of probable anxiety and depression among caregivers of cancer patients. A total ... distress and c) financial expenses involved. These extensive demands ...
ORIGINAL PAPER
Depression and Anxiety Among Family Caregivers of Cancer Patients in an Oncology Clinic Ambigga Devi K* , Sherina MS*, Suthahar A** * Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia **Department of Psychiatry, Universiti Institute Technology Malaysia
Abstract:This cross sectional study was carried out to determine the prevalence of probable anxiety and depression among caregivers of cancer patients. A total of 177 caregivers of cancer patients attending an Oncology Clinic from November 2001 till January 2002 were selected. Data collection was done using the Hospital Anxiety and Depression Scale (HADS). The prevalence of probable anxiety and probable depression among the family caregivers were 48.6 % and 29.4 % respectively. Probable depression was significantly associated with education level (p=0.018), and duration of illness (p=0.03). Where as probable anxiety was significantly associated with age (p=0.003). Hence, this study identified that educational level, age of caregivers and duration of illness in the patient were factors that should be looked into when caregiving of cancer patient was done. Key words: Caregiver, cancer patients,depression, anxiety, oncology clinic Malaysian Journal of Psychiatry March 2005 Vol. 13, No.1
Introduction Cancer is the second leading cause of death in Malaysia. It has been estimated that about 30,000 new cases ofcancer are being diagnosed each year (1). The most common cancer and the number one cause of cancer deaths among women in Malaysia is breast cancer whereas lung cancer is =the main cause of cancer death in Malaysia among males (2). Many types of cancer at the present time could be described as a chronic disease requiring long-term treatment and posing numerous demands on the patients as well as their caregivers. Stress experienced by the caregivers could be due to multiple reasons such as disrupted daily routine, financial problems, lack of family support, loss of physical strength and low self esteem (3). Caring for a disabled friend or Correspondences to: Dr. Ambigga Devi Krishnapillai, Lecturer, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor.email: ambigga(amedie.uum.ed u.my Tel: 603-89468537 Fax: 603-89450151
relative has been shown to be harmful to the health of the caregivers in terms of stress related illness as well as physical injury (4). It was noted that caregiving demands maybe divided into three general categories: physical demands of direct care, such as assistance with activities of daily living, preparation of meals, treatment, medication regimens and transportation, emotional demands ofdealing with concerns ofthe patient and family members as well as their own distress and c) financial expenses involved. These extensive demands associated with caregiving result in a variety of psychological sequelae among home based palliative caregivers, which include anxiety, depression, reduced self-esteem, fatigue, feeling of isolation and somatic health problems (5). The psychological impact of cancer on caregivers has been a prevalent topic of interest to researchers. The fact that family caregivers provide care to ill and disabled relatives is not a new phenomenon. This has been increasingly common oflate. It is estimated that more than 15 million adults currently provide such care which is translated into saving of billions of dollars annually on the formal health care system (6).
AMBIGGA DEVI et al
For the most part, caregiving research has focused on the experiences of caregivers within specific disability groups, particularly dementia and the frail elderly, schizophrenia and intellectual disability. Regardless of disability, most caregivers are middleaged women (7). A review and analysis indicated that women caregivers tend to report higher levels of depression, anxiety and general psychiatric symptomology with lower level of life satisfaction compare to men caregivers (8). Ramirez et al ( 9) mentioned that in the year before the death of a cancer subject the estimated prevalence of anxiety and depression among the informal carers were high, reported at 46% for anxiety and 39% for depression.A study on carers of terminal cancer patients by Rose K (10) highlighted that carers should be given practical advice tailored on the individual's need. These carers should be educated and counseled on behavioral management techniques and coping strategies. This study was conducted to determine the prevalence of depression and anxiety among family caregivers of cancer patients using the Hospital Anxiety and Depression Scale (HADS). By assessing the caregiver's level of burden including emotional problems, these carers who are at high risk can be identified.
Materials and Methods This cross-sectional study was carried out in an Oncology Clinic at a tertiary care center in Wilayah Persekutuan from November 2001 to January 2002. The Clinic Days were on Monday and Friday mornings. There were 2 Specialist and 1 Medical Officer running this clinic. The average attendance per clinic session is 5 new cases and 10-15 follow-up cases. All these patients were initially treated by doctors in government hospitals or private clinics and then referred to this clinic for subsequent treatment and follow up. Only caregivers of cancer patients followed up at the clinic were included in the sample. The principal author in this study identified the main carer of the patient who was responsible for taking care of the
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patient at home, and that particular carer was selected for this study. Ifthat particular carer was not available then the next closest carer fitting the caregiver definition was selected. In this study, caregiver was defined as any individual who had a personal connection and commitment to an individual with cancer and on that basis, was providing care outside of a hospital setting to that individual(11). In this study they were related to the patient either by marriage or blood. Universal sampling of all family caregivers of cancer patients attending the Oncology Clinic was done. Verbal consent was taken and a questionnaire was given to each caregiver. The caregivers were guided by the principal author when they were unsure of the questions but generally the questionnaires were self-administered. Exclusion criteria included those who did not complete the questionnaire. The questionnaire used included sociodemographic information (age, gender, race/ ethnicity, marital status, education level, religion, occupation and cancer type), as well as the Hospital Anxiety and Depression Scale (HADS). The HADS is a 14-item self-rating questionnaire, which includes 7-items which screen for anxiety and another 7-items which screen for depression. It was developed by Zigmond and Snaith (12), and was specifically designed for use in non-psychiatric hospital departments. However, it was also found to be a reliable instrument for screening anxiety and depression in patients attending non-psychiatric units, such as general medical clinics. This scale has also been shown to be a valid measure of the severity ofthese disorders of mood (13), as well as feasible for use in different settings, countries and cultures (14,15,16,17). Abiodun (14) reported its valid use as a screening instrument in non-psychiatric units, which include medical, surgical, antenatal as well as gynecology units in a community sample in Nigeria. The author stablished the sensitivity for the anxiety subscale which was 85.0 % in the medical and surgical wards, while the sensitivity for the depression subscale was 89.5 % in the community sample. At the same time specificity for the anxiety subscale was 90.6 %
DEPRESSION A//ID ANXIETY AMONG FAMILY CAREGIVERS OF CANCER PATIENTS IN AN ONCOLOGY CLINIC
in the community sample, while specificity for depression subscale ranged from 86.6 % in the medical and surgical wards to 91.1 % in the community sample.HADS is presented with score ranges, which indicate the probable absence, possible presence and probable presence ofclinically meaningful degrees of mood disorder. Borderline score ranges from 8 —10. The cut of point for a 'case' may be either the upper or the lower end of the borderline range (12). In this study, the researchers included all possible cases; therefore, the lower end of borderline (score of 8 for each subscale) was used. Therefore the maximum score for anxiety was 21 and depression was 21. Scoring for both anxiety and depression was done separately using HADS in 'this study. A pre-test was done and there were no problems encountered. The questionnaire was found to be easy to administer. The validated Bahasa Malaysia version of the HADS was used in this study. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) program for window (version 10). For the socio demographic characteristics, the analysis used was frequency, mean, median and proportions. To determine ifthere was any significance between variables, statistical tests such as chi-square was used for qualitative data and independent sample t-test was used for quantitative data. '13 ' value of less than 0.05 was taken as statistically significant. Those caregivers who were identified as at risk for probable anxiety and depression were referred to a psychiatrist for further management with their consent.
Results A total of 180 eligible family caregivers of cancer patients were identified for the study but only 177 of them agreed to give consent and were enrolled in the study (response rate of 98%). Table 1 shows that the population of the male subjects was higher (53.7 %) compared to the female subjects, which were 46.3 % . The age of the family caregivers ranged from 21 years to 76 years with a mean of42.1 years. Majority ofthe family caregivers were Malays (52.5 %) and Muslims (52.5%). Majority of the family caregivers were employed (70.6 %),
married (84%) and 53.7% completed their secondary education. Majority of the family caregivers were spouses of the cancer subjects (44.6 %). The duration of cancer among the patients ranged from 1 month to 252 months. The median duration was 12 months among the cancer subjects. There were 26 types of cancers identified among the cancer subjects. The predominant type of cancer was female breast cancer followed by lung and colon cancer (Table 2). From the 177 subjects interviewed, eighty-six family caregivers had scores of 8 and more on the HADS for anxiety and this showed that 48.6 % of subjects were found to have probable anxiety. Fiftytwo family caregivers had scores of 8 and above on the HADS for depression. This result showed that 29.4 % of subjects were found to have probable depression. Table 3 shows that probable depression was significantly associated with education level, where the prevalence of depression was highest among the respondents with secondary education compared to the other levels of education (p
