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Review
Coping strategies and psychological morbidity in family carers of peoplewith dementia: A systematic review and meta-analysis
Ryan Li⁎, Claudia Cooper, Jonathan Bradley, Amanda Shulman, Gill LivingstonDepartment of Mental Health Sciences, University College London, Holborn Union Building, Highgate Hill, London N19 5LW, United Kingdom
Article history:Received 1 March 2011Received in revised form 27 May 2011Accepted 27 May 2011Available online 2 July 2011
Background: 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 andanxiety or depression among carers of people with dementia. We rated study validity usingstandardised checklists. We calculated weighted mean correlations (WMC) for the relation-ships between coping and psychological morbidity, using random effects meta-analyses.Results: We included 35 studies. 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 6 and 12 months later (0.32, 0.10–0.54; N=143). Emotionalsupport and acceptance-based coping correlated with less anxiety (−0.22, 95% CI −0.26 to−0.18; N=628) and depression (−0.20, −0.28 to −0.11; N=848) cross-sectionally; andpredicted anxiety and depression a year later in the only study to measure this. Solution-focused coping did not correlate significantly 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 supportand acceptance-based coping styles are associated with more anxiety and depression cross-sectionally, and there is preliminary evidence from longitudinal studies that they predict thismorbidity. Our findings would support the development of psychological interventions forcarers that aim to modify coping style.
Family carers of people with dementia have high levels ofanxiety and depression (Cooper et al., 2007; Crespo et al.,2005; Pinquart and Sorensen, 2003). This psychologicalmorbidity has been found to be most strongly associatedwith the coping strategies used by the carer, as well asdemographic characteristics of the carer and neuropsychiatricsymptoms and illness severity in the person with dementia(Cooper et al., 2008). Nonetheless earlier studies havereported conflicting results about the relationships betweenemotion-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. Ifcoping strategies are important contributors to carer psycho-logical morbidity, then understanding which styles areprotective and which are detrimental may inform thedevelopment of interventions. Coping strategies were initiallydivided into emotion-focused and problem-focused (Lazarusand Folkman, 1984). Later a third category of dysfunctionalcoping was suggested (Carver et al., 1989).
Kneebone and Martin (2003) reviewed 12 cross-sectionaland 6 longitudinal studies, and concluded that problem-solvingand acceptance styles of coping appear to be advantageousfor carers of people with dementia, but commented theirfindings were limited because studies failed to identify theinfluence of the stressors. Greater stressors would be expectedto elicitmore coping strategies aswell as increasing anxiety anddepression.
We aimed to systematically review and meta-analyse therelationships between coping strategies and psychologicalmorbidity in family carers for people with dementia. Weexamined the measures of coping and re-classified them toensure comparability between studies. We also took intoaccount two specific stressors, the severity of dementia andneuropsychiatric symptoms of the care recipient, as the use ofcoping strategies is expected to increase as stressors increase.
2. Methods
2.1. Search strategy
We searched EMBASE, MEDLINE, PsycINFO, Web ofScience, CINAHL and AMED up to March 2010. The search
terms were: (carer OR caregiver OR caring OR relative ORsupporter OR family); (dementia OR Alzheimer OR cognitiveimpairment); coping; (anxiety OR depression OR mood ORpsychiatric morbidity OR psychological morbidity).We hand-searched relevant reviews and the references of includedstudies. We also asked authors of all the included studieswhether they were aware of any further studies.
2.2. Inclusion and exclusion criteria
We included primary research studies, published inEnglish that reported the relationship (for example ascorrelations or regression analyses) between coping strate-gies and psychological morbidity in family/informal carers ofpeople with any form of dementia. Studies that reported dataon carers of people without dementia were excluded, unlessthey reported the results for dementia carers separately. Weincluded only studies that used standardised, quantitativemeasures of coping and psychological morbidity, and onlywhere the coping measure could be classified according toour categorisation described as follows.
2.3. Categorising coping
We 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. Thethree categories have demonstrated satisfactory psychomet-ric properties for carers of people with dementia (Cooperet al., 2008). For every coping scale used in the includedstudies, RL classified its respective subscales into the threecategories by examining the individual questions. Thisclassification was then discussed with and agreed with twoother authors (GL and CC) (see Table 1).
2.4. Quality assessment
RL and one other author (AS or JB) independently rated thequality of each study, blind to each other's ratings. Disagree-ments were resolved through discussion with GL. Our measureof study validity was adapted from Boyle (1998). For cross-sectional studies, we awarded points as follows:
• Power analysis based on relationship between coping anddepression/anxiety: 1 point
Table 1Classification 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 Dysfunctional
Active coping [I've been concentrating my efforts ondoing something about the situation I'm in] BriefCOPEPlanful problem-solving [I knew what had to bedone, so I doubled my efforts to make things work]Ways of Coping QuestionnaireLogical analysis [Considered several alternatives forhandling the problem] Coping Responses InventoryActive behavioural [Made a plan of action andfollowed 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 Form
Denial [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 Disorders 139 (2012) 1–11
• Clearly defined population: 1 point• Representative sample: 1 point for probability sampling, orwhole population was recruited (for example, consecutivesampling).
• Participants and non-participants comparable: 1 point ifdemonstrated statistically, or if participation rate ≥80%
• Reliability and validity: for each, 0.5 point if measures ofpsychological morbidity and coping validated in targetpopulation, 0.25 points if validated only in anotherpopulation.
• Confounding factors: 1 point if all of the followingconfounders were identified or addressed; carer genderand physical health, care recipient neuropsychiatric symp-toms, carer burden.
For longitudinal studies, we applied two additionalcriteria: 1 point if participants were followed up for at least6 months; 1 point if at least 80% of participants were followedup (or those lost to follow-up were shown to be comparable).We classified studies with a quality score of 3 or greater ashigher quality studies.
2.5. Data extraction
For each study, we extracted any correlation or regressioncoefficients reported for the relationship between a copingsubscale and psychological morbidity. We tabulated thedirection and statistical significance of the relationshipunder the three broad categories of coping (Tables 2 and 3).We excluded correlation or regression coefficients reportedfor individual questions, or for any coping measures thatcould not be categorised using our system.
2.6. Analysis
We conducted meta-analyses by extracting the standardisedbeta regression coefficients from studies for the relationshipsbetween depression, anxiety or mixed psychological morbidityand the categories of coping strategy. We calculated relevantregression coefficients from our own unpublished data (Cooperet al., 2008, 2010). Coefficients were pooled to produce aweighted mean correlation (WMC) coefficient, using a randomeffects model to account for heterogeneity (Hunter and Schmidt,1990). Statistical analysis was conducted using the SPSS 17software package (SPSS Inc., 2008). We used StatsDirect 2.6.6 toproduce forest plots of the results (StatsDirect Ltd., 2008).
As dementia severity was a known confounder in therelationship between carer coping and mental health, weincluded in our meta-analysis only studies that controlled forseverity of dementia (either by cognitive status or duration ofillness) or neuropsychiatric symptoms.
3. Results
3.1. Study description and methods
From 5396 publications identified by our systematicsearches, we included 35 unique studies (28 cross-sectional and seven longitudinal) reported across 37publications. One paper (Shaw et al., 1997) reporteddifferent study procedures for its US and China samples;we have included these two different studies as twoseparate 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 eachfrom Belgium (Schoenmakers et al., 2009), the Netherlands(Pot et al., 2000) and China (Shaw et al., 1997).
3.2. Cross-sectional studies
Table 2 summarises characteristics, results and the qualityof the included cross-sectional studies. Four longitudinalstudies additionally provided cross-sectional baseline data(Cooper et al., 2006; Kinney et al., 2003; Matson, 1994;Vedhara et al., 2000. Table 3). Dysfunctional coping was mostoften reported to be positively associated with anxiety, whilemost papers considering emotional support and acceptance-based coping or solution-focused coping reported non-significant associations with anxiety. For depression, a largemajority of papers reported positive association with dys-functional coping; emotional support and acceptance-basedcoping and solution-focused coping and was most oftenreported with non-significant or negative associations.Overall, there was no observable difference in the directionand statistical significance of findings between higher andlower quality studies.
We extracted and meta-analysed regression coefficientsfrom the 11 studies that controlled for severity of dementia orneuropsychiatric symptoms. All of these studies measuredeither depression or anxiety, except for the single studyproviding extractable data on mixed psychological morbidity(Hinrichsen and Niederehe, 1994).
Table 2Summary of study characteristics and findings: cross-sectional studies. Key: * indicates reported coping factors overlapping into multiple categories, or individual coping inventory items; thus strength of relationship to anysingle category will be overestimated. “Lower quality” studies are those rated less than 3 (before rounding) on our quality checklist. Study quality ratings are shown here rounded to nearest one.
30 Short Zung JCS 24-month follow-up: subgroup analysis only↓ Solution-focused (nursing home placement spouses)↑ Emot. support/acceptance (widowed spouses)
5
Abbreviations:Emot. support/acceptance: Emotional support and acceptance-based coping.Measures of psychological morbidityCES-D: Centre for Epidemiological Studies—Depression; HADS: Hospital Anxiety and Depression Scale; BSI: Brief Symptom Inventory; BDI: Beck Depression Inventory; SPSS: Savage Personality Screening Scale; Short Zung: Short ZungInterviewer Assisted Rating Scale.Coping measuresCOPE: Coping Orientation to Problems Experienced; CRI: Coping Resources Inventory; WCCL: Ways of Coping Checklist; WCQ: Ways of Coping Questionnaire; JCS: Jalowiec Coping Scale.
6R.Li
etal./
Journalof
Affective
Disorders
139(2012)
1–11
5396 hits(5392 electronic search, 4 hand-search)
607 potential references:abstracts retrieved
192 full texts retrieved
35 studies included in review(published across 37 papers)
11 studies with regression analyses controlling for confounders:included in meta-analysis
Excluded: 126 no measures of relationship between coping and anxiety/depression
16 no specific data on carers of people with dementia13 intervention studies
Excluded: 305 did not report all required outcome measures
77 not primary quantitative study33 no specific data on carers of people with dementia
Excluded by title:4342 clearly irrelevant
38 not peer-reviewed journal409 duplicates
Fig. 1. Flowchart of included/excluded studies.
7R. Li et al. / Journal of Affective Disorders 139 (2012) 1–11
3.2.1. AnxietyEmotional support and acceptance-based coping was
associated with less anxiety (WMC=−0.220, 95% CI−0.259 to −0.180; pb0.0005; 3 studies; N=628). Dysfunc-tional coping was associated with more anxiety(WMC=0.390, 95% CI 0.283 to 0.498; pb0.0005; 4 studies;N=688), while solution-focused coping was not significantlyassociated with anxiety (WMC=0.096, 95% CI −0.020–0.212; p=0.104; 4 studies; N=678) (Fig. 2).
3.2.2. DepressionEmotional support and acceptance-based coping was
associated with less depression (WMC=−0.196, 95% CI−0.283 to −0.109; pb0.0005; 5 studies; N=848). Dysfunc-tional coping was associated with more depression(WMC=0.456, 95% CI 0.357 to 0.555; pb0.0005; 10 studies;N=1428), while solution-focused coping was not signifi-
cantly associated with depression (WMC=−0.035, 95% CI−0.113 to 0.043; p=0.376; 4 studies; 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 founddysfunctional coping to be associated with more distress(standardised beta=0.350, pb0.001, N=152), but no signifi-cant association between solution-focused coping and distress(standardised beta=0.090, not significant, N=152). It did notexamine emotional support and acceptance-based coping.
3.3. Longitudinal studies
Table 3 summarises characteristics, results and the quality ofthe included longitudinal studies, two of which provided
-1.0 -0.5 0.0 0.5 1.0
Weighted mean correlation 0.39 (0.28, 0.50)
Cooper et al. 2001 0.56 (0.40, 0.68)
Cooper et al. 2006 0.44 (0.32, 0.54)
Neundorfer 1991 0.53 (0.32, 0.69)
Pruchno & Resch 1989 0.28 (0.17, 0.38)
-1.0 -0.5 0.0 0.5 1.0
Weighted mean correlation
Cooper et al. 2010
-1.0 -0.5 0.0 0.5 1.0
Weighted mean correlation 0.10 (-0.02, 0.21)
Cooper et al. 2010 0.12 (-0.01, 0.25)
Cooper et al. 2006 0.23 (0.04, 0.41)
Proctor et al. 2002 -0.01 (-0.12, 0.10)
Pruchno & Resch 1989 0.38 (0.11, 0.60)
Pruchno & Resch 1989
Cooper et al. 2006
-0.22 (-0.32, -0.11)
-0.29 (-0.46, -0.10)
-0.19 (-0.31, -0.05)
-0.22 (-0.26, -0.18)
a
b
c
Fig. 2. Forest plots showing standardised regression coefficients between coping styles and anxiety, and their weighted mean correlations (random effectsmodels), after controlling for neuropsychiatric symptoms and dementia severity. Parentheses indicate 95% confidence intervals. Studies in bold are higher qualitya: Relationship between solution-focused coping and anxiety b: Relationship between emotional support and acceptance-based coping and anxiety c: Relationshipbetween dysfunctional coping and anxiety.
8 R. Li et al. / Journal of Affective Disorders 139 (2012) 1–11
extractable data for meta-analysis (Cooper et al., 2008; Vedharaet 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 theonly included study (n=93) to measure these types ofcoping (Cooper et al., 2008). Dysfunctional coping atbaseline did not significantly predict anxiety 6 months(Vedhara et al., 2000) or 12 months later (WMC=0.190,95% CI −0.158 to 0.539; Cooper et al., 2008) (p=0.284; 2studies; N=143).
-1.0 -0.5 0.0 0.5 1.0
Weighted mean correlation 0.46 (0.36, 0.56)
Cooper et al. 2010 0.40 (0.22, 0.55)
Kim et al. 2007 0.29 (0.14, 0.43)
Mausbach et al. 2006 0.29 (0.09, 0.47)
Huang et al. 2006 0.55 (0.43, 0.65)
Cooper et al. 2006 0.41 (0.29, 0.52)
Haley et al. 1996 0.74 (0.67, 0.80)
Brashares & Catanzaro 1994 0.12 (-0.11, 0.34)
Kramer 1993 0.63 (0.47, 0.75)
Neundorfer 1991 0.33 (0.08, 0.54)
0.48 (0.39, 0.56)Pruchno & Resch 1989
-1.0 -0.5 0.0 0.5 1.0
Weighted mean correlation -0.20 (-0.28, -0.11)
Cooper et al. 2010 -0.16 (-0.29, -0.03)
Huang et al. 2006 -0.15 (-0.30, 0.02)
Cooper et al. 2006 -0.14 (-0.33, 0.05)
Kramer 1993 0.02 (-0.21, 0.25)
Pruchno & Resch 1989 -0.31 (-0.41, -0.21)
-1.0 -0.5 0.0 0.5 1.0
Weighted mean correlation -0.04 (-0.11, 0.04)
Cooper et al. 2010 -0.02 (-0.16, 0.11)
Cooper et al. 2006 0.11 (-0.09, 0.30)
Kramer 1993 -0.21 (-0.42, 0.02)
Pruchno & Resch 1989 -0.05 (-0.16, 0.06)
a
b
c
Fig. 3. Forest plots showing standardised regression coefficients between coping styles and depression, and their weighted mean correlations (random effectsmodels), after controlling for neuropsychiatric symptoms and dementia severity. Parentheses indicate 95% confidence 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 depressionc: Relationship between dysfunctional coping and depression.
9R. Li et al. / Journal of Affective Disorders 139 (2012) 1–11
3.3.2. DepressionDysfunctional coping significantly predicted depression at
follow-up (WMC=0.321, 95% CI 0.098 to 0.544; p=0.005; 2studies; N=143). Neither emotional support nor acceptance-based coping (standardised beta=−0.149, p=0.28) norsolution-focused coping (standardised beta=0.112, p=0.46)significantly predicted depression a year later (n=93; Cooperet al., 2008).
4. Discussion
This is the first meta-analysis of the relationships betweencarer coping and psychological morbidity and the firstsystematic review to take into account the effect of stressors.
We found consistent evidence from higher quality cross-sectional studies that dysfunctional coping was moderatelycorrelated (WMC≈0.4) with depression and anxiety. Therewas also evidence from two high quality longitudinal studiesthat dysfunctional coping predicted depression 6 and12 months later. Coping strategies based on acceptance andseeking emotional support were correlated cross-sectionallyto a lesser degree (WMC≈0.2) with lower anxiety anddepression in high quality studies. In one study these copingstrategies predicted lower anxiety and depression a year later(Cooper et al., 2008).
Our meta-analysis suggests that solution-focused copingis not cross-sectionally associated with carer mental health,which challenges the typical assumption in the literature that
10 R. Li et al. / Journal of Affective Disorders 139 (2012) 1–11
solution-focused coping has positive implications for carermental health (for example, see Kneebone and Martin, 2003).The only study that explored such a relationship longitudinallyfound that carers who reported using more solution-focusedcoping strategies relative to other forms of coping at baseline,tended to show more symptoms of anxiety and depression at12 months follow-up (Cooper et al., 2008). This might beexplained by the inevitability of dementia as a progressive andincurable illness, in which stressors associated with the illnessbecome less amenable to problem-solving over time (Cooperet al., 2008). This is not to suggest solution-focused behaviourshave no benefits at all; our review did not consider anyoutcomes other than carer psychological morbidity.
Studies that have investigated coping have tended to use awide variety of coping measures (Kneebone and Martin,2003). This is the first review to synthesise studies of carercoping in dementia using a common classification system fordifferent coping measures, enabling meaningful comparisonsof results obtained with different measures.
4.1. Limitations
We could only include just over a quarter of the identifiedstudies in our meta-analysis; the remainder of studies did notcontrol for relevant stressors. There was a particular dearth oflongitudinal studies, and only two included data that wecould extract for analysis. A number of coping subscales couldnot be extracted from otherwise relevant studies, because thecoping subscales did not fit into one of our three pre-definedcategories, but we have no reason to think that thisintroduces a particular bias to our findings.
4.2. Clinical implications
Dysfunctional coping behaviours are performed by every-one to some degree (as are all coping behaviours). Copingscales are not all-or-nothing but instead measure how muchof a coping style is used, and what implications this has forcarer mental health.
Our meta-analysis provides good evidence that thegreater use of dysfunctional coping and less use of copingbased on acceptance and support are associated with anxietyand depression cross-sectionally; there is preliminary evi-dence (from one or two studies) that they also predict thismorbidity from longitudinal studies. This suggests thatpsychological interventions aimed at modifying coping stylecarers use would be rational interventions. We are currentlyrecruiting 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, analysisand interpretation of data; in the writing of the report; and in the decision tosubmit 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.
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