Predictors of mood disorders in cancer patients’ caregivers
Eva Mazzotti, Claudia Sebastiani, Gian Carlo Antonini Cappellini & Paolo Marchetti Supportive Care in Cancer ISSN 0941-4355 Volume 21 Number 2 Support Care Cancer (2013) 21:643-647 DOI 10.1007/s00520-012-1663-9
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Author's personal copy Support Care Cancer (2013) 21:643–647 DOI 10.1007/s00520-012-1663-9
SHORT COMMUNICATION
Predictors of mood disorders in cancer patients’ caregivers Eva Mazzotti & Claudia Sebastiani & Gian Carlo Antonini Cappellini & Paolo Marchetti
Received: 26 March 2012 / Accepted: 19 November 2012 / Published online: 1 December 2012 # Springer-Verlag Berlin Heidelberg 2012
Abstract Introduction Patients’ care has been associated with a high burden of psychological symptoms in caregivers. This study identifies characteristics associated with mood disorders in caregivers of cancer patients. Methods One hundred fifty-two caregivers, aged 24–78 years (average age 51; 60 % females), of cancer patients completed Family Strain Questionnaire (FSQ), Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), and Coping Orientations to the Problems Experienced. We combined this information with patient chart abstraction data. Results Sixty-three percent of females and 38 % of males were scored as positive when screened for mood disorders, as measured by HADS (total score ≥16), and 17 and 5 % for emotional distress as measured by IES (total score ≥50). High scores in FSQ-satisfaction with family relationships and FSQneed for more information about cancer, and low scores in FSQ-thoughts about death are reported. FSQ-emotional burden and FSQ-problems in social involvement are the areas more compromised in females, compared to males. Females, compared to males, use emotional-oriented coping strategies more frequently. Factors independently associated with mood disorders included emotional burden, problems in social involvement, and non-attendance of meeting places; help and assistance from public local services (for patients) decreased the risk of mood disorders in caregivers. E. Mazzotti (*) : C. Sebastiani : G. C. Antonini Cappellini : P. Marchetti Divisione di Oncologia e Oncologia Dermatologica, Istituto Dermopatico dell’Immacolata, Istituto di Ricerca e Cura a Carattere Scientifico, IDI-IRCCS, Via dei Monti di Creta, 104, 00167 Rome, Italy e-mail:
[email protected] P. Marchetti Faculty of Medicine and Psychology, Sant’Andrea Hospital, Sapienza University, Rome, Italy
Conclusions Prevalence of mood disorders is high in cancer patients’ caregivers. These results highlight the need to develop family intervention strategies to minimize the impact of patient’s care on caregivers’ mental health. Keywords Cancer . Caregiver . Coping and adaptation . Families’ burden . Mood disorders . Psychological distress The high prevalence and chronic evolution of cancer are responsible for a major social cost, together with the changes in health care that have shifted much cancer care to the home. In the last years, a great deal of clinical cancer care has been delivered by informal caregivers (i.e., family, friends), and the burden of caring for relatives has been studied [1–7]. Burden of care, a specific domain that can be described as a stressor in the stress-appraisal-coping model, has an emotional, psychological, physical, and economic impact. Psychological and emotional distress in cancer caregivers has largely been reported [8–10]. To date, research on caregivers represents a significant area of deficiency. Hui and colleagues noted that among 1,213 published palliative oncology studies, caregivers were involved in 9 %, the same low percentage of studies dedicated to psychological issues [11]. The aims of the study are: (1) to measure emotional distress, coping strategies, and caregiver-related problems in caregivers of cancer patients; (2) to explore predictors associated to caregiver’s mood disorders.
Materials and methods This study has a descriptive and cross-sectional design. The study population consisted of 152 caregivers of adult cancer patients who were cared for in day care setting at IDI, in
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Rome, Italy. A research assistant approached a consecutive sample of caregivers. They were approached in the waiting room and were asked for written informed consent following thorough information about the purpose of the study. The following inclusion criteria were applied: aged ≥18 years, Italian speaking, physically and mentally able to complete questionnaires, with no upper limit to time elapsed since diagnosis, the participant indicated that she/he provided help to a loved one because of cancer and the participant considered herself the person who provides the most help to the loved one suffering from cancer (so called “primary caregiver”). Exclusion criteria were patients with suspected or proven severe mental health problems. A consecutive sample of 152 caregivers was enrolled in the study. No one refused to participate. The study protocol was approved by the Medical Ethics Committee of the Hospital. Instruments The Hospital Anxiety and Depression Scale (HADS) [12] consists of 14 items, seven for anxiety and seven for depression. Cutoff of ≥16 for total HADS score was chosen for its reasonable screening properties in identifying mood disorders, yielding sensitivities and specificities of approximately 0.86–0.87 [13–15]. The Family Strain Questionnaire (FSQ) [16] consists of a brief semi-structured interview plus 44 dichotomous items. The items covered five specific domains: emotional burden, problems in social involvement, need for more information about the disease, satisfaction with family relationships, and thoughts about death. Information concerning (patient and carer) socioeconomic status, familial relationships, patient’s daily ability (e.g., to wash, dress, move), help and assistance from public local services (e.g., physiotherapist, nurse), and caregiver’s involvement in social and outdoor activities has been collected by interview. As suggested by the authors, a score ≥9 on the first 14-item domain indicates clinically relevant emotional disturbances. Satisfactory psychometric characteristics have been reported for Italian samples. The Impact of Event Scale (IES)-Revised [17] is a 22item self-rated scale reflecting the three DSM-IV PTSD symptom dimensions (intrusion, avoidance, and hyperarousal). For comparability with other studies, participants who reported scores ≥50 have been considered emotional distress cases. The Coping Orientations to the Problems Experienced (COPE) [18] is a 60-item questionnaire comprising 15 discrete scales: (1) use of emotional social support, (2) use of instrumental social support, (3) focusing on the venting of emotion, (4) denial, (5) humor, (6) substance use, (7) behavioral disengagement, (8) mental disengagement, (9) acceptance, (10) restraint coping, (11) positive reinterpretation and growth, (12) planning, (13) active coping, (14) suppression of competing
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activities, and (15) turning to religion. We used the Italian version of COPE, which has good reliability and construct validity [19]. Patient’s clinical data (i.e., date of diagnosis, presence of metastasis) were collected from the hospital medical records. Data analysis For descriptive purposes, the study’s quantitative continuous variables were categorized. We have subdivided subjects into two groups with respect to years of education (≤8, >8), marital status, and changes in caregiver’s involvement in social and outdoor activities (no, yes); into five groups with respect to age (24–33, 34–43, 44–53, 54–63, and 64–78); and into seven with respect to length of the disease (1–4, 5–12, 13–24, 25– 36, 37–48, 49–84, and 85–216 months). A median split on the FSQ subscales, IES-total score, and COPE strategies was used to create two groups. FSQ, IES, and COPE scores were computed on a 0- to 100-point scale (T values) that is characterized by a distribution with a mean of 50 and a standard deviation of 10, to make comparison easier. Data are presented as proportions or means and 95 % confidence intervals (CIs). Differences between groups were tested with Chi-squared or Fisher exact test, and t test or Mann–Whitney nonparametric test. The Spearman rho correlation was used to examine the relationship between ordinal level variables. Univariate and multivariate odds ratios (ORs), and associated 95 % CIs for potential variables associated with HADS-defined caseness of mood disorder (HADS total score ≥16) were estimated using logistic regression models. We used the following model-building process: first we assessed bivariate associations between the dependent variable and each of the potential covariates; covariates not significantly associated (p>0.10) with the outcome were dropped from further consideration in modeling outcome. The remaining candidate covariates were entered into a multiple regression model and subjected to backward selection until all remaining covariates had p value20 %). Analyses were conducted on a sample of 151 caregivers. All statistical analyses were performed in Stata v.11.
Results The sample of caregivers consisted of 91 (60 %) females and 61 (40 %) males, aged from 24 to 78 years; 113 (74.3 %) had
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8 years of education or more, 116 (76.3 %) were married, and 96 (63.2 %) were long-term caregivers (>24 months). Within the group of male caregivers, 75 % cared for their spouse, 25 % for a parent; 37 % of female caregivers cared for their spouse, 36 % for a parent, 10 % for a son/daughter, and 18 % for brother/sister/other (18 %). Six percent of female caregivers had retired from work to assist a patient, compared to 2 % of males. Among patients, 89 (59 %) are females and 63 (41 %) males. The mean age was 58, ranging 22–85. The median time from diagnosis was 12 months (upper limit, 18 years); 108 (71 %) had metastasis. Psychosocial characteristics in caregivers, separated by gender, are shown in Table 1. Clinically relevant emotional disturbances (FSQ-first factor scores ≥9) resulted in 41 (73.2 %) female caregivers and 15 (26.8 %) male caregivers; 57 (62.6 %) females and 23 (38.3 %) males were scored as positive when screened for mood disorders, as measured by HADS (total score ≥16), Table 1 Psychosocial characteristics in caregivers, separately by gender
CI confidence interval, FSQ Family Strain Questionnaire, COPE Coping Orientations to the Problems Experienced, HADS Hospital Anxiety Depression Scale, IES Impact of Event Scale-Revised a
Due to missing values, all questionnaires for one male caregiver were excluded from the analyses
b
Chi-squared test
c
Fisher exact test
FSQ Satisfaction with family relationships Need for more information about cancer Emotional burden problems in social involvement Thoughts about death COPE subscales Positive reinterpretation and growth Active coping Acceptance Planning Turning to religion Suppression of competing activities Restraint coping Use of instrumental social support Use of emotional social support Focusing on the venting emotion Mental disengagement Denial Behavioral disengagement Humor Substance abuse HADS, N (%) Total score IES, N (%) Total score
and 15 (16.5 %) and three (5 %) for emotional distress as measured by IES (total score ≥50). HADS-total score was moderately correlated with IES-total score (rho00.60) and clinically relevant FSQ emotional disturbances (rho00.59). No interaction between gender and length of the disease, for mood disorder or emotional distress, was found. However, 34.5 % of new female caregivers and 63.6 % of long-term caregivers scored positive for emotional disturbance, compared to new male caregivers (27.0 %), and long-term caregivers (21.7 %). Positive reinterpretation and growth was the most frequently adopted coping strategy, followed by active coping and acceptance. Females, compared to males, use more emotional-oriented coping strategies (e.g., use of emotional social support, focusing on the venting of emotion, and mental disengagement). Covariates significantly associated (p
