ORIGINAL ARTICLE

Factors associated with depressive symptoms in cancer familycaregivers of patients receiving chemotherapy

Anna-leila Williams & Alison J. Holmes Tisch &

Jane Dixon & Ruth McCorkle

Received: 2 July 2012 /Accepted: 25 March 2013 /Published online: 7 April 2013# Springer-Verlag Berlin Heidelberg 2013

Keywords Cancer family caregivers . Depression .

Chemotherapy

Introduction

As cancer in the USA transitions to a disease trajectorysimilar to other chronic illnesses, care has moved to outpa-tient settings where patients and their families are responsi-ble for day-to-day management and treatment-related sideeffects [1]. The family member or friend who assumes therole of caregiver has little opportunity to acclimate to theirnew responsibilities, personal response to the diagnosis, orthe healthcare system [2]. The caregiver’s focus and theprimary focus of treatment is the patient [3, 4].

Our understanding of cancer family caregivers’ needsand consequences has grown in recent years as more re-search has been directed toward this population [5, 6]. Thephysical and psychological impact of cancer family caregiv-ing is significant with many associated negative outcomesincluding depression, anxiety, decreased quality of life, fa-tigue, sleep disturbance, pain, and decline in health status[7–10]. In some studies, cancer family caregivers werefound to have worse psychological and quality of life out-comes than the patients for whom they cared [7, 11, 12].

Depression has been widely studied in cancer familycaregivers. Several factors have been associated with in-creased risk of depression related both to the cancer familycaregiver and the care recipient. Commonly reported

associations include female gender, younger age, spousalrelationship to care recipient, high perceived caregiver bur-den, high impact of caregiving on schedule and finances,familial conflict, poor patient performance status, a longertime since diagnosis, lung cancer diagnosis, and palliativetreatment intent [13–20]. Many of these reports were gener-ated from cancer caregiver research samples predominatelycomposed of people of white race, female gender, and thosecaring for patients with a variety of cancers.

As cancer treatment and prognosis have improved, the dis-ease has begun to be reframed within the chronic illness model.The Institute of Medicine’s Cancer Control Continuum in-cludes prevention, early detection, diagnosis, treatment, survi-vorship, and end of life [21]. These phases are marked byunique experiences for both patients and caregivers, often withdistinct stressors and needs. Current caregiver literature doesnot include longitudinal assessment of the caregiver experienceacross all phases of the cancer trajectory; most longitudinalstudies include few time points or short periods of data collec-tion [7, 8, 13, 17]. Until longitudinal studies across the cancertrajectory exist, it is of value to focus research within distinctphases so as to capture aspects of the caregiver experienceunique to particular phases [5]. Phase- specific research informsinterventions designed to meet caregiver needs throughout thecancer trajectory and ultimately will help clinicians identifycaregivers at high risk for untoward consequences and offertimely psychosocial support [22, 23].

The purpose of our secondary analysis was to describelevels of depressive symptoms among a cohort of cancerfamily caregivers during a specific phase along the cancertrajectory, namely, curative treatment, and identify howcaregiver characteristics relate to caregiver depressivesymptoms. Our study adds to the existing literature becauseof the relatively sizeable number of men represented, par-ticipation by those who identify as having Latino ethnicity,as well as restriction to caregivers for patients with lung orcolon cancer receiving chemotherapy with curative intent.

A. Williams (*)Frank H. Netter MD School of Medicine, Quinnipiac University,275 Mount Carmel Road,Hamden, CT 06518, USAe-mail: anna-leila.williams@quinnipiac.edu

A. J. H. Tisch : J. Dixon :R. McCorkleSchool of Nursing, Yale University, PO Box 9740, New Haven,CT 06536, USA

Support Care Cancer (2013) 21:2387–2394DOI 10.1007/s00520-013-1802-y

Methods

The methods for the parent study have been described indetail previously [24, 25]. To summarize the parent study,150 caregivers of patients with stage II or IIIa lung or stageII or III colon cancer receiving chemotherapy with curativeintent were enrolled from the Yale Comprehensive CancerCenter between May 2008 and March 2009. Caregiverswere recruited using population-based sampling techniquesin which all patients presenting for chemotherapy with thetype and stage of cancer examined in this study were re-ferred to the principal investigator (AW) and were asked toidentify their primary family caregiver and provide contactinformation. Eligible family caregivers were over the age of18 and identified by the patient as the primary person onwhom the patient relied for support who did not receivefinancial compensation. Of the 172 patients we approached,165 referred us to caregivers, of whom 150 (90.9 % ofcaregivers) accepted our invitation to participate. The pri-mary reason that caregivers gave for not participating waslack of time. Demographic information was collected, andparticipants completed four survey instruments, includingthe Center for Epidemiological Studies–Depression Scale(CES-D) [26], Caregiver Reactions Assessment (CRA)[27], Big Five Inventory [28], and Determinants of Medita-tion Practice Inventory [24]. For the current analysis, ourvariables were chosen and ordered based on the AdaptedPittsburgh Mind Body Center Model for cancer familycaregivers that demonstrates the interrelationship betweenpsychological, behavioral, and biological responses to astressful event [29].

The Human Investigations Committee at Yale UniversitySchool of Medicine approved the secondary analysis.

Instruments used in secondary analysis

From the parent study, the demographic information survey[including age, gender, relationship to patient, race, ethnic-ity, employment status, patient’s cancer type (colon versuslung) and length of time as a caregiver], CRA—Impact onPhysical Health Subscale and CES-D were included. TheCRA [27], a 24-item Likert scale, was used to assess theperceived impact of caregiving responsibilities on the care-giver’s daily activities and relationships. The CRA has beenused extensively with cancer family caregiver populationswith good internal consistency and content and constructvalidity testing including exploratory and confirmatory fac-tor analysis [27, 30]. There are five subscales, derived fromexploratory factor analysis, that are designed to be used andanalyzed independently: caregiver’s esteem, lack of familysupport, impact on schedule, impact on finances, and impacton physical health [27]. Based on the Adapted PittsburghMind Body Center Model for cancer family caregivers [29],

the impact on physical health subscale (CRA—Impact onHealth) was used in the secondary analysis. CRA—Impacton Health subscale contains four items with a five-pointresponse range from “strongly disagree” to “strongly agree.”Cronbach’s alpha is 0.80 [27].

The CES-D consists of 20 items across six major symp-tom areas for depression. Each item is scored from 0 to 3indicating frequency of occurrence of the symptom duringthe past week. Total scale score may range from 0 to 60,with a score of 16 or more indicating clinically significantdepressive symptomotology [26]. The CES-D has been usedextensively with cancer family caregiver populations; internalconsistency has been consistently around 0.90 [8, 31, 32].

Data analysis

Analyses were conducted using STATA 11. Descriptivestatistics were addressed with univariate analyses and testsfor Gaussian distributions for the CES-D. Bivariate analysisusing Pearson correlations was conducted to determine cor-relations among the control variable (gender), explanatoryvariables (age, relationship to patient, race, ethnicity, em-ployment status, patient’s cancer type, length of time as acaregiver, and CRA—Impact on Health) and outcome var-iable (CES-D). t tests and chi-squared tests were conductedto determine differences in total CES-D score and CES-Dscores dichotomized around the clinically significant cut-offof 16, by control and explanatory variables. Data for lengthof time as caregiver were transformed by the log value, andCRA—Impact on Health and CES-D score weretransformed by the square root to obtain normal distributionfor the bivariate analysis. Multiple linear and logistic regres-sion were used to model significant effects of explanatoryvariables on total CES-D score and CES-D dichotomized at16, respectively. Model fit was assessed with residual anddiagnostic analyses to assure the assumptions of the modelwere met. During multivariate analysis, backward elimina-tion of independent variables (while leaving the controlvariable, gender, in the model) was conducted to find themost parsimonious model. Two-sided significance tests withp<0.05 were interpreted as statistically significant.

Results

Caregiver characteristics

Caregiver demographic characteristics and patient cancertype are summarized in Table 1. While most caregivers inthis study were women there was a sizeable representationof men (n=52; 34.7 %). Using National Institute of Healthcriteria for race and ethnicity [33], the preponderance ofcaregivers identified as white; 8 % (n=12) of the sample

2388 Support Care Cancer (2013) 21:2387–2394

identified as African American and 8 % (n=12) identified asLatino/Hispanic. Of the 12 people who identified their eth-nicity as Latino/Hispanic, 6 identified their race as white, 1identified race as African American, 1 identified race asother, and 4 declined to identify race. The sample wasgenerally well educated, though it is noteworthy that ap-proximately one-third had a high school education or less.More than half the caregivers were employed outside thehome. When evaluated by gender, men and women were ofsimilar age and education levels. Women were equally like-ly to care for a spouse and to identify as white and non-Latino as their male counterparts. Men were more common-ly employed full-time than women. Length of time in therole of caregiver was similar between genders.

Impact on physical health

On average, caregivers reported the caregiving role hada low to moderate impact on their personal healthburden [mean (SD)=1.7 (0.7) total sample; 1.8 (0.7) women;1.5 (0.6) men].

Levels of depressive symptoms

Caregivers in this study had a mean depressive symptom scoreon the CES-D of 11.0 (SD, 8.9; Table 2). Twenty-one percentof participants met the CES-D score criterion for clinicallysignificant depressive symptoms (≥16). The influence of raceand ethnicity on the CES-D can be seen in Table 3.

Table 1 Caregiver characteris-tics by gender (N=150)

Not all percentages equal 100due to roundingaTotal respondents for highestgrade level completed: N=149bTotal respondents for race:N=145

Gender

Total Male Female

Characteristic Number (%)

150 52 (34.7) 98 (65.3)

Highest grade level completeda

No college 50 (34.0) 17 (32.7) 33 (34.0)

At least some college 99 (66.0) 35 (67.3) 64 (66.0)

Relationship to patient

Spouse/partner 67 (44.6) 23 (44.2) 44 (44.9)

Other 83 (55.3) 29 (55.8) 54 (55.1)

Ethnic background

Latino 12 (8.0) 3 (5.7) 9 (9.2)

Not Latino 138 (92.0) 49 (94.2) 89 (90.8)

Raceb

White 125 (83.2) 42 (84.0) 83 (87.4)

African American 12 (8.0) 4 (2.6) 8 (5.2)

Asian/Asian American 6 (4.0) 3 (2.0) 3 (2.0)

Other 2 (1.3) 1 (0.7) 1 (0.7)

Employment status

Full-time 55 (36.7) 26(50.0) 29 (29.6)

Other 95 (63.3) 26(50.0) 69 (70.4)

Patient cancer type

Colon 66 (44.0) 28(53.9) 38 (38.8)

Lung 84 (56.0) 24(46.2) 60 (61.2)

Characteristic Mean (standard deviation)

Length of time as caregiver in months 13.9 (18.5) 14.5 (22.0) 13.6 (16.5)

Caregiver reactions assessment

Health subscale

Average score for subscale 1.7 (0.7) 1.5 (0.6) 1.8 (0.7)

Feels tired all the time 2.1 (1.1) 1.8 (0.9) 2.3 (1.1)

Health has gotten worse 1.8 (1.0) 1.5(0.8) 1.9 (1.1)

Has enough strength to care for (reversed) 1.5 (0.7) 1.3 (0.7) 1.6 (0.6)

Is healthy enough to care for (reversed) 1.4 (0.7) 1.4 (0.7) 1.5 (0.7)

Age in years (range 18–84 years) 52.3 (16.2) 51.5 (17.5) 52.7 (15.5)

Support Care Cancer (2013) 21:2387–2394 2389

Bivariate correlations

Pearson’s correlations for control, explanatory and outcomevariables are presented in Table 4. Latino caregivers weresignificantly younger than their non-Latino counterparts[41.7 and 51.2 years, respectively (p=0.01)]. More time inthe caregiving role was correlated with higher impacts onhealth (p=0.04). Women reported a significantly higherimpact on health (p=0.007) from caregiving as comparedto men. Men and women experienced similar rates of clin-ically significant depressive symptom scores.

Regression analysis: caregiver characteristicsand depressive symptoms

A lower level of education (χ2=8.97, p=0.003), Latinoethnicity (χ2=6.387, p=0.01), and greater impact on health(OR=3.66 p<0.001, CI=1.96–6.85) were significantly as-sociated with higher levels of clinically significant depres-sive symptoms, while identifying as white and greaterimpact on health (β=2.42, p<0.001) were associated witha higher total CES-D score (Table 5).

Latino caregivers were more likely to meet CES-D scorecriterion for clinically significant depressive symptoms,compared to non-Latinos (50.0 versus 18.8 %, p=0.01).

Individuals who identified as white had higher total CES-D scores than those of other races/ethnicities (11.4 versus7.8, p=0.04). Never attending college was significantlyassociated with meeting CES-D score criterion for clinicallysignificant depressive symptoms (34 versus 14 % in care-givers having attended some college, p=0.003). Perceivingthe caregiver role as having a greater impact on health wasassociated with more depressive symptoms, by total scoreand at the clinically significant level (p<0.001 for both).

Multivariate regression

The most parsimonious logistic regression model demon-strates, when controlling for gender, the variables level ofeducation attained, Latino ethnicity, and impact on healthscores contributed to meeting the CES-D criterion for clin-ically significant depressive symptoms (Table 6). Individ-uals with some college education were a third less likely toscreen positive for depression. Caregivers who identified asLatino were 4.6 times more likely to be depressed. Theimpact on health was highly significant, with each 1 pointincrease in the impact on health subscale increasing fourtimes the likelihood of meeting CES-D criterion for clini-cally significant depressive symptoms. Gender remained inthe final model as the control variable.

Discussion

Depression is a frequent consequence of providing informalcare to an individual with cancer. The current study adds toour understanding of caregivers at risk for depression at aspecific time along the cancer trajectory, namely, receivingchemotherapy with curative intent. By limiting the sample bycancer type, stage, and adjuvant chemotherapy treatment, thecaregivers studied were more likely to have similar caregivingexperiences and burden. Caregivers in this study had a rate ofclinically significant depressive symptoms (21 %) on the lowend of the range of caregiver depression prevalence describedin the literature (20–73 %) [34], although markedly elevated

Table 2 CES-D mean scores by gender (total score and score indicat-ing clinically significant depressive symptoms)

Total Male FemaleN=150 N=52 N=98

CES-D Total Score

Mean (standard deviation)

11.0 (8.9) 10.6 (8.6) 11.2 (9.1)

CES-D score indicating clinically significant depressive symptomsa

Frequency (%)

CES-D <16 118.0 (78.7) 41.0 (78.9) 77.0 (78.6)

CES-D ≥16 32.0 (21.3) 11.0 (21.2) 21.0 (21.4)

a A CES-D score ≥16 is indicative of clinically significant depressivesymptoms

Table 3 CES-D mean score byrace and ethnicity

aMean is not reported for oneparticipant since informed con-sent assured participants the datawould only be reported inaggregatebFive participants did not reportRace

Ethnicity

Latino Non-Latino

Race N Mean (standard deviation) N Mean (standard deviation)

White 6 15.3 (15.3) 119 11.2 (8.7)

African American 1 Not reporteda 11 8.5 (8.1)

Asian American 0 6 14.2 (11.6)

Other/did not identify raceb 5 13.6 (8.2) 2 10.5 (2.1)

Total 12 138

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relative to the general population. Studies of interventionsduring active treatment have shown similar levels of depres-sive symptom burden at baseline [7, 35]. A possible explana-tion for comparatively low levels of depressive symptoms forour sample may lie in the regularity of visits to the oncologyteam when patients are receiving chemotherapy and the on-going symptom management support provided by health pro-fessionals [36]. Studies of caregivers for patients nearer todeath [8, 13] and among caregivers for patients receivingexclusively palliative intent of treatment [18] have foundhigher levels of depression. Of note, our study and othersconducted during active treatment [7, 35] used a single de-pression score, which may not have captured as many cases ofdepression as performing diagnostic interviews.

A highly significant association between greater impact onhealth and increased risk for depressive symptoms was foundamong caregivers in this study. Similar findings have beendemonstrated in other active treatment studies [18, 40] and inmeta-analysis in the dementia and older adult caregiver liter-ature [41]. It is unclear from the current study whether poorhealth existed prior to assuming the caregiver role; however,bivariate analysis showed a significant correlation betweenlength of time spent caregiving and greater impact on health.Of note, the median length of caregiving in this study was6.5 months. While previous studies have shown this correla-tion in mixed-phases of disease, the evidence of impact onhealth during curative treatment with such a short period ofcaregiving marks the importance of early intervention forcaregivers of cancer patients. Signs of poor or declining healthamong caregivers may be a warning sign for clinicians thatassessment of caregiver mood is indicated.

Gender differences in levels of caregiver depression havecommonly been reported with women having higher rates of

depression than men [37, 38]. However, the current studyrevealed no significant difference between woman and menin either level of depressive symptoms or rates of meetingCES-D criterion for clinically significant depression. Ourfinding may be moderated by the similarity of caregivingdemands on both genders, equal levels of support throughregular chemotherapy visits, and/or by the positive effects oftreatment with curative intent. Whatever the amelioratinginfluences, our findings highlight the importance of inter-ventions aimed at reducing psychological effects of caregiv-ing among both women and men.

Rates of meeting CES-D criterion for clinically signifi-cant depressive symptoms among Latino caregivers weresignificantly higher than non-Latino counterparts and con-tributed significantly to the multivariate regression model.The size of the Latino subsample (n=12, 8 % of the totalsample) precludes more detailed analysis, and the wideconfidence intervals that accompany these significant resultsrequire these findings be interpreted with caution. The cur-rent literature does not thoroughly address racial and ethnicdifferences among caregiver symptom severity, and moststudies with racial diversity in the sample have focused onAfrican-American and white caregivers [11, 36]. A study bySiefert et al. [39] included Hispanic and African-Americancaregivers and found no difference by race/ethnicity com-pared with white, non-Hispanic individuals on outcomemeasures, including depressive symptoms. The Siefert studyis limited, however, by its small sample size (total N=54;Hispanic n=8) and the fact that the data from Hispanic andAfrican-American participants were combined for analysis.Further study of the Latino caregiver experience is warrantedwith a large sample that accounts for acculturation, country oforigin, primary language, and other variables that further

Table 4 Pearson correlations for control, explanatory, and outcome variables

1 2 3 4 5 6 7 8 9 10 11 12

1. Age 1.00

2. Gender 0.03 1.00

3. Spouse Caregiver 0.41# 0.01 1.00

4. Race n=145 −0.03 −0.05 −0.09 1.00

5. Latino ethnicity −0.19** 0.06 −0.17** 0.08 1.00

6. Less than collegeeducated n=149

−0.05 −0.01 0.04 0.07 −0.10 1.00

7. Employed full time −0.13# −0.20** −0.02 0.14# −0.02 0.12 1.00

8. Colon vs. lung cancer 0.16** 0.14# 0.12 −0.13 −0.04 0.00 0.12 1.00

9. Length of care provided 0.08 0.03 0.03 −0.15* −0.06 0.06 0.03 −0.17** 1.00

10. Health −0.02 0.22*** 0.05 −0.12 0.06 −0.01 −0.04 0.10 0.17** 1.00

11. Total CESD score −0.06 0.04 0.06 −0.17** 0.08 −0.12 −0.04 0.06 −0.04 0.42# 1.00

12. CES-D ≥16 −0.02 0.00 0.06 −0.11 0.21** −0.23*** −0.09 0.00 −0.06 0.35# 0.69# 1.00

N=150, unless otherwise noted

*p<0.10, *p<0.05, ***p<0.01, # p<0.0001

Support Care Cancer (2013) 21:2387–2394 2391

nuance the sample. Until such time, it is inappropriate toascribe clinical significance to these findings.

Higher levels of education were associated with low-er levels of depressive symptoms among our sample.The literature demonstrates inconsistent effects of edu-cation level on caregiver depressive symptoms. In stud-ies of caregivers to patients in active treatment and inthe palliative setting, education level has been associat-ed with lower depressive symptoms [40, 42], higher

depressive symptoms [10], and no effect [16]. Level ofeducation is a marker of socioeconomic status, and lesseducation may correlate with financial concerns, whichis known to increase risk of depressive symptoms [18]and is an unmet need among caregivers [43]. Lowsocioeconomic status is correlated with depression inthe general population [44]. The inverse relationshipbetween level of education and depressive symptomsin our sample and others [40, 42] may represent themediating effect of socioeconomic status. Further studyis needed to substantiate this inference.

Before caregiver needs can be systematically addressedin a substantive way, the components of “greater healthburden” and “socio-economic status” that contribute to de-pression must be parsed. Future research could investigatethe impact of specific caregiver morbidities, as well aspossible mitigation by healthcare access and social supportnetworks. Socio-economic issues to be investigated couldinclude insurance coverage, institutional racism, housing,

Table 5 Associations between depressive symptoms, control, and explanatory variables

Characteristic Mean CESD score Statistic CESD <16 CESD ≥16 Statistic(SD) N (%) N (%)

Total sample (N=150) 11.0 (8.9) 118 (78.7) 32 (21.3)

Age – β=−0.01 SE=0.01 – – OR=.997 SE=0.012

p=0.47 p=0.83 CI=0.97–1.02

Gender t=−0.52, p=0.60 χ2=0.002, p=0.97

Male (n=52) 10.6 (8.5) 41 (78.8) 11 (21.2)

Female (n=98) 11.2 (9.1) 77 (78.6) 21(21.4)

Relationship to patient t=−0.77, p=0.442 χ2=0.467, p=0.49

Spouse (n=67) 11.7 (9.23) 51 (76.1) 16 (23.9)

Nonspouse (n=83) 10.4 (8.6) 67 (80.7) 16 (19.3)

Race t=2.03, p=0.04 χ2=1.616, p=0.20

White (n=125) 11.4 (9.1) 97 (77.6) 28 (22.4)

Non-white (n=20) 7.8 (7.1) 18 (90.0) 2 (10.0)

Ethnicity t=−1.01, p=0.32 χ2=6.387, p=0.011

Latino (n=12) 14.2 (11.6) 6 (50.0) 6 (50.0)

Not Latino (n=138) 10.7 (8.6) 112 (81.2) 26 (18.8)

Highest level of education t=1.73, p=0.09 χ2=8.974, p=0.003

Did not attend college (n=50) 13.2 (10.4) 33 (66.0) 17 (34.0)

Attended college (n=99) 9.9 (7.8) 85 (85.9) 14 (14.1)

Employment status t=0.44, p=0.66 χ2=1.28, p=0.26

Full-time (n=55) 10.5 (8.4) 46 (83.6) 9 (16.7)

Other (n=95) 11.1 (8.0) 72 (75.8) 23 (24.2)

Patient’s cancer site t=−0.68, p=0.50 χ2=0.001, p=0.97

Colon (n=66) 10.2 (8.2) 52 (78.8) 14 (21.2)

Lung (n=84) 11.6 (9.4) 66 (78.5) 18 (21.5)

Length of time as caregiver in months – β=−0.05, SE=0.10 – – OR=0.99, SE=0.13

p=0.61 p=0.43, CI=0.97–1.0

CRA-Impact on Health – β=2.42, SE=0.43 – – OR=3.66, SE=0.32

p≤0.001 p≤0.001, CI=1.96–6.85

Table 6 Most parsimonious multiple logistic regression model forCES-D ≥16

Odds ratio SE p value 95 % CI

Gender 0.54 0.49 0.22 0.21–1.43

Some college 0.31 0.47 0.01 0.12–0.77

Latino ethnicity 4.60 0.74 0.04 1.07–19.80

Impact on health 4.24 0.39 <0.001 1.99–9.04

2392 Support Care Cancer (2013) 21:2387–2394

nutrition, exposure to inter-personal violence, and environ-mental factors, among others.

Age, relationship to patient, type of cancer, racial identi-ty, employment status, or length of time spent in the care-giving role did not significantly predict depressive symptomoutcomes in the modeling scenarios. These findings werenot consistent with the existing literature, which showshigher levels of depressive symptoms among younger care-givers, spouse caregivers, caregivers to lung cancer patients,and employed caregivers. The nature of curative treatmentmay contribute to these inconsistencies. Rigorous treatmentand high burden may have diminished the effects of indi-vidual factors commonly associated with depression.

Strengths of this research lie in the restriction to caregiversat a specific time period in the cancer trajectory, control fordisease type and stage, and therefore treatment modalities andintent of treatment. By reducing uncontrolled variables, wecan assess factors associated with caregiver depressive symp-toms with a higher level of certainty regarding their contrib-uting effect. Implications for research and practice are many.This study is the first to our knowledge to find increased riskamong Latino caregivers for depressive symptoms. Furtherstudies are needed at this phase and in other phases of theillness trajectory to support generalizability of the finding. Asthe population of individuals of Latino ethnicity in the USAincreases, so will their number as cancer family caregivers.The unique needs of the Latino caregiver population need tobe identified and evaluated. The association between poorhealth and increased depressive symptoms early in the care-giver experience highlights for clinicians the importance ofearly assessment and intervention, especially among at riskcaregivers with co-morbidities [45]. Increased depressivesymptoms among less educated individuals may be associatedwith lower socioeconomic status and increased financial con-cerns, both of which may be markers for needed interventionamong cancer family caregivers.

There are limitations of this study. As with any secondaryanalysis, data were not collected with the intention of answer-ing the specific aims of this study. Additional data from thesecaregivers, including patient performance status, caregiverpre-existing health conditions, hours per day spent providingcare, and social support, may have helped inform our findings.The cross-sectional design does not allow for assessment ofchanges over time as caregivers adapt to their role.

Conclusion

Cancer family caregivers of adults receiving chemotherapywith curative intent appear to have a lower rate of depressivesymptoms than caregivers at other stages of disease. How-ever, with 21 % of caregivers in our sample having depres-sive symptoms suggestive of clinical depression, they

clearly are at considerable risk. Associative factors includeLatino ethnicity, less than a college education and greaterimpact on physical health, which is consistent with theAdapted Pittsburgh Mind Body Center Model [29]. Furtherresearch among caregivers of diverse ethnic backgrounds isneeded to confirm our findings. Health professionals shouldassess cancer family caregivers for psychological morbidityearly in the cancer disease trajectory, particularly amongcaregivers with poor or declining personal health.

Acknowledgments The parent study was supported by the NationalInstitute of Health, National Center for Complementary and Alterna-tive Medicine (F31AT003535; PI Williams). We greatly appreciatebiostatistical support provided by Kristopher Fennie, Ph.D.

Conflict of interest The authors do not have a financial relationshipwith the organization that sponsored the research. The authors have fullcontrol of all primary data and agree to allow Supportive Care inCancer to review their data upon request.

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