Depressive symptoms and psychometric evaluation of the PHQ-9 among caregivers of breast cancer patients in Pakistan: a cross-sectional study

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INTRODUCTION: Caregivers of breast cancer patients experience a significant psychological burden, which may lead to moderate-to-severe depressive symptoms. However, limited research has explored the prevalence among caregivers in the Pakistani population. This study aimed to assess the prevalence of moderate-to-severe depressive symptoms among these caregivers. METHODOLOGY: We conducted a multi-step psychometric analysis of the Patient Health Questionnaire-9 (PHQ-9) among caregivers of breast cancer patients recruited from tertiary hospitals across Pakistan. Exploratory Factor Analysis (EFA) employed principal axis factoring with Promax rotation. Assumptions were verified using Bartlett's Test of Sphericity and Kaiser-Meyer-Olkin sampling adequacy. Confirmatory Factor Analysis (CFA) tested the EFA-derived structure, with model fit evaluated using RMSEA, TLI, and χ². Socio-demographic and health-related data were collected through structured questionnaires. Statistical analysis was performed using JAMOVI software, incorporating descriptive statistics, chi-square tests, t-tests/ANOVA, and binomial logistic regression to identify factors associated with moderate-to-severe depressive symptoms among the caregivers of the breast cancer patients. RESULTS: Among 402 caregivers, 186 (46.3%) had moderate-to-severe depressive symptoms, while 216 (53.7%) had no or mild depressive symptoms based on PHQ-9 scores. Overall, 27.1% had mild symptoms, 24.1% had moderate symptoms, 16.4% had moderately severe symptoms, and 5.7% had severe symptoms. EFA revealed a 3-factor solution explaining 46.75% of variance, all primary loadings > 0.52. The CFA confirmed this structure (RMSEA = 0.064; CFI = 0.96; TLI = 0.94), though χ² was significant (p < 0.05). Among caregivers, low monthly income (p = 0.033), a sedentary lifestyle (p = 0.012), and urban residence (p = 0.044) were associated with a higher risk of depressive symptoms. In a multivariate logistic regression analysis, lower education levels were found to be a significant predictor of moderate-to-severe depressive symptoms (p = 0.007). CONCLUSION: A substantial proportion of caregivers of patients with breast cancer in Pakistan experience moderate-to-severe depressive symptoms, indicating a significant and underrecognized mental health burden. The PHQ-9 demonstrated acceptable psychometric performance with a multidimensional structure in this population. Secondary education, higher physical activity, and higher income were associated with increased odds of depressive symptoms. These findings should be interpreted in light of the cross-sectional design and use of self-reported measures. CLINICAL TRIAL NUMBER: Not applicable.

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