Download Interrelationships among Anxiety and Depression in Patients and

Interrelationships among Anxiety and
Depression in Patients and Caregiver Dyads
with Newly Diagnosed Incurable Cancers
Jamie M. Stagl, PhD
Cancer Outcomes Research Program
Massachusetts General Hospital Cancer Center
Harvard Medical School
Society of Behavioral Medicine
April 1, 2016
Incurable cancer
• “Living with cancer is different from living
after cancer”1
• Cancer may be controlled with treatment
• May not grow or spread with treatment
• May not go into remission
Metastatic lung and non-colorectal
gastrointestinal cancer
• Lung cancer:
– Most common cancer worldwide2
– Leading cause of cancer death3
• Gastrointestinal cancer:
– One of leading causes of cancer-related deaths4
• Metastatic lung and GI cancer:
– Poor prognosis (median survival < 1 year5)
– 5-year survival rate = 4%6
Newly diagnosed patients and their
caregivers
• Patients with incurable cancer:
– High physical symptom burden
– High psychological symptom burden and distress
– Poor prognosis
• Caregivers of patients with incurable cancer:
– High care burden
– Poor quality of life
– Complicated bereavement
Caregivers for advanced cancer
patients
• Poor Quality of Life7
– Associated with worse patient physical and
emotional well-being8
– Associated with emotional distress9
• Emotional distress related to lifestyle
interference10
• Caregiver depression at patient’s end-of-life11
Purpose
• Describe prevalence of anxiety and depression
in patients with newly diagnosed incurable
cancer and their caregivers.
• Are anxiety and depression interdependent in
these dyads?
• To what extent are they interdependent?
Methods
• RCT: early palliative care integrated with standard
oncology care, compared to standard oncology care
alone.
• Patients with advanced lung (non-small cell, small cell, or
mesothelioma) or gastrointestinal cancer (hepatobiliary,
esophageal, gastric)
• Diagnosed within past 8 weeks
• Treatment with non-curative intent
• ECOG ≤ 2; > 17 y.o.; English-speaking
• Identified friend or family caregiver
Measures
• Sociodemographics
• Clinical characteristics
• Hospital Anxiety and Depression Scale (range =
0-21)14
– Continuous
– Categorical (clinical cut-off ≥8)
• Actor-Partner Interdependence Modeling
(APIM)
Actor Partner Interdependence
Modeling
• Estimate the unique contribution of patient’s own anxiety
on their partner’s depression over and above the effect of
the partner’s anxiety15
• My depression is not only influenced by my anxiety, my
depression is also influenced by my partner’s depression,
and my partner’s depression is also influenced by my
anxiety, and by my partner’s own anxiety
Actor Partner Interdependence Modeling
e1
Patient
Anxiety
Patient
Depression
Caregiver
Anxiety
Caregiver
Depression
e2
• Distinguishable dyad members
• Bidirectionality is supported if both partner effects are statistically significant
• Accounts for interdependence by allowing the predictor variables and residual variance
in the outcome variables to correlate
Variable
Age (years)
Gender
Male
Female
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Missing
Race
White
Other
African American/Black
Asian
American Indian/Alaskan Native
Education
≤ High School
> High School
Missing
Income
> 50,000
≤ 50,000
Missing
Dependent children (lives with)
No
Yes
Patients (N=350)
Mean (SD) or N (%)
Caregivers (N=275)
Mean (SD) or N (%)
64.86 (10.86)
57.37 (13.61)
189 (54%)
161 (46%)
85 (30.0%)
190 (69.1%)
9 (2.6%)
339 (96.9%)
2 (0.5%)
323 (92.3%)
5 (1.4%)
10 (2.9%)
8 (2.3%)
4 (1.1%)
10.09***
33.35***
271
1
0.13
1
1.69
4
8.13**
1
1.42
1
256 (93%)
4 (1.5%)
6 (2.2%)
8 (2.9%)
1 (0.4%)
73 (26.5%)
201 (73.1%)
1 (0.4%)
189 (54%)
133 (38%)
28 (8%)
-
***p<.001; **p<.01; *p<.05
df
8 (2.9%)
253 (92%)
14 (5.1%)
131 (37.4%)
219 (62.6%)
-
306 (87.4%)
44 (12.6%)
t or χ2
220 (80%)
55 (20%)
Variable
Caregiver employment
Not Working
Working
Missing
Caregiver lives with patient
Yes
No
Missing
Cancer type
Gastrointestinal cancer
Lung cancer
Initial anticancer therapy
Chemotherapy
Radiation
Chemoradiotherapy
No chemotherapy or radiation
ECOG performance status
0
1
2
Patients
Caregivers
Mean (SD) or N (%)
Mean (SD) or N (%)
-
111 (40.4%)
153 (55.6%)
11 (4.0%)
208 (75.7%)
57 (20.7%)
10 (3.6%)
159 (45.4%)
191 (54.6%)
-
278 (79.4%)
67 (19.1%)
3 (0.9%)
2 (0.6%)
-
88 (25.1%)
231 (66.0%)
31 (8.9%)
-
Patient-Caregiver Relationship
Married
182 (66.4%)
Not married
92 (26.35)
Psychiatric Symptoms
Patients
Continuous Scores
Depressive symptoms
Anxiety symptoms
M
4.65
5.31
SD
4.01
3.92
Caregivers
Comparison
M
3.81
6.93
t
3.17**
4.91***
8
SD
3.55
4.41
df
274
274
*
7
6
*
5
4
Patients
3
Caregivers
2
1
0
Depressive Symptoms
Patients
% Meeting Clinical Cut-Off
Depressive symptoms
Anxiety symptoms
N
72
94
%
21%
27%
Anxiety Symptoms
Caregivers
Comparison
N
45
116
χ2
6.35*
4.81*
%
13%
33%
df
1
1
Actor Partner Interdependence Modeling
e1
Patient
Anxiety
0.454
Patient
Depression
1.077
3.600
Caregiver
Anxiety
0.555
Caregiver
Depression
e2
Saturated Model (unconstrained)
Actor Partner Interdependence Modeling
e1
Patient
Anxiety
0.523
Patient
Depression
1.042
3.572
Caregiver
Anxiety
0.523
Caregiver
Depression
e2
Good model fit:
X2 (5) =3.94, p=0.14
RMSEA = 0.053
CFI = 0.993
SRMR= 0.032
Patient Age
(decades)
Actor Partner Interdependence Modeling
Patient
Gender
e1
Patient
Anxiety
0.52
Patient
Depression
Dyad Marital
Status
Caregiver
Anxiety
Caregiver
Gender
Caregiver Age
(decades)
1.188
0.23
Caregiver
Depression
e2
Good model fit:
X2 (6) =6.85, p=0.35
RMSEA = 0.023
CFI = 0.997
SRMR= 0.018
Summary
• Caregivers more likely to struggle with anxiety
• Patients more likely to struggle with depression
• Patients’ and caregivers’ anxiety positively
related to own depression and partner’s
depression
Conclusions
• Distress is interrelated among dyads facing
newly diagnosed metastatic disease
• Dyadic psychosocial interventions that have
been used effectively among early-stage
cancer may be warranted to ameliorate
psychological distress and prevent mood
disorders for patient-caregiver dyads coping
with metastatic cancer.
Future Directions
• Caregiver mental and physical health
trajectory16,17
• How psychiatric symptoms change
longitudinally
• Whether interdependence continues over time
• Observed difference in palliative care study arm
Acknowledgements
Co-authors
Kelly M. Shaffer, MS
Ryan D. Nipp, MD
Joel N. Fishbein, BA
Areej El-Jawahri, MD
William F. Pirl, MD, MPH
Vicki A. Jackson, MD, MPH
Elyse R. Park, PhD, MPH
Jennifer S. Temel, MD
Joseph A. Greer, PhD
Funding sources:
NINR R01 NR012735 (Temel)
NCI K24 CA181253 (Temel)
Research Staff
Emily Gallagher, RN
Justin Escobio, BS
Principal Investigator
Jennifer Temel, MD
All co-investigators
 A special thank you to
patients and their caregivers
for their participation in the
study
References
1. American Cancer Society. http://www.cancer.org/treatment/survivorshipduringandaftertreatment/when-cancer-doesnt-go-away. Accessed 3/28/2016.
2. U.S. National Institutes of Health. National Cancer Institute. SEER Cancer Statistics Review, 1975-2011.
3. Centers for Disease Control and Prevention. National Center for Health Statistics. CDC WONDER On-line Database, compiled from Compressed Mortality File 1999-2012 Series
20 No. 2R, 2014.
4. American Cancer Society. Cancer Facts & Figures 2016. Atlanta, Ga: American Cancer Society; 2016.
5. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin2009;59:225-49.
6. World Health Organization. International Agency for Research on Cancer. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. Lung
Cancer. Accessed November 10, 2014.
7. Morishita M, Kamibeppu K (2014) Quality of life and satisfaction with care among family caregivers of patients with recurrent or metastasized digestive cancer requiring
palliative care. Supportive Care in Cancer 22 (10):2687-2696
8. Wadhwa D, Burman D, Swami N, Rodin G, Lo C, Zimmermann C (2013) Quality of life and mental health in caregivers of outpatients with advanced cancer. Psycho‐Oncology
22 (2):403-410
9. Choi YS, Hwang SW, Hwang IC, Lee YJ, Kim YS, Kim HM, Youn CH, Ahn HY, Koh SJ (2015) Factors associated with quality of life among family caregivers of terminally ill cancer
patients. Psycho‐Oncology
10. Cameron JI, Franche RL, Cheung AM, Stewart DE (2002) Lifestyle interference and emotional distress in family caregivers of advanced cancer patients. Cancer 94 (2):521-527
11. Given B, Wyatt G, Given C, Gift A, Sherwood P, DeVoss D, Rahbar M Burden and depression among caregivers of patients with cancer at the end-of-life. In: Oncology nursing
forum, 2004. vol 6. NIH Public Access, p 1105
12. Badger, T., Segrin, C., Dorros, S. M., Meek, P., & Lopez, A. M. (2007). Depression and anxiety in women with breast cancer and their partners.Nursing research, 56(1), 44-53.
13. Bambauer, K. Z., Zhang, B., Maciejewski, P. K., Sahay, N., Pirl, W. F., Block, S. D., & Prigerson, H. G. (2006). Mutuality and specificity of mental disorders in advanced cancer
patients and caregivers. Social psychiatry and psychiatric epidemiology, 41(10), 819-824.
14. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67(6):361-370
15. Cook, W. L., & Kenny, D. A. (2005). The actor–partner interdependence model: A model of bidirectional effects in developmental studies.International Journal of Behavioral
Development, 29(2), 101-109.
16. Kim Y, Shaffer KM, Carver CS, Cannady RS (2015) Quality of life of family caregivers 8 years after a relative's cancer diagnosis: follow‐up of the National Quality of Life Survey
for Caregivers. Psycho‐Oncology
17. Shaffer KM, Kim Y, Carver CS (2015) Physical and Mental Health Trajectories of Cancer Patients and Caregivers Across the Year Post-Diagnosis: A Dyadic Investigation.
Psychology & health (just-accepted):1-32
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