Pain, 44 (1991) 61-67 0 1991 Elsevier Science Publishers ADONIS 0304395991000574
61 B.V. (Biomedical
Division)
0304-3959/91/$03.50
PAIN 01704
Depression in spouses of chronic pain patients: the role of patient pain and anger, and marital satisfaction * Lauren
Schwartz,
Mark A. Slater, Gary R. Birchler and J. Hampton
Atkinson
V.A. Medical Center and University of California, San Diego, CA (U.S.A.) (Received
5 March
1990, revision received
7 June 1990, accepted
12 June 1990)
Although several studies have shown that spouses of chronic pain patients may experience clinically significant depressive Summary symptoms few studies have comprehensively examined the role of both patient and spouse-related factors in the development and maintenance of this emotional distress. Twenty-nine married male chronic benign low back pain patients and their spouses were recruited in order to examine the role of patient, spouse, and marital factors in spouse depressive symptomatology. The results indicated that 28% percent of the spouses in the sample reported significantly depressed mood. A 2-stage regression analysis was employed that revealed 3 significant predictors of spouse’s depressed mood, namely patient’s average pain, patient’s reported levels of anger and hostility, and the spouse’s level of marital satisfaction. These findings are discussed in terms of their implications for clinical interventions for pain patients and their families. Key words Chronic
pain;
Marital
relationship;
Depression;
Spouses
Introduction
It is well known that chronic pain can produce a range of adverse affects on both the patient and spouse [21,43,51] and several recent studies have investigated the role of the spouse in maintaining chronic pain [16,21], as well as the effects of pain on the spouse [23,43]. In addition to dealing with the altered roles and responsibilities, spouses of chronic pain patients often must deal with the patient’s psychological distress and physical limitations. Given the potential demands placed on spouses of chronic pain patients, it would be expected that this population is at risk for emotional distress, particularly depression. Preliminary data support this assertion. Prevalence surveys indicate relatively higher reports of depressive symptoms in spouses of chronic pain patients as compared to community samples [3,17]. Comstock and Helsnig [17] reported that approximately 16-198 of the females in a community control sample reported depressive symptomatology. By wide
* This research was supported in part by Medical Research Grants to the second and fourth authors from the United States Department of Veterans Affairs. This research was completed in fulfillment of a Master’s Thesis conducted by the first author under supervision of the second author. Correspondence to: Lauren Schwartz, Pain Management Program (116B), San Diego VA Medical Center, San Diego, CA 92161, U.S.A.
way of comparison, studies of spouses of chronic pain patients have indicated that 20-50s of these spouses report significant depressive symptomatology [3,23,29, 421. Unfortunately, many of these previous studies have been conducted in specialty pain clinics and psychiatric samples [2,23,42] and are based on heterogeneous samples including diverse pain locations and etiologies [2,20,42]. Moreover, many studies combine both male and female patients for examining the effects of chronic pain on the spouse and on the marriage [2,42,48]. This is problematic, however, because of mounting evidence suggesting differential sex effects and role expectations for both patients and caretakers depending on gender [5,22,41]. The purpose of the present study was to examine the contribution of 5 dimensions proposed in the literature as important in explaining depressive symptoms in spouses of chronic pain patients. Specifically these multiple factors are: the patient’s pain experience (particularly pain intensity, impairment levels, and duration of pain) [30,39,42]; the patient’s emotional distress (particularly depressive symptoms and anger) [29,48]; the marital relationship (particularly patient and spouse marital satisfaction) [2,6], the spouse’s cognitive sty/e (particularly cognitive distortions) [33]; and spouse’s externaI resources (particularly social supports, economic resources, and patient employment status) [+9,42,47].
62
Three additional aspects of the present study broaden its applicability. First, we studied ambulatory patients rather than hospitalized individuals. Second, our sample was composed of general orthopedic clinic patients rather than individuals preferentially referred for pain clinic consultation. Third, we studied only male chronic low back pain patients and their spouses to control for the potentially confounding effects of pain type and gender.
Methods Subjects
Subjects were 29 consecutive married, male, chronic benign low back pain (CLBP) patients who met inclusion/exclusion criteria for a larger study of psychosocial factors in CLBP, and their spouses. Pain patients were recruited from a general outpatient orthopedic clinic. Inclusion criteria for patients were: (1) ages 21-64 inclusive, (2) low back pain (WJ and below) present on a daily basis for the previous 6 months or longer, and (3) CLBP as the primary medical complaint. Pain patients were excluded from participation if they had: (a) a major co-existing medical illness (e.g., chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure), (b) a coexisting orthopedic or pain problem, (c) organic brain syndrome, schizophrenia, or affective disorder with psychotic features based on criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) [4], or (d) undergone major surgery less than 1 year before evaluation. Furthermore, patients and spouses were required to be fluent and literate in English. Patients and their spouses were paid $20 each for completing the entire research battery, which required approximately 4-6 h of their time. Measures Spouse3
depressive symptoms. Spouse’s depression was assessed using the Beck Depression Inventory (BDI) [lo]. A score of 10 or more has been advanced as indicative of the presence of at least mild depressive symptoms [8]. Reliability and validity data on the BDI are extensive 191. Patient’s pain experience. Duration of CLBP was measured in months since the onset of daily pain. Average pain intensity was rated on a numeric analogue scale (NAS) ranging from 0 to 100, with “0” indicat~g “no pain” and ‘WO” representing “pain as bad as it can be.” Research has shown that the NAS is reliable and highly correlated with other pain assessment measures [31]. The Sickness Impact Profile (SIP) [27] was used to assess functional impairment related to back pain. The SIP is a b~ha~or~ly based, self-report measure of disability. The total impairment score was used as a measure of the patients’ overall disability. The SIP
has acceptable reliability [3X] and validity [ 1l] for a variety of illness populations and has been validated specifically for use with chronic pain patients 1251. Patient’s emotional distress. The patient’s level ol emotional distress was measured using the BDI (Beck Depression Inventory) and the Profile of Moud States (POMS) [35f. The anger/hostility subscale of the POMS was used to assess patient’s anger. Anger was selected in addition to depressive symptoms because of the high frequency with which pain patients exhibit anger and hostility, as well as the likelihood of the direct impact of anger on the spouse’s mood [12]. Muritul reiationship. The Dyadic Adjustment Scale (DAS) [SO] was used to assess marital satisfaction. The DAS is a self-report assessment instrument that contains 32 items. The DAS has been shown to have high levels of reliability and validity [14,15,50]. Internal resources. The spouse’s internal resources were operationaiized as her propensity to make consistent distortions in inte~reting common life events. Such distortions are thought to be important in the development and maintenance of depressive symptomatology [7]. The Cognitive Errors Questionnuire (CEQ) [32,33] was employed to assess such maladaptive thinking based on Beck’s cognitive theory of depression 171. External resources. Several external resources may affect ability to cope with the stress of being married to someone with chronic pain. The Sociul Support Questionnaire (SSQ) [44] was used to assess the spouse’s level of social support. Two indices of social support were calculated, network size (i.e., number of supports available) and satisfaction with supports. A series of studies indicate the high reliablity of this measure [28,44]. Patient employment status (employed or unemployed) and total annual family income were recorded to provide an assessment of the tangible resources available to the spouse to aid her in coping with the patient’s chronic pain. Procedures
This study was part of a larger VA funded program examining psychosocial factors in chronic low back pain. Subjects for this research program were solicited from among outpatients attending a general orthopedic clinic following careful review of medical records to confirm compliance with the study inclusion and exclusion criteria. Patients who met these criteria by chart review were then re-screened in person. Patients who met criteria at both occasions were invited to participate in the study. Patients and their spouses were evaluated concurrently in separate rooms. Following informed consent patients completed demographic and pain rating forms, then all other instruments were ad~~stered to patient and spouse in a randomized order. All interviews and ratings were conducted by personnel who
63
were unaware of the data from self-report, orthopedic and pain measures. Statistical
analysis
Multiple regression analyses were computed to evaluate the value of patient, spouse, and marital factors in the explanation of spouse depression scores. A series of separate regression analyses [37] were conducted within each proposed domain to identify key predictors and to reduce the data set to the minimum number of significant predictors. Variables from each domain that made a significant contribution were used in the second stage of the analysis. At the second stage of the analysis important predictor variables from each domain that were identified at stage 1 were combined in a comprehensive multiple regression model. To determine the predictive ability of the individual and the set (domain) contributions, multiple R squared (R*), R squared change (R* change), bivariate correlation coefficients (r), and beta weights were examined.
Results
Orthopedic diagnoses in our patient sample were spinal stenosis (38%) degenerative disk disease (28%), herniated disk pulposus (14%), post-surgical pain (lo%), spondylolysis or spondylolisthesis (3%), musculoskeletal strain (3%), and no orthopedic disorder (3%). Mean duration of pain was 228 months, or 19 years (range 6-576 months), and average pain intensity (rated on the O-100 Numeric Analog& Scale) was 50.86 (range 1595). Average overall impairment rating on the Sickness Impact Profile was approximately 17% (range: 1.4132.19%) relative to normal levels of functioning. In terms of s~i~emo~ap~c and marital variables, mean age of patients was 53.5 years (range 32-64); mean age of spouses was 51.7 years (range 23-76). These couples predominately were Caucasian (97% of husbands and 90% of wives), had been married for an average of 24.6 years (range l-45) and had an average annual income of approximately $27,000 (range $lO,~-60,~). It should be noted that 13 (45%) of the patients and 11 (38%) of the spouses were employed at the time of evaluation. The mean DAS score was 117.00 (SD. = 19.41) for patients and 117.03 (SD. = 17.50) for spouses, which is comparable to DAS scores for non-distressed marriages (X = 114.80, S.D. = 17.80 [50]. Prevalence of depressed mood
Our first goal was to describe the prevalence of depressive symptomatology in spouses of chronic low back pain patients from a general orthopedic clinic. Table 1 displays the range of scores and the percentage of spouses in each BDI subgroup, reflecting the preva-
TABLE I SAMPLE PREVALENCE OF DEPRESSIVE SPOUSES OF CLBP PATIENTS
SYMPTOMS
Beck Depression Inventory subgroup
BDI score range
% of spouses *
Nondepressed Mildly depressed Moderately depressed
o- 9 IO-13 14-18
72.4% (n = 21) 10.3% (n = 3) 17.2% (n = 5)
IN
* Note: percentages do not total 100% due to rounding error.
lence rates of depressive symptomatology in our sample. Approximately 28% of spouses in our sample reported at least mild depressive symptoms, as evidenced by a BDI score of 10 or greater. The majority of these spouses were in the moderately depressed range, indicated by a BDI score of 14 or above [23]. Additionally, a greater percentage of spouses in our sample reported significantly depressed mood as compared to the pain patients (28% versus 20%). An item analysis revealed that the majority of spouses endorsed vegetative signs of depression (e.g., sleep problems, decreased efficiency; see Table II). This finding suggests that depressive symptoms are quite common in this group, with. the majority of spouses endorsing at least some s~ptoms of depression. Predictors of spouse depression within domains Within the domain of patient’s pain experience
only
patient’s average pain intensity made a significant conTABLE II ITEM ANALYSIS OF SPOUSES TORY SCORES
BECK DEPRESSION
BDI symptoms endorsed
% of sample reporting symptom
Fatigue Sleep disturbances Irritability Decreased efficiency Decreased libido
77 63 54 52 50
Decreased satisfaction Self-criticism Hypochondriasis Loss of interest in others Unattractiveness Feelings of failure Decreased appetite Decision making problems Disappointment Discouraged Sadness Feeling punished Weight loss Crying Guilt feelings Suicidal ideation
33 30 30 21 27 23 23 20 20 17 13 13 13 10 10 7
INVEN-
tribution
to the prediction
of spouse’s
depressed
mood
(r = 0.40; beta = 0.34, P < 0.05). Next, considering tient emotional distress, the strongest predictor
of spouse’s depression scores on the BDI was patient anger, as reported on the POMS (r = 0.40; beta = 0.33, P < 0.05). Patient and spouse scores on the BDI also were moderately correlated (r = 0.31, P < O.OS), but patient depression and anger ratings were highly intercorrelated (r = 0.58, P < 0.01). Thus, patient depressed mood contributed little to the prediction of spouse depressed mood once patient anger had been taken into account (beta = 0.12, P > 0.50). Both of the marital satisfaction variables were related negatively to spouse depressed mood. Spouse’s marital adjustment was the only significant predictor of her depression ratings (r = - 0.41; beta = - 0.34, P < 0.05). The high intercorrelation between spouse and patient marital adjustment variables (r = 0.53, P < 0.01) may account the nonsignificant relationship between patient marital adjustment and spouse depression. Spouse’s internal resources, as measured by the CEQ did not explain a significant portion of the variance in spouse’s depressed mood (r = 0.27, P > 0.10). Spouse’s external resources (i.e., number of, and satisfaction with, social supports; patient employment status; and family income) also did not independently or jointly contribute significantly to our understanding of spouses depressed mood. Combined
model across domains
Significant predictors identified from phase I analyses within each domain (patient average pain intensity, patient anger and spouse marital satisfaction) were combined in a single regression equation to evaluate the prediction of spouse depression across domains. Table III displays the bivariate correlations between each predictor variable and spouse depression; the Rzhange and probability values for each independent variable as it was entered into the equation; and the standardized regression coefficients (beta weights), partial correlations and total R2 after all the variables had been entered into the equation.
TABLE
III
PREDICTING MODEL
SPOUSE
Predictor
DEPRESSION
Beta
FINAL
R2
r
REGRESSION
Partial
Prob.
change Average pain intensity (NAS)
0.36
0.40
0.16
0.40
P < 0.05
Anger/hostility (POMS)
0.31
0.40
0.16
0.31
P < 0.05
Spouse marital satisfaction (DAS) Total equation:
-0.20
-0.41
0.03
-0.21
RZ = 0.35; F (3, 25) = 4.54; P < 0.05.
ns
‘\
pa-
Depressive (BDI)
Symptom\
Patient’s
Average
Pain
Intensity
(WAS)
Spouse’~
Marital
Slrtitfaction
(DAS)
Fig. 1. Predicting
spouse
depressive symptoms: regression results.
graphic
summary
of
As can be seen in Table III, the bivariate correlations between the dependent variable and each of the independent variables were of similar magnitude. When these variables were examined in combination, however, the beta weights and Rfhange for each variable clearly indicated that patient average pain intensity and anger/hostility were the strongest predictors of spouse depressed mood. It also is readily apparent that spouse marital satisfaction contributed little to the prediction beyond the patient pain and anger variables. Fig. 1 presents a graphic summary of these regression results. Patient average pain intensity independently accounts for 16% of the variance in spouse depressed mood. Patient anger uniquely accounts for SW of the variance. Patient anger and spouse marital satisfaction are highly intercorrelated (r = -0.48, P < O.Ol), and these two variables jointly explain another 8% of the variance. Spouse marital satisfaction accounts for very little (3%) of the variance beyond its relationship with patient anger.
Discussion The results of this study indicate that: (1) a significant proportion (28%) of spouses of CLBP patients from a general orthopedic clinic report clinically significant depressive symptoms, and the overwhelming majority of these spouses report at least some depressive symptoms; (2) patient pain and anger are significantly and independently predictive of variations in spouse’s depressed mood; (3) patient anger and spouse marital satisfaction are intercorrelated in the prediction of spouse’s depressed mood, suggesting a possible mediating role of marital satisfaction in the relationship between patient anger and spouse depression; and (4) together patient pain and anger and spouse’s marital satisfaction account for 35% of the variance in spouse
65
depression scores, suggesting a strong association between chronic pain and spouse depression. The rate of depressed mood reported by spouses in the present study is consistent with levels of depressed mood reported by spouses of CLBP patients in other published reports [2,23]. It is interesting to note that even in a group of patients generally reporting moderate pain and impairment levels, a large number of the spouses reported clinically significant depressive symptoms. Moreover, rates of depressed mood in our sample of spouses were higher than estimates of depressed mood in women from community samples [17]. Interestingly, the rate of clinically meaningful depressive symptomatology in our sample of spouses was greater than the rate reported by patients (20%), using the same criteria. This effect is even more dramatic when one notes that the questionnaire employed to measure depression includes somatic symptoms which are likely to be prevalent in this pain population. This finding is quite different than results from earlier pain clinic studies which consistently report higher levels of depression in the patients as compared to spouses [2,23]. We also noted that patient pain and anger independently predicted spouse depressed mood, suggesting that spouse’s dysphoric mood may be a response to the patient’s pain and anger specifically, as well as generally to his health status and psychological well-being. These results are consistent with other studies that have demonstrated that reported levels of pain intensity are not necessarily correlated with levels of emotional distress [2], in this case anger. These data also are consistent with other reports relating-depression and expression of intense negative affect (e.g., anger) in disturbed marital interactions of chronic pain patients [13]. These reports suggest that chronic pain and depression share similar psychological processes, which include difficulty in modulating or effectively expressing intense unacceptable feelings. It may be hypothesized that some spouses of chronic pain patients have difficulty managing the expression of negative affect by their husbands and are thereby particularly vulnerable to suffer depressed mood when placed in a situation where the expression of negative affect is likely (i.e., living with a patient who is experiencing chronic pain). Previous literature has suggested that marital satisfaction is an important mediating variable in determining adjustment in spouses of chronic pain patients [21,51]. We also noted that spouse marital satisfaction significantly predicted her depressed mood. This variable was highly correlated with patient anger, and the pattern of regression coefficients obtained is consistent with the suggestion that marital satisfaction may mediate the relationship between patient anger and spouse depression. Interestingly, evidence of marital satisfaction mediating the effects of pain intensity on spouse depres-
sion was not observed in this study. Further investigation is needed to specifically address the potential role of marital satisfaction as a mediator between patient pain, negative affect and spouse depression. Findings from the present study also are consistent with previous research [2] indicating that patient depressed mood and physical impairment were not associated with the level of emotional distress displayed by spouses. Neither this study nor that of Ahem et al. [2] found that patient’s functional impairment, on the SIP, accounted for a significant portion of the variance in spouse’s emotional distress, indicating that affective and relationship factors may be more important than objective indicators of disability in understanding spouse depression. Given previous findings of a relationship between depression and cognitive errors the present negative findings regarding this relationship were surprising. A closer look at the data, however, revealed the presence of 3 potential outliers (i.e., spouses with very high scores on the CEQ and quite low scores on the BDI). A strong positive correlation between spouse’s depressed mood and her cognitive errors (r = 0.54; P < 0.01) was obtained for the remaining 26 subjects, when these 3 cases were excluded. Additionally, a post-hoc regression analysis, omitting these 3 cases, revealed that spouse’s cognitive errors did contribute significantly to the prediction of spouse’s depressed mood. It is important to note, however, that the original findings regarding the relationships between spouse depression and patient pain, anger, and spouse marital satisfaction remain virtually unchanged even with the deletion of these 3 cases. Moreover, review of the raw data revealed no irregularities or objective reasons for dropping these cases. These data do, however, suggest that the present study may have underestimated the role of cognitive distortions in the development or maintenance of depression in spouses of chronic pain patients. A more detailed report of these data has been presented elsewhere [45]. It is also interesting to note that in general, spouses in our sample endorsed many items reflecting cognitive distortions (i.e., catastrophizing, overgeneralizing, personalizing or selective abstraction). The rate was somewhat higher than rates reported in the literature for control subjects [32,33]. However, little normative data are currently available for this questionnaire, particularly for specific age and gender groups. Thus, it is difficult to make firm conclusions regarding these findings. Therefore, our data, while exploratory, may possibly underestimate the potential role of thinking styles in the depressed mood of spouses of chronic pain patients. Thinking styles may actually mediate the effects that the environment (i.e., pain situation, husband’s mood) may have on the spouse - a possibility that is congruent with our regression analysis results. Further research is needed to examine the potential mediating role
of thinking styles on the association between patient factors and depressed mood in these spouses. Results from this study also suggest that factors in the spouses’ external environment (i.e., social support. economic resources and patients’ employment status), although likely to be of some importance, may have less of a direct impact on the spouses’ depressive symptomatology. These results may, however, be somewhat specific to the particular (relatively homogeneous) sample studied and may play a larger role in other populations. In summary, the results of this study indicate that patients with higher levels of pain and/or anger had spouses who were more emotionally distressed. The findings also revealed an interesting and potentially important relationship between spouses’s depressed mood, her satisfaction with the marriage and the patient’s level of anger. Various psychological theories may have implications for understanding the present results. One such paradigm is the approach-avoidance conflict [34] in which wives of chronic pain patients may be drawn towards their suffering husbands but are also is pushed away by his angry and hostile behavior. On the one hand, the more intense the patient’s pain and suffering the more the spouse may be drawn toward him. On the other hand, the more angry and hostile the patient becomes the more the spouse may be repelled from him. Hence, spouses with husbands who experience high levels of pain and anger are likely to be caught in this approach-avoidance conflict. As a result of being in this conflict situation constantly, spouses may begin to feel helpless and depressed. It is, therefore, also important to recognize the potential for a perception by the spouse of lack of control in this situation and feelings of helplessness. Learned helplessness theory [1,46] suggests that a perceived lack of control over important events in the environment may predispose individuals to depression. Spouses may feel that they have little control over the patient’s behavior and, thus, over their own lives. This pattern, frequently described by pain patients and spouses in clinical settings, may be exacerbated as the patient’s pain and anger increase. Both of these psychological processes may play a role in the spouse’s feelings of depression and distress. Taking what is known from previous research on the potential impact the spouse may have on the patient [21,51], evaluation of the spouse and the marriage should be an integral part of any pain treatment program. Little research has been conducted to explore the impact that the spouse may have on the patient, although it seems likely that the emotional status of the spouse and the quality of the marital relationship affects the patient’s response to treatment. Two studies to date have suggested that certain spousal characteristics serve to maintain impairment in some patients and affect
treatment outcome [40,49]. These preliminary studies underscore the potential impact spouses may have on the patient. However, much additional research is needed. Additionally, we would speculate that spouse’s depressed mood, in particular. has negative effects on the patient. Depressed spouses may be less likely to encourage healthy behaviors and rehabilitative attempts from the patient. Previous studies [18,36] suggest that depressed individuals are preferentially responsive to salient negative cues. Therefore, these spouses may selectively respond to and reinforce salient negative pain behaviors and suffering, maintaining these behaviors [26]. The observation of pain patient and spouse interactions is an exciting area of research which may shed light on these issues by helping us to understand more definitively the roles spouses may play in the patient’s pain and how spouses respond to these salient negative cues from the patient. In a time of dwindling resources, findings from this study may help to predict which spouses are at risk for emotional distress (i.e., maritally distressed spouses, spouses of patients with high levels of pain and/or anger) and are in need of clinical attention beyond the initial evaluation. The present study indicates that the evaluation of CLBP patients should routinely include assessment of spouses. Additionally, a focus on marital issues and anger management may frequently be warranted in comprehensive attempts at pain management. Such relationship issues may be important areas of intervention for pain treatment that may improve the quality of life for both patient and spouse. While spouses previously have been noted to play an important role in the successful rehabilitation of CLBP patients [24], the role of marital factors and spousal evaluation and treatment as an integral part of pain management has yet to be clearly articulated and evaluated. Such work is sorely needed and has only recently been initiated in our laboratory and those of a few other pain researchers.
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67 marital satisfaction and social support to depressive symptomatology, J. Psychopathot. Behav. Assessm., 8 (1986) 305-316. 7 Beck, A.T., Cognitive Therapy and Emotional Disorders, International Universities Press, New York, 1976. 8 Beck, A.T. and Beamsderfer, A., Assessment of depression: The Depression Inventory. In: P. Picket (Ed.), Psychological Measurements in Psychopharmacology: Modern Problems in Pharmacopsychiatry, Viager, Basel, 1974. 9 Beck, A.T., Steer, R.A. and Garbin, M.G., Psychometric properties of the Beck Depression Inventory: 25 years of evaluation. Clin. Psychol. Rev., 8 (1988) 77-100. 10 Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erlbaugb, J., An inventory for measuring depression, Arch. Gen. Psychiat., 4 (1961) 53-63. 11 Bergner, M., Bobbitt, R.A., Pollard, W.E., Martin, D.P. and Gilson, B.S., The sickness impact profile: validation of a health status measure, Med. Care, 14 (1976) 57-67. 12 Beutler, L.E., Daldrup, R., E&e, D., Guest, P., Corbishley, A. and Meredith, K.E., Family dynamics and emotional expression among patients with chronic pain and depression, Pain, 32 (1988) 65-12. 13 Beutler, L.E., EngIe, D., Oro-Beutler, E., Daldrup, R. and Meredith, K., A common link between depression and pain?, J. Consult. Clin. PsychoI., 54 (1986) 752-759. 14 Birchler, G.R., Dyadic adjustment scale. in: M. Hersen and AS. Bellack (Eds.), Dictionary of Behavioral Assessment Techniques, Pergamon Press, New York, 1988. 15 Birchler, G.R. and Webb, L.J., Discriminating interaction in behaviors in happy and unhappy marriages, J. Consult. Clin. Psychef., 45 (1977) 494-495. 16 Block, A.R., Kremer, E.F. and Gaylor, M., Behavioral treatment of chronic pain: the spouses as a discriminant cue for pain behavior, Pain, 9 (1980) 243-252. 17 Cornstock, G.W. and Helsnig, K.J., Symptoms of depression in two communities, Psychol. Med., 6 (1976) 551-563. 18 Coyne, J.C., Depression and the response of others, J. Abnorm. Psychol., 85 (1976) 186-193. 19 Fadden, G., Bebbington, P. and Kuipers, L., The burden of care: the impact of functional psychiatric illness on the patient’s family, Br. J. Psychiat., 150 (1987) 285-292. 20 Flor, H., Kerns, R.D. and Turk, D.C., Role of spouse reinforcement, percieved pain, and activity levels of chronic pain patients, J. Psychosom. Res., 31 (1987) 251-259. 21 Flor, H., Turk, D.C. and Rudy, T.E., Pain and Families II. Assessment and Treatment, Pain, 30 (1987) 29-45. 22 Flor, H., Turk, D.C. and Rudy T.E., Relationship of pain impact and significant other reinforcement of pain behaviors: the role of gender, marital status and marital satisfaction, Pain, 38 (1989) 45-50. 23 Flor, H., Turk, D.C. and Scholz, O.B., Impact of chronic pain on the spouse: maritai, emotional and physical consequences, J. Psychosom. Res., 31 (1987) 63-71. 24 Follick, M.J., Ahem. D.K. and Aberger, E.W. Behavioral treatment of chronic pain. In: J.A. Blumenthal and D. McGee (Eds.), Applications in Behavioral Medicine and Health Psychology: A Clinicians Sourcebook, Professional Resource Exchange, 1985. 25 Foilick, M.J.. Smith, T.W. and Ahem, D.K., The Sickness Impact Profile: a global measure of health status in chronic pain patients, Pain, 21 (1985) 67-76. 26 Fordyce, W.E., Behavioral Methods in Chronic Pain and Illness, Mosby, St. Louis, MO, 1976. 27 Gilson, B.S., Gilson, J.S., Bergner, M., Bobbitt, R.A., Kressel, S., Pollard, W.E. and Vesselagg, M., The Sickness Impact Profile: development of an outcome measure of health care, Am. J. Publ. HIth, 65 (1975) 1304-1310. 28 Heitzman, CA. and Kaplan, R.M., Assessment of methods for measuring social support, Hlth PsychoI., 7 (1988) 75-109.
29 Kerns, R.D. and Turk, D.C., Depression and chronic pain: the mediating role of the spouse, J. Marr. Fam., 46 (1984) 845-852. 30 I&colt-Glaser, J.K., Glaser, R., Shuttleworth, EC, Dyer, C.S., Ogrocki, P. and Speicher, C.E., Chronic stress and immunity in family caregivers of Alzheimer’s disease victims, Psychosom. Med., 49 (1987) 523-535. 31 Kremer. I?., Atkinson, J.H. and IgneIzi, R.J.. Measurement of pain: patient preference does not confound pain measurement, Pain, 10 (1981) 241-248. 32 Lefebvre, M.F., Cognitive distortion in depressed psychiatric and low back pain patients (Doctoral dissertation, University of Vermont), Diss. Abst. Int., 41 (1980) 693B. 33 Lefebvre, M.F., Cognitive distortion and cognitive errors in depressed psychiatric and low back pain patients, J. Consult. Clin. Psychol., 49 (1981) 517-525. 34 Lewin, K., A Dynamic Theory of Personality, McGraw Hill, New York, 1935. 35 McNair, D.M., Lorr, M. and Droppfeman, L.F., Manual for the Profile of Mood States (POMS), Educational and Industrial Testing Service, San Diego, CA, 1971. 36 Pagel, M. and Becker, J., Depressive thinking and depression: relations with personality and social resources, J. Pers. Sot. Psycho]., 52 (1987) 1043-1052. 37 Pedhauzer, E.J., Multiple Regression in Behaviora Research (2nd Edn.), Holt, Rinehart and Winston, New York, 1982. 38 Pollard, W.E., Bobbit, R.A., Bergner, M., Martin, D.P. and Gilson, B.S., The Sickness Impact Profile: reliability of a health status measure, Med. Care, 14 (1976) 146155. 39 Rabins, P.V., Mace, N.L. and Lucas, M.J., The impact of dementia on the family, J. Am. Med. Ass., 248 (1982) 333-335. 40 Roberts, A.H. and Reinbart, L., The behavioral m~agement of chronic pain: long-term follow-up with comparison groups, Pain, 8 (1980) 151-162. 41 Romano, J.M., Turner, J.A. and Clancy, S.L., Sex differences in the relationship of pain patient dysfunction to spouse adjustment, Pain, 39 (1989) 289-295. 42 Rowat, K.M. and Knafl, K.A., Living with chronic pain: the spouse’s perspective, Pain, 23 (1985) 259-271. 43 Roy, R., Chronic pain and marital difficulties, Hlth Sot. Worker, 10 (1985) 199-207. 44 Sarason, I.G., Levine, H.M., Basham, R.B. and Sarason, B.R., Assessing social support: the Social Support Questionnaire, J. Pers. Sot. PsychoI., 44 (1983) 127-139. 45 Schwartz, L., Toward a model of depression in spouses of chronic pain patients, Unpublished 2nd year project/required doctoral program Thesis, University of California San Diego/San Diego State University Joint Doctoral Program in Clinical Psychology, 1989. 46 Seligman, M.E.P., Helplessness: On Depression, Development, and Death, Freeman, San Francisco, CA, 1975. 47 Sexton, D.L. and Munro, B.H., Impact of a husband’s chronic illness (COPD) on the spouse’s life, Res. Nurs. Hhh, 8 (1985) 83-90. 48 Shanfield, S.B., Heiman, E.M., Cope, N. and Jones, J.R., Pain and the marital relationship: psychiatric distress, Pain, 7 (1979) 343351. 49 Slate& M.A., Ahem, D.K., Adams, A.E. and Foliick, M.J., Somatic sensitivity in spouses of chronic pain patients predicts patient outcome: a replication, clarification and extension. Paper presented in: J.M. Roman0 (Chair), Chronic Pam and the Family: New Findings. Presented at the annual meeting of the American Pam Society, Washington, DC, 1986. 50 Spanier. G.B., Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads, J. Marr. Fam., 38 (1976) 15-28. 51 Turk, D.C., Flor, H. and Rudy, T.E., Pam and families. I. Etiology. maintenance and psychosocial impact, Pain, 30 (1987) 3-27.
61 B.V. (Biomedical
Division)
0304-3959/91/$03.50
PAIN 01704
Depression in spouses of chronic pain patients: the role of patient pain and anger, and marital satisfaction * Lauren
Schwartz,
Mark A. Slater, Gary R. Birchler and J. Hampton
Atkinson
V.A. Medical Center and University of California, San Diego, CA (U.S.A.) (Received
5 March
1990, revision received
7 June 1990, accepted
12 June 1990)
Although several studies have shown that spouses of chronic pain patients may experience clinically significant depressive Summary symptoms few studies have comprehensively examined the role of both patient and spouse-related factors in the development and maintenance of this emotional distress. Twenty-nine married male chronic benign low back pain patients and their spouses were recruited in order to examine the role of patient, spouse, and marital factors in spouse depressive symptomatology. The results indicated that 28% percent of the spouses in the sample reported significantly depressed mood. A 2-stage regression analysis was employed that revealed 3 significant predictors of spouse’s depressed mood, namely patient’s average pain, patient’s reported levels of anger and hostility, and the spouse’s level of marital satisfaction. These findings are discussed in terms of their implications for clinical interventions for pain patients and their families. Key words Chronic
pain;
Marital
relationship;
Depression;
Spouses
Introduction
It is well known that chronic pain can produce a range of adverse affects on both the patient and spouse [21,43,51] and several recent studies have investigated the role of the spouse in maintaining chronic pain [16,21], as well as the effects of pain on the spouse [23,43]. In addition to dealing with the altered roles and responsibilities, spouses of chronic pain patients often must deal with the patient’s psychological distress and physical limitations. Given the potential demands placed on spouses of chronic pain patients, it would be expected that this population is at risk for emotional distress, particularly depression. Preliminary data support this assertion. Prevalence surveys indicate relatively higher reports of depressive symptoms in spouses of chronic pain patients as compared to community samples [3,17]. Comstock and Helsnig [17] reported that approximately 16-198 of the females in a community control sample reported depressive symptomatology. By wide
* This research was supported in part by Medical Research Grants to the second and fourth authors from the United States Department of Veterans Affairs. This research was completed in fulfillment of a Master’s Thesis conducted by the first author under supervision of the second author. Correspondence to: Lauren Schwartz, Pain Management Program (116B), San Diego VA Medical Center, San Diego, CA 92161, U.S.A.
way of comparison, studies of spouses of chronic pain patients have indicated that 20-50s of these spouses report significant depressive symptomatology [3,23,29, 421. Unfortunately, many of these previous studies have been conducted in specialty pain clinics and psychiatric samples [2,23,42] and are based on heterogeneous samples including diverse pain locations and etiologies [2,20,42]. Moreover, many studies combine both male and female patients for examining the effects of chronic pain on the spouse and on the marriage [2,42,48]. This is problematic, however, because of mounting evidence suggesting differential sex effects and role expectations for both patients and caretakers depending on gender [5,22,41]. The purpose of the present study was to examine the contribution of 5 dimensions proposed in the literature as important in explaining depressive symptoms in spouses of chronic pain patients. Specifically these multiple factors are: the patient’s pain experience (particularly pain intensity, impairment levels, and duration of pain) [30,39,42]; the patient’s emotional distress (particularly depressive symptoms and anger) [29,48]; the marital relationship (particularly patient and spouse marital satisfaction) [2,6], the spouse’s cognitive sty/e (particularly cognitive distortions) [33]; and spouse’s externaI resources (particularly social supports, economic resources, and patient employment status) [+9,42,47].
62
Three additional aspects of the present study broaden its applicability. First, we studied ambulatory patients rather than hospitalized individuals. Second, our sample was composed of general orthopedic clinic patients rather than individuals preferentially referred for pain clinic consultation. Third, we studied only male chronic low back pain patients and their spouses to control for the potentially confounding effects of pain type and gender.
Methods Subjects
Subjects were 29 consecutive married, male, chronic benign low back pain (CLBP) patients who met inclusion/exclusion criteria for a larger study of psychosocial factors in CLBP, and their spouses. Pain patients were recruited from a general outpatient orthopedic clinic. Inclusion criteria for patients were: (1) ages 21-64 inclusive, (2) low back pain (WJ and below) present on a daily basis for the previous 6 months or longer, and (3) CLBP as the primary medical complaint. Pain patients were excluded from participation if they had: (a) a major co-existing medical illness (e.g., chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure), (b) a coexisting orthopedic or pain problem, (c) organic brain syndrome, schizophrenia, or affective disorder with psychotic features based on criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) [4], or (d) undergone major surgery less than 1 year before evaluation. Furthermore, patients and spouses were required to be fluent and literate in English. Patients and their spouses were paid $20 each for completing the entire research battery, which required approximately 4-6 h of their time. Measures Spouse3
depressive symptoms. Spouse’s depression was assessed using the Beck Depression Inventory (BDI) [lo]. A score of 10 or more has been advanced as indicative of the presence of at least mild depressive symptoms [8]. Reliability and validity data on the BDI are extensive 191. Patient’s pain experience. Duration of CLBP was measured in months since the onset of daily pain. Average pain intensity was rated on a numeric analogue scale (NAS) ranging from 0 to 100, with “0” indicat~g “no pain” and ‘WO” representing “pain as bad as it can be.” Research has shown that the NAS is reliable and highly correlated with other pain assessment measures [31]. The Sickness Impact Profile (SIP) [27] was used to assess functional impairment related to back pain. The SIP is a b~ha~or~ly based, self-report measure of disability. The total impairment score was used as a measure of the patients’ overall disability. The SIP
has acceptable reliability [3X] and validity [ 1l] for a variety of illness populations and has been validated specifically for use with chronic pain patients 1251. Patient’s emotional distress. The patient’s level ol emotional distress was measured using the BDI (Beck Depression Inventory) and the Profile of Moud States (POMS) [35f. The anger/hostility subscale of the POMS was used to assess patient’s anger. Anger was selected in addition to depressive symptoms because of the high frequency with which pain patients exhibit anger and hostility, as well as the likelihood of the direct impact of anger on the spouse’s mood [12]. Muritul reiationship. The Dyadic Adjustment Scale (DAS) [SO] was used to assess marital satisfaction. The DAS is a self-report assessment instrument that contains 32 items. The DAS has been shown to have high levels of reliability and validity [14,15,50]. Internal resources. The spouse’s internal resources were operationaiized as her propensity to make consistent distortions in inte~reting common life events. Such distortions are thought to be important in the development and maintenance of depressive symptomatology [7]. The Cognitive Errors Questionnuire (CEQ) [32,33] was employed to assess such maladaptive thinking based on Beck’s cognitive theory of depression 171. External resources. Several external resources may affect ability to cope with the stress of being married to someone with chronic pain. The Sociul Support Questionnaire (SSQ) [44] was used to assess the spouse’s level of social support. Two indices of social support were calculated, network size (i.e., number of supports available) and satisfaction with supports. A series of studies indicate the high reliablity of this measure [28,44]. Patient employment status (employed or unemployed) and total annual family income were recorded to provide an assessment of the tangible resources available to the spouse to aid her in coping with the patient’s chronic pain. Procedures
This study was part of a larger VA funded program examining psychosocial factors in chronic low back pain. Subjects for this research program were solicited from among outpatients attending a general orthopedic clinic following careful review of medical records to confirm compliance with the study inclusion and exclusion criteria. Patients who met these criteria by chart review were then re-screened in person. Patients who met criteria at both occasions were invited to participate in the study. Patients and their spouses were evaluated concurrently in separate rooms. Following informed consent patients completed demographic and pain rating forms, then all other instruments were ad~~stered to patient and spouse in a randomized order. All interviews and ratings were conducted by personnel who
63
were unaware of the data from self-report, orthopedic and pain measures. Statistical
analysis
Multiple regression analyses were computed to evaluate the value of patient, spouse, and marital factors in the explanation of spouse depression scores. A series of separate regression analyses [37] were conducted within each proposed domain to identify key predictors and to reduce the data set to the minimum number of significant predictors. Variables from each domain that made a significant contribution were used in the second stage of the analysis. At the second stage of the analysis important predictor variables from each domain that were identified at stage 1 were combined in a comprehensive multiple regression model. To determine the predictive ability of the individual and the set (domain) contributions, multiple R squared (R*), R squared change (R* change), bivariate correlation coefficients (r), and beta weights were examined.
Results
Orthopedic diagnoses in our patient sample were spinal stenosis (38%) degenerative disk disease (28%), herniated disk pulposus (14%), post-surgical pain (lo%), spondylolysis or spondylolisthesis (3%), musculoskeletal strain (3%), and no orthopedic disorder (3%). Mean duration of pain was 228 months, or 19 years (range 6-576 months), and average pain intensity (rated on the O-100 Numeric Analog& Scale) was 50.86 (range 1595). Average overall impairment rating on the Sickness Impact Profile was approximately 17% (range: 1.4132.19%) relative to normal levels of functioning. In terms of s~i~emo~ap~c and marital variables, mean age of patients was 53.5 years (range 32-64); mean age of spouses was 51.7 years (range 23-76). These couples predominately were Caucasian (97% of husbands and 90% of wives), had been married for an average of 24.6 years (range l-45) and had an average annual income of approximately $27,000 (range $lO,~-60,~). It should be noted that 13 (45%) of the patients and 11 (38%) of the spouses were employed at the time of evaluation. The mean DAS score was 117.00 (SD. = 19.41) for patients and 117.03 (SD. = 17.50) for spouses, which is comparable to DAS scores for non-distressed marriages (X = 114.80, S.D. = 17.80 [50]. Prevalence of depressed mood
Our first goal was to describe the prevalence of depressive symptomatology in spouses of chronic low back pain patients from a general orthopedic clinic. Table 1 displays the range of scores and the percentage of spouses in each BDI subgroup, reflecting the preva-
TABLE I SAMPLE PREVALENCE OF DEPRESSIVE SPOUSES OF CLBP PATIENTS
SYMPTOMS
Beck Depression Inventory subgroup
BDI score range
% of spouses *
Nondepressed Mildly depressed Moderately depressed
o- 9 IO-13 14-18
72.4% (n = 21) 10.3% (n = 3) 17.2% (n = 5)
IN
* Note: percentages do not total 100% due to rounding error.
lence rates of depressive symptomatology in our sample. Approximately 28% of spouses in our sample reported at least mild depressive symptoms, as evidenced by a BDI score of 10 or greater. The majority of these spouses were in the moderately depressed range, indicated by a BDI score of 14 or above [23]. Additionally, a greater percentage of spouses in our sample reported significantly depressed mood as compared to the pain patients (28% versus 20%). An item analysis revealed that the majority of spouses endorsed vegetative signs of depression (e.g., sleep problems, decreased efficiency; see Table II). This finding suggests that depressive symptoms are quite common in this group, with. the majority of spouses endorsing at least some s~ptoms of depression. Predictors of spouse depression within domains Within the domain of patient’s pain experience
only
patient’s average pain intensity made a significant conTABLE II ITEM ANALYSIS OF SPOUSES TORY SCORES
BECK DEPRESSION
BDI symptoms endorsed
% of sample reporting symptom
Fatigue Sleep disturbances Irritability Decreased efficiency Decreased libido
77 63 54 52 50
Decreased satisfaction Self-criticism Hypochondriasis Loss of interest in others Unattractiveness Feelings of failure Decreased appetite Decision making problems Disappointment Discouraged Sadness Feeling punished Weight loss Crying Guilt feelings Suicidal ideation
33 30 30 21 27 23 23 20 20 17 13 13 13 10 10 7
INVEN-
tribution
to the prediction
of spouse’s
depressed
mood
(r = 0.40; beta = 0.34, P < 0.05). Next, considering tient emotional distress, the strongest predictor
of spouse’s depression scores on the BDI was patient anger, as reported on the POMS (r = 0.40; beta = 0.33, P < 0.05). Patient and spouse scores on the BDI also were moderately correlated (r = 0.31, P < O.OS), but patient depression and anger ratings were highly intercorrelated (r = 0.58, P < 0.01). Thus, patient depressed mood contributed little to the prediction of spouse depressed mood once patient anger had been taken into account (beta = 0.12, P > 0.50). Both of the marital satisfaction variables were related negatively to spouse depressed mood. Spouse’s marital adjustment was the only significant predictor of her depression ratings (r = - 0.41; beta = - 0.34, P < 0.05). The high intercorrelation between spouse and patient marital adjustment variables (r = 0.53, P < 0.01) may account the nonsignificant relationship between patient marital adjustment and spouse depression. Spouse’s internal resources, as measured by the CEQ did not explain a significant portion of the variance in spouse’s depressed mood (r = 0.27, P > 0.10). Spouse’s external resources (i.e., number of, and satisfaction with, social supports; patient employment status; and family income) also did not independently or jointly contribute significantly to our understanding of spouses depressed mood. Combined
model across domains
Significant predictors identified from phase I analyses within each domain (patient average pain intensity, patient anger and spouse marital satisfaction) were combined in a single regression equation to evaluate the prediction of spouse depression across domains. Table III displays the bivariate correlations between each predictor variable and spouse depression; the Rzhange and probability values for each independent variable as it was entered into the equation; and the standardized regression coefficients (beta weights), partial correlations and total R2 after all the variables had been entered into the equation.
TABLE
III
PREDICTING MODEL
SPOUSE
Predictor
DEPRESSION
Beta
FINAL
R2
r
REGRESSION
Partial
Prob.
change Average pain intensity (NAS)
0.36
0.40
0.16
0.40
P < 0.05
Anger/hostility (POMS)
0.31
0.40
0.16
0.31
P < 0.05
Spouse marital satisfaction (DAS) Total equation:
-0.20
-0.41
0.03
-0.21
RZ = 0.35; F (3, 25) = 4.54; P < 0.05.
ns
‘\
pa-
Depressive (BDI)
Symptom\
Patient’s
Average
Pain
Intensity
(WAS)
Spouse’~
Marital
Slrtitfaction
(DAS)
Fig. 1. Predicting
spouse
depressive symptoms: regression results.
graphic
summary
of
As can be seen in Table III, the bivariate correlations between the dependent variable and each of the independent variables were of similar magnitude. When these variables were examined in combination, however, the beta weights and Rfhange for each variable clearly indicated that patient average pain intensity and anger/hostility were the strongest predictors of spouse depressed mood. It also is readily apparent that spouse marital satisfaction contributed little to the prediction beyond the patient pain and anger variables. Fig. 1 presents a graphic summary of these regression results. Patient average pain intensity independently accounts for 16% of the variance in spouse depressed mood. Patient anger uniquely accounts for SW of the variance. Patient anger and spouse marital satisfaction are highly intercorrelated (r = -0.48, P < O.Ol), and these two variables jointly explain another 8% of the variance. Spouse marital satisfaction accounts for very little (3%) of the variance beyond its relationship with patient anger.
Discussion The results of this study indicate that: (1) a significant proportion (28%) of spouses of CLBP patients from a general orthopedic clinic report clinically significant depressive symptoms, and the overwhelming majority of these spouses report at least some depressive symptoms; (2) patient pain and anger are significantly and independently predictive of variations in spouse’s depressed mood; (3) patient anger and spouse marital satisfaction are intercorrelated in the prediction of spouse’s depressed mood, suggesting a possible mediating role of marital satisfaction in the relationship between patient anger and spouse depression; and (4) together patient pain and anger and spouse’s marital satisfaction account for 35% of the variance in spouse
65
depression scores, suggesting a strong association between chronic pain and spouse depression. The rate of depressed mood reported by spouses in the present study is consistent with levels of depressed mood reported by spouses of CLBP patients in other published reports [2,23]. It is interesting to note that even in a group of patients generally reporting moderate pain and impairment levels, a large number of the spouses reported clinically significant depressive symptoms. Moreover, rates of depressed mood in our sample of spouses were higher than estimates of depressed mood in women from community samples [17]. Interestingly, the rate of clinically meaningful depressive symptomatology in our sample of spouses was greater than the rate reported by patients (20%), using the same criteria. This effect is even more dramatic when one notes that the questionnaire employed to measure depression includes somatic symptoms which are likely to be prevalent in this pain population. This finding is quite different than results from earlier pain clinic studies which consistently report higher levels of depression in the patients as compared to spouses [2,23]. We also noted that patient pain and anger independently predicted spouse depressed mood, suggesting that spouse’s dysphoric mood may be a response to the patient’s pain and anger specifically, as well as generally to his health status and psychological well-being. These results are consistent with other studies that have demonstrated that reported levels of pain intensity are not necessarily correlated with levels of emotional distress [2], in this case anger. These data also are consistent with other reports relating-depression and expression of intense negative affect (e.g., anger) in disturbed marital interactions of chronic pain patients [13]. These reports suggest that chronic pain and depression share similar psychological processes, which include difficulty in modulating or effectively expressing intense unacceptable feelings. It may be hypothesized that some spouses of chronic pain patients have difficulty managing the expression of negative affect by their husbands and are thereby particularly vulnerable to suffer depressed mood when placed in a situation where the expression of negative affect is likely (i.e., living with a patient who is experiencing chronic pain). Previous literature has suggested that marital satisfaction is an important mediating variable in determining adjustment in spouses of chronic pain patients [21,51]. We also noted that spouse marital satisfaction significantly predicted her depressed mood. This variable was highly correlated with patient anger, and the pattern of regression coefficients obtained is consistent with the suggestion that marital satisfaction may mediate the relationship between patient anger and spouse depression. Interestingly, evidence of marital satisfaction mediating the effects of pain intensity on spouse depres-
sion was not observed in this study. Further investigation is needed to specifically address the potential role of marital satisfaction as a mediator between patient pain, negative affect and spouse depression. Findings from the present study also are consistent with previous research [2] indicating that patient depressed mood and physical impairment were not associated with the level of emotional distress displayed by spouses. Neither this study nor that of Ahem et al. [2] found that patient’s functional impairment, on the SIP, accounted for a significant portion of the variance in spouse’s emotional distress, indicating that affective and relationship factors may be more important than objective indicators of disability in understanding spouse depression. Given previous findings of a relationship between depression and cognitive errors the present negative findings regarding this relationship were surprising. A closer look at the data, however, revealed the presence of 3 potential outliers (i.e., spouses with very high scores on the CEQ and quite low scores on the BDI). A strong positive correlation between spouse’s depressed mood and her cognitive errors (r = 0.54; P < 0.01) was obtained for the remaining 26 subjects, when these 3 cases were excluded. Additionally, a post-hoc regression analysis, omitting these 3 cases, revealed that spouse’s cognitive errors did contribute significantly to the prediction of spouse’s depressed mood. It is important to note, however, that the original findings regarding the relationships between spouse depression and patient pain, anger, and spouse marital satisfaction remain virtually unchanged even with the deletion of these 3 cases. Moreover, review of the raw data revealed no irregularities or objective reasons for dropping these cases. These data do, however, suggest that the present study may have underestimated the role of cognitive distortions in the development or maintenance of depression in spouses of chronic pain patients. A more detailed report of these data has been presented elsewhere [45]. It is also interesting to note that in general, spouses in our sample endorsed many items reflecting cognitive distortions (i.e., catastrophizing, overgeneralizing, personalizing or selective abstraction). The rate was somewhat higher than rates reported in the literature for control subjects [32,33]. However, little normative data are currently available for this questionnaire, particularly for specific age and gender groups. Thus, it is difficult to make firm conclusions regarding these findings. Therefore, our data, while exploratory, may possibly underestimate the potential role of thinking styles in the depressed mood of spouses of chronic pain patients. Thinking styles may actually mediate the effects that the environment (i.e., pain situation, husband’s mood) may have on the spouse - a possibility that is congruent with our regression analysis results. Further research is needed to examine the potential mediating role
of thinking styles on the association between patient factors and depressed mood in these spouses. Results from this study also suggest that factors in the spouses’ external environment (i.e., social support. economic resources and patients’ employment status), although likely to be of some importance, may have less of a direct impact on the spouses’ depressive symptomatology. These results may, however, be somewhat specific to the particular (relatively homogeneous) sample studied and may play a larger role in other populations. In summary, the results of this study indicate that patients with higher levels of pain and/or anger had spouses who were more emotionally distressed. The findings also revealed an interesting and potentially important relationship between spouses’s depressed mood, her satisfaction with the marriage and the patient’s level of anger. Various psychological theories may have implications for understanding the present results. One such paradigm is the approach-avoidance conflict [34] in which wives of chronic pain patients may be drawn towards their suffering husbands but are also is pushed away by his angry and hostile behavior. On the one hand, the more intense the patient’s pain and suffering the more the spouse may be drawn toward him. On the other hand, the more angry and hostile the patient becomes the more the spouse may be repelled from him. Hence, spouses with husbands who experience high levels of pain and anger are likely to be caught in this approach-avoidance conflict. As a result of being in this conflict situation constantly, spouses may begin to feel helpless and depressed. It is, therefore, also important to recognize the potential for a perception by the spouse of lack of control in this situation and feelings of helplessness. Learned helplessness theory [1,46] suggests that a perceived lack of control over important events in the environment may predispose individuals to depression. Spouses may feel that they have little control over the patient’s behavior and, thus, over their own lives. This pattern, frequently described by pain patients and spouses in clinical settings, may be exacerbated as the patient’s pain and anger increase. Both of these psychological processes may play a role in the spouse’s feelings of depression and distress. Taking what is known from previous research on the potential impact the spouse may have on the patient [21,51], evaluation of the spouse and the marriage should be an integral part of any pain treatment program. Little research has been conducted to explore the impact that the spouse may have on the patient, although it seems likely that the emotional status of the spouse and the quality of the marital relationship affects the patient’s response to treatment. Two studies to date have suggested that certain spousal characteristics serve to maintain impairment in some patients and affect
treatment outcome [40,49]. These preliminary studies underscore the potential impact spouses may have on the patient. However, much additional research is needed. Additionally, we would speculate that spouse’s depressed mood, in particular. has negative effects on the patient. Depressed spouses may be less likely to encourage healthy behaviors and rehabilitative attempts from the patient. Previous studies [18,36] suggest that depressed individuals are preferentially responsive to salient negative cues. Therefore, these spouses may selectively respond to and reinforce salient negative pain behaviors and suffering, maintaining these behaviors [26]. The observation of pain patient and spouse interactions is an exciting area of research which may shed light on these issues by helping us to understand more definitively the roles spouses may play in the patient’s pain and how spouses respond to these salient negative cues from the patient. In a time of dwindling resources, findings from this study may help to predict which spouses are at risk for emotional distress (i.e., maritally distressed spouses, spouses of patients with high levels of pain and/or anger) and are in need of clinical attention beyond the initial evaluation. The present study indicates that the evaluation of CLBP patients should routinely include assessment of spouses. Additionally, a focus on marital issues and anger management may frequently be warranted in comprehensive attempts at pain management. Such relationship issues may be important areas of intervention for pain treatment that may improve the quality of life for both patient and spouse. While spouses previously have been noted to play an important role in the successful rehabilitation of CLBP patients [24], the role of marital factors and spousal evaluation and treatment as an integral part of pain management has yet to be clearly articulated and evaluated. Such work is sorely needed and has only recently been initiated in our laboratory and those of a few other pain researchers.
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