2012 系统综述与荟萃分析.

ReviewCoping strategies and psychological morbidity in family carers of people with dementia:A systematic review and meta-analysisRyan Li ⁎,Claudia Cooper,Jonathan Bradley,Amanda Shulman,Gill LivingstonDepartment of Mental Health Sciences,University College London,Holborn Union Building,Highgate Hill,London N195LW,United Kingdoma r t i c l e i n f o ab s t r ac tArticle history:Received 1March 2011Received in revised form 27May 2011Accepted 27May 2011Available online 2July 2011Background :Carers for people with dementia experience high levels of anxiety and depression.Coping style has been associated with carer anxiety and depression.Method :We systematically reviewed studies examining the relationships between coping and anxiety or depression among carers of people with dementia.We rated study validity using standardised checklists.We calculated weighted mean correlations (WMC)for the relation-ships between coping and psychological morbidity,using random effects meta-analyses.Results :We included 35studies.Dysfunctional coping correlated with higher levels of anxiety (WMC =0.39,95%CI 0.28–0.50;N =688)and depression (0.46,0.36–0.56;N =1428)cross-sectionally,and with depression 6and 12months later (0.32,0.10–0.54;N=143).Emotional support and acceptance-based coping correlated with less anxiety (−0.22,95%CI −0.26to −0.18;N =628)and depression (−0.20,−0.28to −0.11;N=848)cross-sectionally;and predicted anxiety and depression a year later in the only study to measure this.Solution-focused coping did not correlate signi ficantly with psychological morbidity.Limitations :Just over a quarter of the identified studies provided extractable data for meta-analysis,including only two longitudinal studies.Conclusions :There is good evidence that using more dysfunctional,and less emotional support and acceptance-based coping styles are associated with more anxiety and depression cross-sectionally,and there is preliminary evidence from longitudinal studies that they predict this morbidity.Our findings would support the development of psychological interventions for carers that aim to modify coping style.©2011Elsevier B.V.All rights reserved.Keywords:Dementia Carers CopingSystematic review Meta-analysisContents 1.Introduction .......................................................22.Methods .........................................................22.1.Search strategy ...................................................22.2.Inclusion and exclusion criteria ...........................................22.3.Categorising coping ................................................22.4.Quality assessment .................................................22.5.Data extraction ...................................................32.6.Analysis ......................................................33.Results ..........................................................33.1.Study description and methods ...........................................33.2.Cross-sectional studies ...............................................3Journal of Affective Disorders 139(2012)1–11⁎Corresponding author.Tel.:+442072883559;fax:+442072883411.E-mail address:ryan.li@ (R.Li).0165-0327/$–see front matter ©2011Elsevier B.V.All rights reserved.doi:10.1016/j.jad.2011.05.055Contents lists available at ScienceDirectJournal of Affective Disordersj o u r n a l h om e p a g e :w w w.e l s ev i e r.c o m /l o c a t e /j a d3.2.1.Anxiety (7)3.2.2.Depression (7)3.2.3.Mixed psychological morbidity (7)3.3.Longitudinal studies (7)3.3.1.Anxiety (8)3.3.2.Depression (9)4.Discussion (9)4.1.Limitations (10)4.2.Clinical implications (10)Role of funding source (10)Conflict of interest (10)Acknowledgements (10)References (10)1.IntroductionFamily carers of people with dementia have high levels of anxiety and depression(Cooper et al.,2007;Crespo et al., 2005;Pinquart and Sorensen,2003).This psychological morbidity has been found to be most strongly associated with the coping strategies used by the carer,as well as demographic characteristics of the carer and neuropsychiatric symptoms and illness severity in the person with dementia (Cooper et al.,2008).Nonetheless earlier studies have reported conflicting results about the relationships between emotion-focused or dysfunctional coping styles and psycho-logical morbidity(Crespo et al.,2005;Neundorfer,1991; Proctor et al.,2002;Shaw et al.,1997;Vedhara et al.,2001).Coping is the process by which people manage stress.If coping strategies are important contributors to carer psycho-logical morbidity,then understanding which styles are protective and which are detrimental may inform the development of interventions.Coping strategies were initially divided into emotion-focused and problem-focused(Lazarus and Folkman,1984).Later a third category of dysfunctional coping was suggested(Carver et al.,1989).Kneebone and Martin(2003)reviewed12cross-sectional and6longitudinal studies,and concluded that problem-solving and acceptance styles of coping appear to be advantageous for carers of people with dementia,but commented their findings were limited because studies failed to identify the influence of the stressors.Greater stressors would be expected to elicit more coping strategies as well as increasing anxiety and depression.We aimed to systematically review and meta-analyse the relationships between coping strategies and psychological morbidity in family carers for people with dementia.We examined the measures of coping and re-classified them to ensure comparability between studies.We also took into account two specific stressors,the severity of dementia and neuropsychiatric symptoms of the care recipient,as the use of coping strategies is expected to increase as stressors increase.2.Methods2.1.Search strategyWe searched EMBASE,MEDLINE,PsycINFO,Web of Science,CINAHL and AMED up to March2010.The search terms were:(carer OR caregiver OR caring OR relative OR supporter OR family);(dementia OR Alzheimer OR cognitive impairment);coping;(anxiety OR depression OR mood OR psychiatric morbidity OR psychological morbidity).We hand-searched relevant reviews and the references of included studies.We also asked authors of all the included studies whether they were aware of any further studies.2.2.Inclusion and exclusion criteriaWe included primary research studies,published in English that reported the relationship(for example as correlations or regression analyses)between coping strate-gies and psychological morbidity in family/informal carers of people with any form of dementia.Studies that reported data on carers of people without dementia were excluded,unless they reported the results for dementia carers separately.We included only studies that used standardised,quantitative measures of coping and psychological morbidity,and only where the coping measure could be classified according to our categorisation described as follows.2.3.Categorising copingWe categorised coping strategies as solution-focused, emotional support and acceptance-based,or dysfunctional, using Carver's(1997)definitions of problem-focused,emo-tion-focused and dysfunctional coping as a framework.The three categories have demonstrated satisfactory psychomet-ric properties for carers of people with dementia(Cooper et al.,2008).For every coping scale used in the included studies,RL classified its respective subscales into the three categories by examining the individual questions.This classification was then discussed with and agreed with two other authors(GL and CC)(see Table1).2.4.Quality assessmentRL and one other author(AS or JB)independently rated the quality of each study,blind to each other's ratings.Disagree-ments were resolved through discussion with GL.Our measure of study validity was adapted from Boyle(1998).For cross-sectional studies,we awarded points as follows:•Power analysis based on relationship between coping and depression/anxiety:1point2R.Li et al./Journal of Affective Disorders139(2012)1–11•Clearly defined population:1point •Representative sample:1point for probability sampling,or whole population was recruited(for example,consecutive sampling).•Participants and non-participants comparable:1point if demonstrated statistically,or if participation rate≥80%•Reliability and validity:for each,0.5point if measures of psychological morbidity and coping validated in target population,0.25points if validated only in another population.•Confounding factors:1point if all of the following confounders were identified or addressed;carer gender and physical health,care recipient neuropsychiatric symp-toms,carer burden.For longitudinal studies,we applied two additional criteria:1point if participants were followed up for at least 6months;1point if at least80%of participants were followed up(or those lost to follow-up were shown to be comparable). We classified studies with a quality score of3or greater as higher quality studies.2.5.Data extractionFor each study,we extracted any correlation or regression coefficients reported for the relationship between a coping subscale and psychological morbidity.We tabulated the direction and statistical significance of the relationship under the three broad categories of coping(Tables2and3). We excluded correlation or regression coefficients reported for individual questions,or for any coping measures that could not be categorised using our system.2.6.AnalysisWe conducted meta-analyses by extracting the standardised beta regression coefficients from studies for the relationships between depression,anxiety or mixed psychological morbidity and the categories of coping strategy.We calculated relevant regression coefficients from our own unpublished data(Cooper et al.,2008,2010).Coefficients were pooled to produce a weighted mean correlation(WMC)coefficient,using a random effects model to account for heterogeneity(Hunter and Schmidt, 1990).Statistical analysis was conducted using the SPSS17 software package(SPSS Inc.,2008).We used StatsDirect2.6.6to produce forest plots of the results(StatsDirect Ltd.,2008).As dementia severity was a known confounder in the relationship between carer coping and mental health,we included in our meta-analysis only studies that controlled for severity of dementia(either by cognitive status or duration of illness)or neuropsychiatric symptoms.3.Results3.1.Study description and methodsFrom5396publications identified by our systematic searches,we included35unique studies(28cross-sectional and seven longitudinal)reported across37 publications.One paper(Shaw et al.,1997)reported different study procedures for its US and China samples; we have included these two different studies as two separate studies(Fig.1).Most(30)of the studies were from developed,English-speaking countries;of the remainder,two were from Taiwan (Fuh et al.,1999;Huang et al.,2006),and there was one each from Belgium(Schoenmakers et al.,2009),the Netherlands (Pot et al.,2000)and China(Shaw et al.,1997).3.2.Cross-sectional studiesTable2summarises characteristics,results and the quality of the included cross-sectional studies.Four longitudinal studies additionally provided cross-sectional baseline data (Cooper et al.,2006;Kinney et al.,2003;Matson,1994; Vedhara et al.,2000.Table3).Dysfunctional coping was most often reported to be positively associated with anxiety,while most papers considering emotional support and acceptance-based coping or solution-focused coping reported non-significant associations with anxiety.For depression,a large majority of papers reported positive association with dys-functional coping;emotional support and acceptance-based coping and solution-focused coping and was most often reported with non-significant or negative associations. Overall,there was no observable difference in the direction and statistical significance offindings between higher and lower quality studies.We extracted and meta-analysed regression coefficients from the11studies that controlled for severity of dementia or neuropsychiatric symptoms.All of these studies measured either depression or anxiety,except for the single study providing extractable data on mixed psychological morbidity (Hinrichsen and Niederehe,1994).Table1Classification of coping strategies.Selection of coping subscales/factors[exemplar items in brackets]and source coping measure,categorised by RL. Solution-focused Emotional support and acceptance-based DysfunctionalActive coping[I've been concentrating my efforts on doing something about the situation I'm in]Brief COPEPlanful problem-solving[I knew what had to be done,so I doubled my efforts to make things work] Ways of Coping QuestionnaireLogical analysis[Considered several alternatives for handling the problem]Coping Responses Inventory Active behavioural[Made a plan of action and followed it]Health and Daily Living Form Using emotional support[I've been gettingemotional support from others]Brief COPEPositive reappraisal[Changed or grew as aperson in a good way]Ways of CopingQuestionnaireAffective regulation[Tried to see the positiveside of the situation]Coping ResponsesInventoryActive cognitive[Prayed for guidance and/orstrength]Health and Daily Living FormDenial[I've been saying to myself“This isn't real”]Brief COPEAccepting responsibility[Criticized or lecturedmyself]Ways of Coping QuestionnaireAvoidance[Avoided being with people in general]Health and Daily Living FormEmotional discharge[Let my feelings out somehow]3R.Li et al./Journal of Affective Disorders139(2012)1–113.2.1.AnxietyEmotional support and acceptance-based coping was associated with less anxiety (WMC =−0.220,95%CI −0.259to −0.180;p b 0.0005;3studies;N=628).Dysfunc-tional coping was associated with more anxiety (WMC=0.390,95%CI 0.283to 0.498;p b 0.0005;4studies;N=688),while solution-focused coping was not signi ficantly associated with anxiety (WMC=0.096,95%CI −0.020–0.212;p=0.104;4studies;N=678)(Fig.2).3.2.2.DepressionEmotional support and acceptance-based coping was associated with less depression (WMC=−0.196,95%CI −0.283to −0.109;p b 0.0005;5studies;N=848).Dysfunc-tional coping was associated with more depression (WMC=0.456,95%CI 0.357to 0.555;p b 0.0005;10studies;N=1428),while solution-focused coping was not signi fi-cantly associated with depression (WMC=−0.035,95%CI −0.113to 0.043;p=0.376;4studies;N=700)(Fig.3).3.2.3.Mixed psychological morbidityOnly one study provided extractable data on mixed psycho-logical morbidity (Hinrichsen and Niederehe,1994).This found dysfunctional coping to be associated with more distress (standardised beta=0.350,p b 0.001,N=152),but no signi fi-cant association between solution-focused coping and distress (standardised beta=0.090,not signi ficant,N=152).It did not examine emotional support and acceptance-based coping.3.3.Longitudinal studiesTable 3summarises characteristics,results and the quality of the included longitudinal studies,two of which provided5396 hits(5392 electronic search, 4 hand-search)607 potential references:abstracts retrieved192 full texts retrieved35 studies included in review (published across 37 papers)11 studies with regression analysescontrolling for confounders:included in meta-analysisExcluded: 126 no measures of relationship betweencoping and anxiety/depression16 no specific data on carers of people with dementia13 intervention studiesExcluded: 305 did not report all required outcomemeasures77 not primary quantitative study33 no specific data on carers of people with dementiaExcluded by title:4342 clearly irrelevant 38 not peer-reviewed journal409 duplicatesFig.1.Flowchart of included/excluded studies.7R.Li et al./Journal of Affective Disorders 139(2012)1–11extractable data for meta-analysis (Cooper et al.,2008;Vedhara et al.,2000).3.3.1.AnxietyEmotional support and acceptance-based coping was associated with less anxiety (standardised beta =−0.195,p =0.020)and solution-focused coping with greater anxiety a year later (standardised beta =0.299,p =0.002)in the only included study (n =93)to measure these types of coping (Cooper et al.,2008).Dysfunctional coping at baseline did not signi ficantly predict anxiety 6months (Vedhara et al.,2000)or 12months later (WMC =0.190,95%CI −0.158to 0.539;Cooper et al.,2008)(p =0.284;2studies;N =143).0.39 (0.28, 0.50)Cooper et al. 20010.56 (0.40, 0.68)Cooper et al. 20060.44 (0.32, 0.54)Neundorfer 19910.53 (0.32, 0.69)0.28 (0.17, 0.38)Cooper et al. 20100.10 (-0.02, 0.21)Cooper et al. 20100.12 (-0.01, 0.25)Cooper et al. 20060.23 (0.04, 0.41)Proctor et al. 2002-0.01 (-0.12, 0.10)0.38 (0.11, 0.60)Cooper et al. 20060.29 (-0.46, -0.10)abcFig.2.Forest plots showing standardised regression coef ficients between coping styles and anxiety,and their weighted mean correlations (random effects models),after controlling for neuropsychiatric symptoms and dementia severity.Parentheses indicate 95%con fidence intervals.Studies in bold are higher quality.a:Relationship between solution-focused coping and anxiety b:Relationship between emotional support and acceptance-based coping and anxiety c:Relationship between dysfunctional coping and anxiety.8R.Li et al./Journal of Affective Disorders 139(2012)1–113.3.2.DepressionDysfunctional coping signi ficantly predicted depression at follow-up (WMC=0.321,95%CI 0.098to 0.544;p=0.005;2studies;N=143).Neither emotional support nor acceptance-based coping (standardised beta=−0.149,p=0.28)nor solution-focused coping (standardised beta=0.112,p=0.46)signi ficantly predicted depression a year later (n=93;Cooper et al.,2008).4.DiscussionThis is the first meta-analysis of the relationships between carer coping and psychological morbidity and the first systematic review to take into account the effect of stressors.We found consistent evidence from higher quality cross-sectional studies that dysfunctional coping was moderately correlated (WMC ≈0.4)with depression and anxiety.There was also evidence from two high quality longitudinal studies that dysfunctional coping predicted depression 6and 12months later.Coping strategies based on acceptance and seeking emotional support were correlated cross-sectionally to a lesser degree (WMC ≈0.2)with lower anxiety and depression in high quality studies.In one study these coping strategies predicted lower anxiety and depression a year later (Cooper et al.,2008).Our meta-analysis suggests that solution-focused coping is not cross-sectionally associated with carer mental health,which challenges the typical assumption in the literature thatCooper et al. 2010Kim et al. 2007Huang et al. 2006Cooper et al. 2006Haley et al. 1996Kramer 1993Neundorfer 1991Cooper et al. 2010Huang et al. 2006Cooper et al. 2006Kramer 1993Cooper et al. 2010Cooper et al. 2006Kramer 1993abcFig.3.Forest plots showing standardised regression coef ficients between coping styles and depression,and their weighted mean correlations (random effects models),after controlling for neuropsychiatric symptoms and dementia severity.Parentheses indicate 95%con fidence intervals.Studies in bold are higher quality.a:Relationship between solution-focused coping and depression b:Relationship between emotional support and acceptance-based coping and depression c:Relationship between dysfunctional coping and depression.9R.Li et al./Journal of Affective Disorders 139(2012)1–11solution-focused coping has positive implications for carer mental health(for example,see Kneebone and Martin,2003). The only study that explored such a relationship longitudinally found that carers who reported using more solution-focused coping strategies relative to other forms of coping at baseline, tended to show more symptoms of anxiety and depression at 12months follow-up(Cooper et al.,2008).This might be explained by the inevitability of dementia as a progressive and incurable illness,in which stressors associated with the illness become less amenable to problem-solving over time(Cooper et al.,2008).This is not to suggest solution-focused behaviours have no benefits at all;our review did not consider any outcomes other than carer psychological morbidity.Studies that have investigated coping have tended to use a wide variety of coping measures(Kneebone and Martin, 2003).This is thefirst review to synthesise studies of carer coping in dementia using a common classification system for different coping measures,enabling meaningful comparisons of results obtained with different measures.4.1.LimitationsWe could only include just over a quarter of the identified studies in our meta-analysis;the remainder of studies did not control for relevant stressors.There was a particular dearth of longitudinal studies,and only two included data that we could extract for analysis.A number of coping subscales could not be extracted from otherwise relevant studies,because the coping subscales did notfit into one of our three pre-defined categories,but we have no reason to think that this introduces a particular bias to ourfindings.4.2.Clinical implicationsDysfunctional coping behaviours are performed by every-one to some degree(as are all coping behaviours).Coping scales are not all-or-nothing but instead measure how much of a coping style is used,and what implications this has for carer mental health.Our meta-analysis provides good evidence that the greater use of dysfunctional coping and less use of coping based on acceptance and support are associated with anxiety and depression cross-sectionally;there is preliminary evi-dence(from one or two studies)that they also predict this morbidity from longitudinal studies.This suggests that psychological interventions aimed at modifying coping style carers use would be rational interventions.We are currently recruiting participants for such a trial.Role of funding sourceThis study was completed by the authors in their capacities as employees of UCL.UCL had no further role in the study design;in the collection,analysis and interpretation of data;in the writing of the report;and in the decision to submit this paper for publication.Conflict of interestCC and GL authored some of the papers in this review.All other authors declare that they have no conflicts of interest.AcknowledgementsWe would like to thank all authors who responded to our request for publications.ReferencesAshley,N.R.,Kleinpeter,C.H.,2002.Gender differences in coping strategies of spousal dementia caregivers.J.Hum.Behav.Soc.Env.6,29–46.Batt-Leiba,M.I.,Hills,G.A.,Johnson,P.M.,Bloch,E.,1998.Implications of coping strategies for spousal caregivers of elders with dementia.Top.Geriatr.Rehabil.14,54–62.Boyle,M.H.,1998.Guidelines for evaluating prevalence studies.Evid.Based Ment.Health.1,37–39.Brashares,H.J.,Catanzaro,S.J.,1994.Mood regulation expectancies,coping responses,depression,and sense of burden in female caregivers of Alzheimer's patients.J.Nerv.Ment.Dis.182,437–442.Carver,C.S.,1997.You want to measure coping but your protocol's too long: consider the brief COPE.Int.J.Behav.Med.4,92–100.Carver,C.S.,Scheier,M.F.,Weintraub,J.K.,1989.Assessing coping strategies:a theoretically based approach.J.Pers.Soc.Psychol.56,267–283. 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