Prevalence of depression and anxiety among patients with breast cancer in Jeddah, Saudi Arabia

Lubna Abdulrahman Hafiz 1 , Hind Mauafaq Aljifri 2 , Shahad Muneer Abdulaal 3*, Rinad Tariq Siddiqi 4 , Asma Khalid Alamoudi 5
Authors affiliations:
  1. Lubna Abdulrahman Hafiz, College of Medicine, Fakeeh College for Medical Sciences, Jeddah, KSA; Email: Lahafiz@fcms.edu.sa
  2. Hind Mauafaq Aljifri, College of Medicine, Fakeeh College for Medical Sciences, Jeddah, KSA; Email: Hind.aljifri@gmail.com
  3. Shahad Muneer Abdulaal, College of Medicine, Fakeeh College for Medical Sciences, Jeddah, KSA; Email: shahadabdulaal1995@gmail.com
  4. Rinad Tariq Siddiqi, College of Medicine, Fakeeh College for Medical Sciences, Jeddah, KSA; Email: Rinad.siddiqi@gmail.com
  5. Asma Khalid Alamoudi, College of Medicine, Fakeeh College for Medical Sciences, Jeddah, KSA; Email: asmaalamoudiiiii@gmail.com
Correspondence: Shahad Muneer Abdulaal, Email: shahadabdulaal1995@gmail.com
 

ABSTRACT

 

Background & objective:  To accept a cancer diagnosis to the patients by the healthcare professionals, and to it by the patients, often remains the most challenging part of the entire procedure for many survivors of primary or recurrent breast cancer. This study aimed to examine the prevalence of depression and anxiety among patients with breast cancer in Jeddah, Saudi Arabia.

Methodology: A cross-sectional survey study was conducted in Jeddah, Saudi Arabia, between November 2024 and February 2025, to examine the prevalence of depression and anxiety among adult female patients aged over 18 years diagnosed with breast cancer. The convenience sampling technique was utilized in this research. The research participation link was circulated through social media platforms, including Facebook and WhatsApp. PHQ-9 and GAD-7 scales were utilized to measure the prevalence of anxiety and depression.

Results: A total of 137 breast cancer patients were included in the analysis. Anxiety levels were distributed among patients as follows: 46 (33.6%) had mild anxiety, 50 (36.5%) had moderate anxiety, and 41 (29.9%) experienced severe anxiety. Depression severity varied; 11 (8.0%) reported mild symptoms, 54 (39.4%) experienced moderate depression, 42 (30.7%) had moderately severe depression, and 30 (21.9%) suffered from severe depression. The GAD-7 mean score was (12.6 ± 4.9) out of 21, and the PHQ-9 mean score was (15.8 ± 5.21) out of 27. Patients who underwent radiotherapy had significantly higher odds of experiencing depression (P = 0.02) and a nearly significant association with anxiety (P = 0.05). Additionally, surgery showed a borderline protective association with anxiety (P  = 0.05).

Conclusion: Depression and anxiety are common psychological illnesses among females with breast cancer. Psychological intervention should be directed towards high-risk patients. Psychological support program should be facilitated for the patients in order to improve their clinical outcomes.

Abbreviations: GAD-7: Generalized Anxiety Disorder Scale-7, PHQ-9: Patient Health Questionnaire-9, SAR: Saudi Arabian Riyals,

Keywords: Anxiety; Breast cancer; Depression; Saudi Arabia

Citation: Hafiz LA, Aljifri HM, Abdulaal SM, Siddiqi RT, Alamoudi AK. Prevalence of Depression and Anxiety among Patients with Breast Cancer in Jeddah, Saudi Arabia. Anaesth. pain intensive care 2025;29(7):685-693. DOI: 10.35975/apic.v29i7.2953

Received: April 17, 2025; Revised: April 21, 2025; Accepted:  April 28, 2025.

 

1. INTRODUCTION

 

Breast cancer is a serious public health issue and the primary cause of cancer-related deaths among women globally.1 It is projected that there would be 17 million cancer deaths and 27 million new cancer cases worldwide in 2030.2 In a population of 33,554,333, Saudi Arabia reported 10,518 cancer-related fatalities and 24,485 new cancer cases in 2018.3 Compared to 20% in industrialized nations, over 50% of breast cancer cases in Saudi Arabia are diagnosed at an advanced stage.3 Although death rates are frequently lower in high-income nations because of improved access to early detection and treatment, high-income countries generally have higher incidence rates than low- and middle-income ones.4
Regarding the variables that raise the risk of breast cancer, they can be linked to genetic, hormonal, and environmental factors, which are the primary risk factors for the disease and show a higher frequency in women over 50.5 Different cancer therapies and drugs are available, including radiation therapy and surgery to treat a particular tumor or part of the body, as well as chemical treatments like immunotherapy, chemotherapy, and targeted therapy. The adverse effects of cancer treatments are numerous. Adverse effects may differ between medications and treatment modalities, as well as between individuals.6-9
The diagnosis itself can contribute to or worsen poor mental health.10,11 Receiving a cancer diagnosis was often the most challenging part of the entire procedure for many survivors of primary or recurrent breast cancer.12 Anxiety and depression are common psychological illnesses among patients diagnosed with cancer in both inpatient and outpatient settings.13 According to previous review articles, anxiety symptoms are widespread and last throughout the course of cancer therapy in individuals with newly diagnosed breast cancer.14-16 According to another analysis, after receiving a breast cancer diagnosis, more than 22% of women have symptoms of depression.16 This research aimed to examine the prevalence of anxiety and depression among female patients diagnosed with breast cancer in Saudi Arabia.

 

2. METHODOLOGY

 

2.1. Study design
A cross-sectional survey study was conducted in Jeddah, Saudi Arabia, between November 2024 and February 2025 to examine the prevalence of depression and anxiety among female patients diagnosed with breast cancer.

2.2. Study population and sampling procedure
The study population for this research comprised female patients diagnosed with breast cancer. The inclusion criteria for this study were adult female patients aged over 18 years and currently residing in Saudi Arabia. This research did not exclude eligible patients based on the stage of their disease, socioeconomic status, or type of cancer therapy.

The convenience sampling technique was utilized in this research. The research participation link was circulated through social media platforms, including Facebook and WhatsApp. The research inclusion criteria were mentioned in the invitation letter. Patients who met the inclusion criteria were invited to take part in this research.

2.3. Study instruments
This research examined female cancer patients’ demographic characteristics, including their marital status, nationality, monthly income, education level, smoking status, and disease status. Besides, this research examined patients’ cancer therapy and disease profile (comorbidities, disease duration, and metastasis). The prevalence rates of depressed and anxious symptoms were established using a cut-off point as advised by the developers of the Patient Health Questionnaire 9 (PHQ-9) and Generalized Anxiety Disorder Scale (GAD-7)  scales and utilized in previous research.17-20 Depressive symptomatology will be characterized by a total score of 15 or above on the PHQ-9 instrument, signifying moderately severe or severe depression.21 Anxiety symptomatology will be characterized using the GAD-7 instrument, with a total score of 15 or higher signifying severe anxiety symptoms.22 A higher score indicates a more depressed and anxious severe case.

2.4. Ethical approval
This study was approved by the Institutional Review Board (IRB) at Fakeeh College for Medical Sciences (Approval No: 530/IRB/2023).

2.5. Data analysis
The Statistical Package for the Social Sciences (SPSS) software, version 29 was used to analyze the data for this research. Categorical variables were summarized as frequency and percentage, and the mean and the standard deviation (SD) were utilized to express continuous variables such as the GAD-7 and PHQ-9 scores. Based on the literature, the scores were categorized into four categories; the severe category in both scores was used to define the dummy variables for multiple logistic regression analyses. The findings of the regression analysis were presented as adjusted odds ratios (AOR) with their corresponding 95% confidence interval. The level of significance was defined as a P < 0.05.

 

3. RESULTS

 

A total of 137 breast cancer patients were included in the analysis. Among those, 93 (67.9%) were married, 21 (15.3%) were single, 12 (8.8%) were divorced, and 11 (8.0%) were widowed. The majority were Saudi nationals (n= 99, 72.3%), while 38 (27.7%) were non-Saudi. Regarding monthly income, 69 (50.4%) had more than 7500 SAR (Saudi Arabian Riyals) monthly income, and 25 patients (18.2%) had less than 2500 SAR monthly. Most of the participants (65, 47.4%) had a bachelor's degree, followed by 28 participants who had a high school degree (20.4%). Regarding the smoking status, only 10 patients were currently smoking (7.3%), and 111 patients (81.0%) never smoked. Almost half of the patients were in the first and second stages of their disease (Table 1).

 

Table 1: Demographic characteristics among breast cancer patients
Demographic characteristics N (%)
Marital status Single 21 (15.3)
Married 93 (67.9)
Divorced 12 (8.8)
Widowed 11 (8.0)
Nationality Non-Saudi 38 (27.7)
Saudi 99 (72.3)
Monthly income Less than 2500 SAR 25 (18.2)
2500-5000 SAR 22 (16.1)
5000-7500 SAR 21 (15.3)
More than 7500 SAR 69 (50.4)
Education level Primary school or less 19 (13.9)
High school 28 (20.4)
Diploma 11 (8.0)
Bachelor 65 (47.4)
Post graduate 14 (10.2)
Smoking status Non-Smoking 111 (81.0)
Previous smoking 16 (11.7)
Currently smoking 10 (7.3)
Disease stage Unknown 35 (25.5)
1st degree 34 (24.8)
2nd degree 34 (24.8)
3rd degree 16 (11.7)
4th degree 18 (13.1)
SAR: Saudi Arabia Riyal
 

Table 2 presents the cancer therapies received by the patients. Surgery was performed in 93 (67.9%) patients, while 44 (323.1%) didn’t undergo surgery. Chemotherapy was administered to 83 (60.6%) patients. Furthermore, a total of 81 patients (59.1%) were given radiotherapy, and target therapy was the least common, with only 22 patients (16.1%). Additional details about cancer therapy modalities are provided in Table 2.

 

Table 2: Cancer therapy modalities used
Cancer therapy N (%)
Surgery 93 (67.9)
Chemotherapy 83 (60.6)
Radiotherapy 81 (59.1)
Target therapy 22 (16.1)
Immunotherapy 20 (14.6)
Hormonal therapy 72 (52.6)
Unknown 15 (10.9)
 

The most common comorbidities were hypertension (n= 35, 25.5%), diabetes mellitus (n= 31, 22.6%), and dyslipidemia (n= 24, 17.5%). Disease duration varied, with 39 patients (28.5%) having the cancer for 6-12 months and 34 patients (24.8%) for more than 2 years. The majority of patients (n= 123, 89.8%) didn’t have metastasis (Table 3).

 

Table 3: Comorbidities, disease duration, and mental health in breast cancer patients
Parameters N (%)
Comorbidities Diabetes mellitus 31 (22.6)
Hypertension 35 (25.5)
Cardiovascular diseases 7 (5.1)
Respiratory 11 (8.0)
Dyslipidemia 24 (17.5)
Others 78 (56.9)
Disease duration < 6 months 33 (24.1)
6-12 month 39 (28.5)
1-2 years 31 (22.6)
> 2 years 34 (24.8)
Metastasis Yes 14 (10.2)
Diagnosed with anxiety Yes 23 (16.8)
Diagnosed with depression Yes 14 (10.2)
 

Anxiety levels were distributed among patients as follows: 46 (33.6%) had mild anxiety, 50 (36.5%) had moderate anxiety, and 41 (29.9%) experienced severe anxiety. Depression severity varied, with 11 (8.0%) reporting mild symptoms, 54 (39.4%) experiencing moderate depression, 42 (30.7%) having moderately severe depression, and 30 (21.9%) suffering from severe depression. The GAD-7 mean score was (12.6 ± 4.9) out of 21, and the PHQ-9 mean score was (15.8 ± 5.21) out of 27, (Table 4).

 

Table 4: The GAD-7 and PHQ-9 categories
Depression and anxiety status classification N (%)
GAD-7 Mild 46 (33.6)
Moderate 50 (36.5)
Severe 41 (29.9)
PHQ-9 Mild 11 (8.0)
Moderate 54 (39.4)
Moderately severe 42 (30.7)
Severe 30 (21.9)
GAD-7: Generalized Anxiety Disorder Scale-7,  
PHQ-9: Patient Health Questionnaire-9
 

The most commonly reported issues were feeling tired or having little energy, with 32 (23.4%) experiencing it nearly every day and 67 (48.9%) on several days. Sleep disturbances were also prevalent, with 21 (15.3%) reporting trouble sleeping nearly every day.  Loss of interest or pleasure in activities affected 16 (11.7%) nearly every day, while 48 (35.0%) experienced it on several days. feelings of depression or hopelessness were reported by 7 (5.1%) nearly every day, and 45 (32.8%) on several days. Additional details about the PHQ-9 score are provided in Table 5.

Feeling nervous or anxious was reported by 48 (35.0%) on several days and 9 (6.6%) nearly every day. Excessive worrying was common, with 59 (43.1%) worrying too much on several days and 13 (9.5%) nearly every day. Trouble relaxing affected 52 (38.0%) on several days, while 15 (10.9%) experienced it nearly every day. Irritable mood was also considerable, with 19 (13.9%) feeling easily annoyed more than half the days and 18 (13.1%) nearly every day. Additional details about the GaD-7 score are provided in Table 5.

Patients who underwent radiotherapy had significantly higher odds of experiencing depression (AOR = 3.27, 95% CI: 1.17-9.10, P = 0.02) and nearly significant association with anxiety (AOR=3.14, 95% CI: 0.99-10.01, P = 0.05). Additionally, surgery showed a borderline protective association with anxiety (AOR = 0.29, 95% CI: 0.08-1.01, p =0.05). Additional details about factors associated with anxiety and depression are provided in Table 5.

 

Table 5: Factors associated with anxiety and depression
 
 Factors		 PHQ-9 GAD-7
AOR (95%CI) P value AOR (95%CI) P value
Marital status Single (Reference) 1.00 1.00
Married 1.32 (0.38-4.56) 0.665 0.95 (0.25-3.63) 0.937
Divorced 3.09 (0.45-21.48) 0.253 1.20 (0.18-8.14) 0.849
Widowed 0.95 (0.12-7.38) 0.960 0.10 (0.00-2.02) 0.132
Income < 2500 SAR (Reference) 1.00 1.00
2500-5000 SAR 1.60 (0.34-7.42) 0.551 0.63 (0.13-3.07) 0.565
5000-7500 SAR 1.57 (0.36-6.92) 0.552 0.54 (0.11-2.59) 0.438
More than 7500 SAR 1.14 (0.26-5.03) 0.858 0.62 (0.13-2.81) 0.532
Nationality Non-Saudi (Reference) 1.00 1.00
Saudi 0.85 (0.27-2.66) 0.782 1.26 (0.38-4.21) 0.704
Education level Primary school or less (Reference) 1.00 1.00
High school 1.32 (0.30-5.80) 0.714 0.65 (0.13-3.25) 0.595
Diploma 3.91 (0.55-27.64) 0.171 1.72 (0.23-13.02) 0.601
Bachelor 1.96 (0.40-9.51) 0.403 1.20 (0.21-6.71) 0.836
Post graduate 1.12 (0.16-7.70) 0.907 0.45 (0.04-4.65) 0.500
Smoking Non-Smoking (Reference) 1.00 1.00
Previous smoking 1.82 (0.44-7.43) 0.405 1.27 (0.30-5.33) 0.743
Currently smoking 0.84 (0.18-4.01) 0.826 2.55 (0.51-12.75) 0.255
Disease stage Unknown (Reference) 1.00 1.00
1st degree 0.41 (0.11-1.55) 0.188 1.54 (0.37-6.38) 0.550
2nd degree 0.53 (0.13-2.07) 0.358 1.29 (0.29-5.74) 0.739
3rd degree 0.21 (0.04-1.10) 0.065 0.24 (0.03-2.07) 0.196
4th degree 0.89 (0.19-4.16) 0.883 1.29 (0.27-6.26) 0.752
Surgery No (Reference) 1.00 1.00
Yes 0.44 (0.14-1.34) 0.149 0.29 (0.08-1.01) 0.051
Chemotherapy No (Reference) 1.00 1.00
Yes 2.57 (0.92-7.17) 0.073 2.14 (0.70-6.50) 0.181
Radiotherapy No (Reference) 1.00 1.00
Yes 3.27 (1.17-9.10) 0.023 3.14 (0.99-10.01) 0.053
Target No (Reference) 1.00 1.00
Yes 0.35 (0.11-1.18) 0.091 0.48 (0.12-1.89) 0.291
Immunotherapy No (Reference) 1.00 1.00
Yes 1.28 (0.36-4.49) 0.704 2.46 (0.63-9.65) 0.198
Hormonal therapy No (Reference) 1.00 1.00
Yes 1.17 (0.45-3.01) 0.744 0.73 (0.25-2.13) 0.566
SAR: Saudi Arabia Riyal; GAD-7: Generalized Anxiety Disorder Scale-7; PHQ-9: Patient Health Questionnaire-9
P < 0.05 considered significant
 

4. DISCUSSION

 

This study aimed to examine the prevalence of anxiety and depression among female patients diagnosed with breast cancer in Saudi Arabia. In this study, around half of the patients were in the first and second stages of their disease. Breast cancer is the most prevalent malignancy among Saudi women and in the Saudi population overall. Although approximately 72% of patients achieve a 5-year survival, this rate remains slightly lower than that reported in Western countries.23,24 Low screening rates and a comparatively large percentage of presentations in advanced stages (12.5%) are likely the causes of a decreased survival rate.23 Furthermore, according to a Ministry of Health report, Saudi women are more likely to be diagnosed at an advanced stage, with 57.3% of cases being regional or distant metastatic breast cancers, compared to 37% of cases in the United States.25 The majority of the Saudi Arabian data that is currently available relates to women's and health professionals' attitudes regarding screening, as well as their knowledge and views of it.26
In this study, surgery was performed in 93 (67.9%) patients. The two most common methods of breast surgery are either breast-conserving surgery (lumpectomy) or complete removal of the breast (mastectomy), which is typically followed by breast reconstruction. A lumpectomy involves removing the breast tumor along with a margin of healthy tissue. "No ink on tumor" refers to the absence of tumor cells near the tissue edge, which is the recommended margins status.27 Research indicates that lumpectomy plus irradiation and complete mastectomy are comparable in terms of overall survival (OS) and relapse-free rates.28 The presence of diffuse microcalcifications (suspicious or malignant-appearing), diseases that cannot be included by local excision with a tolerable cosmetic outcome, and ATM (ataxia-telangiesctasia mutated) mutations (biallelic inactivation) are among the conditions that preclude breast-conserving surgery.27
In this study, chemotherapy was administered to 83 (60.6%) of the patients Alkylating agents, antimetabolites, and tubulin inhibitors are among the families of cytotoxic drugs that make up breast cancer chemotherapy.29 Cyclophosphamide is a nitrogen mustard alkylating agent that breaks DNA strands.30 Anthracyclines (doxorubicin, daunorubicin, epirubicin, and idarubicin) work by inducing DNA intercalation, which inhibits macromolecular biosynthesis.30 Taxanes, such as docetaxel and paclitaxel, bind to microtubules and stop them from disassembling, which causes cell cycle arrest and apoptosis.31 Furthermore, a total of 81 patients (59.1%) were given radiotherapy. Since Röngten's discovery of the X-ray in 1895, radiation therapy has been utilized to treat cancer.32 The entire breast or a section of it (after breast-conservative surgery), the chest wall (following mastectomy), and the local lymph nodes are exposed to high-energy radiation.33
A history of anxiety or depression, a younger age at diagnosis, a lack of social support, burdensome somatic symptoms, ongoing cancer treatment, certain medication treatments, concerns about death and disease recurrence, altered body image,34 and changes in femininity, sexuality, and attractiveness 35 are risk factors for anxiety and depression in women with breast cancer. During but not after treatment, adjuvant chemotherapy may raise the risk of anxiety, depression, or both.36. Effective methods of identifying patients who are at risk for psychological distress are essential, as depression and anxiety are common diagnoses after breast cancer.37 In the already taxing emotional state following a breast cancer diagnosis, they compound the challenges brought on by many social and familial issues that worsen the disease, as well as therapeutic approaches like mastectomy and chemotherapy.38
Additionally, psychological distress (depression and anxiety symptoms) has been linked to increased mortality risk and worse physical function.39,40 The prevalence of depression in our study was 30.7% of the patients found to have moderately severe depression, and 30 (21.9%) suffered from severe depression. which is less than the finding of the study that enrolled 74 patients diagnosed with breast cancer in the general surgery clinic at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, which was 36.5%41  and lower than the findings of other studies, which ranged between 49.2% and 68.7%.42,43
Our study found that approximately 29.9% of patients experienced severe anxiety. This is comparable to a previous study conducted at the General Surgery Clinic of King Abdulaziz University Hospital in Jeddah, Saudi Arabia, which reported a generalized anxiety disorder (GAD) prevalence of 24.3%, though this rate was lower than that reported in other studies41 which ranged between 48.6%  and 73.3%.42,43 We hypothesize that the reason our study's results were lower than those of previous articles was that the questionnaire's timing varied depending on the period between diagnosis and management stage, which may have affected respondents' responses.

When undergoing radiation therapy, the patient must lie alone on a table with a large machine overhead, which can cause anxiety, fear, and a sense of isolation. Radiation therapy side effects are also problematic; in the United States, approximately 350,000 cancer patients receive radiation therapy annually, and cancer patients often report fears of the treatment (such as being "burned," or causing sterility, sickness, or vomiting.44
Additionally, 60% of patients experience significant anxiety before treatment, and 80% of them after.42 A previous study found that among 1346 patients receiving radiation therapy for head and neck cancer, 46% experienced emotional distress, 26% experienced anxiety, 9% experienced depression, and 27% experienced claustrophobia. Women were significantly more likely to experience emotional distress, depression, and anxiety (P < 0.001).45 Anxiety is listed as one of the common systemic toxicities of radiation treatment, along with pain, fatigue, and anorexia.46 Therefore, it is possible that the anxiety observed in our patients was a side effect of the radiation.

In our study, surgery showed a borderline protective association with anxiety (AOR = 0.29, 95% CI0.08-1.01, p =0.05). A previous study shows the psychological dysfunction rate among patients who had surgery for breast cancer ranged from 30 to 47%, according to multiple studies on the subject. There was no discernible difference between patients who had a modified radical mastectomy (MRM) and those who had breast-conserving surgery (BCS).47
It is important to identify depression in breast cancer patients because it has significant effects on the course and prognosis of the disease.44 Research has shown that psychological factors, such as stress and depression, can affect a person's overall quality of life and the course of their illness after receiving a cancer diagnosis. For these patients, concurrent psychiatric counseling will improve their quality of life, and psychiatric therapy for cancer patients should aim to increase resilience in addition to treating depression, anxiety, and stress.44
 

5. CONCLUSION

 

Depression and anxiety are common psychological illnesses among females with breast cancer. Psychological intervention should be directed towards high-risk patients. A psychological support program should be facilitated for the patients in order to improve their clinical outcomes.

7. Data availability
The numerical data generated during this research is available with the authors.

8. Ethical considerations
Ethical approval was granted by the institutional ethical committee. Written informed consents were obtained from all of the participants..

9. Conflict of interest
All authors declare that there was no conflict of interest.

10. Funding
The study utilized the hospital resources only, and no external or industry funding was involved.

11. Authors’ contribution
LAH: Conceptualization, investigation, methodology, resources, validation, writing- original draft, writing – review and editing.

HMA; SMA; RTS; AKA: investigation, resources, validation, writing- original draft, writing – review and editing.

 

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