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Table of Contents
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 165-169

The prevalence of anxiety, stress, and depression with respect to coping strategies in caregivers of patients with head injuries

1 Department of Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
2 Randomized Controlled Trial Research Center, Shahroud University of Medical Sciences, Shahroud, Iran
3 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Nursing, School of Nursing and Midwifery, Hamedan University of Medical Sciences, Hamedan, Iran
5 Department of Nursing, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud; Kashmar Center of Higher Health Education, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Submission22-May-2019
Date of Decision13-Sep-2019
Date of Acceptance18-Sep-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Mr. Reza Mohammadpourhodki
7th Sq. Shahroud University of Medical Sciences, Shahroud
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/atr.atr_35_19

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Context: Psychological problems are very common in traumatic patients' caregivers necessitating usage of appropriate coping strategies to promote their mental health. Aim: The aim of this study was to assess anxiety, stress, and depression as well as coping strategies in caregivers of patients with head injuries. Settings and Design: In this cross-sectional study, 127 caregivers of traumatic patients referred to educational hospitals of Zabol city were selected by convenience sampling method. Subjects and Methods: The data were collected using a demographic questionnaire, as well as Depression, Anxiety and Stress Scale-21 and the Jalowiec coping strategies tools. The data were analyzed using descriptive statistics, one-way ANOVA, independent samples Student's t-test, and multivariate regression model. Results: Our findings showed that more than 70% of the caregivers of patients with head injuries suffered from severe and very severe stress and anxiety. The multivariate regression model demonstrated a negative and significant relationship between either stress (B = −0.81 P = 0.001) or depression (B = −1.23 P = 0.000) and problem-based coping strategies. Furthermore, stress (B = 0.64 P = 0.006) and anxiety (B = 0.74 P = 0.002) were negatively associated with emotional-based coping strategies. Conclusion: Considering the high rates of anxiety, stress, and depression in caregivers of patients with head injuries and significant associations observed between these variables and problem-based strategies, it is necessary to identify and obviate factors leading to anxiety and to educate coping strategies to these individuals.

Keywords: Anxiety, coping strategies, depression, family caregivers, head injuries, stress

How to cite this article:
Keramati M, Ebrahimi H, Basirinezhad MH, Shamsizadeh M, Mohammadpourhodki R. The prevalence of anxiety, stress, and depression with respect to coping strategies in caregivers of patients with head injuries. Arch Trauma Res 2019;8:165-9

How to cite this URL:
Keramati M, Ebrahimi H, Basirinezhad MH, Shamsizadeh M, Mohammadpourhodki R. The prevalence of anxiety, stress, and depression with respect to coping strategies in caregivers of patients with head injuries. Arch Trauma Res [serial online] 2019 [cited 2023 Mar 24];8:165-9. Available from: https://www.archtrauma.com/text.asp?2019/8/3/165/271689

  Introduction Top

Brain injury is the most devastating accident-born health consequence. Despite widespread medical advances, brain injuries still remain major causes of mortality and morbidity among populations and especially youths.[1]

According to the results of a study among students of medical universities in Tehran, accident is the third leading cause of death and the main reason of hospitalization in Iran.[2] Trauma-born temporary or permanent disabilities affect not only patients but also their families.[3] Studies have shown that traumatic patients' family members experience high levels of pressure attending and admitting patients to hospitals. This pressure often leads to behavioral bewilderment and psychological frustration presenting as anxiety and stress which adversely affect daily routine in these individuals.[4] Caregivers' psychological distresses may further propagate to patients and healthcare personnel disturbing their communications as well.[5] In fact, caregivers' mental health directly affects the quality of healthcare services.[6]

Coping strategies are necessary to counteract with stressful situations [7] and include a set of cognitive and behavioral attempts [8] aiming to manage internal and external tensions and mitigate their impacts.[9],[10] Coping approaches against stressful situations are generally divided into problem-based and emotional-based strategies. The problem-based coping strategies represent actions aiming to alter or mitigate the stressful situation through finding solutions for the psychological problem. On the other hand, emotional-based coping strategies comprise a combination of emotional responses to a problem. Emotional strategies are commonly used when individuals perceive an irreversible problem and generally aim to reduce the stress, but not to logically solve the problem.[11] Researchers believe that in facing stressful situations, the concept of coping is more important than the stress itself. In fact, coping strategies and not stress affect individuals' daily functions.[12]

It is recommended for family caregivers to recruit active adaptive strategies to improve their physical and mental health.[13],[14] Given the acute nature of cerebral trauma, patients and their caregivers are prone to psychological problems including stress and anxiety which can affect the quality of care provided by caregivers. Therefore, it is important for caregivers to use appropriate coping strategies to overcome these problems. The aim of this study was to determine relationships between coping strategies and stress, depression, and anxiety in caregivers of patients with head injuries referred to educational hospitals of Zabol city during 2016–2018.

  Subjects and Methods Top

This was a cross-sectional study carried out in educational hospitals of Zabol city from June 2016 to April 2018. The study population included 127 family caregivers of inpatients and outpatients with head injuries chosen by convenience sampling method. The inclusion criteria comprised being a first-degree relative to the patient, sharing a main role in supporting the patient, reading and writing abilities, willing to participate in the study, and having no history of psychiatric disorders. Exclusion criteria comprised being illiterate, not willing to participate, and using antianxiety drugs.

Three data collection tools included (1) a demographic questionnaire, (2) the Depression, Anxiety, and Stress Scale-21 (DASS-21) questionnaire, and (3) the Jalowiec coping style questionnaire. The demographic questionnaire included five questions about age, gender, occupation, and marital status.

As a shortened version of the DASS-42 questionnaire, DASS-21 was initially presented by Lovibond and Lovibond in 1995. Individuals can independently complete the DASS-21 questionnaire with no need for counseling with a psychologist.[14] In the DASS-21 questionnaire, each item is scored from 0 to 3. Depression, anxiety, and stress scores are then calculated by summing the scores of relevant items (i.e., items 2, 6, 8, 11, 12, 14, and 18 for stress, items 1, 4, 7, 9, 15, 19, and 20 for anxiety, and items 3, 5, 10, 13, 16, 17, and 21 for depression).

Antony et al. reported the Cronbach's alpha coefficients of 0.91, 0.94, and 0.87 for stress, depression, and anxiety, respectively.[15] The validity and reliability of DASS-21 questionnaire have been confirmed for being used in Iranians. In a study by Sahebi et al., on 970 students and military staff, the translated version of the scale was comparable to its original version retrieving the internal consistency values of 0.77, 0.79, and 0.78 for depression, anxiety, and stress, respectively.[16]

The coping strategy tool was adapted from the Jalowiec questionnaire. This tool consisted of 39 questions with 15 and 24 questions related to problem-based and emotional-based coping strategies, respectively. The scoring was based on Likert scale assigning either 5 (very high), 4 (high), 3 (moderate), 2 (few), or 1 (never) score to each item. Questions with negative meaning were scored in a reverse manner. The final score ranged from 15 to 75 for problem-based and from 24 to 120 for emotional-based coping styles. The score obtained for the problem-based coping style was categorized as either weak (score of 0–20), moderate (score of 21–40), or good (score of 41–60). The score obtained for the emotional-based style was also classified as either weak (score of 0–32), moderate (score of 33–64), or good (score of 65–96).[17] The content and construct validities were adequately assessed with test–retest correlation coefficients of 0.85 and 0.86 for problem-based and emotional-based coping strategies, respectively,[17] in Iran; the reliability of the standard Jalowiec coping strategy questionnaire has been determined as r = 0.87.[18]

Necessary explanations were provided to patients' and their caregivers by the researcher. The participants were also ensured about the anonymity and confidentiality of the provided data. The participants were free to withdraw from the study at any stage. The study protocol was approved by the Ethics Committee of Zabol University of Medical Sciences (ethical code: zbmu. 1.REC.1394.18).

Descriptive (mean and frequency) and analytical (independent Student's t-test, one-way ANOVA, and Pearson correlation coefficient) statistics were used to analyze the data. The confidence interval level was considered 95%.

  Results Top

Most of the participants in this study were males (58.26%) and married (64.57%). Detailed information about the individuals' demographic characteristics has been presented in [Table 1].
Table 1: The distribution of demographic features in family caregivers of patients with head trauma

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The means of emotional-based and problem-based coping strategies scores were 71.00 ± 5.41 and 50.60 ± 7.89, respectively.

According to the results of the DASS-21 questionnaire, 63.8% of the individuals had very severe stress. Moreover, 18.9% and 51.2% of the caregivers suffered from very severe depression and severe anxiety, respectively [Table 2].
Table 2: The distribution of stress, depression, and anxiety among family caregivers of patients with head trauma

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Problem-based coping strategies were negatively associated with stress and depression [Table 3]. Regression analysis showed that one unit increase in stress and depression decreased the utility of problem-based coping strategies by 0.816 and 1.23, respectively.
Table 3: Association of stress and depression with problem-based coping strategies in multivariate regression model

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Emotional-based coping strategies were positively associated with stress and anxiety [Table 4]. Regression analysis showed that one unit increase in stress and anxiety increased the utility of emotional-based coping strategies by 0.643 and 0.745, respectively.
Table 4: Association of stress and anxiety with emotional-based coping strategies in multivariate regression model

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  Discussion Top

The aim of this study was to investigate the relationship between coping strategies and anxiety, stress, and depression in family caregivers of patients with head injuries. In this study, most of the caregivers recruited emotional-based coping strategies and represented severe depression and stress. Furthermore, more than half of them revealed moderate to severe anxiety. Furthermore, most family caregivers represented severe depression which was in line with the studies of Mazzotti et al. and Rumpold et al. in which more than half of cancer patients' caregivers suffered from psychiatric and mood disorders.[19],[20] On the other hand, Manteghi et al. reported mild depression in psychic devotees' caregivers [21] which was against the results of the present study. This difference may be explained by different statistical populations and also delayed manifestation of depression.

Our findings showed that most of the caregivers suffered from severe and very severe anxiety. This finding was similar to the results of Manteghi et al. (2010) who examined anxiety in companions of patients admitted to hospital special care units.[21] In another study, Safaeian et al. (2017) investigated the relationship between caring pressure and stress, anxiety, and depression in the caregivers of cancer patients admitted to Imam Reza Hospital of Bojnourd and showed that >50% of the caregivers suffered from moderate anxiety.[22] This difference can be due to the different tools recruited for measuring anxiety in our study and that of Safaeian et al.

Most of our participants had severe and very severe stress. Likewise, Papastavrou et al. who assessed depression in cancer patients' companions [23] and Rahmani Anaraki et al. who examined depression in the companions of patients with psychological disorders described severe stress in the participants.[6]

According to the scores obtained here, most of the family caregivers had used emotional coping methods. In line with our observation, previous studies also revealed higher mean scores for emotional-based than problem-based strategies indicating higher utility of the former styles by caregivers.[24],[25] As trauma is often a complicated and sudden event, family members have a short time to be adapted to the situation and therefore usually employ emotional-based coping strategies.

In this study, we found a positive and significant relationship between emotional-based coping styles and stress. This was while problem-based coping strategies were inversely and significantly correlated with stress. This indicated that caregivers with lower stress level were more likely to exploit problem-based coping approaches. In line, Papastavrou et al. showed that cancer patients' caregivers with severe stress applied emotional-based coping approaches while individuals with lower stress more frequently applied problem-based coping approaches.[23] Accordingly, using problem-based coping strategies can reduce stress in family caregivers.[26]

In this study, caregivers who utilized problem-based coping methods had lower level of depression. In parallel, researchers have found that patients with severe depression more frequently used emotional-based and maladaptive coping methods leading them toward frustration.[27] On the other hand, improvement in depression has been associated with more frequent recruitment of problem-based coping styles.

We further observed that caregivers who exploited emotional-based coping methods had lower anxiety level. Previous studies have also described a significant and inverse relationship between anxiety and emotional-based coping methods.[28],[29] In another study, however, a direct and significant relationship was observed between anxiety and emotional-based coping method.[30] This disagreement may be related to variabilities in the adaptability levels, availability of supporting services, and previous experience of stressful situations affecting individuals' responses to stressful situations.[31]

  Conclusion Top

The findings of this study showed that a considerable ratio of traumatic patients' family caregivers suffered from severe anxiety and depression. Most of the caregivers exploited emotional-based rather than problem-based coping strategies exacerbating their anxiety. It is recommended to implement interventional programs to educate appropriate coping strategies to family caregivers to cope with their anxiety and depression. More extensive and diverse studies are warranted to promote mental health and reduce anxiety in caregivers.


This article was approved by the Zabol University of Medical Sciences (zbmu. 1.REC.1394.18). The researchers appreciate the authorities of Amir Al-Momenin Hospital of Zabol, traumatic patients, and their caregivers for their kind cooperation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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