East Asian Arch Psychiatry 2011;21:44-51

ORIGINAL ARTICLE

Miss Das Priscilla, MSc, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia.
Dr Awang Hamidin, MBBS, Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia.
Prof Mohd. Zain Azhar, MD, Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia.
Prof Khin Ohnmar Naing Noorjan, MBBS, Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia.
Dr Mohd. Said Salmiah, MD, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia.
Dr Khalid Bahariah, MBBS, Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia.

Address for correspondence: Miss Das Priscilla, c/o Department of Psychiatry, Faculty of Medicine and Health Sciences, University Putra Malaysia, 43400 Serdang, Selangor Darul Ehsan, Malaysia.
Tel: (60) 017-2043 187;
Fax: (60) 0389414629;
Email: daspriscilla@yahoo.com

Submitted: 16 September 2010; Accepted: 29 December 2010

pdf Full Paper in PDF

Introduction

Cancer is a major public health problem in Malaysia.¹ A total of 21,773 patients in Peninsular Malaysia alone were diagnosed with cancer in 2006.² Among men, haematological cancers such as leukaemia (3.6%) and lymphoma (4.2%) were the eighth and ninth leading types of cancer, respectively. Whilst among women, lymphoma (2.4%) was the tenth most frequent cancer. Overall, lymphoma (3.2%) was 1 of the 10 most frequent cancers in Peninsular Malaysia.²

In the past 2 decades, research has focused on coping styles among individuals with life-threatening illnesses. A number of researchers have investigated coping styles among cancer patients. To our knowledge, there is limited research examining coping styles among haematological cancer patients. Varying aspects of coping can be assessed using the Brief COPE questionnaire developed by Carver.³ This questionnaire assesses different types of coping, such as active coping, planning, positive reframing, acceptance, humour, religion, use of emotional support and instrumental support, self-distraction, denial, venting, substance use, behavioural disengagement, and self-blame.³ Psychiatric disorders such as depression are the most prevalent mental health problems that can be easily diagnosed in cancer patients.⁴

The aim of the present study was to assess such coping styles among haematological cancer patients in Ampang Hospital, Malaysia, and investigate factors that influence these coping styles such as psychiatric characteristics, as well as socio-demographic and clinical factors.

Methods

This study was conducted within the haematological wards at Ampang Hospital in Kuala Lumpur, Malaysia between May 2009 and December 2009. The hospital is a tertiary referral centre for haematological illnesses. The study entailed a cross-sectional design, and was approved by Ethical Committees of the Ministry of Health and the Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.

Consecutively admitted eligible patients to the haematological wards were recruited to participate in the study. The inclusion criteria were: aged 15 years or above; diagnosed with haematological cancer; ability to communicate in English, Malay, Mandarin or Tamil; and cognitively fit to be interviewed and give informed consent. Each patient’s socio-demographic profile and clinical status were recorded. Socio-demographic factors such as gender, ethnicity, marital status, highest level of formal education, occupation status, total monthly household income, family members, and types of caregivers were retrieved from the patients. Haematological cancer diagnoses were assessed from the medical records and included leukaemia, lymphoma and multiple myeloma.

The Brief COPE questionnaire self-report instrument was used to measure patient coping styles. The questionnaire is composed of 14 subscales dealing with specific coping styles in response to difficult and stressful life events. Each scale was associated with 2 test items. Each item was rated as follows: 1 = “I usually don’t do this at all”; 2 = “I usually do this a little bit”; 3 = “I usually do this a medium amount”; and 4 = “I usually do this a lot.” The coping strategies were scored by summing the 2 items within each scale (ranged 2-8).³ The questionnaire has sufficient validity^3,5 and reliability.³ Both English and Malay versions of the Brief COPE questionnaire have good validity and reliability in the Malaysian population.^6,7 In this study, it was translated into Tamil and Mandarin according to standard forward and backward translation procedures, by native speakers of the relevant languages. Two subjects translated for each language and 2 others translated it back to the original language. This was done to ensure that the original meaning of the questionnaire was maintained throughout the study.

Psychiatric disorders were assessed by the Mini- International Neuropsychiatric Interview (MINI) version 6.0.0, questionnaire module A. This consists of 5 questions with multiple sub-questions, which are used to diagnose major depressive disorder (MDD) [unpublished data]. The questionnaire has 96% sensitivity and 88% specificity and was developed according to the criteria of both the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and the 10th edition of the International Classification of Diseases.⁸ According to the DSM-IV classification, the 9 symptoms of MDD were: depressed mood, loss of interest, weight loss or weight gain, sleeping difficulties, psychomotor agitation, fatigue, feelings of worthlessness, poor concentration, and frequent thoughts of death. Patients are diagnosed with MDD if they have at least 5 symptoms including depressed mood or loss of interest for a 2-week period of time.⁹ The interviewer (first author) was trained to use the MINI questionnaire by senior psychiatrists who had experience and were certified in using the MINI.

The data were analysed using the Statistical Package for the Social Sciences, Windows version 17.0. Descriptive statistics were determined, including means, percentages and ranges. Bivariate logistic regression analyses were used to assess the predictors of depression status as a function of coping styles. In the study, MDD was treated as the dependent variable and coping styles as covariates, because previous studies¹⁰ showed that the depressive symptomatology is associated with certain subscales of coping styles. A 1-tailed Mann-Whitney U test for non- parametric data was performed to investigate between- group differences in coping styles for several factors, including depression, socio-demographic characteristics, and clinical features. In all cases, a p value of less than 0.05 was considered statistically significant.

Results

A total of 105 haematological cancer patients were included in this study. The response rate was 83%. The mean age of the participants was 40 (95% confidence interval, 37-44) years. The characteristics of the respondents are shown in Table 1. In terms of clinical diagnoses, 24% had non-Hodgkin lymphoma, 23% had acute myelogenous leukaemia, 14% had acute lymphoblastic leukaemia, 11% had Hodgkin lymphoma, and 29% had other haematological cancers.

The characteristics of the patients’ coping styles, with mean scores summing 2 items within each coping strategy, are shown in Table 2. The coping strategies used (in descending order of frequency) were: behavioural disengagement (7.2), active coping (6.4), denial (6.3), venting (6.2), self-distraction (6.2), substance use (6.0), acceptance (5.1), humour (4.9), use of emotional support (4.9), use of instrumental support (4.8), religion (4.7), positive reframing (4.4), planning (3.5), and self-blame (2.5).

Of these 105 respondents, 25% were diagnosed with MDD. Table 3 displays the results of the binary logistic regression analyses examining the predictors of MDD as a function of coping styles. The entry of predictors starts with self-distraction and positive reframing coping styles. The rationale for selection of these 2 variables was based on the significant p value of less than 0.05 in the binary logistic regression model, compared with other variables which were not significant. The final model Nagelkerke R² value showed about 14% of the variation in the outcome variable of MDD. The correlations between the predictors did exist but were moderate (r = –0.4 to –0.6). The overall accuracy of this model to predict patients having MDD with a predicted probability of 0.5 or greater was 76%, with the sensitivity of 8% and the specificity of 99%. Among these predictors, the self-distraction coping style (odds ratio = 1.7; p = 0.01) and positive reframing coping style (odds ratio = 0.5; p = 0.02) were found to be significant and related to MDD.

Table 4 displays between-group differences in coping styles with regard to depression status, as well as clinical and socio-demographic factors. The results indicated that depressed haematological cancer patients reported significantly higher self-distraction (p = 0.03) and humour (p = 0.03) coping styles than non-depressed patients. In addition, active coping (p = 0.05), venting (p = 0.02), acceptance (p = 0.04), and religion (p = 0.01) coping strategies were used significantly more often by patients who had been diagnosed with haematological cancer for less than 6 months, compared with those diagnosed earlier.

Female haematological cancer patients used more instrumental support (p = 0.001), venting (p = 0.01) and acceptance (p = 0.003) coping styles compared with male counterparts. The Malay patients employed self-distraction coping styles (p = 0.04) and behavioural disengagement (p = 0.01) significantly more often than the non-Malays. In addition, patients having a Malaysian Certificate of Education (MCE) or lower level reported more positive reframing (p = 0.05) coping styles compared with those who had received higher levels of education. Patients without children reported more substance use (p = 0.05) and the use of emotional support (p = 0.04) coping styles than those with children. Besides, patients with 6 family members or less employed positive reframing (p = 0.003), planning (p = 0.03), denial (p = 0.03) and substance use (p = 0.01) coping styles more often than those having more than 6 family members. The patients who earned RM 1,000 or less per month utilised more self-distraction (p = 0.02) and behavioural disengagement (p = 0.04) coping styles compared with higher earners.

Table 4 also shows between-group differences in coping styles as a function of primary caregiver type in these haematological cancer patients. Patients who had a spouse as a primary caregiver reported significantly higher active coping (p = 0.03) and positive reframing (p = 0.04) coping styles compared with those who did not. Patients with non- spouse caregivers used emotional support (p = 0.02) and planning (p = 0.01) as their coping styles significantly more often than those with a spouse caregiver. Patients who had child caregivers reported using religious coping styles (p = 0.003) significantly more often than other patients. Patients with parents as caregivers used emotional support coping styles (p = 0.004) more often than those without, whereas the latter practised acceptance coping styles (p = 0.04) significantly more often. Patients with other caregivers apart from a spouse, children and parents employed instrumental support (p = 0.02), planning (p = 0.01) and self-blame (p = 0.04) coping styles more often.

Discussion

All 3 predominant ethnicities of the Malaysian population (Malay, Chinese and Indian) were well represented, the proportion of each group being consistent with National Cancer Registry Report in 2006.² The prevalence of MDD was 25%, comparable to a study by Bukberg et al,¹¹ who found the overall prevalence of MDD to be 24% in cancer patients. The primary aim of this study was to investigate coping styles among haematological cancer patients. The patients who applied positive reframing and self- distraction coping styles were related to the absence or presence of MDD. Moreover, depressed haematological cancer patients employed more self-distraction and humour coping styles compared with the non-depressed. This finding is consistent with another study¹⁰ showing that depressive symptomatology among primary care patients was associated with self-distraction, emotional venting, and self-blame coping styles.

The Brief COPE questionnaire addressed problem-focused coping (active coping, planning, use of instrumental support), emotionally focused coping (use of emotional support, positive reframing, religion), adaptive coping (acceptance, humour), and maladaptive coping (self-distraction, denial, substance use, behavioural disengagement, venting, and self-blame) styles.¹² Notably, cancer patients with impaired psychosocial characteristics have more emotional distress and may exhibit these maladaptive behaviours.¹³ Furthermore, long-term cancer survivors with optimism tended to have less health-related worries as well as lower levels of depression and anxiety.¹⁴

In addition, patients who had spouses as primary caregivers practised more positive reframing coping styles compared with those with primary caregivers other than a spouse. With respect to educational attainment, the MCE is a Malaysian higher secondary school level examination. Patients who only attained this level of education or less reported more positive reframing compared with those having higher levels of education. In a longitudinal study¹⁵ of end-stage cancer patients, positive mood evidently played an important role in attenuating depressive symptoms in addition to facilitating spiritual and overall life satisfaction.

Patients with primary caregivers apart from a spouse used emotional support and planning as their chief coping styles. Prior studies¹² have shown that patients with chronic depressive symptoms reported less coping styles of planning. Female patients used more instrumental support, venting, and acceptance coping styles compared with their male counterparts. A previous study¹² showed that emotional venting coping styles were related to more depressive symptoms in primary care patients.

In the present study, patients with more than 6 family members utilised positive reframing, planning, denial and substance use coping styles to a lesser degree than those with fewer family members. Patients with caregivers other than a spouse, children or parents employed more instrumental support, planning and self-blame. This finding was consistent with another study,¹⁶ which found that cancer patients used positive reframing, planning, and self-distraction most often. Malay patients employed self- distraction and behavioural disengagement coping styles more than non-Malays. These results should be interpreted with caution as self-distraction coping styles lead to a low survival rate among haematological cancer patients.¹⁷

Self-distraction, active coping, planning, religion, self-blame, emotional venting, and positive reframing coping styles were significantly associated with patient illness cognition.¹⁰ The most frequently used coping methods in recently diagnosed breast cancer patients were planning, positive reframing, and self-distraction.¹⁶ The present study indicated that patients whose haematological cancer had been diagnosed less than 6 months earlier employed more active coping styles, venting, acceptance and religion compared with those diagnosed more than 6 months earlier. Patients with longer illness duration tended to practise acceptance-resignation coping, which was related to practising negative self-perception during recovery and post-recovery.¹⁸

In this study, patients without parents as their primary caregivers practised more acceptance coping styles. Cancer patients with ineffective coping styles had a proclivity for avoidance and acceptance-resignation coping.¹⁸ Patients without children reported more substance use and emotional support coping styles than those with children. Patients with parents as their primary caregivers used more emotional support coping styles compared with others. It is difficult to compare these results with other studies because, to our knowledge, there are no studies investigating these factors. Patients who had children as their caregivers were more dependent on religious coping than the others. In another study,¹⁰ the majority of primary care patients reported that religious coping styles might be helpful and effective in overcoming depressive symptoms.

In terms of socio-economic status, patients who earned RM 1,000 or less per month (considered as poor) employed more self-distraction and behavioural disengagement coping styles compared with higher earners. These coping styles were similar to other study¹⁸ examining mixed samples of cancer patients (including lymphoma cancer patients) and patients with other illness. Specifically, patients with low socio-economic status reported avoidance coping styles, had less self-directed lives and more negative self-perception. Patients with a low self-image, external locus of control, negative mood and feelings that they were not coping well with their disease also exercised avoidance coping behaviour. Moreover, less information about their medications lead patients to practise avoidance coping styles.¹⁸

In a systematic review of patients coping with haematological diseases, Koehler et al¹³ formulated coping into 2 levels: conscious and unconscious coping. Behavioural (information retrieving), cognitive (positive reformation), and affective (mourning) characteristics are coping strategies that are classified as conscious-level strategies. Conversely, unconscious coping strategies take the form of a reaction. Thus, to accept an ostensibly undesirable diagnosis they use humour, continued denial, or regression (making immature statements). Koehler et al¹³ also stressed that coping efforts must be evaluated at these 2 levels. Therefore, early identification of poor coping styles is clinically important, and cancer patients should readily attempt to adopt positive coping, so as to increase chances of survival and prevent relapse.¹³

Limitations

First, this was a cross-sectional study, so it is difficult to conclude that the identified coping styles are either risk or protective factors for MDD. Second, portions of the self- report questionnaire were read aloud to patients to clarify their answers, for which reason, the results should be interpreted with caution.

Conclusion

The present study provides novel data on the coping strategies used by Malaysian haematological cancer patients. The coping styles that were used, in descending order of frequency, were: behavioural disengagement, active coping, denial, venting, self-distraction, substance use, acceptance, humour, use of emotional support, use of instrumental support, religion, positive reframing, planning, and self- blame. The coping styles were associated with the presence of MDD, as well as with socio-demographic characteristics and clinical factors. Self-distraction and positive reframing coping styles were the 2 significant predictors related to MDD.

Acknowledgement

This study was supported by the Research University Grant Scheme (RUGS) of the Universiti Putra Malaysia (Project No.: 04-03-08-0458RU [91463]) and National Science Fellowship Scheme by Ministry of Science, Technology and Innovation. We would like to thank the Director of Ampang Hospital and consulting haematologist: Dr Ong Tee Chuan and Dr Chang Kian Meng. We also thank the staff of the haematological units as well as the patients who participated in this study.

References

1. Lim GC. Overview of cancer in Malaysia. Jpn J Clin Oncol 2002;32 Suppl: S37-42.
2. Zainal AO, Zainudin MA, Nor Saleha IT. Malaysia cancer statistics, data and figure Peninsular Malaysia 2006. Website: http://www.moh.gov.my/images/gallery/Report/Cancer/MalaysiaCancerStatistics_2006.pdf. Accessed 1 Oct 2008.
3. Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med 1997;4:92-100.
4. Prieto JM, Atala J, Blanch J, Carreras E, Rovira M, Cirera E, et al. Role of depression as a predictor of mortality among cancer patients after stem-cell transplantation. J Clin Oncol 2005;23:6063-71.
5. Schulz U, Schwarzer R. Long-term effects of spousal support on coping with cancer after surgery. J Soc Clin Psychol 2004;23:716-32.
6. Yusoff N, Low WY, Yip CH. Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy: a Malaysian study. Med J Malaysia 2009;65:41-4.
7. Yusoff N, Low WY, Yip CH. Reliability and validity of the Malay version of Brief COPE Scale: a study on Malaysian women treated with adjuvant chemotherapy for breast cancer. Malaysian Journal of Psychiatry 2009;18:1-9.
8. Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, et al. The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability. Eur Psychiatry 1997;12:232-41.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision. Washington DC, American Psychiatric Association; 2000.
10. Brown C, Dunbar-Jacob J, Palenchar DR, Kelleher KJ, Bruehlman RD, Sereika S, et al. Primary care patients’ personal illness models for depression: a preliminary investigation. Fam Pract 2001;18:314- 20.
11. Bukberg J, Penman D, Holland JC. A prevalence study of depression in a cancer population. Proc Am Soc Clin Oncol 1980;21:382.
12. Rohland BM. CMHC Survey — Preliminary report. Website: http://www.medicine.uiowa.edu/icmh/archives/reports/Rptpre.pdf. Accessed 30 Jun 2010.
13. Koehler M, Koenigsmann M, Frommer J. Coping with illness and subjective theories of illness in adult patients with haematological malignancies: systematic review. Crit Rev Oncol Haematol 2009;69:237-57.
14. Deimling GT, Bowman KF, Sterns S, Wagner LJ, Kahana B. Cancer- related health worries and psychological distress among older adult, long-term cancer survivors. Psychooncology 2006;15:306-20.
15. Rabkin JG, McElhiney M, Moran P, Acree M, Folkman S. Depression, distress and positive mood in late-stage cancer: a longitudinal study. Psychooncology 2009;18:79-86.
16. Li J, Lambert VA. Coping strategies and predictors of general well- being in women with breast cancer in the People’s Republic of China. Nurs Health Sci 2007;9:199-204.
17. Tschuschke V, Hertenstein B, Arnold R, Bunjes D, Denzinger R, Kaechele H. Associations between coping and survival time of adult leukemia patients receiving allogeneic bone marrow transplantation: results of a prospective study. J Psychosom Res 2001;50:277-85.
18. Feifel H, Strack S, Nagy VT. Coping strategies and associated features of medically ill patients. Psychosom Med 1987;49:616-25.