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Preloss Psychosocial Resources Predict Depressive Symptom Trajectories Among Terminally Ill Cancer Patients' Caregivers in Their First Two Years of Bereavement

Open ArchivePublished:April 16, 2019DOI:https://doi.org/10.1016/j.jpainsymman.2019.04.003

      Abstract

      Context

      Postloss depressive symptom trajectories are heterogeneous and predicted by preloss psychosocial resources, but this evidence was from one old study on caregivers of patients with terminal cancer for whom these issues are highly relevant.

      Objectives

      To identify depressive symptom trajectories among cancer patients' bereaved caregivers and examine if they are predicted by preloss psychosocial resources while considering caregiving burden.

      Methods

      Preloss psychosocial resources (sense of coherence and social support) were measured among 282 caregivers. Depressive symptoms were measured by the Center for Epidemiological Studies–Depression scale at one, three, six, 13, 18, and 24 months after loss (Center for Epidemiological Studies–Depression scores ≥16 indicate severe depressive symptoms). Distinct depressive symptom trajectories and their predictors were identified by latent-class growth analysis.

      Results

      We identified five depressive symptom trajectories (prevalence): endurance (47.2%), resilience (16.7%), transient reaction (20.2%), prolonged symptomatic (11.7%), and chronically distressed (4.2%). Over two years after loss, the endurance group never experienced severe depressive symptoms. Severe depressive symptoms lasted six, seven to 12, and 18 months for the resilience, transient-reaction, and prolonged-symptomatic groups, respectively. The chronically distressed group's severe depressive symptoms persisted. The endurance and chronically distressed groups had the best and weakest psychological resources, respectively. Endurance-group caregivers perceived the greatest social support, whereas the resilience and transient-reaction groups had higher social support than the prolonged-symptomatic group.

      Conclusions

      Most (84.1%) caregivers' depressive symptoms subsided within one year after loss. Preloss psychosocial resources predicted depressive symptom trajectories for bereaved caregivers. Health care professionals can help caregivers adjust their bereavement by providing support to enhance their sense of coherence and encouraging social contacts while they are providing end-of-life care.

      Key Words

      Introduction

      Family caregivers of patients with terminally ill cancer carry heavy caregiving burdens
      National Alliance for Caregiving cancer
      Cancer caregiving in the US report.
      and suffer tremendous emotional distress from anticipating the loss of their beloved.
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      • Guldin M.B.
      Do we need to change our understanding of anticipatory grief in caregivers? a systematic review of caregiver studies during end-of-life caregiving and bereavement.
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      Preloss grief in family caregivers during end of life cancer care: a nationwide population based cohort study.
      Many family caregivers providing end-of-life (EOL) care to patients with cancer (20–73%)
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      suffer severe depressive symptoms that do not end with the patient's death.
      Grieving during bereavement is a dynamic and individualized adjustment process.
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      Bereaved family members' depressive symptom trajectories are heterogeneous
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      and were classified in a systematic review into five groups.
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      The first group (prevalence = 54.2%) endured well the hardship of losing a beloved, as indicated by their depressive symptom levels remaining below the Center for Epidemiological Studies–Depression [CES-D] cutoff score (≤16) for severe depressive symptoms throughout four to five years of bereavement. The second bereaved-caregiver group (8.8%) suffered severe depressive symptoms when they first transitioned into bereavement but quickly recovered within three to six months after loss. Severe depressive symptoms of the third group (7.7%) took seven to 12 months to subside. The final two groups (19.4% and 9.9%) experienced prolonged periods of severe depressive symptoms, which improved gradually only for the fourth bereaved-caregiver group.
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      Caregiving outcomes are mediated by a complex web of 1) contextual factors, 2) caregiving burden, 3) available psychosocial resources, and 4) appraisal of caregiving.
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      Predictors of bereaved family members' distinct depressive symptom trajectories include their demographics (contextual factors),
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      When caregiving ends: the course of depressive symptoms after bereavement.
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      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
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      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
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      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      caregiving stress,
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      When caregiving ends: the course of depressive symptoms after bereavement.
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      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      psychological (coping) resources,
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      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      and social support.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      Among these predictors, psychosocial resources
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      are most often investigated and modifiable. When individuals lose a beloved, they can maintain or rapidly recover their psychological well-being if they have adequate psychosocial resources to cope.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      • Bonanno G.A.
      • Westphal M.
      • Mancini A.D.
      Resilience to loss and potential trauma.
      • Park C.L.
      • Folkman S.
      Stability and change in psychosocial resources during caregiving and bereavement in partners of men with AIDS.
      • Levy L.H.
      • Martinkowski K.S.
      • Derby J.F.
      Differences in patterns of adaptation in conjugal bereavement: their sources and potential significance.
      • Lazarus R.S.
      • Folkman S.
      Stress, appraisal and coping.
      • Pitceathly C.
      • Maguire P.
      The psychological impact of cancer on patients' partners and other key relatives: a review.
      People with superior psychological resources tend to be more resilient when facing the challenging and stressful event of death of a beloved
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      • Bonanno G.A.
      • Westphal M.
      • Mancini A.D.
      Resilience to loss and potential trauma.
      • Park C.L.
      • Folkman S.
      Stability and change in psychosocial resources during caregiving and bereavement in partners of men with AIDS.
      • Levy L.H.
      • Martinkowski K.S.
      • Derby J.F.
      Differences in patterns of adaptation in conjugal bereavement: their sources and potential significance.
      • Lazarus R.S.
      • Folkman S.
      Stress, appraisal and coping.
      • Pitceathly C.
      • Maguire P.
      The psychological impact of cancer on patients' partners and other key relatives: a review.
      because they are more likely to appraise demands positively, comprehend situations realistically, and mobilize internal and external resources required to resolve difficult circumstances more efficiently, as specified by Antonovsky's sense of coherence (SOC).
      • Antonovsky A.
      Unraveling the mystery of health.
      Therefore, they are likely to experience fewer postloss depressive symptoms throughout bereavement or their severe depressive symptoms subside quickly within six months after loss.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      In contrast, family members lacking adequate psychological resources commonly experience prolonged severe depressive symptoms.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Lotterman J.H.
      • Bonanno G.A.
      • Galatzer-Levy I.
      The heterogeneity of long-term grief reactions.
      Another factor that may buffer the negative effects of bereavement, thereby reducing the likelihood of severe postloss depressive symptoms, is sufficient social resources.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      The stronger family members' preloss social support, the greater the likelihood that they have low-level depressive symptom trajectories throughout bereavement.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      However, findings on postloss depressive symptom trajectories from caregivers of chronically ill patients
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      • Levy L.H.
      • Martinkowski K.S.
      • Derby J.F.
      Differences in patterns of adaptation in conjugal bereavement: their sources and potential significance.
      cannot be directly applied to family members of patients with terminally ill cancer, which was investigated in only one 25-year-old study.
      • Levy L.H.
      • Martinkowski K.S.
      • Derby J.F.
      Differences in patterns of adaptation in conjugal bereavement: their sources and potential significance.
      The cancer trajectory is characterized by precipitous physical deterioration in the last few months before death,
      • Teno J.M.
      • Weitzen S.
      • Fennell M.L.
      • et al.
      Dying trajectory in the last year of life: does cancer trajectory fit other diseases?.
      and family caregivers of patients with terminal cancer shoulder great caregiving demands,
      National Alliance for Caregiving cancer
      Cancer caregiving in the US report.
      • Nielsen M.K.
      • Neergaard M.A.
      • Jensen A.B.
      • et al.
      Preloss grief in family caregivers during end of life cancer care: a nationwide population based cohort study.
      • Washington K.T.
      • Pike K.C.
      • Demiris G.
      • Oliver D.P.
      Unique characteristics of informal hospice cancer caregiving.
      • Sautter J.M.
      • Tulsky J.A.
      • Johnson K.S.
      • et al.
      Caregiver experience during advanced chronic illness and last year of life.
      • Kim Y.
      • Schulz R.
      Family caregivers' strains: comparative analysis of cancer caregiving with dementia, diabetes, and frail elderly caregiving.
      psychiatric morbidities,
      • Rumpold T.
      • Schur S.
      • Amering M.
      • et al.
      Informal caregivers of advanced-stage cancer patients: every second is at risk for psychiatric morbidity.
      and financial responsibilities.
      • Guerriere D.N.
      • Zagorski B.
      • Fassbender K.
      • et al.
      Cost variations in ambulatory and home-based palliative care.
      In addition, three studies
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      focused on family members who might not be as affected as family caregivers by heavy caregiving burdens.
      Of six studies
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      on predictors of depressive symptom trajectories, only one
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      was guided by a theoretical framework. In addition, how caregiving burden and preloss psychosocial resources predict postloss psychological adjustment and bereavement outcomes has been explained by two conflicting models of the caregiving-bereavement relationship (wear-and-tear vs. relief models).
      • Boerner K.
      • Schulz R.
      Caregiving, bereavement and complicated grief.
      The wear-and-tear model posits that caregiving accumulates stress, depleting caregivers' resources for coping with bereavement, whereas the relief model hypothesizes that after the difficulties of caregiving, death of the care recipient brings the caregiver relief and thus better bereavement outcomes.
      • Boerner K.
      • Schulz R.
      Caregiving, bereavement and complicated grief.
      Thus, caregiving context and caregiving demand must be considered when examining which theory is more appropriate in explaining bereaved caregivers' use of psychosocial resources to adjust to bereavement grief. Therefore, the purpose of this study was to identify depressive symptom trajectories among bereaved caregivers of patients with terminally ill cancer and to examine if these trajectories are predicted by preloss psychosocial resources while considering caregiving context and EOL-caregiving burden based on the theoretical framework of cognitive stress, appraisal, and coping.
      • Pearlin L.
      • Mullan J.
      • Semple S.
      • et al.
      Caregiving and the stress process: an overview of concepts and their measures.
      • Lazarus R.S.
      • Folkman S.
      Stress, appraisal and coping.

      Methods

      Study Design and Sample

      This study was a secondary analysis of data from a longitudinal study on death and dying for terminally ill cancer patient-family caregiver dyads.
      • Kuo S.C.
      • Chou W.C.
      • Hou M.M.
      • et al.
      Changes in and modifiable patient-and family caregiver related factors associated with cancer patients' high self perceived burden to others at the end of life: a longitudinal study.
      Adult patients with cancer were referred by their oncologist who declared them terminally ill when their disease continued to progress and was unresponsive to curative treatments. Eligibility criteria for family caregivers included the following: 1) identified by the patient as the family member most involved with their care without payment; 2) >21 years old; and 3) willing to participate and able to communicate with data collectors. Patient-caregiver dyads were recruited by convenience from March 2009 through December 2012 and followed up through December 2015. The study site's ethics committee approved the study (98-0476B).

      Measures

      Outcome Variable

      Caregivers' depressive symptoms were measured with the 20-item CES-D.
      • Radloff L.S.
      The CES-D scale: a self-report depression scale for research in the general population.
      Each item (symptom) is rated for its frequency during the past week on a scale from 0 to 3. Total scores range from 0 to 60; scores ≥16 indicate severe depressive symptoms.

      Independent Variables

      Preloss psychosocial resources were our primary independent variable and other variables were treated as covariates. Of note, caregiving appraisal
      • Pearlin L.
      • Mullan J.
      • Semple S.
      • et al.
      Caregiving and the stress process: an overview of concepts and their measures.
      was not included in this study.
      Caregivers' preloss psychological resources (i.e., coping capacity) were measured by the 13-item SOC scale.
      • Antonovsky A.
      Unraveling the mystery of health.
      SOC, an important coping capacity for adjusting to stressors to restore homeostasis,
      • Antonovsky A.
      Unraveling the mystery of health.
      has three components: comprehensibility (a belief that life is structured, rational, and predictable), meaningfulness (life is challenging but worthwhile), and manageability (resources suffice to manage challenges).
      • Antonovsky A.
      Unraveling the mystery of health.
      Total SOC scale scores range from 13 to 91; higher scores indicate stronger SOC. The SOC scale was validated by showing that SOC was a psychological resource that helped family caregivers adjust to EOL-caregiving stresses.
      • del-Pino-Casado R.
      • Rafael A.
      • López-Martínez C.
      • Orgeta V.
      Sense of coherence, burden and mental health in caregiving: a systematic review and meta-analysis.
      • Hiyoshi-Taniguchi K.
      • Becker C.B.
      • Kinoshita A.
      Social workers can use sense of coherence to predict burnout of end-of-life care-givers.
      • Tang S.T.
      • Chang W.C.
      • Chen J.S.
      • et al.
      Course and predictors of depressive symptoms among family caregivers of terminally ill cancer patients until their death.
      • Tang S.T.
      • Cheng C.C.
      • Lee K.C.
      • et al.
      Mediating effects of sense of coherence on family caregivers' depressive distress while caring for terminally ill cancer patients.
      Caregivers' social resources were measured by the 19-item Medical Outcomes Study Social Support Survey,
      • Sherbourne C.D.
      • Stewart A.L.
      The MOS social support survey.
      which assesses emotional, informational, tangible, and affectionate support, as well as positive social interaction. Total scores are computed, and raw scale scores are transformed to a 0–100 scale; higher scores indicate better perceived social support. The Taiwanese version of the 19-item Medical Outcomes Study Social Support Survey has been used and validated in family caregivers, with good reliability and validity.
      • Shyu Y.I.L.
      • Tang W.R.
      • Liang J.
      • Weng L.J.
      Psychometric testing of the social support survey on a Taiwanese sample.

      Covariates/Contextual Factors

      Demographic characteristics included gender, age, financial status, and relationship with the patient (spouse, child, other).
      Subjective caregiving burden (impact on schedule, health, and finances, caregiver esteem in providing care [rewarding or causing resentment], and lack of family support) was measured by the 24-item Caregiver Reaction Assessment scale.
      • Given C.W.
      • Given B.
      • Stommel M.
      • et al.
      The caregiver reaction assessment (CRA) for caregivers to persons with chronic physical and mental impairments.
      Responses are rated on five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Total score ranges from 24 to 120. Higher scores represent stronger negative caregiving impact.
      Objective caregiving load included care tasks, level of care, and daily time spent caregiving. Care tasks and level of care were determined by rating the amount of assistance provided in personal care, homemaking, transportation, and health care on a four-point scale from none at all to a lot.
      • Emanuel E.J.
      • Fairclough D.L.
      • Slutsman J.
      • et al.
      Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients.
      Time spent caregiving was measured on a six-point scale for <2, 3–5, 6–8, 9–12, 13–16, and 17–24 hours/day. A composite score was calculated for these five items. Scores range from 5 to 22; higher scores indicate greater objective caregiving load.

      Data Collection

      Caregivers were interviewed by experienced, trained oncology nurses after study enrollment (for their baseline preloss caregiving experience) and approximately every two weeks thereafter until the patient died or they declined to participate. Participants were interviewed in person to minimize their attrition by showing support and validating their responses. Bereaved caregivers were surveyed one, three, six, 13, 18, and 24 months after loss via phone and mail.

      Data Analysis

      Latent depressive symptom trajectories during bereavement were identified using latent-class growth analysis with a continuous latent-class indicator (total CES-D scores) using Mplus (version 7.2).
      • Muthén B.
      Latent variable analysis: growth mixture modeling and related techniques for longitudinal data.
      The first analysis identified distinct depressive symptom trajectories over caregivers' first two years of bereavement. Each identified trajectory comprised a homogenous group of bereaved caregivers sharing a distinct depressive symptom pattern over the first two years of bereavement.
      Model fit to the data was evaluated by minimum values of the Akaike information criterion,
      • Akaike H.
      Factor analysis and AIC.
      Bayesian information criterion,
      • Schwarz G.
      Estimating the dimension of a model.
      and sample-size adjusted Bayesian information criterion,
      • Schwarz G.
      Estimating the dimension of a model.
      the entropy measure.
      • Collins L.M.
      • Lanza S.T.
      Latent class and latent transition analysis: With applications in the social, behavioral, and health sciences.
      The entropy measure, which estimates classification accuracy by summarizing the distinguishability of identified trajectories, ranges from 0 to 1, with values near 1 indicating good overall fit. These criteria, as well as adequate sample size (no less than 5% of the total sample),
      • Wickrama K.K.
      • Lee T.K.
      • O'Neal C.W.
      • Lorenz F.O.
      Higher-order growth curves and mixture modeling with Mplus: A practical guide.
      (p.215) parsimony, and the substantive clinical/theoretical meaningfulness of the latent class identification, were factored in deciding the optimal number of classes.
      The proper shape of each trajectory (i.e., linear or quadratic) was tested by fitting polynomial regressions of CES-D scores on linear and quadratic terms of time over the first two bereavement years, based on caregivers in each depressive symptom trajectory. Trajectory shapes were based on significance (P < 0.05) of linear and/or quadratic terms of time; the shape was quadratic if the quadratic term was significant, and linear, if the quadratic term was not significant, but the linear term was significant.
      The second analysis involved a multinomial logistic regression to test predictors of bereaved caregivers' membership within distinct depressive symptom trajectories. We modeled the latent depressive symptom trajectories with contextual factors, preloss caregiving burden, depressive symptoms, and psychosocial resources. Preloss caregiving burden, depressive symptoms, and social support were measured at the last assessment before bereavement, whereas SOC scores were measured at enrollment.
      MPlus uses a robust full-information maximum-likelihood estimation procedure for handling missing data. Full-information maximum-likelihood estimation assumes missing data are unrelated to the outcome variable, that is, missing at random. We evaluated missingness in relation to latent-class patterns and found nonsignificant results for patterns of missingness by class, indicating that no depressive symptom trajectory was associated with missing data at any time point (Appendix). As such, we continued our analyses with the assumption of missing at random.

      Results

      Participant Characteristics

      Of 432 eligible caregivers, 392 were recruited (Fig. 1), but 43 withdrew (due to being too busy caregiving or perceiving an emotional burden from participation) before completing the last survey before the patient's death. Only 263 bereaved caregivers participated in the one-month postloss assessment (Fig. 1). The 22 bereaved caregivers who skipped the one-month postloss survey returned later (n = 285). Three caregivers had incomplete data for the first bereavement year, leaving 282 in our final sample. Caregivers who agreed and refused to complete postloss surveys were similar in demographic characteristics (Table S1), except participants had heavier objective and subjective caregiving burdens and less social support than those who declined. Bereaved caregivers who completed and withdrew from postloss surveys did not differ significantly in the last CES-D score assessed in any postloss survey except at 18 months before the latter caregivers withdrew (Table S2). Bereaved caregivers who completed the 18-month postloss survey had fewer depressive symptoms than those who withdrew 13 months after loss.

      Depressive Symptom Trajectories and Their Prevalence

      Five distinct depressive symptom trajectories were identified as optimal, based on model fit indices (Table 1), parsimony, adequate sample size, and clinical/theoretical meaningfulness of class identification. We labeled the five depressive symptom trajectories: endurance, resilience, transient reaction, prolonged symptomatic, and chronically distressed (Fig. 2). Polynomial regression results indicated that the most appropriate shape for each trajectory was linear (Table S3).
      Table 1Model Fit Indices of Distinct Depressive Symptom Trajectories for Bereaved Caregivers
      Model FitAICBICSSBICEntropy
      2 class9802.979857.609810.040.86
      3 class9733.459799.019741.930.72
      4 class9713.419789.899723.300.69
      5 class9708.189795.599719.490.70
      6 class9705.269803.599717.970.71
      AIC = Akaike information criterion; BIC= Bayesian information criterion; SSBIC = sample-size adjusted Bayesian information criterion.
      Bold indicates the lowest value. The entropy value for five trajectories was 0.7, indicating moderate overall model fit.
      Figure thumbnail gr2
      Fig. 2Caregivers' depressive symptom trajectories over the first two years of bereavement. Note: Solid black line (CES-D score = 16) indicates cutoff score for severe depressive symptoms. CES-D = Center for Epidemiological Studies–Depression Scale.
      Overall depressive symptom levels for all groups were high at the beginning of bereavement and decreased over time, with levels for each group, except the chronically distressed group, dropping below the cutoff score at different follow-up times (Fig. 2). CES-D scores for the endurance group (prevalence = 47.2%) were below the cutoff (CES-D score = 16), slowly decreasing over the two-year study. CES-D scores for the resilience group (prevalence = 16.7%) were above the cutoff for the first three to six months of bereavement and fell thereafter below the cutoff, followed by a slowly downward trending depressive symptom trajectory. CES-D scores were >16 for the transient-reaction group (prevalence = 20.2%) from one to six months after loss and dropped rapidly afterward to below the cutoff. Mean CES-D scores for both the prolonged-symptomatic (prevalence = 11.7%) and chronically distressed (prevalence = 4.2%) groups exceeded the cutoff at 18 months after loss, but the depressive symptom level improved at 24 months after loss for the prolonged-symptomatic group (CES-D score <16; Fig. 2), whereas the chronically distressed group's CES-D scores remained above the cutoff.

      Preloss Psychosocial Resources: SOC and Social Support Predict Depressive Symptom Trajectories

      Depressive symptom trajectories were predicted by the preloss psychological resource SOC. Among the five groups, the endurance group had the strongest SOC (Tables 2 and 3). The resilience group had stronger SOC than the transient-reaction and chronically distressed groups, with SOC of the transient-reaction and prolonged-symptomatic groups stronger than that of the chronically distressed group. Therefore, the chronically distressed group had the weakest SOC among all groups (Tables 2 and 3).
      Table 2Participants' Baseline (Enrollment) Characteristics
      CharacteristicTotal (N = 282)Depressive Symptom Trajectory
      Endurance (n = 133)Resilience (n = 47)Transient Reaction (n = 57)Prolonged Symptomatic (n = 33)Chronically Distressed (n = 12)
      Gender (%)
       Male39.040.640.428.151.533.3
       Female61.059.459.671.948.566.7
      Relationship with patient (%)
       Spouse55.353.461.756.151.558.3
       Adult children28.431.621.326.336.48.3
       Others16.315.017.017.512.133.3
      Financially sufficient (%)
       Yes73.180.074.464.969.741.7
       No19.415.414.921.124.258.3
       Refused to answer7.54.610.614.06.10.0
      Age, yrs (mean [SD])48.35 (11.98)45.69 (11.63)49.70 (12.24)51.79 (12.73)51.15 (10.31)48.58 (10.94)
      CRA (mean [SD])66.31 (12.25)65.65 (13.32)66.68 (10.11)67.75 (12.89)65.27 (9.29)71.92 (11.31)
      Objective caregiving load (mean [SD])16.85 (4.81)16.29 (4.99)16.94 (4.34)17.21 (4.85)18.03 (4.47)17.75 (5.14)
      CES-D score (mean [SD])22.73 (12.31)20.23 (11.96)22.89 (12.23)25.54 (11.97)22.27 (10.36)37.58 (11.44)
      SOC score (mean [SD])50.41 (7.61)54.67 (6.68)50.64 (6.71)45.58 (5.86)47.03 (5.94)40.22 (3.77)
      Social support score (mean [SD])55.04 (18.64)61.59 (15.74)54.31 (15.69)51.58 (20.99)43.20 (18.06)47.81 (24.21)
      SD = standard deviation; CRA = Caregiver Reaction Assessment; CES-D = Center for Epidemiological Studies–Depression Scale; SOC = sense of coherence.
      Table 3Preloss Predictors of Individual Postloss Depressive Symptom Trajectories
      Potential Predictor
      We controlled not only for the aforementioned significant confounders but also for three nonsignificant confounders: caregiver-patient relationship, financial sufficiency, and preloss depressive symptoms.
      Adjusted Odds Ratio (95% Confidence Interval)
      Endurance vs.Resilience vs.Transient Reaction vs.Prolonged Symptomatic vs.
      ResilienceTransient ReactionPSCDTransient ReactionPSCDPSCDCD
      Psychosocial resources
       SOC1.10
      P < 0.01.
      (1.04–1.18)
      1.24
      P < 0.01.
      (1.15–1.33)
      1.17
      P < 0.01.
      (1.08–1.26)
      1.45
      P < 0.01.
      (1.16–1.45)
      1.12
      P < 0.01.
      (1.23–1.71)
      1.06 (0.98–1.14)1.32
      P < 0.01.
      (1.28–1.55)
      0.94 (0.87–1.02)1.17
      P < 0.05.
      (1.00–1.37)
      1.25
      P < 0.01.
      (1.06–1.47)
       Social Support1.03
      P < 0.05.
      (1.01–1.06)
      1.04
      P < 0.01.
      (1.02–1.07)
      1.08
      P < 0.01.
      (1.04–1.12)
      1.07
      P < 0.05.
      (1.01–1.12)
      1.01 (0.91–1.12)1.05
      P < 0.01.
      (0.01–1.08)
      1.03 (0.98–1.08)1.04
      P < 0.05.
      (1.00–1.07)
      1.02 (0.97–1.07)0.9 (0.94–1.04)
      Contextual Factors
       Gender
      Female
      Male as reference.
      0.60 (0.26–1.42)0.29
      P < 0.05.
      (0.11–0.79)
      0.46 (0.17–1.27)1.36 (0.21–8.98)0.17 (0.48–1.34)1.24 (0.422–3.65)2.26 (0.35–14.81)2.60 (0.86–7.85)4.74 (0.74–30.36)1.82 (0.27–12.33)
      Age, yrs0.98 (0.94–1.01)0.95
      P < 0.05.
      (0.91–0.99)
      0.95
      P < 0.05.
      (0.91–0.96)
      0.97 (0.89–1.06)0.97 (0.93–1.01)0.97 (0.93–1.02)0.99 (0.91–1.08)1.00 (0.96–0.05)1.02 (0.94–1.11)1.02 (0.93–1.11)
      Caregiving demand
       Subjective caregiving burden1.03 (0.99–1.07)1.02 (0.976–1.06)1.07
      P < 0.05.
      (1.02–1.13)
      1.07 (0.97–1.19)0.99 (0.95–1.03)1.04 (0.99–1.10)1.05 (0.95–1.16)1.05
      P < 0.05.
      (1.00–1.11)
      0.91 (0.72–1.15)1.00 (0.91–1.11)
       Objective caregiving load0.92
      P < 0.05.
      (0.84–1.01)
      0.93 (0.84–1.02)0.82
      P < 0.01.
      (0.72–0.94)
      0.85 (0.67–1.07)1.01 (0.91–1.12)0.90 (0.79–1.03)0.92 (0.73–1.17)0.89 (0.78–1.02)1.06 (0.96–1.16)1.023 (0.80–1.31)
      PS = prolonged symptomatic; CD = chronically distressed.
      a We controlled not only for the aforementioned significant confounders but also for three nonsignificant confounders: caregiver-patient relationship, financial sufficiency, and preloss depressive symptoms.
      b P < 0.01.
      c P < 0.05.
      d Male as reference.
      For social resources, endurance caregivers perceived the best social support (Tables 2 and 3), whereas the resilience and transient-reaction groups perceived higher social support than the prolonged-symptomatic group. Perceived social support did not differ significantly among the other groups.
      For contextual factors, the endurance group had fewer female caregivers than the transient-reaction group and was younger than the transient-reaction and prolonged-symptomatic groups (Table 3). For caregiving burden, the endurance group carried a lower objective caregiving load than the resilience and prolonged-symptomatic groups. Perceived subjective caregiving burden was significantly higher for the endurance and transient-reaction groups than the prolonged-symptomatic group (Tables 2 and 3).

      Discussion

      We identified five distinct depressive symptom trajectories (prevalence) for bereaved family caregivers of patients with terminally ill cancer: endurance (47.2%), resilience (16.7%), transient reaction (20.2%), prolonged symptomatic (11.7%), and chronically distressed (4.2%). Over the first two years of bereavement, the endurance group never experienced severe depressive symptoms, whereas the resilience, transient-reaction, and prolonged-symptomatic groups' severe depressive symptoms lasted six, seven to 12, and 18 months, respectively. The chronically distressed group's severe depressive symptoms persisted. These depressive symptom trajectories were predicted by caregivers' preloss psychosocial resources, SOC and social support. The endurance group had the strongest SOC and best perceived social support followed by the resilience group, whereas the chronically distressed group had the weakest SOC and the prolonged-symptomatic group perceived the lowest social support of all groups (Tables 2 and 3). These findings go beyond previous studies
      • Tang S.T.
      • Chang W.C.
      • Chen J.S.
      • et al.
      Course and predictors of depressive symptoms among family caregivers of terminally ill cancer patients until their death.
      • Tang S.T.
      • Cheng C.C.
      • Lee K.C.
      • et al.
      Mediating effects of sense of coherence on family caregivers' depressive distress while caring for terminally ill cancer patients.
      • Ling S.F.
      • Chen M.L.
      • Li C.Y.
      • et al.
      Trajectory and influencing factors of depressive symptoms in family caregivers before and after the death of terminally ill patients with cancer.
      by showing that preloss psychosocial resources not only help family caregivers of patients with terminal cancer adjust to the stress of EOL caregiving for a beloved but also facilitate their bereavement adjustment by increasing the likelihood of being in groups that adjusted well throughout the first two years of bereavement or quickly recovered within the first six months after loss.
      The overall prevalence for the endurance, resilience, and transient-reaction groups was 84.1%, consistent with the conclusion of a systematic review
      • Kuo S.C.
      • Sun J.L.
      • Tang S.T.
      Trajectories of depressive symptoms for bereaved family members of chronically ill patients: a systematic review.
      that 70%–85% of bereaved individuals' grief reactions return to normal at six to 12 months after their relative's death. The summed prevalence (15.9%) of the prolonged-symptomatic (11.7%) and chronically distressed (4.2%) groups was also similar to the 10%–30% prevalence of chronic-depressive groups reported to persist past the first year of bereavement.
      • Kuo S.C.
      • Sun J.L.
      • Tang S.T.
      Trajectories of depressive symptoms for bereaved family members of chronically ill patients: a systematic review.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      • Bonanno G.A.
      • Westphal M.
      • Mancini A.D.
      Resilience to loss and potential trauma.
      • Lotterman J.H.
      • Bonanno G.A.
      • Galatzer-Levy I.
      The heterogeneity of long-term grief reactions.
      However, the prevalences of our endurance and resilience groups were lower and higher, respectively, than those reported in a prospective study
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      and a six-study review.
      • Kuo S.C.
      • Sun J.L.
      • Tang S.T.
      Trajectories of depressive symptoms for bereaved family members of chronically ill patients: a systematic review.
      These differences may be due to the long postloss follow-up intervals for those studies.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Galatzer-Levy I.R.
      • Bonanno G.A.
      Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults.
      Our study collected data at one, three, six, 13, 18, and 24 months after loss, whereas Bonanno et al.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      only collected data at six and 18 months after loss, leading to their resilience group being classified as endurance.
      Our finding that endurance-group caregivers had the best psychosocial resources (the highest SOC and social support) echoes reports that personal psychological resources facilitate bereavement adjustment.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Ott C.H.
      • Lueger R.J.
      • Kelber S.T.
      • Prigerson H.G.
      Spousal bereavement in older adults: common, resilient, and chronic grief with defining characteristics.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      • Park C.L.
      • Folkman S.
      Stability and change in psychosocial resources during caregiving and bereavement in partners of men with AIDS.
      Although the endurance caregivers were providing EOL care and facing the loss of their beloved, they had the strongest SOC to help them attribute meaning to these stresses, understand their challenges, and use internal and external resources to manage these stresses, thereby maintaining psychological well-being throughout the first two years of bereavement.
      Moreover, although bereaved family caregivers in the endurance and transient-reaction groups perceived heavier subjective caregiving burdens than prolonged-symptomatic caregivers (Table 3), they were helped in adjusting to their bereavement grief by their superior perceived social support, both practical and psychological, from family members as commonly practiced in Asian cultures.
      • Chow A.Y.
      • Chan C.L.
      • Ho S.M.
      Social sharing of bereavement experience by Chinese bereaved persons in Hong Kong.
      • Kuo S.C.
      • Chou W.C.
      • Chen J.S.
      • et al.
      Longitudinal changes in and modifiable predictors of the prevalence of severe depressive symptoms for family caregivers of terminally ill cancer patients over the first two years of bereavement.
      • Tsai P.J.
      Pattern of grief expression in Chinese families.
      These results support the relief model of the relationship between EOL caregiving and bereavement.
      • Boerner K.
      • Schulz R.
      Caregiving, bereavement and complicated grief.
      Under heavy subjective caregiving burdens, caregivers with stronger social resources (e.g., social support) not only experience the death of their beloved as relieving the difficulties/stresses of EOL caregiving but also adjust more rapidly to the loss. Thus, their psychological well-being returns to normal notably quicker than for caregivers in the prolonged-symptomatic group.
      Furthermore, endurance-group caregivers were significantly younger than those in the transient-reaction and prolonged-symptomatic groups and their objective caregiving load was less than that of the resilience and prolonged-symptomatic groups (Tables 2 and 3). Younger bereaved caregivers tend to have more internal and external resources to help them adjust to bereavement grief,
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      and caregivers with lower objective caregiving loads have better psychological adjustment during bereavement.
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      The resilience and transient-reaction groups both recovered within the time frame recognized as normal grief (CES-D scores dropped below 16 within six to 12 months after loss).
      • Kuo S.C.
      • Sun J.L.
      • Tang S.T.
      Trajectories of depressive symptoms for bereaved family members of chronically ill patients: a systematic review.
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Park C.L.
      • Folkman S.
      Stability and change in psychosocial resources during caregiving and bereavement in partners of men with AIDS.
      In Asian cultures, after family members complete funeral ceremonies, social norms pressure them to not immerse themselves in sadness; expressions of grief are not encouraged. Mourning in public is considered inappropriate.
      • Chow A.Y.
      • Chan C.L.
      • Ho S.M.
      Social sharing of bereavement experience by Chinese bereaved persons in Hong Kong.
      • Tsai P.J.
      Pattern of grief expression in Chinese families.
      In addition, Asian family members facing the death of a relative are influenced by Confucianism to support each other.
      • Chow A.Y.
      • Chan C.L.
      • Ho S.M.
      Social sharing of bereavement experience by Chinese bereaved persons in Hong Kong.
      • Tsai P.J.
      Pattern of grief expression in Chinese families.
      Compared with individualistic Western families, Asian families provide stronger support, including practical assistance and psychological support, to help bereaved caregivers adjust more quickly to their grief reactions.
      • Chow A.Y.
      • Chan C.L.
      • Ho S.M.
      Social sharing of bereavement experience by Chinese bereaved persons in Hong Kong.
      • Kuo S.C.
      • Chou W.C.
      • Chen J.S.
      • et al.
      Longitudinal changes in and modifiable predictors of the prevalence of severe depressive symptoms for family caregivers of terminally ill cancer patients over the first two years of bereavement.
      Therefore, although the normal resolution of grief for caregivers from Western cultures is within six to 12 months after loss,
      • Park C.L.
      • Folkman S.
      Stability and change in psychosocial resources during caregiving and bereavement in partners of men with AIDS.
      bereaved people in Asian cultures usually adapt to the grieving response within six months,
      • Kuo S.C.
      • Chou W.C.
      • Chen J.S.
      • et al.
      Longitudinal changes in and modifiable predictors of the prevalence of severe depressive symptoms for family caregivers of terminally ill cancer patients over the first two years of bereavement.
      suggesting that our transient-reaction group had an atypical depressive symptom trajectory pattern for bereaved Taiwanese family caregivers. However, the resilience and transient-reaction caregivers mourned differently (in term of initial depressive symptom levels and the time needed for these levels to subside below the CES-D cutoff score) because of having the second best and second weakest psychological resources (SOC) among the five groups, respectively (Tables 2 and 3).
      The two groups with long-lasting depressive symptoms, prolonged symptomatic and chronically distressed, were differentiated only by the strength of psychological resources (SOC). Both groups carried the heaviest objective caregiving loads among the five groups but perceived the lowest social support (Table 2), as reported,
      • Aneshensel C.S.
      • Botticello A.L.
      • Yamamoto-Mitani N.
      When caregiving ends: the course of depressive symptoms after bereavement.
      • Zhang B.
      • Mitchell S.L.
      • Bambauer K.Z.
      • Jones R.
      • Prigerson H.G.
      Depressive symptom trajectories and associated risks among bereaved Alzheimer disease caregivers.
      supporting the wear-and-tear model of caregiving
      • Boerner K.
      • Schulz R.
      Caregiving, bereavement and complicated grief.
      for their prolonged/chronic severe depressive symptoms. However, the stronger SOC of those in the prolonged-symptomatic group (ranked third highest) might have helped them to better comprehend the challenges of the grieving process and to mobilize more internal and external resources to find new meaning and value in their situation than those in the chronically distressed group. Thus, the prolonged-symptomatic group might have slowly recovered from their grief, taking over two years to return to their normal psychological state. However, being embedded in difficult caregiving circumstances and lacking the benefits of inner strength (i.e., SOC), bereaved family caregivers in the chronically distressed group failed to find meaning in their situation,
      • Bonanno G.A.
      • Lehman D.R.
      • Tweed R.G.
      • et al.
      Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss.
      • Bonanno G.A.
      • Wortman C.B.
      • Nesse R.M.
      Prospective patterns of resilience and maladjustment during widowhood.
      • Lotterman J.H.
      • Bonanno G.A.
      • Galatzer-Levy I.
      The heterogeneity of long-term grief reactions.
      clearly comprehend, and appropriately manage grieving demands, probably contributing to their highest depressive symptom level.

      Study Limitations

      Our sample of family caregivers of patients with terminally ill cancer was recruited by convenience from a hospital in Taiwan, limiting the generalizability of our results to national and international targets. Future studies should be replicated in different hospitals, countries, regions, and cultures to enhance the applicability of our findings. A substantial proportion of bereaved caregivers withdrew from postloss surveys; bereaved caregivers who completed the 18-month postloss survey had fewer depressive symptoms at 13 months after loss than those who withdrew. Whether our findings are applicable to those dropouts remains unknown, but we found that postloss data were missing at random. The reliability of our classification into five depressive symptom trajectories might have been limited, especially for the small number of caregivers in the chronically distressed group. Our study findings should be validated in larger samples. Caregivers' depressive symptom patterns and potential preloss predictors (measured only at baseline or the last assessment before the patient's death) were explored only over the first two years of bereavement. Thus, our findings do not adequately capture depressive symptom patterns of bereavement, comprehensively identify predictors of distinct depressive symptom trajectories for bereaved family caregivers (e.g., preloss factors measured further away from the patient's death), or account for the roles of other potentially modifiable factors (e.g., EOL care quality, health care professional support) in predicting the depressive symptom trajectories. We recommend increasing the number of preloss and postloss data collection times to understand how depressive symptom trajectories are impacted by EOL-caregiving experiences beyond the first two years of bereavement.

      Conclusion

      Five distinct depressive symptom trajectories were identified by their initial levels and rates of change in depressive symptoms for bereaved caregivers over their first two years of bereavement. Distinct depressive symptom trajectories were predicted by preloss psychosocial resources (i.e., SOC and perceived social support). Health care professionals should become aware of bereavement-grief patterns for family caregivers of terminal patients and factors predisposing these caregivers to differing postloss depressive symptom trajectories while the patients are still alive. Health care professionals should be alert to caregivers whose initial extraordinarily high depressive symptom levels are sustained over the first two years of bereavement and refer them for appropriate management.
      • Zisook S.
      • Katherine S.
      Grief and bereavement: what psychiatrists need to know.
      Early identification of psychosocially vulnerable groups would enable professionals to provide appropriate interventions to enhance psychological resources (e.g., their SOC) and to mobilize social support for high-risk groups while providing EOL caregiving, thus facilitating bereaved caregivers' adjustment to bereavement grief and avoiding becoming prolonged symptomatic or chronically distressed.

      Disclosures and Acknowledgments

      The authors declare no conflicts of interest exist. This work was supported by the National Science Council (NSC99–2628-B-182–031-MY2), the National Health Research Institute (NHRI-EX108–10704PI), and Chang Gung Memorial Hospital (BMRP888).

      Appendix. Approach for Handling Missing Data in Relation to Latent-Class Growth Analysis in MPlus

      MPlus uses a robust full-information maximum-likelihood (FIML) estimation procedure for handling missing data
      • Muthén B.
      Latent variable analysis: Growth mixture modeling and related techniques for longitudinal data.
      . The appropriateness of FIML is widely endorsed
      • Enders C.K.
      The impact of nonnormality on full information maximum-likelihood estimation for structural equation models with missing data.
      • Baraldi A.N.
      • Enders C.K.
      An introduction to modern missing data analyses.
      . FIML assumes missing data are unrelated to the outcome variable, that is, missing at random. Maximum-likelihood estimators have been shown in simulation studies to provide unbiased estimates when data are missing at random, that is, missingness may occur with some level of predictability but that predictability is not related to the study focus, unlike the assumption that data are missing completely at random. Even when the assumption of missing at random does not hold up, strong evidence indicates that using maximum-likelihood estimators provides more accurate estimates than removing data listwise.
      • Muthén B.
      Latent variable analysis: Growth mixture modeling and related techniques for longitudinal data.
      Thus, we used a set of analyses tailored to assess missingness in relation to latent-class patterns. This analysis revealed nonsignificant results for patterns of missingness by class, indicating that no pattern of depressive symptom outcomes was more likely to be missing data at any time point (Little's Missing Completely at Random test: chi-square = 53.84, df = 59, Sig. = 0.67). As such, we felt confident and continued our analysis with the assumption of missing at random.
      Table S1Comparison of Bereaved Caregivers Who Completed vs. Withdrew From Surveys (N = 344)
      CharacteristicCompleted (n = 282)Withdrew (n = 62)χ2/FP
      Gender, %0.060.807
       Male38.740.3
       Female61.359.7
      Relationship with patient, %1.760.414
       Spouse54.445.1
       Adult children29.215.5
       Other16.419.4
      Financially sufficient, %4.470.107
       Yes73.082.2
       No19.28.1
       Refused to answer7.89.7
      Age (yrs), mean (SD)48.48 (11.92)46.77 (13.52)0.990.322
      Subjective caregiving burden, mean (SD)16.78 (4.82)14.42 (5.60)3.380.001
      Objective caregiving load, mean (SD)66.06 (12.28)62.21 (10.53)2.290.023
      Preloss CES-D score, mean (SD)22.96 (12.04)19.71 (10.53)1.940.053
      Preloss SOC score, mean (SD)50.41 (7.61)51.18 (7.62)−0.650.515
      Preloss social support score, mean (SD)55.04 (18.64)65.65 (14.38)−3.85<0.001
      SD = standard deviation; CES-D = Center for Epidemiological Studies–Depression Scale; SOC = sense of coherence.
      Table S2Comparison of Mean CES-D Scores for Bereaved Caregivers Who Completed and Withdrew From the Study at Different Postloss Times
      Postloss Time, monthsCompletedWithdrewtP
      Mean (SD)Mean (SD)
      323.22 (12.65)21.60 (12.65)0.550.582
      617.30 (10.12)13.31 (9.73)1.530.127
      1314.99 (10.71)15.06 (11.23)−0.030.980
      1810.66 (7.43)18.00 (11.40)−3.420.001
      249.52 (7.27)14.09 (12.35)−1.900.060
      SD = standard deviation; CES-D = Center for Epidemiological Studies–Depression Scale.
      Table S3Trajectory Shapes Determined by Fitting Polynomial Regressions of CES-D Scores on Linear and Quadratic Terms
      ClassInterceptLinearQuadratic
      EstimateSEEstimateSE
      Endurance15.16
      P < 0.01.
      −5.94
      P < 0.01.
      0.79−3.422.02
      Resilience20.43
      P < 0.01.
      −5.64
      P < 0.01.
      1.37−2.870.00
      Transient reaction35.51
      P < 0.01.
      −15.95
      P < 0.01.
      1.28−5.3110.09
      Prolonged symptomatic28.70
      P < 0.01.
      −7.25
      P < 0.01.
      1.39−0.7814.14
      Chronically distressed40.65
      P < 0.01.
      −8.46
      P < 0.01.
      2.09−1.781.719
      SE = standard error; CES-D = Center for Epidemiological Studies–Depression Scale.
      a P < 0.01.

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