Depression and Health-Related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer

YAPNU-50949; No of Pages 7 Archives of Psychiatric Nursing xxx (2017) xxx–xxx

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Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer Hung-Yu Lin a,b, Hui-Ling Lai c,d, Chun-I Chen e, Chiung-Yu Huang f,⁎ a

Medical College, I-Shou University, Taiwan Department of Urology, E-Da Hospital, Kaohsiung, Taiwan Tzu Chi University, Hualien, Taiwan d Buddhist Tzu Chi General Hospital, Hualien, Taiwan e I-Shou University, No. 1, Sec. 1, Syuecheng Rd., Kaohsiung, Taiwan f I-Shou University, No. 8, Yida Rd., Yanchao District, Kaohsiung County 82445, Taiwan b c

a r t i c l e

i n f o

Article history: Received 4 December 2016 Revised 17 April 2017 Accepted 22 April 2017 Available online xxxx Keywords: Health-related quality of life Prostate cancer Resourcefulness Erectile dysfunction Depressive symptoms

a b s t r a c t Objective: This study aimed to identify the determinants of depressive symptoms (DSs) and health-related quality of life (HRQOL) in survivors of prostate cancer (PC). Methods: This study used a descriptive, correlational design to assess a sample of 133 individuals with PC. The participants were face-to-face interviewed to collect demographic data and disease characteristics, assess selfcontrol schedule, and survey health status. Correlation analysis, Student's t-test, ANOVA, and regression analysis were applied. Results: Over half the patients had depressive symptoms, and 96.1% had erectile dysfunction. Lack of resourcefulness was found to decrease PC-specific quality of life (PCQOL) and physical quality of life (PQOL). The participants who were more resourceful showed a better mental quality of life (MQOL) and PQOL (r = 0.53**; r = 0.41**) and fewer DSs (r = −0.52**). Most participants were stage II and IV, and there were significantly different effects on PQOL and MQOL related to cancer stage. Regarding the different outcomes of various therapies, the findings suggested that survivors of PC who underwent radical prostatectomy were more likely to have a better MQOL than those who underwent other treatments. In addition, resourcefulness had mediating effects on pain, PQOL/MQOL, and DSs in the patients with PC. Conclusions: Good mental health and resourcefulness can help patients with PC reduce pain and enhance positive thinking and may augment PQOL and MQOL. © 2017 Elsevier Inc. All rights reserved.

BACKGROUND Prostate cancer (PC) is considered a stressful life experience and can result in major challenges to a male's basic values by threatening his identity and impairing his psychological functioning. PC is also the most common form of cancer in males and remains a life-threatening illness (Weber, Roberts, Mills, Chumbler, & Algood, 2008; Chambers et al., 2016). An increasing number of individuals are being diagnosed with cancer every year, and PC is the most frequent malignancy and the second most common cause of cancer-related death in Australian and American males (American Cancer Society, 2016; Australian Institute of Health and Welfare, 2014). It is also the seventh leading cause of cancer-related death among men in Taiwan (Ministry of

⁎ Corresponding author. E-mail addresses: [email protected] (H.-Y. Lin), [email protected] (H.-L. Lai), [email protected] (C.-I. Chen), [email protected] (C.-Y. Huang).

Health and Welfare, 2016). Although Asian males have a lower prevalence of PC than males from the West, the prevalence of PC has recently increased in Taiwan (Ministry of Health and Welfare, 2016), and the cancer may not be protected against by cultural factors (Sim & Cheng, 2005). Various specific treatments for PC have been proven effective and can increase life expectancy. Such treatments include surgery, brachytherapy, thulium laser treatment, and high-intensity focused ultrasound (HIFU). These treatments can impact a patient's health-related quality of life (HRQOL). Generally, HRQOL is expression for physical quality of life (PQOL) and mental quality of life (MQOL). Recently, the incidence and prevalence of PC in males have been increasing worldwide (Schroder, 2010). Progressive treatments and diagnostic aids improve longevity and enhance quality of life for survivors of PC. However, this life-threating disease can also be associated with physical and psychological health problems (Reeve et al., 2009; Sim & Cheng, 2005). In addition to the increasing number of PC patients, the adverse health problems, including depression, anxiety, pain, sexual problems and difficulty urinating, that occur during the progression of

http://dx.doi.org/10.1016/j.apnu.2017.04.014 0883-9417/© 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014

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H.-Y. Lin et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx

the disease should be assessed and treated by applying psychosocial or alternative therapies to survivors of PC (Steginga, Turner, & Donovan, 2008). However, this aspect of the management of PC has often been neglected. Although currently available interventions do have beneficial effects, over 30% of individuals with PC suffer from cancer progression or the effects of various invasive treatments (Hsiao, Loescher, & Moore, 2007). Survivors of PC may have anxiety related to the disease and its treatment. They may experience depressive symptoms (DSs), shock after diagnosis, and fear during prostate-specific antigen (PSA) assessment. Additionally, cancer recurrence after treatment and the presence of fatigue and pain may be aggravated by social and psychological factors and impotence during and after treatment. Healthcare professionals should recognize these problems and enhance their patients' coping skills during their adjustment to new situations to improve their HRQOL. Studies of the clinical significance of depression in males with PC are currently insufficient. Patients with PC may have negative thoughts, especially when they experience unresolved pain, sexual problems, and incontinence. This situation may result in depression. Roth et al. (1998) reported that 15.2% of PC patients exhibit depression (Bennett & Badger, 2005). Moreover, when males with PC have other symptoms, such as prominent pain, side effects caused by treatments, or a previous history of depression (Cliff & MacDonagh, 2000), the incidence of depression may increase. For example, Heim and Oei (1993) reported that depression is strongly correlated with pain in patients with PC. Additionally, Gerbershagen et al. (2008) found that patients with localized PC without pain had better HRQOL and lower anxiety and depression. Additionally, Chen, Chang, and Yeh (2000) reported that patients with pain had more depressive symptoms than patients without pain after assessing a sample of Taiwanese oncology patients. The symptoms of PC itself and the side effects of the associated treatments can cause distress in patients with PC (Sharifi, Gulley, & Dahut, 2005). The side effects of hormonal therapies can be particularly distressing for asymptomatic patients, as they can result in osteoporosis, anaemia, fatigue, erectile dysfunction, risk of diabetes (Higano, 2003), and changes in cognitive functioning (Wittmann et al., 2009). These effects have been associated with HRPQOL and MQOL (Nam et al., 2014; Stanford et al., 2000). HRQOL is a multidimensional construct with both physical and emotional components. HRQOL is associated with coping not only with disease-specific physical complications but also with the impact of treatments as well as the decision-making related to therapy that occurs in a patient's everyday life (Namiki, Ishidoya, Tochigi, Ito, & Arai, 2009; Nelson, Balk, & Roth, 2010). Both PC and its treatment can affect disease-specific and general aspects of a patient's life; however, such effects may differ based on PC stage and the treatments used. HRQOL in men with more advanced-stage disease is inconsistent. Moreover, longitudinal studies have indicated that urinary problems, bowel problems, and sexual dysfunction may occur in men with PC either before or after treatment (Litwin, McGuigan, Shpall, & Dhanani, 1999). Some evidence suggests that advanced disease alone may have a substantial impact on sexual function. While patients with advanced PC may consider sexual function less of priority than patients who are at an earlier stage (Clark, Rieker, Propert, & Talcott, 1999), it has been reported that aging and the use of combinations of treatments are factors that may exacerbate erectile dysfunction and/or other issues related to HRQOL (Namiki, Ishidoya, Kawamura, Tochigi, & Arai, 2010). Therefore, additional studies of HRQOL in patients with PC are needed. Resourcefulness, a measure of an individual's coping capacity, may be required for individuals with PC. Resourcefulness has been studied in the context of several areas of medicine. Recently, researchers have reported that nurses with greater resourcefulness show fewer depressive symptoms (Wang et al., 2015) and that females with breast cancer who have greater resourcefulness also exhibit more help-seeking behaviour and have a better HRQOL (Huang et al., 2010).

The current study aimed to understand the associations that exist among factors related to disease and different treatment strategies and their impact on health outcomes. Additionally, we examined whether resourcefulness plays a mediation role with regard to DSs (PQOL/MQOL) in adults with PC.

CONCEPTUAL MODEL Resourcefulness has been conceptualized as a cognitive skill that results in behavioural changes that help individuals use internal processes, such as cognition and emotions, to perform daily activities (i.e., it is considered a self-care skill) (Rosenbaum, 1990). Additionally, resourcefulness is a self-regulated ability that may be applied to cope with psycho-physiological stress responses and to manage negative thoughts or behaviours through positive thinking. Zauszniewski, Eggenschwiler, Preechawong, Roberts, and Morris (2006) adapted Rosenbaum's concept and defined the following two forms of resourcefulness: personal (self-help) and social (help-seeking) resourcefulness. Because self-control behaviours may ameliorate health and decrease DSs among individuals with PC, resourcefulness is also the central concept in the current study's model. The current study was derived from a resourcefulness model that posits that individuals with higher resourcefulness can minimize the effects of different stressors (e.g., duration of disease, severity of cancer, erectile function, and PSA) on health status. DSs were investigated after controlling for selected demographic variables. Therefore, this study examined the relationships that exist among selected demographic variables, disease characteristics, and health. Previous studies of resourcefulness have been conducted to understand its effects on varied phenomena. In a study of a geriatric population, the presence of DSs was negatively correlated with resourcefulness and personal care (Zauszniewski et al., 2006). Huang et al. (2010) suggested that more resourceful survivors of breast cancer exhibit fewer depressive symptoms. In addition, certain mediators of resourcefulness were identified by Huang et al. (2007) and Zauszniewski and Chung (2001). However, there is insufficient knowledge regarding the relationship that exists between resourcefulness and HRQOL in patients with PC. To that end, the following three research questions were posed: 1. What is the prevalence of DSs and its relationship to HRQOL in patients with PC? 2. Does resourcefulness mediate the relationship between disease characteristics and DSs (PQOL/MQOL) in individuals with PC? 3. What are the differences caused by treatment effects on health outcomes in patients with PC?

METHODS STUDY DESIGN AND POPULATION A cross-sectional, descriptive correlational design was employed to examine relationships among demographics, PC disease characteristics (stage, therapy, pain, erectile function, and PSA), resourcefulness, and health outcomes in patients with PC. The sample size included 133 participants with PC aged over 20 years old. This sample size was calculated according to Cohen (1988) to achieve a power of 0.80 with a medium effect size of 0.15 and an alpha value of 0.05 for correlational statistics. To be eligible for the study, the enrolled patients with PC were also required to be free of other comorbid physical or psychological conditions. After Institutional Review Board (IRB) approval was obtained, the potential participants who met the inclusion criteria were provided complete information about the study and were free to participate or drop out at any time. After receiving written informed consent from the participants, an investigator conducted individual face-to-face, structured interviews to collect data.

Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014

H.-Y. Lin et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx

MEASUREMENTS The following data were collected: demographic information; disease characteristics; International Index of Erectile Function (IIEF; Rosen et al., 1997); prostate-specific, 25-item prostate cancer quality of life questionnaire PR25 (QLQ PR-25) (Borghede & Sullivan, 1996); self-care schedule for measuring resourcefulness (Rosenbaum, 1990), Centre for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977); and the Short Form of the Medical Outcomes Survey (SF-36) (McHorney, Ware, & Raczek, 1993). The IIEF, a 5-item inventory with a 5-point scale (1 = very low or almost never to 5 = high or almost always) was used as a diagnostic tool for erectile dysfunction. The IIEF-5 score is the sum of the ordinal responses to the 5 items, with higher scores indicating better erectile function. IIEF-5 scores of 21 or below are considered to denote erectile dysfunction (Rosen et al., 1997). Cronbach's α coefficient was 0.91 for this measure in this study. The EORTC QLQ PR25 was developed by a research group studying PCQOL (Borghede & Sullivan, 1996). This is a 4-point scale used to assess prostate problems (1 = not at all to 4 = very much). The score represents the sum of the ordinal responses to 25 items. Nineteen of these items (1–19) were reversed in our study, with higher scores associated with better PCQOL. The possible scores ranged from 25 to 100. The value for Cronbach's α for this measure in our study was 0.89. Depressive symptoms were measured using the CES-D (Radloff, 1977). The CES-D is a 20-item inventory with a 4-point Likert scale (0 = rarely or none of the time to 3 = most or all the time) to assess how frequently an individual has experienced certain symptoms or feelings over the previous week. The total score is the sum of the ordinal responses to 20 items, with higher scores indicating more severe depression. Scores of 16 or above are considered a risk for clinical depression (Radloff, 1977). For the classification of level of depression, scores lower than 16 indicated that mood status was stable without depression; scores of 16 to 20 indicated that mood status had reached mild depressive symptoms; scores of 21 to 26 indicated that mood status had reached moderate depressive symptoms; and scores of 27 to 60 indicated that mood status had reached severe depressive symptoms. The Cronbach's α for the study was 0.86. Resourcefulness was measured using the 36-item self-control schedule (SCS) reported by Rosenbaum (1990). The items are evaluated based on an individual's report of the extent to which they represent their own behaviour. The SCS uses a Likert-type scale that ranges from − 3 (very uncharacteristic of me) to + 3 (very characteristic of me); the scores can range from −108 to +108. The SCS was translated into Chinese, and the reliability of the SCS in Taiwanese samples has been reported as 0.88 (Huang et al., 2010). Eleven items (4, 6, 8, 9, 14, 16, 18, 19, 21, 29, and 35) were reversed, and the possible score ranged from −108 to +108. According to Rosenbaum (1990), the reliability and validity of the SCS have been well established (Huang et al., 2010). Cronbach's α was 0.84 for the current study. The SF-36 questionnaire was designed as a generic indicator of health (McHorney et al., 1993). The SF-36 measures HRQOL and includes 8 subscales that are relevant to the general health of an individual, including physical function, role limitations, bodily pain, social function, general mental health, role limitations, vitality, energy or fatigue, and general health perceptions. HRQOL is typically divided into two components, PQOL and MQOL, and it was employed in this manner in this study. The value for Cronbach's α in our study ranged from 0.75 to 0.82 among these subscales. DATA ANALYSIS Preliminary data analysis included a description of the sample using frequency distributions for categorical variables and descriptive statistics. Pearson's correlation was used to evaluate the degrees and strengths of the relationships among the study variables. Hierarchical

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regression was used to answer the study questions. According to Baron and Kenny (1986) and Gogineni, Alsup, and Gillespie (1995), complete mediation occurred if resourcefulness strongly affected DSs and the effect of pain on DSs was reduced enough to become non-significant. Moreover, ANOVA was used to determine whether there were significant differences among individuals with PC with regard to levels of DSs, PQOL, and MQOL. Post hoc power analysis was also performed. SPSS version 19.0 was used for the above analyses. A p-value b 0.05 indicated statistical significance.

RESULTS SAMPLE CHARACTERISTICS A sample of 133 adults with PC participated in the study, and their average age was 74.7 (±7.9) years (Table 1). Most of the participants were married (N = 108, 81.2%), and 92 respondents (69.2%) reported a monthly household income of under 25,000 New Taiwan (NT) dollars (1 US dollar = 32.5 NT dollars). With regard to education, 62 of the participants completed elementary school (46.6%), whereas 21 (15.9%) were illiterate. In addition, 42.1% of the participants had stage II cancer (N = 56). Regarding treatment, 32 of the participants had been treated with hormone therapy or “watchful waiting” as opposed to surgery. Brachytherapy was the most common treatment, followed by radical prostatectomy. Based on the IIEF assessment, 128 (96.1%) of the participants suffered from an erectile disorder.

Table 1 Subject characteristics (N = 133). Variables

Mean (SD)

Age (years) Duration (months) Pain (1–10) Marital status Single Married/cohabitating Widowed Divorced (other) Education (in years) Illiterate Elementary Junior high High school College(or above) Household monthly income (NT dollars) b25,000 N25,000–50,000 N50,000–75,000 N75,000–100,000 Disease stage I II III IV Therapy Watchful waiting/active surveillance Radical prostatectomy TURP/TUIP Brachytherapy Thulium lasers IIEF With disorders (b15) Without disorders Depressive symptoms ≥16 b16

74.7 (7.9) 34.9 (28.8) 2.1 (1.3)

N (%)

1 (0.8) 108(81.2) 22(16.5) 2(1.5) 21 (15.9) 62 (46.6) 18 (13.5) 18 (13.5) 14 (10.5) 92 (69.2) 13 (9.8) 17 (12.8) 11 (8.2) 5 (3.8) 56(42.1) 26(19.5) 46(34.6) 32(24.1) 23(17.3) 14(10.5) 43(32.3) 21(21) 128(96.1) 5(3.9) 75(56.4) 58(43.6)

Note: TURP: transurethral resection of the prostate; TUIP: transurethral incision of the prostate.

Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014

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H.-Y. Lin et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx

various therapies, the findings suggested that the patients with PC who underwent prostatectomy had better MQOL than those who underwent other treatments; however, there was no significant difference in PQOL between patients who underwent brachytherapy and those who were subjected to prostatectomy. As shown in Table 3, the participants with higher education were more likely to have fewer DSs than those with lower education. Additionally, the patients with erectile dysfunction had more DSs than the individuals without an erectile disorder. However, there were no significant differences among the various treatments used.

PREVALENCE OF DEPRESSIVE SYMPTOMS DSs were measured using the CES-D (Radloff, 1977)34], for which the mean score was 16.9 (SD = 5.9). The total scores were categorised as follows: normal, 0–15; mild depression, 16–20; moderate depression, 21–26; and severe depression, 27–60. In this study, the DS scores ranged from 3 to 33. Seventy-five participants (56.4%) presented a score of 16 or greater. Based on the recommended classification of DSs, 56.4% of the patients had symptoms of depression that were scaled as mild (31.5%), moderate (18.7%), or severe (6.2%).

MEDIATING EFFECTS OF RESOURCEFULNESS

RELATIONSHIPS BETWEEN DEMOGRAPHIC CHARACTERISTICS, RESOURCEFULNESS, DSs, PQOL, AND MQOL

Resourcefulness showed mediating effects on DSs, PQOL and MQOL (Fig. 1a, b and c, respectively); in other words, when participants were more resourceful, they presented better PQOL and MQOL and fewer depressive symptoms. As shown in Fig. 1a, resourcefulness mediated the relationship between pain and DSs. In step 1 of the analysis, pain significantly affected DSs (β = 0.18, t [2.124] = 0.036, p b 0.05). In step 2 of the analysis, pain significantly affected resourcefulness (β = −0.18, t [−2.073] = 0.04, p b 0.05), and resourcefulness strongly affected DSs (β = − 0.52, t [− 7.004] = 0.000, p b 0.001). However, in step 3 of the analysis, the effect of pain on DSs was reduced and became non-significant when resourcefulness was entered into the regression (β = 0.09, t [1.220] = 0.225). As described earlier in the data analysis section, complete mediation was considered to have occurred if resourcefulness strongly affected DSs and the effect of pain on DSs was reduced such that it became non-significant. These results suggest that the capacity to reduce DSs relies on an individual's resourcefulness. That is, lower pain is associated with a higher level of resourcefulness, and higher pain is associated with greater DSs. When an individual has greater resourcefulness, the relationship between pain and DSs may be reduced or even non-significant. As shown in Fig. 1b, resourcefulness mediated the relationship between pain and PQOL. In step 1 of the analysis, pain significantly affected PQOL (β = − 0.23, t [− 2.644] = 0.009, p b 0.01). In step 2 of the analysis, pain significantly affected resourcefulness (β = − 0.18, t [− 2.073] = 0.04, p b 0.05), and resourcefulness strongly affected PQOL (β = 0.37, t [4.620] = 0.000, p b 0.001). However, in step 3 of the analysis, the effect of pain on PQOL was reduced and became non-significant when resourcefulness was entered into the regression (β = −0.11, t [− 1.573] = 0.08). As described earlier in the data analysis section, complete mediation was considered to have occurred if resourcefulness strongly affected PQOL and the effect of pain on PQOL was reduced to the point of becoming non-significant. These results suggest that increasing PQOL relies on an individual's resourcefulness. That is, lower

As shown in Tables 2 and 3, participant age was negatively correlated with erectile function (IIEF) (r = −0.30⁎⁎), PCQOL (r = −0.19⁎) and PQOL (r = − 0.48⁎⁎) and positively correlated with PSA (r = 0.18⁎). Household income was positively correlated with resourcefulness and MQOL (r = 0.22⁎ and r = 0.33⁎⁎, respectively) but negatively correlated with symptoms of depression (r = − 0.20⁎). The participants' IIEF scores showed a positive relationship with their PCQOL and PQOL scores (r = 0.48⁎⁎ and r = 0.29⁎⁎, respectively) and negative relationships with depressive symptoms and stage of cancer (r = − 0.19⁎ and r = − 0.25⁎⁎, respectively). The participants with higher disease severity (i.e., stage) showed significantly lower resourcefulness (r = −0.27⁎⁎) and, to a lesser extent, lower PQOL and MQOL (r = − 0.26⁎⁎ and r = −0.27⁎⁎, respectively). PCQOL was significantly related to PQOL and resourcefulness (r = 0.39⁎⁎ and r = 0.18⁎, respectively); thus, greater PCQOL indicated greater PQOL. Furthermore, when a participant showed a high PCQOL score, he was more likely to present with fewer DSs (r = −0.28⁎⁎). Regarding resourcefulness, the participants who were more resourceful showed better MQOL and PQOL scores (r = 0.53⁎⁎ and r = 0.41⁎⁎, respectively) and fewer DSs (r = −0.52⁎⁎). That is, when patients with PC have greater resourcefulness, they more likely have better HRQOL and fewer DSs. DIFFERENCES BETWEEN DEMOGRAPHIC CHARACTERISTICS, DSs, PQOL, AND MQOL As shown in Table 3, the participants with higher education were more likely to have better PQOL and MQOL. However, the participants who made b25,000 NT dollars per month had better MQOL, whereas income showed no significant relationship to PQOL. There were significant differences related to disease stage and PQOL and MQOL scores. The patients with stage IV PC had poorer MQOL than those with stage I through stage III PC. Regarding the differences associated with the Table 2 Correlations among variables (N = 133). Variables 1. Age 2. Education 3. Income 4. Pain 5. Duration 6. IIEF 7. PSA 8. Disease Stage 9. DSs 10.PCQOL 11. Resourcefulness 12. PQOL 13 MQOL

1

2

3

4

−0.30⁎⁎ −0.14 0.05 0.09 −0.30⁎⁎ 0.18⁎ 0.09 0.11 −0.19⁎

0.13 −0.15 0.09 0.07 −0.07 −0.19⁎ −0.27⁎⁎

−0.05 −0.20⁎ 0.18⁎ 0.19⁎ 0.22⁎⁎ −0.20⁎

−0.12 −0.11 −0.05 0.22⁎ 0.21⁎

−0.03 0.28⁎⁎ 0.26⁎⁎ 0.28⁎⁎

0.10 0.22⁎ 0.01 0.33⁎⁎

−0.13 −0.18⁎ −0.24⁎⁎ −0.22⁎

0.03 −0.48⁎⁎ −0.08

5

0.03 −0.08 −0.23⁎⁎ −0.11 0.01 0.10 0.01 0.22⁎

6

−0.06 −0.25⁎⁎ −0.19⁎ 0.48⁎⁎

7

−0.01 0.29⁎⁎

0.18⁎ 0.23⁎⁎ −0.20⁎ −0.24⁎⁎ −0.23⁎⁎

0.03

−0.15

8

9

10

11

12

0.17⁎ −0.13 −0.27⁎⁎ −0.26⁎⁎ −0.27⁎⁎

−0.28.⁎⁎ −0.52⁎⁎ −0.47⁎⁎ −0.55⁎⁎

0.18⁎ 0.39⁎⁎ 0.16

0.41⁎⁎ 0.53⁎⁎

0.55⁎⁎

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Note 1. (Bonferroni corrections should be applied for the given number of correlations). Note 2. IIEF = International Index of Erectile Function; PSA = Prostate Specific Antigen; DSs = Depressive symptoms; PCQOL = Prostate cancer specific Quality of life; PQOL: Physical Quality of life; MQOL: Mental Quality of life. ⁎ p b 0.05. ⁎⁎ p b 0.01

Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014

H.-Y. Lin et al. / Archives of Psychiatric Nursing xxx (2017) xxx–xxx

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Table 3 The differences among characteristics, PQOL, MQOL and DSs (N = 133). Variables

Education ≦6grades N6grades Income ≦25,000 N25,000 Disease stage Stage I Stage II Stage III Sage IV Therapy ① Watchful waiting ② Prostatectomy ③ TURP/TUIP ④ Brachytherapy ⑤ Thulium lasers IIEF With disorders (b15) Without disorders Depressive symptoms ≥16 b16

N

PQOL

MQOL

DSs

Mean ± SD

t or F

Mean ± SD

t or F

Mean ± SD

t or F

83 50

51.9 57.6

t = −2.98⁎⁎, p = 0.003

48.5 51.0

t = −2.56⁎⁎; p b 0.01

17.8 15.4

t = −2.32⁎; p = 0.022

92 41

53.8 54.8

t = −0.455; p = 0.65

50.6 47.2

t = 3.36⁎⁎⁎; p b 0.001

16.3 17.8

t = −1.34; p = 0.182

5 56 26 46

53.4 ± 13.0 57.0 ± 9.4 55.0 ± 9.4 49.8 ± 12.4

F = 3.95⁎⁎; p b 0.01 IV b II & III

50.2 ± 4.2 50.7 ± 4.1 50.6 ± 5.0 47.0 ± 6.9

F = 4.52⁎⁎; p = 0.005 IV b I ~ III I N II ~ IV

15.2 ± 5.9 16.1 ± 5.8 16.2 ± 5.1 18.4 ± 6.3

F = 1.671; p = 0.177

32 23 14 43 21

50.9 ± 11.4 59.9 ± 7.2 49.5 ± 11.8 56.2 ± 9.9 50.9 ± 12.6

128 5

53.5 66.4

75 58

47.4 51.9

F = 3.99⁎⁎; p = 0.004 ② N ①,③ ④ N ①,③ t = −2.63⁎⁎; p b 0.01

47.2 ± 7.5 51.5 ± 4.2 46.9 ± 5.0 50.7 ± 4.8 49.4 ± 4.2

F = 3.55⁎⁎; p = 0.009 ② N ①,③ ④ N ①,③,⑤ ②N③

t = −0.971; p = 0.33 49.3 51.8

t = −5.65⁎⁎⁎; p b 0.001

F = 1.285; p = 0.279 18.1 ± 6.6 15.7 ± 5.6 18.6 ± 5.8 15.8 ± 6.1 17.5 ± 4.4

47.4 51.9

t = 3.227⁎; p = 0.02

17.2 8.8 t = −4.95⁎⁎⁎; p b 0.001

Note: TURP: transurethral resection of the prostate; TUIP: transurethral incision of the prostate. ⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.

pain is associated with a higher level of resourcefulness and also greater PQOL. When an individual has greater resourcefulness, the relationship between pain and PQOL may be reduced or become non-significant. As shown in Fig. 1c, resourcefulness mediated the relationship between pain and MQOL. In step 1 of the analysis, pain significantly affected MQOL (β = − 0.20, t [− 2.33] = 0.02, p b 0.05). In step 2 of the analysis, pain significantly affected resourcefulness (β = − 0.18,

t [− 2.073] = 0.04, p b 0.05), and resourcefulness strongly affected MQOL (β = 0.54, t [7.30] = 0.000, p b 0.001). However, in step 3 of the analysis, the effect of pain on MQOL was reduced and became non-significant when resourcefulness was entered into the regression (β = −0.10, t [−1.411] = 0.16). As described earlier in the data analysis section, complete mediation was considered to have occurred if resourcefulness strongly affected MQOL and the effect of pain on MQOL was reduced such that it became non-significant. These results suggest that achieving increased MQOL relies on an individual's resourcefulness. That is, lower pain is associated with a higher level of resourcefulness and with greater MQOL. When an individual has greater resourcefulness, the relationship between pain and MQOL may be reduced or become non-significant. DISCUSSION

Fig. 1. Mediating effects of resourcefulness occurred between pain and DSs, PQOL, and MQOL.

Nurses' perspectives regarding the identification of risk factors for depression in survivors of PC have been investigated in recent years. However, depression in men has not been sufficiently studied in Taiwan and Asia. Thus, empirical data must be generated to encourage healthcare providers and family members to assess men for maladaptive behaviours as well as the expression of DSs. Our current study identified a much higher percentage of patients with PC experiencing DSs than previous studies (Jayadevappa, Malkowicz, Chhatre, Johnson, & Gallo, 2012; Roth et al., 1998). We considered that most individuals at risk for DSs have advanced disease, feel distress with respect to the side effects of their treatments, worry about recurrence, and may have a history of clinical depression or a lack of resourcefulness. Additionally, in the current study, the majority of participants were not highly educated—some completed elementary school and others were illiterate—which was significantly related to the presence of DSs. Most of the surveyed respondents had incomes lower than NT$ 25,000 per month; the participants with higher incomes were more likely to have greater resourcefulness and thus better MQOLs than those with lower incomes. Additionally, participant age was negatively correlated with erectile function and PQOL, consistent with previous studies. Based on the above findings, healthcare providers might choose

Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014

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intervention therapies or treatments based on minimizing concerns over side effects in the future or search for more effective methods of decreasing distress for survivors of PC. In the current study, 96% of the participants experienced erectile disorder, which was related to the presence of DSs and lower PQOL. Educational content related to the above that presents the benefits or side effects associated with various treatments should be provided to survivors of PC and their family members to improve their understanding of such outcomes. Furthermore, the majority of the participants in the current study had a lower educational status (i.e., no education beyond elementary school or illiteracy), which must be taken into consideration when applying interventions. For instance, healthcare professionals should provide education about various treatments using easily learned content describing how certain treatments for PC may increase erectile dysfunction and impact PQOL, MQOL, and DSs. In Taiwanese culture, elderly men may not reveal their feelings about erectile dysfunction. However, the results of this study demonstrated that patients with better erectile function presented better PQOL and prostate-specific QOL. Thus, healthcare providers may consider the use of active therapies, such as sexual rehabilitation and cognitive behavioural therapy, to help patients improve erectile dysfunction. Prostate cancer screening with PSA testing can effectively reduce mortality, although such screening remains controversial. In our centre, we routinely monitor PSA every three months, as PSA is positively related to cancer stage and DSs. Thus, healthcare providers can receive insights into the physical and mental status of survivors of PC by measuring their PSA levels. Regarding the different treatments options used for our sample, most of the participants underwent brachytherapy, the side effects of which include bloody urine and semen with bowel discomfort. These symptoms may last for months. Other treatments also have side effects. It is difficult to predict whether a given side effect will become permanent or only temporary. However, healthcare providers should inform survivors of PC about the side effects associated with various treatments, as different treatments were found to significantly affect MQOL and PQOL in these patients. The enrolled patients whose PC was at a more advanced stage reported worse PQOL and MQOL. In addition, resourcefulness was found to play a crucial role in mediating pain and HRQOL, ultimately enhancing HRQOL. Healthcare professionals should assess an individual's skills based on their condition and recommend appropriate intervention strategies. When survivors of PC have less resourcefulness, they are more likely to have negative health-related outcomes. To help patients with PC achieve a positive attitude about their health condition or treatment course, nurses should provide psychosocial education. Because individuals with PC may have side effects from invasive therapies, positive thinking and/or effective control skills may enhance their ability to cope during their long therapeutic journey. Regarding the mediating effects of resourcefulness with regard to pain and health outcomes, the patients with PC who had greater resourcefulness showed better PQOL, better MQOL, and fewer symptoms of depression. As a mediator, resourcefulness significantly reduces the impact of pain on health outcomes. These findings are consistent with those of previous studies showing that individuals with low resourcefulness are more likely to be depressed in situations that cause elevated stress (Huang et al., 2010; Huang, Perng, Chen, & Lai, 2008; Huang et al., 2007). Based on these findings, nurses should provide psychological education interventions to patients with PC to improve their resourcefulness regarding pain control, which should consequently influence their health outcomes. Treatments for localized PC are highly associated with significant urinary problems, bowel problems, and erectile dysfunction and consequently diminish a patient's HRQOL (European Association of Urology, 2015). In the current study, the majority of participants chose brachytherapy, which may lead to soreness and bruising between the legs at the sites of needle entry as well as discomfort while passing urine.

These side effects can last for weeks or months and may be associated with the higher prevalence of depression for patients with PC measured here compared to previous studies. Hence, making a treatment decision for patients with PC is challenging. Healthcare professionals should provide detailed information to patients regarding their treatment choices and also use well-prepared prostate management strategies. Furthermore, HRQOL in males with PC is affected by both disease-specific and treatment-related effects. For males with more advanced disease, sexual function may be less of a priority. Few methodological limitations exist in this study, as a convenience sampling method was used. Our sample included only individuals with PC who resided in local areas, thus limiting the generalizability of our results. Furthermore, inclusion in the sample population was voluntary, which might have resulted in a sample that is less representative of the general population. Moreover, the cross-sectional nature of the present data also makes it difficult to assess the outcome variables over time. Thus, multiple different time series of outcome variables should be assessed in a future study. The final notable limitation is associated with the treatment categories used, which could be considered in further detail in future research. CONCLUSIONS The current findings revealed the following: 1) survivors of PC have a high prevalence of DSs; 2) individual resourcefulness has direct and mediating effects on DSs and HRQOL in patients with PC; 3) and no treatment is superior for the survival of these patients. The above information should be used by healthcare professionals to help choose the best treatment strategy on an individual basis. In Taiwanese culture, patients with PC who choose their own treatment options usually follow their physician's suggestions and generally opt for brachytherapy, transurethral resection of the prostate, or transurethral incision, all of which are as effective as radical prostatectomy. We recommend that future studies comparing the effects of different treatments consider the post-treatment timeframe, which may influence findings on health outcomes. IMPLICATIONS FOR NURSING A high percentage of males with PC exhibit depressive symptoms. Nurses can endeavour to prevent or assess depressive symptoms in survivors of PC. Such symptoms may be particularly associated with disease-related side effects or feelings of distress following treatment. The identification and prevention of depressive symptoms are also important for patients who are not receiving invasive treatments because they have a terminal status, as such patients may need additional support. An individual's QOL is determined by their mental and physical status prior to diagnosis, their attitude toward their disease, their willingness to make compromises, their choice of therapies, and their ability to take advantage of supportive resources that may help reduce stress and increase self-control skills. In addition, HRQOL is a multidimensional construct that involves a patient's perspective of their own physical and mental status and also encompasses their reactions to coping with stressful life circumstances. In this study, we showed that resourcefulness has mediating effects on pain, DSs, PQOL, and MQOL. When participants were more resourceful, they presented better PQOL, better MQOL and fewer DSs. Therefore, self-control skills (resourcefulness) are helpful to patients striving to cope with surviving cancer. Nurses can help patients build self-control skills by educating them on self-care and self-help strategies. According to the findings of this study and Rosenbaum's resourcefulness concept, nursing managers may establish individual or group cognitive behavioural therapy containing improving patients' cognitive skills in their behavioural changes to help individuals use internal processes, so that they can get help when facing distress. Additionally, PC

Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014

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Please cite this article as: Lin, H.-Y., et al., Depression and Health-related Quality of Life and Their Association With Resourcefulness in Survivors of Prostate Cancer, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.04.014