Abstract
This study aimed to determine the predictive factors of depression among relatives of person deceased by brain death. In this study, 106 first-degree relatives of people who died of due to brain death were studied. Of the study units, 72.64% had levels of depression (severe, moderate, and mild). Among the dependent variables concerning deceased person, age and gender of the deceased were significantly correlated with the depression of their relatives. Among the variables concerning relatives, low level of education, unemployment and time elapsed after brain death have significant role in the incidence or prediction of their depression (p < 0.05). The results indicated a high prevalence of depression among relatives of men aged 30–50 who died because of brain death. It is recommended to consider this fact in planning to care relatives, especially among the low-educated, the unemployed and experiencing the first year of death, of people deceased by brain death.
Mood disorders cover a wide range of psychological issues, to which depression is the most prevalent (Uher et al., 2014; Varcarolis, 2016). The prevalence of depression, according to the World statistics, varies from 2.6% among men in Western (developed) countries to 5.9% among African women (World Health Organization [WHO], 2017). In Iran, the prevalence of depression in a national study was reported to be 12.7% (Sharifi et al., 2015) as depression is now the fourth-leading cause of the global disease burden (Shahraz et al., 2014)
Symptoms of depression are characterized by changes in appetite, weight, sleep and activity, lack of energy, feeling guilty, difficulty in thinking and decision making, and recurrent thoughts of death or suicide (Chirita & Untu, 2016). Indeed, the symptoms of depression vary by culture, as somatic symptoms of depression are more highlighted in Iranian society (Amini et al., 2013; Zarean et al., 2014). Symptoms of depression affect relatively all features of an individual's existence, including one’s body and social relationships. (Montazeri et al., 2013). It is a life-threatening condition by suicide (Ahmed et al., 2017; O’connor, 2016), and a psychological factor for absenteeism (D. Johnston, Harvey, et al., 2019), incapacity (Meng et al., 2017), and decrease in quality of life (K. M. Johnston, Powell, et al., 2019).
There are several factors contributing to depression. One of the major causes of depression is stressful life events, such as defects in interpersonal communication that play an important role in the development of depression (Park et al., 2017; Rudolph et al., 2016). One of the causes of interpersonal communication failure is the death of a loved one (Bowen, 2018). Occasionally, the death of loved ones occurs due to brain death or abnormal events, in which the relatives or the intimates are more likely to react to loss and consequently leads to depression (Boelen & Lenferink, 2020; Hosseinrezaei et al., 2014). Concerning the reasons, some researchers believe that accepting loved one’s demise due to brain death is fundamentally different and more stressful than gradual deaths with pre-awareness. Thus, it is much more difficult to tolerate and then have more psychological consequences for relatives (Hosseinrezaei et al., 2014). Other researchers have also cited the association of abnormal and premature death with complicated grief and the association of complicated grief with depression as the reason for the higher prevalence of depression among relatives of this group (Kristensen et al., 2012; Melhem et al., 2013). Kristensen et al. (2012) also consider that if relatives feel loved one's death is preventable, they will react to this loss with rage and belligerence, impugning themselves or others in the process, so these factors contribute to depression, its severity, and its duration. Accordingly, some scholars such as Hosseinrezaei et al. (2014) estimate prevalence of depression 75% in Iran among relatives of people died by brain death, whilst more than 15,000 brain deaths ensue annually in Iran because of accidents, especially crash or traffic collisions (Yazdimoghaddam & Manzari, 2017).
Researchers in this study believe that, according to their considerations over authentic databases, no study has conducted to determine the predictive factors of depression among relatives of people died by brain death. There have also been very few studies addressing only some of the factors contributing to psychological condition among these people (Cinque & Bianchi, 2010; Hosseinrezaei et al., 2014; Jacoby et al., 2005; Tavakoli et al., 2008). For instance, a study in 2014 by Hossein Rezaei et al. on relatives of person died by brain death has indicated that the prevalence of depression is significantly higher among children of deceased as compared with other members, yet sex, age and education of members are not correlated to their depression. One of the variables we favored in this regard was organ donation and its association with the depression of members. In this regard, only three studies have been found that their results were reported contradictory and did not support each other, (Abedi et al., 2012; Hosseinrezaei et al., 2014; Jacoby et al., 2005). These studies have highlighted the fact that further studies are needed to clarify different aspects of the issue.
Given the significance of depression and its high burden on the individual, family and society, lack of studies conducted on the prevalence of depression among relatives of deceased primarily caused by brain death, and undetermined factors concerning depression of families of the deceased due to brain death, the present study aimed to determine the predictive factors of depression among relatives of people died by brain death in Iranian society. Two hypotheses were sought in this study: (1) There is a relationship between deceased-related variables and brain death (such as demographic variables, time elapsed after death, and organ donation) with relatives’ depression. (2) There is a relationship between the demographic variables of relatives and the depression.
Materials and Methods
Study Design
This study was a descriptive correlational study that was conducted from 5 November 2018 to 26 January 2019.
Setting
The study was conducted on first-degree relatives of the deceased who lived in Zanjan province, one of the northwestern provinces of Iran, with 1300,000 population.
Sampling and Participants
For sample size calculation, we considered α = 0.05 and power = 80%. Necessary sample size was calculated at least 102 participants. The sampling method embraced multistage process. In the first stage, five hospitals out of eleven hospitals in the province were selected by simple random sampling. The following criteria were taken into account: (1) At least two months after death on the basis of DSM-IV-TR (Ogasawara et al., 2018); (2) Consenting to participate in the study; (3) Not having physical illnesses, based on self-report; (4) Not having depression before death of relative, based of participants reports; (5) No more than two years have passed since the death of the deceased. Based on some inclusion criteria (specially at least two months after death, and not more than two years have passed since the death of the deceased) the records of cases of brain death in selected hospitals were reviewed to access addresses of eligible families. In this stage, 141 families with almost average 4 members were recognized. Out of 141 families, 5 families were excluded due to unwillingness to participate in the study (n = 136). Next, from the eligible family members, one of them was selected by simple random sampling. In this process one of the researchers (MR) went to the address of the families, assessed the family members according to the inclusion criteria, selected one of them, and gave her/him a questionnaire to complete. From the 136 distributed questionnaires, 106 were correctly filled and analyzed. It should be noted that the attritions or excluded persons were homogeneous in terms of demographic characteristics with the remaining samples in the study.
Ethical Considerations
The study proposal was approved by the Research Council and Ethics Committee of Zanjan University of Medical Sciences with code ZUMS.REC. 891233. Hospital managers permitted access to the records of deceased patients due to brain death. The objectives of the study were clearly explained for the participants. The principle of missing a name was observed for the participants. Research units were reserved to be free to participate or not in the research.
Instruments
Two questionnaires (demographic questionnaire for relatives and Beck Depression Inventory-21 scale) and one form (for evaluating the characteristics of the deceased) were applied to collect data. The demographic questionnaire of the relatives included questions regarding age, sex, education, marital status, employment, place of residence, relative to the deceased. The Beck Depression Inventory-21 (BDI-21) has 21 questions, rated as a four-point Likert scale, ranging from zero to three. The score of 11 is considered as a cut-off point on this scale. The score of less than 11, the score of 11–18, the score of 19 to 29, and the score of more than 30 indicate respectively represent no-depression to mild depression, mild to moderate depression, moderate to severe depression, and severe depression (Beck et al., 1988). The deceased profile form contained questions about some variables related to the deceased that were completed by researchers based on information in the deceased's hospital file and included variables such as age, sex, having record of organ donation or not, and the length of hospitalization of the deceased until It was time to die.
Data Analysis
SPSS software version 20 was used for data analysis. To determine the predictive factors of depression among relatives of patients with brain death, firstly the linear relationship of each factor was determined using t-test and chi-squared test and then to define the coefficient of significance and chance of depression, all significant variables entered into multivariate logistic regression model. P < 0.05 was considered significant in this study.
Results
Descriptive Results on Demographic Characteristics of the Deceased and Relatives
According to the results, 52% of the participants were female and 63% were married and the mean age of the subjects was 38.89 ± 9.21 years. The majority of the subjects (67%) were employed and 65% resided in the city. In terms of the ratio of deceased to research units, the ratio of siblings (33%), parents (28%) and spouse or children (39%). Regarding the time elapsed since the death of a person until the time of sampling, 44% of the deceased was between 2 and 12 months and 56% more than 12 months. 53% was of donor group and 47% of non-donor group (Table 1).
Characteristics of Participants, Deceased, and Logistic Regression Results for Prediction of Depression Status Among Relatives of the Deceased.
The Relationship Between Demographic Variables of Deceased and Relatives With Their Depression
The mean depression score of the research units was 17.4 ± 11.46. Among the relatives, 72.64% of the subjects had several levels of depression. Logistic regression analysis indicated that if the deceased were male, the possibility of their relatives being depressed was 7.5 times higher than those of the deceased female. If the deceased were in the age group of 30–50, relatives were 9.94 times more likely to have depression than other age groups. Regarding the dependent demographic variables and their association with depression, the results revealed that relatives with low education were 15.63 times more likely to have depression than those with a high school or higher. Female relatives were nearly depressed likely twice more than men, although this difference was not statistically significant. Working people were 11.6 times more likely to be depressed than those who were unemployed, and those whose loved one’s death elapsed between two to twelve months were more likely to be depressed than others. In addition, the results showed that the phenomenon of donation or non-donation did not correlate with relatives' depression (Table 1).
Discussion
This study aimed to determine the predictive factors of depression among relatives of brain death patients in Zanjan province. As an introduction to this section, after reviewing past studies, it should be noted that previous studies were very limited for the same purpose as of our study. However, there have been a significant number of studies on factors associated with complicated grief. Since it has been shown that there is a significant relationship between complicated grief and depression of relatives the deceased (Melhem et al., 2013; Salloum et al., 2019), we also used these studies to interpret and justify the findings.
Our study indicated that a significant percentage of relatives (72.64%) of patients with brain death had some degree of depression. In the past, some researchers have shown a high prevalence of depression among relatives of patients with brain death, for example; Borges and Prasanth (2016) revealed that the prevalence of depression among relatives of this type of death in India is 66%. Similarly, Hosseinrezaei et al. (2014) reported a 75% prevalence of depression in relatives of the deceased by brain death in their study. The prevalence of depression in this group of people is high in comparison to the prevalence of this disorder in the general population which is less than 10% (WHO, 2017). Comparing the prevalence of depression in among relatives studied with the global prevalence of depression indicates a significant difference between the two statistics. The reasons for this difference are evidence since death by brain death has very devastating effects, psychologically speaking, on their first-degree relatives, and the loss of a loved one in an unexpected incidence through the destruction of social support (Zara, 2020), separation distress and disorder in self-concept (Keyes et al., 2014) leads to depression and anxiety in relatives. Kristensen et al. (2012) propose three reasons for higher psychological complications, such as depression, among relatives of such deaths compared to natural deaths: first, understanding the reality of such deaths is difficult to the relatives; second, one of the important variables to get along with death is pre-death care, where abnormal deaths take this opportunity and final farewell away to a loved one from relatives; and third, sudden deaths usually befall due to terrifying causes giving relatives the feeling of a helpless witness.
Our study highlighted that depression was more likely among relatives of deceased men aged 30–50. Li et al. (2015) have also shown that the death of a husband or father of the family is significantly related to complicated grief. Since one of the important factors affecting the psychological complications of relatives is the perception of the level of support (Burke et al., 2019). Seemingly, vacancies in men of reproductive age are more likely to be felt because of the active role they can play in supporting the family, and the loss of men at this age has more psychological strain on relatives causing depression. In other words, the high prevalence of depression among the relatives of the deceased can be justified through the different family roles exerted by men and women in families (Schmitt, 2008). It should be noted that in Iran the traditional pattern of gender-oriented role segregation still persists and may explicate the results of this study.
Our study indicated that if loved one's death was elapsed less than one year (between 2 and 12 months), the possibility of depression among his/her relatives was more likely, seemingly they are able to adapt to the situation after one year. This finding is in line with the results of the study by Boelen and Lenferink (2020). Kristensen et al. (2012) further confirm the finding that psychological reactions to natural deaths usually subside within the first 6 months, yet sudden and abnormal deaths are usually associated with prolonged grief (6 to 12 months). The researchers report the reasons for the severe response of relatives in abnormal deaths as following: the severe shock and lethargy caused by these types of absences, the synergistic effect of trauma and grief reactions, and the difficulty of filling the gap of missing the loved one.
The results revealed that organ donation or non-organ donation does not play a role in the rate of depression among relatives, which was consistent with two other studies in this regard (Hosseinrezaei et al., 2014; Tavakoli et al., 2008). In other words, it can be concluded that organ donation has no negative or protective effect on the process of relieving grief and the degree of subsequent depression caused by donor’s brain death.
Our study showed that having “none or primary education” is one of the significant predictive factors of depression in relatives. In other words, relatives of low literacy are more likely to become depressed after the death of a loved one. However, in this context, the results of previous studies that have mainly concentrated on the relationship between literacy levels and long and complicated grief are inconsistent, for example, Burke et al. (2019) indicated that there was no significant relationship between these two variables (level of literacy and psychological distress). However, another set of studies consistent with our study has shown that low literacy is one of the important variables predicting psychological disorders among relatives (Burke & Neimeyer, 2013).
Consistent with some previous studies on the factors associated with complicated grief (Li et al., 2015), and depression (Salloum et al., 2019). With regard to abnormal and sudden deaths, our study demonstrated that the gender of relatives had no relation to depression. Still, other studies have shown that psychological reactions (Burke et al., 2019; Kristensen et al., 2015), depression (Boelen & Lenferink, 2020) and loss of loved ones in women are significantly greater and more severe than men.
Unlike some previous studies that examined factors associated with the psychological reactions and complicated grief of the relatives of the deceased (Boelen & Lenferink, 2020; Burke & Neimeyer, 2013; Li et al., 2015), our study showed that age was not associated with depressive symptoms in relatives. This finding, however, confirms the findings of some other researchers in the past (Salloum et al., 2019).
The results showed that there was no relationship between the deceased and depression of family members of the deceased. This finding is acknowledged by the study by Salloum et al. (2019). Yet other studies have also shown that the prevalence of psychological disorders is higher and more common in the spouse or children of the deceased or the deceased's parents (Boelen & Lenferink, 2020; Li et al., 2015). There was a positive correlation between the depression rate and the unemployment rate. This finding supports the results of the study by Álvaro et al., (2019).
Relying on previous studies (Probst et al., 2006), we expected that villagers would be more frequently and severely depressed because of poor health, poverty, and chronic diseases, yet the results, contrary to our expectation, showed a high prevalence of depression among relatives based on their location (city and country residents) is not significantly different. This finding confirms the results of some other relatively recent studies in the past, for example; Kessler & et al. in 2003 also showed that there was no relationship between depression and place of residence. The existence of such inconsistencies can be justified by the influence of cultural factors on the incidence of depression, which some scholars have emphasized (Weaver et al., 2015).
Concerning marital status and its association with depression, the results of this study in line with the study by Bruce et al. (1990), showed that marital status has no relation to depression. Previous studies, however, have found that single individuals are more likely to become depressed than married ones, regardless of whether they have lost loved ones (Bulloch et al., 2017; Hadianfar et al., 2019). The pattern of depression in relatives of person died by brain death appears to be different from that of depression in another comprehensive study, and further studies are needed to clarify the unknown dimensions of depression among them.
Finally, it should be pointed out that, in light of the results of this study and the inconsistencies in the results of previous studies regarding the factors associated with depression in relatives of people with sudden and abnormal deaths such as brain death, factors such as different data collection, data collection tool, and statistical methods play significant role in these inconsistencies.
Limitations
The present study, like many other studies, had some limitations; the most important limitation was the incompleteness of the third section of the questionnaire (section on the profile of the deceased) due to incomplete hospitalization case of persons with brain death, explaining the fact that in the history of the deceased person and his case only gender, age, and length of hospitalization were recorded before death. Another limitation of the study that affected the generalizability of the results was the low sample size, which was not possible due to the limited resources available to expand the research environment. The third limitation of this study was the design, which was descriptive and could not investigate the causal relationships between the variables. The fourth limitation was the use of a questionnaire to assess depression and its severity, which validates its subject bias error. The fifth limitation of the study was that we examined only some of demographic characteristics of the relatives and the deceased. However, many factors may play crucial role in depression. The last limitation of this study was the limited number of studies on the factors associated with depression of relatives of people died by brain death that challenged the findings. Despite these limitations, this study contributes to existing knowledge about the frequency of depression among relatives of those died by brain death and related factors in the East.
Conclusion and Clinical Implications
Due to the high prevalence of depression in unemployed relatives with low education of the deceased men in reproductive age, laypersons and professionals should support these people through well-known and specialized techniques in this regard as following; representing a more distress-releasing image of death (dying in sleep or feeling no pain); supporting in confrontations, in which grieving families are understood about the ruthless reality of death in a compassionate and sympathetic context; having perception about the condition and facts of the occurrence (for instance, the cause of death), which can be significant in managing understanding of the reality of death, yet this has not been optimized for further adjustment. However, given the limitations of this study, more studies with larger sample sizes and other communities are required to reach definite answers to the research question and to explain the unknown aspects of the relationship between variables of patients with brain death with demographic variables and depression. Future studies need to address other demographic variables of the deceased such as being employed or unemployed, type of job, income, sick or healthy, etc., which were unfortunately ignored due to deficiencies in hospital records. Finally, it is suggested that other studies consider some other factors that we did not employ in this investigation.
Footnotes
Acknowledgments
We would like to extend our gratitude to all the families of the deceased who cooperated in the implementation of the sincere plan for their undoubted assistance.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Zanjan University of Medical Sciences under Grant 891233.
