Comment on: "The status and determinants of demoralization in patients with colorectal cancer: a cross-sectional study in China".

Zhou et al. investigated demoralization syndrome (DS) among Chinese patients with colorectal cancer and identified cancer metastasis, anxiety, and depression as factors independently associated with greater DS severity. Their study provides valuable evidence for psychological screening and supportive care in this population. In this comment, we highlight two analytical considerations that may further strengthen the interpretation of their findings. First, although social support was associated with DS severity in univariate analysis, the loss of statistical significance after multivariable adjustment should not be interpreted as evidence of irrelevance; rather, social support may influence DS indirectly through anxiety, depression, or disease burden. Mediation or path analysis may therefore better reflect the underlying causal structure. Second, dichotomizing the continuous DS-II score into mild versus moderate-to-severe categories may reduce statistical power and obscure clinically meaningful variation. Analyzing the DS-II score as a continuous or ordinal outcome could provide a more informative assessment of the determinants of DS.