Care givers' depression, anxiety, distress, and somatization as ...

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Original Article

Care givers’ depression, anxiety, distress, and somatization as predictors of identical symptoms in cancer patients ABSTRACT Context: The critical condition of the cancer patient and the stringent medical procedures do not often warrant the accessibility of the patient for psychological evaluation. Therefore, the study is conceptualized to assess the psychological problems of caregivers, which in turn have their impact upon cancer patients. Aims: The objective of the study was to explore the relationships between depression, anxiety, distress, and somatization in cancer patients and their caregivers along with age, gender, and relationship; and to measure whether these psychological problems of caregivers were predictors of the identical symptoms of the cancer patients. Materials and Methods: Four‑Dimensional Symptom Questionnaire was used to measure depression, anxiety, distress, and somatization of cancer patients and their caregivers. The sample had 200 participants, with 100 patients (male = 47 and female = 53) and 100 caregivers (male = 36 and female = 64) selected by purposive sampling method. Statistical Analysis Used: The data were analyzed by using descriptive statistics, product‑moment correlations, simple and multiple linear regression analyses. Results: Significant correlations were found between cancer patients’ depression and anxiety, and caregivers’ depression, anxiety, distress, and somatization; patients’ distress and somatization, and caregivers’ anxiety and age, respectively. It was also found that anxiety was a significant predictor of distress in patients, and that caregivers’ depression, anxiety, distress, and somatization significantly predicted depression and anxiety in cancer patients. Conclusions: The association between depression, anxiety, distress, and somatization of caregivers and patients indicates the need for psychological interventions to manage these problems of caregivers, which would in turn help managing the identical symptoms in patients. KEY WORDS: Anxiety, depression, distress, somatization

INTRODUCTION Cancer is the leading cause of death worldwide. [1] Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. Cancer is caused by both external factors such as tobacco, chemicals, radiation, and infectious organism as well as internal factors such as inherited mutations, hormones, immune conditions, and mutation that occur from metabolism.[2] The risk of developing cancer increases with the increase in age, especially middle age onward and in many countries the incidence rates of cancer are high in males than females.[3] Cancer is affecting the lives of many, there were an estimated 14.1 million cancer cases around the world in 2012, of these 7.4 million cases were in men and 6.7 million cases were in women. As per Indian population census data, the rate of mortality due to cancer in India was high and alarming with

Gadiraju Padmaja, Chhakchhuak Vanlalhruaii, Suvashisa Rana, Durgesh Nandinee, Meena Hariharan Centre for Health Psychology, University of Hyderabad, Gachibowli, Hyderabad, Telangana, India For correspondence: Dr. Gadiraju Padmaja, Centre for Health Psychology, University of Hyderabad, Gachibowli, Hyderabad ‑ 500 046, Telangana, India. E‑mail: gpadmaja2008 @gmail.com

about 806,000 existing cases by the end of the last century.[4] Cancer is the second most common disease in India, its prevalence in India is estimated to be around 2.0–2.5 million, with over 7–8 lakh new cases identified every year.[5] Whatever the type of cancer and the stage is, diagnosis of cancer creates psychological problems in not only cancer patients but also their caregivers. The connotation of psychological problem in the study is confined to four dimensions such as depression, anxiety, distress, and somatization. Psychological distress is common among cancer patients and their caregivers; this can in turn have a profound effect on their disease progression. Cancer patients rely almost always on family, friends, and significant others, in their journey of dealing with their illness. Carer, especially spouse often symbolically shared in the illness and presented the struggle with cancer as a joint one.[6] One

Journal of Cancer Research and Therapeutics - January-March 2016 - Volume 12 - Issue 1

Access this article online Website: www.cancerjournal.net DOI: 10.4103/0973-1482.146088 PMID: *** Quick Response Code:

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Padmaja, et al.: Care givers’ depression, anxiety, distress and somatisation

meta‑analysis on caregivers found that caregivers’ depressive symptoms had stronger associations with physical health than did objective stressors. Higher levels of care recipient behavior problems were more consistently related to poor caregiver health than were care receiver impairment and intensity of caregiving.[7] Also, there is a significant relationship between fatigue and the impact of care on the daily schedule.[8] Depression is common among cancer patients and can affect the personal relations, clinical course and prognosis of cancer disease and quality of life of whole family.[6] Female caregivers with a history of psychiatric morbidity as well as those who take a more negative view of the patient’s illness and its impact on their lives are more vulnerable to high distress or develop an affective disorder. The caregivers are more likely to become more distressed and develop psychiatric morbidity as the illness advances and treatment is palliative.[9] Patients and their caregivers have interdependence relationship, each person affects the other. A meta‑analysis confirmed that there is a positive association between patient and carer psychological distress.[10] Along with depression, anxiety is also seen among cancer patients and their caregivers. Co‑morbidity of depression and anxiety is also common among cancer patients and associated with a reduced chance of survival[11] and decreased compliance with chemotherapy.[12] Caring a patient can be a very stressful job and difficult, the demands of caregiver’s role and seeing the patient suffer can create a great distress. Especially for family caregiver seeing their loved one suffering can be painful, and also they may be responsible for other member of the family for example children. The level of anxiety is high among both genders of primary caregivers, and depression was significantly more prevalent in female primary caregivers.[13] Also, depression was highly prevalent among family caregivers of cancer patients, and care burden was its best predictor.[14] Studies demonstrate the mutuality between patients and their caretakers. In one study, it is found that cancer patients’ symptoms and lesser degree of their immobility were the strong predictors of patient depression, which in turn predicted caregivers’ depression.[15] A study was done to see the mutuality of psychiatric disorder in both advanced cancer patients and their informal caregivers. This study showed that when patients met criteria for any psychiatric diagnosis, then caregivers are 7.9 times more likely to meet criteria for any psychiatric disorder and vice versa.[16] It is also found that spousal caregivers consistently exhibit higher depressive symptoms than non‑spouse caregivers.[17] Another parameter that is examined is somatic symptoms. The causes of somatic symptoms in cancer can be many and varied. These could be due to anxiety, depression, somatization, or a manifestation of illness behavior. One study concluded that patient’s condition can also influence somatic symptoms in their caregivers.[18] At the start of palliative care, the 54

caregivers’ mean physical functioning score was better than patients’, there were similar mental functioning scores, similar proportion were depressed and significantly more caregivers than patients were anxious. However, at the start of terminal period, more caregivers were found depressed and had higher level of perceived burden. The presence of high stress and depression in cancer patients are found to have negative effects on the caregivers.[19] The interaction of high levels of depression coupled with high levels of stress in women with breast cancer was significantly associated with lowered physical health and well‑being in their partners. When depression is combined with any additional stress, the level of physical distress was significantly greater.[20] Two meta‑analyses pointed that a reciprocal relationship existed between the emotional distress reported by patients with cancer and their spouse caregivers. Their findings indicated that patients’ distress affected spouses’ distress and, conversely, spouses’ distress affected patients’ distress.[10,21] In a study that examined how anxiety was transmitted between patients with cancer and their caregivers and found that the pathway from caregiver to patient had a greater effect on the transmission of anxiety within couples than did the pathway from patient to caregiver.[22] In view of the studies that reported the association between psychological problems like depression, anxiety, distress, and somatization in cancer patients and caregivers individually, the present study attempted to explore the relationships between all the four aforesaid psychological problems of cancer patients and their caregivers along with age, gender, and relationship. The study also sought to measure whether psychological problems of caregivers were predictors of psychological problems of cancer patients. MATERIALS AND METHODS Participants In this correlational study, 200 participants (patients = 100, caregivers = 100) were selected from three specific cancer hospitals by means of purposive sampling method. The selected patients were from the head and neck (22%), gynecological (17%), breast (14%), stomach (13%), lungs (6%), and liver (5%) cancer categories, respectively. The remaining few cases belonged to other types of cancers. Of 100 patients, there were 47 male and 53 female patients, whereas in case of caregivers, there were 36 male and 64 female. The patients’ age ranged from 5 to 79 years and caregivers’ age ranged between 18 and 76 years. Among caregivers, 93% were either spouse or blood relatives and 7% were either distant relatives or significant others. So far as the socioeconomic status of participants was concerned, 54% were from lower socioeconomic status, 40% of from middle, and 6% are from high socioeconomic status. Cancer patients in stage 4 of the disease and having known mental illness were excluded from the study.

Journal of Cancer Research and Therapeutics - January-March 2016 - Volume 12 - Issue 1


Padmaja, et al.: Care givers’ depression, anxiety, distress and somatisation

Instrument The Four‑Dimensional Symptom Questionnaire (4DSQ) having 50 items was used in this study. Each of the items were measured in terms of 5‑point scale (5 = very often or constantly to 0 = No). The questionnaire included items like during the past week, did you suffer from disturbed sleep? During the past week, did you feel that everything is meaningless? The questionnaire measured psychological problems that comprised four dimensions, such as depression (6 items), anxiety (12 items), distress (16 items), and somatization (16 items).The higher the score, the higher was the problem in the respective dimension. The Cronbach’s alpha varied between 0.84 and 0.94, whereas test‑retest reliability ranged from 0.89 to 0.94; the criterion validity of the 4DSQ was also established.[23] Procedure Two hospitals from Hyderabad and one hospital from Aizawl specialized in cancer care were approached for the study and necessary permission was obtained. The investigators approached different wards of the selected hospitals and established rapport with the patients. During the process of establishing the rapport the investigators explained the purpose of the study. From those who gave consent to participate in the study, the investigators obtained the informed consent. The investigators also met the caregivers of those patients who gave their consent and obtained their informed consent to participate in the study. After obtaining informed consent form from both the patients and their caregivers, demographic details were obtained. The 4DSQ was administered individually on the patients as well as caregivers after giving necessary instructions. The average time of administration of the questionnaire took 20–30 minutes. At the end of each administration, the participant concerned was debriefed. RESULTS The data were analyzed by means of descriptive statistics, product‑moment correlations, simple and multiple linear regression analyses. Table 1 revealed the inter‑correlation among caregivers’ depression, anxiety, distress, and somatization with patients’ Table 1: Correlation between patients’ depression, anxiety, distress, and somatization with caregivers’ depression, anxiety, distress, and somatization Caregiver’s Depression Anxiety Distress Somatization Age Gender Relation

Patient’s Depression 0.22* 0.32** 0.20* 0.24* −0.13 −0.07 −0.06

**P