Predictive role of family dysfunction on psychological morbidity in breast cancer patients

Table 1 Participant characteristics and demographic profile by psychological health status, n (%)/mean ± SD

Variable	Total (n = 285)	Normal psychological health (n = 167)	Psychological problems (n = 118)	Statistical value	P value
Age (years)	52.7 ± 11.3	54.8 ± 10.9	49.6 ± 11.8	t = 3.64	0.001
Age groups				χ2 = 8.92	0.011
≤ 50 years	118 (41.4)	61 (36.5)	57 (48.3)
51-60 years	109 (38.2)	68 (40.7)	41 (34.7)
> 60 years	58 (20.4)	38 (22.8)	20 (17.0)
Marital status				χ2 = 6.78	0.034
Married	224 (78.6)	137 (82.0)	87 (73.7)
Unmarried	28 (9.8)	13 (7.8)	15 (12.7)
Divorced/widowed	33 (11.6)	17 (10.2)	16 (13.6)
Education level				χ2 = 9.34	0.025
Primary school and below	44 (15.4)	21 (12.6)	23 (19.5)
Junior high school	55 (19.3)	29 (17.4)	26 (22.0)
High school	98 (34.4)	58 (34.7)	40 (33.9)
College and above	88 (30.9)	59 (35.3)	29 (24.6)
Residence				χ2 = 3.21	0.073
Urban	203 (71.2)	123 (73.7)	80 (67.8)
Rural	82 (28.8)	44 (26.3)	38 (32.2)
Employment status				χ2 = 12.45	0.006
Employed	156 (54.7)	98 (58.7)	58 (49.2)
Retired	67 (23.5)	42 (25.1)	25 (21.2)
Unemployed	42 (14.7)	18 (10.8)	24 (20.3)
Other	20 (7.1)	9 (5.4)	11 (9.3)

Table 2 Family functioning assessment and psychological health outcomes by group status, n (%)/mean ± SD

Variable	Total (n = 285)	Normal psychological health (n = 167)	Psychological problems (n = 118)	Statistical value	P value
Family functioning assessment (FAD scores)
Affective responsiveness	1.91 ± 0.55	1.68 ± 0.43	2.24 ± 0.61	t = 7.95	< 0.001
Affective responsiveness dysfunction	101 (35.4)	38 (22.8)	63 (53.4)	χ2 = 27.78	< 0.001
Affective involvement	1.78 ± 0.49	1.59 ± 0.38	2.05 ± 0.55	t = 7.34	< 0.001
Affective involvement dysfunction	79 (27.7)	28 (16.8)	51 (43.2)	χ2 = 23.12	< 0.001
Behavior control	1.85 ± 0.53	1.64 ± 0.41	2.15 ± 0.59	t = 7.56	< 0.001
Behavior control dysfunction	91 (31.9)	35 (21.0)	56 (47.5)	χ2 = 22.34	< 0.001
General functioning	1.89 ± 0.47	1.67 ± 0.35	2.21 ± 0.52	t = 9.15	< 0.001
Overall family dysfunction	93 (32.6)	28 (16.8)	65 (55.1)	χ2 = 45.23	< 0.001
Psychological health outcomes (HADS scores)
Anxiety score (HADS-A)	6.8 ± 4.2	4.3 ± 2.1	10.5 ± 4.8	t = 12.89	< 0.001
Anxiety symptoms (≥ 8)	80 (28.1)	0 (0.0)	80 (67.8)	χ2 = 89.45	< 0.001
Severe anxiety (≥ 11)	45 (15.8)	0 (0.0)	45 (38.1)	χ2 = 56.78	< 0.001
Depression score (HADS-D)	7.1 ± 4.5	4.1 ± 2.3	11.2 ± 5.1	t = 13.67	< 0.001
Depression symptoms (≥ 8)	91 (31.9)	0 (0.0)	91 (77.1)	χ2 = 98.23	< 0.001
Severe depression (≥ 11)	52 (18.2)	0 (0.0)	52 (44.1)	χ2 = 61.45	< 0.001
Comorbid anxiety and depression	53 (18.6)	0 (0.0)	53 (44.9)	χ2 = 67.89	< 0.001

FAD: Family Assessment Device; HADS: Hospital Anxiety and Depression Scale; HADS-A: Hospital Anxiety and Depression Scale-anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-depression subscale.

Table 3 Correlation analysis between family functioning and psychological health by group status, mean ± SD

Family functioning dimension	Normal psychological health (n = 167)	Psychological problems (n = 118)	Statistical value	P value
Communication dysfunction
FAD score	1.74 ± 0.45	2.43 ± 0.68	t = 9.24	< 0.001
Correlation with anxiety	r = 0.234	r = 0.612	z = 4.67	< 0.001
Correlation with depression	r = 0.198	r = 0.589	z = 4.23	< 0.001
R2 (variance explained)	5.5%	37.4%	F = 45.67	< 0.001
Role dysfunction
FAD score	1.69 ± 0.42	2.34 ± 0.64	t = 8.67	< 0.001
Correlation with anxiety	r = 0.212	r = 0.578	z = 4.12	< 0.001
Correlation with depression	r = 0.189	r = 0.534	z = 3.89	< 0.001
R2 (variance explained)	4.0%	33.4%	F = 38.94	< 0.001
Affective responsiveness dysfunction
FAD score	1.68 ± 0.43	2.24 ± 0.61	t = 7.95	< 0.001
Correlation with anxiety	r = 0.195	r = 0.523	z = 3.67	< 0.001
Correlation with depression	r = 0.167	r = 0.498	z = 3.45	0.001
R2 (variance explained)	3.3%	27.4%	F = 32.78	< 0.001
Problem-solving dysfunction
FAD score	1.67 ± 0.41	2.18 ± 0.58	t = 7.83	< 0.001
Correlation with anxiety	r = 0.178	r = 0.467	z = 3.12	0.002
Correlation with depression	r = 0.156	r = 0.434	z = 2.89	0.004
R2 (variance explained)	2.8%	21.8%	F = 26.45	< 0.001

FAD: Family Assessment Device.

Table 4 Univariate analysis of risk factors for psychological morbidity, n (%)

Risk factor	Normal psychological health (n = 167)	Psychological problems (n = 118)	OR (95%CI)	χ2 value	P value
Demographic factors
Age
> 50 years	106 (63.5)	61 (51.7)	1.00 (reference)	4.12	0.042
≤ 50 years	61 (36.5)	57 (48.3)	1.58 (1.02-2.44)		0.041
Education level
> High school	117 (70.1)	69 (58.5)	1.00 (reference)	5.34	0.021
≤ High school	50 (29.9)	49 (41.5)	1.71 (1.09-2.69)		0.020
Employment status
Employed/retired	140 (83.8)	83 (70.3)	1.00 (reference)	8.23	0.004
Unemployed	18 (10.8)	24 (20.3)	2.14 (1.28-3.57)		0.004
Other	9 (5.4)	11 (9.3)	1.67 (0.89-3.12)		0.112
Household income
≥ 5000 yuan/month	91 (54.5)	47 (39.8)	1.00 (reference)	7.89	0.005
< 5000 yuan/month	76 (45.5)	71 (60.2)	1.89 (1.21-2.95)		0.005
Marital status
Married	137 (82.0)	87 (73.7)	1.00 (reference)	3.21	0.073
Unmarried/divorced/widowed	30 (18.0)	31 (26.3)	1.63 (0.95-2.78)		0.077
Residence
Urban	123 (73.7)	80 (67.8)	1.00 (reference)	1.23	0.267
Rural	44 (26.3)	38 (32.2)	1.33 (0.81-2.18)		0.259
Disease-related factors
TNM stage
Early stage (I-II)	119 (71.3)	66 (55.9)	1.00 (reference)	7.34	0.007
Advanced stage (III-IV)	48 (28.7)	52 (44.1)	2.31 (1.47-3.63)		< 0.001
Molecular subtype
Luminal A/B	129 (77.2)	81 (68.6)	1.00 (reference)	8.92	0.030
HER2-positive	24 (14.4)	21 (17.8)	1.39 (0.75-2.58)		0.291
Triple-negative	14 (8.4)	16 (13.6)	2.67 (1.35-5.28)		0.005

OR: Odds ratio; CI: Confidence interval; TNM: Tumor-node-metastasis-based; HER2: Human epidermal receptor 2.

Table 5 Multivariate logistic regression analysis of family dysfunction as a predictor

Variable	β coefficient	SE	Wald χ2	OR (95%CI)	P value
Family functioning variables
Overall family dysfunction	1.178	0.291	16.42	3.247 (1.832-5.756)	< 0.001
Communication dysfunction	1.025	0.274	14.01	2.789 (1.623-4.791)	< 0.001
Role dysfunction	0.851	0.263	10.45	2.341 (1.389-3.947)	0.001
Affective responsiveness dysfunction	0.638	0.252	6.42	1.892 (1.156-3.096)	0.011
Problem-solving dysfunction	0.467	0.267	3.06	1.595 (0.946-2.691)	0.080
Control variables (final model)
Age (≤ 50 years vs > 50 years)	0.587	0.271	4.69	1.799 (1.059-3.057)	0.024
TNM stage (III-IV vs I-II)	0.798	0.276	8.35	2.221 (1.293-3.815)	0.003
Treatment side effects (severe vs mild)	0.689	0.264	6.81	1.992 (1.188-3.340)	0.007
Variables not retained in final model
Education (≤ high school vs > high school)	0.421	0.298	1.99	1.523 (0.849-2.734)	0.158
Employment (unemployed vs employed)	0.487	0.345	1.99	1.627 (0.827-3.201)	0.158
Molecular subtype (triple-negative)	0.567	0.398	2.03	1.763 (0.808-3.847)	0.154
Surgical method (mastectomy vs BCS)	0.423	0.289	2.14	1.527 (0.866-2.690)	0.143

SE: Standard error; OR: Odds ratio; CI: Confidence interval; TNM: Tumor-node-metastasis-based; BCS: Breast conserving surgery.