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Hidden Morbidity in Cancer: Spouse

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 VOLUME 25 䡠 NUMBER 30 䡠 OCTOBER 20 2007

JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T

Hidden Morbidity in Cancer: Spouse Caregivers

Michal Braun, Mario Mikulincer, Anne Rydall, Andrew Walsh, and Gary Rodin

From the Sharett Institute of Oncology, A B S T R A C T

Hadassah University Hospital, Jerusalem;
Psychology Department, Bar-Ilan Univer- Purpose
sity, Ramat-Gan, Israel; Behavioral Sciences This study assesses psychological distress among advanced cancer patients and their spouse
and Health Research Division, Toronto
caregivers, while examining the relative contribution of caregiving burden and relational variables
General Hospital, University Health
Network; Psychosocial Oncology and Pallia-
(attachment orientation and marital satisfaction) to depressive symptoms in the spouse caregivers.
tive Care Department, Princess Margaret
Methods
Hospital; and Psychosocial Oncology
A total of 101 patients with advanced GI or lung cancer and their spouse caregivers were recruited
Research Division, Ontario Cancer Institute,
University Health Network, Toronto, Canada.
for the study. Measures included Beck Depression Inventory–II (BDI-II), Caregiving Burden scale,
Experiences in Close Relationships scale, and ENRICH Marital Satisfaction scale.
Submitted November 25, 2006; accepted
August 9, 2007. Results
Supported by the Canadian Institutes of
A total of 38.9% of the caregivers reported significant symptoms of depression (BDI-II ⱖ 15)
Health Research (Grant No. CIHR compared with 23.0% of their ill spouses (P ⬍ .0001). In a hierarchical regression predicting
MOP-62861; G.R.); the Princess Marga- caregiver’s depression, spouse caregiver’s age and patient’s cancer site were entered in the first
ret Hospital Foundation, in the memory step, objective caregiving burden was entered in the second step, subjective caregiving burden
of Mr. Gerald Kirsh; and from the was entered in the third step, caregiver’s attachment scores were entered in the fourth step, and
Department Psychiatry, University
caregiver’s marital satisfaction score was entered in the fifth step. The final model accounted for
Health Network, Toronto, Canada.
37% of the variance of caregiver depression, with subjective caregiving burden (␤ ⫽ .38; P ⬍ .01),
Presented at the 8th World Congress caregiver’s anxious attachment (␤ ⫽ .21; P ⬍ .05), caregiver’s avoidant attachment (␤ ⫽ .20;
of Psycho-Oncology, Venice, Italy,
P ⬍ .05), and caregiver’s marital satisfaction (␤ ⫽ ⫺.18; P ⬍ .05) making significant contributions
October 18-21, 2006.
to the model.
Authors’ disclosures of potential con-
flicts of interest and author contribu- Conclusion
tions are found at the end of this Spouse caregivers of patients with advanced cancer are a high-risk population for depression.
article. Subjective caregiving burden and relational variables, such as caregivers’ attachment orientations
Address reprint requests to Michal and marital dissatisfaction, are important predictors of caregiver depression.
Braun, PhD, Sharett Institute of Oncol-
ogy, Hadassah University Hospital, POB J Clin Oncol 25:4829-4834. © 2007 by American Society of Clinical Oncology
12000, Jerusalem 91120, Israel; e-mail:
bmichal2@hadassah.org.il.

© 2007 by American Society of Clinical

Oncology
0732-183X/07/2530-4829/$20.00
DOI: 10.1200/JCO.2006.10.0909
INTRODUCTION
Cancer and its treatment have a major influence on
both patients and their significant others. The recent
trend toward longer survival and toward ambula-
tory and home care has increased the number of
informal family caregivers and may have amplified
their burden.1-3 In most cases, the spouse becomes
the primary informal caregiver.4
Spouse caregivers of cancer patients have been
found to be adversely affected by the illness in phys-
ical and psychological areas.3,5,6 Their emotional
distress may be as high as or even higher than that of
the patients themselves.4,7-11 Caring for spouse care-
givers may be important not only to relieve their
distress but also because this may have positive
effects for their ill spouses.12 With regard to the
latter, spousal support has been found to buffer
against patients’ distress.13
Most studies of cancer caregivers have exam-
ined the impact of subjective and objective caregiv-
ing burden on caregivers’ distress.4,14 Whereas
depression is a general affective state, caregiving bur-
den is a multidimensional construct15 focusing on
the specific caregiving consequences. Objective
caregiving burden refers to concrete care tasks, such
as assistance with self-care, financial management,
and medical and emotional care. In this study, we
assessed the amount of caregivers’ time devoted to
these tasks. Subjective caregiving refers to the expe-
rience of caregiving and caregivers’ appraisal of their
role as caregivers.4,16,17 Objective and subjective
components are only moderately correlated.18 Some
evidence suggests that the impact of objective bur-
den on caregivers’ distress is mediated by caregivers’
subjective burden.19,20
Caregiving is an interpersonal exchange,
and therefore relational factors may be impor-
tant determinants of caregivers’ well-being.
Surprisingly, however, few studies have exam-
ined this hypothesis.3,21 The current study ex-
amines the impact on caregivers’ depression of

4829
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142.150.190.39
 Braun et al
relational factors, such as their attachment orientation and
marital satisfaction.
Bowlby’s attachment theory22-24 highlighted the need for prox-
imity to others to obtain support and protection as well as individual
differences in the way people relate to others. Attachment orientation
refers to the way people interact and feel in close relationships, along
two main dimensions.22-25 Anxious attachment reflects the degree to
which a person worries that a relationship partner will not be available
in times of need.25 Avoidant attachment reflects the extent to
which a person distrusts a relationship partner’s goodwill and seeks
independence and emotional distance.25 Individuals scoring low
on these dimensions are securely attached and form satisfactory
close relationships.25
The emphasis within the attachment theory on the continuity of
care seeking and caregiving across the life span22,26-28 provides a useful
framework for studying caregiving between adult partners. Previous
studies have found that attachment anxiety or avoidance is more likely
to interfere with effective and sensitive caregiving.29,30 Specifically,
individuals with more avoidant attachment are less likely to provide
care,31 and the care they provide is insensitive and controlling.30 Al-
though those with more anxious attachment long for closeness and
intimacy, they are more likely to be focused on their own needs rather
than on needs of their partners.32 In addition, they are likely to feel
overwhelmed by distress and to provide care compulsively.30,33
Although attachment insecurity has been shown to interfere with
caregiving of older relatives34 and dementia patients,35 there is only
one study examining the contribution of caregivers’ attachment
orientations to caregiving of cancer patients. Kim and Carver36
have found that caregivers’ attachment insecurity was unrelated to
frequency of care, but was related to heightened subjective caregiv-
ing burden.
Past studies have found significant associations between marital
dissatisfaction and psychological distress among spouse caregivers of
cancer patients.10,37-39 However, no study has examined the extent to
which caregivers’ marital satisfaction contributes to their distress, in-
dependent of their attachment orientation in the cancer context. In
fact, Collins and Feeney40 found among healthy couples that percep-
tions of caregiving within couple relationships were influenced by
both marital satisfaction and attachment orientations. In this study,
we examined the unique contribution of these two factors to depres-
sion of spouse caregivers of advanced cancer patients. We hypothe-
sized that caregivers’ attachment insecurities, marital dissatisfaction,
and subjective and objective caregiving burden would be associated
with higher levels of caregiver depression.
METHODS
Participants
Participants recruited for this study were spouses of patients who partic-
ipated in a larger longitudinal study of the will to live (WTL) and desire for
hastened death among metastatic cancer patients.41 The spouse caregivers who
participated in the current study were not part of the WTL study. Patients were
recruited from outpatient clinics at Princess Margaret Hospital, a comprehen-
sive cancer treatment center in Toronto, Canada. Participants were eligible if
they were defined as the primary caregiver by a patient with stage III or IV lung
cancer or stage IV GI cancer; married to, or in a common law relationship, with
this patient; and able to speak and read English. This study received approval
from the University Health Network Research Ethics Board, and all partici-
pants provided written informed consent.
4830
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142.150.190.39
Procedure
Patients who identified their spouses as their primary caregivers were
approached by a research assistant to request permission to contact the
spouses. The spouses were contacted by a research assistant at the hospital or at
home by telephone. If spouses were approached at the hospital, informed
written consent was obtained and participants were given the questionnaire
package to complete at home and return by mail. If spouses were contacted by
telephone, the consent form and the questionnaires were mailed to their
homes, and the signed consent form and completed questionnaires were
returned by mail. Reminder telephone calls were made after 2 weeks.
Measures
Demographic and medical data were collected from the spouse, the
patient, and from the patient’s medical chart. Data included age, sex, educa-
tion, country of birth, primary language, duration of relationship, employ-
ment status, date of cancer diagnosis, and cancer site and stage. Caregivers
completed the Demand subscale from the Caregiving Burden Scale42 to assess
objective caregiving burden. This scale measures how much time a caregiver
devoted to 14 caregiving tasks. Ratings were made on a 5-point scale ranging
from 1 (little or no time) to 5 (a great deal of time; Cronbach’s ␣ ⫽ .92). They
also completed the Difficulty subscale of the Caregiving Burden Scale42 to
assess subjective caregiving burden, which measures how difficult caregivers
appraised the management of 14 caregiving tasks. Ratings were made on a
5-point scale ranging from 1 (little or no difficulty) to 5 (a great deal of
difficulty; Cronbach’s ␣ ⫽ .93).
Caregivers also completed two relational measures. First, the 36-item
Experiences in Close Relationships Scale 43 was used to assess attachment
anxiety and avoidance orientations. Participants are asked to think about their
close relationships, without focusing on a specific partner, and rate the extent
to which each item described their feelings in close relationships. Ratings were
done on a 7-point scale. Eighteen items assess attachment anxiety (Cronbach’s
␣ ⫽ .87) and 18 items assess attachment avoidance (Cronbach’s ␣ ⫽ .78).
Attachment researchers44 recommend the use of the Experiences in Close
Relationships scale continuous scores of anxiety and avoidance because there
is no evidence for true attachment categories. The reliability and validity of the
two continuous scores have been demonstrated in a wide variety of samples
and in different languages.43,45 Second, the 15-item ENRICH Marital Satisfac-
tion Scale,46 assessing satisfaction in various areas of marital relationship.
Ratings were done on a 5-point scale (Cronbach’s ␣ ⫽ .89). The ENRICH
Marital Satisfaction Scale has been shown to have high reliability and validity.46
Patients and caregivers completed the Beck Depression Inventory–II
(BDI-II).47 This is a 21-item scale assessing intensity of depressive symptoms
(Cronbach’s ␣ ⫽ .92). Higher scores reflect more depressive symptoms, and a
cutoff of 15 has been shown to have high sensitivity and specificity for diagno-
sis of major depression in cancer populations.48
Given that the WTL study was longitudinal in design with follow-up
assessments every 1 to 2 months, patient’s scores on the BDI-II were taken
from the assessment time that corresponded most closely to the date of com-
pletion of the spouse caregiver questionnaire package. The mean time differ-
ence between patient and spouse completion of questionnaire was 13.5 days
(standard deviation [SD] ⫽ 6), whereas 92.1% completed questionnaires
within the same month.
Statistical Analysis
Data were analyzed using the Statistical Package for the Social Sciences,
version 12.0 for Windows 2000 (SPSS; SPSS Inc, Chicago, IL). Missing data
were examined and found to range from 0% to 13% across the study measures.
Mean substitution was used for missing total scores, by imputing mean total
scores for patients by cancer site (GI or lung). This resulted in minimal,
nonsignificant changes in SDs, and analyses run without imputation demon-
strated no change in the results. Statistical tests were two tailed with ␣ set at .05.
Descriptive statistics were calculated to provide information about partici-
pants’ characteristics, prevalence of depression, and association between vari-
ables. Hierarchical regression was used to examine the main predictions.
JOURNAL OF CLINICAL ONCOLOGY
 The Hidden Morbidity in Cancer: Spouse Caregivers

RESULTS Table 1. Additional Sample Characteristics of the Spouse Caregivers

No. of
Sample Characteristics Variable Participants %
Of the 300 participants in the WTL study between November
Highest level of education
2002 and December 2004, 210 (70%) were married or living in a
Grade school 12 11.9
common law relationship. Of these, 192 (91.4%) identified their High school 25 24.8
spouse as their primary caregiver. Seven patients died and 22 withdrew Professional school 3 3
from the WTL study before their spouses were contacted, and one College 23 22.8
spouse caregiver was not contacted. Of the 162 eligible spouse caregiv- Undergraduate 25 24.8
ers, 131 (80.9%) consented to participate and 105 (80.2%) returned Graduate training 8 7.9
Country of birth
their questionnaires. Data from four spouses were not included be-
Canada 62 61.4
cause their ill partners withdrew from the WTL study before the
Western Europe 15 14.9
spouses’ questionnaires were completed. Therefore, the analyses were Eastern Europe 3 3
run on 101 couples of patients and caregivers. Far East 5 5
The mean and median age of spouses was 60.0 years (SD ⫽ 10.6 United States 4 4
years; range, 31 to 80 years). For patients, the mean age was 61.8 years Other 7 6.9
and the median was 63.0 years (SD ⫽ 10.3 years; range, 28 to 81 years). Missing 5 5
First marriage
Seventy-seven spouses were female (76.2%), 93 (92.1%) were mar-
Yes 74 73.3
ried, and eight (7.9%) were living in a common law relationship. The No 23 22.8
mean duration of the relationship was 30.4 years and the median was Missing 4 4
31 years (SD ⫽ 14.1 years; range, 1 to 55 years). Seventy-five patients Primary language
(74.3%) were diagnosed with GI cancer and 26 patients (25.7%) were English 93 92.1
diagnosed with lung cancer, and the mean duration of illness was 2.2 Other 7 6.9
years (SD ⫽ 2.0 years; range, 0.04 to 8.3 years). There were no signif- Missing 1 1
Religious affiliation
icant sex differences on any of the study variables and the mean
Protestant 37 36.6
relationship duration was not associated with these variables. Addi- Roman Catholic 26 25.7
tional sample characteristics are listed in Table 1. Intercorrelations Christian (unspecified) 6 5.9
among the study variables are listed in Table 2. Jewish 4 4
Dutch Reformed 5 5
Depression Among Patients and Spouse Caregivers None 16 15.8
The mean depression score among spouse caregivers on the Missing 7 6.9
BDl-II was 13.0 (SD ⫽ 7.9); among patients the mean depression score Employment status
was 9.4 [SD ⫽ 6.7; t(1,100) ⫽ 4.52; P ⬍ .0001]. A greater proportion of Working 45 44.6
Not working 52 51.5
spouses scored above the clinically significant cutoff of 15 on the
Missing 4 4
BDI-II compared with their ill partners (38.9% v 23.0%; ␹2 ⫽ 24.8;
df ⫽ 1; P ⬍ .0001).
Objective and Subjective Caregiving Burden
Spouses scored an average of 2.5 (SD ⫽ 0.9; range, 1 to 4.9) on
objective caregiving burden, indicating that the amount of time de- P ⬍ .0001). In step 5, caregivers’ marital satisfaction was entered and
voted to caregiving tasks was moderate. They scored an average of 1.9 accounted for an additional 2.8% of the variance (F1,92 ⫽ 4.44;
(SD ⫽ 0.8; range, 1 to 4.4) on subjective caregiving burden, indicating P ⬍ .05). Overall, this model explained a total of 37% of the variance of
low to moderate perceived difficulty in providing care to patients. spouse caregivers’ depression scores, with subjective caregiving bur-
den, caregivers’ anxiety and avoidance attachment orientations, and
Predictors of Spouse Caregivers’ Depression marital satisfaction remaining as the significant predictors (Table 3).
Hierarchical regression was used to determine to what extent
subjective caregiving burden, attachment scores, and marital satisfac-
DISCUSSION
tion contribute to the prediction of spouse caregivers’ depression,
beyond the contribution of objective caregiving burden. Spouse care-
givers’ age and patients’ type of cancer (GI v lung) were controlled by Findings from the current study suggest a high prevalence of depres-
entering them in step 1 of the analysis, and together they accounted for sion in spouse caregivers of patients with advanced cancer. Almost
8.5% of the variance in caregivers’ depression scores (F2,97 ⫽ 5.59; 40% of the spouse caregivers reported depressive symptoms in a range
P ⬍ .01). In step 2, objective caregiving burden was entered and that is likely to be clinically significant, a prevalence that is almost
accounted for an additional 5.6% of the variance (F1,96 ⫽ 6.38; two-fold that of their ill partners. These findings are compatible with
P ⬍ .05). In step 3, subjective caregiving burden was entered and those of previous studies of spouse caregivers of cancer patients.3,4,7-10
accounted for an additional 10.6% of the variance in spouse caregiv- Previous studies attributed the high prevalence of psychological
ers’ depression (F1,95 ⫽ 13.75; P ⬍ .0001). In step 4, spouse caregivers’ morbidity in caregivers of cancer patients to objective and subjective
anxious and avoidant attachment scores were entered, and together aspects of caregiving burden.4,6,18,29,49 We replicated these findings
they accounted for an additional 12.1% of the variance (F2,93 ⫽ 9.17; and showed that subjective caregiving burden was more important

www.jco.org 4831
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142.150.190.39
 Braun et al

Table 2. Pearson Correlations Between the Main Study Variables

Caregiver’s Caregiver’s Demand Difficulty Caregiver’s Avoidant Caregiver’s Anxious
Depression Age Subscale Subscale Attachment Orientation Attachment Orientation
Variable (BDI-II) (years) (CBS) (CBS) (ECR) (ECR)
Caregiver’s depression — — — — — —
Caregiver’s age ⫺0.21ⴱ — — — — —
Demand subscale (CBS) 0.28† ⫺0.03 — — — —
Difficulty subscale (CBS) 0.42‡ ⫺0.01 0.73‡ — — —
Caregiver’s avoidant attachment (ECR) 0.35‡ ⫺0.03 ⫺0.01 0.04 — —
Caregiver’s anxious attachment (ECR) 0.39‡ ⫺0.18 0.23ⴱ 0.22ⴱ 0.37‡ —
Marital satisfaction (EMS) ⫺0.38‡ 0.10 ⫺0.24ⴱ ⫺0.29† ⫺0.19 ⫺0.11

Abbreviations: BDI-II, Beck Depression Inventory–II; CBS, Caregiving Burden Scale; ECR, Experiences in Close Relationships; EMS, ENRICH Marital Satisfaction Scale.
ⴱ
P ⬍ .05.
†P ⬍ .01.
‡P ⬍ .001.

than objective caregiving burden in predicting caregivers’ depres-
sion. Other studies have reported similar findings across different
patient populations.50
This study is unique in providing information about the contri-
bution of relational variables to spouse caregivers’ depression. Higher
caregivers’ attachment anxiety and avoidance were associated with
more depression. The diagnosis of cancer in a partner may activate the
attachment system.51 At this point, anxiously attached individuals
are likely to become self-preoccupied and provide insensitive care-
giving.30,40,52-54 Furthermore, in response to the plight of their
spouses, these individuals are at risk to become emotionally over-
whelmed55,56 by heightened fear of death and heightened accessibility
of death-related thoughts.45,57 Moreover, anxiously attached individ-
uals are prone to chronic grief after bereavement58-61 due to their fear
of abandonment.62 Therefore, such individuals might have a stronger
tendency to experience depression when facing their spouses’ cancer
and potential loss of their partners.
More avoidant individuals may have less adequate knowledge
about how to support others, and have less sense of relationship
trust.52 Moreover, they tend to distance themselves from needy part-
ners as well as from signals of others’ suffering.62 However, this regu-
latory strategy might fail to inhibit distress when representations of
attachment insecurity are contextually accessible.63 Avoidant strate-
gies have been shown to be effective in reducing distress in neutral
situations but not in chronic and severely threatening contexts.63
When facing a spouse’s advanced-stage cancer, the regulatory strate-
Table 3. Hierarchical Regression Predicting Spouse Caregiver’s Depression
Variable ␤ T
Cancer type (GI v lung) .16 1.9
Caregiver’s age ⫺.15 ⫺1.89
Caregiving Demand subscale score (CBS) ⫺.12 ⫺1.02
Subjective caregiving burden (Difficulty subscale .38 3.22
score; CBS)
Caregiver’s avoidant attachment orientation (ECR) .20 2.27
Caregiver’s anxious attachment orientation (ECR) .21 2.28
Caregiver’s marital satisfaction (EMS) ⫺.18 ⫺2.11
Abbreviations: CBS, Caregiving Burden Scale; ECR, Experiences in Close
Relationships; EMS, ENRICH Marital Satisfaction Scale.
gies of avoidant individuals may be shattered due to the knowledge of
the impending death and separation, which, in turn, can result in
heightened depression.
The correlation among attachment scores in the current study is
higher than that found in other attachment studies. However, this
trend has also been found in other samples of older people who are
married for a long time and who share children,63 as in our sample.
In our study, problems in the marital relationship (marital dis-
satisfaction) were also an important contributor to spouse caregivers’
depression. Other studies have shown that marital dissatisfaction con-
tributes to distress of spouse caregivers of cancer patients.10,37-39 In our
study, marital dissatisfaction was found to be an even more important
contributor to depression than objective caregiving burden. Giving
care to advanced cancer patients demands not only that the spouse be
attuned to partner’s needs, but also requires the couple to interact in
intimate and difficult situations. In such circumstances, it may be
fulfilling to give care to someone with whom the caregiver shares a
satisfactory relationship.
There are a number of limitations in this study that need to be
considered. First, although all the patients in this study were diagnosed
with metastatic cancer, most of them were still functioning physically
at a relatively high level. As a result, the objective caregiving burden
was not very high and the scores were skewed. Additional research
should be conducted closer to the end of life in patients with more
caregiving needs. Second, the response rate was low, although the
response is compatible with other studies of spouses of cancer pa-
tients.7 Therefore, the possibility of self-selection should be taken into
account. Third, two thirds of our caregivers were women. This could
have had an influence on our results in some undetected way, al-
P though we did not find sex differences. Fourth, the relatively small
.061
sample size makes it difficult to examine interactions between study
.063 variables and whether results might be different for different sub-
.31 groups (age, sex). We analyzed some of these interactions (attachment
.002 scores by objective caregiving, sex) via hierarchical regressions and
none of them were significant. Additional studies should try to repli-
.025
.025 cate our findings in a larger sample while examining relevant interac-
.038 tions. Finally, the cross-sectional nature of the study limits our ability
to determine causal relationships. Although subjective caregiving bur-
den and marital satisfaction can influence caregivers’ depression, de-
pression can also influence subjective caregiving burden and marital

4832 JOURNAL OF CLINICAL ONCOLOGY

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Copyright © 2007 American Society of Clinical Oncology. All rights reserved.
142.150.190.39
 The Hidden Morbidity in Cancer: Spouse Caregivers

satisfaction. In addition, we were not able to control or examine the

effects of participants’ depression before the cancer diagnosis.
Our study identifies spouse caregivers of advanced cancer pa-
tients as a high-risk population for depression and highlights the
important role of relational variables in predicting such symptoms.
The ability of individuals to adjust to their role as caregivers of ill
spouses is affected both by relational variables and by the subjectively
experienced burden of caregiving. Additional research is needed to
understand better the role that relational variables play in caregivers’
experience and distress. Clinically, there is a need to assist caregivers in
their new and demanding role. It is also important to be sensitive to the
meaning that caregivers bring to this role based on their attachment
orientation. In addition, there is a need to acknowledge the impor-
tance of couple relationships to the welfare of both spouse caregivers
and patients while facing cancer. Couples interventions should be
developed and assimilated.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
The author(s) indicated no potential conflicts of interest.
AUTHOR CONTRIBUTIONS
Conception and design: Michal Braun, Mario Mikulincer, Gary Rodin
Administrative support: Michal Braun, Anne Rydall, Andrew Walsh
Collection and assembly of data: Michal Braun, Andrew Walsh
Data analysis and interpretation: Michal Braun, Mario Mikulincer,
Andrew Walsh, Gary Rodin
Manuscript writing: Michal Braun, Mario Mikulincer, Anne Rydall,
Gary Rodin
Final approval of manuscript: Michal Braun, Mario Mikulincer,
Gary Rodin

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