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Predictors of Depressed Mood in Spouses of Women With Breast Cancer

Frances Marcus Lewis, Kristin A. Fletcher, Barbara B. Cochrane, Jesse R. Fann

From the School of Nursing; Department of Psychiatry and Behavioral Sciences, University of Washington; and the Departments of Biobehavioral and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA

Corresponding author: Frances Marcus Lewis, PhD, University of Washington, Box 357262, Seattle, WA 98195-7262; e-mail: fmlewis{at}u.washington.edu

	ABSTRACT

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Purpose Depressed mood in spouses of women with breast cancer deleteriously affects their own and their wife's functioning and their marital communication. However, no study has examined why some spouses get depressed whereas others do not, particularly during the first months of diagnosis and treatment, a known difficult time for couples. The current study has two purposes: to test a predictive model of spouses’ depressed mood and to evaluate the model's accuracy in distinguishing between normal and clinically depressed spouses.

Methods Data were obtained from standardized questionnaires completed by 206 spouses and 206 wives recently diagnosed with nonmetastatic breast cancer. Spouses’ depressed mood was measured by the Center for Epidemiological Studies–Depression Scale. A total of 19 variables were extracted from the literature for testing in the model, including psychological, social, demographic, and disease- and treatment-related variables.

Results Spouses were more likely to be depressed if they were older, less well educated, more recently married, reported heightened fears over their wife's well-being, worried about their job performance, were more uncertain about their future, or were in less well-adjusted marriages. The model correctly classified 89.2% of spouses’ mood (² = 79.1; P < .001).

Conclusion Spouses of women with local or regional breast cancer need to be screened for depressed mood and triaged into supportive services to better assist them manage the threat of their wife's breast cancer.

	INTRODUCTION

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In 2007, an estimated 178,480 women in the United States will be newly diagnosed with local or regional breast cancer and an additional 62,030 women will be diagnosed with in situ disease.¹ Although there is high potential for cure with nonmetastatic disease, breast cancer is known to cause substantial distress (anxiety, depressed mood) in the diagnosed woman's spouse, regardless of stage of disease.^2-5

Distress in the spouse has been demonstrated in both cross-sectional and longitudinal studies, and significantly elevated levels of psychosocial morbidity occur up to 3 years postdiagnosis.^2-4,6-28 Spouses’ distress reach or exceed their wives’ distress and remain higher than normal levels.^{4,6,17,18,29-33}

Distress, especially depressed mood, has important consequences for the diagnosed wife. Mood disturbance in the spouse is associated with higher distress in cancer patients,^34-37 strains the marriage, and negatively affects couples’ interactions and coping with their problems.^{6,25,26,38,39} Research has also linked negative or hostile interpersonal behaviors in marital couples with downregulated immune function, especially in the female member in the couple.⁴⁰

Despite evidence of depressed mood in spouses of women with breast cancer, little is known about what predicts which spouse will be more depressed or which spouse will reach clinical levels of depressed mood. Prior studies have failed to examine depressed mood within a multivariate model that includes wives’ medical treatment and demographic factors and plausible sources known from completed descriptive studies. The absence of such a study has constrained the development of evidence-based programs to assist spouses.^3,12,41 There are two purposes to the current study: to test a predictive model of spousal depressed mood and to evaluate the model's accuracy in predicting clinical levels of depressed mood in spouses of women with nonmetastatic breast cancer.

Nineteen variables were extracted from the literature as plausible sources of spouses’ depressed mood, 11 theoretical variables and nine diagnosis, treatment, and demographic variables. Each of the 11 theoretical variables are described herein and can be broadly organized within four theories: a transactional model of coping^42,43; a relational model of adjustment^{13,38,41,44-47}; sex-related role theory^48-50; and an existential model of loss.^51,52 The treatment and demographic variables were spouse's age, education, length of marriage, medical treatment complexity, type of surgery (breast conserving or non–breast conserving), treatment status (receiving or not receiving adjuvant), number of adolescent children, and spouses’ use of counseling services.

Depressed mood in the diagnosed wife affects spouses’ depressed mood.^37,53-55 In a study of 58 patients with cancer, the greater the depressed mood in the diagnosed patient, the greater the depressed mood in the spouse.³⁷ In a study of 150 cancer patients and caregivers, patient depressed mood significantly predicted caregiver depression.⁵⁶

Marital adjustment significantly affects spouses’ mood.^53,57 In a study of 73 couples involved in cancer treatment, depression increased as interpersonal conflict increased.⁵⁸ In a seminal paper on the impact of marital adjustment on spousal mood, spouses’ depressed mood significantly increased as marital adjustment decreased.³⁸

Interpersonal disconnection about the breast cancer is a potential source of depressed mood in the spouse.⁵⁹ Both the diagnosed wife and her spouse struggle with how much and how to talk about the cancer.^60-65 In a study of 120 breast cancer patients and their partners, lower rates of communication about the breast cancer in the couple were associated with higher depressive levels.⁶⁶

Concern over wife's well-being may affect spousal depressed mood. Even with early-stage disease, spouses fear their wife might die from the cancer.^2,62 Spouses watch their wife suffer from the debilitating effects of treatment and worry about whether she is or is not responding well.²

Diminished social activities have a documented link with spouses’ depressed mood.⁵⁴ Social activities provide an avenue for support as well as distraction for the spouse and such activities can be among the first things relinquished to help the ill wife.^59,67 In a study of 75 cancer patients and spouse-caregivers, restricted activities in the caregiver's routine mediated caregiver stress and depressed mood.⁶⁸ In another, spouses reported that the cancer disrupted their routines and lifestyle at work and home and heightened their sense that things were falling apart.⁶²

Altered sexual activity can potentially affect spouse mood. In a seminal study by Wellisch's team, husbands of women with mastectomies rated their own and their wife's sexual functioning before and after surgery.²¹ There were more self- and other negative evaluations after the mastectomy compared with before surgery. In another study of 67 spouses of women with breast cancer, one spouse said, "The most difficult part was just accepting the fact that her breast had to be removed. To know that something you truly enjoyed for these years was no longer going to be there... . "⁶²

Job-related concerns are potential sources of spousal distress. In Wellisch's classic study, almost half of the husbands reported their ability to work was temporarily affected.²¹ Problems at work, sleep disturbance, and increased depression were also noted in a recent study of 20 Israeli spouses of women with breast cancer.⁶⁹

Low confidence in emotionally supporting the wife about the breast cancer may affect spouses’ mood. Spouses claim they have no confidence in being able to emotionally support their wife about the breast cancer and struggle on their own to understand her emotions.⁶² Interview studies reveal that spouses do not always have the skills to identify what the wife views as supportive.^{61-63,65,70,71}

Low confidence in managing the cancer is associated with increased spousal distress.⁷² Spouses are overwhelmed with every aspect of their wife's breast cancer.^61,62,65,71 Commonly, spouses claim that nothing before or since has prepared them for their wife's breast cancer.

Illness-related uncertainty is a source of spouses’ depressed mood. Spouses report difficulty adjusting to the cancer-related uncertainty and its impact on their future.^73,74 As one spouse stated, "She could be dead in a year... and it's not knowing that leaves you hanging".⁶²

Feeling excluded from the medical team can affect spouses’ distress. In a focus group study, spouses reported feeling isolated, left out of the support available to their wives, and left out by the health care team. "You're sort of isolated." "You are sitting there all by yourself".^61,65

	METHODS

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Study Design and Sample
The current study was part of a larger clinical trial involving couples dealing with newly diagnosed nonmetastatic breast cancer. Data analyzed for the current study were baseline data obtained for the total sample before random assignment. Study participants were recruited from 70 sites from two states in the Pacific Northwest. Eligibility criteria required that the woman be diagnosed with nonmetastatic breast cancer (stage 0, I, IIA, or IIB) or in situ disease (lobular carcinoma in situ or ductal carcinoma in situ) within 8 months; be married or partnered in an intimate relationship of 6 months or longer with a man; and be able to read, speak, and write in English. Diagnosis and disease staging were verified through surgical pathology report. Following institutional review board approval, signed informed consent was obtained from both diagnosed women and spouses.

Study Measures
The 11 theoretical variables were measured by standardized questionnaires with well established validity and reliability.^38,44,75-80 Internal consistency reliabilities for study measures calculated for the study sample are on the diagonal in Table 1.

The quality of the marital relationship was measured by the Spanier Dyadic Adjustment Scale (DAS), a 32-item self-report scale that has four factor-derived subscales: dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression.⁸⁰ Total scale scores can range from 0 to 150. Both total and subscale scores have high internal consistency reliability and construct validity. In tests of the construct validity in families with chronic illness in the wife (diabetes, fibrocystic breast disease, breast cancer), total scale scores on the DAS significantly predicted family coping behavior (β = –.62; P = .0001); child psychosocial functioning (β = –.35; P = .006); and total household functioning (β = –.35; P = .001).³⁸

Interpersonal Disconnection From the Wife About Breast Cancer is a 5-item subscale of the Mutuality and Interpersonal Sensitivity (MIS), a 23-item standardized questionnaire that measures the content and means of couples’ communication with each other about the breast cancer (Lewis et al, manuscript in preparation). The 5-item subscale measures the degree to which spouses attend to and support each other's feelings and responses to the breast cancer. Content, criterion, and construct validity of the scale has been examined in couples impacted by nonmetastatic breast cancer; the total score on the DAS significantly correlates with the total score of the MIS; r = .58 (two-tailed P < .001).⁹¹

The following six subscales are from the Demands of Illness Inventory: Concern for Wife's Well-Being, Diminished Social Activities, Altered Sexual Activity, Job-Related Concerns, and Feeling Excluded by Medical Team.^92-94 The Demands of Illness Inventory measures the perceived pressures or concerns the spouse explicitly attributes to his wife's breast cancer. Both content and construct validity have been well established with multiple populations of patients influenced by serious chronic medical illness.^92-94

Confidence to Manage Breast Cancer and Confidence to Emotionally Support the Wife About Cancer are subscales of the Cancer Self-Efficacy Scale (CASE), a 19-item self-report measure of the spouse's personal confidence to manage the impact of breast cancer. The measure derives from Bandura's Social Cognitive Theory.^95,96 Content validity of the CASE was established through a review of confidential case-intensive interviews of women diagnosed with early-stage breast cancer.^44,77 Criterion validity was estimated by correlating scores on the CASE with the total scale and subscale scores on the General Self-Efficacy Scale.

Illness-Related Uncertainty is a 12-item subscale of the Coherence Scale, a self-report measure that derives from Antonovsky's model of coherence, Yalom's model of meaninglessness, and Frankl's model of meaning.^97-99 Coherence is the extent to which the spouse has an expectation of resolve that things will work out as best as can be expected; is able to reasonably predict future events; and has a sense that life is ordered.^100-103 Content and construct validity have been tested in studies of spouses and patients with cancer or HIV/AIDS.^100-104

Data Analytic Strategies
Data analysis proceeded in three phases: preparatory, model testing, and model evaluation, all of which were completed using SPSS for Windows version 11.5 (SPSS Inc, Chicago, IL).

Preparatory Phase
Before analysis, sampling distributions were inspected for kurtosis, skewness, and outliers. Colinearity was inspected by examining bivariate correlations between each independent variable and by computing tolerance values of the independent variables in relation to the dependent variable.¹⁰⁵ There was no evidence of colinearity in any of the analyses.

Model Testing
Spouses’ depressed mood (total score on CES-D) was regressed using forward stepwise regression onto the hypothesized predictors after controlling for the empirical variables, entered in block format. Colinearity was concurrently examined by reviewing the tolerance and variance inflation factors (VIF) in the regression models. The final estimated model was reviewed for accuracy and interpretability. Those variables not entered were also reviewed to rule out erroneous exclusion.

Model Evaluation
Logistic regression was used to examine the model's accuracy in correctly classifying spouses with clinically significant depressed mood (CES-D scores of 16 or higher). All covariates were entered into the logistic regression model as a block in step 1; all the independent variables from the model testing phase were next entered in stepwise fashion using the same analytic steps as were used in model testing.

	RESULTS

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Sample Description
A total of 206 spouses and 206 wives constituted the study sample. Couples were in long-term marriages that averaged 16.74 years (± 8.21 years) and had a median of two children, 44% of whom were adolescents. The majority (62%) of households had incomes of $50,000 or more. Spouses averaged 45.26 years in age (± 7.46 years); the majority were college educated, and most worked part- or full-time. Spouses were primarily white (91.1%) but 8.9% were African American, Native American, Asian, or Hispanic. A total of 22 spouses (10.7%) received or were seeking professional counseling, including participation in ongoing support or professional counseling for issues related to the breast cancer. Spouses’ scores on the CES-D ranged from 0 to 55 with a mean of 9.9 (± 8.5); 39 (19%) had a score of 16 or higher.

Women averaged 43.09 years of age (± 6.02) and 65% worked part- or full- time. The majority of women, 122 (59.8%), underwent mastectomy; 82 (40.2%) underwent lumpectomy with nodal dissection. A total of 73.3% of the women were receiving adjuvant treatment at the time of their spouse's participation in the study, and the average time since the woman's diagnosis was 5.0 months (± 2.6). Wives were primarily white (90.6%), but 9.4% were African American, Native American, Asian, or Hispanic. Women's CES-D scores ranged from 0 to 50 with an average of 11.6 (± 8.7); 60 women (29%) scored 16 or higher (Table 2).

View this table: [in this window] [in a new window]   Table 4. Logistic Regression Predicting Clinical Depression (CES-D 16)

	DISCUSSION

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Nineteen variables were extracted from the literature as potential predictors of spouses’ depressed mood, but only seven significantly distinguished between depressed and nondepressed spouses. Results suggest that middle-class, well-educated spouses in long-term, child-rearing relationships were depressed by the threat of losing their wife to the cancer and the related uncertainty in their personal and work life. None of the medical or treatment variables significantly predicted whether the spouse was depressed. Rather, it was the spouse's view of the breast cancer and its threat to his wife that affected his mood.

Although study participants’ wives were diagnosed with early-stage disease, spouses’ views of the cancer were highly charged and dominated by fears and concerns. These fears intruded into their job performance and raised existential worries about the future. Counter to expectation, the objective characteristics of the breast cancer and its medical treatment did not affect spouses’ depressed mood. Even the use of counseling services did not distinguish between depressed and nondepressed spouses. Except for age, education, and length of marriage, none of the spouse's background characteristics predicted his depressed mood. Being older and less well educated put spouses at significantly greater risk for depression. Older and less well-educated spouses appear to be limited in their ability to frame the breast cancer in nonthreatening terms.

A forgiveness factor seems to be operating in the data. Spouses were "forgiving" of behavior in their wife or themselves that might have been more important under other circumstances. For example, the wife's depressed mood, the couples’ altered social life, or their changed sexual activity did not significantly affect his mood. Although these are arguably important factors, they were not salient for spouses during their wife's initial treatment and early recovery. The spouse's fears of losing his wife to the disease took precedence over everything.

The overall logistic model correctly classified 89.2% of spouses’ depressed mood, but it was more successful in classifying nondepressed spouses (98.2%) than depressed spouses (51.3%). Future research is needed to further refine the model, including testing additional variables that were not included in the current study.

How to assist the spouse with his depressed mood goes beyond current results. However, three approaches appear relevant: a behavioral management model, an existential counseling model, or a combination of both. A behavioral management model would help spouses gain skills to better deal with the impact of their wife's cancer on their everyday life, including its related stress. Most behavioral management programs have focused on skill enhancement in patients, not spouses.^106,107 However, a recent behavioral management intervention for spouses resulted in significant improvements in spouses’ depressed mood, anxiety, skills, and self-care.¹⁰⁸ An existential counseling model would focus on more directly processing spouses’ fears about their wife's well-being and more directly address spouses’ personal uncertainty and vulnerability. The third model would include elements from both models.

Regarding limitations of the present study, results are limited to highly educated, predominantly middle-class, child-rearing white spouses and wives, and may not generalize to other populations. Data are also limited to self-report questionnaires.

Prediction is not causation. Study results do not allow us to argue that the significant predictors caused spouses’ depressed mood. We can argue only that the predictors were significantly associated with spouses’ depressed mood and distinguished between depressed and nondepressed spouses. Furthermore, depressed mood is not the same as a diagnosis of clinical depression. The CES-D is a screening tool, not a diagnostic measure.

	AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

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The author(s) indicated no potential conflicts of interest.

	AUTHOR CONTRIBUTIONS

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Conception and design: Frances Marcus Lewis, Barbara B. Cochrane

Financial support: Frances Marcus Lewis

Administrative support: Frances Marcus Lewis, Barbara B. Cochrane

Provision of study materials or patients: Frances Marcus Lewis

Collection and assembly of data: Frances Marcus Lewis, Kristin A. Fletcher, Barbara B. Cochrane

Data analysis and interpretation: Frances Marcus Lewis, Kristin A. Fletcher, Barbara B. Cochrane, Jesse R. Fann

Manuscript writing: Frances Marcus Lewis, Kristin A. Fletcher, Barbara B. Cochrane, Jesse R. Fann

Final approval of manuscript: Frances Marcus Lewis, Barbara B. Cochrane, Jesse R. Fann

	NOTES

 
Supported by National Cancer Institute, National Institutes of Health Grants No. R01-CA-55-347 and R01-CA-78424.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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Submitted September 5, 2007; accepted November 28, 2007.

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