ANGER AND DEPRESSION AMONG CHRONICALLY ILL PATIENTS: EXPLORATION OF RISK AND PROTECTIVE FACTORS FOR WELLBEING AND QUALITY OF LIFE

Abstract

Present study was conducted to explore the commonly reported psychological issues among chronically ill patients and to explore the risk and protective factors with regard to their impact on well-being and quality of life of patients. Cancer, cardiac and diabetic patients (as per WHO, these three are among top ten causes of deaths in year 2010, NVSS, 2013) were taken from Oncology, General medicine and Cardiology department of Pakistan Institute of Medical Sciences Islamabad (PIMS)). The objectives and hypotheses were formulated within the theoretical framework of Diathesis stress model, self -determination theory and disability stress coping strategy theory. The research was completed in two parts. Part- I of the study comprised of three phases. Phase I dealt with the Identification of psychological issues, risk and protective factors (through focus groups and in-depth interviews) by using multi informant approach (patients, caregivers, doctors, nurses and para-medics). Data was analyzed through content analysis. Inter-rater reliability was established for both focus group discussion (Krippendorff’s alpha = .89) and interviews (Krippendorff’s alpha = .83). The findings of this phase suggested psychological issues faced by patients. Through committee approach the indicators of these issues were labeled in two major groups i.e., depression and anger, whereas the other indicators were grouped as social support and coping strategies (which can be figured out as a risk and protective factor). Beck Depression Inventory (Khan, 1996) was used to assess the depression among patients, Social Support Scale (Malik, 2002) for the assessment of social support, Coping Strategies Questionnaire (Kausar & Munir, 2004) for the assessment of coping strategies, WHO Quality of Life Questionnaire (Khalid & Kausar, 2006) for the assessment of quality of life, Psychological wellbeing scale (Ansari, 2010) was used for the assessment of psychological well-being and for the assessment of anger an indigenous scale was developed. Phase – II dealt with the development of the scale to measure the anger among chronically ill patients. This phase was divided into three steps i.e., review of literature and previous scales, item pool generation and the Exploratory Factor Analysis (KMO = .71). Three factors xxi emerged i.e., state anger (11 items, anger control-in (8 items) and anger control – out (6 items). The content validity was established. In Phase-III of present research, the psychometric properties of all the instruments were established on a sample of 300 patients were taken from PIMS and it was found that scale have sound psychometric properties i.e., alpha coefficients, item total correlations and inter-scale correlations. Part II of the study was conducted on a sample of 500 chronically ill patients. The results revealed that there is a significant negative relationship between depression, state anger, anger control-in and anger control-out with psychological well-being and quality of life. Multiple regression revealed predictive role of depression, state anger, anger control-in and anger control-out for the psychological well-being ((depression predicting environmental mastery (β = -.46, p = .000) and state anger predicting environmental mastery (β =.15, p = .000), (prediction of autonomy from depression (β = .37, p = .000) and from anger control-in (β =-.14, p = .000), (prediction of personal growth from depression (β = -.46, p = .000) and from state anger (β =.13, p = .003), (prediction of positive relations from depression (β = .03, p = .000) and from anger control-in (β =-.09, p = .02), depression predicting purpose in life ((β = -.45, p = .000), prediction of self-acceptance from depression (β = -.39, p = .000) and anger control-in (β =.13, p = .003)) and quality of life (predicting physical functioning from state control-out (β = -.21, p = .000), (predicting psychological functioning from state anger (β = -.31, p = .000), from anger control-in (β = -.10, p = .01) and from anger control-out (β = .35, p = .000), prediction of social relations from depression (β = .12, p = .01), from state anger (β = -.26, p = .000) and from anger control-in (β = -.16, p = .000), and predicting environment from state anger (β = -.36, p = .000), from anger control-in (β = -.15, p = .000) and from anger control-out (β = .33, p = .000) among chronically ill patients. To find out the moderating role of coping strategies and social support analysis was computed and results supported the hypotheses that coping strategies i.e., social support (tangible support, social network support) significantly play the moderating role in relationship between depression and psychological well- being (self - acceptance, positive relationship with other and autonomy), whereas esteem support acted as moderator between relationship of state anger and psychological well -being (environmental mastery, personal growth). MANOVA was computed on the xxii demographic variables which were further explored with the ANOVA analysis. The significant multivariate main effect of education and marital status, education with age was followed by univariate analyses of variance, which revealed significant differences in depression, informational support, social network support, environmental mastery, self-acceptance, autonomy, purpose in life and personal growth. Tangible support (female M = 17.18, SD = 3.17, Males M = 16.42, SD = 15.29), environmental mastery (female M = 33.01, SD = 13.46, Males M = 27.38, SD = 4.60), positive relations with others (female M = 34.76, SD = 10.50, Males M = 29.92, SD = 11.93) and personal growth (females = 32.06, SD = 10.49, Males M = 28.27, SD = 10.59) is significantly high among female patients as compared to males. Depression is significantly high among those patients who are from nuclear family system (Nuclear M = 16.74, SD = 15.36, Joint M= 13.51, SD = 11.23) whereas environmental mastery (Nuclear M = 29.47, SD = 14.39, Joint M = 34.29, SD = 13.40), positive relations with others (Nuclear M = 32.02, SD = 11.39, Joint M= 35.51, SD = 10.38) and personal growth (Nuclear M = 29.09, SD = 10.90, Joint M = 32.44, SD = 10.41) is high among those patients who are from joint family system. Concluding the present study, depression and anger were figured out as commonly reported psychological issues. Avoidance focused and active distractive coping strategies play risk factor for psychological well-being and quality of life, whereas active focused and religious focused coping strategies along with high level of social support play significant role as protective factors. The present study has important implications in devising a proper treatment plan for chronically ill patients.