Psychiatry Research xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Actor-partner interdependence analysis in depressed patient-caregiver

dyads: Influence of emotional intelligence and coping strategies on anxiety
and depression
⁎
Serres Margueritea, , Boyer Laurentb, Alessandrini Marineb, Leroy Tanguyc, Baumstarck Karineb,
Auquier Pascalb, Zendjidjian Xaviera,b
a
Department of Psychiatry, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, 13005 Marseille, France
b
EA 3279, Self-Perceived Health Assessment Research Unit, School of Medicine, Aix Marseille Université, France
c
Social Psychology Research Group (GRePS EA 4163), Université Lumière Lyon 2, Bron, France

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: Major depressive disorder (MDD) is a leading cause of suffering for both patients and their natural
Depression caregivers. A preliminary study highlights the association of emotional intelligence (EI) and coping strategies
Caregivers with quality of life. However, there is a lack of studies concerning dyadic (i.e., patient and natural caregiver)
Dyads characteristics’ impact on anxious and depressive symptoms. In a sample of MDD patients-caregivers dyads, we
Emotional intelligence
explored the influence of EI and coping strategies on anxious and depressive symptoms using the actor-partner
Coping
Anxiety
interdependence model (APIM).
Methods: The cross-sectional study included 79 MDD patient-caregiver dyads. Self-reported data, completed by
patients and their primary caregivers, were collected including socio-demographic, EI using TEIQue-SF, coping
strategies using BriefCope, depressive symptoms using Beck Depression Inventory, anxious symptoms using
STAI. The APIM was used to test the dyadic effects of EI and coping strategies on anxious and depressive
symptoms, using structural equation modelling.
Results: Patients and caregivers reported both anxious and depressive symptoms. Coping strategies, such as
problem solving, positive thinking and avoidance, exhibited evidence of actor (degree to which the individual's
coping strategies are associated with their own anxiety or depression level) and partner effect (degree to which
the individual's coping strategies are associated with the anxiety or depression level of the other member of the
dyad). The caregivers’ EI was associated with a decrease of their own depression level contrary to patients for
which the results were not significant. The patients’ and caregivers’ EI was associated with a decrease of their
own level of anxiety.
Conclusion: EI and coping strategies were moderately associated with anxious and depressive symptomatology
among MDD patient-caregiver dyads. These results suggest that targeted interventions could be proposed to both
patients and caregivers.

1. Introduction
Major depressive disorder (MDD) is an important cause of suffering
for patients, but MDD also affects patients' families and caregivers
(Heru et al., 2004; Heru and Ryan, 2004; Magne-Ingvar and Öjehagen,
2005). Caregivers of patients with MDD experience burden across
multiple life domains (e.g. emotional, social, physical, financial and
relationship burden) that affects their ability to care for the patient and
deteriorates their health. As a result of this burden associated with
patients’ symptomatology, caregivers report anxious and depressive
symptoms (Jenkins and Schumacher, 1999; Kumar and Gupta, 2014).
Patient and caregiver constitute a dyad, i.e. attributes and behaviours of
one dyad member can affect the mental health state of the other in-
dividual (Kenny and Cook, 1999). However, little is known about the
interactions within dyads in the specific context of MDD. There is thus a
need in understanding how patients and caregivers interact within the
dyad to cope with symptomatology and problems of daily life. Coping is
usually defined as thoughts and behaviours that are implemented to
manage internal and external demands of situations appraised as
stressful (Lazarus and Folkman, 1984). The literature generally opposes

⁎
Corresponding author.
E-mail address: marguerite.serres@hotmail.com (S. Marguerite).

http://dx.doi.org/10.1016/j.psychres.2017.08.082
Received 18 April 2017; Received in revised form 18 June 2017; Accepted 28 August 2017
0165-1781/ © 2017 Elsevier B.V. All rights reserved.

Please cite this article as: Serres, M., Psychiatry Research (2017), http://dx.doi.org/10.1016/j.psychres.2017.08.082
S. Marguerite et al.
active coping strategies considered as an efficient method to address
stressful events, to passive coping strategies considered as a psycholo-
gical risk factor for adverse responses to stressful life events (Boyer
et al., 2017; Holahan and Moos, 1987). In addition, emotional in-
telligence (EI) (i.e. the capacity of individuals to recognize their own
and other people's emotions and to use emotional information to guide
thinking and behaviour) influences interactions within the dyads
(Mayer et al., 1990, 2008a) and is predictive of psychological adjust-
ment and correlated positively with psychological well-being (Austin
et al., 2005; Ciarrochi et al., 2002; Schutte et al., 2002).
To date, very few works have addressed the dyad situation in the
context of MDD. Most studies have examined the influence of each
person's characteristics based on the independence assumption (i.e.
uncorrelated observations among dependent variables). But recent
studies reported that the independence assumption is violated in dyads
because the relationship between patients and caregivers is deeply in-
terdependent. One of the appropriate way to measure this inter-
dependence is the actor-partner interdependence model (APIM) (Kenny
et al., 2006). Previous studies using APIM explored relationships be-
tween patients and caregivers in cancer (Baumstarck et al., 2016;
Goldzweig et al., 2016), heart failure (Chung et al., 2009) and hearing
loss (Lazzarotto et al., 2016). To our knowledge, no study used the
APIM method to examine dyads in MDD, except one on reciprocal
criticism in a small sample of 33 MDD patients and their spouses
(Peterson and Smith, 2010) and one on quality of life (Boyer et al.,
2017).
The objective of this study was to examine the influence of EI and
coping strategies on the level of depression and anxiety among MDD
patients-caregivers dyads using APIM.
2. Methods
2.1. Design, setting and procedure
We conducted a cross-sectional study in the psychiatric department
of a French public teaching hospital in the South of France (Marseille).
The recruitment of patient-caregiver dyads was conducted during a 6
months period. Health care staff identified inpatients who had a diag-
nosis of MDD according to the DSM-IV criteria (American Psychiatric
Association, 2000), were between 18 and 64 years old and had been
hospitalized for at least 48 h. Each patient was asked by medical or
nursing staff to name his or her primary natural or family caregiver and
whether we could contact the caregiver. A caregiver, or informal care-
giver is an unpaid individual involved in assisting others with activities
of daily living and/or medical tasks (EUFAMI Guide to Caregivers,
2017).
If the patient and the caregiver agreed and met the inclusion cri-
teria, the data were collected via self-report questionnaires on the dis-
charge day. The study was conducted in accordance with the Helsinki
Declaration and French laws and regulations (Code de la Santé
Publique, article L.1121-1/Loi de Santé Publique no. 2004-806 du 9
août 2004 relative à la politique de santé publique et ses décrets
d’application du 27 août 2006). The data collection was approved by
the Commission Nationale de l’Informatique et des Libertés (CNIL no.
1223715). All the patients were informed of the study and gave their
written, informed consent after a standardised and structured clinical
interview.
2.2. Data collection
The same data were collected for the patient and the caregiver and
included the following socio-demographic characteristics: gender, age,
marital status (single, couple), educational level (< 12 years, > = 12
years), employment status (with, without employment) and the re-
lationship between the patient and caregiver (partner, not partner).
Depression severity was assessed using the Beck Depression
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Psychiatry Research xxx (xxxx) xxx–xxx
Inventory Short-Form (13 items) (Beck and Beamesderfer, 1974).
Higher scores indicate more severe symptomatology.
Anxiety severity was assessed using the state-trait anxiety inventory
(STAI (Spielberger and Gorsuch, 1970)). The STAI consists of two
subscales: “state anxiety” (STAI-YA), or the transitory emotional re-
sponse to a stressful situation, and “trait anxiety” (STAI-YB), or the
relatively stable and long-standing disposition to respond to stress
(Spielberger et al., 1993). Our sample only fulfilled the STAI-YB. Higher
scores indicate more severe symptomatology.
EI was assessed using the Trait Emotional Intelligence Questionnaire
- Short Form (TEIQue-SF) (Cooper and Petrides, 2010; Mikolajczak
et al., 2007a; Petrides, 2009). It's a self-report questionnaire of 30 items
that provide a global score of general emotional functioning; higher
scores indicate higher trait EI.
Coping strategies were assessed using the Brief Coping Orientation
to Problems Experienced Scale (BriefCope) (Carver, 1997; Muller and
Spitz, 2003). It's a multidimensional measure that presents fourteen
scales all assessing different coping dimensions. This questionnaire in-
cludes 28 items that explore the following 14 strategies: self-distraction,
active coping, denial, substance use, use of emotional support, use of
instrumental support, behavioural disengagement, venting, positive
reframing, planning, humour, acceptance, religion, and self-blame. A
recent work proposed a reduction to 4 dimensions: social support,
problem solving, avoidance, and positive thinking (Baumstarck et al.,
2017). Higher scores in these 4 dimensions reflect a higher tendency to
implement the corresponding coping strategies.
2.3. Statistical analysis
Data were expressed in proportion or by mean and standard de-
viation. Correlations between depression, anxiety, coping strategies and
EI scores were performed for patients and caregivers using Spearman's
correlation test. To assess the dyadic effects of EI and coping strategies
on depression and anxiety, the APIM with distinguishable dyads was
assessed using structural equation modelling (Cook and Kenny, 2005).
The APIM is useful to determine how parameters (EI, coping strategies,
depression and anxiety) of each participant (namely patients and
caregivers) are influenced not only by internal factors but also by fac-
tors related to the other member of the dyad. Structural equation
modelling simultaneously examines both paths in the APIM: two actor
effects (i.e., each person's depression score regressed on their own
coping strategies as on their own EI profile) and two partner effects
(i.e., each person's depression score regressed on the other person's
coping strategies as on the other's EI profile).
3. Results
3.1. Sample
One hundred and thirty-eight patients were eligible during the study
period, 109 patients and their corresponding primary natural or family
caregiver agreed to participate and met the inclusion criteria. Finally,
79 patients and their corresponding caregiver were included in dyads
analyses (because of 30 incomplete questionnaires). Participants (n =
79) and non-participants (n = 59) did not differ in gender, age, edu-
cational level and length of hospitalisation.
The mean Beck score was 15.4 (SD = 6.5) for the patients and 6.7
(SD = 6.3) for the caregivers. The mean STAI score was 59.6 (SD =
11.3) for the patients and 43.9 (SD = 11.7) for the caregivers. The
mean TEIQue-SF score index was 121.2 (SD = 32.2) for patients and
148.4 (SD = 23.7) for caregivers. Concerning the coping strategies,
patients used preferentially avoidance and social support strategies,
caregivers implemented preferentially problem solving and positive
thinking strategies. The characteristics of the included patients and
their main caregivers are presented in Table 1.
S. Marguerite et al. Psychiatry Research xxx (xxxx) xxx–xxx

Table 1 when they used problem solving and positive thinking strategies. When
Sample characteristics of MDD patients and their caregivers. they were avoidant, they were more anxious and depressed. Patients’
anxiety and depression were not significantly associated with the
Patients N = 79
Gender Men 27 (34.2) caregivers’ EI and coping strategies.
Age M ± SD 41.6 ± 14.8 In the same way as observed with patients, caregivers’ level of an-
Marital status Single 38 (50.7) xiety and depression was significantly lower when they had higher EI
Couple 37 (49.3) scores and when they used problem solving and positive thinking
Educational level Low (< 12 years) 23 (29.1)
High (> = 12 years) 56 (70.9)
strategies. Caregivers were also more anxious and depressed when they
Employment status Without employment 64 (81.0) were avoidant. Caregivers’ level of anxiety and depression were not
With employment 15 (19.0) significantly associated with the patients’ EI. Lower level of depression
Relationship between patient and Partner 31 (39.2) of caregivers was associated with the preferential use of problem sol-
caregiver Not Partnera 48 (60.8)
ving strategies by the patients. We did not find this correlation about
Beck M ± SD 15.4 ± 6.5
STAI M ± SD 59,6 ± 11,3 caregivers’ level of anxiety.
TEIQue-SF Index M ± SD 121 ± 32.2
Coping strategies
Problem Solving M ± SD 29,8 ± 22.6 3.3. Results of the APIM on depression
Positive thinking M ± SD 23,2 ± 17.7
Avoidance M ± SD 37,8 ± 15.4
Social Support M ± SD 41,3 ± 19.6 The results of the APIM are presented in the Figs. 1 (EI and Beck)
and 2 (Coping and Beck).
Caregivers N = 79
Gender Men 37 (49.3) The caregivers’ EI was associated with a decrease of their own de-
Age M ± SD 50.6 ± 13.5 pression level contrary to patients for which the results were not sig-
Marital status Single 22 (30.1) nificant. We did not identify any partner effect.
Couple 51 (69.9)
With coping strategies, we found several actor effects and one
Educational level Low (< 12 years) 21 (29.2)
High (> = 12 years) 51 (70.8)
partner effect. The use of problem solving strategies by patients was
Employment status Without employment 28 (37.8) associated with a decrease of their own depression level and of care-
With employment 46 (62.2) givers’ depression level. The use of positive thinking by patients and
Beck M ± SD 6.7 ± 6.3 caregivers was associated with a decrease of their own depression level.
STAI M ± SD 43,9 ± 11,7
On the contrary the use of avoidance by patients and caregivers in-
TEIQue-SF Index M ± SD 148,4 ± 23.7
Coping strategies creases their own level of depression. We did not find any actor or
Problem Solving M ± SD 52,9 ± 24.9 partner effect between social support strategies and patients’ or care-
Positive thinking M ± SD 44,0 ± 18.3 givers’ level of depression.
Avoidance M ± SD 21,1 ± 10.4
Social Support M ± SD 36,2 ± 20.6

M ± SD: the mean ± standard deviation.
Beck (Beck Depression Inventory): higher scores indicate a higher severity of the de-
pression.
STAI (state-trait anxiety inventory): higher scores indicate higher anxiety.
TEIQue-SF (Trait Emotional Intelligence Questionnaire - Short Form): higher scores in-
dicate higher trait EI.
a
Son or daughter 8(16.7); Father or mother 25(52.1); Brother or sister 3(6.2); Friend
12(25.0).
3.2. Relationships between emotional intelligence, coping strategies,
depression and anxiety
All the correlations between EI, coping strategies, depression and
anxiety are reported in Table 2. The level of patients’ anxiety and de-
pression was significantly lower when they had higher EI scores, and
3.4. Results of the APIM on the anxiety level
The results of the actor partner interdependence model are pre-
sented in the Figs. 1 (EI and STAI) and 3 (Coping and STAI).
The patients’ and caregivers’ EI was associated with a decrease of
their own anxiety level. We did not identify any partner effect.
With coping strategies, we found several actor effects and one
partner effect. The use of avoidance strategies by caregivers increases
their own anxiety and patients’ anxiety. As well as the results of de-
pression level, the use of positive thinking and problem solving stra-
tegies by patients and caregivers was associated with a decrease of their
own level of anxiety. We did not find any actor or partner effect be-
tween using social support strategies and patients or caregivers’ level of
anxiety.

Table 2
Correlations between anxiety, depression, emotional intelligence and coping strategies for MDD patients and caregivers.

Patients Caregivers

TEIQue-SF BriefCope TEIQue-SF BriefCope

Emotional intelligence Social Problem Avoidance Positive Emotional intelligence Social Problem Avoidance Positive
support solving thinking support solving thinking

Patients’ Beck − 0.418** − 0.188 − 0.335** 0.319** − 0.428** − 0.043 − 0.043 − 0.178 0.113 − 0.148
Patients’ STAI − 0.446** − 0.093 − 0.364** 0.307* − 0.326* − 0.024 0.098 − 0.166 0.187 − 0.221
Caregivers’ Beck − 0.149 0.022 − 0.336** 0.146 − 0;188 − 0.428** 0.058 − 0.261* 0.465** − 0.399**
Caregivers’ STAI − 0.067 0.034 − 0.134 0.081 − 0;092 − 0.609** − 0.014 − 0.272* 0.385** − 0.468**

TEIQue-SF (Trait Emotional Intelligence Questionnaire - Short Form): higher scores indicate higher trait EI.
BriefCope (Brief Coping Orientation to Problems Experienced Scale): higher scores in these 4 dimensions reflect a higher tendency to implement the corresponding coping strategies.
Beck (Beck Depression Inventory): higher scores indicate a higher severity of the depression.
STAI (State-Trait Anxiety Inventory): higher scores indicate higher anxiety.
* p < 0.05.
** p < 0.01. Significant differences are in bold.

3
S. Marguerite et al. Psychiatry Research xxx (xxxx) xxx–xxx

Fig. 1. Illustration of relationships between Emotional

Intelligence, Beck score and STAI using the actor–partner
interdependence model. TEIQue-SF (Trait Emotional
Intelligence Questionnaire – Short Form), Beck (Beck Depression
Inventory), STAI (State-Trait Anxiety Inventory), Significant re-
sults (p < 0.05) are in bold.

TEIQue-S
SF (Trait Emootional Intelliggence Questio
onnaire - Shorrt Form)

Beck (Beeck Depressionn Inventory)

STAI (State-Trait Anx

xiety Inventoryy)

Significannt results (p<0

0.05) are in boold.

Fig. 2. Illustration of relationships between coping strategies

and Beck score using the actor-partner interdependence
model. Beck (Beck Depression Inventory), Significant results
(p < 0.05) are in bold.

Beck (Beeck Depressionn Inventory)

0.05) are in boold.

Significannt results (p<0

Fig. 3. Illustration of relationships between coping strategies

and STAI using the actor–partner interdependence model.
STAI (State-Trait Anxiety Inventory), Significant results
(p < 0.05) are in bold.

STAI (State-Trait Anx

xiety Inventoryy)

Significannt results (p<0

0.05) are in boold.

4. Discussion anxiety among caregivers of individuals with MDD, in contrast to other

The major results of this study may be summarized as follows: (i)
caregivers experience both substantial depressive and anxious symp-
tomatology; (ii) EI showed an actor effect on depression and anxiety
level; and (iii) coping strategies showed actor and partner effects on
anxiety and depression level within the dyad.
In line with previous studies on caregivers of patients with chronic
illnesses (Jacobs et al., 2017; Liang et al., 2016), caregivers of MDD
patients also experiments anxiety and depression symptoms. A STAI
score higher than 39–40 suggests clinically significant symptoms for
anxiety (Addolorato et al., 1999; Julian, 2011; Spielberger and
Gorsuch, 1970) and a Beck score ranged from 4 to 7 suggests the pre-
sence of mild depression (Beck et al., 1988). To date, few studies have
focused on exploring psychiatric symptoms such as depression and
diseases such as schizophrenia (Gupta et al., 2015; Stanley et al., 2017),
dementia (Ask et al., 2014; Martin et al., 2006) or cancer (Borges et al.,
2017; Nijboer et al., 1999). The results of the European Federation of
Associations of Families of People with Mental Illness (EUFAMI) in-
ternational survey reported that having a family member with severe
mental illness results in emotional, social, physical, financial and re-
lationship burden (EUFAMI, 2014). This burden conducts to caregivers’
psychological distress, defined as a state of emotional suffering char-
acterized by symptoms of depression (e.g. loss of interest, sadness and
hopelessness) and anxiety (e.g. restlessness, feeling tense) (Mirowsky
and Ross, 2002). Although apparently less cumbersome to deal with
than psychotic symptoms (Zendjidjian et al., 2012), our findings sug-
gest that depressive and anxiety symptoms in MDD patients are parti-
cularly difficult to cope with for caregivers. In line with this hypothesis,

4
S. Marguerite et al.
Liang et al. reported that the risk factors for caregiver's anxiety and
depression symptoms were increased when patients with cognitive
impairment had higher level of depression (Liang et al., 2016). In the
same way, anxiety and depressive symptoms are interrelated among
dyads facing a newly diagnosed incurable disease (Jacobs et al., 2017).
Our findings may support the systematic assessment of depression and
anxiety symptoms in caregivers of patients with MDD. Taking into ac-
count depression and anxiety symptoms in caregivers is of importance
both for the caregivers themselves and indirectly for patients’ health
because caregivers’ health may affect their ability to care for the pa-
tients (Boyer et al., 2017; van Wijngaarden et al., 2004).
The actor effect between EI and symptoms confirms previous studies
that reported that higher levels of EI were associated with various po-
sitive health outcomes (Austin et al., 2005; Boyer et al., 2017; Martins
et al., 2010). For the caregivers, high levels of EI were moderately re-
lated to lower anxiety and depression level. Previous studies on care-
givers reported that higher scores of EI were inversely associated with
depression (Liang et al., 2016) and anxiety (Weaving et al., 2014).
Although the mechanism by which EI influences these outcomes is not
entirely understood, some studies have shown higher EI scores to be
associated with significantly lower reactivity to stress at both psycho-
logical and biological levels (Mikolajczak et al., 2007b). EI seems to
moderate the relationship between stress and mental health (Ciarrochi
et al., 2002). In the same way, patients’ EI influences positively their
level of anxiety in our study. The absence of statistically significant link
between EI and level of depression is not in line with previous studies
which reported that EI is reduced in depressive patients (Martins et al.,
2010) and is a predictor of depression (Lloyd et al., 2012). However, we
cannot exclude a lack of statistical power because the APIM approach
preferentially requires a large sample size. From a therapeutic point of
view, the question is to determine whether EI can be taught to patients
and caregivers. This issue is not resolved, some conceptualizations
suggesting that EI is a fixed quality difficult to change whereas other
conceptualizations considering that EI is a dynamic ability amenable to
change (Mayer et al., 2008b). Future studies should explore the ther-
apeutic options to improve EI and explore the benefit on symptoms.
Finally, the coping strategies employed by the individuals have a
moderate impact on their own anxiety and depression level (i.e. actor
effect) but also on the other person of the dyad (i.e. partner effect). As
expected (Baumstarck et al., 2017; Holahan and Moos, 1987), active
coping strategies (i.e. problem solving and positive thinking) were as-
sociated with lower level of symptoms contrary to passive coping
strategies (i.e. avoidance) which were associated with higher level of
symptoms (Billings and Moos, 1984, 1981). These findings suggest that
a systematic assessment of patient and caregiver coping styles could be
conducted to identify individuals who do not use healthy coping stra-
tegies and to offer targeted psychological interventions (Iseselo et al.,
2016; Kartalova-O’Doherty and Doherty, 2008). Problem-solving
therapy interventions for patients and their caregivers have showed
positive findings (Bell and D’Zurilla, 2009; Vázquez González et al.,
2013). Some studies reported that psychoeducation programs, cognitive
behavioural therapy and mindfulness helped patients and caregivers
increase coping efficiency and improve their symptoms (Boele et al.,
2013; Carlson, 2016; Keng and Tong, 2016). Dyadic interventions are
subject of recent studies (Stahl et al., 2017), and need to be further
developed.
4.1. Limitations and perspectives
The present study needs to be considered in the light of the fol-
lowing limitations.
First, the representativeness of the sample could be questioned, and
may limit the generalization of the main findings: it is a relatively small
sample, and all depressed patients were recruited in the same French
teaching hospital, during the period of their hospitalisation. This does
not allow to generalize our findings neither to global affective disorders
5
Psychiatry Research xxx (xxxx) xxx–xxx
nor to outpatient care. Moreover, only one primary caregiver, desig-
nated by the patient, was recruited. There could be variety in the types
of coping associated with caregiving among different caregivers, due to
different family roles and perceptions of caregiving (Kartalova-
O’Doherty and Doherty, 2008; Priestley and McPherson, 2016). Further
studies should not be restricted to the primary caregiver.
Secondly, we conducted a cross-sectional study that, contrarily to
longitudinal study, cannot explore the influence of EI and coping stra-
tegies on depression and anxiety over time. This temporality link re-
mains unknown. Future studies should focus on the longitudinal re-
lationship between EI, coping strategies and symptomatology in
patients and their caregivers.
Thirdly, an interesting data was not collected and should be in-
cluded in future studies. The daily time spent between the caregiver and
the patient has not been specifically assessed, and this data is known to
influence caregivers’ burden.
Lastly, we chose to measure EI with a trait measure. Several con-
ceptualizations coexist in the research literature including ability ap-
proach. Thus, future studies should explore ability EI in the context of
MDD.
5. Conclusion
This study shows that EI and coping strategies are related to anxious
and depressive symptoms of MDD patients and their caregivers.
Moreover, certain coping strategies implemented by one member of the
dyad influence directly the mental health of the other individual. These
findings suggest that patients and their caregivers may be considered
together as a system to fully address each individual's psychiatric
symptoms. Future research should discern when dyadic versus in-
dividual psychosocial interventions would be optimal in order to im-
prove patients’ and caregivers’ mental health.
Funding
None.
Acknowledgements
The authors are grateful to Thérèse Auriol-Vigne, Chloe Jover,
Kevin Alimi, Pierre Arquilliere, nurse staff and all of the patients and
caregivers for their participation in the study.
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