Effects of Written Emotional Disclosure on Burden,Trauma Symptoms and Health Status in Primary Caregivers of The Patient:A meta-analysis

Ya-Nan Leng1,Min Zhang1,Ting-Ting Liu1,Yu-Qi Li1,Xiao-Li Pang2

1Department of Graduate,Tianjin University of Traditional Chinese Medicine,Tianjin,301617,China;

2Department of Nursing,Tianjin University of Traditional Chinese Medicine,Tianjin,301617,China.

Abstract Objective:The meta-analysis aims to evaluate the efficacy of written emotional disclosure on burden,trauma symptoms and health status in primary caregivers of the patient.Methods:Randomized controlled trials (RCTs) of written emotional disclosure in primary caregivers of the patient were retrieved from multiple electronic databases such as the Cochrane Library,PubMed,EMBASE,Web of Science,China National Knowledge Infrastructure(CNKI),VIP Database for Chinese Technical Periodicals (VIP),Chinese Biomedicine Database (CBM) and Wan Fang database (Wan Fang) until August 2019.The eligible studies were screened and evaluated independently by two researchers.Then,we analyzed the extracted data by RevMan 5.3 software.Results:A total of 7 randomized controlled trials (RCT) with 352 primary caregivers were included.The quality evaluation grade of the 3 articles included in the literature was“A”,and the rests was“B”.Meta-analysis showed that compared with the control group,written emotional disclosure could alleviate the burden of patients' primary caregivers [SMD=0.26,95%CI (0.02,0.49),P=0.03].The results showed that there was no significant difference between the two groups in alleviating trauma-like symptoms [MD=3.30,95% CI (-4.52,11.11),P=0.41].There was no significant difference in the mean score of the General Health Questionnaire (GHQ) between the two groups [MD=-1.94,95% CI (-11.11,7.23),P=0.68].Besides,there was no significant difference between the two groups in improving their physical and mental health [SMD=0.28,95% CI (-0.17,0.73),P=0.22;SMD=-0.43,95% CI (-0.88,0.02),P=0.06].Conclusion:Written emotional disclosure can effectively alleviate the burden in patients' primary caregivers.However,the effects on trauma-like symptoms,the GHQ score and health status need to be verified by further studies.

Keywords:Written emotional disclosure,Caregivers,Meta-analysis

Introduction

Written emotional expression refers to the expression of the deepest emotions and feelings in an important experience,such as stress or trauma,in a prescribed time [1].At present,it has gradually developed into a more mature psychological intervention method,and has been widely used in breast cancer patients,postpartum patients and hospice patients[2-5].Some studies have confirmed that writing emotional expression can effectively promote patients'understanding of their own diseases,improve patients'symptoms burden and quality of life [6].However,the effect of writing emotional expression in the primary caregivers of patients is still controversial.Previous studies have shown that the primary caregivers bear greater physical,social,economic and emotional burdens when their family are ill,which can lead to a series of adverse events [7].The physical and mental state of the caregiver has a greater impact not only on his/her own health but also on the rehabilitation and treatment of the patient [8].How to alleviate the burden,traumatic symptoms and improve the quality of life of the caregivers has become an important issue that cannot be ignored.Therefore,the purpose of this study is to systematically evaluate the effect of writing emotional expression in caregivers.

1 Materials and methods

1.1 Inclusion and exclusion criteria

1.1.1 Study Design

Randomized controlled trials were included.

1.1.2 Subjects

We included caregivers who provided unpaid care to someone with whom they shared a social or familial relationship.Caregiver must be at 18 years of age or older.

1.1.3 Types of interventions

The experimental intervention was that the caregiver including the most painful and frustrating experiences in their lives,or the things they care most about should write at the prompt of the researcher with a specified time.The important thing is to let them let go of themselves and express their inner thoughts and feelings.The control group were instructed to write objectively about a specified topic on each day,such as a neutral topic related to their everyday activities.

1.1.4 Outcome

The main outcome indicators included caregiver burden and traumatic symptoms.The assessment tools included Burden Inventory (BI),The Parenting Stress Index (PSI) and Zarit Burden Interview (ZBI).Impact of Events Scale (IES) was used to assess traumatic symptoms.Secondary outcome indicators were caregivers' health status assessed by RAND 36-item Health Survey,Health Status Questionnaire (SF-36)and GHQ.

1.1.5 Exclusion criteria

(1) the result of methodological quality assessment was“C”;(2) a literature without a full text,duplicate literature,case report,or summary of experience;(3)data could not be extracted because of incomplete infromation;(4) literature which were not published in Chinese and English.

1.2 Search strategy

The electronic databases were retrieved,including the Cochrane Library,PubMed,Embase,Web of Science,China National Knowledge Infrastructure (CNKI),VIP Database for Chinese Technical Periodicals (VIP),Chinese Biomedicine Database (CBM) and Wan Fang database (Wan Fang).The retrieval time was from the establishment of each database to August 2019.The retrieval strategy was formulated according to the characteristics of each database,and a combination of subject words and free words was adopted.The search terms were listed as follows:(“expressive writing”O(jiān)R“ written emotional expression“ OR“experimental disclosure”O(jiān)R“written emotional disclosure”O(jiān)R“Writing”O(jiān)R“Written Communication”) AND(“caregiver*”O(jiān)R“carer*”O(jiān)R“care giver*”O(jiān)R“caregiver*,family”O(jiān)R“spouse”O(jiān)R“father”O(jiān)R“mother”) AND (“randomized controlled trial*”O(jiān)R“RCT”O(jiān)R“random”O(jiān)R“randomized clinical trial*”).

1.3 Data extraction

Two researchers screened these studies independently according to the inclusion and exclusion criteria.The data in each included study was extracted independently by two researchers using a pre-designed data extraction form.The extracted contents included study characteristics (author and year),publication time,national,sample size,age of caregivers,intervention times and outcome indicators.

1.4 Methodological quality assessment

Two researchers independently evaluated the included literature according to the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [9].The evaluation items included:(1) Random sequence generation;(2) Allocation concealment;(3) Blinding of participants and personnel;(4) Blinding of outcome assessment;(5) Incomplete outcome data;(6) Selective reporting;(7) Other sources of bias.Each item is described as“l(fā)ow risk of bias”,“high risk of bias”or“unclear”.If the above standards are fully met,the quality grade of the literature is“A”.If partial satisfied,the“B”grade quality evaluation result is given.If the above standards are all not satisfied,the result of the quality evaluation result is“C”.Two researchers crosschecked the evaluation results.If there was any doubt,they negotiated or invited the third party to intervene in arbitration.

1.5 Data analysis

Meta-analysis was conducted using the RevMan 5.3 software.Continuous variables can be represented by mean difference (MD),and standardized mean difference (SMD) with 95% confidence interval (CI).Heterogeneity across the included results was tested by chi-square test.WhenP＞ 0.1 and I2 ＜ 50%,the homogeneity was identity.Fixed-effect model was used.WhenP≤ 0.1 or I2 ≥ 50%,the heterogeneity was obvious .If there is only statistical heterogeneity across studies,random effects-model could be used.If the heterogeneity was too obvious and the source of the heterogeneity could be not determined,descriptive analysis was conducted.

2 Results

2.1 Study selection

We identified 564 potentially eligible literatures with 109 in Chinese and 455 in English.Duplicate literatures were removed by EndNote software.Finally,seven studies were included [10-16].All included literatures were published in English.The detailed process of literature screening,such as reasons and number of selection or deletion,is shown in Figure 1.The basic characteristics of the included literatures is shown in Table 1.

2.2 Methodological quality assessment of included trials

Results of methodological quality evaluation and evidence classification are shown in Table 2.The results of risk of bias assessment are shown in Figure 2.

2.3 Meta-analysis results

2.3.1 Effect of written emotional disclosure on burden in primary caregivers of the patient

Five studies with 291 primary caregivers reported the effect of written emotional disclosure on caregiver burden [11,12,14-16].The results showed no heterogeneity across studies (P=0.80,I2=0%).The meta-analysis of the fixed-effect model showed that the burden of primary caregivers in the written emotional disclosure group was lower than that in the control group,and the difference was statistically significant[SMD=0.26,95% CI (0.02,0.49),P=0.03](Figure 3).

2.3.2 Effect of written emotional disclosure on trauma symptoms in primary caregivers of the patient

Two studies reported the score of IES between the written emotional disclosure group and control group[10,14].Heterogeneity test results showed that the homogeneity between the studies was good (P=0.30,I2=7%).The meta-analysis of the fixed-effect model showed that the psychological distress caused by stressful events was similar between two groups,and the difference was not statistically significant [MD=3.30,95% CI (-4.52,11.11),P=0.41](Figure 4).

2.3.3 Effect of written emotional disclosure on health status in primary caregivers of the patient

Four [10,13-15]studies reported on the health status of caregivers.Two [10,14]of these studies reported the score of GHQ between the written emotional disclosure group and control group.The heterogeneity test showed that there was the heterogeneity among the studies (P=0.13,I2=56%).The meta-analysis of the random effect model showed that the overall health status of caregivers in written emotional disclosure group was higher than that in control group,and the difference was not statistically significant [MD=-1.94,95% CI (-11.11,7.23),P=0.68](Fig 5).Jones [13]et al.used RAND to evaluate the impact of writing emotional disclosure on the physical and mental health of caregivers.The results showed that after 3 months of intervention,the score of the experimental group was higher than control group,and there was no significant difference (P＞ 0.05).Schwartz [15]et al.used SF-36 to evaluate the effect of writing intervention on health-related quality of life of caregivers.The results of 4 months follow-up showed that the score of the experimental group was higher than that of the control group,with no significant difference (P＞ 0.05).

Figure 1.Study flow diagram

Table 1.The basic characteristics of included studies

Table 2.Methodological Quality Assessment

Figure 2.Risk of bias summary and graph

Figure 3.Forest plot of burden

Figure 4.Forest plot of trauma symptoms

Figure 5.Forest plot of health status

3 Discussion

3.1 Methodological quality of included studies

Among the included literatures,the quality evaluation grade of the 3 [10,12,13]articles was“A”,and that of others was“B”.Only one [12]study reported specific randomized grouping method (online-generated random sequence).Three [10,12,13]studies mentioned the use of sealed envelopes or folders for the purpose of allocating concealment.All studies reported the number of subjects who dropped out or disappeared,and the baseline was comparable.

3.2 Written emotional disclosure can alleviate the burden of caregivers

Most patients suffer from a long course of illness and complicated conditions.The caregivers need longterm care during the diagnosis and treatment,which causes pain to the patients and increases burden on the caregivers [17].Caregivers can benefit from writing not only because it can relieve stress,but also through the self-regulation of writing,they can express their inner true thoughts,help then to calmly think about the problem,and show a more rational acceptance of reality [18].This study shows that written emotional disclosure can alleviate the burden of caregivers,which is consistent with the conclusion of Harvey[19].Caregivers tend to suppress negative feelings when interacting with sufferers so as to shield sufferers from further burden themselves.However,suppressing feelings of burden increases the potential for rumination and resentment [20].Written emotional expression can enable patients to experience their negative emotions many times and gradually adapt to them,alleviate the long-term accumulation of negative experience,so that the burden of patients can be released slowly in this process.

3.3 Effect of written emotional disclosure on improving traumatic symptoms and quality of life of caregivers is uncertain

The suffering and emotional burdens of caregivers from these responsibilities lead to a decreased quality of life and disturbed body physiology [21],which can also seriously affect their daily work and family relations.The tremendous changes made caregivers prone to traumatic symptoms and negative emotions,and the quality of life and care ability decreased significantly.Caregivers have long known and witnessed patients exposed to traumatic events,which increases the risk that caregivers exhibit traumatic symptoms [22].This system review found that there was no significant difference between the two groups in terms of traumatic symptoms and health status.The reason may be that participants did not fully explore their thoughts and feelings as they had been instructed,consequently,did not experience reduced stress,physical or psychological symptoms as would have been predicted[10].Written emotional disclosure intervention makes a trauma easier to manage psychologically by helping people make sense out of confusing and upsetting events in their lives [18].Considering the obvious heterogeneity of the included literature and insufficient research to confirm the validity of this conclusion,it is suggested that follow-up studies can further investigate the relationship between written emotional expression and caregivers' traumatic symptoms and quality of life.

4 Conclusion

Written emotional disclosure has an obvious effect in alleviating the caregiver burden,but its effect in improving caregivers' traumatic symptoms and quality of life is uncertain.There is a lack of multi-center and large-sample studies to verify it.Furthermore,it is worth noting that there is no uniform standard implementation plan for written emotional disclosure intervention,which is also the reason for some heterogeneity in this study.There are differences in intervention time,form,frequency,intensity and implementation personnel.Therefore,researchers should unify intervention programs and evaluation criteria of efficacy,make the research process rigorous and standardized,and provide reliable evidence for the promotion and application of writing emotional disclosure in caregivers.

Authors' contributions

Ya-Nan Leng conceived and designed this experiment.Min Zhang and Ting-Ting Liu performed the search.Min Zhang and Yu-Qi Li analyzed the data.Xiao-Li Pang recheck the data and results.Ya-Nan Leng wrote the paper.All authors offer to help when submitting materials.