Despite improvements in the early detection and medical treatments, a diagnosis of breast cancer continues to elicit greater distress on women than any other medical diagnosis, regardless of the prognosis . The nature of this distress can range from psychiatric morbidity, such as depression or anxiety, to post-traumatic stress symptoms [18, 19].
Breast cancer patients may experience depression and/or anxiety at any stage of their illness from pre-diagnosis to the terminal phase of the illness.
It was assumed that the level of psychological distress would be higher around the time of diagnosis. In the current study, the prevalence of anxiety, depression, and perceived stress symptoms in the study group was high (73.3%, 68.7%, and 78.2% respectively) and the prevalence of mixed anxiety depression in the study group was 31.25%.
This was consistent with studies of Mehnert and Koch  and Burgess et al.  which showed that the prevalence of psychological distress among breast cancer patients is high, and they are at higher risk of developing severe anxiety and depression.
The results of the present study were higher than those of Allam et al.  who found that anxiety was prevalent in a rate of 15–25% of the examined cancer breast female patients. Their rates of major depressive disorder were reaching 42.5%; putting in consideration this smaller sample size (40 cases), the difference could be explained.
Our results were also higher than that of the results of a study conducted by Hassan et al.  who found the prevalence of anxiety and depression were 31.7% and 22.0% respectively. Also, another study conducted by Vahdaninia et al.  who found 38.4% of their breast cancer patients experienced severe anxiety and 22.2% had severe depression.
A systematic review of observational studies about prevalence of depression in breast cancer survivors done by Zainal et al.  showed that in the Western countries, the prevalence of depression ranges from 1 to 56%, whereas the prevalence of depression from Asian studies was between 12.5 and 31%.
A Turkish study by Dastan and Buzlu  reported that 35% of their breast cancer patients had anxiety, while another Asian study reported a lower prevalence of 16% .
When the severity of depression and anxiety disorders were evaluated, it revealed that most cases were of the moderate to severe form of anxiety (65.6%) and depression (50%) respectively. This was consistent with Wellisch et al.  who concluded that cancer patients can experience moderate to severe anxiety while waiting for the results of their diagnostic procedures.
In the present study, 31.8% and 26.2% of early stage breast cancer patients had depression and anxiety symptoms respectively compared to 68.2% and 73.8% of advanced stage breast cancer patients had depression and anxiety symptoms respectively. This was consistent with Moyer and Salovey  who found that advanced disease is often considered a risk factor for increased vulnerability to depression and anxiety. Severe psychiatric symptoms are rare among early stage of breast cancer patients (patients with good prognoses), and more common among patients with more advanced stages.
Nevertheless, this was not consistent with other studies like Turner et al.  and Li et al.  who evaluated Australian patients using a structured psychiatric interview (DSM-IV). Among their patients, 303 Australian women with early stage and 227 with advanced breast cancer, the rates of psychiatric morbidity were notably equivalent . This suggests that the stress of the diagnosis was more relevant than stage of disease .
In our study, the mean age of the studied group was 52.29 ± 11.64 years, ranging from 30.0 to 75.0 years. This was consistent with Ng et al.  who found that majority of patients had age group of 41–60 years followed by age group of 20–40 years. This finding was also supported by the study conducted by Hassan et al.  and The National Cancer Registry 2003 , which shows that the commonest age of breast cancer is between 40 and 49 years with mean age of 50 years old.
Most participating women (50.0%) were illiterate or with basic educational level; they were found to be with the highest prevalence of breast cancer. For the impact of psychiatric morbidity due to the educational level, the prevalence of anxiety and depression was more common in educated women (54.8%) (56.8%) respectively as compared to illiterate women (45.2% and 43.2%) respectively. This somehow might be explained by the fact that patients with higher educational levels have a greater opportunity to be aware about their disease and its related aspects. However, a study conducted by Mehnert et al.  found that lower educational level has been a predictor of psychological comorbidity in patients with breast cancer.
Married women (73.4%) were found to have the highest prevalence of breast cancer. For the impact of psychiatric morbidity due to marital status, married woman (71.4%) showed much higher prevalence of anxiety than single women (28.6%). Also, married woman (79.5%) showed much higher prevalence of depression than single women (20.5%). In our opinion, married women were more depressed and anxious because they have families to take care of, which is the biggest commitment in their lives. Feel of low self-esteem after having surgery might also contributed to their psychiatric morbidity. Since the perception of breast cancer as a fatal disease, they were more worried about their lives and their future. In this study, marital status was not significantly associated with depression or anxiety. This was not consistent with a study conducted by Aass et al.  and Hassan et al. , which showed that neither the patient’s civil status (married, widowed, single) nor their situation of living (living alone or with partner) as significantly related to the prevalence of anxiety and depression.
However, not statistically significant, our study indicated that marital status affects the severity of the psychiatric symptoms whether depressive or anxiety symptoms. Married females were presented with moderate to severe forms of depression as compared to unmarried females. Few studies had examined the effect of marital status. Akechi et al.  explained lower rates of the psychological distress found in his sample to the marital status and other factors; married females had lesser psychological distress.
Most of the patients who underwent surgical operation (81.8%) had depressive symptoms, while 81% of them had anxiety symptoms with no significant statistical difference than patients who had no surgery.
Other researchers studied the psychological effect of different type of surgical procedures per se. The study conducted by Wellisch et al.  revealed that lumpectomy promotes a more intact body image. Another study by Cohen et al.  showed that women who had undergone breast-conserving surgery experienced greater levels of psychological distress and worse QoL from 3 years after surgery onward than did the women with mastectomy.
In this study, patients’ occupational status was studied to investigate any association between their economic level and psychiatric morbidity. From the findings, most of the patients were not working, 95.3% and 73.4% did not have enough income per month. This situation was considered as low living status due to the high living cost in an urban setting. Some of the patients were living in rural areas where the cost of transportation and accommodation can be considerably high. Consequently, majority of the patients claimed that they felt burdened by cancer treatment and its expenses, especially when referring to their economic status.
Depression was more prevalent among the unemployed (97.7%) and patients who were living in rural areas (77.3%) but without statistically significant difference. Anxiety was present among all the unemployed or non-working patients (100%) with significant difference than working patients and was present in 81% of patients who live in rural areas (81%) but without significant difference with patient living in urban areas. This supported by Ell  and Hassan et al. , who found that low-income women are characterized by the prevalent of anxiety and depression due to unlikely of receiving any treatments.
In this study, socioeconomic status data were taken from the breast cancer patients to study the relation of economic status towards anxiety and depression. The lower economic status and higher treatment expenses were directly associated with anxiety and depression percentage. Travel to the hospital for treatment needs budget in terms of transportation, fuel, tolls, parking fee, and accommodation. Besides, family or friends who accompany the patient for treatment are not entitled for the hospital meals. Hence, extra expenses are needed to buy for the meals. This supported by Ell , who found that major depression disorder (MDD) is prevalent among low-income breast cancer women. It appears to be correlated with pain, anxiety, depression, and health-related quality of life. Due to the low economic status, these women are unlikely to receive psychiatry treatment or supportive counseling.
The prevalence of distress in the study group was 78.2%. This was consistent with Ng et al.  who found that 50% of the subjects experienced high level of distress. Also, this result was like Burgess et al.  who reported that up to 50% of the women with breast cancer experience high levels of distress with more than 30% of the women with early breast cancer had depression, anxiety, or both at diagnosis. Also, Zabora et al.  and Fallowfield et al.  showed that the prevalence of psychological distress in cancer patients is reported to be above 30%.
In this study, Spearman correlation analysis did not show any significant correlation of perceived level of stress with depression (r 0.22, p 0.07) or anxiety (r 0.09, p 0.47). This was different from Pandey et al.  where distress was found to have positive correlation with anxiety and depression suggesting a possible overlap of the two constructs. However, Ng et al.  demonstrated that the perceived level of distress among the breast cancer patients was positively associated with the level of anxiety but not depression.