Exploring the interconnectedness of fatigue, depression, anxiety and potential risk and protective factors in cancer patients: a network approach
Open accessAbstract
Researchers have extensively studied fatigue, depression and anxiety in cancer patients. Several risk and protective factors have been identified for these symptoms. As most studies address these constructs, independently from other symptoms and potential risk and protective factors, more insight into the complex relationships among these constructs is needed. This study used the multivariate network approach to gain a better understanding of how patients' symptoms and risk and protective factors (i.e. physical symptoms, social withdrawal, illness cognitions, goal adjustment and partner support) are interconnected. We used cross-sectional data from a sample of cancer patients seeking psychological care (n = 342). Using network modelling, the relationships among symptoms of fatigue, depression and anxiety, and potential risk and protective factors were explored. Additionally, centrality (i.e. the number and strength of connections of a construct) and stability of the network were explored. Among risk factors, the relationship of helplessness and physical symptoms with fatigue stood out as they were stronger than most other connections in the network. Among protective factors, illness acceptance was most centrally embedded within the network, indicating it had more and stronger connections than most other variables in the network. The network identified key connections with risk factors (helplessness, physical symptoms) and a key protective factor (acceptance) at the group level. Longitudinal studies should explore these risk and protective factors in individual dynamic networks to further investigate their causal role and the extent to which such networks can inform us on what treatment would be most suitable for the individual cancer patient.
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Patients who are more accepting of their CRF show lower fatigue levels, suggesting acceptance may protect against fatigue persistence.
“Regarding protective factors, patients who are more accepting of their CRF show lower fatigue levels, suggesting that acceptance may protect patients from fatigue persistence.4,6,13”
From Exploring the dynamic interconnectedness of protective and perpetuating factors of cancer-related fatigue (2023) · cites this paper as [13]
The Discussion (page unavailable) identifies acceptance of illness as a centrally connected protective factor, and the introduction reports prior associations between illness cognitions and fatigue. But the study measured acceptance of illness, not acceptance of CRF, and its cross-sectional findings do not establish that acceptance protects against fatigue persistence; the Abstract calls for longitudinal work to investigate a causal role. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe EMA protocol Energy InSight was developed based on quantitative and qualitative research findings, CRF literature, and clinical expertise.
“Based on our quantitative (i.e., cross-sectional group-level network analysis) and qualitative research findings (i.e., metaethnography), the CRF literature, and our clinical expertise, we developed the EMA protocol Energy InSight. 6,13,20”
From Exploring the dynamic interconnectedness of protective and perpetuating factors of cancer-related fatigue (2023) · cites this paper as [13]
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Network analysis: An integrative approach to the structure of psychopathology
Borsboom, D., & Cramer, A. O. J. (2013) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-050212-185608 · Cited by 4,359 · see citing works
Self-citationA network theory of mental disorders
Borsboom, D. (2017) · World Psychiatry · doi:10.1002/wps.20375 · Cited by 3,482 · see citing works
A tutorial on regularized partial correlation networks
Epskamp, S., & Fried, E. I. (2018) · Psychological Methods · doi:10.1037/met0000167 · Cited by 2,918 · see citing works
Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011) · The Lancet Oncology · doi:10.1016/s1470-2045(11)70002-x · Cited by 2,449 · see citing works
Comorbidity: a network perspective
Cramer, A. O. J., Waldorp, L. J., van der Maas, H. L. J., & Borsboom, D. (2010) · Behavioral and Brain Sciences · doi:10.1017/s0140525x09991567 · Cited by 1,575 · see citing works
Self-citationWrosch, C., Scheier, M. F., Miller, G. E., Schulz, R., & Carver, C. S. (2003) · Personality and Social Psychology Bulletin · doi:10.1177/0146167203256921 · Cited by 991 · see citing works
Network analysis of depression and anxiety symptom relationships in a psychiatric sample
Beard, C., Millner, A. J., Forgeard, M. J. C., Fried, E. I., Hsu, K. J., Treadway, M. T., Leonard, C. V., Kertz, S. J., & Björgvinsson, T. (2016) · Psychological Medicine · doi:10.1017/s0033291716002300 · Cited by 929 · see citing works
Piet, J., Würtzen, H., & Zachariae, R. (2012) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0028329 · Cited by 436 · see citing works
Compen, F., Bisseling, E., Schellekens, M., Donders, R., Carlson, L., van der Lee, M., & Speckens, A. (2018) · Journal of Clinical Oncology · doi:10.1200/jco.2017.76.5669 · Cited by 248 · see citing works
Self-citationBekhuis, E., Schoevers, R. A., van Borkulo, C. D., Rosmalen, J. G. M., & Boschloo, L. (2016) · Psychological Medicine · doi:10.1017/s0033291716001550 · Cited by 89 · see citing works
Schellekens, M. P. J., Karremans, J. C., van der Drift, M. A., Molema, J., van den Hurk, D. G. M., Prins, J. B., & Speckens, A. E. M. (2017) · Mindfulness · doi:10.1007/s12671-016-0602-0 · Cited by 85 · see citing works
Self-citationPeters, M. E. W. J., Goedendorp, M. M., Verhagen, S. A. H. H. V. M., van der Graaf, W. T. A., & Bleijenberg, G. (2014) · Psycho-Oncology · doi:10.1002/pon.3481 · Cited by 33 · see citing works
Garssen, B., Van der Lee, M., Van der Poll, A., Ranchor, A. V., Sanderman, R., & Schroevers, M. J. (2016) · Psychology & Health · doi:10.1080/08870446.2016.1204447 · Cited by 17 · see citing works
Self-citation
Flagged first, then by citations
Research works printed but not linked: 43
- Agasi-Idenburg SC Thong MSY Punt CJA Stuiver MM Aaronson NK Comparison of symptom clusters associated with fatigue in older and younger survivors of colorectal cancer Supportive care in cancer: Official Journal of the Multinational Association of Supportive Care in Cancer 2017 25 625 632 10.1007/s00520-016-3451-4 27770205 · DOI · Paper page
- Bos EH Wanders RBK Group-level symptom networks in depression—Reply JAMA Psychiatry 2016 73 411 412 10.1001/jamapsychiatry.2015.3157 26914967 · DOI
- Boschloo L Van Borkulo CD Borsboom D Schoevers RA A prospective study on how symptoms in a network predict the onset of depression Psychotherapy and Psychosomatics 2016 85 183 184 10.1159/000442001 27043457 · DOI · Paper page
- Brown LF Kroenke K Cancer-Related fatigue and its associations with depression and anxiety: A systematic review Psychosomatics 2009 50 440 447 10.1016/S0033-3182(09)70835-7 19855028 PMC2902246 · DOI
- Bruggeman-Everts FZ Wolvers MDJ van de Schoot R Vollenbroek-Hutten MMR Van der Lee ML Effectiveness of two web-based interventions for chronic cancer-related fatigue compared to an active control condition: Results of the “Fitter na kanker” Randomized Controlled Trial Journal of Medical Internet research 2017 19 e336 10.2196/jmir.7180 29051138 PMC5668634 · DOI
- Chabowski M Polański J Jankowska-Polanska B Lomper K Janczak D Rosinczuk J The acceptance of illness, the intensity of pain and the quality of life in patients with lung cancer Journal of thoracic disease 2017 9 2952 10.21037/jtd.2017.08.70 29221267 PMC5708453 · DOI
- Costantini G Epskamp S Borsboom D Perugini M Mõttus R Waldorp LJ Cramer AOJ State of the aRt personality research: A tutorial on network analysis of personality data in R Journal of Research in Personality 2015 54 13 29 10.1016/j.jrp.2014.07.003 · DOI
- Costenbader E Valente TW The stability of centrality measures when networks are sampled TT Social Networks 2003 25 283 307 10.1016/S0378-8733(03)00012-1 · DOI
- Cramer AOJ van Borkulo CD Giltay EJ van der Maas HLJ Kendler KS Scheffer M Borsboom D Major depression as a complex dynamic system PLoS ONE 2016 11 e0167490 10.1371/journal.pone.0167490 27930698 PMC5145163 · DOI
- de Haes J van Knippenberg F Neijt J Measuring psychological and physical distress in cancer patients: Structure and application of the Rotterdam Symptom Checklist British Journal of Cancer 1990 62 1034 1038 10.1038/bjc.1990.434 2257209 PMC1971567 · DOI
- Donovan KA McGinty HL Jacobsen PB A systematic review of research using the diagnostic criteria for cancer-related fatigue Psycho-Oncology 2013 22 737 744 10.1002/pon.3085 22544488 · DOI
- Epskamp S Borsboom D Fried EI Estimating psychological networks and their accuracy: A tutorial paper Behavior Research Methods 2017 10.3758/s13428-017-0862-1 PMC5809547 28342071 · DOI · Paper page
- Epskamp S Cramer AOJ Waldorp LJ Schmittmann VD Borsboom D Qgraph: Network visualizations of relationships in psychometric data Journal of Statistical Software 2012 48 1 18 10.18637/jss.v048.i04 · DOI
- Evers AWM Kraaimaat FW van Lankveld W Jongen PJH Jacobs JWG Bijlsma JWJ Beyond unfavorable thinking: The illness cognition questionnaire for chronic diseases Journal of Consulting and Clinical Psychology 2001 69 1026 1036 10.1037/0022-006X.69.6.1026 11777106 · DOI · Paper page
- Fried EI Cramer AOJ Moving forward: Challenges and directions for psychopathological network theory and methodology Perspectives on Psychological Science 2017 10.1177/1745691617705892 28873325 · DOI
- Fried EI Epskamp S Nesse RM Tuerlinckx F Borsboom D What are “good” depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis Journal of Affective Disorders 2016 189 314 320 10.1016/j.jad.2015.09.005 26458184 · DOI
- Fried EI van Borkulo CD Cramer AOJ Boschloo L Schoevers RA Borsboom D Mental disorders as networks of problems: A review of recent insights Social Psychiatry and Psychiatric Epidemiology 2017 52 1 10 10.1007/s00127-016-1319-z 27921134 PMC5226976 · DOI
- Friedman J Hastie T Tibshirani R Sparse inverse covariance estimation with the graphical lasso Biostatistics 2008 9 432 441 10.1093/biostatistics/kxm045 18079126 PMC3019769 · DOI · Paper page
- Guloksuz S Pries LK van Os J Application of network methods for understanding mental disorders: Pitfalls and promise Psychological Medicine 2017 10.1017/s0033291717001350 28578740 · DOI
- Hofman M Ryan JL Figueroa-Moseley CD Jean-Pierre P Morrow GR Cancer-related fatigue: The scale of the problem The Oncologist 2007 12 4 10 10.1634/theoncologist.12-s1-4 17573451 · DOI · Paper page
- Hudson JL Bundy C Coventry PA Dickens C Exploring the relationship between cognitive illness representations and poor emotional health and their combined association with diabetes self-care. A systematic review with meta-analysis Journal of Psychosomatic Research 2018 76 265 274 10.1016/j.jpsychores.2014.02.004 24630175 · DOI
- Husson O Mols F van de Poll-Franse L de Vries J Schep G Thong MSY Variation in fatigue among 6011 (long-term) cancer survivors and a normative population: A study from the population-based profiles registry Supportive Care in Cancer 2015 23 2165 2174 10.1007/s00520-014-2577-5 25556703 · DOI
- Kamen C Mustian KM Heckler C Janelsins MC Peppone LJ Mohile S The association between partner support and psychological distress among prostate cancer survivors in a nationwide study Journal of Cancer Survivorship 2015 9 492 499 10.1007/s11764-015-0425-3 25603949 PMC4510042 · DOI
- Kampshoff CS Verdonck-de Leeuw IM Oijen MG Sprangers MA Buffart LM Ecological momentary assessments among patients with cancer: A scoping review European Journal of Cancer Care 2019 28 e13095 10.1111/ecc.13095 31090160 PMC9285429 · DOI
- Korfage IJ Essink-Bot M-L Janssens ACJW Schröder FH de Koning HJ Anxiety and depression after prostate cancer diagnosis and treatment: 5-year follow-up British Journal of Cancer 2006 94 1093 1098 10.1038/sj.bjc.6603057 16622434 PMC2361242 · DOI
- Kuijer RG Ybema JF Buunk BP De Jong MG Active engagement, protective and overprotection: Intimate partners of patients Journal of Social and Clinical Psychology 2000 19 256 276 10.1521/jscp.2000.19.2.256 · DOI
- Li L Moore D Acceptance of disability and its correlates The Journal of social psychology 1998 138 13 25 10.1080/00224549809600349 9517309 · DOI
- Liu H Lafferty J Wasserman L The nonparanormal: Semiparametric estimation of high dimensional undirected graphs Journal of Machine Learning Research 2009 10 2295 2328 PMC4729207 26834510
- Maes S Leventhal H de Ridder DTD Zeidner M Endler N Coping with chronic diseases Handbook of coping: Theory, research, applications 1996 Oxford Wiley 221 251
- McWilliams LA Sarty G Kowal J Wilson KG A network analysis of depressive symptoms in individuals seeking treatment for chronic pain The Clinical Journal of Pain 2017 33 899 904 10.1097/AJP.0000000000000477 28873079 · DOI
- Miaskowski C Barsevick A Berger A Casagrande R Grady P Jacobsen P Advancing symptom science through symptom cluster research: Expert panel proceedings and recommendations JNCI: Journal of the National Cancer Institute 2017 10.1093/jnci/djw253 28119347 PMC5939621 · DOI
- Opsahl T Agneessens F Skvoretz J Node centrality in weighted networks: Generalizing degree and shortest paths Social Networks 2010 32 245 251 10.1016/j.socnet.2010.03.006 · DOI
- Richardson EM Schüz N Sanderson K Scott JL Schüz B Illness representations, coping, and illness outcomes in people with cancer: A systematic review and meta-analysis Psycho-Oncology 2017 26 724 737 10.1002/pon.4213 27412423 · DOI
- Schroevers MJ Kraaij V Garnefski N Cancer patients’ experience of positive and negative changes due to the illness: Relationships with psychological well-being, coping, and goal reengagement Psycho-Oncology 2011 20 165 172 10.1002/pon.1718 20217657 · DOI
- Schroevers MJ Sanderman R van Sonderen E Ranchor AV The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: Depressed and positive affect in cancer patients and healthy reference subjects Quality of Life Research 2000 9 1015 1029 10.1023/A:1016673003237 11332223 · DOI
- Scott JA Lasch KE Barsevick AM Piault-Louis E Patients’ experiences with cancer-related fatigue: A review and synthesis of qualitative research Oncology Nursing Forum 2011 38 E191 203 10.1188/11.ONF.E191-E203 21531669 · DOI · Paper page
- Tibshirani R Regression shrinkage and selection via the lasso Journal of the Royal Statistical Society 1996 58 267 288
- Van der Lee ML Schellekens MPJ Capturing the complexity of mental disorders in the medically ill: The network approach on behavioral medicine Translational Behavioral Medicine 2019 10.1093/tbm/ibz019 30753678 · DOI · Paper page
- Vercoulen JHMM Swanink CMA Fennis JFM Galama JMD van der Meer JWM Bleijenberg G Dimensional assessment of chronic fatigue syndrome Journal of Psychosomatic Research 1994 38 383 392 10.1016/0022-3999(94)90099-X 7965927 · DOI · Paper page
- Westbrook TD Maddocks K Andersen BL The relation of illness perceptions to stress, depression, and fatigue in patients with chronic lymphocytic leukaemia Psychology and health 2016 31 891 902 10.1080/08870446.2016.1158259 26982998 PMC5118868 · DOI
- Worm-Smeitink M Gielissen M Bloot L van Laarhoven HWM van Engelen BGM van Riel P The assessment of fatigue: Psychometric qualities and norms for the checklist individual strength Journal of Psychosomatic Research 2017 98 40 46 10.1016/j.jpsychores.2017.05.007 28554371 · DOI · Paper page
- Zhu L Ranchor AV van der Lee M Garssen B Almansa J Sanderman R Schroevers MJ Co-morbidity of depression, anxiety and fatigue in cancer patients receiving psychological care Psycho-Oncology 2017 26 444 451 10.1002/pon.4153 27193933 · DOI
- Zhu L Ranchor AV van der Lee M Garssen B Sanderman R Schroevers MJ The role of goal adjustment in symptoms of depression, anxiety and fatigue in cancer patients receiving psychosocial care: A longitudinal study Psychology and Health 2015 30 268 283 10.1080/08870446.2014.969263 25264270 · DOI
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“13 Therefore we included an item on acceptance and catastrophizing.”
BackgroundSelf-citation
- Authors
- Schellekens, M. P. J., Wolvers, M. D. J., Schroevers, M. J., Bootsma, T. I., Cramer, A. O. J., & van der Lee, M. L.
- Affiliations
- Tilburg University (NL)
- Helen Dowling Instituut (NL)
- University Medical Center Groningen (NL)
- Corresponding author
- Schellekens, Melanie P. J.
- ORCID
- Venue
- Journal of Behavioral Medicine
- Published
- 2019-08-22
- Volume
- 43
- Issue
- 4
- Pages
- 553-563
- ISSN
- 0160-7715 (ISSN-L)
- 1573-3521
- PMC
- PMC7366596
- OpenAlex
- W2969840533
- Cited by
- 93
- References
- 13
- Citations by year
- 2026: 11 · 2025: 13 · 2024: 30 · 2023: 18 · 2022: 7 · 2021: 11 · 2020: 2 · 2019: 1
- FWCI
- 2.19
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Journal of Behavioral Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- Research portal (Tilburg University) (publishedVersion, other-oa)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion, cc-by)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by)
- Funders
- KWF Kankerbestrijding (10761)
- Topics
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cancer-related cognitive impairment studies
- Keywords
- cancer-related fatigue, depression, anxiety, risk and protective factors, helplessness, somatic symptoms, acceptance of illness, social withdrawal, illness cognitions, goal adjustment, partner support, psychological care, symptom networks, network centrality
- MeSH terms
- Adult, Anxiety, Anxiety Disorders, Cross-Sectional Studies, Depression, Emotions, Fatigue, Female, Humans, Longitudinal Studies, Male, Middle Aged, Neoplasms, Risk Factors, Protective Factors
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