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Applied Counseling
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Received 02 March 2024 Volume 6, Issue 2, pp 129-134
Revised 12 April 2024
Accepted 22 April 2024
Published online 01 June 2024 E-ISSN: 3041-8518

The Mediating Role of Guilt in the Relationship Between Suffering

and Depression Among Caregivers of Elderly Patients with Life-
Threatening Diseases

Rahele. Masoudi Sani1 , Afsaneh. Taheri2* , Narges. Babakhani2

1 PhD student, Department of Clinical Psychology, Rodehen Branch, Islamic Azad University, Rodehen, Iran
2 Assistant Professor, Department of Psychology, Rodehen Branch, Islamic Azad University, Rodehen, Iran

* Corresponding author email address: [email protected]

A r t i c l e I n f o A B S T R A C T
Article type: Objective: With the increasing elderly population, the prevalence of life-
Original Research threatening diseases has also risen, leading to a higher demand for informal
caregiving alongside professional care. Family members, serving as informal
How to cite this article: caregivers, face significant physical and psychological consequences, including
Masoudi Sani, R., Taheri, A., & Babakhani, depression. Thus, the present study aimed to examine the mediating role of guilt
N. (2024). The Mediating Role of Guilt in the in the relationship between the experience of suffering and depression among
Relationship Between Suffering and
Depression Among Caregivers of Elderly caregivers of elderly patients with life-threatening diseases.
Patients with Life-Threatening Diseases. Methods and Materials: In this study, a correlational-descriptive method was
Journal of Assessment and Research in utilized. A sample of 240 participants was conveniently selected from the
Applied Counseling, 6(2), 129-134. oncology, CCU, and ICU departments of Imam, Fatemeh-Zahra, Bu Ali Sari, and
http://dx.doi.org/10.61838/kman.jarac.6.2.16
Razi Qaemshahr hospitals. Participants responded to Beck's Depression
Inventory (1996), Schulz's Suffering Scale (2010), and Eysenck's Guilt Inventory
(2007). Data were analyzed using SPSS and AMOS software.
Findings: The analysis revealed that depression in caregivers can be explained
© 2024 the authors. Published by KMAN
Publication Inc. (KMANPUB), Ontario, through the mediation of guilt, based on their experiences of suffering. Suffering
Canada. This is an open access article under has a direct effect on depression among caregivers. Additionally, suffering
the terms of the Creative Commons directly affects the sense of guilt in caregivers; similarly, guilt directly impacts
Attribution-NonCommercial 4.0 their depression. Indirect effects of suffering on depression through the mediating
International (CC BY-NC 4.0) License. role of guilt were also identified.
Conclusion: Based on the findings, interventions aimed at reducing depression
in caregivers of elderly patients with life-threatening diseases should pay special
attention to the variables of suffering and guilt.
Keywords: Depression, Suffering, Guilt, Elderly, Life-threatening diseases.

1. Introduction the elderly population is expected to coincide with an

increase in the prevalence of chronic diseases and,
A ging is a global issue. It is projected that by 2050, the
elderly population worldwide will reach
consequently, an increased dependency in daily life
activities (Kazemi et al., 2021; Kazemi et al., 2019). Among
approximately one billion (Aung et al., 2021). The growth in these, cancer, cardiovascular diseases, and cerebral strokes
 Masoudi Sani et al. Journal of Assessment and Research in Applied Counselling 6:2 (2024) 129-134

are the most prevalent in the elderly population (Jaracz & 2. Methods and Materials
colleagues, 2014). These diseases not only affect the patients
2.1. Study Design and Participants
but also profoundly impact the lives of family members and
caregivers (Chan et al., 2022; Chen et al., 2017), who are The present study is foundational in purpose and
known as informal caregivers. These family members, who quantitative (descriptive-correlational) in method, utilizing
care for their loved ones without receiving any financial Structural Equation Modeling (SEM). The statistical
compensation or sufficient training, primarily do so because population includes caregivers of elderly patients with life-
of emotional ties (Grosbois et al., 2022; Johansen et al., threatening diseases in Mazandaran province; specifically,
2018). immediate family members over 60 years old who require
Family caregivers (informal) are described as hidden care due to heart disease, cancer, and stroke, and are cared
patients and need support and self-care to cope with the for at home (meaning they are not residing in nursing
negative impact of the disease or disability of their loved homes). Non-random, convenient sampling was employed
ones (Aghajani et al., 2018). Ignoring the issues of this group in this research. In this way, by visiting the oncology, CCU,
and their inability to adapt to the situation (caring for an and ICU departments at Imam Reza, Bu Ali, and Fatemeh
elderly patient with a life-threatening disease) can lead to Zahra (S) hospitals in Sari, and Razi hospital in Qaemshahr,
personal, family, and social crises. Based on research Mazandaran in 2022, the desired samples were identified;
evidence, caregivers looking after terminally ill family accordingly, the number of samples needed in this study was
members are at a high risk of developing depression determined based on the number of factors in the used
(Johansen et al., 2018; Park & Kim, 2016). Experiencing questionnaires, totaling 10 factors; thus, the required sample
depression can adversely affect the quality of life of these size is 150 people (150 = 10 × 15). Considering the
caregivers (Menon et al., 2017). Furthermore, studies have possibility of attrition (e.g., due to damaged or incomplete
shown that 45% of family caregivers of patients with heart questionnaires), 240 participants were selected for this
failure experience symptoms of depression (Naderi et al., study. This number also increases the statistical power of the
2018). This pressure can lead to factors such as inadequate test.
patient care, abandonment of the patient, family isolation,
and disruption in family relationships (Grosbois et al., 2022; 2.2. Measures
Kazemi et al., 2019).
Given the discussed content, it appears necessary to 2.2.1. Depression
examine the relationship between depression and the
The Beck Depression Inventory was first created by Beck
intensity of suffering experienced by caregivers of elderly
and his colleagues in 1961, revised in 1971, and published
patients with life-threatening diseases. In this area,
in 1978. The 21-item version used in this study has a four-
depression is likely predictable due to the high presence of
point scale ranging from 0 to 3, thus scores can range from
this variable, and the role of guilt seems to enhance
0 to 63. To assess the reliability of the Beck Depression
(mediate) the relationship between depression and the
Inventory, an extensive analysis of various efforts to
experience of suffering. Based on searches in domestic and
determine internal consistency has shown coefficients
international research, no study examining the mediating
ranging from 0.73 to 0.92, with an average of 0.86. In Iran,
role of guilt in the relationship between suffering and
the reliability of this questionnaire in a sample of 94 people
depression among caregivers of elderly patients with life-
was as follows: Cronbach's alpha coefficient 0.91, test-retest
threatening diseases was found; hence, the importance of
reliability coefficient 0.89, and retest coefficient 0.94.
examining this model and the necessity of conducting this
Mansour and Dadsetan (1987) reported a reliability of 0.83
research are emphasized. Accordingly, the research question
and validity of 0.80. In the research of Sharifi Darani and
of the current study is: Is there a relationship between the
Ghasemi Davari (2012), the reliability and validity of the
experience of suffering and depression with the mediating
Beck Depression Inventory were estimated at 0.85 and 0.76,
role of guilt among caregivers of elderly patients with life-
respectively. The correlation of the Beck Depression
threatening diseases?
Inventory with its first edition was 0.93 (Basharpoor et al.,
2017; Beck et al., 1996).

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2.2.2. Suffering Experience and Perception and split-half methods to test the reliability, obtaining
coefficients of 0.67 and 0.68, respectively, and correlating
This scale, designed by Schulz et al. (2010), can be used
the score with a criterion question showed a significant
to measure the experience and perception of suffering. This
relationship (p < 0.001, r = 0.28). The validity and reliability
scale evaluates three dimensions of suffering: physical,
of this questionnaire were also confirmed in Zargar and
psychological, and existential/spiritual. The physical
colleagues' research (2012) (Arian et al., 2021).
dimension includes 9 items in two parts, where respondents
rate on a four-point Likert scale from never (0) to always (3), 2.3. Data analysis
with total scores ranging from 0 to 27 (Schulz et al., 2010).
Reliability of this test and its dimensions were calculated by In Structural Equation Modeling, AMOS software was
Schulz and colleagues (2010) in three groups: African- used to determine the significance of model fit. The model
American (physical 0.63, psychological 0.90, and fitting and hypothesis testing were conducted
existential/spiritual 0.86), Caucasian (physical 0.43, simultaneously within the framework of the initial model. In
psychological 0.87, and existential/spiritual 0.84), and this regard, a preliminary analysis of the data's normality
Hispanic (physical suffering 0.60, psychological 0.85, and assumptions was conducted before performing the necessary
existential/spiritual 0.83). In Iran, the Cronbach's alpha statistical analyses with AMOS.
coefficients for this test and its dimensions were evaluated
by Pirasteh Motlagh and Nikmanesh (2012) in patients with 3. Findings and Results
AIDS, with the following results: physical 0.71, The final sample size of the current study, after removing
psychological 0.84, and existential/spiritual 0.81 (Pirasteh damaged and incomplete questionnaires, included 240
Motlagh & Nikmanesh, 2012). individuals. Demographic results showed that among the
sample of patients, 55% were male and 45% were female.
2.2.3. Guilt
Regarding the caregivers, approximately 56% were female
The Eysenck Guilt Inventory, designed to measure the and 44% were male. The mean age of the patients was 70.64
sense of guilt, is scored on a scale from 0 to 1. The minimum years with a standard deviation of about 8 years, the
score is 0 and the maximum is 30, with a cutoff point at 15. minimum age was 60, and the maximum was 93 years. The
In Hariri's study, three items were removed due to low factor mean age of the caregivers was 43.55 years with a standard
loading, and the final questionnaire contains 27 items; thus, deviation of about 12 years, the minimum age was 21, and
the minimum obtainable score is 0 and the maximum is 27. the maximum was 75 years. Among the total sample of
A high score indicates a high sense of guilt and provides a patients, about 40% were unemployed, approximately 38%
total score for this variable. To assess the reliability of this were self-employed, and 21% were employed. Additionally,
questionnaire, both Cronbach's alpha and split-half methods the results indicate that most caregivers were self-employed
were used, yielding alpha coefficients of 0.77 and a split-half (about 45%), with approximately 30% unemployed and 24%
coefficient of 0.76. Hariri (2008) used both Cronbach's alpha employed.

Table 1

Descriptive Statistics

Variable Number of Items Mean Standard Deviation Skewness Kurtosis Minimum Maximum
Depression 21 22.11 11.40 0.19 -0.62 1 53
Guilt 28 15.80 5.44 -0.01 -0.33 1 28
Physical Suffering 9 16.10 7.096 -0.023 -0.418 0 33
Psychological Suffering 15 27.19 11.026 -0.261 -0.584 1 50
Existential Suffering 9 18.72 8.459 0.519 -0.054 1 43
Total Score 62 62.01 23.347 -0.276 -0.422 5 110

The data from Table 1 show that the mean total score for skewness and kurtosis indices for the total score of this
depression is 22.11 with a standard deviation of 11.40. The variable range between -1 and 1, indicating a normal
range of scores for this variable is between 1 and 53. The distribution of the variables. Statisticians consider

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distributions with skewness and kurtosis indices between -2

and 2 as normal; however, some researchers conservatively
accept a range of -1 to 1 as acceptable.

Table 2

Significance of Direct Coefficients for Variables

From To Standardized Non-standardized Standard Error Critical Ratio Significance Level

Variable Variable Coefficients (β) Coefficients (b) (S.E.) (C.R.) (p)
Suffering Depression 0.287 0.848 0.362 2.343 0.019
Suffering Guilt 0.533 0.75 0.201 3.733 0.001
Guilt Depression 0.27 0.566 0.142 3.979 0.001

As observed from the data in Table 2, the main path Moreover, the main path coefficient between suffering
coefficient between suffering and depression in the model is and guilt is positive and significant at the 0.01 level. This
significant at the 0.05 level. Therefore, this specific specific hypothesis is therefore confirmed, meaning that
hypothesis is confirmed, indicating a positive and significant with other variables held constant, an increase in suffering
relationship between these two variables. The value of the by one unit leads to an increase in guilt by 0.533 units.
critical ratio, equivalent to the observed t-value, is greater Finally, the main path coefficient between guilt and
than 1.96; thus, this specific hypothesis is also confirmed at depression is positive and significant at the 0.001 level. This
the 0.05 level. The standardized beta coefficient between the specific hypothesis is therefore confirmed, meaning that
two variables is 0.287, meaning that with other variables with other variables held constant, an increase in guilt by one
held constant, an increase in suffering by one unit results in unit results in an increase in depression by 0.27 units.
an increase in depression by 0.287 units.

Table 3

Indirect Standard Effects of the Suffering Variable on the Depression Variable

From Variable Through Mediating Variable To Variable Indirect Effect Significance (sig) Lower 95% Upper 95%
Suffering Guilt Depression 0.144 0.002 0.09 0.246

Based on the data in Table 3, the indirect effect between occur that are not chosen by the individual and many of
the variables of suffering and depression through the them, especially due to their sudden nature, are accompanied
mediating variable of guilt is 0.144 and is statistically by great suffering; many are also associated with existential
significant. Thus, the mediating role of guilt in the conflicts such as facing mortality, feelings of loneliness,
relationship between these two variables is confirmed. uncontrollability of life, and the loss of current life meaning
(Dimkov, 2020).
4. Discussion and Conclusion The results also showed that suffering has a direct effect
on the sense of guilt in caregivers of elderly patients with
The current study aimed to investigate the mediating role
life-threatening diseases, significant at the level of 0.001 (β
of guilt in the relationship between suffering and depression
= 0.533). Thus, there is also a positive and significant
in caregivers of elderly patients with life-threatening
relationship between these two variables. These findings are
diseases. The results indicated that suffering directly affects
consistent with prior research (Applebaum et al., 2016;
depression in caregivers of elderly patients with life-
Arian et al., 2021; Brea et al., 2016; Breitbart, 2017; Dale,
threatening diseases, confirmed at the significance level of
2017; Gambin & Sharp, 2018; Hoffman, 2018; Levinson et
0.05 (β = 0.287); meaning that there is a positive and
al., 2016; Luck & Luck-Sikorski, 2021; Miller, 2017;
significant relationship between these two variables. This
Sangani et al., 2019). This finding can be explained by the
finding aligns with the prior research (Fong et al., 2022;
fact that caring for a loved one who has reached old age and
Gambin & Sharp, 2018; Rodrigo-Baños et al., 2021; Schulz
faces a life-threatening illness brings to mind human
et al., 2010). It can be explained that in human life, events
vulnerability, the reality of death, and the fragility of the

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body, leading to immense suffering. Guilt and shame from Declaration of Interest
not feeling adequate as a caregiver and being ineffective in
The authors of this article declared no conflict of interest.
preventing death or, at least, the pain of a loved one, trigger
a self-critical and derogatory voice in this group of
Ethical Considerations
caregivers.
The results further demonstrated that guilt has a direct The study protocol adhered to the principles outlined in
effect on depression in caregivers of elderly patients with the Helsinki Declaration, which provides guidelines for
life-threatening diseases, confirmed at the significance level ethical research involving human participants.
of 0.001 (β = 0.27); meaning that there is a positive and
significant relationship between depression and the sense of Transparency of Data
guilt. This finding is consistent with the prior research
In accordance with the principles of transparency and
(Gambin & Sharp, 2018; Luck & Luck-Sikorski, 2021). In
open research, we declare that all data and materials used in
explaining the direct effect of guilt on depression in
this study are available upon request.
caregivers, one could say that facing one's own death or that
of others highlights human limitations both in terms of time
Funding
and function. Many existentialists explain "angst" in relation
to existential guilt (Luck & Luck-Sikorski, 2021). This research was carried out independently with
Additionally, the results indicated that suffering affects personal funding and without the financial support of any
depression indirectly through the mediating role of guilt in governmental or private institution or organization.
caregivers of elderly patients with life-threatening diseases,
confirmed at the significance level of 0.001 (β = 0.144). Authors’ Contributions
Therefore, it can be stated that guilt plays a mediating role
All authors equally contributed in this article.
between suffering and depression. This finding is consistent
with prior research (Aljuaid et al., 2022; Baghcheghi &
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