhancing local academic infrastructure, promoting equitable funding models, and supporting mentorship and collaboration programs that empower LMIC researchers to lead and disseminate their own findings. International Collaboration: Opportunities and Gaps Collaboration networks remain fragmented and regionally clustered, with limited cross-regional integration. Most partnerships occur between high-income countries (HICs) and select LMIC institutions, often driven by funding structures and established academic relationships. While these collaborations contribute valuable capacity building, they also risk perpetuating dependency and limiting local research autonomy. Encouraging South-South collaborations ( 18 ) where LMIC institutions partner directly with one another could foster shared learning based on contextual similarities and accelerate methodological innovation suited to local realities. Future international partnerships should prioritize equitable authorship, leadership roles, and agenda-setting power for LMIC researchers to ensure balanced knowledge production. Methodological and Conceptual Challenges The reliance on Western-developed screening instruments (e.g., HADS, PHQ-9) poses challenges for cultural validity in LMIC contexts. These tools often capture symptoms that align poorly with local languages of distress, potentially underestimating or misclassifying depressive experiences. Developing and validating culturally adapted assessment tools is therefore essential for improving the accuracy of depression measurement and comparability across diverse populations. Additionally, the disconnect between studies identifying prevalence and risk factors and those evaluating interventions suggests a gap in translational research. Few studies link the identification of psychological burden to the testing of context-appropriate interventions. Strengthening this research continuum from problem identification to solution development should be a central focus of future psycho-oncology research agendas. Strategic Directions and Future Research Priorities Based on the bibliometric mapping, several strategic priorities emerge for advancing this field: Capacity Building : Establish regional centers of excellence in psycho-oncology research within LMICs and support early-career investigator networks. Equitable Collaboration : Promote LMIC-led research consortia and equitable authorship in multinational studies. Methodological Innovatio n: Develop culturally relevant screening and intervention tools using mixed-method designs. Diversity of Focus : Expand research beyond breast and cervical cancers to include male cancers, pediatric oncology, and palliative care populations. Implementation Research : Integrate evidence-based interventions into clinical oncology settings and evaluate their scalability and cost-effectiveness. Findings emphasise the need for integrating mental health research into national cancer control plans, consistent with the WHO Global Initiative for Childhood Cancer and similar psycho-oncology strategies aimed at embedding psychosocial care within comprehensive cancer management in LMICs. Conclusion This bibliometric review provides a valuable map of a growing and emergent research body on depression in cancer patients in low- and middle-income countries (LMICs), although there is a considerable geographic and thematic variation that exists to date. The field has advanced from simply documenting prevalence to the predictors and impacts, however, there remain many gaps in intervention work, cultural adaptation of screening tools, and types of cancer. The noticeable collaboration clusters also offer opportunities for greater knowledge transfer across regions and research team capacities, while the nature of the temporal evolution in research themes suggests that the field is maturing and is becoming more responsive to the potentially complex challenges associated with psycho-oncological care. Given the projected growth of cancer burden in LMICs (and indeed high-income countries), the importance of addressing the psychological aspects of cancer care as part of a continuum of cancer healthcare is becoming increasingly important when providing an optimal package of care to patients. The future of research looking at cancer patients' psychological dimensions should focus on the development of culturally adapted screening and intervention approaches, investing in regions that have more limited research capacity, and enhancing research capacity through the development of cross-national collaborations to enable sharing of knowledge and resources to advance the field. By mapping the current landscape and identifying promising directions, this review aims to inform strategic research investments and policy development to ultimately improve the quality of life and outcomes for cancer patients experiencing depression in LMIC settings. Declarations Conflict of Interest: The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript. Ethical Declaration This study is a bibliometric analysis of published literature. Therefore, ethical approval was not required. Study Registration No study registration was performed. Clinical Trial Number Not Applicable Funding Statement: The authors received no financial support for the research, authorship, and/or publication of this article. Author Contribution Author TZL drafted and manuscript and analysed the data. Author NTTT and FBAH reviewed and finalized the manuscript. Data Availability The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209–49. Caruso R, Nanni MG, Riba M, Sabato S, Mitchell AJ, Croce E, et al. Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review. 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07:37:58","extension":"xml","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63562,"visible":true,"origin":"","legend":"","description":"","filename":"1d45d69b0ee14916b18f7ab4fbf114321structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/3113f62591084e8e47737eac.xml"},{"id":96162220,"identity":"fb755afd-591f-4025-8c31-8aeb081c37a4","added_by":"auto","created_at":"2025-11-18 08:57:41","extension":"html","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71512,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/c509aba17db26a5941258b16.html"},{"id":96250271,"identity":"806407ca-3bdd-4768-af4c-0cfe7950c1a6","added_by":"auto","created_at":"2025-11-19 07:37:54","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":239021,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the selection process of the included studies.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/535726389f5a4bc1f6074b13.jpeg"},{"id":96251178,"identity":"339804a4-93c4-46f8-b4dd-4f3c3c389567","added_by":"auto","created_at":"2025-11-19 07:39:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":81029,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of the number of publications from 2000- April 2025.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/c94c7c6ab841c055373ab94e.png"},{"id":96162218,"identity":"126ba699-d1d7-4c6c-a108-d93957b3f7ae","added_by":"auto","created_at":"2025-11-18 08:57:41","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":178431,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of the source of journals with the highest number of publications\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/c6205ae03c8cb8cad0b0297d.jpeg"},{"id":96249170,"identity":"cf34b1c0-41b2-4adb-8a26-f13115f55633","added_by":"auto","created_at":"2025-11-19 07:30:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":184173,"visible":true,"origin":"","legend":"\u003cp\u003eCountry Collaboration Network in Research on Depression Among Cancer Patients in LMICs (2000-April 2025)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/8bd0273cd0378df6a6dccf4e.png"},{"id":96162227,"identity":"545ba3f9-cd5d-49a5-94e9-392389d1ab5f","added_by":"auto","created_at":"2025-11-18 08:57:41","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":431456,"visible":true,"origin":"","legend":"\u003cp\u003eCo-authorship network analysis in research of Depression Among Cancer Patients in LMICs (2000-April 2025)\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/7b9ebb10e345c293176c0155.png"},{"id":96162224,"identity":"9019da62-a40b-4d6c-a75c-9c775792f9e1","added_by":"auto","created_at":"2025-11-18 08:57:41","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1114948,"visible":true,"origin":"","legend":"\u003cp\u003eKeyword network analysis in research of Depression Among Cancer Patients in LMICs (2000-April 2025)\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/deabcafd51f3df37bddaf18e.png"},{"id":96257142,"identity":"658b62f6-1e4d-41dd-97fc-d1d6814c0e50","added_by":"auto","created_at":"2025-11-19 07:51:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2821779,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8079820/v1/e4482dfa-674c-4194-aeb4-dffb095ec0f7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Bibliometric Review of Depression Among Cancer Patients in Low- and Middle-Income Countries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer has remained a prominent contributor to morbidity and mortality globally, with a disproportionate burden increasingly shifting to Low- and Middle-Income Countries (LMICs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Disorders of psychological distress often affect cancer survivors beyond the physical presentation of illnesses and treatment, making depression one of the most prevalent mental health comorbidities (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Meta-analyses estimate that between 8% and 24% of cancer patients experience depression which can be significantly higher than general population estimates (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) whereas one of the studies (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)showed that severe depressive symptoms are observed in about 25% of cancer patients, and this rate increases to 77% among those with advanced disease.\u003c/p\u003e\u003cp\u003eThe distress of depression generally amplifies in LMIC settings, compounded by limited mental health resources and service, delays in diagnoses, the stigma of mental instability, and lack of psycho-oncological services (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite these hurdles, the last few decades have seen increased research interest in the psychological elements of cancer care in LMICs, demonstrating more awareness of the need for a comprehensive approach to cancer management that recognizes the relative importance of both physical and human needs (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This disparity underscores the broader challenge of integrating psycho-oncology within the global mental health agenda, as emphasized in the WHO Comprehensive Mental Health Action Plan 2013\u0026ndash;2030, which calls for equitable inclusion of mental health in all disease care pathways, including cancer.\u003c/p\u003e\u003cp\u003eBibliometric analysis provides a solid methodological approach to identify the topography of scientific production in a particular domain of interest, yielding data on trends in research, landmark contributions, collaborative networks, and theme development (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Several bibliometric analyses have been conducted in relation to cancer research (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and mental health research in these settings (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, no systematic bibliometric analysis has so far probed the intersection of these two subfields; the research on depression in cancer patients in LMICs.\u003c/p\u003e\u003cp\u003eThis review seeks to bridge this gap by systematically mapping and analyzing scientific literature on depression in cancer patients in LMICs from the year 2000 to April 2025 using bibliometric methods. The objectives of the study are to;\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eQuantify trends in publication and scientific production in the field overtime\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDetermine the most influential countries, institutions, authors, and journals contributing to this area of research\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExamine collaboration patterns and research networks among institutions and researchers\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExplore the landscape of themes and the evolution of research themes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIdentify literature gaps and suggest areas for further research\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eBy critical examination of the existing research on depression among cancer patients in LMICs, this review aims to inform researchers, clinicians, policymakers, and funding agencies about what is now known, what is currently trending, and what still needs to be investigated in this important yet low-priority area of psycho-oncology.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Data Source\u003c/h2\u003e\u003cp\u003eThis bibliometric review was conducted following the established guidelines for science mapping and bibliometric analysis (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Data were retrieved from the Scopus database, selected for its broad coverage of peer-reviewed literature and structured metadata suitable for bibliometric analysis, particularly for LMIC research outputs. Data extraction was performed on April 30, 2025, ensuring inclusion of all records published between January 1, 2000 and April 30, 2025.\u003c/p\u003e\u003cp\u003eAlthough Scopus offers extensive coverage, it may underrepresent non-indexed or non-English-language journals common in LMICs. Nonetheless, it remains the most comprehensive database for large-scale, structured bibliometric data suitable for quantitative mapping.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive search string combined terms related to cancer, depression, prevalence/predictors, and LMICs. The Boolean search syntax was:\u003c/p\u003e\u003cp\u003e(cancer OR neoplasm* OR tumor* OR tumour* OR oncology) AND (depression OR \"depressive symptoms\" OR \"depressive disorder\") AND (prevalence OR epidemiology OR \"epidemiological study\" OR \"risk factor*\" OR predictor* OR determinant* OR \"associated factor*\") AND ([list of LMICs as defined by World Bank])\u003c/p\u003e\u003cp\u003eThe search was limited to English peer-reviewed articles. Reference lists were screened to identify additional relevant studies.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eStudies were included if they: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) focused on depression or depressive symptoms with cancer patients; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) conducted in or focused on LMICs as defined by the World Bank; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) focused on prevalence, predictors, risk factors, or associated factors of depression; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) original research articles published in peer-reviewed journals; and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) had full bibliometric metadata.\u003c/p\u003e\u003cp\u003eExclusion criteria included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) studies that did not relate to cancer or depression; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) intervention trials without prevalence or risk factor reporting; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) editorials, letters, protocols, case reports, and conference abstracts; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) studies that were conducted in high-income countries; and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) articles that did not contain full bibliometric metadata.\u003c/p\u003e\u003cp\u003eThe initial search returned 425 publications, which were reviewed initially based on titles and abstracts. Following adherence to inclusion and exclusion criteria, 173 publications were included in the final analysis as per figure (1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eData Extraction and Analysis\u003c/h3\u003e\n\u003cp\u003eThe bibliographic data for the 173 publications was extracted from Scopus in CSV format, including Authors, title, abstract, keywords, journal, publication year, citations, affiliations, and countries. The data was cleaned and standardized to ensure consistent author names, keywords, and institutional affiliations.\u003c/p\u003e\u003cp\u003eQuantitative bibliometric analyses were conducted using Bibliometrix (R package) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and a VOSviewer (version 1.6.19), a software application for building and visualizing bibliometric networks (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The following analyses were conducted:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePublication trends analysis: Examining the distribution of publications over time and across journals, countries, and institutions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCo-authorship analysis: Identifying collaboration patterns among authors, institutions, and countries.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCitation analysis: Examining citation patterns to identify influential publications, authors, and journals.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eKeyword co-occurrence analysis: Analyzing the co-occurrence of author keywords and index keywords to identify research themes and clusters.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTemporal analysis: Examining the evolution of research themes over time through overlay visualization.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThresholds were set to optimize interpretability: a minimum of 2 documents for authors, institutions, and countries, and 10 keyword occurrences for inclusion in network maps. Cluster identification was performed using the association strength algorithm in VOSviewer.\u003c/p\u003e\n\u003ch3\u003eMethodological Considerations\u003c/h3\u003e\n\u003cp\u003eThe use of a single database (Scopus) may underrepresent LMIC publications from non-indexed or regional journals, potentially biasing geographic and linguistic representation. In addition, focusing exclusively on peer-reviewed journal articles excludes gray literature, Non-Governmental Organisation (NGO) reports, and national guidelines that may hold contextual relevance. The World Bank\u0026rsquo;s LMIC classification also encompasses countries with wide variability in health systems and research infrastructure, which should be considered when interpreting geographic disparities in publication output.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003ePublication Trajectory\u003c/h2\u003e\u003cp\u003eA bibliometric review identified 173 papers that met the inclusion criteria between 2000 and April 2025 as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The trend in publications takes three periods:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eA formative stage (2000\u0026ndash;2012) of intermittent publications at fewer than 3 papers yearly.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eA developmental stage (2013\u0026ndash;2017) of moderate but variable growth (5\u0026ndash;8 papers yearly); and\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAn acceleration stage (2018\u0026ndash;2025) of exponential growth with 22\u0026ndash;28 papers yearly by 2022\u0026ndash;2025.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThis non-linear growth pattern illustrates an inflection point beginning in late 2017, which represents a paradigm shift in research prioritization. The inflection point is coincident with several external events: publication of the Lancet Commission on Global Mental Health (2018), WHO's incorporation of mental health into the Sustainable Development Goals framework, and increased availability of funding for global psycho-oncology research from major foundations.\u003c/p\u003e\u003cp\u003eThe notable growth from 2018 onwards coincides with global policy initiatives emphasizing mental health integration into cancer care. Overall, the period between 2017 and 2023 recorded an approximately eightfold increase in annual publication volume.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSubject and Journal Distribution Patterns\u003c/h3\u003e\n\u003cp\u003eAnalysis by discipline revealed that most publications were indexed under Medicine (83.8%, n\u0026thinsp;=\u0026thinsp;145), followed by Biochemistry/Genetics/Molecular Biology (13.3%, n\u0026thinsp;=\u0026thinsp;23), Psychology (11.6%, n\u0026thinsp;=\u0026thinsp;20), and Nursing (11.0%, n\u0026thinsp;=\u0026thinsp;19). Only a small proportion appeared in the Social Sciences (1.2%) and Humanities (0.6%), suggesting limited interdisciplinary engagement.\u003c/p\u003e\u003cp\u003eJournal-level analysis reveals a dispersed dissemination environment with 173 papers spread out in 88 journals, giving a high dispersion ratio of 0.51 (where 1.0 would signify complete dispersion). The most frequent publication outlets were PLOS One and Psycho-Oncology (each 4.6%, n\u0026thinsp;=\u0026thinsp;8), followed by Asian Pacific Journal of Cancer Prevention (2.3%, n\u0026thinsp;=\u0026thinsp;4). Most papers appeared in international rather than regional journals, reflecting uneven access to local publication platforms (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eGeographic and Institutional Distribution\u003c/h2\u003e\u003cp\u003eGeographically, research output was dominated by a few countries. India (24.3%, n\u0026thinsp;=\u0026thinsp;42), Ethiopia (18.5%, n\u0026thinsp;=\u0026thinsp;32), and Pakistan (8.7%, n\u0026thinsp;=\u0026thinsp;15) accounted for over half of all LMIC publications. High-income countries also contributed substantially through collaborations, with the United States (15.0%, n\u0026thinsp;=\u0026thinsp;26) and United Kingdom (8.1%, n\u0026thinsp;=\u0026thinsp;14) ranking among the top five contributors.\u003c/p\u003e\u003cp\u003eInstitutionally, output was concentrated among a few centers. Addis Ababa University (n\u0026thinsp;=\u0026thinsp;12), University of Gondar (n\u0026thinsp;=\u0026thinsp;9), and Bahir Dar University (n\u0026thinsp;=\u0026thinsp;6) were the leading institutions, collectively producing 28.6% of total publications. Ethiopia\u0026rsquo;s research output appeared centralized around a few key universities, whereas India exhibited a more distributed institutional structure.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e visualizes the collaborative research efforts between countries in the study of depression among cancer patients in Low- and Middle-Income Countries. The size of the country shading indicates the volume of publications, while the thickness of the lines represents the strength of co-authorship between nations.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eCo-authorship Network Analysis\u003c/h2\u003e\u003cp\u003eThe co-authorship network (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) revealed regionally clustered collaborations with limited cross-regional integration. The largest cluster, led by Pakistani researchers (e.g., Zahid N., Ahmad K., Bhamani S.S., Asad N.), demonstrated strong internal connections but few external partnerships. Similar patterns were observed across other large clusters, indicating nationally focused collaboration.\u003c/p\u003e\u003cp\u003eBetween 2020 and 2022, newer clusters emerged with greater inter-country linkages, suggesting gradual diversification and growth of collaborative networks. However, minimal overlap existed between researchers studying epidemiological factors and those developing interventions, highlighting a gap in translational collaboration within the field.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eThematic Analysis of the Keywords\u003c/h2\u003e\u003cp\u003eKeyword analysis identified four major thematic clusters (see Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), reflecting the conceptual structure of research on depression among cancer patients in LMICs:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCluster 1: Methodological Aspects\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eEmphasized epidemiological and statistical studies featuring terms such as \u0026ldquo;data,\u0026rdquo; \u0026ldquo;p value,\u0026rdquo; and \u0026ldquo;confidence interval.\u0026rdquo; Research was often country-specific, particularly from Ethiopia, and primarily focused on prevalence and risk associations.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCluster 2: Clinical Assessment and Quality of Life\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eFocused on measurement tools such as \u0026ldquo;depression scale,\u0026rdquo; \u0026ldquo;HADS,\u0026rdquo; and \u0026ldquo;HRQoL,\u0026rdquo; frequently used in studies from India. This cluster represented efforts to assess the psychological and physical dimensions of cancer-related depression.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCluster 3: Cancer Types and Treatment Dimension\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eHighlighted disease-specific focus areas especially \u0026ldquo;breast cancer,\u0026rdquo; \u0026ldquo;cervical cancer,\u0026rdquo; and \u0026ldquo;surgery\u0026rdquo; and their associations with \u0026ldquo;depressive disorder\u0026rdquo; and \u0026ldquo;risk factors.\u0026rdquo; This cluster underscored the dominance of female cancer types in the literature.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCluster 4: Evidence Synthesis and Intervention\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eIncluded terms such as \u0026ldquo;intervention,\u0026rdquo; \u0026ldquo;systematic review,\u0026rdquo; \u0026ldquo;meta-analysis,\u0026rdquo; and \u0026ldquo;mental health.\u0026rdquo; These publications reflected a more recent shift (average publication year- 2022) toward evidence-based approaches and intervention-oriented studies.\u003c/p\u003e\u003cp\u003eTogether, these clusters illustrate a transition in the field from descriptive epidemiology toward more comprehensive, evidence-informed psycho-oncology research.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis bibliometric review constitutes the first total overview of research on depression in cancer patients in LMICs, and includes an overall analysis of the development, state, and directions of the field. Our data demonstrates meaningful patterns and accompanying consequences regarding the organisation of research, translation to clinical practice, and policy formulation.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eResearch Growth and Evolution\u003c/h2\u003e\u003cp\u003eThe sharp increase in publications since 2018 (850%) exhibits increasing recognition of psychosocial elements of cancer care. This may be considered analogous to the \"catch-up science\" observed in other areas of global health, which often involves increased research activities in neglected areas of research, more rapidly, once identified as a research priority. This increase coincides with the Lancet Commission on Global Mental Health (2018) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), which illustrates the multifaceted interconnections between global health agenda-setting, funding priorities, and research interest.\u003c/p\u003e\u003cp\u003eImportantly, the transition from descriptive studies of prevalence to more sophisticated analyses of predictors, quality of life, and interventions suggests a gradual shift toward applied and translational research. This evolution indicates that psycho-oncology in LMICs is maturing beyond epidemiological mapping toward generating actionable knowledge for clinical and policy implementation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eGeographic Disparities\u003c/h2\u003e\u003cp\u003eThe dominance of publications from a few countries particularly India, Ethiopia, and Pakistan reveals major geographic imbalances. Many LMICs with high cancer burdens and limited psychosocial support systems remain underrepresented. This pattern reflects structural inequities in research capacity, infrastructure, and funding.\u003c/p\u003e\u003cp\u003eThe relationship between national research productivity and cancer mortality-to-incidence ratios (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) suggests a paradox: countries facing the greatest cancer-related psychosocial challenges contribute the least to the evidence base (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Addressing this imbalance requires targeted investment in research capacity, particularly in underrepresented regions such as Sub-Saharan Africa (outside Ethiopia) and Southeast Asia.\u003c/p\u003e\u003cp\u003eBuilding sustainable psycho-oncology research networks will require multi-level interventions enhancing local academic infrastructure, promoting equitable funding models, and supporting mentorship and collaboration programs that empower LMIC researchers to lead and disseminate their own findings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eInternational Collaboration: Opportunities and Gaps\u003c/h2\u003e\u003cp\u003eCollaboration networks remain fragmented and regionally clustered, with limited cross-regional integration. Most partnerships occur between high-income countries (HICs) and select LMIC institutions, often driven by funding structures and established academic relationships. While these collaborations contribute valuable capacity building, they also risk perpetuating dependency and limiting local research autonomy.\u003c/p\u003e\u003cp\u003eEncouraging South-South collaborations (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) where LMIC institutions partner directly with one another could foster shared learning based on contextual similarities and accelerate methodological innovation suited to local realities. Future international partnerships should prioritize equitable authorship, leadership roles, and agenda-setting power for LMIC researchers to ensure balanced knowledge production.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eMethodological and Conceptual Challenges\u003c/h2\u003e\u003cp\u003eThe reliance on Western-developed screening instruments (e.g., HADS, PHQ-9) poses challenges for cultural validity in LMIC contexts. These tools often capture symptoms that align poorly with local languages of distress, potentially underestimating or misclassifying depressive experiences. Developing and validating culturally adapted assessment tools is therefore essential for improving the accuracy of depression measurement and comparability across diverse populations.\u003c/p\u003e\u003cp\u003eAdditionally, the disconnect between studies identifying prevalence and risk factors and those evaluating interventions suggests a gap in translational research. Few studies link the identification of psychological burden to the testing of context-appropriate interventions. Strengthening this research continuum from problem identification to solution development should be a central focus of future psycho-oncology research agendas.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrategic Directions and Future Research Priorities\u003c/h2\u003e\u003cp\u003eBased on the bibliometric mapping, several strategic priorities emerge for advancing this field:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCapacity Building\u003c/b\u003e: Establish regional centers of excellence in psycho-oncology research within LMICs and support early-career investigator networks.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEquitable Collaboration\u003c/b\u003e: Promote LMIC-led research consortia and equitable authorship in multinational studies.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMethodological Innovatio\u003c/b\u003en: Develop culturally relevant screening and intervention tools using mixed-method designs.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDiversity of Focus\u003c/b\u003e: Expand research beyond breast and cervical cancers to include male cancers, pediatric oncology, and palliative care populations.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eImplementation Research\u003c/b\u003e: Integrate evidence-based interventions into clinical oncology settings and evaluate their scalability and cost-effectiveness.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFindings emphasise the need for integrating mental health research into national cancer control plans, consistent with the WHO Global Initiative for Childhood Cancer and similar psycho-oncology strategies aimed at embedding psychosocial care within comprehensive cancer management in LMICs.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis bibliometric review provides a valuable map of a growing and emergent research body on depression in cancer patients in low- and middle-income countries (LMICs), although there is a considerable geographic and thematic variation that exists to date. The field has advanced from simply documenting prevalence to the predictors and impacts, however, there remain many gaps in intervention work, cultural adaptation of screening tools, and types of cancer. The noticeable collaboration clusters also offer opportunities for greater knowledge transfer across regions and research team capacities, while the nature of the temporal evolution in research themes suggests that the field is maturing and is becoming more responsive to the potentially complex challenges associated with psycho-oncological care. Given the projected growth of cancer burden in LMICs (and indeed high-income countries), the importance of addressing the psychological aspects of cancer care as part of a continuum of cancer healthcare is becoming increasingly important when providing an optimal package of care to patients.\u003c/p\u003e\u003cp\u003eThe future of research looking at cancer patients' psychological dimensions should focus on the development of culturally adapted screening and intervention approaches, investing in regions that have more limited research capacity, and enhancing research capacity through the development of cross-national collaborations to enable sharing of knowledge and resources to advance the field. By mapping the current landscape and identifying promising directions, this review aims to inform strategic research investments and policy development to ultimately improve the quality of life and outcomes for cancer patients experiencing depression in LMIC settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of Interest:\u003c/h2\u003e\u003cp\u003eThe authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Declaration\u003c/strong\u003e\u003cp\u003eThis study is a bibliometric analysis of published literature. Therefore, ethical approval was not required.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eStudy Registration\u003c/h2\u003e\u003cp\u003eNo study registration was performed.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Statement:\u003c/h2\u003e\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor TZL drafted and manuscript and analysed the data. Author NTTT and FBAH reviewed and finalized the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCaruso R, Nanni MG, Riba M, Sabato S, Mitchell AJ, Croce E, et al. Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review. Acta Oncol. 2017;56(2):146\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePitman A, Suleman S, Hyde N, Hodgkiss A. Depression and anxiety in patients with cancer. BMJ. 2018;361:k1415.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrebber AMH, Buffart LM, Kleijn G, Riepma IC, de Bree R, Leemans CR, et al. Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psychooncology. 2014;23(2):121\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBattat M, Omair N, WildAli MA, Alkaissi A, Amer R, Koni AA, et al. Assessment of depression symptoms among cancer patients: a cross-sectional study from a developing country. Sci Rep. 2024;14(1):11934.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePramesh CS, Badwe RA, Bhoo-Pathy N, Booth CM, Chinnaswamy G, Dare AJ, et al. Priorities for cancer research in low- and middle-income countries: a global perspective. Nat Med. 2022;28(4):649\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGyawali B, Sharma S, Shilpakar R, Dulal S, Pariyar J, Booth CM, et al. Overview of Delivery of Cancer Care in Nepal: Current Status and Future Priorities. JCO Glob Oncol. 2020 July;6:1211\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEllegaard O, Wallin JA. The bibliometric analysis of scholarly production: How great is the impact? Scientometrics. 2015;105(3):1809\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu Z, Gao X, Ren B, Zhang S, Xu L. A bibliometric analysis of segmentectomy versus lobectomy for non-small cell lung cancer research (1992\u0026ndash;2019). Med (Baltim). 2021;100(13):e25055.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMilley K, Chima S, Karnchanachari N, McNamara M, Druce P, Emery J. General practice-based cancer research publications: a bibliometric analysis 2013\u0026ndash;2019. Br J Gen Pract. 2023;73(727):e133\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNiazi S, Vargas E, Spaulding A, Gustetic E, Ford N, Paly D, et al. Barriers to accepting mental health care in cancer patients with depression. Soc Work Health Care. 2020 July;59(6):351\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin TZ, Thet Lwin ZM, Aung LT, Tuyenthi Thanh NTT, Htet S. Global overview of psychological first aid (PFA) in disaster contexts: a bibliometric review to inform social work practice. Social Work Mental Health 0(0):1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAria M, Cuccurullo C. \u003cem\u003ebibliometrix\u003c/em\u003e: An R-tool for comprehensive science mapping analysis. Journal of Informetrics. 2017;11(4):959\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Eck NJ, Waltman L. VOS Viewer 1.6.2 [Internet]. 2019. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.vosviewer.com/documentation/Manual_VOSviewer_1.6.11.pdf\u003c/span\u003e\u003cspan address=\"https://www.vosviewer.com/documentation/Manual_VOSviewer_1.6.11.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018;392(10157):1553\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoi E, Lee S, Nhung BC, Suh M, Park B, Jun JK, et al. Cancer mortality-to-incidence ratio as an indicator of cancer management outcomes in Organization for Economic Cooperation and Development countries. Epidemiol Health. 2017;39:e2017006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiehl TM, Ahmed KS, Pourdashti S, Stalter L, Hellner J, Harrison EM et al. Disparities in Cancer Mortality Worldwide: A Novel Metric for Measuring Global Disparities and Prioritizing Cancer Control Efforts. JCO Glob Oncol. 2025;(11):e2400336.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGray K, Gills BK. South\u0026ndash;South cooperation and the rise of the Global South. Third World Q. 2016;37(4):557\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dimh","sideBox":"Learn more about [Discover Mental Health](https://www.springer.com/44192)","snPcode":"","submissionUrl":"","title":"Discover Mental Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Depression, Cancer, Psycho-oncology, Mental health, Bibliometric analysis","lastPublishedDoi":"10.21203/rs.3.rs-8079820/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8079820/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eDepression is an important comorbidity among cancer patients, particularly in resource-limited settings. This bibliometric review aims to map and describe the scientific landscape of approaches to understanding depression among cancer patients in Low- and Middle-Income Countries (LMICs).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA bibliometric analysis of research on depression among cancer patients was conducted using data from Scopus. The quantitative bibliometric analysis was performed using the Bibliometrix R package and the VOSviewer platform. The bibliometric analysis analyzed the publication output, keyword co-occurrence to profile publication trends, research hotspots, leading authors, countries, institutions, and collaboration networks.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe analysis identified 173 eligible publications. The output consistently increased after 2018. Overall, the highest number of publications were produced by India (n\u0026thinsp;=\u0026thinsp;42), Ethiopia (n\u0026thinsp;=\u0026thinsp;32), and the United States (n\u0026thinsp;=\u0026thinsp;26). The dominant research themes included studies of breast cancer (n\u0026thinsp;=\u0026thinsp;38), depression scale (n\u0026thinsp;=\u0026thinsp;46), and data (n\u0026thinsp;=\u0026thinsp;58). The co-authorship analysis identified distinct collaborative clusters while the keyword analysis identified four major thematic clusters: methodological aspects, clinical assessment, cancer type and treatment dimensions, and evidence synthesis \u0026amp; interventions. The temporal analysis revealed an evolution from predominantly basic studies of prevalence, toward increased sophistication in research on predictors and interventions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis review highlights the growing research interest in depression among cancer patients in LMICs, while geographic and thematic gaps remain. While breast cancer dominates literature, other prevalent cancers remain understudied. Future research must focus on developing culturally adapted screening tools, implementing context-specific interventions, and increasing international collaboration to address the psycho-oncological needs of cancer patients in low-resource settings.\u003c/p\u003e","manuscriptTitle":"A Bibliometric Review of Depression Among Cancer Patients in Low- and Middle-Income Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-18 08:57:36","doi":"10.21203/rs.3.rs-8079820/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-19T07:52:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-12T09:48:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-12T09:45:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Mental Health","date":"2025-11-10T18:19:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dimh","sideBox":"Learn more about [Discover Mental Health](https://www.springer.com/44192)","snPcode":"","submissionUrl":"","title":"Discover Mental Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d758dad-af22-4b58-87fa-4b083b7a5dab","owner":[],"postedDate":"November 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T14:27:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-18 08:57:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8079820","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8079820","identity":"rs-8079820","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}