Review
The psychological impact of cancer on patients’ partners and other key relatives: a review

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Abstract

Partners and other family members are key supports for cancer patients. Most cope well with the caregiving role, but an important minority become highly distressed or develop an affective disorder. Female carers and those with a history of psychiatric morbidity are more vulnerable, as are those who take a more negative view of the patient's illness and its impact on their lives. Carers are likely to become more distressed and develop psychiatric morbidity as the illness advances and treatment is palliative. Carers are also more at risk when they lack a support network of their own and when there are relationship difficulties with the patient. The review discusses why, given this evidence, carers fail to take advantage of interventions designed to help them and those who participate derive only limited psychological benefits.

Introduction

Patients’ preferences and economic considerations mean that most cancer patients receive their medical care as outpatients or within their own homes. The increasing reliance on informal carers to provide practical and emotional support has generated research into the demands and impact of the carer's role. This review considers the prevalence of psychological distress and psychiatric morbidity among carers, the factors related to distress and morbidity, and interventions designed to support carers.

Section snippets

Prevalence of psychiatric morbidity amongst carers—is there a problem?

Most cancer patients’ carers adjust, but some report high levels of emotional distress or psychiatric morbidity (major depressive illness, anxiety or adjustment disorders) 1, 2, 3, 4, 5.

Studies using self-report questionnaires have found that between 20 and 30% of carers are probable cases of psychiatric morbidity 2, 5, 6, 7, 8, 9. Studies of patients with advanced disease or receiving palliative care report probable caseness rates amongst carers of between 30 and 50% 10, 11, 12.

The few studies

How chronic are carers’ psychological problems?

Some studies suggest that carers’ distress reduces over time after diagnosis [15], but others show it increases 16, 17. There is evidence that, for some carers, psychological difficulties are prolonged 4, 13, 16. In a longitudinal study of breast patients and their husbands, Northouse and colleagues [18] found that the husbands’ emotional distress after diagnosis predicted their distress a year later. Haddad [13] found that in 40% of partners who developed an affective disorder, the episode

What factors are associated with psychological distress amongst carers?

Individual and systemic models have been investigated. The way carers appraise cancer-related events and the demands placed upon them, and how they cope with these issues have been considered important mediators of their subsequent psychological adjustment 2, 7, 18, 21. In systemic models, the marital dyad or family has been the focus for investigation 12, 22, 23, 24, 25, 26.

Demographic factors

Female gender, young age and lower social class have been associated with depression in the general population [27]. The same associations have been found in carers of cancer patients [28], but findings have not been so consistent.

Female carers are more likely to be emotionally distressed and develop affective disorders than males 5, 13, 29, 30, 31. Hagedoorn and colleagues [5] found that 35% of female partners compared with 12% of male partners scored over the cut-off for depression on the

Coping style

Avoidance has been related to poor psychological adjustment in carers 6, 7, 30, 43. Caregivers who avoided issues related to the patients’ medical condition or treatment or were passively resigned to their situation in Rodrigue and Hoffman's [6] study were more highly distressed. Morse and Fife [30] studied partners after patients’ diagnoses, at first remission, after recurrence and when patients had advanced disease. They found that avoidance by, for example, keeping others from knowing how

Informal support

Positive adjustment to the cancer predicament has been associated with the availability of support and confidants 16, 47, 48. However, a stronger association has been found between a lack of support and high levels of emotional distress or affective disorders 6, 9, 49. The mental health of carers has been found to improve in the year after diagnosis when carers felt the adequacy of support they received had improved [16]. Schumacher and colleagues [29] found that social support mediated between

Interventions

Over the last 20 years, a wide range of interventions for carers has been reported. Some have been designed for families 59, 60 or couples 57, 61, 62, 63. Some interventions have focused on carers in groups 64, 65, 66, 67, 68, 69 or as individuals 46, 62, 70, 71, 72, 73, 74. Whilst most interventions have been offered face-to-face, some have been conducted over the telephone [63] or reinforced by computer-driven sources of information and support [74].

The basis, aims and designs of

Conclusions

An important minority of carers of cancer patients become highly distressed, clinically depressed and anxious. There is a need, therefore, to determine how best to try to prevent these problems. The existing literature affords some useful markers for identifying carers likely to be at risk. So, carers in conflicted relationships, who have a negative view of illness-related events or the impact of the caring role on their lives are more likely to have problems, especially if they receive little

Acknowledgments

This work is supported by Cancer Research UK.

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