# Role of Sense of Coherence in Mediating the Relationship Between End-of-Life Caregiving Burden and Bereavement Depressive-Symptom Trajectory

## TL;DR

A strong sense of coherence helps reduce psychological distress in caregivers after the death of a loved one, especially those with high caregiving burdens.

## Contribution

This study longitudinally examines how sense of coherence mediates the relationship between caregiving burden and depressive symptoms during bereavement.

## Key findings

- SOC partially or completely mediates the impact of caregiving burden on depressive symptoms during the first two years of bereavement.
- Stronger SOC is associated with recovery and resilience trajectories, while weaker SOC is linked to more distressing depressive-symptom trajectories.
- The SOC-mediating effect is more pronounced in caregivers with severe caregiving burdens.

## Abstract

The results of meta-analyses indicate sense of coherence (SOC) has a positive effect in terms of reducing subjective caregiving burden and depressive symptoms in family caregivers. However, the mechanism by which SOC mediates psychological distress remains unexplored longitudinally.

This study was designed to examine how SOC mediates the impact of self-perceived caregiving burden on depressive symptoms during the first 2 years of bereavement following the care-recipient’s death.

For this secondary analysis, 649 individuals who had provided end-of-life caregiving to cancer patients were recruited and enrolled as participants. Their appraisal of caregiving burden over the patient’s last 6 months was categorized into four (slight, mild, moderate, and severe) trajectories based on the Caregiver Reaction Assessment (CRA) score. Using multinomial logistic regression, how SOC mediates the relationship between CRA trajectories and seven depressive-symptom trajectories (minimal-impact-resilience, recovery, preloss-only, delayed-symptomatic, relief, prolonged-symptomatic, chronically persistent distressed) was examined using the three recommended steps for mediation analysis.

The largest percentage (27.6%) of participants endured moderate-to-severely high end-of-life (EOL) caregiving burden, and one-fourth (24.0%) experienced distressing depressive-symptom trajectories (i.e., delayed symptomatic, relief, prolonged symptomatic, and chronically persistent distressed) from EOL caregiving over the first two bereavement years. Unlike the more severe depressive-symptom trajectories, the minimal-impact-resilience and recovery trajectories were shown to be associated with having a stronger SOC. Furthermore, SOC mediation was found to eliminate or reduce the risks for the most distressing depressive-symptom trajectories (preloss-only, delayed-symptomatic, relief, prolonged-symptomatic, and chronically persistent-distressed), whereas the effects on milder trajectories (minimal-impact-resilience and recovery trajectories) were weaker. The SOC-mediating effect was more pronounced among those participants in the severe burden CRA trajectory than their peers in the slight-to-moderate caregiving burden trajectories.

Based on the findings, SOC completely or partially mediates the effects of end-of-life caregiving burden on caregiver depressive symptoms during the first two bereavement years following care-recipient death. Strengthening SOC—especially in heavily burdened caregivers—through high-quality end-of-life care may ease caregiving burden and reduce the psychological distress of caregiving during the bereavement period.