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Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Psychological and physical distress are interdependent in breast cancer survivors and their partners a
b
Chris Segrin & Terry A. Badger a
Department of Communication, University of Arizona, Tucson, AZ, USA b
College of Nursing, University of Arizona, Tucson, AZ, USA Published online: 02 Jan 2014.
To cite this article: Chris Segrin & Terry A. Badger (2014): Psychological and physical distress are interdependent in breast cancer survivors and their partners, Psychology, Health & Medicine, DOI: 10.1080/13548506.2013.871304 To link to this article: http://dx.doi.org/10.1080/13548506.2013.871304
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2013 http://dx.doi.org/10.1080/13548506.2013.871304
Psychological and physical distress are interdependent in breast cancer survivors and their partners Chris Segrina* and Terry A. Badgerb a Department of Communication, University of Arizona, Tucson, AZ, USA; bCollege of Nursing, University of Arizona, Tucson, AZ, USA
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(Received 31 May 2013; accepted 28 November 2013) Objective: Breast cancer diagnosis and treatment negatively affect quality of life in survivors and their supportive partners. The purpose of this investigation was to assess the degree of dyadic interdependence in psychological and physical symptom distress in dyads adjusting to breast cancer. Method: Participants were 49 breast cancer survivors and their partners, who were spouses, other family members, or friends of the survivor. Psychological distress (depression, anxiety, and negative affect) and physical symptom distress were measured at three points in time, each separated by eight weeks. Results: Survivors and partners exhibited significant interdependence in psychological and physical symptom distress over the four-month course of the investigation. This was evident in longitudinal partner effects in actor–partner interdependence models as well as in significant T1→T3 indirect effects mediated by partner distress. Conclusions: The course of breast cancer survivors’ psychological and physical symptom distress is significantly affected by that of their supportive partners and vice versa. Keywords: breast cancer; depression; close relationships; dyadic interdependence
Breast cancer diagnosis and treatment often trigger various forms of physical and psychological distress that have profound effects on quality of life. This distress is manifest in symptoms of depression, anxiety, and fatigue for example (Linden, Paulhus, & Dobson, 1986; Ullrich, Rothrock, Lutgendorf, Jochimsen, & Williams, 2008). Such psychological and physical distress is associated with a range of poor quality of life outcomes in addition to mortality (Denollet, Maas, Knottnerus, Keyzer, & Pop, 2009; Giese-Davis et al., 2006). Breast cancer can have equally powerful effects on the distress of cancer survivors’ close social network members, such as intimate partners, family, and friends (Given et al., 2006; Martire, Lustig, Schulz, Miller, & Helgeson, 2004; Segrin & Badger, 2011). Partners of breast cancer survivors often experience the same or higher levels of emotional or psychological distress as cancer survivors themselves (HassonOhayon, Goldzweig, Braun, & Galinsky, 2010; Manne et al., 2007; Segrin & Badger, 2013) in addition to psychiatric morbidity and poor physical health (Bambauer et al., 2006; Sjovall et al., 2009). There is some evidence to suggest that the psychological distress of cancer survivors and their partners may be interdependent (Gregorio et al., 2012; Kim et al., 2008; Segrin, Badger, Dorros, Meek, & Lopez, 2007). These findings are of considerable *Corresponding author. Email: [email protected] © 2013 Taylor & Francis
2
C. Segrin and T.A. Badger
importance by indicating that distress of survivors’ partners has teleological significance in the survivors’ own experience of distress. The primary aim of this investigation is therefore to determine whether and to what extent women recently diagnosed with breast cancer experience psychological and physical distress that is interdependent with that of their supportive partners. Method Participants
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Participants were 51 dyads composed of a woman with breast cancer and her supportive partner. Breast cancer survivors were on average 26 weeks (SD = 23.30) from their cancer diagnosis. Other demographic characteristics of the sample appear in Table 1. Procedures Participants were part of an investigation of telephone-delivered psychosocial interventions for breast cancer survivors and their supportive partners conducted during 2011–2012 (Badger, Segrin, Pasvogel, & Lopez, in press). Survivors were asked to
Table 1.
Demographic characteristics of participants.
Variable Age Sex Female Male Race/ethnicity Asian/Pacific Islander Black Latina/o White Other/unknown Disease stage I II III IV Unknown Treatment* Surgery Chemotherapy Radiation Hormone blocking Relationship Spouse/significant other Daughter Sibling Mother Friend Other *
Survivors
Partners
53.08 (12.84)
51.71 (14.24)
100% 0%
57% 43%
4% 6% 33% 55% 2%
4% 4% 43% 49% 0%
Dyads
31% 31% 31% 2% 5% 76% 76% 20% 10%
These figures do not sum to 100% due to receipt of multiple treatments by most participants.
43% 19% 12% 10% 8% 8%
Psychology, Health & Medicine
3
designate a supportive partner (anyone the survivor identified as a significant person in her cancer recovery) for participation in the study. Upon recruitment and after informed consent, 51 dyads were randomly assigned to participate in one of three telephone-delivered interventions and baseline measures were taken. At the end of the eight-week intervention period (T2), a second measurement occurred, followed by a third (T3) eight weeks after the T2, for a total duration of 16 weeks. Two dyads did not complete the T2 and T3 assessment and were thus dropped from all analyses.
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Measures Measures in this investigation were taken over the phone at T1, T2, and T3 by trained data collectors in either English or Spanish as preferred by the participant. Symptoms of depression were assessed with the 20-item Center for Epidemiological Studies-Depression scale (Radloff, 1977). The state version of the State-Trait Anxiety Inventory was administered to assess current levels of anxiety (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Negative affect was measured with the negative affect scale of the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988). Finally, distress associated with illness symptoms was assessed with the general symptom distress scale (GSDS) (Badger, Segrin, & Meek, 2011). The GSDS contains 12 symptoms that are commonly experienced by cancer patients but that are also experienced in conjunction with a wide variety of illnesses and ailments (e.g. nausea, cough, and sleep difficulties). Scores for depression, anxiety, and negative affect were log-transformed to compensate for positively skewed distributions. Means, standard deviations, and reliabilities for all measures appear in Table 2. Analyses Tests of dyadic interdependence were conducted with structural equation modeling in AMOS 18.0 following the actor–partner interdependence model (APIM) (Kenny & Cook, 1999; Kenny, Kashy, & Cook, 2006). In these analyses, dyadic interdependence Table 2.
Means, standard deviations, and reliabilities for all study variables from T1–T3. Survivors
Depression α Anxiety α Negative affect α Symptom distress α*
Partners
T1
T2
T3
T1
T2
T3
Scale range
17.92 (13.34) .94 35.00 (12.56) .94 20.00 (8.86) .92 4.39 (2.33) .63
12.41 (10.46) .91 32.76 (12.04) .95 17.92 (7.46) .88 3.98 (2.50) .69
7.46 (9.24) .93 26.44 (9.25) .95 13.72 (5.05) .89 3.13 (2.17) .66
11.51 (8.90) .88 29.80 (7.52) .89 18.04 (6.19) .83 2.04 (2.16) .73
8.00 (10.14) .93 28.51 (9.56) .95 16.04 (7.10) .90 1.98 (1.90) .63
5.11 (6.53) .96 25.47 (7.72) .95 14.76 (6.99) .91 1.66 (2.00) .74
0–60 20–80 10–50 0–12
Notes: Standard deviations appear in ( ) beneath their respective means. * Because the GSDS is an inventory of physical symptoms, not all of which are caused by a common latent variable, a high degree of internal consistency is not to be expected.
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C. Segrin and T.A. Badger
is indicated by statistically significant partner effects (i.e., an effect from one dyad member to the other, as indicated, for example, by survivor T1→partner T2 and partner T2→survivor T3). For each indicator of distress, two APIMs were compared; one in which all of the paths from survivor variables were constrained equal to their respective paths from the partner variables, and one in which all paths were unconstrained and thus free to vary. Comparison of the fit of these two models consistently indicated that the constrained model had the best fit and thus all subsequent results are from the constrained models. We also tested two indirect effects in each model. We refer to these as interpersonal indirect effects and they are indicated by those situations where person B’s T2 variable mediates the association between person A’s T1 and T3 association on that same variable. To test these indirect effects, a series of planned tests were conducted, two for each APIM, based on 2000 bootstrap samples to estimate standard errors and 95% confidence intervals (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002; Mackinnon, Lockwood, & Williams, 2004) using AMOS 18.0. Missing data were estimated with stochastic regression imputation. Results Results from the APIM for survivors’ and partners’ depression appear in Figure 1 and reveal statistically significant T2→T3 partner effects, and marginal ( p = .06) T1→T2 partner effects, suggesting that each participant’s Tn→Tn+1 changes in symptoms of depression can be predicted from his or her partner’s Tn symptoms of depression. Specifically, the higher one dyad member’s depression was at Tn, the higher her or his partner’s depression was at Tn+1. Tests of the T1→T3 indirect effects appear in Table 3, indicating a significant indirect effect for survivors’ T1→T3 symptoms of depression through partners’ T2 symptoms of depression, and vice versa. Collectively, the results of the APIM analysis and interpersonal indirect effects provide evidence of a causal effect of one dyad member’s symptoms of depression and the subsequent symptoms of depression experienced by his or her partner. Results for anxiety appear in Figure 2. Dyadic interdependence was evident in T1→T2 partner effects, but not T2→T3 partner effects. The higher one dyad member’s
.39
survivor depression T1
.67***
.12 p =.06
survivor depression T2
.19*
.24 .16 p = .06
partner depression T1
.53***
survivor depression T3
.53***
.69
.23**
partner depression T2
.74***
partner depression T3
Figure 1. Actor–partner interdependence for depression over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 6.82, df = 8, p = .56, χ2/df = 0.85, CFI = 1.0, RMSEA = .00(.00–.15). *p < .05. **p < .01. ***p < .001.
Psychology, Health & Medicine Table 3.
5
Longitudinal interpersonal indirect effects.
Indirect effect ST1 depression→PT2 depression→ST3 depression PT1 depression→ST2 depression→PT3 depression ST1 anxiety→PT2 anxiety→ST3 anxiety PT1 anxiety→ST2 anxiety→PT3 anxiety ST1 negative affect→PT2 negative affect→ST3 negative affect PT1 negative affect→ST2 negative affect→PT3 negative affect ST1 symptom distress→PT2 symptom distress→ST3 symptom distress PT1 symptom distress→ST2 symptom distress→PT3 symptom distress
β
95% confidence interval
.10*** .16*** .07*** .10*** .14*** .20*** .04***
.06–.14 .11–.21 .03–.11 .06–.16 .09–.19 .14–.25 .03–.05
.10***
.09–.12
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*** p < .001. S = survivor, P = partner.
.36
survivor anxiety T1
.71***
.21*
survivor anxiety T2 -.01
.30* .13*
partner anxiety T1
.65***
survivor anxiety T3
.56***
.55
-.01
partner anxiety T2
.72***
partner anxiety T3
Figure 2. Actor–partner interdependence for anxiety over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 5.00, df = 8, p = .76, χ2/df = 0.63, CFI = 1.0, RMSEA = .00(.00–.12). *p < .05. ***p < .001.
anxiety was at baseline, the higher the other dyad member’s anxiety was at T2. Both interpersonal indirect effects for T1→T3 anxiety were statistically significant and positive in direction indicating that T1→T3 changes in one dyad member’s anxiety are explained by the level of her or his partner’s anxiety at T2. The APIM for negative affect appears in Figure 3 in which all four partner effects were statistically significant indicating that the higher one dyad member’s negative affect was at Tn, the higher the other dyad member’s negative affect was at Tn+1. Statistically significant interpersonal indirect effects that appear in Table 2 indicate that T1→T3 changes in one dyad member’s negative affect can be explained at least in part from the other dyad member’s T2 negative affect. The APIM for symptom distress appears in Figure 4 and reveals statistically significant T1→T2 partner effects, but no significant T2→T3 partner effects. Tests of the interpersonal indirect effects that appear in Table 2 indicate that each dyad member’s T1→T3 changes in symptom distress were mediated by the other’s T2 level of symptom distress. The positive sign of these indirect effects implies that the higher one
6
C. Segrin and T.A. Badger .49
survivor negative affect T1
.55***
.24**
survivor negative affect T2
.15*
.30* .20**
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partner negative affect T1
.59***
survivor negative affect T3
.41***
.49
.18*
partner negative affect T2
.58***
partner negative affect T3
Figure 3. Actor–partner interdependence for negative affect over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 7.56, df = 8, p = .48, χ2/df = 0.95, CFI = 1.0, RMSEA = .00(.00–.16). *p < .05. **p < .01. ***p < .001.
.37
survivor symptom distress T1
.08
.53***
.25**
survivor symptom distress T2 .13
.19**
partner symptom distress T1
.62***
survivor symptom distress T3
.60***
.53
.08
partner symptom distress T2
.64***
partner symptom distress T3
Figure 4. Actor–partner interdependence for symptom distress over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 11.83, df = 9, p = .22, χ2/df = 1.32, CFI = .97, RMSEA = .08(.00–.19). **p < .01. ***p < .001.
dyad member’s T2 symptom distress was, the more the other partner’s symptom distress increased from T1→T3, and vice versa. Discussion This investigation indicates that the psychological distress of breast cancer survivors and their partners might be causally related early in the trajectory of survivorship. The analysis of three waves of longitudinal data with strict statistical controls for prior dyadic interdependence indicated that, in most cases, one dyad member’s Tn distress was predictive of the other dyad member’s Tn+1 distress. In other words, the more one person was distressed, the more his or her partner was distressed at the next wave of measurement, or the less distressed one dyad member was, the less distressed his or her partner was at the subsequent wave of measurement. All of the T1–T3 indirect effects, mediated by the partner’s T2 distress, were statistically significant suggesting that one
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Psychology, Health & Medicine
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dyad member’s distress explains at least some of the other dyad member’s T1–T3 changes in distress over the four-month course of this investigation. These results illustrate an emotional contagion effect (Hatfield, Cacioppo, & Rapson, 1994). Perhaps because significant psychological distress often prompts physical symptoms such as nausea and lack of appetite (e.g. Linden et al., 1986), the results show that during the first two waves of measurement, survivors and partners exhibited interdependent symptoms of physical distress. This has not been heretofore documented in the literature. This dyadic interdependence in psychological distress and symptom distress argues that supportive partners constitute more than a mere social backdrop to the disease and its treatment. Rather, the welfare of these individuals may have a substantial influence on quality of life of the breast cancer survivor, and vice versa. This study adds to a growing body of evidence that supports a compelling argument for providing services to the supportive partners of women with breast cancer, not just for the sake of the partners’ welfare, but literally for the well-being of the breast cancer survivor herself. References Badger, T.A., Segrin, C., & Meek, P. (2011). Development and validation of an instrument for rapidly assessing symptoms: The general symptom distress scale. Journal of Pain and Symptom Management, 41, 535–548. Badger, T.A., Segrin, C., Pasvogel, A., & Lopez, A.M. (in press). Psychosocial interventions delivered by telephone vs. videophone to improve quality of life in early-stage breast cancer survivors and their supportive partners. Journal of Telemedicine and Telecare. Bambauer, K.Z., Zhang, B., Maciejewski, P.K., Sahay, N., Pirl, W.F., Block, S.D., Prigerson, H.G. (2006). Mutuality and specificity of mental disorders in advanced cancer patients and caregivers. Social Psychiatry and Psychiatric Epidemiology, 41, 819–824. Denollet, J., Maas, K., Knottnerus, A., Keyzer, J.J., & Pop, V.J. (2009). Anxiety predicted premature all-cause and cardiovascular death in a 10-year follow-up of middle-aged women. Journal of Clinical Epidemiology, 62, 452–456. Giese-Davis, J., Wilhelm, F.H., Conrad, A., Abercrombie, H.C., Sephton, S., Yutsis, M., ... Spiegel, D. (2006). Depression and stress reactivity in metastatic breast cancer. Psychosomatic Medicine, 68, 675–683. Given, B., Given, C.W., Sikorskii, A., Jeon, S., Sherwood, P., & Rahbar, M. (2006). The impact of providing symptom management assistance on caregiver reaction: Results of a randomized trial. Journal of Pain and Symptom Management, 32, 433–443. Gregorio, S.W., Carpenter, K.M., Dorfman, C.S., Yang, H.C., Simonelli, L.E., & Carson, W.E., 3rd. (2012). Impact of breast cancer recurrence and cancer-specific stress on spouse health and immune function. Brain, Behavior, and Immunity, 26, 228–233. Hasson-Ohayon, I., Goldzweig, G., Braun, M., & Galinsky, D. (2010). Women with advanced breast cancer and their spouses: Diversity of support and psychological distress. Psycho-Oncology, 19, 1195–1204. Hatfield, E., Cacioppo, J.T., & Rapson, R.L. (1994). Emotional contagion. Cambridge: Cambridge University Press. Kenny, D.A., & Cook, W.L. (1999). Partner effects in relationship research: Conceptual issues, analytic difficulties, and illustrations. Personal Relationships, 6, 433–448. Kenny, D.A., Kashy, D.A., & Cook, W.L. (2006). Dyadic data analysis. New York, NY: Guilford Press. Kim, Y., Kashy, D.A., Wellisch, D.K., Spillers, R.L., Kaw, C.K., & Smith, T.G. (2008). Quality of life of couples dealing with cancer: Dyadic and individual adjustment among breast and prostate cancer survivors and their spousal caregivers. Annals of Behavioral Medicine, 35, 230–238. Linden, W., Paulhus, D.L., & Dobson, K.S. (1986). Effects of response styles on the report of psychological and somatic distress. Journal of Consulting and Clinical Psychology, 54, 309–313.
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MacKinnon, D.P., Lockwood, C.M., Hoffman, J.M., West, S.G., & Sheets, V. (2002). A comparison of methods to test mediation and other intervening variable effects. Psychological Methods, 7, 83–104. Mackinnon, D.P., Lockwood, C.M., & Williams, J. (2004). Confidence limits for the indirect effect: Distribution of the product and resampling methods. Multivariate Behavioral Research, 39, 99. Manne, S.L., Norton, T.R., Ostroff, J.S., Winkel, G., Fox, K., & Grana, G. (2007). Protective buffering and psychological distress among couples coping with breast cancer: The moderating role of relationship satisfaction. Journal of Family Psychology, 21, 380–388. Martire, L.M., Lustig, A.P., Schulz, R., Miller, G.E., & Helgeson, V.S. (2004). Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness. Health Psychology, 23, 599–611. Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Segrin, C., & Badger, T. (2011). Interdependence in family systems adjusting to breast and prostate cancer. In M.M. Day (Ed.), Going through this together: Family communication and health transitions (pp. 19–55). Cresskill, NJ: Hamptom Press. Segrin, C., & Badger, T.A. (2013). Interdependent psychological distress between Latinas with breast cancer and their supportive partners. Journal of Latina/o Pyshoclogy, 1, 21–34. Segrin, C., Badger, T., Dorros, S.M., Meek, P., & Lopez, A.M. (2007). Interdependent anxiety and psychological distress in women with breast cancer and their partners. Psycho-Oncology, 16, 634–643. Sjovall, K., Attner, B., Lithman, T., Noreen, D., Gunnars, B., Thome, B., & Olsson, H. (2009). Influence on the health of the partner affected by tumor disease in the wife or husband based on a population-based register study of cancer in Sweden. Journal of Clinical Oncology, 27, 4781–4786. Spielberger, C., Gorsuch, R., Lushene, R., Vagg, P., & Jacobs, G. (1983). Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press. Ullrich, P.M., Rothrock, N.E., Lutgendorf, S.K., Jochimsen, P.R., & Williams, R.D. (2008). Adjustment and discussion of cancer: A comparison of breast and prostate cancer survivors. Psychology & Health, 23, 391–406. Watson, D., Clark, L.A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070.
Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Psychological and physical distress are interdependent in breast cancer survivors and their partners a
b
Chris Segrin & Terry A. Badger a
Department of Communication, University of Arizona, Tucson, AZ, USA b
College of Nursing, University of Arizona, Tucson, AZ, USA Published online: 02 Jan 2014.
To cite this article: Chris Segrin & Terry A. Badger (2014): Psychological and physical distress are interdependent in breast cancer survivors and their partners, Psychology, Health & Medicine, DOI: 10.1080/13548506.2013.871304 To link to this article: http://dx.doi.org/10.1080/13548506.2013.871304
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2013 http://dx.doi.org/10.1080/13548506.2013.871304
Psychological and physical distress are interdependent in breast cancer survivors and their partners Chris Segrina* and Terry A. Badgerb a Department of Communication, University of Arizona, Tucson, AZ, USA; bCollege of Nursing, University of Arizona, Tucson, AZ, USA
Downloaded by [134.117.10.200] at 07:39 02 June 2014
(Received 31 May 2013; accepted 28 November 2013) Objective: Breast cancer diagnosis and treatment negatively affect quality of life in survivors and their supportive partners. The purpose of this investigation was to assess the degree of dyadic interdependence in psychological and physical symptom distress in dyads adjusting to breast cancer. Method: Participants were 49 breast cancer survivors and their partners, who were spouses, other family members, or friends of the survivor. Psychological distress (depression, anxiety, and negative affect) and physical symptom distress were measured at three points in time, each separated by eight weeks. Results: Survivors and partners exhibited significant interdependence in psychological and physical symptom distress over the four-month course of the investigation. This was evident in longitudinal partner effects in actor–partner interdependence models as well as in significant T1→T3 indirect effects mediated by partner distress. Conclusions: The course of breast cancer survivors’ psychological and physical symptom distress is significantly affected by that of their supportive partners and vice versa. Keywords: breast cancer; depression; close relationships; dyadic interdependence
Breast cancer diagnosis and treatment often trigger various forms of physical and psychological distress that have profound effects on quality of life. This distress is manifest in symptoms of depression, anxiety, and fatigue for example (Linden, Paulhus, & Dobson, 1986; Ullrich, Rothrock, Lutgendorf, Jochimsen, & Williams, 2008). Such psychological and physical distress is associated with a range of poor quality of life outcomes in addition to mortality (Denollet, Maas, Knottnerus, Keyzer, & Pop, 2009; Giese-Davis et al., 2006). Breast cancer can have equally powerful effects on the distress of cancer survivors’ close social network members, such as intimate partners, family, and friends (Given et al., 2006; Martire, Lustig, Schulz, Miller, & Helgeson, 2004; Segrin & Badger, 2011). Partners of breast cancer survivors often experience the same or higher levels of emotional or psychological distress as cancer survivors themselves (HassonOhayon, Goldzweig, Braun, & Galinsky, 2010; Manne et al., 2007; Segrin & Badger, 2013) in addition to psychiatric morbidity and poor physical health (Bambauer et al., 2006; Sjovall et al., 2009). There is some evidence to suggest that the psychological distress of cancer survivors and their partners may be interdependent (Gregorio et al., 2012; Kim et al., 2008; Segrin, Badger, Dorros, Meek, & Lopez, 2007). These findings are of considerable *Corresponding author. Email: [email protected] © 2013 Taylor & Francis
2
C. Segrin and T.A. Badger
importance by indicating that distress of survivors’ partners has teleological significance in the survivors’ own experience of distress. The primary aim of this investigation is therefore to determine whether and to what extent women recently diagnosed with breast cancer experience psychological and physical distress that is interdependent with that of their supportive partners. Method Participants
Downloaded by [134.117.10.200] at 07:39 02 June 2014
Participants were 51 dyads composed of a woman with breast cancer and her supportive partner. Breast cancer survivors were on average 26 weeks (SD = 23.30) from their cancer diagnosis. Other demographic characteristics of the sample appear in Table 1. Procedures Participants were part of an investigation of telephone-delivered psychosocial interventions for breast cancer survivors and their supportive partners conducted during 2011–2012 (Badger, Segrin, Pasvogel, & Lopez, in press). Survivors were asked to
Table 1.
Demographic characteristics of participants.
Variable Age Sex Female Male Race/ethnicity Asian/Pacific Islander Black Latina/o White Other/unknown Disease stage I II III IV Unknown Treatment* Surgery Chemotherapy Radiation Hormone blocking Relationship Spouse/significant other Daughter Sibling Mother Friend Other *
Survivors
Partners
53.08 (12.84)
51.71 (14.24)
100% 0%
57% 43%
4% 6% 33% 55% 2%
4% 4% 43% 49% 0%
Dyads
31% 31% 31% 2% 5% 76% 76% 20% 10%
These figures do not sum to 100% due to receipt of multiple treatments by most participants.
43% 19% 12% 10% 8% 8%
Psychology, Health & Medicine
3
designate a supportive partner (anyone the survivor identified as a significant person in her cancer recovery) for participation in the study. Upon recruitment and after informed consent, 51 dyads were randomly assigned to participate in one of three telephone-delivered interventions and baseline measures were taken. At the end of the eight-week intervention period (T2), a second measurement occurred, followed by a third (T3) eight weeks after the T2, for a total duration of 16 weeks. Two dyads did not complete the T2 and T3 assessment and were thus dropped from all analyses.
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Measures Measures in this investigation were taken over the phone at T1, T2, and T3 by trained data collectors in either English or Spanish as preferred by the participant. Symptoms of depression were assessed with the 20-item Center for Epidemiological Studies-Depression scale (Radloff, 1977). The state version of the State-Trait Anxiety Inventory was administered to assess current levels of anxiety (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Negative affect was measured with the negative affect scale of the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988). Finally, distress associated with illness symptoms was assessed with the general symptom distress scale (GSDS) (Badger, Segrin, & Meek, 2011). The GSDS contains 12 symptoms that are commonly experienced by cancer patients but that are also experienced in conjunction with a wide variety of illnesses and ailments (e.g. nausea, cough, and sleep difficulties). Scores for depression, anxiety, and negative affect were log-transformed to compensate for positively skewed distributions. Means, standard deviations, and reliabilities for all measures appear in Table 2. Analyses Tests of dyadic interdependence were conducted with structural equation modeling in AMOS 18.0 following the actor–partner interdependence model (APIM) (Kenny & Cook, 1999; Kenny, Kashy, & Cook, 2006). In these analyses, dyadic interdependence Table 2.
Means, standard deviations, and reliabilities for all study variables from T1–T3. Survivors
Depression α Anxiety α Negative affect α Symptom distress α*
Partners
T1
T2
T3
T1
T2
T3
Scale range
17.92 (13.34) .94 35.00 (12.56) .94 20.00 (8.86) .92 4.39 (2.33) .63
12.41 (10.46) .91 32.76 (12.04) .95 17.92 (7.46) .88 3.98 (2.50) .69
7.46 (9.24) .93 26.44 (9.25) .95 13.72 (5.05) .89 3.13 (2.17) .66
11.51 (8.90) .88 29.80 (7.52) .89 18.04 (6.19) .83 2.04 (2.16) .73
8.00 (10.14) .93 28.51 (9.56) .95 16.04 (7.10) .90 1.98 (1.90) .63
5.11 (6.53) .96 25.47 (7.72) .95 14.76 (6.99) .91 1.66 (2.00) .74
0–60 20–80 10–50 0–12
Notes: Standard deviations appear in ( ) beneath their respective means. * Because the GSDS is an inventory of physical symptoms, not all of which are caused by a common latent variable, a high degree of internal consistency is not to be expected.
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C. Segrin and T.A. Badger
is indicated by statistically significant partner effects (i.e., an effect from one dyad member to the other, as indicated, for example, by survivor T1→partner T2 and partner T2→survivor T3). For each indicator of distress, two APIMs were compared; one in which all of the paths from survivor variables were constrained equal to their respective paths from the partner variables, and one in which all paths were unconstrained and thus free to vary. Comparison of the fit of these two models consistently indicated that the constrained model had the best fit and thus all subsequent results are from the constrained models. We also tested two indirect effects in each model. We refer to these as interpersonal indirect effects and they are indicated by those situations where person B’s T2 variable mediates the association between person A’s T1 and T3 association on that same variable. To test these indirect effects, a series of planned tests were conducted, two for each APIM, based on 2000 bootstrap samples to estimate standard errors and 95% confidence intervals (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002; Mackinnon, Lockwood, & Williams, 2004) using AMOS 18.0. Missing data were estimated with stochastic regression imputation. Results Results from the APIM for survivors’ and partners’ depression appear in Figure 1 and reveal statistically significant T2→T3 partner effects, and marginal ( p = .06) T1→T2 partner effects, suggesting that each participant’s Tn→Tn+1 changes in symptoms of depression can be predicted from his or her partner’s Tn symptoms of depression. Specifically, the higher one dyad member’s depression was at Tn, the higher her or his partner’s depression was at Tn+1. Tests of the T1→T3 indirect effects appear in Table 3, indicating a significant indirect effect for survivors’ T1→T3 symptoms of depression through partners’ T2 symptoms of depression, and vice versa. Collectively, the results of the APIM analysis and interpersonal indirect effects provide evidence of a causal effect of one dyad member’s symptoms of depression and the subsequent symptoms of depression experienced by his or her partner. Results for anxiety appear in Figure 2. Dyadic interdependence was evident in T1→T2 partner effects, but not T2→T3 partner effects. The higher one dyad member’s
.39
survivor depression T1
.67***
.12 p =.06
survivor depression T2
.19*
.24 .16 p = .06
partner depression T1
.53***
survivor depression T3
.53***
.69
.23**
partner depression T2
.74***
partner depression T3
Figure 1. Actor–partner interdependence for depression over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 6.82, df = 8, p = .56, χ2/df = 0.85, CFI = 1.0, RMSEA = .00(.00–.15). *p < .05. **p < .01. ***p < .001.
Psychology, Health & Medicine Table 3.
5
Longitudinal interpersonal indirect effects.
Indirect effect ST1 depression→PT2 depression→ST3 depression PT1 depression→ST2 depression→PT3 depression ST1 anxiety→PT2 anxiety→ST3 anxiety PT1 anxiety→ST2 anxiety→PT3 anxiety ST1 negative affect→PT2 negative affect→ST3 negative affect PT1 negative affect→ST2 negative affect→PT3 negative affect ST1 symptom distress→PT2 symptom distress→ST3 symptom distress PT1 symptom distress→ST2 symptom distress→PT3 symptom distress
β
95% confidence interval
.10*** .16*** .07*** .10*** .14*** .20*** .04***
.06–.14 .11–.21 .03–.11 .06–.16 .09–.19 .14–.25 .03–.05
.10***
.09–.12
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*** p < .001. S = survivor, P = partner.
.36
survivor anxiety T1
.71***
.21*
survivor anxiety T2 -.01
.30* .13*
partner anxiety T1
.65***
survivor anxiety T3
.56***
.55
-.01
partner anxiety T2
.72***
partner anxiety T3
Figure 2. Actor–partner interdependence for anxiety over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 5.00, df = 8, p = .76, χ2/df = 0.63, CFI = 1.0, RMSEA = .00(.00–.12). *p < .05. ***p < .001.
anxiety was at baseline, the higher the other dyad member’s anxiety was at T2. Both interpersonal indirect effects for T1→T3 anxiety were statistically significant and positive in direction indicating that T1→T3 changes in one dyad member’s anxiety are explained by the level of her or his partner’s anxiety at T2. The APIM for negative affect appears in Figure 3 in which all four partner effects were statistically significant indicating that the higher one dyad member’s negative affect was at Tn, the higher the other dyad member’s negative affect was at Tn+1. Statistically significant interpersonal indirect effects that appear in Table 2 indicate that T1→T3 changes in one dyad member’s negative affect can be explained at least in part from the other dyad member’s T2 negative affect. The APIM for symptom distress appears in Figure 4 and reveals statistically significant T1→T2 partner effects, but no significant T2→T3 partner effects. Tests of the interpersonal indirect effects that appear in Table 2 indicate that each dyad member’s T1→T3 changes in symptom distress were mediated by the other’s T2 level of symptom distress. The positive sign of these indirect effects implies that the higher one
6
C. Segrin and T.A. Badger .49
survivor negative affect T1
.55***
.24**
survivor negative affect T2
.15*
.30* .20**
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partner negative affect T1
.59***
survivor negative affect T3
.41***
.49
.18*
partner negative affect T2
.58***
partner negative affect T3
Figure 3. Actor–partner interdependence for negative affect over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 7.56, df = 8, p = .48, χ2/df = 0.95, CFI = 1.0, RMSEA = .00(.00–.16). *p < .05. **p < .01. ***p < .001.
.37
survivor symptom distress T1
.08
.53***
.25**
survivor symptom distress T2 .13
.19**
partner symptom distress T1
.62***
survivor symptom distress T3
.60***
.53
.08
partner symptom distress T2
.64***
partner symptom distress T3
Figure 4. Actor–partner interdependence for symptom distress over times 1–3. Notes: Coefficients in italics are squared multiple correlations. Model fit: χ2 = 11.83, df = 9, p = .22, χ2/df = 1.32, CFI = .97, RMSEA = .08(.00–.19). **p < .01. ***p < .001.
dyad member’s T2 symptom distress was, the more the other partner’s symptom distress increased from T1→T3, and vice versa. Discussion This investigation indicates that the psychological distress of breast cancer survivors and their partners might be causally related early in the trajectory of survivorship. The analysis of three waves of longitudinal data with strict statistical controls for prior dyadic interdependence indicated that, in most cases, one dyad member’s Tn distress was predictive of the other dyad member’s Tn+1 distress. In other words, the more one person was distressed, the more his or her partner was distressed at the next wave of measurement, or the less distressed one dyad member was, the less distressed his or her partner was at the subsequent wave of measurement. All of the T1–T3 indirect effects, mediated by the partner’s T2 distress, were statistically significant suggesting that one
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Psychology, Health & Medicine
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dyad member’s distress explains at least some of the other dyad member’s T1–T3 changes in distress over the four-month course of this investigation. These results illustrate an emotional contagion effect (Hatfield, Cacioppo, & Rapson, 1994). Perhaps because significant psychological distress often prompts physical symptoms such as nausea and lack of appetite (e.g. Linden et al., 1986), the results show that during the first two waves of measurement, survivors and partners exhibited interdependent symptoms of physical distress. This has not been heretofore documented in the literature. This dyadic interdependence in psychological distress and symptom distress argues that supportive partners constitute more than a mere social backdrop to the disease and its treatment. Rather, the welfare of these individuals may have a substantial influence on quality of life of the breast cancer survivor, and vice versa. This study adds to a growing body of evidence that supports a compelling argument for providing services to the supportive partners of women with breast cancer, not just for the sake of the partners’ welfare, but literally for the well-being of the breast cancer survivor herself. References Badger, T.A., Segrin, C., & Meek, P. (2011). Development and validation of an instrument for rapidly assessing symptoms: The general symptom distress scale. Journal of Pain and Symptom Management, 41, 535–548. Badger, T.A., Segrin, C., Pasvogel, A., & Lopez, A.M. (in press). Psychosocial interventions delivered by telephone vs. videophone to improve quality of life in early-stage breast cancer survivors and their supportive partners. Journal of Telemedicine and Telecare. Bambauer, K.Z., Zhang, B., Maciejewski, P.K., Sahay, N., Pirl, W.F., Block, S.D., Prigerson, H.G. (2006). Mutuality and specificity of mental disorders in advanced cancer patients and caregivers. Social Psychiatry and Psychiatric Epidemiology, 41, 819–824. Denollet, J., Maas, K., Knottnerus, A., Keyzer, J.J., & Pop, V.J. (2009). Anxiety predicted premature all-cause and cardiovascular death in a 10-year follow-up of middle-aged women. Journal of Clinical Epidemiology, 62, 452–456. Giese-Davis, J., Wilhelm, F.H., Conrad, A., Abercrombie, H.C., Sephton, S., Yutsis, M., ... Spiegel, D. (2006). Depression and stress reactivity in metastatic breast cancer. Psychosomatic Medicine, 68, 675–683. Given, B., Given, C.W., Sikorskii, A., Jeon, S., Sherwood, P., & Rahbar, M. (2006). The impact of providing symptom management assistance on caregiver reaction: Results of a randomized trial. Journal of Pain and Symptom Management, 32, 433–443. Gregorio, S.W., Carpenter, K.M., Dorfman, C.S., Yang, H.C., Simonelli, L.E., & Carson, W.E., 3rd. (2012). Impact of breast cancer recurrence and cancer-specific stress on spouse health and immune function. Brain, Behavior, and Immunity, 26, 228–233. Hasson-Ohayon, I., Goldzweig, G., Braun, M., & Galinsky, D. (2010). Women with advanced breast cancer and their spouses: Diversity of support and psychological distress. Psycho-Oncology, 19, 1195–1204. Hatfield, E., Cacioppo, J.T., & Rapson, R.L. (1994). Emotional contagion. Cambridge: Cambridge University Press. Kenny, D.A., & Cook, W.L. (1999). Partner effects in relationship research: Conceptual issues, analytic difficulties, and illustrations. Personal Relationships, 6, 433–448. Kenny, D.A., Kashy, D.A., & Cook, W.L. (2006). Dyadic data analysis. New York, NY: Guilford Press. Kim, Y., Kashy, D.A., Wellisch, D.K., Spillers, R.L., Kaw, C.K., & Smith, T.G. (2008). Quality of life of couples dealing with cancer: Dyadic and individual adjustment among breast and prostate cancer survivors and their spousal caregivers. Annals of Behavioral Medicine, 35, 230–238. Linden, W., Paulhus, D.L., & Dobson, K.S. (1986). Effects of response styles on the report of psychological and somatic distress. Journal of Consulting and Clinical Psychology, 54, 309–313.
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