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Investigation of Depression in Cancer Patient’s Caregivers in Combined Military Hospital, Rawalpindi

Background: Cancer is the second leading cause of death, responsible for 1 in 6 deaths globally and Caregivers play a major role in cancer patients' care and rehabilitation. They may face several psychological issues like depression along with physical and emotional disadvantages, and significant financial consequences. The objective of this study is to find out the associations of Depression with demographic variables among family caregivers of cancer patients in combined Military Hospital, Rawalpindi.
Methods: This was a cross-sectional study conducted in the OPD and IPD of the Oncology department of CMH, Rawalpindi between February and July 2020. The 384 adult cancer patient’s caregivers visiting oncology department were assessed to find out level of depression after getting informed consent. Data was collected by Demographic questionnaire and Beck Depression Inventory (BDI) tool. Chi-square test and Likelihood ratio chi-square test used to find association.
Results: Out of all 384 caregivers 181 (47.1 %) were males and 203 (52.9 %) were females. 267 (69.5 %) were diagnosed as non-depressive while 117 (30.5 %) were diagnosed as Depressive. A considerable association has been found between Depression and Age of caregivers (p= 0.006), Gender of caregivers (p <0.05), employment status of caregivers (0.02) and relationship to a cancer patient (p = 0.003).
Conclusion: A high prevalence of depression is found in cancer patient’s caregivers and Depression is significantly associated with Age of caregivers, Gender of caregivers, employment status of caregivers, and the relationship to cancer patients.


Introduction
ancer, which influences all ages and countries regardless of their economic status is constantly expanding and speaks to a genuine general public health issue around the world (1). Ferlay et al reported that 18.1 million new cancer cases worldwide and 9.6 million cancer-related deaths occurred in 2018 (2). Cancer is the second main source of death around the world, responsible for 1 in 6 deaths globally (3). Europe having only 9% of the global population accounts for 23.4% of the total cancer cases and 20.3% of the cancer deaths, followed by the Americas' 21% of incidence and 14.4% of cancer deaths globally. Unlike other regions, the shares of cancer deaths in Asia (57.3%) and Africa (7.3%) are higher than the shares of incidence (48.4% and 5.8%, respectively) since these regions are more C likely to develop certain forms of cancer, linked to worse forecast and higher mortality rates and restricted access in many of the continent's countries to timely detection and treatment (4). The agestandardized incidence rate of cancer in Pakistan is 114 and the risk of developing cancer before the year of 75 years is 8.8 % in Pakistan. The estimated number of prevalent cases of cancer is 154 per 1,00,000 population both sexes all ages in Pakistan (5). Speaking of the term cancer is identified with a dangerous situation regardless of the expanding awareness of clinical information in Pakistan. The diagnosis of cancer disease influences the patients as well as primary caregivers engaged in the patient care (6). Family caregivers (FC) are "relatives, family members, friends, or neighbors who give support associated with associate degree underlying physical or mental incapability that goes past normal and normative social support provided in social relationships however is unpaid for those services (7). FCs may perform a critical role in the care and treatment of patients having cancer because of the shifting of treatment towards outpatient care, besides cancer poses an ever-growing care problem. These established increased roles for both the emotional and physical care and treatment of patients who have been passed to family and friends (1). Cancer patients typically need help from family and friends in addition to specialized medical treatment and care. Family caregivers assist patients with personal care, transportation, emotional support, finances, and symptom management throughout their caregiving process (8). Caregivers frequently compromise their own needs, placing themselves at increased risk of stress and possible psychosocial harm which can exceed the normal limit and that of the patient (9). Caregivers may face several psychological issues like depression and a decrease in Quality of Life (QoL). There is a trend towards reduced stay in hospital due to the ever-expanding population, so more out-patient and home treatment has put a heavier weight on FCs including physical and emotional disadvantages with significant financial consequences. Grief, sorrow, and anxiety are unremarkably related to FCs of cancer patients who in several instances become of a long depression (10). 350 million people from all age groups affected from depression that is a very common mental disorder worldwide.
A unipolar depressive disorder is predictable to be the most noteworthy cause of disease burden by the year 2030 (11). A systematic review done by Pilevarzadeh et al., 2019 examined the prevalence of depression in patients with breast cancer and concluded that the worldwide prevalence of depression was 32.2% in 47,424 investigations, related to 30 countries. Specifically, in comparison to developing countries, the incidence of depression was highest in the Eastern Mediterranean Region (12). Epidemiological reports around the nation put the prevalence rates of depression and nervousness issues somewhere in the range of 22% and 60% with occurrence differing generally among metropolitan and rural settings. Among the many minimized inhabitants, the most helpless against depression are the females, the older, those from lower financial gatherings, and uneducated people. Depression is the most common psychological maladjustment and is the fourth driving reason for years lost because of the inability in the country (13) As per the literature search, there was little data available on the investigation of depression in cancer patient's caregivers in Pakistan. This study was conducted to help policymakers to identify the caregiver's problems, and how they are affected by the process of caregiving, and also it provided evidence regarding the Depression level in cancer patient's caregivers. The main purpose of this study was to assess the mental health of caregivers of cancer patients and recommend measures to improve their mental health by generating evidence for advocacy and awareness.

Methodology
This quantitative study used an analytical crosssectional study design to determine the prevalence of depression and find out an association between the level of depression and demographic variables of cancer patient's caregivers. 24.0% Figure 1 shows the percentage of the level of Depression in cancer patient's caregivers according to the BDI scale. In table 4.2 demographic variables and relationship to a patient were cross tab with depression status as normal or depressive according to BDI score interpretation and it also shows the analysis of their association between them. A significant association was found between the gender of caregivers and the Depression status (P < 0.05). The age of caregivers had also a statistically significant association with the depression status of caregivers (P < 0.05). The educational status of caregivers (p = 0.166) shows no association with the depression status of cancer patients caregivers. After analyzing the association of the employment status of caregivers with the depression status, it has been revealed that employment status (p= 0.02) has a significant association with depression status. There has been found no significant association between marital status (p= 0.739) and depression status of caregivers. The total household income of caregivers having (p= 0.499) also has no significant association with the Depression status of caregivers as p > 0.05. Likewise, Time since diagnosis of cancer having (p= 0.184) also has no significant association with the depression status of cancer patients caregivers but, there has been a strong association between the relationship to the patient (p = 0.003) and the depression status of caregivers.

Discussion
The caregiving process can affect the mental health of caregivers to cancer patients. The detrimental negative effect of caregiving has been identified among caregivers because of comprehensive caregiving demand and limited resources (15

Conclusion
This study showed a significant association between depression in caregivers and Age of caregivers, Gender of caregivers, the employment status of caregivers, and the relationship to cancer patients. It also revealed that a high prevalence of depression is found in caregivers of cancer patients. This study concluded that Female caregivers of older age having retired or unemployed and have close relationships with cancer patients are more prone to depression as compared to other factors. It is a starting point for the advocacy of mental health issues in caregivers to cancer patients so that policymakers and healthcare professionals take necessary actions to minimize the risk factors causing depression in caregivers. There is a robust need for palliative care provision to caregivers so that they can perform caregiving tasks more efficiently.