C International Psychogeriatric Association 2014 International Psychogeriatrics (2014), 26:7, 1191–1199 doi:10.1017/S1041610214000337
Predicting anxiety and depression among family carers of people with Chronic Obstructive Pulmonary Disease ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Cristina Jácome,1 Daniela Figueiredo,1,2 Raquel Gabriel,1,2 Joana Cruz3 and Alda Marques1,2 1
School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal Unidade de Investigação e Formação sobre Adultos e Idosos (UniFAI), Porto, Portugal 3 Department of Health Sciences (SACS), University of Aveiro, Aveiro, Portugal 2
ABSTRACT
Background: Chronic Obstructive Pulmonary Disease (COPD) can be highly incapacitating, imposing a significant burden on family members, however, limited research has been conducted on psychological health of family carers. Thus, this study examined anxiety and depression symptoms in family carers of people with COPD and their predictors. Methods: A cross-sectional study was conducted with family carers and respective patients with COPD. The caregiving situation and the perceived burden, through the Carers’ Assessment of Difficulties Index, were collected from family carers. Patients’ COPD severity and activities limitation were assessed. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression symptoms in family carers and patients. Scores ࣙ8 were considered clinically significant. Results: A total of 203 family carers (58.2 ± 14.8 years old; 75.4% female) and respective patients with COPD (69.2 ± 11.5 years old; 36.5% female) were included. Clinically significant anxiety symptoms (HADS-anxiety ࣙ8) were present in 63.5% (n = 129) of family carers, depression symptoms (HADS-depression ࣙ8) were in 34% (n = 69) and both were in 27.1% (n = 55). Perceived burden [odds ratio (OR) 1.04, 95% confidence intervals (CI) = 1.01–1.06; 1.05, 95% CI = 1.03–1.07] and patients’ activities limitation (OR 1.32, 95% CI = 1.01–1.79; 1.41, 95% CI = 1.01–1.96) were significant predictors of anxiety and depression symptoms. Anxiety symptoms were also predicted by female gender (OR 0.33, 95% CI = 0.16–0.66) and depression symptoms by older age (OR 1.03, 95% CI = 1.01–1.06). Conclusion: Family carers of patients with COPD experience anxiety and depression symptoms. Perceived burden, female gender, older age, and patient’s activities limitation were predictors of these distressing symptoms. These findings highlight the need to address family carers’ needs, namely by investigating the effectiveness of supportive interventions on family’s psychological health. Key words: family carers, COPD, anxiety, depression, psychological health
Introduction Chronic Obstructive Pulmonary Disease (COPD) is highly prevalent, especially among older people, and it is projected to be the seventh leading cause of years lived with disability by 2030 (Mathers and Loncar, 2006). At early grades, COPD is characterized by cough, sputum production, and breathlessness associated with persistent airflow
Correspondence should be addressed to: Daniela Figueiredo, School of Health Sciences, University of Aveiro (ESSUA); Agras do Crasto— Campus Universitário de Santiago, Edifício 30, 3810–193 Aveiro, Portugal. Phone: +00351-234-372-462; Fax: +00351-234-401-597. Email: [email protected]. Received 24 Sep 2013; revision requested 29 Nov 2013; revised version received 11 Feb 2014; accepted 11 Feb 2014. First published online 13 March 2014.
obstruction. However, as the disease progresses, exacerbations and comorbidities severely affect patients’ physical and social dimensions of life (Vestbo et al., 2013). The gradual disability experienced by patients contributes toward the dependence on family members assistance, who become central to provide support (Bergs, 2002). COPD has, therefore, the potential to become highly distressing for both patients and family carers. In recent years, negative impacts on the psychological health of patients with COPD have been described (Qian et al., 2013), however, limited research has been conducted regarding the psychological health of family carers. The assumption that a caregiving role impacts on family carers’ psychological health is well
1192
C. Jácome et al.
documented for other chronic diseases. In family carers of patients with dementia, cancer, or stroke, 40% to 51% experience anxiety (Greenwood and Mackenzie, 2010; Mitchell et al., 2013) and 18% to 33% depression (Berg et al., 2005; Grov et al., 2005; Greenwood and Mackenzie, 2010; Mitchell et al., 2013). The Stress Process Model (Pearlin et al., 1990) is a useful conceptual framework to identify potential predictors of emotional distress among family carers. It helps to understand the complex interaction of the sociodemographic context of care (e.g., age, gender, kin relationship, and living arrangements), care demands (e.g., activities of daily living/instrumental activities of daily living dependencies, number of tasks, and hours of care), carers’ resources (e.g., coping and social support) and carers’ outcomes (physical and psychological health) (Pearlin et al., 1990). The model has been largely tested in the context of different chronic diseases, such as dementia, cancer, or stroke and a number of variables have been found to be associated with family carers’ psychological distress. The most significant are the female gender (Kim et al., 2007; Huang et al., 2009), the hours spent on caregiving tasks (Sorensen et al., 2006), the kin relationship with the patient (Kim et al., 2007), and patients’ functional dependence (Gaugler et al., 2003). These variables are also expected to play a role in the psychological health of family carers of patients with COPD; however, this is still unknown. Moreover, previous research also suggests that each chronic disease poses distinct caregiving challenges (Molloy et al., 2005). For instance, chronic diseases characterized by cognitive impairments (e.g., Alzheimer’s disease) and/or unpredictable courses (e.g., cancer) have been described as more stressful (Kim and Schulz, 2008, Huang et al., 2009). However, COPD-specific characteristics, such as the patient’s breathlessness and the difficulty in predicting when exacerbations will occur and how they will end, might pose other distinct care demands (Grant et al., 2012). Thus, this study aimed to analyze anxiety and depression symptoms in family carers of people with COPD and to identify their predictor variables.
Methods Study design and participants A cross-sectional study with a convenience sample of family carers and respective patients with COPD was conducted. The study received full approval from the Institutional Ethics Committee. The sample was recruited from three primary care centers and one district hospital. Family carers were included if they were the person who provided
the largest amount of support to patients diagnosed with COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (Vestbo et al., 2013). Family carers and patients were included if they were (i) ࣙ 18 years old; and (ii) able to understand the purpose of the study and voluntarily consent to participate. Family carers and patients were excluded if one of them (i) presented severe psychiatric conditions and/or inability to understand and co-operate or (ii) refused to participate. Eligible patients were identified by General Practitioners. The clinic secretaries contacted via telephone all identified patients, explained the purpose of the study, and asked about their willingness to participate and to identify their primary family carer. If patients and family carers agreed to participate, they were invited to attend to an arranged meeting in their primary care center or hospital where researchers informed, both verbally and in a written form, about the study procedures. A total of 266 dyads of family carers and relatives with COPD were contacted and informed about the study, 33 refused to participate as they did not perceive the relevance of the study, and 30 failed to attend the meeting. The final sample comprised 203 dyads. All participants were included after signing the informed consent. Data collection procedures Data of family carers and patients were collected in separate rooms. All instruments were administrated in a face-to-face interview conducted by two trained health professionals, a physiotherapist and a gerontologist. FAMILY CARERS
Sociodemographic data, namely gender, age, educational level (measured using standardized categories), occupation situation, and information on the caregiving situation (kin relationship with the patient, caregiving period, and hours of care provided per week) were recorded from family carers. The Portuguese version of the Carers’ Assessment of Difficulties Index (CADI) was used to assess carers’ perceived burden (Brito, 2002), since burden has been associated with carers’ global psychological health outcomes (Savundranayagam et al., 2011). CADI consists of 30 items and for each item, participants indicate in a 4-point scale if the statement: “does not apply” (0); “applies, but not stressful” (1); “applies and finds it quite stressful” (2); or “applies and finds it very stressful” (3). The total score ranges between 30 and 90 and higher scores indicate greater subjective burden. The Portuguese version of CADI has shown high internal consistency with a Cronbach’s alpha of
Anxiety and depression in carers of COPD
0.92 (Brito, 2002). In the present study, similar internal consistency was found (Cronbach’s alpha coefficient of 0.94). The Portuguese version of the Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression symptoms (Pais-Ribeiro et al., 2007). This scale has good reliability and validity (Snaith, 2003). The HADS contains 14 items, seven measuring anxiety symptoms (HADSA) and seven depression symptoms (HADS-D), which are scored separately (Pais-Ribeiro et al., 2007). Each item has a 4-point response category, so the possible scores range from 0 (minimum symptom load) to 21 (maximum symptom load) for HADS-A and for HADS-D. A score ࣙ8 in the HADS-A/HADS-D was used to consider the presence of clinically significant anxiety and depression symptoms (Pais-Ribeiro et al., 2007). Cronbach’s alpha coefficients found in the present study, 0.80 for anxiety and 0.71 for depression, were similar to those described by Pais-Ribeiro et al. (2007). PATIENTS
Patients’ sociodemographic data, lung function, activities limitation resulting from breathlessness and psychological health (HADS) were assessed. A spirometric test, using a portable spirometer (MicroLab 3500, CareFusion, Kent, UK), was performed according to the guidelines of lung function testing (Miller et al., 2005). The COPD severity was classified as early (mild and moderate) or advanced (severe and very severe) in accordance with the GOLD criteria (Vestbo et al., 2013). Activities limitation resulting from breathlessness were assessed by asking patients to select the statement from the Modified British Medical Research Council questionnaire (mMRC) that best described their respiratory limitation (Vestbo et al., 2013). The questionnaire comprises five grades in a scale from 0 to 4, with higher grades indicating greater perceived respiratory limitation. This scale is simple and valid to characterize the impact that dyspnea has on activities among patients with COPD (Vestbo et al., 2013). Statistical analysis Descriptive statistics were used to describe the sociodemographic and clinical characteristics of the sample and to examine the frequency of clinically significant anxiety and depression symptoms in family carers and patients. Sociodemographic and caregiving variables of family carers with clinically significant anxiety and depression symptoms (HADS-A/HADS-Dࣙ8) were compared with family carers without these symptoms (HADS-
1193
A/HADS-D2 163 (80.3%) Caregiving hours per week n (%) ࣘ20 hours 127 (62.6%) >20 hours 76 (37.4%) COPD severity n (%) Early Advanced mMRC, Median [IQR]
69.2 ± 11.5 74 (36.5%) 22 (10.8%) 116 (57.2%) 52 (25.6%) 13 (6.4%) 159 (78.3%) 28 (13.8%) 16 (7.9%)
137 (67.5%) 66 (32.5%) 3 [2, 4]
Abbreviations: COPD, Chronic Obstructive Pulmonary Disease; M, mean; IQR, interquartile range; mMRC, Modified British Medical Research Council questionnaire; SD, standard deviation.
lower educational levels (no education completed, primary school and secondary school; chi square tests p = 0.010 and p = 0.007) (Table 2). Anxiety symptoms were also found to be related with unemployed status (chi-square test p = 0.011) and depression symptoms with an older age (independent t-test p = 0.009).
CARERS’ PSYCHOLOGICAL HEALTH AND CAREGIVING SITUATION
The presence of anxiety or depression symptoms was not significantly different among the types of kin relationship with the patient (chi-square tests p = 0.280 and p = 0.826) or with cohabitation (chisquare tests p = 0.509 and p = 0.167) (Table 2). However, both were significantly more frequent in family carers with high subjective burden (Mann– Whitney U-tests p = 0.001). Depression symptoms were also found to be more frequent in carers providing care for longer periods (chi-square test p = 0.026) and during more hours per week (chisquare test p = 0.018) (Table 2).
CARERS’ PSYCHOLOGICAL HEALTH AND PATIENTS’ CHARACTERISTICS
The frequency of depression symptoms was higher in family carers caring for patients with advanced COPD (chi-square test p = 0.023) (Table 3). The frequency of anxiety and depression symptoms was also higher in family carers of patients’ with greater activities limitation resulting from breathlessness (mMRC) (Mann–Whitney U-tests p = 0.012 and p = 0.001). No statistically significant differences were observed for the other characteristics.
REGRESSION MODELS
Two multivariate logistic regressions were performed to identify the predictors of clinically significant anxiety and depression symptoms (Table 4). Based on the values of odds ratio (OR), if family carers increased in one point the perceived burden, then the odds of developing anxiety (HADS-Aࣙ8) or depression (HADS-Dࣙ8) symptoms would be 1.04 [95% confidence intervals (CI) = 1.01–1.06] or 1.05 (95% CI = 1.03–1.07)
Anxiety and depression in carers of COPD
1195
Table 2. Psychological health of family carers and sociodemographic/caregiving characteristics (n = 203) FAMILY CARERS
SOCIO-DEMOGRAPHIC CHARACTERISTICS
FAMILY CARERS
NOT ANXIOUS
ANXIOUS
NOT DEPRESSED
DEPRESSED
( H A D S - A 20 hours 28 (37.8%) CADI, Median [IQR] 6 [2, 15]
58.2 ± 13.1
0.964∗
61.6 ± 11.2
0.009∗
109 (84.5%) 20 (15.5%)
0.001‡
95 (70.9%) 39 (29.1%)
58 (84.1%) 11 (15.9%)
0.027‡
6 (4.7%) 59 (45.7%) 41 (31.8%) 23 (17.8%)
0.010‡
2 (1.5%) 56 (41.8%) 34 (25.4%) 42 (31.3%)
4 (5.8%) 32 (46.4%) 25 (36.2%) 8 (11.6%)
0.007‡
57 (44.2%) 37 (28.7%) 35 (27.1%)
0.011‡
63 (47%) 44 (32.8%) 27 (20.2%)
36 (52.2%) 18 (26.1%) 15 (21.7%)
0.612‡
81 (62.8%) 35 (27.1%) 5 (3.9%) 8 (6.2%)
0.280‡
76 (56.7%) 38 (28.4%) 6 (4.5%) 14 (10.4%)
47 (68.1%) 14 (20.3%) 3 (4.3%) 5 (7.3%)
0.826‡
97 (75.2%) 32 (24.8%)
0.509‡
97 (72.4%) 37 (27.6%)
55 (79.7%) 14 (20.3%)
0.167‡
24 (18.6%) 105 (81.4%)
0.365‡
32 (23.9%) 102 (76.1%)
8 (11.6%) 61 (88.4%)
0.026‡
81 (62.8%) 48 (37.2%) 14 [4.5, 32]
0.549‡
92 (68.7%) 42 (31.3%) 6 [2, 16]
36 (52.2%) 33 (47.8%) 20 [9, 37.5]
0.018‡
0.001†
56.5 ± 16.1
0.001†
∗ , independent t-tests; ‡, Chi-square tests; †, Mann–Whitney U-tests. Abbreviations: CADI, Carers’ Assessment of Difficulties Index; HADS-A, Hospital Anxiety and Depression Scale—Anxiety; HADS-D, Hospital Anxiety and Depression Scale—Depression; IQR, interquartile range; M, mean; SD, standard deviation.
Table 3. Psychological health of family carers and patients’ characteristics FAMILY CARERS
PATIENTS’ CHARACTERISTICS
FAMILY CARERS
NOT ANXIOUS
ANXIOUS
NOT DEPRESSED
DEPRESSED
( H A D S - A
Predicting anxiety and depression among family carers of people with Chronic Obstructive Pulmonary Disease ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Cristina Jácome,1 Daniela Figueiredo,1,2 Raquel Gabriel,1,2 Joana Cruz3 and Alda Marques1,2 1
School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal Unidade de Investigação e Formação sobre Adultos e Idosos (UniFAI), Porto, Portugal 3 Department of Health Sciences (SACS), University of Aveiro, Aveiro, Portugal 2
ABSTRACT
Background: Chronic Obstructive Pulmonary Disease (COPD) can be highly incapacitating, imposing a significant burden on family members, however, limited research has been conducted on psychological health of family carers. Thus, this study examined anxiety and depression symptoms in family carers of people with COPD and their predictors. Methods: A cross-sectional study was conducted with family carers and respective patients with COPD. The caregiving situation and the perceived burden, through the Carers’ Assessment of Difficulties Index, were collected from family carers. Patients’ COPD severity and activities limitation were assessed. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression symptoms in family carers and patients. Scores ࣙ8 were considered clinically significant. Results: A total of 203 family carers (58.2 ± 14.8 years old; 75.4% female) and respective patients with COPD (69.2 ± 11.5 years old; 36.5% female) were included. Clinically significant anxiety symptoms (HADS-anxiety ࣙ8) were present in 63.5% (n = 129) of family carers, depression symptoms (HADS-depression ࣙ8) were in 34% (n = 69) and both were in 27.1% (n = 55). Perceived burden [odds ratio (OR) 1.04, 95% confidence intervals (CI) = 1.01–1.06; 1.05, 95% CI = 1.03–1.07] and patients’ activities limitation (OR 1.32, 95% CI = 1.01–1.79; 1.41, 95% CI = 1.01–1.96) were significant predictors of anxiety and depression symptoms. Anxiety symptoms were also predicted by female gender (OR 0.33, 95% CI = 0.16–0.66) and depression symptoms by older age (OR 1.03, 95% CI = 1.01–1.06). Conclusion: Family carers of patients with COPD experience anxiety and depression symptoms. Perceived burden, female gender, older age, and patient’s activities limitation were predictors of these distressing symptoms. These findings highlight the need to address family carers’ needs, namely by investigating the effectiveness of supportive interventions on family’s psychological health. Key words: family carers, COPD, anxiety, depression, psychological health
Introduction Chronic Obstructive Pulmonary Disease (COPD) is highly prevalent, especially among older people, and it is projected to be the seventh leading cause of years lived with disability by 2030 (Mathers and Loncar, 2006). At early grades, COPD is characterized by cough, sputum production, and breathlessness associated with persistent airflow
Correspondence should be addressed to: Daniela Figueiredo, School of Health Sciences, University of Aveiro (ESSUA); Agras do Crasto— Campus Universitário de Santiago, Edifício 30, 3810–193 Aveiro, Portugal. Phone: +00351-234-372-462; Fax: +00351-234-401-597. Email: [email protected]. Received 24 Sep 2013; revision requested 29 Nov 2013; revised version received 11 Feb 2014; accepted 11 Feb 2014. First published online 13 March 2014.
obstruction. However, as the disease progresses, exacerbations and comorbidities severely affect patients’ physical and social dimensions of life (Vestbo et al., 2013). The gradual disability experienced by patients contributes toward the dependence on family members assistance, who become central to provide support (Bergs, 2002). COPD has, therefore, the potential to become highly distressing for both patients and family carers. In recent years, negative impacts on the psychological health of patients with COPD have been described (Qian et al., 2013), however, limited research has been conducted regarding the psychological health of family carers. The assumption that a caregiving role impacts on family carers’ psychological health is well
1192
C. Jácome et al.
documented for other chronic diseases. In family carers of patients with dementia, cancer, or stroke, 40% to 51% experience anxiety (Greenwood and Mackenzie, 2010; Mitchell et al., 2013) and 18% to 33% depression (Berg et al., 2005; Grov et al., 2005; Greenwood and Mackenzie, 2010; Mitchell et al., 2013). The Stress Process Model (Pearlin et al., 1990) is a useful conceptual framework to identify potential predictors of emotional distress among family carers. It helps to understand the complex interaction of the sociodemographic context of care (e.g., age, gender, kin relationship, and living arrangements), care demands (e.g., activities of daily living/instrumental activities of daily living dependencies, number of tasks, and hours of care), carers’ resources (e.g., coping and social support) and carers’ outcomes (physical and psychological health) (Pearlin et al., 1990). The model has been largely tested in the context of different chronic diseases, such as dementia, cancer, or stroke and a number of variables have been found to be associated with family carers’ psychological distress. The most significant are the female gender (Kim et al., 2007; Huang et al., 2009), the hours spent on caregiving tasks (Sorensen et al., 2006), the kin relationship with the patient (Kim et al., 2007), and patients’ functional dependence (Gaugler et al., 2003). These variables are also expected to play a role in the psychological health of family carers of patients with COPD; however, this is still unknown. Moreover, previous research also suggests that each chronic disease poses distinct caregiving challenges (Molloy et al., 2005). For instance, chronic diseases characterized by cognitive impairments (e.g., Alzheimer’s disease) and/or unpredictable courses (e.g., cancer) have been described as more stressful (Kim and Schulz, 2008, Huang et al., 2009). However, COPD-specific characteristics, such as the patient’s breathlessness and the difficulty in predicting when exacerbations will occur and how they will end, might pose other distinct care demands (Grant et al., 2012). Thus, this study aimed to analyze anxiety and depression symptoms in family carers of people with COPD and to identify their predictor variables.
Methods Study design and participants A cross-sectional study with a convenience sample of family carers and respective patients with COPD was conducted. The study received full approval from the Institutional Ethics Committee. The sample was recruited from three primary care centers and one district hospital. Family carers were included if they were the person who provided
the largest amount of support to patients diagnosed with COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (Vestbo et al., 2013). Family carers and patients were included if they were (i) ࣙ 18 years old; and (ii) able to understand the purpose of the study and voluntarily consent to participate. Family carers and patients were excluded if one of them (i) presented severe psychiatric conditions and/or inability to understand and co-operate or (ii) refused to participate. Eligible patients were identified by General Practitioners. The clinic secretaries contacted via telephone all identified patients, explained the purpose of the study, and asked about their willingness to participate and to identify their primary family carer. If patients and family carers agreed to participate, they were invited to attend to an arranged meeting in their primary care center or hospital where researchers informed, both verbally and in a written form, about the study procedures. A total of 266 dyads of family carers and relatives with COPD were contacted and informed about the study, 33 refused to participate as they did not perceive the relevance of the study, and 30 failed to attend the meeting. The final sample comprised 203 dyads. All participants were included after signing the informed consent. Data collection procedures Data of family carers and patients were collected in separate rooms. All instruments were administrated in a face-to-face interview conducted by two trained health professionals, a physiotherapist and a gerontologist. FAMILY CARERS
Sociodemographic data, namely gender, age, educational level (measured using standardized categories), occupation situation, and information on the caregiving situation (kin relationship with the patient, caregiving period, and hours of care provided per week) were recorded from family carers. The Portuguese version of the Carers’ Assessment of Difficulties Index (CADI) was used to assess carers’ perceived burden (Brito, 2002), since burden has been associated with carers’ global psychological health outcomes (Savundranayagam et al., 2011). CADI consists of 30 items and for each item, participants indicate in a 4-point scale if the statement: “does not apply” (0); “applies, but not stressful” (1); “applies and finds it quite stressful” (2); or “applies and finds it very stressful” (3). The total score ranges between 30 and 90 and higher scores indicate greater subjective burden. The Portuguese version of CADI has shown high internal consistency with a Cronbach’s alpha of
Anxiety and depression in carers of COPD
0.92 (Brito, 2002). In the present study, similar internal consistency was found (Cronbach’s alpha coefficient of 0.94). The Portuguese version of the Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression symptoms (Pais-Ribeiro et al., 2007). This scale has good reliability and validity (Snaith, 2003). The HADS contains 14 items, seven measuring anxiety symptoms (HADSA) and seven depression symptoms (HADS-D), which are scored separately (Pais-Ribeiro et al., 2007). Each item has a 4-point response category, so the possible scores range from 0 (minimum symptom load) to 21 (maximum symptom load) for HADS-A and for HADS-D. A score ࣙ8 in the HADS-A/HADS-D was used to consider the presence of clinically significant anxiety and depression symptoms (Pais-Ribeiro et al., 2007). Cronbach’s alpha coefficients found in the present study, 0.80 for anxiety and 0.71 for depression, were similar to those described by Pais-Ribeiro et al. (2007). PATIENTS
Patients’ sociodemographic data, lung function, activities limitation resulting from breathlessness and psychological health (HADS) were assessed. A spirometric test, using a portable spirometer (MicroLab 3500, CareFusion, Kent, UK), was performed according to the guidelines of lung function testing (Miller et al., 2005). The COPD severity was classified as early (mild and moderate) or advanced (severe and very severe) in accordance with the GOLD criteria (Vestbo et al., 2013). Activities limitation resulting from breathlessness were assessed by asking patients to select the statement from the Modified British Medical Research Council questionnaire (mMRC) that best described their respiratory limitation (Vestbo et al., 2013). The questionnaire comprises five grades in a scale from 0 to 4, with higher grades indicating greater perceived respiratory limitation. This scale is simple and valid to characterize the impact that dyspnea has on activities among patients with COPD (Vestbo et al., 2013). Statistical analysis Descriptive statistics were used to describe the sociodemographic and clinical characteristics of the sample and to examine the frequency of clinically significant anxiety and depression symptoms in family carers and patients. Sociodemographic and caregiving variables of family carers with clinically significant anxiety and depression symptoms (HADS-A/HADS-Dࣙ8) were compared with family carers without these symptoms (HADS-
1193
A/HADS-D2 163 (80.3%) Caregiving hours per week n (%) ࣘ20 hours 127 (62.6%) >20 hours 76 (37.4%) COPD severity n (%) Early Advanced mMRC, Median [IQR]
69.2 ± 11.5 74 (36.5%) 22 (10.8%) 116 (57.2%) 52 (25.6%) 13 (6.4%) 159 (78.3%) 28 (13.8%) 16 (7.9%)
137 (67.5%) 66 (32.5%) 3 [2, 4]
Abbreviations: COPD, Chronic Obstructive Pulmonary Disease; M, mean; IQR, interquartile range; mMRC, Modified British Medical Research Council questionnaire; SD, standard deviation.
lower educational levels (no education completed, primary school and secondary school; chi square tests p = 0.010 and p = 0.007) (Table 2). Anxiety symptoms were also found to be related with unemployed status (chi-square test p = 0.011) and depression symptoms with an older age (independent t-test p = 0.009).
CARERS’ PSYCHOLOGICAL HEALTH AND CAREGIVING SITUATION
The presence of anxiety or depression symptoms was not significantly different among the types of kin relationship with the patient (chi-square tests p = 0.280 and p = 0.826) or with cohabitation (chisquare tests p = 0.509 and p = 0.167) (Table 2). However, both were significantly more frequent in family carers with high subjective burden (Mann– Whitney U-tests p = 0.001). Depression symptoms were also found to be more frequent in carers providing care for longer periods (chi-square test p = 0.026) and during more hours per week (chisquare test p = 0.018) (Table 2).
CARERS’ PSYCHOLOGICAL HEALTH AND PATIENTS’ CHARACTERISTICS
The frequency of depression symptoms was higher in family carers caring for patients with advanced COPD (chi-square test p = 0.023) (Table 3). The frequency of anxiety and depression symptoms was also higher in family carers of patients’ with greater activities limitation resulting from breathlessness (mMRC) (Mann–Whitney U-tests p = 0.012 and p = 0.001). No statistically significant differences were observed for the other characteristics.
REGRESSION MODELS
Two multivariate logistic regressions were performed to identify the predictors of clinically significant anxiety and depression symptoms (Table 4). Based on the values of odds ratio (OR), if family carers increased in one point the perceived burden, then the odds of developing anxiety (HADS-Aࣙ8) or depression (HADS-Dࣙ8) symptoms would be 1.04 [95% confidence intervals (CI) = 1.01–1.06] or 1.05 (95% CI = 1.03–1.07)
Anxiety and depression in carers of COPD
1195
Table 2. Psychological health of family carers and sociodemographic/caregiving characteristics (n = 203) FAMILY CARERS
SOCIO-DEMOGRAPHIC CHARACTERISTICS
FAMILY CARERS
NOT ANXIOUS
ANXIOUS
NOT DEPRESSED
DEPRESSED
( H A D S - A 20 hours 28 (37.8%) CADI, Median [IQR] 6 [2, 15]
58.2 ± 13.1
0.964∗
61.6 ± 11.2
0.009∗
109 (84.5%) 20 (15.5%)
0.001‡
95 (70.9%) 39 (29.1%)
58 (84.1%) 11 (15.9%)
0.027‡
6 (4.7%) 59 (45.7%) 41 (31.8%) 23 (17.8%)
0.010‡
2 (1.5%) 56 (41.8%) 34 (25.4%) 42 (31.3%)
4 (5.8%) 32 (46.4%) 25 (36.2%) 8 (11.6%)
0.007‡
57 (44.2%) 37 (28.7%) 35 (27.1%)
0.011‡
63 (47%) 44 (32.8%) 27 (20.2%)
36 (52.2%) 18 (26.1%) 15 (21.7%)
0.612‡
81 (62.8%) 35 (27.1%) 5 (3.9%) 8 (6.2%)
0.280‡
76 (56.7%) 38 (28.4%) 6 (4.5%) 14 (10.4%)
47 (68.1%) 14 (20.3%) 3 (4.3%) 5 (7.3%)
0.826‡
97 (75.2%) 32 (24.8%)
0.509‡
97 (72.4%) 37 (27.6%)
55 (79.7%) 14 (20.3%)
0.167‡
24 (18.6%) 105 (81.4%)
0.365‡
32 (23.9%) 102 (76.1%)
8 (11.6%) 61 (88.4%)
0.026‡
81 (62.8%) 48 (37.2%) 14 [4.5, 32]
0.549‡
92 (68.7%) 42 (31.3%) 6 [2, 16]
36 (52.2%) 33 (47.8%) 20 [9, 37.5]
0.018‡
0.001†
56.5 ± 16.1
0.001†
∗ , independent t-tests; ‡, Chi-square tests; †, Mann–Whitney U-tests. Abbreviations: CADI, Carers’ Assessment of Difficulties Index; HADS-A, Hospital Anxiety and Depression Scale—Anxiety; HADS-D, Hospital Anxiety and Depression Scale—Depression; IQR, interquartile range; M, mean; SD, standard deviation.
Table 3. Psychological health of family carers and patients’ characteristics FAMILY CARERS
PATIENTS’ CHARACTERISTICS
FAMILY CARERS
NOT ANXIOUS
ANXIOUS
NOT DEPRESSED
DEPRESSED
( H A D S - A
