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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 53-57

Care givers' depression, anxiety, distress, and somatization as predictors of identical symptoms in cancer patients


Centre for Health Psychology, University of Hyderabad, Gachibowli, Hyderabad, Telangana, India

Date of Web Publication13-Apr-2016

Correspondence Address:
Gadiraju Padmaja
Centre for Health Psychology, University of Hyderabad, Gachibowli, Hyderabad - 500 046, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.146088

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 > 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.

Keywords: Anxiety, depression, distress, somatization


How to cite this article:
Padmaja G, Vanlalhruaii C, Rana S, Nandinee D, Hariharan M. Care givers' depression, anxiety, distress, and somatization as predictors of identical symptoms in cancer patients. J Can Res Ther 2016;12:53-7

How to cite this URL:
Padmaja G, Vanlalhruaii C, Rana S, Nandinee D, Hariharan M. Care givers' depression, anxiety, distress, and somatization as predictors of identical symptoms in cancer patients. J Can Res Ther [serial online] 2016 [cited 2019 Dec 11];12:53-7. Available from: http://www.cancerjournal.net/text.asp?2016/12/1/53/146088




 > Introduction Top


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 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 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 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 Top


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.

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 Top


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' depression, anxiety, distress, and somatization. Significant positive correlations were found between caregivers' depression and patients depression r(198) =0.22, P <.05. The caregivers' depression and patients anxiety r(198)=0.36, P <.01 was found to be significant. It was also found that there was significant relation between caregivers' anxiety and patients depression r(198)=.32, P <.01 and caregivers' anxiety and patients anxiety r(198) =.35, P <.01. Significant correlation was found between caregivers' distress and patients depression r(198) =.20, P <.05 and caregivers' distress and patients' anxiety r(198) =.37, P <.01. The relation between caregivers' somatization and patients depression was found to be significant r(198) =.24, P <.01 and caregivers' somatization and patients anxiety r(198)=.33, P <.01. There is a significant negative correlation found between caregivers' age and patients somatization r(198)=.26, P <.01 for the entire sample of caregiver and patients (N = 200).
Table 1: Correlation between patients' depression, anxiety, distress, and somatization with caregivers' depression, anxiety, distress, and somatization

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To find out the independent contribution of caregivers' anxiety with patients' distress and caregivers' age with patients' somatization simple linear analysis were done separately. The result was presented in [Table 2]. It is revealed from [Table 2] that caregivers' anxiety explained statistically significant (6%) proportion of the variance in patients distress, R2=0.06, adjusted R2= 0.06, F(1,198) =6.27, P <.05. The relationship between caregivers' anxiety and patients distress was positive, β=.25, P <.05, with increases in patients' anxiety being associated with patients' distress. The analysis also revealed that statistically significant (6%) proportion of the variance in patients'somatization was explained by caregivers' age, R2=.06, adjusted R2=.06, F(1,198) =6.92, P <.05. the relationship between patients'somatization and caregivers' age was negative, β =−.26, P <.05 with increase of caregiver's age being associated with decrease of patients' somatization.
Table 2: Summary of simple regression between caregivers' anxiety with patients' distress and caregivers' age with patients' somatisation

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[Table 3] presents the results of the multiple linear regressions. The results revealed that the combined predictors', caregivers' depression, anxiety, distress, and somatization explained 12% of the variance in patients depression, R 2=0.12, adjusted R 2=0.12, F(3,196)=3.41, P <.05. Caregivers' anxiety β =.40 was found to be significant, P <.05. The results further revealed that the combined predictors, caregivers depression, anxiety, distress, and somatisation explained 17% of the variance in patients anxiety, R 2=.17, adjusted R 2=.17, F(3,196) =5.05, P <.01.
Table 3: Summary of multiple regression analysis for variables

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 > Discussion Top


Depression, anxiety, and distress are common among cancer patients, and their caregivers due to the strain caused by the disease and caretaking, respectively. Issues like treatment, medical expenses, change in role, and assistance required by the patients can have profound effects on both the patients and their caregivers. Patients and caregivers have interdependence and known to influence each other. Results show that patients' depression and anxiety are significantly correlated with caregivers' depression, anxiety, distress, and somatization. Patients' distress and somatization are also significantly correlated with caregivers' anxiety and age, respectively. Studies also suggest that a reciprocal relationship exists between the emotional distress reported by patients with cancer and their spouse caregivers [2],[10] and between patients' and caregivers' distress.[16] It is also evident from the results that caregivers' anxiety is a significant predictor of distress in patients. The findings are in line with a study that found that psychological problems are seen in caregivers when patients have psychological problems and vice versa though they are manifested in different forms in both.[16] Cancer patients and their caregivers can have influence on each other and their mutuality related to psychological problem.[15],[16] There is a new dimension of the findings of the study that emphasizes that the caregivers' age is a significant contributor toward the patients' somatization. The results also show that caregivers' depression, anxiety, distress, and somatization significantly predict depression and anxiety in cancer patients. Mentioning the pathway of influence from caregiver to patient that often goes unrecognized by healthcare professionals, one study suggests that interventions that decrease caregivers' anxiety may decrease patients' anxiety and, subsequently, have a calming effect on patients.[22] The association found between depression, anxiety, distress, and somatization of caregivers and patients indicates the need for designing psychological interventions to manage the depression, anxiety, distress, and somatization of caregivers, which in turn may help managing the identical symptoms in patients.


 > Conclusion Top


The findings of the study show us a new dimension of measuring cancer patients' psychological problems by taking into consideration the caregivers' psychological problems. Because the critical condition of the cancer patients or the stringent medical procedures often act as impediment in the psychological assessment, it is appropriate to predict patients' psychological problems from their caregivers' problems. For a caregiver, caring for the patient who is facing serious health challenges due to cancer may lead to negative consequences like the psychological problems discussed so far. Hence, greater attention needs to be paid to the psychological problems of the caregivers so that appropriate supportive interventions are planned, as this in turn would be instrumental in the adversarial growth of the patients. Social support, especially family support, being a highly effective psycho-social support intervention, if caregivers' well-being is enhanced, they contribute further to the well-being of the patients. Individual tailor-made interventions targeting the patients and caregivers separately as well as combined interventions for both may help in a long way. Evidence-based psychotherapeutic techniques are recommended to support the psychological needs of family caregivers who struggle to cope with the reality of cancer being diagnosed for their close member of the family.

Thus, a family-centered intervention primarily involving both the caregiver (s) and patient needs to be tailored. Health psychological intervention involving both informational as well as psychological support can be integrated into such intervention programs paving way to the acceptance of and dealing with the existing reality in more rational manner by caregivers. This helps them in providing better psycho-social support to the patient. Vulnerable caregivers need to be identified and a synergic model integrating informational and psychosocial resources into the intervention needs to be planned. Future research could be directed toward exploring such unique interventions.


 > Acknowledgment Top


The authors are grateful to the Hospitals, Doctors, Patients and Caregivers who have cooperated in data collection.

 
 > References Top

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