Aging & Mental Health
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20
Depressive symptoms in couples living with heart failure: the role of congruent engagement in heart failure management Karen S. Lyons, Shirin O. Hiatt, Jill M. Gelow, Jonathan Auld, James O. Mudd, Christopher V. Chien & Christopher S. Lee To cite this article: Karen S. Lyons, Shirin O. Hiatt, Jill M. Gelow, Jonathan Auld, James O. Mudd, Christopher V. Chien & Christopher S. Lee (2017): Depressive symptoms in couples living with heart failure: the role of congruent engagement in heart failure management, Aging & Mental Health, DOI: 10.1080/13607863.2017.1381945 To link to this article: http://dx.doi.org/10.1080/13607863.2017.1381945
Published online: 29 Sep 2017.
Submit your article to this journal
Article views: 10
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=camh20 Download by: [University of Essex]
Date: 01 October 2017, At: 04:23
AGING & MENTAL HEALTH, 2017 https://doi.org/10.1080/13607863.2017.1381945
Depressive symptoms in couples living with heart failure: the role of congruent engagement in heart failure management Karen S. Lyonsa, Shirin O. Hiatta, Jill M. Gelowb, Jonathan Aulda, James O. Muddb, Christopher V. Chienb and Christopher S. Leec
Downloaded by [University of Essex] at 04:23 01 October 2017
a School of Nursing, Oregon Health and Science University, Portland, OR, USA; bKnight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA; cSchool of Nursing/Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
ABSTRACT
ARTICLE HISTORY
Objectives: The life-threatening context of heart failure (HF), high variability of the illness and complexity of care place considerable demands on both the adult patient and his/her spouse. The current study examines the role of congruent engagement in HF management behaviors on the depressive symptoms of the couple living with HF. Method: A cross-sectional design was used to examine 60 couples living with HF. Multilevel modeling was used to examine partner and within-dyad effects of engagement in HF behaviors on depressive symptoms. Results: Just over one quarter (27%) of couples had both members experiencing at least mild depressive symptoms. Controlling for stage of HF and one’s own level of engagement, one’s partner’s level of engagement was significantly associated with one’s level of depressive symptoms; higher levels of engagement by one’s partner were associated with lower levels of depressive symptoms. Additionally, spouses had lower levels of depressive symptoms when they had similar levels of engagement to their partner with HF; spouses had higher levels of depressive symptoms when they had higher levels of engagement than their partner with HF. Conclusion: Findings confirm the importance of screening both members of the couple for depression and fostering collaboration within the couple.
Received 7 March 2017 Accepted 15 September 2017
Introduction Heart failure (HF) affects more than 5 million Americans (Go et al., 2013) with worldwide prevalence expected to increase (World Health Organization, 2016). Adults with HF, who are primarily older adults, experience poor quality of life (Westlake, Dracup, Fonarow, & Hamilton, 2005) with only 50% surviving to five years post-diagnosis (Roger et al., 2004). The life-limiting context of HF, coupled with the high variability of the illness and complexity of care, place considerable demands on both the adult with HF and his/her spouse. Estimates of clinical depression in adults with HF are as high as 20% with depressive symptoms commonly-reported in HF samples (Freedland et al., 2016; Rutledge, Reis, Linke, Greenberg, & Mills, 2006). Spouses also experience depressive symptoms (Rohrbaugh et al., 2002) and in some cases levels as high as those reported by adults with HF (Chung, Moser, Lennie, & Rayens, 2009; Pihl, Jacobsson, Fridlund, Stromberg, & Martensson, 2005). Depressive symptoms in HF are particularly salient given the increased risk for mortality and hospitalization (Freedland et al., 2016; Hooley, Butler, & Howlett, 2005; Jiang et al., 2001). HF is the most common reason for hospitalization among older adults (Ross et al., 2010). Management of HF is a combination of optimal clinical care, evidence-based treatments and self-care behaviors (Riegel et al., 2009). These self-care behaviors involve evaluation and management of HF symptoms when they occur (i.e. management behaviors) and appropriately contacting health care providers when symptoms deteriorate (i.e. consulting behaviors). Effective self-care CONTACT Karen S. Lyons
[email protected]
© 2017 Informa UK Limited, trading as Taylor & Francis Group
KEYWORDS
Self-care; management behaviors; consulting behaviors; dyadic coping; congruence
behaviors have been associated with increased event-free survival, greater quality of life and lower levels of depressive symptoms (Hwang, Moser, & Dracup, 2014; Lee et al., 2015b; Lee, Moser, Lennie, & Riegel, 2011; Riegel et al., 2009). Nevertheless, evidence suggests that adults with HF vary greatly in their engagement in these care behaviors (Lee et al., 2015a) with inadequate engagement found in samples across multiple countries (Jaarsma et al., 2013).
A dyadic perspective Social support has long been identified as a key determinant of HF clinical event-risk and mortality (Wu et al., 2013) and increased adherence to treatment and better illness management (Riegel et al., 2009), particularly when that social support is from a spouse (Rohrbaugh, Shoham, & Coyne, 2006). Indeed, recent evidence suggests that spouses play a substantial role in the management of HF (Buck et al., 2015). A major challenge for couples coping with life-threatening illness is to work together to manage the illness while restoring balance to the relationship (Berg & Upchurch, 2007; Revenson, Kayser, & Bodenmann, 2005). Yet, patients and spouses often avoid communication to protect their partner from the fear and uncertainty they feel, removing an important and much needed source of support for both members of the couple (Manne, Badr, Zaider, Nelson, & Kissane, 2010; Robbins, Lopez, Weihs, & Mehl, 2014; Song et al., 2012). There is broad consensus regarding the interdependent and transactional nature of the couple living with illness with
Downloaded by [University of Essex] at 04:23 01 October 2017
2
K. S. LYONS ET AL.
many of the existing dyadic frameworks including concepts of dyadic or collaborative coping (Badr & Acitelli, 2017; Berg & Upchurch, 2007; Bodenmann, 2005; Regan et al., 2015; Revenson & DeLongis, 2011). These dyadic models move beyond an individualistic approach to illness to focus on the reciprocal and interactive ways spouses influence one another (i.e. partner effects). Concepts such as dyadic coping acknowledge the importance of active engagement and collaborative strategies for both members, with research suggesting that how couples cope and manage illness together can impact their psychological adjustment (Badr & Acitelli, 2005; Berg et al., 2008; Franks et al., 2012; Rottmann et al., 2015). The developmental-contextual model of couples coping with illness views the illness experience as an interdependent, interpersonal process (Berg & Upchurch, 2007). The model proposes that adjustment is an interplay of how the couple appraises and copes with the illness as a unit, in addition to developmental factors such as stage of disease. Dyadic coping is conceptualized as a continuum of spousal involvement (e.g. uninvolved, supportive, collaborative, and control) with active engagement or collaboration purported to lead to better adjustment through open communication, joint problemsolving and greater collaborative illness management. The majority of research examining the important role of dyadic coping and spousal involvement on couple adjustment is in such illness contexts as cancer and diabetes (Berg & Upchurch, 2007; Berg et al., 2008; Franks et al., 2012; Johnson et al., 2015; Khan, Stephens, Franks, Rook, & Salem, 2013; Schokker et al., 2011; Traa, DeVries, Bodenmann, & Den Oudsten, 2015), with far less evidence in the life-limiting context of heart failure (Coyne et al., 2001; Rohrbaugh, Mehl, Shoham, Reilly, & Ewy, 2008; Sebern & Riegel, 2009). HF research is still primarily focused on the adult with HF, with a relatively recent focus on the family member providing care and the importance of the dyadic relationship in HF (Agren, Evangelista, & Stromberg, 2010; Bidwell, Lyons, & Lee 2017; Buck et al., 2015; Hooker, Grigsby, Riegel, & Bekelman, 2015; Wingham et al., 2015). Although caregiving research and dyadic science are still emerging areas in HF, notable exceptions have examined the interdependent context of the HF couple using dyadic methodologies that explore both actor and partner effects (Chung et al., 2009; Vellone et al., 2014). A mix of qualitative and quantitative research has begun to examine collaborative illness management and communication within the HF couple and associations with better outcomes for both members of the couple (Lee, et al., 2015c; Retrum, Nowels, & Bekelman, 2013; Rohrbaugh et al., 2008; Sebern, Brown, & Flatley-Brennan, 2016), with evidence suggesting that behavioral indicators of collaboration (e.g. joint problem-solving, collaborative illness management, positive interactions) may play a relatively greater role than selfreported relationship indicators on long-term survival of the adult with HF (Rohrbaugh et al., 2006). Nevertheless, there is a dearth of knowledge regarding the role of spousal engagement and collaborative illness management on the psychological adjustment of the HF couple, creating clinical challenges on how to best support couples living with this complex, life-threatening condition. The current study is the first known study to examine the roles of engagement in HF management and consulting behaviors by both members of the couple and associations with depressive symptoms of the couple living with HF. Drawing upon the developmental-contextual model and the
concept of collaborative coping (Berg & Upchurch, 2007), we hypothesize that (1) greater engagement in the management of HF by one’s partner will be associated with lower depressive symptoms (controlling for one’s own level of engagement) and (2) couples with similar levels of engagement (i.e. greater collaboration) will experience lower levels of depressive symptoms. Stage of HF will be included as a key contextual covariate.
Method Participants and procedures Adults with HF and their spouse/partners were recruited from a HF clinic at a large academic health center in the U.S. Pacific Northwest. Adults with HF were required to be communitydwelling, have a confirmed diagnosis of HF for at least one year (including echocardiographic evidence and formal diagnosis by a cardiologist), and co-reside with a spouse/partner who was willing and eligible to participate. Couples were not required to be married or heterosexual. Adults with HF were not eligible if they were in receipt of a mechanical circulatory support device or transplantation, had an additional terminal condition or had moderate-severe cognitive impairment. Potential participants were initially identified by study cardiologists involved in the adult with HF’s care. Research staff, not involved in the adult with HF’s care, briefly described the study to couples who were interested and screened for eligibility. Adults with HF and their spouses, who were eligible and consented to be enrolled in the study, completed separate surveys. Of the initial 152 clinic patients identified as potential participants, 76 (50%) were eligible and interested (30% did not have an eligible spouse/partner; 3% were not interested in participating). Sixty four couples consented to be in the study, but only 60 couples had available data for the current analyses. The study was approved by the Institutional Review Board at Oregon Health and Science University.
Measures HF management behaviors Engagement in HF management behaviors was measured using the 6-item subscale of the Self-Care of Heart Failure Index v.6.2 (SCHFI) (Riegel, Lee, Dickson, & Carlson, 2009). Items capture recognition of HF symptoms and appropriate responses when they occur (e.g. taking an extra water pill, reducing salt in diet). Scores are standardized to 0–100 with higher scores indicating greater engagement in HF management behaviors. The subscale has demonstrated strong reliability and validity across HF populations (Barbaranelli, Lee, Vellone, & Riegel, 2014), as has the caregiver version (CCSCHFI) (Vellone et al., 2013). Cronbach’s alphas in the current sample were .71 for adults with HF and .80 for spouses. HF consulting behaviors Engagement in HF consulting behaviors was measured using the 4-item consulting behavior subscale of the European Heart Failure Self-Care Behavior Scale (EHFScB-9) (Jaarsma, Arestedt, Martensson, Dracup, & Stromberg, 2009). Items capture appropriate responses to HF symptoms when they occur, namely, to contact a provider and seek guidance (e.g. if my [my spouse’s] shortness of breath increases I contact my [her/ his] doctor or nurse). Response options range from 1
AGING & MENTAL HEALTH
(I completely agree) to 5 (I don’t agree at all) for a scale range of 4–20. Lower scores indicate greater engagement in appropriate consulting behaviors. The scale has demonstrated good reliability and validity (Jaarsma et al., 2009), including in the current sample (adults with HF = .84; spouses = .94).
Downloaded by [University of Essex] at 04:23 01 October 2017
Depressive symptoms Depressive symptoms were measured using the 9-item Patient Health Questionnaire (PHQ9) (Kroenke, Spitzer, & Williams, 2001). Based on the DSM-IV criteria for depression, the PHQ9 asks participants to respond to nine items on a 0 (not at all) to 3 (nearly every day) scale. Scores are summed with higher scores indicating greater depressive symptomatology. The scale has demonstrated strong reliability and validity evidence, including 88% sensitivity and specificity for major depression (score of 10 or greater) (Kroenke et al., 2001), with scores of 5 indicating mild depressive symptoms. Cronbach’s alphas in the current sample were .84 for adults with HF and .83 for spouses. Analysis plan Multilevel modeling was used to analyze data at the level of the couple . The model estimates a latent score for each member of the couple (i.e. one for the adult with HF and one for the spouse), controlling for the interdependencies in outcomes (Lyons & Sayer, 2005). Two dyadic models of depressive symptoms were tested using HLM 7 (one examining the role of HF management behaviors and one examining the role of HF consulting behaviors). An unconditional (i.e. no covariates) within-dyad model was first run to estimate the population averages of depressive symptoms within couples and to determine the variability in depressive symptoms across couples. This initial, unconditional model represented depressive symptoms for both adults with HF and their spouses as the sum of a latent score plus a residual term that captures measurement error. Next, two between-dyad models were run, each of which consisted of simultaneous regression equations for adults with HF and their spouses, adjusted for the effects of predictors in each equation (i.e. HF management behaviors or consulting behaviors). Each of these two between-dyad models allowed for the examination of actor (e.g. the role of adult with HF management behaviors on adult with HF depressive symptoms) and partner effects (e.g. the role of spouse HF consulting behaviors on adult with HF depressive symptoms), controlling for the interdependence in depressive symptoms within couples. HLM uses full information maximum likelihood estimation (FIMLE). A multi-parameter hypothesis test within HLM was used to test for differences between depressive symptoms of adults with HF and spouses. Additionally, we compared the fit of each conditional model with the unconditional model using a chi square deviance test, where degrees of freedom are the difference in number of model parameters. Finally, to determine the role of congruence (a within-dyad versus across-dyad effect) of HF management and consulting behaviors on depressive symptoms, we tested both models including a term that represented the interaction between the management (or consulting) behaviors of adults with HF and spouses. Interaction effects are reported only for those models where the effect was significant; otherwise main effects are reported.
3
Results Sample characteristics Couples were primarily White, had attended at least some college, and had been together, on average for almost 30 years (see Table 1). Spouses were significantly younger than adults with HF (p < .05). The majority of adults with HF were men (67%) and had been living with the illness, on average, almost seven years; almost three-quarters had a NYHA class of III/IV, indicting symptomatic and moderate-to-advanced HF. On average, adults with HF reported significantly higher engagement in management behaviors t(59) = 3.90, p < .001 than spouses; there were no significant differences between adults with HF and spouses in engagement in consulting behaviors.
Depressive symptoms Descriptive analysis revealed a total of 16 couples (27%) had both an adult with HF and a spouse experiencing mild-moderate depressive symptoms and 17 couples where neither member of the couple reported mild or greater levels of depressive symptomatology. Fixed effects results of an unconditional model found similar levels of average depressive symptoms to raw score data presented in Table 1. Depressive symptoms were 6.86, p < .001 for adults with HF and 4.13, p < .001 for spouses. A multi-parameter hypothesis test confirmed that adults with HF, on average, reported significantly higher levels of depressive symptoms than spouses (p < .01). Variance components for both adults with HF and their spouses indicated significant heterogeneity in depressive symptoms across couples.
Heart failure management behaviors Table 2 captures the effects of HF management behaviors on the depressive symptoms of adults with HF and their spouses. Greater engagement in management by the adult with HF was associated with lower depressive symptoms for spouses t (55) = ¡2.56, p < .05. Similarly, greater spousal engagement in management was associated with lower depressive symptoms for adults with HF t(55) = ¡2.18, p < .05. Importantly, the interaction between management behaviors by adults with HF and their spouses was associated with the depressive symptoms of spouses. As depicted in Figure 1 when adults with HF and spouses are similar in their level of engagement in HF management behaviors (high or low), there is a low level of depressive symptoms for spouses. Dissimilar levels of engagement in HF management behaviors had both positive Table 1. Adults with HF and spouse characteristics (N = 60 couples). Characteristic Adults with HF Spouses Age (years), mean (§SD) 59.45 (11.92) 57.75 (11.91)* Women (%) 33.3 66.7 Non-Hispanic White (%) 88.3 86.7 Attended some college (%) 79.7 78.3 Currently employed part/full-time (%) 18.3 40.0 a 73.3 – NYHA class III/IV (%) Years with heart failure, mean (§SD) 6.93 (5.19) – Years together, mean (§SD) 29.53 (16.56) – Heart failure management behaviors, 65.52 (21.83) 50.15 (27.99) mean (§SD) *** Heart failure consulting behaviors, mean 8.38 (4.13) 8.47 (5.19) (§SD) Depressive symptoms, mean (§SD) 6.85 (5.17) 4.04 (4.36)*** a New York Heart Association. *p < .05; **p < .01; ***p < .0.
4
K. S. LYONS ET AL.
Table 2. Multilevel models predicting adults with HF and spouse depressive symptoms. Adults with HF B (SE) t Effect size (r) B (SE) HF management behaviors Intercept 6.86 (1.33)*** Adults with HF management behaviors 0.04 (0.02) 1.74 Spouse management behaviors ¡0.05 (0.02)* ¡2.18 Adults with HF X spouse management ¡0.01 (0.00) ¡1.85 Behaviors 20.40 (8)* Model comparisona x2 (df) HF consulting behaviors Intercept 5.98 (1.22)*** Adults with HF consulting behaviors 0.19 (0.15) 1.27 Spouse consulting behaviors 0.33 (0.12)** 2.72 18.27 (6)** Model comparisona x2 (df)
Spouses t
Effect size (r)
.23 .28 .24
4.13 (0.87)*** ¡0.09 (0.04)* 0.02 (0.02) ¡0.01 (0.00)*
¡2.56 1.20 ¡2.25
.33 .16 .30
.17 .34
3.25 (1.03)** 0.38 (0.13)** ¡0.05 (0.11)
2.87 ¡0.49
.36 .07
a
Downloaded by [University of Essex] at 04:23 01 October 2017
Deviance statistics used to compare conditional model (i.e. with covariates) to unconditional (i.e. no covariates) model. Higher scores indicate more engagement in management behaviors; lower engagement in consulting behaviors. All models controlled for NYHA class (i.e. severity of HF). pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi B = unstandardized coefficient; effect size r ¼ t2 6 ðt 2 þ dfÞ. *p < .05; **p < .01; ***p < .001.
and negative associations with depressive symptoms, with highest levels of depressive symptoms reported by spouses that had higher levels of engagement than their partner with HF (controlling for severity of HF).
Heart failure consulting behaviors The engagement of adults with HF in consulting behaviors was significantly associated with spouse depressive symptoms t(56) = 2.87, p < .01. Further, spouse engagement in HF consulting behaviors was significantly associated with the depressive symptoms of adults with HF t(56) = 2.72, p < .01 (Table 2). In both cases, higher levels of engagement by one’s partner was significantly associated with lower levels of depressive symptoms for both members of the couple.
Discussion Little is known about how couples living with HF collaborate and work together to manage the salient symptoms that can lead to adverse consequences, including hospitalization, for the adult with HF. In particular, it is unknown if couples living with HF who engage in similar levels of HF management and consulting behaviors experience better psychological health than couples experiencing complementary levels of engagement. The current study is the first known study to examine congruent collaboration in engagement in HF care behaviors
Figure 1. Interaction of adult with HF management behaviors and spouse management behaviors as predictors of spouse depressive symptoms. High and low levels of HF management behaviors represent 1 SD above and below the mean, respectively.
within the couple and associations with the depressive symptoms of the couple. Several findings are noteworthy. First, adults with HF, on average, reported significantly higher levels of depressive symptoms than spouses. Second, approximately one quarter of the sample included couples where both members reported depressive symptoms that were mild or moderate. Third, controlling for one’s own level of engagement in HF care behaviors (i.e. management and consulting), higher levels of engagement by one’s partner were associated with lower levels of depressive symptoms for both members of the couple, supporting our first hypothesis. Fourth, results suggest that when couples engage in similar levels of HF management behaviors spouses experience lower depressive symptoms; spouses experience higher levels of depressive symptoms when they have high levels of engagement but their partner with HF has low engagement, providing partial support for our second hypothesis. Finally, effect sizes for partner effects and interaction effects were moderate. The current study builds upon previous research that has examined the important role of social support and, in particular marital quality in HF (Rohrbaugh et al., 2006). Not only do the current findings support the importance of the spouse’s engagement in managing the illness, but the dyadic approach in this study advances understanding of the transactional nature of HF management within the couple and supports the developmental-contextual model (Berg & Upchurch, 2007). In the case of both types of HF care behaviors (i.e. management and consulting behaviors), the engagement of one’s partner was significantly associated with lower depressive symptoms for both members of the couple. These unique partner effects (controlling for one’s own engagement) strongly support the need for a dyadic perspective of a lifethreatening condition where it may be common to reduce the couple to the individual roles of patient and caregiver. From a clinical perspective, the focus is often on the engagement in HF care behaviors of either the adult with HF or the spouse, as long as someone is engaged. The current findings, however, support the concepts of dyadic coping (Berg & Upchurch, 2007) in promoting better psychological heath and adjustment for the couple, in that, one’s partner’s engagement matters. Similarly, the current study examined the concept of congruence or collaborative engagement and found that spouses
Downloaded by [University of Essex] at 04:23 01 October 2017
AGING & MENTAL HEALTH
had lower levels of depressive symptoms when they and their partners with HF had similar levels of engagement in management behaviors (either high or low). When a spouse reported low levels of engagement, they experienced low levels of depressive symptoms, regardless of the engagement level of their partner with HF. Spouses experienced highest levels of depressive symptoms when they had high levels of engagement but their partner had low levels of engagement. Thus, the findings partially support our hypothesis that depressive symptoms would be lower when members of the couple had similar responses rather than complementary responses. The idea of congruence in response to illness has also been described by Revenson & DeLongis (2011). Given that spouses were primarily women, it is possible that this benefit to similar, more collaborative engagement may reflect the more relational self-construals and identities that women define themselves by, as compared to those of men (KiecoltGlaser & Newton, 2001). Research in cancer has shown that women, regardless of role, experience poorer psychological adjustment (Hagedoorn, Sanderman, Coyne, Bolks, & Tuinstra, 2008). It may be that women are also more influenced by levels of collaboration within the couple. Indeed, spouses experienced highest levels of depressive symptoms when they had a high level of engagement but their partner with HF had a low level of engagement. Although this may first appear to represent an adult with HF that may be unable to engage due to severity of disease, these findings controlled for stage of disease. Clearly, further work with larger, more gender-balanced samples is needed. Finally, just over one quarter of the couples in the sample had both members experiencing at least mild depressive symptoms. Not only does this reinforce the psychological strain that such a complex, highly variable and life-threatening condition places on both members of the couple, but also underscores the need for attention to the mental health of both members, particularly given the need for spouse engagement in the management of HF. Research suggests that family members with high levels of depressive symptoms may be less likely to be effective in providing care and managing illness (Coon, Thompson, Steffen, Sorocco, & GallagherThompson, 2003; Northouse, Katapodi, Song, Zhang, & Mood, 2010). Thus, careful screening and attention to both members of the couple living with HF are needed.
Limitations The study had several limitations. The sample size was relatively small, which limited the number of variables included in each model (though all models controlled for severity of HF). The sample size may also have attenuated the ability to uncover significant within-dyad interaction effects not found in the current study, particularly given the effect size found for the management behavior interaction on depressive symptoms for adults with HF. Replication is needed in larger samples; larger samples would also allow for more complex investigation of whether there are types of couples who benefit more from similar versus complementary responses. Replication is also needed in more gender-balanced and diverse samples to increase the generalizability of findings. Similarly, the current study was cross-sectional in design preventing an examination of directionality or change over time. More research is needed to understand the way couples living with HF manage the illness over time. In particular, how does
5
collaboration and dyadic coping evolve, if at all, with symptom severity, and what are the implications for couple wellbeing?
Strengths and implications Despite these limitations, the current study not only highlighted the need for a dyadic perspective of depressive symptoms within HF couples, but also greater attention to the transactional and collaborative nature of how couples may navigate and manage HF together. Findings suggest the important role a partner’s level of engagement can play, above and beyond one’s own engagement, as well as the potential importance of similar versus complementary levels of engagement. Given the salience of engagement in these HF care behaviors to prevent acute and adverse consequences for the adult with HF and the presence of depressive symptoms in both members of the HF couple, it may be beneficial for HF clinicians to reframe their approach from a more traditional, individual perspective that targets patient and caregiver with separate needs to a more dyadic perspective that views the couple as an interdependent unit with common goals of relational wellness and optimal quality of life. Facilitating and discussing such common goals and collaborative approaches within the clinical setting may be particularly fruitful. For example, encouraging the couple to take a teambased approach to engaging in HF health behaviors such as diet regulation and physical activity together, rather than something done solely by the adult with HF. Similarly, as has been called for in other illness contexts, there is a need to ensure assessment of depressive symptoms for both members of the HF couple (Moser et al., 2016). Couples facing a life-threatening illness such as HF can experience social constraints and levels of anxiety and fear that can impede communication and collaboration (Badr & Carmack Taylor, 2008; Zhang & Siminoff, 2003), undermining the supportive nature of the couple. Thus, greater attention to couples who may be struggling to engage in open communication or collaborative efforts, or spouses who may be experiencing depressive symptoms may be especially needed. This novel study has shed light on the need for a dyadic perspective of HF and goes beyond the role of spousal involvement to examine the potential implications of how couples manage the illness together. Greater focus is needed on how couples living with HF navigate and manage the illness over time, the roles of collaborative and congruent engagement in illness management, and the identification of types of couples who may benefit more or less from similar versus complementary responses. Such discoveries can help to address the clinical challenges of how best to support both members as they traverse such a daunting and often unpredictable journey together.
Disclosure statement The authors report no conflicts of interest.
Funding This research was supported by an innovations grant from the Oregon Health and Science University School of Nursing.
6
K. S. LYONS ET AL.
Downloaded by [University of Essex] at 04:23 01 October 2017
References Agren, S., Evangelista, L. S., & Stromberg, A. (2010). Do partners of patients with heart failure experience caregiver burden ? European Journal of Cardiovascular Nursing, 9, 254–262. Badr, H., & Acitelli, L. K. (2005). Dyadic adjustment in chronic illness: Does relationship talk matter ? Journal of Family Psychology, 19, 465–469. Badr, H., & Acitelli, L. K. (2017). Re-thinking dyadic coping in the context of chronic illness. Current Opinion in Psychology, 13, 44–48. doi:10.1016/j. copsyc.2016.03.001 Badr, H., & Carmack Taylor, C. L. (2008). Effects of relationship maintenance on psychological distress and dyadic adjustment among couples coping with lung cancer. Health Psychology, 27, 616–627. doi:10.1037/0278-6133.27.5.616 Barbaranelli, C., Lee, C. S., Vellone, E., & Riegel, B. (2014). Dimensionality and reliability of the self-care of heart failure index scales: Further evidence from confirmatory factor analysis. Research in Nursing & Health, 37, 524–537. doi:10.1002/nur.21623 Berg, C. A., & Upchurch, R. (2007). A developmental-contextual model of couples coping with chronic illness across the adult life span. Psychological Bulletin, 133, 920–954. doi:10.1037/0033-2909.133.6.920 Berg, C. A., Wiebe, D. J., Butner, J., Bloor, L., Bradstreet, C., Upchurch, R., … Patton, G. (2008). Collaborative coping and daily mood in couples dealing with prostate cancer. Psychology and Aging, 23, 505–516. doi:2008-13050-003 Bidwell, J. T., Lyons, K. S., & Lee, C. S. (2017). Caregiver well-being and patient outcomes in heart-failure: A meta-analysis. Journal of Cardiovascular Nursing, 32, 373-382. doi:10.1097/JCN.0000000000000350. Bodenmann, G. (2005). Dyadic coping and its significance for marital functioning. In T. A. Revenson, K. Kayser, & G. Bodenmann (Eds.), Couples coping with stress: Emerging perspectives on dyadic coping (pp. 33–50). Washington, DC: American Psychological Association. Buck, H. G., Harkness, K., Wion, R., Carroll, S. L., Cosman, T., Kaasalainen, S., … Arthur, H. M. (2015). Caregivers’ contributions to heart failure selfcare: A systematic review. European Journal of Cardiovascular Nursing, 14, 79–89. Chung, M. L., Moser, D. K., Lennie, T. A., & Rayens, M. K. (2009). The effects of depressive symptoms and anxiety on quality of life in patients with heart failure and their spouses: Testing dyadic dynamics using actorpartner interdependence model. Journal of Psychosomatic Research, 67, 29–35. doi:10.1016/j/jpsychores.2009.01.009 Coon, D. W., Thompson, L., Steffen, A., Sorocco, K., & Gallagher-Thompson, D. (2003). Anger and depression management: Psychoeducational skill training interventions for women caregivers of a relative with dementia. The Gerontologist, 43, 678–689. Coyne, J. C., Rohrbaugh, M. J., Shoham, V., Sonnega, J., Nicklas, J. M., & Cranford, J. A. (2001). Prognostic importance of marital quality for survival of congestive heart failure. American Journal of Cardiology, 88, 526–529. Franks, M. M., Sahin, Z. S., Seidel, A. J., Shields, C. G., Oates, S. K., & Boushey, C. J. (2012). Table for two: Diabetes distress and diet-related interactions of married patients with diabetes and their spouses. Families, Systems, & Health, 30, 154–165. doi:10.1037/a0028614 Freedland, K. E., Hesseler, M. J., Carney, R. M., Steinmeyer, B. C., Skala, J. A., Davila-Roman, V. G., & Rich, M. W. (2016). Major depression and longterm survival of patients with heart failure. Psychosomatic Medicine, 78, 896–903. doi:10.1097/PSY.0000000000000346 Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Borden, W. B., … Turner, M. B. (2013). Heart disease and stroke statistics–2013 update: A report from the American Heart Association. Circulation, 127, e6–e245. doi:10.1161/CIR.0b013e31828124ad Hagedoorn, M., Sanderman, R., Coyne, J. C., Bolks, H. N., & Tuinstra, J. (2008). Distress in couples coping with cancer: A meta-analysis and critical review of role and gender effects. Psychological Bulletin, 134, 1– 30. doi:10.1037/0033-2909.134.1.1 Hooker, S. A., Grigsby, M. E., Riegel, B., & Bekelman, D. B. (2015). The impact of relationship quality on health-related outcomes in heart failure patients and informal family caregivers: An integrative review. Journal of Cardiovascular Nursing, 30(4 Suppl. 1), S52–S63. Hooley, P. J. D., Butler, G., & Howlett, J. G. (2005). The relationship of quality of life, depression, and caregiver burden in outpatients with congestive heart failure. Congestive Heart Failure, 11, 303–310. Hwang, B., Moser, D. K., & Dracup, K. (2014). Knowledge is insufficient for self-care among heart failure patients with psychological distress. Health Psychology, 33, 588–596. doi:10.1037/a0033419
Jaarsma, T., Arestedt, K., Martensson, J., Dracup, K., & Stromberg, A. (2009). The European Heart Failure Self-Care Behavior scale revised into a nine-item scale (EHFScB-9): A reliable and valid international instrument. European Journal of Heart Failure, 11, 99–105. doi:10.1093/ eurjhf/hfn007 Jaarsma, T., Stromberg, A., Ben Gal, T., Cameron, J., Driscoll, A., Duengen, H. D., … Huang, T. Y. (2013). Comparison of self-care behaviors of heart failure patients in 15 countries world-wide. Patient Education and Counseling, 92, 114–120. Jiang, W., Alexander, J., Christopher, E., Kuchibhatla, M., Gaulden, L. H., Cuffe, M. S., … O’ Conner, C. M. (2001). Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Archives of Internal Medicine, 161, 1849–1856. Johnson, M. D., Anderson, J. R., Walker, A., Wilcox, A., Lewis, V. L., & Robbins, D. C. (2015). Spousal overprotection is indirectly associated with poorer dietary adherence for patients with type 2 diabetes via diabetes distress when active engagement is low. British Journal of Health Psychology, 20, 360–373. doi:10.1111/bjhp.12105 Khan, C. M., Stephens, M. A. P., Franks, M. M., Rook, K. S., & Salem, J. K. (2013). Influences of spousal support and control on diabetes management through physical activity. Health Psychology, 32, 739–747. doi:10.1037/a0028609 Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472–503. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. doi:jgi01114 [pii] Lee, C. S., Gelow, J. M., Mudd, J. O., Green, J. K., Hiatt, S. O., Chien, C., & Riegel, B. (2015 a). Profiles of self-care management versus consulting behaviors in adults in heart failure. European Journal of Cardiovascular Nursing, 14, 63–72. doi:10.1177/1474515113519188 Lee, C. S., Moser, D. K., Lennie, T. A., & Riegel, B. (2011). Event-free survival in adults with heart failure who engage in self-care management. Heart & Lung, 40, 12–20. Lee, C. S., Mudd, J. O., Hiatt, S. O., Gelow, J. M., Chien, C., & Riegel, B. (2015 b). Trajectories of heart failure self-care management and changes in quality of life. European Journal of Cardiovascular Nursing, 14, 486–494. doi:10.1177/1474515114541730 Lee, C. S., Vellone, E., Lyons, K. S., Cocchieri, A., Bidwell, J. T., D’ Agostino, F., … Riegel, B. (2015 c). Patterns and predictors of patient and caregiver engagement in heart failure care: A multi-level dyadic study. International Journal of Nursing Studies, 52, 588–597. doi:10.1016/j. ijnurstu.2014.11.005 Lyons, K. S., & Sayer, A. G. (2005). Longitudinal dyad models in family research. Journal of Marriage and Family, 67, 1048–1060. Manne, S., Badr, H., Zaider, T., Nelson, C., & Kissane, D. (2010). Cancerrelated communication, relationship intimacy, and psychological distress among couples coping with localized prostate cancer. Journal of Cancer Survivorship, 4, 74–85. Moser, D. K., Arslanian-Engoren, C., Biddle, M. J., Chung, M. L., Dekker, R. L., Hammash, M. H., … Lennie, T. A. (2016). Psychological aspects of heart failure. Current Cardiology Reports, 18, 119. Northouse, L. L., Katapodi, M. C., Song, L., Zhang, L., & Mood, D. W. (2010). Interventions with family caregivers of cancer patients: A meta-analysis of randomized trials. CA: A Cancer Journal for Clinicians, 60, 317–339. Pihl, E., Jacobsson, A., Fridlund, B., Stromberg, A., & Martensson, J. (2005). Depression and health-related quality of life in elderly patients suffering from heart failure and their spouses: A comparative study. European Journal of Heart Failure, 7, 583–589. doi:10.1016/j.ejheart.2004.07.016 Regan, T. W., Lambert, S. D., Kelly, B., Falconier, M., Kissane, D., & Levesque, J. V. (2015). Couples coping with cancer: Exploration of theoretical frameworks from dyadic studies. Psycho-oncology, 24, 1605–1617. Retrum, J. H., Nowels, C. T., & Bekelman, D. B. (2013). Patient and caregiver congruence: The importance of dyads in heart failure care. Journal of Cardiovascular Nursing, 28, 129–136. doi:10.1097/JCN.0b013e3182435f27 Revenson, T. A. (2003). Scenes from a marriage: Examining support, coping, and gender within the context of chronic illness. In J. Suls & K. A. Wallston (Eds.), Social psychological foundations of health and illness (pp. 530–559). Malden, MA: Blackwell Publishing. Revenson, T. A., & DeLongis, A. (2011). Couples coping with chronic illness. In S. Folkman (Ed.), The Oxford handbook of stress, health, and coping (pp. 101–123). New York, NY: Oxford University Press. Revenson, T. A., & Kayser, K., & Bodenmann, G. (2005). Couples coping with stress: Emerging perspectives on dyadic coping. Washington, DC: American Psychological Association.
Downloaded by [University of Essex] at 04:23 01 October 2017
AGING & MENTAL HEALTH
Riegel, B., Lee, C. S., Dickson, V. V., & Carlson, B. (2009). An update on the self-care of heart failure index. Journal of Cardiovascular Nursing, 24, 485–497. doi:10.1097/JCN.0b013e3181b4baa0 Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., … Whellan, D. J. (2009). State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation, 120, 1141–1163. doi:10.1161/ CIRCULATIONAHA.109.192628 Robbins, M. L., Lopez, A. M., Weihs, K. L., & Mehl, M. R. (2014). Cancer conversations in context: Naturalistic observation of couples coping with breast cancer. Journal of Family Psychology, 28, 380–390. doi:10.1037/ a0036458 Roger, V. L., Weston, S. A., Redfield, M. M., Hellermann-Homan, J. P., Killian, J., Yawn, B. P., & Jacobsen, S. J. (2004). Trends in heart failure incidence and survival in a community-based population. JAMA, 292(3), 344–350. Rohrbaugh, M. J., Cranford, J. A., Shoham, V., Nicklas, J. M., Sonnega, J. S., & Coyne J. C. (2002). Couples coping with congestive heart failure: Role and gender differences in psychological distress. Journal of Family Psychology, 16, 3–13. Rohrbaugh, M. J., Mehl, M. R., Shoham, V., Reilly, E. S., & Ewy, G. A. (2008). Prognostic significance of spouse we talk in couples coping with heart failure. Journal of Consulting and Clinical Psychology, 76, 781–789. doi:10.1037/a0013238 Rohrbaugh, M. J., Shoham, V., & Coyne, J. C. (2006). Effect of marital quality on eight-year survival of patients with heart failure. American Journal of Cardiology, 98, 1069–1072. Ross, J. S., Chen, J., Lin, Z., Bueno, H., Curtis, J. P., Keenan, P. S., & Krumholz, H. M. (2010). Recent national trends in readmission rates after heart failure hospitalization. Circulation: Heart Failure, 3, 97–103. doi:10.1161/CIRCHEARTFAILURE.109.885210 Rottmann, N., Hansen, D. G., Larsen, P. V., Niicolaisen, A., Flyger, H., Johansen, C., & Hagedoorn, M. (2015). Dyadic coping within couples dealing with breast cancer: A longitudinal, population-based study. Health Psychology, 34, 486–495. doi:10.1037/hea0000218 Rutledge, T., Reis, V. A., Linke, S. E., Greenberg, B. H., & Mills, P. J. (2006). Depression in heart failure: A meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. Journal of American College of Cardiology, 48, 1527–1537. doi:10.1016/j. jacc.2006.06.055 Schokker, M. C., Links, T. P., Bouma, J., Keers, J. C., Sanderman, R., Wolffenbuttel, B. H. R., & Hagedoorn, M. (2011). The role of overprotection by
7
the partner in coping with diabetes: A moderated mediation model. Psychology and Health, 26, 95–111. doi:10.1080/08870440903342325 Sebern, M., & Riegel, B. (2009). Contributions of supportive relationships to heart failure self-care. European Journal of Cardiovascular Nursing, 8, 97–104. doi:10.1016/j/ejcnurse.2008.07.004 Sebern, M., Brown, R., & Flatley-Brennan, P. (2016). Shared care contributions to self-care and quality of life in chronic cardiac patients. Western Journal of Nursing Research, 38, 837–857. doi:10.1177/ 0193945915626877 Song, L., Northouse, L. L., Braun, T. M., Cimprich, B., Ronis, D. L., & Mood, D. W. (2012). Study of dyadic communication in couples managing prostate cancer: A longitudinal perspective. Psycho-oncology, 21, 72–81. doi:10.1002/pon.1861 Traa, M. J., DeVries, J., Bodenmann, G., & Den Oudsten, B. L. (2015). Dyadic coping and relationship functioning in couples coping with cancer: A systematic review. British Journal of Health Psychology, 20, 85–114. doi:10.1111/bjhp.12094 Vellone, E., Chung, M. L., Cocchieri, A., Rocco, G., Alvaro, R., & Riegel, B. (2014). Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: Testing dyadic dynamics using the actorpartner interdependence model. Journal of Family Nursing, 20, 120– 141. Vellone, E., Riegel, B., Cocchieri, A., Barbaranelli, C., D’Agostino, F., Glaser, D., … Alvaro, R. (2013). Validity and reliability of the caregiver contribution to self-care of heart failure index. Journal of Cardiovascular Nursing, 28(3), 245–255. doi:10.1097/JCN.0b013e318256385e Westlake, C., Dracup, K., Fonarow, G. C., & Hamilton, M. (2005). Depression in patients with heart failure. Journal of Cardiac Failure, 11, 30–35. Wingham, J., Frost, J., Britten, N., Jolly, K., Greaves, C., Abraham, C., & Dalal, H. (2015). Needs of caregivers in heart failure management: A qualitative study. Chronic Illness, 11, 304–319. doi:10.1177/ 1742395315574765 World Health Organization. (2016). Chronic diseases. Retrieved fromhttp:// www.who.int/topics/chronic_diseases/factsheets/en/ Wu, J., Frazier, S. K., Rayens, M. K., Lennie, T. A., Chung, M. L., & Moser, D. K. (2013). Medication adherence, social support, and event-free survival in patients with heart failure. Health Psychology, 32, 637–646. doi:10.1037/a0028527 Zhang, A. Y., & Siminoff, L. A. (2003). Silence and cancer: Why do families and patients fail to communicate ? Health Communication, 15, 415– 429.
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20
Depressive symptoms in couples living with heart failure: the role of congruent engagement in heart failure management Karen S. Lyons, Shirin O. Hiatt, Jill M. Gelow, Jonathan Auld, James O. Mudd, Christopher V. Chien & Christopher S. Lee To cite this article: Karen S. Lyons, Shirin O. Hiatt, Jill M. Gelow, Jonathan Auld, James O. Mudd, Christopher V. Chien & Christopher S. Lee (2017): Depressive symptoms in couples living with heart failure: the role of congruent engagement in heart failure management, Aging & Mental Health, DOI: 10.1080/13607863.2017.1381945 To link to this article: http://dx.doi.org/10.1080/13607863.2017.1381945
Published online: 29 Sep 2017.
Submit your article to this journal
Article views: 10
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=camh20 Download by: [University of Essex]
Date: 01 October 2017, At: 04:23
AGING & MENTAL HEALTH, 2017 https://doi.org/10.1080/13607863.2017.1381945
Depressive symptoms in couples living with heart failure: the role of congruent engagement in heart failure management Karen S. Lyonsa, Shirin O. Hiatta, Jill M. Gelowb, Jonathan Aulda, James O. Muddb, Christopher V. Chienb and Christopher S. Leec
Downloaded by [University of Essex] at 04:23 01 October 2017
a School of Nursing, Oregon Health and Science University, Portland, OR, USA; bKnight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA; cSchool of Nursing/Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
ABSTRACT
ARTICLE HISTORY
Objectives: The life-threatening context of heart failure (HF), high variability of the illness and complexity of care place considerable demands on both the adult patient and his/her spouse. The current study examines the role of congruent engagement in HF management behaviors on the depressive symptoms of the couple living with HF. Method: A cross-sectional design was used to examine 60 couples living with HF. Multilevel modeling was used to examine partner and within-dyad effects of engagement in HF behaviors on depressive symptoms. Results: Just over one quarter (27%) of couples had both members experiencing at least mild depressive symptoms. Controlling for stage of HF and one’s own level of engagement, one’s partner’s level of engagement was significantly associated with one’s level of depressive symptoms; higher levels of engagement by one’s partner were associated with lower levels of depressive symptoms. Additionally, spouses had lower levels of depressive symptoms when they had similar levels of engagement to their partner with HF; spouses had higher levels of depressive symptoms when they had higher levels of engagement than their partner with HF. Conclusion: Findings confirm the importance of screening both members of the couple for depression and fostering collaboration within the couple.
Received 7 March 2017 Accepted 15 September 2017
Introduction Heart failure (HF) affects more than 5 million Americans (Go et al., 2013) with worldwide prevalence expected to increase (World Health Organization, 2016). Adults with HF, who are primarily older adults, experience poor quality of life (Westlake, Dracup, Fonarow, & Hamilton, 2005) with only 50% surviving to five years post-diagnosis (Roger et al., 2004). The life-limiting context of HF, coupled with the high variability of the illness and complexity of care, place considerable demands on both the adult with HF and his/her spouse. Estimates of clinical depression in adults with HF are as high as 20% with depressive symptoms commonly-reported in HF samples (Freedland et al., 2016; Rutledge, Reis, Linke, Greenberg, & Mills, 2006). Spouses also experience depressive symptoms (Rohrbaugh et al., 2002) and in some cases levels as high as those reported by adults with HF (Chung, Moser, Lennie, & Rayens, 2009; Pihl, Jacobsson, Fridlund, Stromberg, & Martensson, 2005). Depressive symptoms in HF are particularly salient given the increased risk for mortality and hospitalization (Freedland et al., 2016; Hooley, Butler, & Howlett, 2005; Jiang et al., 2001). HF is the most common reason for hospitalization among older adults (Ross et al., 2010). Management of HF is a combination of optimal clinical care, evidence-based treatments and self-care behaviors (Riegel et al., 2009). These self-care behaviors involve evaluation and management of HF symptoms when they occur (i.e. management behaviors) and appropriately contacting health care providers when symptoms deteriorate (i.e. consulting behaviors). Effective self-care CONTACT Karen S. Lyons
[email protected]
© 2017 Informa UK Limited, trading as Taylor & Francis Group
KEYWORDS
Self-care; management behaviors; consulting behaviors; dyadic coping; congruence
behaviors have been associated with increased event-free survival, greater quality of life and lower levels of depressive symptoms (Hwang, Moser, & Dracup, 2014; Lee et al., 2015b; Lee, Moser, Lennie, & Riegel, 2011; Riegel et al., 2009). Nevertheless, evidence suggests that adults with HF vary greatly in their engagement in these care behaviors (Lee et al., 2015a) with inadequate engagement found in samples across multiple countries (Jaarsma et al., 2013).
A dyadic perspective Social support has long been identified as a key determinant of HF clinical event-risk and mortality (Wu et al., 2013) and increased adherence to treatment and better illness management (Riegel et al., 2009), particularly when that social support is from a spouse (Rohrbaugh, Shoham, & Coyne, 2006). Indeed, recent evidence suggests that spouses play a substantial role in the management of HF (Buck et al., 2015). A major challenge for couples coping with life-threatening illness is to work together to manage the illness while restoring balance to the relationship (Berg & Upchurch, 2007; Revenson, Kayser, & Bodenmann, 2005). Yet, patients and spouses often avoid communication to protect their partner from the fear and uncertainty they feel, removing an important and much needed source of support for both members of the couple (Manne, Badr, Zaider, Nelson, & Kissane, 2010; Robbins, Lopez, Weihs, & Mehl, 2014; Song et al., 2012). There is broad consensus regarding the interdependent and transactional nature of the couple living with illness with
Downloaded by [University of Essex] at 04:23 01 October 2017
2
K. S. LYONS ET AL.
many of the existing dyadic frameworks including concepts of dyadic or collaborative coping (Badr & Acitelli, 2017; Berg & Upchurch, 2007; Bodenmann, 2005; Regan et al., 2015; Revenson & DeLongis, 2011). These dyadic models move beyond an individualistic approach to illness to focus on the reciprocal and interactive ways spouses influence one another (i.e. partner effects). Concepts such as dyadic coping acknowledge the importance of active engagement and collaborative strategies for both members, with research suggesting that how couples cope and manage illness together can impact their psychological adjustment (Badr & Acitelli, 2005; Berg et al., 2008; Franks et al., 2012; Rottmann et al., 2015). The developmental-contextual model of couples coping with illness views the illness experience as an interdependent, interpersonal process (Berg & Upchurch, 2007). The model proposes that adjustment is an interplay of how the couple appraises and copes with the illness as a unit, in addition to developmental factors such as stage of disease. Dyadic coping is conceptualized as a continuum of spousal involvement (e.g. uninvolved, supportive, collaborative, and control) with active engagement or collaboration purported to lead to better adjustment through open communication, joint problemsolving and greater collaborative illness management. The majority of research examining the important role of dyadic coping and spousal involvement on couple adjustment is in such illness contexts as cancer and diabetes (Berg & Upchurch, 2007; Berg et al., 2008; Franks et al., 2012; Johnson et al., 2015; Khan, Stephens, Franks, Rook, & Salem, 2013; Schokker et al., 2011; Traa, DeVries, Bodenmann, & Den Oudsten, 2015), with far less evidence in the life-limiting context of heart failure (Coyne et al., 2001; Rohrbaugh, Mehl, Shoham, Reilly, & Ewy, 2008; Sebern & Riegel, 2009). HF research is still primarily focused on the adult with HF, with a relatively recent focus on the family member providing care and the importance of the dyadic relationship in HF (Agren, Evangelista, & Stromberg, 2010; Bidwell, Lyons, & Lee 2017; Buck et al., 2015; Hooker, Grigsby, Riegel, & Bekelman, 2015; Wingham et al., 2015). Although caregiving research and dyadic science are still emerging areas in HF, notable exceptions have examined the interdependent context of the HF couple using dyadic methodologies that explore both actor and partner effects (Chung et al., 2009; Vellone et al., 2014). A mix of qualitative and quantitative research has begun to examine collaborative illness management and communication within the HF couple and associations with better outcomes for both members of the couple (Lee, et al., 2015c; Retrum, Nowels, & Bekelman, 2013; Rohrbaugh et al., 2008; Sebern, Brown, & Flatley-Brennan, 2016), with evidence suggesting that behavioral indicators of collaboration (e.g. joint problem-solving, collaborative illness management, positive interactions) may play a relatively greater role than selfreported relationship indicators on long-term survival of the adult with HF (Rohrbaugh et al., 2006). Nevertheless, there is a dearth of knowledge regarding the role of spousal engagement and collaborative illness management on the psychological adjustment of the HF couple, creating clinical challenges on how to best support couples living with this complex, life-threatening condition. The current study is the first known study to examine the roles of engagement in HF management and consulting behaviors by both members of the couple and associations with depressive symptoms of the couple living with HF. Drawing upon the developmental-contextual model and the
concept of collaborative coping (Berg & Upchurch, 2007), we hypothesize that (1) greater engagement in the management of HF by one’s partner will be associated with lower depressive symptoms (controlling for one’s own level of engagement) and (2) couples with similar levels of engagement (i.e. greater collaboration) will experience lower levels of depressive symptoms. Stage of HF will be included as a key contextual covariate.
Method Participants and procedures Adults with HF and their spouse/partners were recruited from a HF clinic at a large academic health center in the U.S. Pacific Northwest. Adults with HF were required to be communitydwelling, have a confirmed diagnosis of HF for at least one year (including echocardiographic evidence and formal diagnosis by a cardiologist), and co-reside with a spouse/partner who was willing and eligible to participate. Couples were not required to be married or heterosexual. Adults with HF were not eligible if they were in receipt of a mechanical circulatory support device or transplantation, had an additional terminal condition or had moderate-severe cognitive impairment. Potential participants were initially identified by study cardiologists involved in the adult with HF’s care. Research staff, not involved in the adult with HF’s care, briefly described the study to couples who were interested and screened for eligibility. Adults with HF and their spouses, who were eligible and consented to be enrolled in the study, completed separate surveys. Of the initial 152 clinic patients identified as potential participants, 76 (50%) were eligible and interested (30% did not have an eligible spouse/partner; 3% were not interested in participating). Sixty four couples consented to be in the study, but only 60 couples had available data for the current analyses. The study was approved by the Institutional Review Board at Oregon Health and Science University.
Measures HF management behaviors Engagement in HF management behaviors was measured using the 6-item subscale of the Self-Care of Heart Failure Index v.6.2 (SCHFI) (Riegel, Lee, Dickson, & Carlson, 2009). Items capture recognition of HF symptoms and appropriate responses when they occur (e.g. taking an extra water pill, reducing salt in diet). Scores are standardized to 0–100 with higher scores indicating greater engagement in HF management behaviors. The subscale has demonstrated strong reliability and validity across HF populations (Barbaranelli, Lee, Vellone, & Riegel, 2014), as has the caregiver version (CCSCHFI) (Vellone et al., 2013). Cronbach’s alphas in the current sample were .71 for adults with HF and .80 for spouses. HF consulting behaviors Engagement in HF consulting behaviors was measured using the 4-item consulting behavior subscale of the European Heart Failure Self-Care Behavior Scale (EHFScB-9) (Jaarsma, Arestedt, Martensson, Dracup, & Stromberg, 2009). Items capture appropriate responses to HF symptoms when they occur, namely, to contact a provider and seek guidance (e.g. if my [my spouse’s] shortness of breath increases I contact my [her/ his] doctor or nurse). Response options range from 1
AGING & MENTAL HEALTH
(I completely agree) to 5 (I don’t agree at all) for a scale range of 4–20. Lower scores indicate greater engagement in appropriate consulting behaviors. The scale has demonstrated good reliability and validity (Jaarsma et al., 2009), including in the current sample (adults with HF = .84; spouses = .94).
Downloaded by [University of Essex] at 04:23 01 October 2017
Depressive symptoms Depressive symptoms were measured using the 9-item Patient Health Questionnaire (PHQ9) (Kroenke, Spitzer, & Williams, 2001). Based on the DSM-IV criteria for depression, the PHQ9 asks participants to respond to nine items on a 0 (not at all) to 3 (nearly every day) scale. Scores are summed with higher scores indicating greater depressive symptomatology. The scale has demonstrated strong reliability and validity evidence, including 88% sensitivity and specificity for major depression (score of 10 or greater) (Kroenke et al., 2001), with scores of 5 indicating mild depressive symptoms. Cronbach’s alphas in the current sample were .84 for adults with HF and .83 for spouses. Analysis plan Multilevel modeling was used to analyze data at the level of the couple . The model estimates a latent score for each member of the couple (i.e. one for the adult with HF and one for the spouse), controlling for the interdependencies in outcomes (Lyons & Sayer, 2005). Two dyadic models of depressive symptoms were tested using HLM 7 (one examining the role of HF management behaviors and one examining the role of HF consulting behaviors). An unconditional (i.e. no covariates) within-dyad model was first run to estimate the population averages of depressive symptoms within couples and to determine the variability in depressive symptoms across couples. This initial, unconditional model represented depressive symptoms for both adults with HF and their spouses as the sum of a latent score plus a residual term that captures measurement error. Next, two between-dyad models were run, each of which consisted of simultaneous regression equations for adults with HF and their spouses, adjusted for the effects of predictors in each equation (i.e. HF management behaviors or consulting behaviors). Each of these two between-dyad models allowed for the examination of actor (e.g. the role of adult with HF management behaviors on adult with HF depressive symptoms) and partner effects (e.g. the role of spouse HF consulting behaviors on adult with HF depressive symptoms), controlling for the interdependence in depressive symptoms within couples. HLM uses full information maximum likelihood estimation (FIMLE). A multi-parameter hypothesis test within HLM was used to test for differences between depressive symptoms of adults with HF and spouses. Additionally, we compared the fit of each conditional model with the unconditional model using a chi square deviance test, where degrees of freedom are the difference in number of model parameters. Finally, to determine the role of congruence (a within-dyad versus across-dyad effect) of HF management and consulting behaviors on depressive symptoms, we tested both models including a term that represented the interaction between the management (or consulting) behaviors of adults with HF and spouses. Interaction effects are reported only for those models where the effect was significant; otherwise main effects are reported.
3
Results Sample characteristics Couples were primarily White, had attended at least some college, and had been together, on average for almost 30 years (see Table 1). Spouses were significantly younger than adults with HF (p < .05). The majority of adults with HF were men (67%) and had been living with the illness, on average, almost seven years; almost three-quarters had a NYHA class of III/IV, indicting symptomatic and moderate-to-advanced HF. On average, adults with HF reported significantly higher engagement in management behaviors t(59) = 3.90, p < .001 than spouses; there were no significant differences between adults with HF and spouses in engagement in consulting behaviors.
Depressive symptoms Descriptive analysis revealed a total of 16 couples (27%) had both an adult with HF and a spouse experiencing mild-moderate depressive symptoms and 17 couples where neither member of the couple reported mild or greater levels of depressive symptomatology. Fixed effects results of an unconditional model found similar levels of average depressive symptoms to raw score data presented in Table 1. Depressive symptoms were 6.86, p < .001 for adults with HF and 4.13, p < .001 for spouses. A multi-parameter hypothesis test confirmed that adults with HF, on average, reported significantly higher levels of depressive symptoms than spouses (p < .01). Variance components for both adults with HF and their spouses indicated significant heterogeneity in depressive symptoms across couples.
Heart failure management behaviors Table 2 captures the effects of HF management behaviors on the depressive symptoms of adults with HF and their spouses. Greater engagement in management by the adult with HF was associated with lower depressive symptoms for spouses t (55) = ¡2.56, p < .05. Similarly, greater spousal engagement in management was associated with lower depressive symptoms for adults with HF t(55) = ¡2.18, p < .05. Importantly, the interaction between management behaviors by adults with HF and their spouses was associated with the depressive symptoms of spouses. As depicted in Figure 1 when adults with HF and spouses are similar in their level of engagement in HF management behaviors (high or low), there is a low level of depressive symptoms for spouses. Dissimilar levels of engagement in HF management behaviors had both positive Table 1. Adults with HF and spouse characteristics (N = 60 couples). Characteristic Adults with HF Spouses Age (years), mean (§SD) 59.45 (11.92) 57.75 (11.91)* Women (%) 33.3 66.7 Non-Hispanic White (%) 88.3 86.7 Attended some college (%) 79.7 78.3 Currently employed part/full-time (%) 18.3 40.0 a 73.3 – NYHA class III/IV (%) Years with heart failure, mean (§SD) 6.93 (5.19) – Years together, mean (§SD) 29.53 (16.56) – Heart failure management behaviors, 65.52 (21.83) 50.15 (27.99) mean (§SD) *** Heart failure consulting behaviors, mean 8.38 (4.13) 8.47 (5.19) (§SD) Depressive symptoms, mean (§SD) 6.85 (5.17) 4.04 (4.36)*** a New York Heart Association. *p < .05; **p < .01; ***p < .0.
4
K. S. LYONS ET AL.
Table 2. Multilevel models predicting adults with HF and spouse depressive symptoms. Adults with HF B (SE) t Effect size (r) B (SE) HF management behaviors Intercept 6.86 (1.33)*** Adults with HF management behaviors 0.04 (0.02) 1.74 Spouse management behaviors ¡0.05 (0.02)* ¡2.18 Adults with HF X spouse management ¡0.01 (0.00) ¡1.85 Behaviors 20.40 (8)* Model comparisona x2 (df) HF consulting behaviors Intercept 5.98 (1.22)*** Adults with HF consulting behaviors 0.19 (0.15) 1.27 Spouse consulting behaviors 0.33 (0.12)** 2.72 18.27 (6)** Model comparisona x2 (df)
Spouses t
Effect size (r)
.23 .28 .24
4.13 (0.87)*** ¡0.09 (0.04)* 0.02 (0.02) ¡0.01 (0.00)*
¡2.56 1.20 ¡2.25
.33 .16 .30
.17 .34
3.25 (1.03)** 0.38 (0.13)** ¡0.05 (0.11)
2.87 ¡0.49
.36 .07
a
Downloaded by [University of Essex] at 04:23 01 October 2017
Deviance statistics used to compare conditional model (i.e. with covariates) to unconditional (i.e. no covariates) model. Higher scores indicate more engagement in management behaviors; lower engagement in consulting behaviors. All models controlled for NYHA class (i.e. severity of HF). pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi B = unstandardized coefficient; effect size r ¼ t2 6 ðt 2 þ dfÞ. *p < .05; **p < .01; ***p < .001.
and negative associations with depressive symptoms, with highest levels of depressive symptoms reported by spouses that had higher levels of engagement than their partner with HF (controlling for severity of HF).
Heart failure consulting behaviors The engagement of adults with HF in consulting behaviors was significantly associated with spouse depressive symptoms t(56) = 2.87, p < .01. Further, spouse engagement in HF consulting behaviors was significantly associated with the depressive symptoms of adults with HF t(56) = 2.72, p < .01 (Table 2). In both cases, higher levels of engagement by one’s partner was significantly associated with lower levels of depressive symptoms for both members of the couple.
Discussion Little is known about how couples living with HF collaborate and work together to manage the salient symptoms that can lead to adverse consequences, including hospitalization, for the adult with HF. In particular, it is unknown if couples living with HF who engage in similar levels of HF management and consulting behaviors experience better psychological health than couples experiencing complementary levels of engagement. The current study is the first known study to examine congruent collaboration in engagement in HF care behaviors
Figure 1. Interaction of adult with HF management behaviors and spouse management behaviors as predictors of spouse depressive symptoms. High and low levels of HF management behaviors represent 1 SD above and below the mean, respectively.
within the couple and associations with the depressive symptoms of the couple. Several findings are noteworthy. First, adults with HF, on average, reported significantly higher levels of depressive symptoms than spouses. Second, approximately one quarter of the sample included couples where both members reported depressive symptoms that were mild or moderate. Third, controlling for one’s own level of engagement in HF care behaviors (i.e. management and consulting), higher levels of engagement by one’s partner were associated with lower levels of depressive symptoms for both members of the couple, supporting our first hypothesis. Fourth, results suggest that when couples engage in similar levels of HF management behaviors spouses experience lower depressive symptoms; spouses experience higher levels of depressive symptoms when they have high levels of engagement but their partner with HF has low engagement, providing partial support for our second hypothesis. Finally, effect sizes for partner effects and interaction effects were moderate. The current study builds upon previous research that has examined the important role of social support and, in particular marital quality in HF (Rohrbaugh et al., 2006). Not only do the current findings support the importance of the spouse’s engagement in managing the illness, but the dyadic approach in this study advances understanding of the transactional nature of HF management within the couple and supports the developmental-contextual model (Berg & Upchurch, 2007). In the case of both types of HF care behaviors (i.e. management and consulting behaviors), the engagement of one’s partner was significantly associated with lower depressive symptoms for both members of the couple. These unique partner effects (controlling for one’s own engagement) strongly support the need for a dyadic perspective of a lifethreatening condition where it may be common to reduce the couple to the individual roles of patient and caregiver. From a clinical perspective, the focus is often on the engagement in HF care behaviors of either the adult with HF or the spouse, as long as someone is engaged. The current findings, however, support the concepts of dyadic coping (Berg & Upchurch, 2007) in promoting better psychological heath and adjustment for the couple, in that, one’s partner’s engagement matters. Similarly, the current study examined the concept of congruence or collaborative engagement and found that spouses
Downloaded by [University of Essex] at 04:23 01 October 2017
AGING & MENTAL HEALTH
had lower levels of depressive symptoms when they and their partners with HF had similar levels of engagement in management behaviors (either high or low). When a spouse reported low levels of engagement, they experienced low levels of depressive symptoms, regardless of the engagement level of their partner with HF. Spouses experienced highest levels of depressive symptoms when they had high levels of engagement but their partner had low levels of engagement. Thus, the findings partially support our hypothesis that depressive symptoms would be lower when members of the couple had similar responses rather than complementary responses. The idea of congruence in response to illness has also been described by Revenson & DeLongis (2011). Given that spouses were primarily women, it is possible that this benefit to similar, more collaborative engagement may reflect the more relational self-construals and identities that women define themselves by, as compared to those of men (KiecoltGlaser & Newton, 2001). Research in cancer has shown that women, regardless of role, experience poorer psychological adjustment (Hagedoorn, Sanderman, Coyne, Bolks, & Tuinstra, 2008). It may be that women are also more influenced by levels of collaboration within the couple. Indeed, spouses experienced highest levels of depressive symptoms when they had a high level of engagement but their partner with HF had a low level of engagement. Although this may first appear to represent an adult with HF that may be unable to engage due to severity of disease, these findings controlled for stage of disease. Clearly, further work with larger, more gender-balanced samples is needed. Finally, just over one quarter of the couples in the sample had both members experiencing at least mild depressive symptoms. Not only does this reinforce the psychological strain that such a complex, highly variable and life-threatening condition places on both members of the couple, but also underscores the need for attention to the mental health of both members, particularly given the need for spouse engagement in the management of HF. Research suggests that family members with high levels of depressive symptoms may be less likely to be effective in providing care and managing illness (Coon, Thompson, Steffen, Sorocco, & GallagherThompson, 2003; Northouse, Katapodi, Song, Zhang, & Mood, 2010). Thus, careful screening and attention to both members of the couple living with HF are needed.
Limitations The study had several limitations. The sample size was relatively small, which limited the number of variables included in each model (though all models controlled for severity of HF). The sample size may also have attenuated the ability to uncover significant within-dyad interaction effects not found in the current study, particularly given the effect size found for the management behavior interaction on depressive symptoms for adults with HF. Replication is needed in larger samples; larger samples would also allow for more complex investigation of whether there are types of couples who benefit more from similar versus complementary responses. Replication is also needed in more gender-balanced and diverse samples to increase the generalizability of findings. Similarly, the current study was cross-sectional in design preventing an examination of directionality or change over time. More research is needed to understand the way couples living with HF manage the illness over time. In particular, how does
5
collaboration and dyadic coping evolve, if at all, with symptom severity, and what are the implications for couple wellbeing?
Strengths and implications Despite these limitations, the current study not only highlighted the need for a dyadic perspective of depressive symptoms within HF couples, but also greater attention to the transactional and collaborative nature of how couples may navigate and manage HF together. Findings suggest the important role a partner’s level of engagement can play, above and beyond one’s own engagement, as well as the potential importance of similar versus complementary levels of engagement. Given the salience of engagement in these HF care behaviors to prevent acute and adverse consequences for the adult with HF and the presence of depressive symptoms in both members of the HF couple, it may be beneficial for HF clinicians to reframe their approach from a more traditional, individual perspective that targets patient and caregiver with separate needs to a more dyadic perspective that views the couple as an interdependent unit with common goals of relational wellness and optimal quality of life. Facilitating and discussing such common goals and collaborative approaches within the clinical setting may be particularly fruitful. For example, encouraging the couple to take a teambased approach to engaging in HF health behaviors such as diet regulation and physical activity together, rather than something done solely by the adult with HF. Similarly, as has been called for in other illness contexts, there is a need to ensure assessment of depressive symptoms for both members of the HF couple (Moser et al., 2016). Couples facing a life-threatening illness such as HF can experience social constraints and levels of anxiety and fear that can impede communication and collaboration (Badr & Carmack Taylor, 2008; Zhang & Siminoff, 2003), undermining the supportive nature of the couple. Thus, greater attention to couples who may be struggling to engage in open communication or collaborative efforts, or spouses who may be experiencing depressive symptoms may be especially needed. This novel study has shed light on the need for a dyadic perspective of HF and goes beyond the role of spousal involvement to examine the potential implications of how couples manage the illness together. Greater focus is needed on how couples living with HF navigate and manage the illness over time, the roles of collaborative and congruent engagement in illness management, and the identification of types of couples who may benefit more or less from similar versus complementary responses. Such discoveries can help to address the clinical challenges of how best to support both members as they traverse such a daunting and often unpredictable journey together.
Disclosure statement The authors report no conflicts of interest.
Funding This research was supported by an innovations grant from the Oregon Health and Science University School of Nursing.
6
K. S. LYONS ET AL.
Downloaded by [University of Essex] at 04:23 01 October 2017
References Agren, S., Evangelista, L. S., & Stromberg, A. (2010). Do partners of patients with heart failure experience caregiver burden ? European Journal of Cardiovascular Nursing, 9, 254–262. Badr, H., & Acitelli, L. K. (2005). Dyadic adjustment in chronic illness: Does relationship talk matter ? Journal of Family Psychology, 19, 465–469. Badr, H., & Acitelli, L. K. (2017). Re-thinking dyadic coping in the context of chronic illness. Current Opinion in Psychology, 13, 44–48. doi:10.1016/j. copsyc.2016.03.001 Badr, H., & Carmack Taylor, C. L. (2008). Effects of relationship maintenance on psychological distress and dyadic adjustment among couples coping with lung cancer. Health Psychology, 27, 616–627. doi:10.1037/0278-6133.27.5.616 Barbaranelli, C., Lee, C. S., Vellone, E., & Riegel, B. (2014). Dimensionality and reliability of the self-care of heart failure index scales: Further evidence from confirmatory factor analysis. Research in Nursing & Health, 37, 524–537. doi:10.1002/nur.21623 Berg, C. A., & Upchurch, R. (2007). A developmental-contextual model of couples coping with chronic illness across the adult life span. Psychological Bulletin, 133, 920–954. doi:10.1037/0033-2909.133.6.920 Berg, C. A., Wiebe, D. J., Butner, J., Bloor, L., Bradstreet, C., Upchurch, R., … Patton, G. (2008). Collaborative coping and daily mood in couples dealing with prostate cancer. Psychology and Aging, 23, 505–516. doi:2008-13050-003 Bidwell, J. T., Lyons, K. S., & Lee, C. S. (2017). Caregiver well-being and patient outcomes in heart-failure: A meta-analysis. Journal of Cardiovascular Nursing, 32, 373-382. doi:10.1097/JCN.0000000000000350. Bodenmann, G. (2005). Dyadic coping and its significance for marital functioning. In T. A. Revenson, K. Kayser, & G. Bodenmann (Eds.), Couples coping with stress: Emerging perspectives on dyadic coping (pp. 33–50). Washington, DC: American Psychological Association. Buck, H. G., Harkness, K., Wion, R., Carroll, S. L., Cosman, T., Kaasalainen, S., … Arthur, H. M. (2015). Caregivers’ contributions to heart failure selfcare: A systematic review. European Journal of Cardiovascular Nursing, 14, 79–89. Chung, M. L., Moser, D. K., Lennie, T. A., & Rayens, M. K. (2009). The effects of depressive symptoms and anxiety on quality of life in patients with heart failure and their spouses: Testing dyadic dynamics using actorpartner interdependence model. Journal of Psychosomatic Research, 67, 29–35. doi:10.1016/j/jpsychores.2009.01.009 Coon, D. W., Thompson, L., Steffen, A., Sorocco, K., & Gallagher-Thompson, D. (2003). Anger and depression management: Psychoeducational skill training interventions for women caregivers of a relative with dementia. The Gerontologist, 43, 678–689. Coyne, J. C., Rohrbaugh, M. J., Shoham, V., Sonnega, J., Nicklas, J. M., & Cranford, J. A. (2001). Prognostic importance of marital quality for survival of congestive heart failure. American Journal of Cardiology, 88, 526–529. Franks, M. M., Sahin, Z. S., Seidel, A. J., Shields, C. G., Oates, S. K., & Boushey, C. J. (2012). Table for two: Diabetes distress and diet-related interactions of married patients with diabetes and their spouses. Families, Systems, & Health, 30, 154–165. doi:10.1037/a0028614 Freedland, K. E., Hesseler, M. J., Carney, R. M., Steinmeyer, B. C., Skala, J. A., Davila-Roman, V. G., & Rich, M. W. (2016). Major depression and longterm survival of patients with heart failure. Psychosomatic Medicine, 78, 896–903. doi:10.1097/PSY.0000000000000346 Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Borden, W. B., … Turner, M. B. (2013). Heart disease and stroke statistics–2013 update: A report from the American Heart Association. Circulation, 127, e6–e245. doi:10.1161/CIR.0b013e31828124ad Hagedoorn, M., Sanderman, R., Coyne, J. C., Bolks, H. N., & Tuinstra, J. (2008). Distress in couples coping with cancer: A meta-analysis and critical review of role and gender effects. Psychological Bulletin, 134, 1– 30. doi:10.1037/0033-2909.134.1.1 Hooker, S. A., Grigsby, M. E., Riegel, B., & Bekelman, D. B. (2015). The impact of relationship quality on health-related outcomes in heart failure patients and informal family caregivers: An integrative review. Journal of Cardiovascular Nursing, 30(4 Suppl. 1), S52–S63. Hooley, P. J. D., Butler, G., & Howlett, J. G. (2005). The relationship of quality of life, depression, and caregiver burden in outpatients with congestive heart failure. Congestive Heart Failure, 11, 303–310. Hwang, B., Moser, D. K., & Dracup, K. (2014). Knowledge is insufficient for self-care among heart failure patients with psychological distress. Health Psychology, 33, 588–596. doi:10.1037/a0033419
Jaarsma, T., Arestedt, K., Martensson, J., Dracup, K., & Stromberg, A. (2009). The European Heart Failure Self-Care Behavior scale revised into a nine-item scale (EHFScB-9): A reliable and valid international instrument. European Journal of Heart Failure, 11, 99–105. doi:10.1093/ eurjhf/hfn007 Jaarsma, T., Stromberg, A., Ben Gal, T., Cameron, J., Driscoll, A., Duengen, H. D., … Huang, T. Y. (2013). Comparison of self-care behaviors of heart failure patients in 15 countries world-wide. Patient Education and Counseling, 92, 114–120. Jiang, W., Alexander, J., Christopher, E., Kuchibhatla, M., Gaulden, L. H., Cuffe, M. S., … O’ Conner, C. M. (2001). Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Archives of Internal Medicine, 161, 1849–1856. Johnson, M. D., Anderson, J. R., Walker, A., Wilcox, A., Lewis, V. L., & Robbins, D. C. (2015). Spousal overprotection is indirectly associated with poorer dietary adherence for patients with type 2 diabetes via diabetes distress when active engagement is low. British Journal of Health Psychology, 20, 360–373. doi:10.1111/bjhp.12105 Khan, C. M., Stephens, M. A. P., Franks, M. M., Rook, K. S., & Salem, J. K. (2013). Influences of spousal support and control on diabetes management through physical activity. Health Psychology, 32, 739–747. doi:10.1037/a0028609 Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472–503. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. doi:jgi01114 [pii] Lee, C. S., Gelow, J. M., Mudd, J. O., Green, J. K., Hiatt, S. O., Chien, C., & Riegel, B. (2015 a). Profiles of self-care management versus consulting behaviors in adults in heart failure. European Journal of Cardiovascular Nursing, 14, 63–72. doi:10.1177/1474515113519188 Lee, C. S., Moser, D. K., Lennie, T. A., & Riegel, B. (2011). Event-free survival in adults with heart failure who engage in self-care management. Heart & Lung, 40, 12–20. Lee, C. S., Mudd, J. O., Hiatt, S. O., Gelow, J. M., Chien, C., & Riegel, B. (2015 b). Trajectories of heart failure self-care management and changes in quality of life. European Journal of Cardiovascular Nursing, 14, 486–494. doi:10.1177/1474515114541730 Lee, C. S., Vellone, E., Lyons, K. S., Cocchieri, A., Bidwell, J. T., D’ Agostino, F., … Riegel, B. (2015 c). Patterns and predictors of patient and caregiver engagement in heart failure care: A multi-level dyadic study. International Journal of Nursing Studies, 52, 588–597. doi:10.1016/j. ijnurstu.2014.11.005 Lyons, K. S., & Sayer, A. G. (2005). Longitudinal dyad models in family research. Journal of Marriage and Family, 67, 1048–1060. Manne, S., Badr, H., Zaider, T., Nelson, C., & Kissane, D. (2010). Cancerrelated communication, relationship intimacy, and psychological distress among couples coping with localized prostate cancer. Journal of Cancer Survivorship, 4, 74–85. Moser, D. K., Arslanian-Engoren, C., Biddle, M. J., Chung, M. L., Dekker, R. L., Hammash, M. H., … Lennie, T. A. (2016). Psychological aspects of heart failure. Current Cardiology Reports, 18, 119. Northouse, L. L., Katapodi, M. C., Song, L., Zhang, L., & Mood, D. W. (2010). Interventions with family caregivers of cancer patients: A meta-analysis of randomized trials. CA: A Cancer Journal for Clinicians, 60, 317–339. Pihl, E., Jacobsson, A., Fridlund, B., Stromberg, A., & Martensson, J. (2005). Depression and health-related quality of life in elderly patients suffering from heart failure and their spouses: A comparative study. European Journal of Heart Failure, 7, 583–589. doi:10.1016/j.ejheart.2004.07.016 Regan, T. W., Lambert, S. D., Kelly, B., Falconier, M., Kissane, D., & Levesque, J. V. (2015). Couples coping with cancer: Exploration of theoretical frameworks from dyadic studies. Psycho-oncology, 24, 1605–1617. Retrum, J. H., Nowels, C. T., & Bekelman, D. B. (2013). Patient and caregiver congruence: The importance of dyads in heart failure care. Journal of Cardiovascular Nursing, 28, 129–136. doi:10.1097/JCN.0b013e3182435f27 Revenson, T. A. (2003). Scenes from a marriage: Examining support, coping, and gender within the context of chronic illness. In J. Suls & K. A. Wallston (Eds.), Social psychological foundations of health and illness (pp. 530–559). Malden, MA: Blackwell Publishing. Revenson, T. A., & DeLongis, A. (2011). Couples coping with chronic illness. In S. Folkman (Ed.), The Oxford handbook of stress, health, and coping (pp. 101–123). New York, NY: Oxford University Press. Revenson, T. A., & Kayser, K., & Bodenmann, G. (2005). Couples coping with stress: Emerging perspectives on dyadic coping. Washington, DC: American Psychological Association.
Downloaded by [University of Essex] at 04:23 01 October 2017
AGING & MENTAL HEALTH
Riegel, B., Lee, C. S., Dickson, V. V., & Carlson, B. (2009). An update on the self-care of heart failure index. Journal of Cardiovascular Nursing, 24, 485–497. doi:10.1097/JCN.0b013e3181b4baa0 Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., … Whellan, D. J. (2009). State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation, 120, 1141–1163. doi:10.1161/ CIRCULATIONAHA.109.192628 Robbins, M. L., Lopez, A. M., Weihs, K. L., & Mehl, M. R. (2014). Cancer conversations in context: Naturalistic observation of couples coping with breast cancer. Journal of Family Psychology, 28, 380–390. doi:10.1037/ a0036458 Roger, V. L., Weston, S. A., Redfield, M. M., Hellermann-Homan, J. P., Killian, J., Yawn, B. P., & Jacobsen, S. J. (2004). Trends in heart failure incidence and survival in a community-based population. JAMA, 292(3), 344–350. Rohrbaugh, M. J., Cranford, J. A., Shoham, V., Nicklas, J. M., Sonnega, J. S., & Coyne J. C. (2002). Couples coping with congestive heart failure: Role and gender differences in psychological distress. Journal of Family Psychology, 16, 3–13. Rohrbaugh, M. J., Mehl, M. R., Shoham, V., Reilly, E. S., & Ewy, G. A. (2008). Prognostic significance of spouse we talk in couples coping with heart failure. Journal of Consulting and Clinical Psychology, 76, 781–789. doi:10.1037/a0013238 Rohrbaugh, M. J., Shoham, V., & Coyne, J. C. (2006). Effect of marital quality on eight-year survival of patients with heart failure. American Journal of Cardiology, 98, 1069–1072. Ross, J. S., Chen, J., Lin, Z., Bueno, H., Curtis, J. P., Keenan, P. S., & Krumholz, H. M. (2010). Recent national trends in readmission rates after heart failure hospitalization. Circulation: Heart Failure, 3, 97–103. doi:10.1161/CIRCHEARTFAILURE.109.885210 Rottmann, N., Hansen, D. G., Larsen, P. V., Niicolaisen, A., Flyger, H., Johansen, C., & Hagedoorn, M. (2015). Dyadic coping within couples dealing with breast cancer: A longitudinal, population-based study. Health Psychology, 34, 486–495. doi:10.1037/hea0000218 Rutledge, T., Reis, V. A., Linke, S. E., Greenberg, B. H., & Mills, P. J. (2006). Depression in heart failure: A meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. Journal of American College of Cardiology, 48, 1527–1537. doi:10.1016/j. jacc.2006.06.055 Schokker, M. C., Links, T. P., Bouma, J., Keers, J. C., Sanderman, R., Wolffenbuttel, B. H. R., & Hagedoorn, M. (2011). The role of overprotection by
7
the partner in coping with diabetes: A moderated mediation model. Psychology and Health, 26, 95–111. doi:10.1080/08870440903342325 Sebern, M., & Riegel, B. (2009). Contributions of supportive relationships to heart failure self-care. European Journal of Cardiovascular Nursing, 8, 97–104. doi:10.1016/j/ejcnurse.2008.07.004 Sebern, M., Brown, R., & Flatley-Brennan, P. (2016). Shared care contributions to self-care and quality of life in chronic cardiac patients. Western Journal of Nursing Research, 38, 837–857. doi:10.1177/ 0193945915626877 Song, L., Northouse, L. L., Braun, T. M., Cimprich, B., Ronis, D. L., & Mood, D. W. (2012). Study of dyadic communication in couples managing prostate cancer: A longitudinal perspective. Psycho-oncology, 21, 72–81. doi:10.1002/pon.1861 Traa, M. J., DeVries, J., Bodenmann, G., & Den Oudsten, B. L. (2015). Dyadic coping and relationship functioning in couples coping with cancer: A systematic review. British Journal of Health Psychology, 20, 85–114. doi:10.1111/bjhp.12094 Vellone, E., Chung, M. L., Cocchieri, A., Rocco, G., Alvaro, R., & Riegel, B. (2014). Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: Testing dyadic dynamics using the actorpartner interdependence model. Journal of Family Nursing, 20, 120– 141. Vellone, E., Riegel, B., Cocchieri, A., Barbaranelli, C., D’Agostino, F., Glaser, D., … Alvaro, R. (2013). Validity and reliability of the caregiver contribution to self-care of heart failure index. Journal of Cardiovascular Nursing, 28(3), 245–255. doi:10.1097/JCN.0b013e318256385e Westlake, C., Dracup, K., Fonarow, G. C., & Hamilton, M. (2005). Depression in patients with heart failure. Journal of Cardiac Failure, 11, 30–35. Wingham, J., Frost, J., Britten, N., Jolly, K., Greaves, C., Abraham, C., & Dalal, H. (2015). Needs of caregivers in heart failure management: A qualitative study. Chronic Illness, 11, 304–319. doi:10.1177/ 1742395315574765 World Health Organization. (2016). Chronic diseases. Retrieved fromhttp:// www.who.int/topics/chronic_diseases/factsheets/en/ Wu, J., Frazier, S. K., Rayens, M. K., Lennie, T. A., Chung, M. L., & Moser, D. K. (2013). Medication adherence, social support, and event-free survival in patients with heart failure. Health Psychology, 32, 637–646. doi:10.1037/a0028527 Zhang, A. Y., & Siminoff, L. A. (2003). Silence and cancer: Why do families and patients fail to communicate ? Health Communication, 15, 415– 429.
