“Use Positive Reframing, Not Behavioural Disengagement” Coping Strategy for Caregivers of Palliative Cancer Patients

Caregivers of palliative cancer patients (CPCP) who are depressed put both the patients and them at risk forserious physical and psychological complications. This study investigated the prevalence of depression and its contributing factors among the CPCP in Malaysia using the diagnostic tool and validated questionnaires. About 6% of CPCPs was diagnosed to have a major depressive disorder (MDD). Coping by ‘behavioural disengagement’ increased the odds for MDD whileusing ‘positive reframing’ was protective for MDD. The CPCP should be trained with beneficial types of copingstrategy to help them reduce the burden of caregiving and to ensure optimum mental health status.

psychosocial care and spiritual support for the patient and families may improve quality of life (Estel et al., 2017). While several studies have been done to investigate coping strategy for the patients with palliative cancer treatment (Chirico et al., 2017;Richardson et al., 2017), studies to describe coping strategy of the CPCPs is still very limited. It is crucial to managing stress among theCPCPs to help reduce their emotional burden and identify their needs to ensure the health and better quality of life.
Currently, the gap is clear that sparse of knowledge on mental health status and coping style of the CPCPs to inform effective ways of managing stress related to the caregiving burden and its implications. Hence, this study aims to determine the prevalence of depression among the CPCPs and investigate its contributing factors, including how coping strategy associated with depression.

Material and Methods
This was a cross-sectional study to determinethe prevalence of the depressive disorder among theCPCPs and its associated factors. It was carried out in a Palliative Cancer Clinic of one of the public hospitals in the northernstate of Malaysia, which providespalliative care for more than 800 cases ofcancer patients every year. Participants were selected using convenience sampling.The study included CPCPs who were attending the clinic and accompanying patients in the wards. The "CPCPs" was defined as the individual who selfdeclared her or himself as the person who had assumed the responsibility for caregiving of the palliative cancer patient. The CPCP may or may not related by the family tie, live with the patient, involved with decision-making regarding the patient. Those aged 18 to 65 years old, able to communicate fluently in Bahasa Malaysia or English and able to give informed consent were included in the study. We excluded those with a lack of mental capacity (mentally disturbed, intellectual disability, etc.).
The consented participants were given Proforma sociodemographic questionnaire, Multidimensional Scale of Perceived Social Support (MSPSS), Brief-COPE, Depression, Anxiety and Stress Scale-21 (DASS-21) and Mini International Neuropsychiatric Inventory (MINI). The Proforma sociodemographic data collected were the CPCPs' sociodemographic background, caregiving backgrounds and patients' background. Caregiving backgrounds include CPCPs' relationship to the patient, their status of living with patient, duration of caregiving, the voluntariness of caregiving, involvement in making the decision, history of training for caregiving and the presence of physical illness. Patients' background included were age, duration of illness, presence and number of physical symptoms, number of admissions, Eastern Cooperative Oncology Group (ECOG) Score (scored by treating oncologist), self-care capabilities and hospice support.
The CPCPs' support was assessed using MSPSS, a 12-items Likert scale with a score from 1(Strongly Disagreed) to 7 (Strongly Agreed) that measures social support perceived by the participant received from three specific sources either family, friends or significant others. The scale has been translated in Malay and validated with good internal consistency (Cronbach α of 0.89) (Ng, Siddiq, Aida, Zainal, & Koh, 2010) The CPCPs' types of coping were measured with Brief-COPE, a 28 items Likert scale that measures 14 dimensions of coping strategy. It has been translated into Malay and validated with internal consistencies ranging from 0.51 to 0.99 (Yusoff, Low, & Yip, 2009).
The CPCPs were also screened for depression using DASS-21, and those with positive results were then confirmed the diagnosis with MINI. DASS-21 has been translated into Malay and validated for depression, anxiety and stress (Musa, Fadzil, & Zain, 2007;Nordin, Kaur, Soni, Por, & Miranda, 2017). Moreover, MINI is a locally validated structured diagnostic interview instrument which was used to diagnose depressive disorder following the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) (Mukhtar et al., 2012).
Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 23. Data were not normally distributed, hence nonparametric tests were used. Univariate and multivariate analyses were carried out to determine the significance of the association between depressive disorder and the various factors. The p-value of less than 0.05 with a confidence interval of 95% was taken as statistically significant. Ethical

Depression among CPCPs
Initial screening with DASS indicated that 15(5%) of participants had mild to moderate depression; 19(9%) had mild to moderate anxiety, and 14(4%) had mild stress. The prevalence of the depressive disorder, diagnosed using MINI Major Depressive Disorder criteria among the participants was 6.1% (n=8).
 Coping Strategy. Table 3 shows the 14 dimensions of coping strategy based on Brief-COPE and the differences between types of coping among the CPCPs who had and do not have a depressive disorder. The five most commonly used coping were religious coping, acceptance, active coping, positive reframing and the use of instrumental support.
 Perceived social support.
Overall the perceived total support among the CPCPs was noted to be high (Med=5.17; IQR =1.17). The most common type of cancer is of the digestive organs (41; 31.29%), followed by breast (23; 17.55%) and female genital organ (13, 9.92%). Others were malignant neoplasms of lip, oral cavity and pharynx, urinary tract, lymphoid, hematopoietic and related tissue, male genital organs, mesothelium and soft tissue, thyroid and other endocrine glands, ill-defined, other secondary and unspecified sites, melanoma and other malignant neoplasms of skin and neoplasms of unspecified behaviour.  9 strategy were unlikely to have a depressive disorder (p=0.03, OR=0.38, CI=0.15-0.93). Refer to Table 5 for further details of the contributing factors.

Discussion
While patients with advanced cancer requiring palliative cares are dealing with their suffering and the illness, their CPCPs are experiencing stress, coping with their own personal issues as well as caring for the patients. These can bring to various psychological and physical challenges on top of concerns on death and dying issues. We found about 6% of CPCPs in this study had a major depressive disorder. This finding is higher than other multi-centre studies which also used similar diagnostic instrument in their study (Vanderwerker, Laff, Kadan-Lottick, McColl, & Prigerson, 2005). Using the Structured Clinical Interview for the DSM-IV (SCID), the authors found that only 4.5% of the CPCPs had a major depressive disorder. These findings, however, was lower than the percentage of depression in the general population (James et al., 2018). Perhaps, bereavement and caregiving those with cancer receiving palliative care alone may not contribute much to depression compared to other more stressful and well-known risk factors such as childhood neglect, trauma, and violence and acute life events (such as financial crisis) (Herrman et al., 2019).
To ensure the health of the patient and the CPCPs, both should have healthy coping strategies. Our study indicates that the best way for the CPCPs to cope with the stress and protect themselves from depression is by using positive reframing, supporting the previous findings found by other researchers (Litzelman et al., 2018). Having positive reframing type of coping encourages the CPCPs to analyse the situation and change their thought from 'seeing the glass half empty, to see the glass half full'. For example, "Wow-you have made it through four sessions of chemotherapy, and you only have four left!" (Eldridge, 2020). Positive reframing may not change the patients' illness condition totally, but it may undoubtedly reduce the negative perceptions and put things into a healthier viewpoint. In a review of psychological adaptation during the cancer experience, experts in psychology indicated that psychosocial interventions (including positive reframing) might enhance the psychological and physiological adaptation indicators (such asneuroendocrine changes) in cancerpatients. However, less is known about whether it may influence tumour activity,tumour growth-promoting processes, recurrence and survival rates of the patients (Antoni, 2013).In an interesting study among breast cancer patients, using positive reframing has been shown to reduce the stress experienced by both the patients and their partner (Robbins, Wright, María López, & Weihs, 2019). Furthermore, in a review study of caregiving, Marino, Haley, and Roth (2017) suggested that act of caregiving is perceived positive when the CPCPs feel satisfied and happy, have thoughts of having a purpose, meaning, and direction in life, have autonomous and self-acceptance thoughts while caring for the ill patient. These create constructive personal growth, positive relationship and sense of mastery of the challenges they are facing (Marino et al., 2017).
On the contrary, our study indicated that using behavioural disengagement type of coping may increase the chance of having a depressive disorder. This type of coping involves responses such as avoidance, denial, and wishful thinking; the style of diverting away from dealing with the stressor and/or its related emotions (Dijkstra & Homan, 2016). CPCPs with this type of coping acting as though the stressor (having cancer or its complication) does not occur, so that it does not have to be reacted to it, behaviourally or emotionally. On the other hand, he or she may have a fantasy (such as cancer may be cured by itself) which is damaging to the cancer patients (Carver & Connor-Smith, 2010). Several studies have shown that using this type of coping may result in more negative consequences of the stressor than other types of active coping strategies (Dijkstra & Homan, 2016). Supporting our study, experts in psychology who explored the multiple mediation effects of personal psychological resources between caregiving burden and depression in spousal CPCPs, agreed that by avoiding the stressor, the CPCPs had a higher tendency for depression (Khalaila & Cohen, 2016).

Conclusion
The findings of this research are relevant to inform authorities of the need for clinicians to address factors underpin depression among the CPCPs of palliative cancer patients. The type of coping used by the CPCPs should be addressed comprehensively to minimise caregiving burden, maintain the psychological and physical health of the CPCPs and to prevent complications. Enhancing knowledge of stress prevention through effective coping strategy and early detection of depression among CPCPs is crucial so that early and fast treatment and counselling can be offered to them. Together with coping strategies, the support system is equally essential to prevent depression among them. It is recommended that CPCPs who have depression to be given a chance to get access to effective treatment and rehabilitation.
This study provides insights to the contributing factors of depression and the role of coping strategies while providing caregiving among CPCPs of palliative cancer patients; nevertheless, we would like to inform that the study was limited by its design and suggest a more robust prospective study, and larger sample sizes to determine the causal factors for depression among the CPCPs. We are aware that many other personal and environmental factors that could influence depression among them.