Objective Heightened psychological distress after cancer is common but likely highly heterogeneous. This raises potential challenges in how and when to target services; however, data describing longitudinal patterns of distress are limited. This study describes the long term psychological outcomes for colorectal cancer (CRC) survivors and trajectories of adjustment over time. Methods A prospective survey of a population‐based sample of 1966 CRC survivors assessed sociodemographic variables, perceived social support and psychological distress, including distress subtypes of anxiety, depression and somatization, at six time points from 5 months to 5 years post‐diagnosis. Results Over the 5‐year trajectory, the prevalence of high overall distress ranged between 44% and 32% but was greater for men compared with women (p < 0.001). Four distress trajectory styles within clusters were identified for overall distress and for each distress subtype with a constant low distress group providing the basis for comparison. Higher distress trajectories varied for overall distress and distress subtypes but were generally differentiated by gender, younger age, lower education, poor socioeconomic advantage, late disease stage and poor social support. Conclusions For global distress, by comparison with women, men with CRC are vulnerable to distress, with men who are younger and with low education and poor social support being a priority for targeted intervention. While distress screening early in the cancer experience will identify those with a constant high distress trajectory, others with late emerging distress or caseness may be missed. On this basis, distress screening through the illness trajectory into long term survivorship seems warranted. Copyright © 2012 John Wiley & Sons, Ltd.