INT'L. J. PSYCHIATRY I N MEDICINE, Vol. 20H)37-48, 1990

STRESS, SOCIAL SUPPORT, AND SYMPTOMS OF DEPRESSION IN SPOUSES OF THE MEDICALLY ILL ELIZABETH M. RIDEOUT, R.N.,M.Sc. McMaster University GARY M. R0DIN.M.D.. F.R.C.P. (C.) CHRISTINE H. LITTLEFIELD, PH.D., C. PSYCH. Toronto General Hospital and University of Toronto

ABSTRACT

This study investigated the level and frequency of depressive symptoms in spouses of dialysis patients, as a function of a) severity of patient disease, b) level of stress experienced by the spouse, and c) perception of support from the ill partner. The subjects were forty patients who had begun dialysis in the last year and their spouses. Measures of depression, impact on family, perceived social support, and disease severity were applied. Significant depressive symptoms were reported by 20 percent of spouses. Symptom severity was not correlated with age, sex, or occupation of the spouses, nor with level of depression or functional impairment of the dialysis patients. The amount of social support received from the ill partner accounted for 37 percent of the variance in spouse depression, while social and financial stressors reported by the spouse explained 1.3 percent of the variance in spouse symptoms. These findings suggest that depressive symptoms in spouses of dialysis patients are associated with the social and economic consequences of the illness for the family but even more so with the amount of perceived support from the patient. The determinants of this perceived support need further exploration. (Int'l. J. Psychiatry in Medicine 20~37-48. 1990) Key Words: stress, social support, depression, spouses, chronic illness, renal failure.

While the adjustment of patients to chronic medical illness is being studied extensively at present, relatively little systematic research has explored the psychosocial reactions of their spouses. There is descriptive evidence suggesting that such spouses must cope with continuing, and indeed, chronic stressors, particularly in the areas of diminished social functioning, role changes, and 37 0 1990. Baywood Publishing Co.. Inc.

doi: 10.2190/YBXJ-WPDJ-QB0Y-183G http://baywood.com

38 / E. M. RIDEOUT, G. M. RODlN AND C. H. LITTLEFIELD

financial burden [ 1, 21 . It has been reported also that a significant proportion of spouses respond to these stressors with symptoms of distress. For instance, Block and Boyer and Shanfield et al. found the SCL-90 scores of chronic pain patients to be significantly higher than scores of control subjects [3, 41. In addition, Carnwath and Johnson reported that 3 1 percent of spouses of a large cohort of stroke patients had a definite or probable diagnosis of major depression as assessed by the Hamilton Rating Scale [5]. Flor, Turk and Scholz found that 26 percent of spouses of low back pain patients reported depressed mood, as indicated by a score greater than fourteen on the Beck Depression Inventory [6]. Lowry and Atcherson used the Shipley Hartford measure to study patients and spouses at zero, three, and six months after beginning home hemodialysis [7]. Although one-third of spouses reported symptoms of depression, insomnia, and decreased ability to think at the initiation of dialysis, only 10 percent reported such symptoms after six months. This evidence suggests that life with a chronically ill partner is a source of difficulty for spouses and that some respond with symptoms of distress, while others d o not. Surprisingly, there are no studies on the association of the severity of financial and social stresses experienced by spouses of medically ill patients with the degree of spousal adjustment, despite the extensive general literature on the relationship between level of stressors and psychological distress (8-101. Furthermore, although the significance of social support as a moderator between stress and distress is well documented [ 11, 121, only one recent study has explored this relationship in spouses of ill patients. In that study, Schulz et al., found that perceived support was a significant predictor of level of depression in spouses whose partners had experienced a first stroke [ 131. The purpose of this study was to identify variables associated with depressive symptoms in spouses of patients with chronic medical illness. A primary focus for the study was the contribution of social support from the ill partner as a moderator of depressive symptoms in the well partner (hereafter referred to as the “spouse”). Patients receiving dialysis treatment for end stage renal disease and their spouses comprised our sample. Individuals receiving treatment for chronic renal disease were the population chosen since they are relatively homogeneous with regards to treatment programs and associated stresses and strains, yet heterogeneous in age, education, and occupation [ 141. The spouses of these patients represent a group who must face the ongoing difficulties of life with a partner with an incurable disease which would result in death without treatment and which demands considerable lifestyle change [IS]. The study had three objectives: 1 . To assess the level and frequency of depressive symptoms in spouses of

patients currently being treated for end stage renal disease.

DEPRESSIVE SYMPTOMS IN SPOUSES OF T H E ILL

I 39

2. To document the relationship between level of spouse depression and a) level of financial and social stressors experienced by the spouse and b) level of depressive symptoms and physical health of the patient. 3. To test whether social support moderates the relationship between financial and social stressors and level of depressive symptoms experienced by the spouse.

METHOD Subjects Spouse adjustment was the outcome of interest in this study and patientillness variables such as disease severity and level of depression were among the independent variables. Thus, both members of the marital dyad were asked to enroll in the study. Patients who began dialysis at one of three teaching hospitals in Toronto, Ontario, between May 1986 and January 1988, were approached to participate, if they met the following inclusion criteria:

1. Eighteen years of age or older, 2. Able to understand the test measures, 3. Not too ill to participate, 4. Currently living with their spouse, and 5. Dialysis treatment begun for the first time within the past twelve months. Eligible patients who agreed to participate were asked if their spouse would also take part in the study.

Procedure Patients were approached during regular outpatient clinic visits or during their dialysis treatment by one of two trained interviewers and asked to participate in the study. An information letter for the spouse was given to those patients who enrolled in the study and who believed their spouse would also participate. Packets of questionnaires were distributed at that time, with instructions that patient and spouse complete the measures independently without collaboration, and return them by mail or in person at the next clinic visit. Follow-up telephone calls to encourage completion of the questionnaires were made in those few instances where there was delay in returning the packages. Written consent was obtained from participating patients and spouses.

Measures Spouses - Spouses completed the following self-report questionnaires: 1. Centre for Epidemiologic Study-Depression

Scale (CES-D), developed for use in epidemiologic surveys within the general population, measures

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E. M. RIDEOUT, G. M. RODIN AND C. H.LITTLEFIELD

the frequency of occurrence of twenty symptoms of depression [16]. The range of scores on the CES-D is zero to sixty, with higher scores indicating the presence of more symptoms, weighted by frequency of occurrence. lnvestigators suggest that a cut-off score of sixteen or greater is indicative of significant depressive symptomatology [ 17, 181. 2. Impact on Family Scale, developed to assess the impact of chronic childhood illness on the family, consists of four dimensions: financial, social, personal strain, and mastery [ 191. It was modified for use with adults and only the financial and social subscales were administered in this study. The resulting nine-item scale assesses whether respondents feel financial burden and decreased social activity have resulted from the chronic illness of their partner (e.g., “the illness is causing financial problems for the family”; “we see family and friends less because of the illness”). 3 . Perceived Social Support Scale, a twenty-item scale designed to assess perceived support from friends and from family [20] ; the word “spouse” was substituted for the word “family” in the version here. This measure was used to tap the extent to which an individual believes his/her needs for social support from spouse are fulfilled. Total scores for the scale range from twenty, indicating minimal perceived support, to 120, indicating maximum perceived support.

Patients - Patients completed the CES-D and a functional measure of disease severity, the Sickness Impact Profile (SIP). The SIP is a 136-item measure used to assess a subject’s perception of his performance of daily activities in such areas as work, recreation, eating, social and emotional interaction, and physical function [21,22]. Severity of patient disease was determined from the fiftytwo-item physical function subscale that asks respondents to answer “yes” or “no” to items involving ambulation, mobility, and body care and movements. Results are reported as standard scores with a range of 0 to 100. Items assessing social interaction, communication, alertness behavior, and emotional behavior combine to produce a psychosocial dimension score. The internal reliability of each of the measures was computed for both spouses and patients using Cronbach’s alpha. Coefficients for all measures were greater than 0.8, indicating an acceptable level of reliability [23].

RESULTS Of fifty-six eligible dyads, forty (70%) patient/spouse pairs enrolled and subsequently completed the entire study package. The sixteen patients who refused to involve their spouses in the study did so because they felt their spouses were already too overburdened to take on the additional effort it would entail. All fifty-six patients agreed to complete study questionnaires, making

DEPRESSIVE SYMPTOMS IN SPOUSES OF T H E ILL / 41

Table 1. Comparison of Patient Respondents and Ref users Respondents

SIP (Physical) SIP (Psychological) p

N=40

Refusers N = 16

Test Statistic

X = 51.5

X = 59.6

t = 1.91 NS

10 6

xz = 0.02 NS

x = 17.99 x =21.64

t = 2.73" t = 4.48'

26 14 = 8.73

x x=

8.95

s: 0.001

comparisons possible between those who enrolled with their spouses and those who did not (the refusers). Those who did enroll did not differ significantly from the refusers on age, or sex. They did differ significantly on severity of diseasc, with scores on both the physical and psychosocial dimensions of the Sickness Impact Profile higher for refusers, indicating that the patients who did agree t o include their spouses in the study reported less physical and psychosocial impairment related to their illess (Table I). Within the forty patient/spouse dyads who participated, the majority of spouses were feniale (65%), the mean age of both patients and spouses was fiftyune years (range 2 4 to 77 years) and the couples, all in their first marriages, had been married for an average of 26.8 years (range 0.6 t o 5 4 years). The number of children per couple ranged from zero t o eleven, a mean of 2.8 children was reported and only a minority of couples had dependent children at home. All patients had been on dialysis for less than one year (X = 10.2 weeks; SD = 9.7) and a variety of dialysis treatments were represented, with 25 percent on centre hemodialysis, 58 percent on continuous ambulatory peritoneal dialysis, and 18 percent on intermittent peritoneal dialysis. The sample was predominantly white and middle class. The mean score for depressive symptoms of spouses was 9.3 (SD = 8.8). There were eight respondents (20%) with scores greater than sixteen (the cut-off score suggested as indicating significant depressive symptoms [ 17,181 ). In contrast to findingsin the general population, age, sex, and socioeconomic status were unrelated t o level o f depressive symptoms in this spouse sample [24]. The mean CES-D score was higher in women than in men (10.8 compared to 7.2), but the difference did not achieve significance. Functional health status, treatment modality, duration of kidney disease, and duration of patients' treatment were unrelated to spouse depression. Data were available on the past history and family history of depression for twenty-seven of forty of the spouses. None reported either a previous depressive episode or a positive family history of depression.

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E . M. RIDEOUT, G. M. R O D l N A N D C. H. LITTLEFIELD

Table 2. Range of Scores, Means, and Standard Deviations on Measures Measure

Possible Scores

Mean

(SO)

0- 60 0- 60 0-100 9 - 36

9.3 9.5 8.7 15.1

(8.8) (10.1 1 (11.1) (6.1 1

20-120

101.1

(16.6)

CES-D (SPOUW) CES-D (patient) Severity of disease (patient) Impact on family subscale Perceived social support (from partner)

Table 3. Correlation Matrix of Variables Spouse Depression (SCES-Dl

CES-D SIP-Physical Stress Support from partner

-0.17 0.19 0.36' -0.57""

Patient Depression (CES-0)

0.07 0.10 0.10

Disease Severity (SIP-Physical)

Spouse Stress (Stress)

0.38 "

-0.07

-0.26

p < 0.01 * * p < 0.001

Patients' mean depression score ( F = 9.5 f 10.1) was similar to that of the spouses'; eight patients (20%) also reported scores greater than sixteen on the CES-D. The possible range of scores for all study measures and the means and standard deviations are presented in Table 2. The correlations among variables are presented in Table 3. Three correlations are of particular interest. The measure of patient illness severity (SIP) was correlated significantly with financial and social stressors reported by the spouse (r = .38, p < 0.01) suggesting that patients who reported more impaired physical function imposed more burden on their spouses. The spouses' level of depression was not correlated significantly with either impairment in physical functioning or depressive symptoms of the patient/partner. Finally, spouse level of depression was correlated negatively with perception of support from the ill partner (r = - 0 . 5 7 , ~ < 0.001) and correlated positively with the financial and social burden of the illness (r = 0.36, p < 0.01).

Multiple Regression Analysis Multiple linear regression analyses were conducted to examine the combined effect of patient illness variables (severity of illness and level of depression) and financial and social stressors reported by spouse on the spouse's level of depressive symptoms. First, all three variables were entered, using stepwise regression; together they explained 17 percent of the variance in spouse depression [F = 2.35 (df3, 34);p = 0.081 . The financial/social stressors

DEPRESSIVE SYMPTOMS IN SPOUSES OF T H E I L L I 43

Table 4. Multiple Regression Results for Spouse Level of Depression on Patient Illness Variables and Stressors Reported by Spouse Variables

B

Patient level of depression Patient severity of disease Stressors reported by spouse

-0.18

p

0.06 0.5

Beta

-0.21 0.07 0.35

Partial Correlation

-0.21 0.06 0.36

t-value

-1.32 0.41 2.05“

< 0.05

Table 5. Multiple Regression of Spouse Level of Depression on Stressors Reported by Spouse, Support from Partner, and Stress X Support Interaction Variables

Stressors reported by spouse Perceived support from partner Stress X support

Partial Correlation

B

Beta

0.18

0.12

0.07

0.46

-12.26 0.29

0.66 0.27

-1.22

-1.53 0.63

0.09

t-value

Table 6. Multiple Regression of Spouse Level of Depression on Stressors Reported by Spouse and Support from Ill Partner Variables

Stressors reported by spouse Perceived support from partner P

B

Beta

Partial Correlation

t-value

0.32

0.22

0.21

1.56

-0.27

-0.51

-0.49

-3.6”

< 0.001

experienced by the spouse carried a beta weight of 0.35 (p < 0.05); beta weights were not significant for either of the patient illness variables. To determine the particular effect of financial/social stressors on depression in the spouse, patient depression and severity of illness were removed from the equation. This analysis accounted for 13 percent of the variance and the model reached significance [F= 5.1 (df 1,36); p = 0.031 (see Table 4). Stepwise regression analysis with controlled entry of variables was also used to test whether social support moderated the relationship between the stressors reported by the spouse and level of depressive symptoms. The moderating or “buffering” effect of social support was tested by including in the analysis an interaction term. Spouse level of stress, perceived support from partner, and the two-way interaction of stress X support were entered into the analysis in that order. Although this model explained 29 percent of the variance in

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E. M. RIDEOUT. G. M. RODlN AND C. H. LITTLEFIELD

spouse level o f depression [ F =4.4 (df3,33);p = 0.011, none o f the three predictor variables carried beta weights that reached significance (see Table 5). Since the overall model achieved significance, a further regression analysis was conducted t o explore the possible direct effect of social support on level of depressive symptoms in spouses (see Table 6). The interaction term was removed from the model and the explained variance increased t o 37 percent. Perceived support from partner had a beta weight of -0.5 1 ( p < 0.001), suggesting that perceived social support had a strong and direct effect on spouse level of depression.

DISCUSS ION We found that 20 percent of spouses of patients with end stage renal disease reported significant depressive symptoms, a rate similar to that reported in surveys of the general population [16, 25,261 and at the upper end of the range reported by Boyd et al. [18]. However, it is lower than rates reported in previous studies o f depression in spouses of the medically ill. Both Carnwath and Johnson and Schulz et al. found depressive symptoms in about one-third of spouses o f stroke patients [5, 131, while 26 percent of spouses of chronic pain patients reported depressed mood [6]. It is possible that differences in measurement account for the lower levels of depression in this sample as compared with spouses of stroke and pain patients. It could also be that stroke and pain patients require greater levels of direct caregiving from spouses than d o dialysis patients. There is some evidence that perceived burden of care is inversely related t o the wellbeing of spouses o f patients post-stroke [ 131. Certainly, it is noteworthy that 30 percent of the eligible patients chose not t o participate in the study because they felt their spouses were already too overburdened by the situation. It could be that our sample was biased toward those spouses who had adapted well t o their partner’s illness. Social support from the ill partner emerged as the most significant predictor of spouse level o f depression. We had hypothesized that social support would have a moderating effect between spouse stress and spouse level of depression. The data did not support that prediction. Instead, social support had a strong and direct effect o n level o f depressive symptoms. In other words, a lack of support from the ill partner was a risk factor for depressive symptoms while high support protected against depression, regardless of level of stress. One reason for a direct rather than buffering effect may have been the insufficient range of stress scores reported by spouse respondents. Since the buffering model is predicated o n the belief that support is a moderator of high stress, it is desirable to have a broad range o f stress scores [27,28]. Social support is thought to enhance the individual’s sense of love and belonging, feelings whch in turn protect against the exigencies of stress [28]. The implication is that social support strengthens the person against the

DEPRESSIVE SYMPTOMS

IN SPOUSES OF

THE I L L /

45

uncertainty and despair that might lead t o disordered functioning. This study supports the notion that psychological functioning may be directly dependent upon the degree of social support experienced by an individual, and that individuals without a supportive environment have an increased vulnerability t o depressive symptoms [ 2 7 . 2 9 ] . Neither disease severity nor level o f depression in the patient were correlated significantly with spouse level of depression. This lack of relationship between severity of disease and spouse depression is in agreement with two earlier studies in which the patients’ self-reported intensity of pain and functional impairment due to pain were unrelated t o level of depression in spouses o f chronic pain patients [6, 301. It may be that factors such as duration or stage of disease are better predictors of spouse adjustment than the severity of the disease. For cxaniple, Carnwath and Johnson found that level of depression of spouses o f stroke patients increased with duration of time since stroke [S], and Cassileth et al. reported that spouse mood was correlated significantly with stage of cancer, such that spouses o f patients in the latter stage of their illness were more likely t o report mood disorder [ 3 1 1. The lack o f a significant correlation between the levels of depression reported by spouse and patient in our study is at odds with other studies in which a significant relationship between patient and spouse mood has been reported [3-51.The findings o f the present study may be due t o restriction on range of measurement o f depression in that both patients and their spouses reported relatively low levels o f depressive symptoms. In line with previous research, o u r data demonstrated a significant relationship between depressive symptoms and the financial and social st ressors reported by the spouse. This finding emerged despite the relatively low levels of stress reported by spouses. The significant relationship between stress and distress was, o f course, expected, given the widely reported association between these variables [8-101. In this study, 13 percent o f the varinnce in spouse depression was explained by severity o f reported social and financial change imposed by the illness. A similar proportion o f the variance in depression was found in previous studies o f the prediction of depression by measures of life stress [ 9 ] .

CONCLUSIONS We found that one-fifth of patients with end stage renal disease and their spouses reported the presence of significant symptoms of depression. Spouses who experienced higher levels o f financial and social stress and lower levels of support from partner were at greater risk for depressed mood. Illness-related factors in patients, including treatment modality, and physical and psychological functioning were unrelated to spouse mood. These findings suggest that spouses who undergo a significant socioeconomic change related t o illness in their

46 I E. M. RIDEOUT. G. M. RODlN AND C. H. LITTLEFIELD

partner and who receive little support from the ill partner may benefit from psychosocial support. However, controlled intervention studies would be needed to confirm the benefit of such approaches in depressed spouses with little perceived support. For those spouses reporting high levels of financial and/or social stress, appropriate referrals to relevant and available agencies in the community might prove helpful. Similarly, in those cases where spouses d o not feel support or commitment from their ill partner, couple counselling and/or help to identify and access alternate sources of support seems warranted. Further understanding of the psychological costs of life with an ill partner would more likely be derived from longitudinal rather than cross-sectional research wherein patients with a wider range of severity and duration of disease are enrolled. Since levels of and mechanisms for depressed mood may be similar among spouses of end stage renal disease patients and those of healthy individuals, the inclusion of a control group o f couples without chronic illness may help to identify the extent to w h c h the present findings are specific to marital dyads in which one partner is medically ill. ACKNOWLEDGMENTS

This research was assisted by the Ontario Mental Health Foundation (OMHF) and the Ministry of Health Ontario (MOH) and was carried out while E. M. R. was supported by a research fellowship from the MOH. C. H. L. is a Longterm Research Fellow of the OMHF. The authors wish to thank the Departments of Nephrology at Toronto General, Toronto Western, and Wellesley Hospitals, Toronto, for their cooperation and assistance in the collection of these data; Drs. Paul Garfinkel and Melvin Silverman for their comments and discussion; Dr. Michael Murray for his assistance with data analysis; and Anne Rydall for her assistance with data management. This article is based on the Masters of Science thesis completed by the first author at the Institute for Medical Sciences, University of Toronto. REFERENCES 1. G. D. Chowanec and Y. M. Bin&, End Stage Renal Disease (ESRD) and the Marital Dyad: A Literature Review and Critique, Social Science and Medicine, 16, pp. 1551-1558, 1982.

2. D. C. Turk and R. D. Kerns, Health, Illness and Families: A Life Span Perspective, John Wiley, New York, 1985. 3. A. R. Block and S. L. Boyer, The Spouse’s Adjustment to Chronic Pain: Cognitive and Emotional Factors, Social Science and Medicine, 1 9 , pp. 1313-1317, 1984. 4. S . B. Shanfield, E. M. Heinman, D. N. Cape, and J. R. Jones, Pain and the Marital Relationship: Psychiatric Distress, Pain, 7, pp. 343-35 1, 1979.

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5 . T. C. M. Carnwath and D. A. W. Johnson, Psychiatric Morbidity among Spouses of Patients with Stroke, British Medical Journal, 294, pp. 409-4 1 1,

1981.

6. B. H. Flor, D. C. Turk, and 0. B. Scholz, Impact of Chronic Pain o n the 7.

8. 9.

10.

1 1. 12. 13.

14. 15.

16.

17.

18.

19. 20.

21.

Spouse: Marital, Emotional, and Physical Consequences, Journal of Psychosomatic Research, 3 1 , pp. 63-71, 1987. M. R. Lowry and E. Atcherson, Spouse-assistant’s Adjustment t o Home Hemodialysis, Journal of Chronic Diseases, 37, pp. 293-300, 1984. L. I. Pearlin, M. A. Leiberman, E. G. Menaghan, and J. T. Mullen, The Stress Process, Journal of Health and Social Behavior, 22, pp. 337-356, 198 1. P. A. Thoits, Dimensions of Life Events that Influence Psychological Distress: An Evaluation and Synthesis of the Literature, in Psychosocial Stress: Trends in Theory and Research, H. B. Kaplan (ed.), Academic Press, New York, 1983. B. Wheaton, Stress, Personal Coping Resources and Psychiatric Symptoms: An Interactive Model, Journal of Health and Social Behavior, 2 4 , pp. 208-229, 1983. S. Cohen and S. L. Syme, Social Support and Health, Academic Press, New York, 1985. I. G. Sarason and B. R. Sarason, Social Support: Theory, Research, and Applicafion, Martinus Njhoff, The Hague, 1985. R. Schulz, C. A. Tornpkins, and M. J. Rau, A Longitudinal Study of the Psychosocial Impact of Stroke o n Primary Support Persons, Psychology of Aging, 3 , pp, 131-141, 1988. S. A. Posen (ed.), Canadian Renal Failure Registery, Kidney Foundation of Canada, 1985. R. W. Evans, D. L Manninen, L. P. Garrison, I. G. Hart, C. K.Blagg, R. A. Gutnian, A. R. Hull and E. G. Lowrie, The Quality of Life of Patients with End-Stage Renal Disease, NEWEngland Journal ofMedicinc,, 312, pp. 553-559, 1985. L S. Radloff, The CES-D Scale: A Ncw Self-Report Scale-Depression Scale for Research in t h e General Population, Applied Psychology Measurement, I , pp. 385-401, 1977. J. Barrett, T. Oxman, and P. Gerber, Prevalence of Depression and Its Correlates in a General Medical Practice, Journal of Affective Disorders, 12, pp. 167-174, 1987. J. H. Boyd, M. M. Weissman, W. D. Thompson, and J. K. Meyers, Screening for Depression in a Community Sample, Archives of General Psychiatry, 3 9 , pp. 1 195- 1200, 1982. R. E. K. Stein and C. K. Reissman, The Development of an Impact o n Family Scale: Preliminary Findings, Medical Care, 18, pp. 465-47 1, 1980. M. E. Procidano and K. Heller, Measures of Perceived Social Support from Friends and from Family: Three Validation Studies, Americun Journul of Community Psychology, 1 1 , pp. 1-24, 1983. M. Bergner, R. A. Bobbitt, W. B. Carter, and B. S. Gilson, The Sickness Impact Profile: Development and Final Revision of a Health Status Measure, Medical Care, 19, pp. 187-805, 198 1.

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22. W. E. Pollard, R. A. Bobbitt, M. Bergner, D. P. Martin, and B. S. Gilson, T h e Sickness Impact Profile: Reliability of a Health Status Measure, Medical Care, 14, pp. 146-155, 1976. 23. M. J. Allen and W . M. Yen, Introduction to Test Measurement, Brooks/Cole, Monterey, 1979. 24. R. M. A. Hirschfeld and C. K. Cross, Epidemiology of Affective Disorders: Psychosocial Risk Factors, Archives of General Psychiatry, 39, pp. 35-46, 1982. 25. R. E. Roberts and S. W. Vernon, The Centre for Epidemiologic Study Depression Scale: Use in a Community Sample, American Journal of Psychiatry, 140, pp. 41-46, 1983. 26. G. E. Barnes, R. F. Currie, and A. Segall, Symptoms of Depression in a Canadian Urban Sample, Canadian Journal of Psychiatry, 33, pp. 386-393, 1988. 27. S. Cohen and T. A. Wills, Stress, Social Support, and the Buffering Hypothesis, Psychological Bulletin, 98, pp. 3 10-357, 1985. 28. P. A. Thoits, Conceptual, Methodological, and Theoretical Problems in Studying Social Support as a Buffer against Life Stress, Journal of Health and Social Behavior, 23, pp. 145-159, 1982. 29. J. Bowlby, Developmental Psychiatry Comes of Age, American Journal of Psychiatry, 145, pp. 1-1 1, 1988. 30. R. D. Kerns and D. C. Turk, Depression and Chronic Pain: The Mediating Role of the Spouse, Journal of Marriage and the Family, 4 6 , pp. 845-952, 1984. 31. B. R. Cassileth, E. J. Lusk, T. B. Strouse, D. S. Miller, L. L. Brown, and P. A. Cross, A Psychological Analysis of Cancer Patients and Their Next of Kin, Cancer, 5 5 , pp. 72-76, 1985.

Direct reprint requests to: Elizabeth M. Rideout, R.N., M.Sc. R o o m 2J 19 Health Sciences Centre McMaster University 1200 Main Street West Hamilton, Ontario Canada L8N 325

Stress, social support, and symptoms of depression in spouses of the medically ill.

This study investigated the level and frequency of depressive symptoms in spouses of dialysis patients, as a function of a) severity of patient diseas...
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