Support Care Cancer (2015) 23:1925–1931 DOI 10.1007/s00520-014-2548-x
ORIGINAL ARTICLE
Association between depressive symptoms and changes in sleep condition in the grieving process Hitoshi Tanimukai & Hiroyoshi Adachi & Kei Hirai & Tomoko Matsui & Megumi Shimizu & Mitsunori Miyashita & Satoru Tsuneto & Yasuo Shima
Received: 1 July 2014 / Accepted: 30 November 2014 / Published online: 10 December 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Bereaved families often suffer from insomnia and depression. However, the associations between depressive state and changes in sleep condition during the grieving process have not been investigated. This study aimed to clarify the prevalence of insomnia symptoms and to explore associations between present depressive state and changes in sleep condition in the grieving process in bereaved families of Japanese patients with cancer. H. Tanimukai (*) : H. Adachi Department of Psychiatry, Osaka University Health Care Center, 1-17, Machikaneyama-cho, Toyonaka, Osaka 560-0043, Japan e-mail: [email protected] H. Tanimukai Oncology Center, Osaka University Hospital, Osaka, Japan H. Adachi Sleep Medical Center, Osaka University Hospital, Osaka, Japan K. Hirai Department of Complementary and Alternative Medicine, Osaka University Graduate School of Medicine, Osaka, Japan T. Matsui Clinical Thanatology and Geriatric Behavioral Science, Graduate School of Human Sciences, Osaka University, Osaka, Japan M. Shimizu : M. Miyashita Department of Nursing, Tohoku University School of Health Sciences, Miyagi, Japan S. Tsuneto Department of Multidisciplinary Cancer Treatment, Graduate School of Medicine Kyoto University, Kyoto, Japan Y. Shima Department of Palliative Medicine, Tsukuba Medical Center Hospital, Ibaraki, Japan
Methods A cross-sectional, multicenter survey was conducted in 103 certified palliative care units. A questionnaire asking insomnia symptoms and depressive symptoms by the Center for Epidemiological Studies Depression Scale (CES-D) was mailed to bereaved families (N=987). The association between present depressive state (CES-D ≥7) and sleep conditions in the grieving process were analyzed. Results A total of 561 families were enrolled for analysis. Fifty-three percent of family members were considered to be in a depressive state at the time of the investigation. Prevalence of past insomnia was 86.5 % at “within a few weeks before the patient’s death” (T1) and 84.5 % at “within 6 months after the patient’s death” (T2) in all bereaved family members. However, in contrast to decreased severity of insomnia between T1 and T2 in the non-depressive group (p30 min were at a 2.14 times higher risk of death [15]. Furthermore, multiple epidemiological studies have observed complaints of poor sleep quality in 50–90 % of subjects with diagnosed depression [16, 17]. Sleep problems are thus not negligible and should not be overlooked. Early detection and intervention for sleep problems in bereaved people are required. However, sleep problems experienced among bereaved individuals have been poorly followed up and/or underestimated by medical staff. In addition, the prevalence of detailed insomnia symptoms in a large-scale bereavement study has not been investigated. The present study aimed to clarify the prevalence of insomnia symptoms and depressive symptoms using a questionnaire survey of more than 500 bereaved Japanese families. In addition, we explored associations between present depressive state and changes in sleep condition in the grieving process, since sleep problems have recently been indicated as a risk and/or a predictor of major depressive disorder [18]. Here, we tried to seek a more effective and practical method for detecting possible depression in the bereaved as early as possible by
Support Care Cancer (2015) 23:1925–1931
following insomnia symptoms at different time-points during the grieving process.
Methods This research was part of the Japan Hospice and Palliative Care Evaluation Study 2 (JHOPE-2), a cross-sectional, anonymous, multicenter survey. Of 153 certified palliative care units (PCUs) associated with Hospice Palliative Care Japan, 103 agreed to participate in this study. We mailed the questionnaire to bereaved families identified by the participating institutions in October 2010, and again in November 2010 to non-responding families. A sheet explaining the aims and methods of the survey was included along with the questionnaire, and return of the completed questionnaire was regarded as consent to participate in the study. If the family did not want to participate in the survey, they were requested to return the questionnaire by checking the “no participation” box and a second questionnaire was not mailed out. Ethical and scientific validity was confirmed by the institutional review board of Tohoku University. Subjects Primary palliative care physicians responsible for caring for patients in the participating PCUs identified potential participants based on the following criteria: (1) bereaved adult family members of adult cancer patients (one family member selected for each patient); (2) capable of replying to a selfreported questionnaire; (3) aware of the diagnosis of malignancy; and 4) no serious psychological distress, as recognized by the primary palliative care physician. The last criterion, which was adopted in the same way as in our previous surveys [19–22], was applied on the assumption that primary palliative care physicians could identify families who would suffer serious psychological distress resulting from this survey because these physicians were closely involved in caring for the patient’s relatives in an inpatient care setting (mean admission period, 43 days). Physicians at each participating hospital completed a list of included and excluded families and sent it to the research team after deleting confidential patient information. Questionnaire form for sleep conditions Demographic information about patients and their families was collected from the surviving members of each family. To probe sleeping conditions at the time of questionnaire completion, we asked the participant to rate four insomnia symptoms (difficulty initiating sleep; difficulty maintaining sleep; waking too early; and poor sleep quality) during the past week on a scale of 0 to 4 (0, “none”; 1, “mild”; 2,
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“moderate”; 3, “severe”; 4, “very severe”). This study defined “insomnia symptoms” as present if a score of ≥1 for at least one of the four insomnia symptoms. In retrospectively investigating sleep conditions before and after bereavement, we simply asked about the presence and severity (“none”, “mild”, “moderate”, “severe,” or “very severe”) of sleep difficulties at each of three periods: (1) within a few weeks before the patient’s death (T1); (2) within 6 months after the patient’s death (T2); and (3) over 6 months after the patient’s death (T3). The reasons why we set 6 months after bereavement as the breakpoint of the grieving process are: (1) the risk of MDD appears to peak during the first 6 months of bereavement [6, 7] and (2) 6 months after bereavement appears to represent the most effective timing for identifying bereaved families at higher risk of developing prolonged grief [23]. This study did not add a period in the immediate aftermath of bereavement because the purpose of this retrospective study was not to investigate the acute influence of bereavement, but rather to clarify the effects of anticipatory grief and grief after death on sleep condition. We defined the presence of insomnia at a time-point as a response of “mild” to “very severe”. The scheme for recall of sleep conditions is shown in Fig. 1.
symptoms. The differences among these variables were analyzed by Chi-square tests. To analyze the association between present depressive state and sleep conditions in the grieving process, main effects (period (T1, T2, T3) or CES-D) and interaction (period×CES-D score) were first analyzed by twoway repeated-measures analysis of variance (ANOVA). Multiple ANOVA (M-ANOVA) was then used to evaluate the simple main effect (period or CES-D score). To investigate continual changes in sleep conditions during the grieving process, we compared changes of severity of insomnia (e.g., mean score at T2−mean score at T1) at each period (D1, T1− T2; D2, T2 − T3) between the two groups using the Bonferroni-Dunn test. A t test was used to compare the ratio of change of severity of insomnia (e.g., (mean score at T2− mean score at T1)/mean score at T1) at each period (D1, D2) in the depressive group to that in the non-depressive group. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) Version 21.
Questionnaire form for psychological condition
Of the 987 questionnaires sent out, 665 families responded (response rate, 67 %). Sixty-four families who responded declined to participate (effective response rate, 61 %). Another 40 families failed to provide sex and/or age and other essential items in the questionnaire. As a result, data from 561 family members were analyzed. Mean age of subjects was 61.4± 12.1 years (mean±standard deviation (SD); range, 23–89 years). Participants comprised 198 males (35 %) and 363 females (65 %). CES-D ≥7 was observed 298 participants (53.1 %) and the mean CES-D score for this depressive group was 10.39±2.92 (range, 7–22). The prevalence of depressive symptoms (CES-D ≥7) was significantly higher in women than in men (χ2 =7.8, df=1, p=0.005) and in spouses than in nonspouses (χ2 =12.3, df=1, p
ORIGINAL ARTICLE
Association between depressive symptoms and changes in sleep condition in the grieving process Hitoshi Tanimukai & Hiroyoshi Adachi & Kei Hirai & Tomoko Matsui & Megumi Shimizu & Mitsunori Miyashita & Satoru Tsuneto & Yasuo Shima
Received: 1 July 2014 / Accepted: 30 November 2014 / Published online: 10 December 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Bereaved families often suffer from insomnia and depression. However, the associations between depressive state and changes in sleep condition during the grieving process have not been investigated. This study aimed to clarify the prevalence of insomnia symptoms and to explore associations between present depressive state and changes in sleep condition in the grieving process in bereaved families of Japanese patients with cancer. H. Tanimukai (*) : H. Adachi Department of Psychiatry, Osaka University Health Care Center, 1-17, Machikaneyama-cho, Toyonaka, Osaka 560-0043, Japan e-mail: [email protected] H. Tanimukai Oncology Center, Osaka University Hospital, Osaka, Japan H. Adachi Sleep Medical Center, Osaka University Hospital, Osaka, Japan K. Hirai Department of Complementary and Alternative Medicine, Osaka University Graduate School of Medicine, Osaka, Japan T. Matsui Clinical Thanatology and Geriatric Behavioral Science, Graduate School of Human Sciences, Osaka University, Osaka, Japan M. Shimizu : M. Miyashita Department of Nursing, Tohoku University School of Health Sciences, Miyagi, Japan S. Tsuneto Department of Multidisciplinary Cancer Treatment, Graduate School of Medicine Kyoto University, Kyoto, Japan Y. Shima Department of Palliative Medicine, Tsukuba Medical Center Hospital, Ibaraki, Japan
Methods A cross-sectional, multicenter survey was conducted in 103 certified palliative care units. A questionnaire asking insomnia symptoms and depressive symptoms by the Center for Epidemiological Studies Depression Scale (CES-D) was mailed to bereaved families (N=987). The association between present depressive state (CES-D ≥7) and sleep conditions in the grieving process were analyzed. Results A total of 561 families were enrolled for analysis. Fifty-three percent of family members were considered to be in a depressive state at the time of the investigation. Prevalence of past insomnia was 86.5 % at “within a few weeks before the patient’s death” (T1) and 84.5 % at “within 6 months after the patient’s death” (T2) in all bereaved family members. However, in contrast to decreased severity of insomnia between T1 and T2 in the non-depressive group (p30 min were at a 2.14 times higher risk of death [15]. Furthermore, multiple epidemiological studies have observed complaints of poor sleep quality in 50–90 % of subjects with diagnosed depression [16, 17]. Sleep problems are thus not negligible and should not be overlooked. Early detection and intervention for sleep problems in bereaved people are required. However, sleep problems experienced among bereaved individuals have been poorly followed up and/or underestimated by medical staff. In addition, the prevalence of detailed insomnia symptoms in a large-scale bereavement study has not been investigated. The present study aimed to clarify the prevalence of insomnia symptoms and depressive symptoms using a questionnaire survey of more than 500 bereaved Japanese families. In addition, we explored associations between present depressive state and changes in sleep condition in the grieving process, since sleep problems have recently been indicated as a risk and/or a predictor of major depressive disorder [18]. Here, we tried to seek a more effective and practical method for detecting possible depression in the bereaved as early as possible by
Support Care Cancer (2015) 23:1925–1931
following insomnia symptoms at different time-points during the grieving process.
Methods This research was part of the Japan Hospice and Palliative Care Evaluation Study 2 (JHOPE-2), a cross-sectional, anonymous, multicenter survey. Of 153 certified palliative care units (PCUs) associated with Hospice Palliative Care Japan, 103 agreed to participate in this study. We mailed the questionnaire to bereaved families identified by the participating institutions in October 2010, and again in November 2010 to non-responding families. A sheet explaining the aims and methods of the survey was included along with the questionnaire, and return of the completed questionnaire was regarded as consent to participate in the study. If the family did not want to participate in the survey, they were requested to return the questionnaire by checking the “no participation” box and a second questionnaire was not mailed out. Ethical and scientific validity was confirmed by the institutional review board of Tohoku University. Subjects Primary palliative care physicians responsible for caring for patients in the participating PCUs identified potential participants based on the following criteria: (1) bereaved adult family members of adult cancer patients (one family member selected for each patient); (2) capable of replying to a selfreported questionnaire; (3) aware of the diagnosis of malignancy; and 4) no serious psychological distress, as recognized by the primary palliative care physician. The last criterion, which was adopted in the same way as in our previous surveys [19–22], was applied on the assumption that primary palliative care physicians could identify families who would suffer serious psychological distress resulting from this survey because these physicians were closely involved in caring for the patient’s relatives in an inpatient care setting (mean admission period, 43 days). Physicians at each participating hospital completed a list of included and excluded families and sent it to the research team after deleting confidential patient information. Questionnaire form for sleep conditions Demographic information about patients and their families was collected from the surviving members of each family. To probe sleeping conditions at the time of questionnaire completion, we asked the participant to rate four insomnia symptoms (difficulty initiating sleep; difficulty maintaining sleep; waking too early; and poor sleep quality) during the past week on a scale of 0 to 4 (0, “none”; 1, “mild”; 2,
Support Care Cancer (2015) 23:1925–1931
1927
“moderate”; 3, “severe”; 4, “very severe”). This study defined “insomnia symptoms” as present if a score of ≥1 for at least one of the four insomnia symptoms. In retrospectively investigating sleep conditions before and after bereavement, we simply asked about the presence and severity (“none”, “mild”, “moderate”, “severe,” or “very severe”) of sleep difficulties at each of three periods: (1) within a few weeks before the patient’s death (T1); (2) within 6 months after the patient’s death (T2); and (3) over 6 months after the patient’s death (T3). The reasons why we set 6 months after bereavement as the breakpoint of the grieving process are: (1) the risk of MDD appears to peak during the first 6 months of bereavement [6, 7] and (2) 6 months after bereavement appears to represent the most effective timing for identifying bereaved families at higher risk of developing prolonged grief [23]. This study did not add a period in the immediate aftermath of bereavement because the purpose of this retrospective study was not to investigate the acute influence of bereavement, but rather to clarify the effects of anticipatory grief and grief after death on sleep condition. We defined the presence of insomnia at a time-point as a response of “mild” to “very severe”. The scheme for recall of sleep conditions is shown in Fig. 1.
symptoms. The differences among these variables were analyzed by Chi-square tests. To analyze the association between present depressive state and sleep conditions in the grieving process, main effects (period (T1, T2, T3) or CES-D) and interaction (period×CES-D score) were first analyzed by twoway repeated-measures analysis of variance (ANOVA). Multiple ANOVA (M-ANOVA) was then used to evaluate the simple main effect (period or CES-D score). To investigate continual changes in sleep conditions during the grieving process, we compared changes of severity of insomnia (e.g., mean score at T2−mean score at T1) at each period (D1, T1− T2; D2, T2 − T3) between the two groups using the Bonferroni-Dunn test. A t test was used to compare the ratio of change of severity of insomnia (e.g., (mean score at T2− mean score at T1)/mean score at T1) at each period (D1, D2) in the depressive group to that in the non-depressive group. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) Version 21.
Questionnaire form for psychological condition
Of the 987 questionnaires sent out, 665 families responded (response rate, 67 %). Sixty-four families who responded declined to participate (effective response rate, 61 %). Another 40 families failed to provide sex and/or age and other essential items in the questionnaire. As a result, data from 561 family members were analyzed. Mean age of subjects was 61.4± 12.1 years (mean±standard deviation (SD); range, 23–89 years). Participants comprised 198 males (35 %) and 363 females (65 %). CES-D ≥7 was observed 298 participants (53.1 %) and the mean CES-D score for this depressive group was 10.39±2.92 (range, 7–22). The prevalence of depressive symptoms (CES-D ≥7) was significantly higher in women than in men (χ2 =7.8, df=1, p=0.005) and in spouses than in nonspouses (χ2 =12.3, df=1, p
