Psycho-Oncology

Psycho-Oncology 22: 13891395 (2013)

Published online 7 August 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3153

Desire for formal psychological support among caregivers of

patients with cancer: prevalence and implications for
screening their needs
Isabelle Merckaert1,2, Yves Libert2,3, Frdrique Lieutenant1, Anglique Moucheux4, Christine Farvacques4,
Jean-Louis Slachmuylder4 and Darius Razavi1,2*
1
Universit Libre de Bruxelles, Facult des Sciences Psychologiques et de lducation, Brussels, Belgium
2
Institut Jules Bordet, Unit de Psycho-oncologie, Brussels, Belgium
3
Cliniques Universitaires Saint Luc, Centre du Cancer, Brussels, Belgium
4
Psycho-oncology Center (asbl), Brussels, Belgium
*Correspondence to: Abstract
Universit Libre de Bruxelles,
Av. F. Roosevelt, 50 CP 191, Objective: To investigate the prevalence of desire for formal psychological support of primary
B-1050 Bruxelles, Belgium. caregivers of patients with cancer and to identify caregivers and patients socio-demographic and
E-mail: drazavi@ulb.ac.be psychological characteristics as well as patients disease-related characteristics associated with this
desire.
Methods: This is a multicenter, cross-sectional study assessing desire for formal psychological
support among consecutive primary caregivers of patients with cancer. Patients and caregivers com-
pleted the Hospital Anxiety and Depression Scale and reported their desire for formal psychological
support.
Results: Two-hundred and eighty-two patientcaregiver dyads were assessed. Forty percent of
patients had breast cancer, 16% had a hematologic cancer, 12% had a gastrointestinal cancer, and
32% had another solid tumor. Nineteen percent of caregivers reported desiring formal support, and
54% experienced moderate to high levels of distress. Regression analysis showed that caregivers desire
for formal support was negatively associated with caregivers age (Exp(B) = 0.95; p < 0.001) and
education levels (Exp(B) = 0.35; p = 0.032) and positively with caregivers level of distress (Exp
(B) = 1.08; p < 0.001) and with patients desire for formal psychological support (Exp(B) = 2.54;
p = 0.008). These variables only predicted 25% of caregivers who desire formal support.
Conclusions: One out of ve caregivers desires formal psychological support although one out of
two caregivers experiences signicant levels of distress. The weak association between caregivers
Received: 8 March 2012 desire for formal support and distress emphasizes the need to implement systematic screenings of both
Revised: 1 June 2012 their distress and their desire for formal psychological support in oncology.
Accepted: 15 July 2012 Copyright 2012 John Wiley & Sons, Ltd.

Introduction physical wellbeing [15,16], a decrease in family and marital

Because of the evolution of medicine and the organization of
care, partners, parents, children, and other family members
have become key supports for patients with cancer through-
out the course of the disease. As a consequence, relatives
have to deal with a dual role: on the one hand, they have
to deal with their emotional responses to patients diagnosis
and prognosis and with their own difculties, and on the
other hand, they have to deal with the high demands of the
caregiver role [15].
Although many caregivers deal reasonably well with
this dual role, studies have reported that 1050% of
caregivers experience high levels of distress [68] and that
their levels of distress are comparable to those found in
patients [1,9,10]. Moreover, the levels of distress encoun-
tered among caregivers of patients with cancer have been
found to be higher than those found in the general popula-
tion [11,12]. Studies have shown that caregivers are likely
to become more distressed as the disease progresses and
treatment becomes palliative [13] and that they report
receiving less social support than patients [14]. Caregivers
distress has been linked with a decrease in their own
functioning [17] and with patients poor social rehabilitation
[17], poor treatment adherence [18], and increased emo-
tional distress [10]. These ndings highlight the need to
offer formal psychological support to caregivers.
Few studies have investigated desire for formal psycho-
logical support among primary caregivers of patients with
cancer. One recent study on mental health service use
among caregivers of patients with advanced cancer has
reported that only 46% of caregivers with a psychiatric
disorder accessed mental health services [8]. Results of
this study are consistent with the literature on support
services that has shown that the severity of symptoms
is not necessarily the key factor in peoples desire for
professional help [19].
The aim of this study was, rst, to investigate the prev-
alence of desire for formal psychological support among
primary caregivers of patients with cancer and, second,
to identify factors that are likely to be associated with this
desire. First, we hypothesized that caregivers desire for
formal support would be positively associated with their
distress levels. Second, we hypothesized that caregivers
desire for formal support would be associated with the

Copyright 2012 John Wiley & Sons, Ltd.

1390
psychological (increased distress) and medical difculties
encountered by the patient (disease and treatment difcul-
ties such as being in chemotherapy or in the advanced
phases of the disease) as those difculties may increase
the burden of caregiving [20]. Third, as caregivers and
patients are likely to share similar difculties and similar
beliefs about the effectiveness of psychological inter-
ventions, we hypothesized that caregivers desire for
formal psychological support would be associated with
patients own desire. Finally, we hypothesized that care-
givers socio-demographic characteristics (such as being
younger, being a woman, having a higher education
level, and working part or fulltime) would be positively
associated with their desire for formal psychological
support as those factors have been shown to inuence
reported distress and support seeking in a general popu-
lation [2023] and among patients with cancer [24].
It should be noted that this study is a part of a larger
study on patients and caregivers needs. The rst part
of this study, published by our group, showed a weak
association between patients desire for formal psycholog-
ical support and patients distress. In this study, although
about 60% of patients with cancer experienced moderate
to high levels of distress, only 20% reported a desire for
formal psychological support [24].
Methods
Subjects and setting
This study was conducted in 10 Belgian hospitals. Patients
with cancer were recruited from chemotherapy day units,
radiotherapy units, hemato-oncology units, medical oncol-
ogy units, and breast cancer clinics. All specialist physi-
cians working in these units were invited to participate
in the study and asked for their permission to approach
their patients. The local ethics committees approved of
the study.
During the recruitment period, all consecutive inpati-
ents fullling the inclusion criteria and one out of two
outpatients (among those who consulted the participating
physicians or were being treated in the participating day
care units) were invited to participate. One out of two
outpatients was not approached for feasibility reason.
To fulll the inclusion criteria, patients had to be
inpatients or outpatients and to be t enough to complete
the questionnaire according to their physician; patients
and their caregivers had to be at least 18 years old, to be
aware of the cancer diagnosis, to be French or Dutch-
speaking, and to be free of any cognitive dysfunction
(as reported by their physician). They both gave their
written informed consent. They were excluded when the
patient had just been diagnosed or was hospitalized in
palliative care units. Chosen caregivers had to be the
person that the included patients pointed out as the
person who, among their relatives, had helped them
the most during the last month. This person was con-
tacted and asked to participate in the study. Patients
and caregivers were not necessarily recruited on the same
day. It should be noted that neither the patient nor his or
her primary caregiver received any incentive to participate
in the study.
Copyright 2012 John Wiley & Sons, Ltd.
I. Merckaert et al.
Study and assessment procedure
This is a multicentered, descriptive, and cross-sectional
study. Patients and caregivers were assessed individually
by independent investigators and were asked to complete
questionnaires separately. Completion of the questionnaires
lasted about 1 h. Both patients and relatives completed the
rst part of the questionnaires with the help of the investiga-
tor whether face-to-face or by phone. When they were used
to the way of completion, they could choose to continue
with the investigator or to do it alone. They could phone
the investigator whenever they had questions.
Questionnaires
Patients and caregivers socio-demographic data
Each patient and caregiver provided demographic informa-
tion including age, gender, occupational status, and educa-
tion level. Caregivers reported whether they had children.
Caregiverpatient relationship characteristics
Caregivers reported whether they lived with the patient,
their family tie with him or her, and the length of their
relationship and of caregiving in months.
Patients disease-related and treatment-related charac-
teristics
Data were provided by physicians regarding patients diag-
nosis (type of disease, time since diagnosis, and disease
stage), prognosis, and treatment (previous and current).
The Hospital Anxiety and Depression Scale [25]
Patients and caregivers completed the Hospital Anxiety
and Depression Scale (HADS), a four-point 14-item self-
report instrument assessing anxiety (7 items) and depres-
sion (7 items) in physically ill subjects during the week
before completion. Each item is scored from 0 to 3, so that
the maximum for each subscale is 21. The validated
French and Dutch versions of the HADS have been used
[26,27]. Its use has also been tested for caregivers [28].
The use of the total score is recommended to assess
psychological distress. The recommended cut-off scores
are 13 (moderate distress) and 19 (severe distress) [26].
Patients and caregivers desire for formal psychological
support
The CAncer Rehabilitation Evaluation System (CARES)
[29,30] was adapted to measure patients and caregivers
desire for formal psychological support. The CARES is
a cancer-specic self-administered quality of life question-
naire designed to assess the impact of treatment on
patients ability to function. The questionnaire was for-
mally translated from the original version to French and
Dutch. This 138-item questionnaire allows the assessment
of 38 categories of difculties potentially experienced by
patients with cancer. The scale assesses six general
domains (physical difculties, problems with medical
interactions, psychosocial, sexual and marital difculties,
and an other domain including items such as treatment-
related problems or economic barriers). Two items about
death were excluded from the questionnaire. Patients and
Psycho-Oncology 22: 13891395 (2013)
DOI: 10.1002/pon
Desire for psychological support among caregivers of cancer patients
caregivers reported to what extend the difculty applied
to them in the last month on a Likert scale ranging from
0 not at all (no problem) to 4 very much (severe
problem). Whenever a patient or a caregiver reported
encountering at least a little difculty regarding one of
the items of a specic category, he or she had to report
whether he or she desired to receive support from relatives
and from professionals for this difculty. Caregivers were
asked to answer the following question: During the last
month, today included, as a result of the difculties that
you reported having experienced, have you desired help
from: (. . .) a psychologist (yes/no), a psychiatrist (yes/
no) (. . .). For the purpose of this study, a dichotomous
variable was computed according to the fact that patients
and caregivers reported or not desiring formal psycholog-
ical support from a psychologist and/or a psychiatrist to
deal with at least one of the difculty categories [24].
Desire for support from psychologists and psychiatrists
was chosen as in Belgium, formal psychological support
is mainly provided by these two categories of profes-
sionals in oncology.
Statistical analyses
Statistical analysis of the data consisted rst of a descrip-
tive analysis of all included patients and relatives. We then
tested the association between each potential predictor
and caregivers desire for formal psychological support
using parametric and nonparametric tests as appropriate
(Students t-test, MannWhitney U-test, and chi-squared
test). All tests were two-tailed, and alpha was set at 0.05.
A Backward Stepwise (Conditional) logistic regression model
was computed. Variables with a univariate p-value 0.05
were entered in the model.
Results
Subjects
Patients recruitment procedure has been published previ-
ously in detail [24]. Three-hundred and eighty-two patients
were included in the patient study. Of these, 330 patients
(86%) met entry criteria by virtue of having a caregiver
who also met entry criteria. It should be noted that 48
patients (12.5%) had no caregiver. Thirty-two dyads (9%)
refused to be surveyed (15 patients did not allow us to con-
tact their caregiver, and 17 caregivers refused participation).
All told, we surveyed 298 dyads and 282 dyads (85% of
eligible dyads) completed the survey. No information
was collected regarding nonrespondents. Mean duration
between patients and caregivers questionnaire completion
was 7 days (SD = 12.9).
Caregivers desire for psychological support
Fifty-four caregivers (19%) reported desiring formal psy-
chological support. More precisely, 18 caregivers (14%)
desired formal support among the 130 caregivers who
reported no signicant levels of distress, and 36 caregivers
(24%) desired formal support among the 152 caregivers
who reported moderate to severe distress.
Copyright 2012 John Wiley & Sons, Ltd.
1391
Patients disease-related and treatment-related
characteristics and patients and caregivers socio-
demographic and psychological characteristics
Tables 13 display patients and their caregivers charac-
teristics and the association between these characteristics
and caregivers desire for formal support. Caregivers
tended to be middle-aged (52 ! 14), 54% were female,
77% were at least high school educated, and 57% were
spouses of the patients. The median duration of caregiving
was 30 months (!50). Forty percent of patients had breast
cancer, 16% had a hematologic cancer, 12% had a gastro-
intestinal cancer, and 32% had another solid tumor.
Factors associated with caregivers desire for formal
psychological support
Five variables were entered in the regression analysis:
caregivers age, gender, education level, distress (HADS),
and patients desire for psychological support. Backward
Stepwise (Conditional) logistic regression analysis (Table 4)
showed that caregivers desire for formal psychological
support was associated positively with being younger,
having a higher degree of education, being more distressed,
and with patients desire for support. It should be noted
that caregivers gender was excluded from the nal model.
It should also be noted that this model only predicted
desire for psychological support for 25% of caregivers
who desired support.
Discussion
This study shows that one out of ve caregivers (19%)
desires formal psychological support and that one out of
two caregivers (54%) experiences signicant levels of
distress. The frequency of signicant levels of distress
reported by caregivers in this study and the prevalence
of their desire for formal psychological support are similar
to that found in patients with cancer [24,31].
As hypothesized, factors associated positively with
caregivers desire for formal psychological support were
the following: caregivers higher distress levels, patients
and caregivers younger age, caregivers female gender,
caregivers higher level of education, and patients own
desire for formal support. Contrary to our hypotheses,
caregivers desire was not associated with patients emo-
tional and medical difculties. Regression analysis showed
that caregivers desire for formal support was associated
with their levels of distress, with caregivers younger age
and higher education levels, and with patients own desire
for formal support. It should be noted that the variables
remaining in the logistic regression analysis only correctly
predicted 25% of caregivers who desire formal support.
Regarding the inuence of distress levels on caregivers
desire for formal support, it is important to report that,
among caregivers who present moderate to severe dis-
tress, only one out of four caregivers (24%) desires formal
psychological support (compared with one out of seven
caregivers (14%) among caregivers who reported no sig-
nicant levels of distress). This goes in line with studies
on help-seeking behaviors that have noted that the severity
of symptoms is not the only key factor associated with
peoples desire for professional help [19]. Many reasons
Psycho-Oncology 22: 13891395 (2013)
DOI: 10.1002/pon
1392 I. Merckaert et al.

Table 1. Primary caregivers and patients socio-demographic characteristics associated with primary caregivers desire for psychological
support (n = 282)
Caregivers desiring support (n = 54) Caregivers not desiring support (n = 228)

Characteristics N % N % p

Primary caregivers socio-demographic characteristics

Age* <0.001
Mean 43.9 53.5
Standard deviation 10.6 13.6
Gender 0.023
Men 17 31.5 112 49.1
Women 37 68.5 116 50.9
Children 0.846
Yes 45 83.3 185 81.1
No 9 16.7 43 18.9
Educational level 0.020
Junior high school or less 6 11.1 59 26.0
High school graduation or more 48 88.9 168 74.0
Occupational status 0.098
Working part or full time 33 61.1 110 48.2
Invalid, incapacitated, unemployed, homemaker, or retired 21 38.9 118 51.8
Language 0.651
French-speaking 32 59.3 127 55.7
Dutch-speaking 22 40.7 101 44.3
Primary caregiverpatient relationship characteristics
Living with the patient 0.117
Yes 29 53.7 149 65.6
No 25 46.3 78 34.4
Family tie 0.285
Partner 27 50.0 134 58.8
Other 27 50.0 94 41.2
Length of caregiving (in months)* 0.967
Mean 24.5 31.8
Standard deviation 38.5 52.3
Patients socio-demographic characteristics
Age* 0.001
Mean 50.4 57.5
Standard deviation 14.5 12.4
Gender 0.263
Male 22 40.7 73 32.0
Female 32 59.3 155 68.0
Educational level 0.407
Junior high school or less 13 75.9 70 30.8
High school graduation or more 41 75.9 157 69.2
Occupational status 0.203
Working part or full time 16 29.6 47 20.8
Invalid, incapacitated, unemployed, homemaker, or retired 38 70.4 179 79.2
Patients desire for formal psychological support 0.011
Yes 20 37.0 45 19.8
No 34 63.0 182 80.2

*MannWhitney.

could explain this. First, as it has been reported, caregivers
may not perceive the severity of their symptoms [8].
Second, caregivers may consider that they should focus
on helping the patient and therefore leave their own needs
behind. This hypothesis is supported by studies that have
shown that primary caregivers tend to neglect their own
health because of their involvement in their caregiver role
[32]. Finally, this weak association may also be explained
by other factors that have been hypothesized to inuence
help-seeking behaviors (e.g., perception of barriers to obtain
help and limited beliefs in the effectiveness of formal
psychological interventions) [19].
Second, this study shows that caregivers desire for
formal psychological support is associated with patients
desire for formal psychological support but not with
patients emotional and medical difculties. Several reasons,
that could be interconnected, may explain this association.
For example, caregivers and patients closeness may lead
to similar beliefs about formal psychological support.
Caregivers and patients may also desire formal support to
protect one another from the expression of distress or dif-
culties. Caregivers and patients may moreover desire formal
support to respond more optimally to the others needs.
Third, as expected, caregivers desire for formal psycho-
logical support is inuenced by patients or caregivers
socio-demographic characteristics: patients and caregivers
being younger, caregivers being women, caregivers having
a higher education level, caregivers living with children,
and caregivers having a shorter relationship with the patient.
The fact that younger caregivers are more prone to desire
formal psychological support is similar to results of studies
on help-seeking conducted in a population of patients with
cancer [24] and in the general population [22]. This may
be explained by a cohort attitude toward psychological

Copyright 2012 John Wiley & Sons, Ltd. Psycho-Oncology 22: 13891395 (2013)
DOI: 10.1002/pon
Desire for psychological support among caregivers of cancer patients 1393

Table 2. Patients disease and treatment characteristics associated with primary caregivers desire for psychological support (n = 282)
Caregivers desiring support (n = 54) Caregivers not desiring support (n = 228)

Characteristics N % N % p

Disease characteristics
Type of disease NA
Hematologic cancer 16 29.6 36 15.8
Head, neck, and lung cancer 3 5.6 21 9.2
Breast cancer 21 38.9 92 40.4
Gastrointestinal cancer 5 9.3 28 12.3
Gynecologic cancer 1 1.9 11 4.8
Prostate cancer 1 1.9 8 3.5
Other solid tumors (brain, urinary, etc.) 7 13.0 32 14.0
Disease stage 0.893
In remission 25 46.3 94 42.7
Not in remission 13 24.1 56 25.5
Too early to assess 16 29.6 70 31.8
Prognosis 0.367
Less than 1 year 14 25.9 41 18.0
1 year or more 37 68.5 168 73.7
Too early to assess 3 5.6 19 8.3
Karnofsky performance status score 1.000
80 or more 40 75.5 166 74.1
Less than 80 13 24.5 58 25.9
Treatment characteristics
Previous cancer treatment 0.848
Yes 45 80.4 179 81.0
No 11 19.6 42 19.0
Current cancer treatment 1.000
Yes 43 79.6 177 79.4
No 11 20.4 46 20.6
Type of current cancer treatment
Surgery 0.840
Yes 8 14.8 37 16.6
No 46 85.2 186 83.4
Chemotherapy 0.129
Yes 30 55.6 97 43.5
No 24 44.4 126 56.5
Radiation therapy 0.076
Yes 5 9.3 46 20.6
No 49 90.7 177 79.4
Hormone therapy 0.380
Yes 5 9.3 33 14.8
No 49 90.7 190 85.2
Immunotherapy 0.573
Yes 5 9.3 16 7.2
No 49 90.7 207 92.8
Psychotropic treatment 0.213
Yes 17 32.7 51 23.5
No 35 67.3 166 76.5
Time since diagnosis* 0.732
Mean 36.8 36.7
Standard deviation 54.9 55.7
Setting characteristics 0.346
Inpatient 32 60.4 138 61.1
Outpatient in consultation 19 35.8 67 29.6
Outpatient in 1 day unit 2 3.8 21 9.3

*MannWhitney.

support. This may also be explained by the fact that younger
caregivers are in a phase of life with numerous challenges to
deal with (children, work, and couple issues). This may
explain that having children is associated with caregivers
desire for formal support. It is important to note that
caregivers desire for support was associated with their
gender but that gender was excluded from the regression
analysis. This limited impact of gender is not consistent
with the literature on support seeking [3335]. This may
be explained by the fact that caregivers in our study were
chosen by patients as the person who had helped them the
most during the last month. The role of primary caregiver,
due to the burden of caregiving or due to the endorsement
of the role, may overrule men and womens difference in
attitudes towards formal support.
Several limitations of our study should be acknowl-
edged. Our entry criteria limited our participants to those
t enough to participate and, hence, might have biased
our sample towards more functional dyads: that is, those
caregivers who were more distressed might not have been
captured. Also, the sample size limited our ability to
obtain a sample representative of all cancers, thus limiting

Copyright 2012 John Wiley & Sons, Ltd. Psycho-Oncology 22: 13891395 (2013)
DOI: 10.1002/pon
1394 I. Merckaert et al.

Table 3. Psychological factors associated with primary caregivers desire for psychological support (n = 282)*
Caregivers desiring support (n = 54) Caregivers not desiring support (n = 228)

Characteristics Mean SD Mean SD p

Primary caregivers
Psychological characteristics
Hospital Anxiety and Depression Scale (HADS)
Anxiety 10.5 4.5 9.2 4.5 0.041
Depression 6.0 4.6 4.7 3.7 0.083
Distress (total score) 16.5 8.4 13.9 7.5 0.033
Patients
Psychological characteristics
Hospital Anxiety and Depression Scale (HADS)
Anxiety 8.6 4.6 8.9 4.6 0.608
Depression 5.0 4.1 5.1 3.7 0.823
Distress (total score) 13.6 7.5 14.0 7.1 0.497

*MannWhitney.

Table 4. Factors associated with primary caregivers desire for formal psychological support (logistic regression analysis) (n = 279)
Predictors OR 95% CI p

Primary caregivers characteristics

Socio-demographic characteristics
Age 0.95 0.93 to 0.96 <0.001
Educational level (lower versus higher) 0.35 0.13 to 0.91 0.032
Psychological characteristics
Distress (HADS) 1.08 1.03 to 1.12 <0.001
Patients characteristics
Socio-demographic characteristics
Age
Educational level (lower versus higher)
Psychological characteristics
Distress (HADS)
Disease and treatment characteristics
Desire for formal psychological support (yes versus no) 2.54 1.27 to 5.07 0.008

Five variables were entered in the model: caregivers age, gender, educational level, distress (HADS), and patients desire for psychological support. The full logistic regression model
correctly predicts 24.5% of cases in the group of caregivers who desire formal psychological support and 96.9% of cases in the group of caregivers who do not desire formal
psychological support. Overall, the model correctly predicts 83.2% of cases. The goodness-of-t of the nal model had a HosmerLemeshow t statistic w2 (8) = 3.68, p = 0.88.
HADS, Hospital Anxiety and Depression Scale.

the generalizability of our results. Finally, an interviewer
bias could have affected the result as respondent could
choose to have assistance with completing the survey
if needed.
To our knowledge, this is one of the rst studies inves-
tigating desire for formal psychological support among
caregivers of patients with cancer and aiming to identify
factors that are likely to be associated with this desire.
Several results should be highlighted. First, our study
shows a weak association between caregivers desire for
formal support and distress (three out of four caregivers
who experience high or moderate levels of distress do
not express a desire for formal support). Second, our study
shows that caregivers desire for formal psychological
support is associated with socio-demographic factors such
as age, education level and, most importantly, with
patients own desire for formal support. Third, it should
be noted that these factors only predicted 25% of
caregivers who expressed a desire for formal support.
Although these results may be useful to better understand
caregivers process of help-seeking, they emphasize the
need to implement systematic screenings of both distress
and desire for formal psychological support, throughout
the course of the disease, not only for patients as it is
widely carried out nowadays in oncology [36], but also
for their caregivers. Moreover, and in particular for
caregivers with moderate or severe distress who do not
express a desire for a formal support, screening could be as-
sociated with psychoeducational interventions focusing on
the negative consequences of prolonged distress (decrease
in personal, familial, and social wellbeing and functioning),
on the potential benets of formal psychological support
and on the type of psychological support available.
It may be also useful to add such a screening on physi-
cians agenda. There is, in this perspective, the need to
develop communication skills training programs for
physicians to teach communication skills promoting
detection of caregivers distress and needs in different
contexts, when the caregiver is met alone and when the
caregiver is accompanied by the patient [37,38].
The results of this study highlight the need to further
investigate the process of help-seeking by caregivers and
the factors associated with it. Further studies should be
model-based and include all possibly associated variables
identied from similar studies. This will allow developing
interventions designed to initiate as early as possible an

Copyright 2012 John Wiley & Sons, Ltd. Psycho-Oncology 22: 13891395 (2013)
DOI: 10.1002/pon
Desire for psychological support among caregivers of cancer patients
appropriate support for caregivers in oncology. Future
research should also focus on at least three additional
issues. First, as caregiving is differently rooted in cultures,
this type of study should be repeated in different countries.
Second, future studies should test, on the one hand, the
benets for caregivers and patients of systematic screen-
ings of distress and desire for formal psychological
support for caregivers and, on the other hand, the nancial
costs of this screening. Third, support interventions
specically designed for caregivers of patients with cancer
should be developed and tested for their efcacy.
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Copyright 2012 John Wiley & Sons, Ltd.
Acknowledgements
This study was supported by the SPF Sant Publique of Belgium
(Appel doffre-2002-16). The study sponsor had no role in study
design, data collection, data analysis, or data interpretation, or in
the writing of the report.
Conict of interest
The authors have no nancial and personal relationships
with other people or organizations that could inappropri-
ately inuence their work.
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Psycho-Oncology 22: 13891395 (2013)
DOI: 10.1002/pon