Abstract
Aim: Interaction of patient in marital dyad may have bearing on long-term patient outcome. Depression, subjective stress, and marital discord have been reported in healthy spouses of patients with end-stage renal disease (ESRD). Depressed patients on dialysis along with their spouses can function as depressed dyad. We looked at the incidence and factors associated with depression and marital stress among Indian hemodialysis patients and their spouses. Methods: A total of 49 (32 males, 17 females) patients on maintenance hemodialysis and their spouses were independently administered Beck Depression Inventory (BDI), Revised Dyadic Adjustment Scale, and self-rated subjective quality-of-life scale. Their demographic parameters, socioeconomic status, and type of family (nuclear or joint) were also noted. Results: About 57.1% of patients were depressed compared with 42.8% of spouses (p = 0.133). In both patients and spouses, BDI correlated with quality of life and perceived marital stress. About 36.7% of patients and 24.4% of spouses reported marital stress (p = 0.69). Male spouses had more marital stress compared with female spouses (p < 0.0001). Depression and marital stress in patients and spouses was not associated with socioeconomic status, literacy levels, and employment. Depression in patients had direct correlation with depression in spouse (r = 0.572, p < 0.0001) and degree of marital dissatisfaction in spouse (r = 0.623, p < 0.0001). Patients living in nuclear family were more depressed and had more marital stress. Conclusion: Married ESRD patients and their spouses function as a complex psychosocial dyad with significant two-way interactions. Social support, as is seen in joint families, leads to significantly lesser depression and better marital understanding.
INTRODUCTION
Patients with end-stage renal disease (ESRD) are subject to a variety of psychological disorders. This could be related to several factors like financial strain, feeling of loss of role both at home and workplace, and restriction in lifestyle. Depression is the most common psychiatric illness in patients with ESRD.Citation1 In fact, depression has even been noted in patients being initiated on dialysis. A recent study from the United States found that 44% of patients being initiated on dialysis have at least borderline depression.Citation2 Depression has been inversely correlated with quality of life (QOL),Citation3–5 with Steele et al.Citation6 reporting depression to be a stronger co-relate of QOL than even dialysis adequacy. Depression, loss of role, and marital strain perceived by patient can contribute as a trigger for depressive effect on spouse. Also, due to increasing dependency of these patients, the spouse of these patients can feel isolation, loss of social activity, increased workload, and negative economic consequences.Citation7 These couples have also been reported to have higher incidence of depression, difficulty with sexual adjustments, and perception of decreased intimacy along with communication problems.Citation8 Since individual adjustments take place in context of marital dyad, non-patient spouse’s emotional distress and marital dissatisfaction may impact these adjustments in patient as well. Also for patients involved in dyadic relationship, dyadic conflict may be critical in not only perception of well being of patient but also his or her ability to adhere to a complex medical regimen or adapt to a stressful condition.Citation3
Only few studies have looked at the relationship of depression and marital conflict with QOL and outcome among dialysis patients. A study from the United States looking at marital discord among predominantly Afro-American patients on maintenance hemodialysis noted that the perception of dyadic conflict was associated with 46% increase in relative risk of death.Citation3 Also, the effect of spousal response on patient’s perception of disease and psychosocial adjustments and vice versa has been scarcely evaluated. In one such study, it was seen that spouses of patients with higher depression scores were more depressed than spouses of patients with lower depression scores.Citation8 Further authors found a significant negative correlation between extent of spousal depressive symptoms and spousal marital satisfaction. All these complex adjustments in the marital dyad occur in the context of larger social subsystems, and therefore the social support to these couples can influence their psychosocial status and level of adjustment. Each society has its own set of unique socioeconomic features, which can positively or adversely affect the persons’ psychological state and response to stress. This study was undertaken to look at the incidence and degree of depression, marital dissatisfaction, and QOL among Indian ESRD patients and their spouses and to assess patient, spousal, and social factors that contribute to depression and marital dissatisfaction among these patients and their spouses.
METHODS
The study was carried out in an urban state-run tertiary care hospital in northern India among couples who were staying together for >1 year and in whom one partner was on maintenance hemodialysis for ≥3 months. Patients, who were diabetic, had coronary artery disease, hepatitis B and C infections, and those who had been treated with interferon, antidepressants, and steroids were excluded. Couples whose spouses were on antidepressants or had any chronic illness were also excluded from the study. Sixty-eight patients were screened by convenience sampling. Eleven patients were excluded due to associated co-morbidities (five had diabetes, two had hepatitis C infection, and four had coronary artery disease). Eight couples were further excluded (three spouses had diabetes, two refused consent, and three couples were not currently staying together). Finally, 49 couples were enrolled. Demographic and medical profile of study population was representative of the dialysis population at our center. Patients themselves filled the entire questionnaires or it was read out to them in case of poor vision or if they were illiterate. Ethical clearance was obtained from the ethics committee of the institute and all the related consent was obtained.
MEASURES
Depression
Beck Depression Inventory (BDI) is a well-validated tool to assess depression in patients on dialysis and ESRD.Citation1,9 It is a 21-item questionnaire, which deals with both the emotional and somatic aspects of depression. The questions are presented in a four-point Likert scale wherein 0 represents absence of problem and 3 represents extreme problem, with total scores ranging from 0 to 63. We used a cutoff of 15 to diagnose mild to moderate depression and a cutoff greater than 29 to diagnose severe depression.
Marital Satisfaction
Revised Dyadic Adjustment Scale (RDAS) is a self-reporting measure for use in married and cohabiting couples to measure relationship satisfaction and adjustment. It contains 14 items on a Likert scale ranging from 0 to 5 with a total score ranging from 0 to 70.Citation10 It has three subscales: dyadic consensus scale, dyadic satisfaction scale, and dyadic cohesion scale. Previous studies that evaluated marital dissatisfaction among couples in which one partner had ESRD traditionally used the Dyadic Adjustment Scale (DAS).Citation3,8 DAS is a multidimensional scale with four subscales. Two of its subscales, dyadic satisfaction subscale and affectional expression subscale, have been shown to be problematic.Citation11,12 Further, the basic scale was tested on separated and divorced individuals rather than distressed/non-distressed couples. RDAS is an improvement over DAS and has an acceptable level of construct and validity. It correlates well with DAS and is successful in discriminating between distressed and non-distressed couples. Finally its subscales have adequate internal consistency and excellent split-half reliability coefficients.Citation10 We used value ≥40 as indicator of marital strain.
Assessment of Socioeconomic Status
Kuppuswamy Urban Index is an indicator of the socioeconomic status of urban Indian residents. The scale is based on three subscales: education, occupation, and family income. The sum of the three subscales reflects the overall socioeconomic status. Based on the scale, couples are divided into poor, lower-middle, middle, upper-middle, and rich classes. However, for the sake of convenience, the poor and the lower-middle classes were clubbed together and the upper-middle and rich classes were clubbed together. The scale is well validated in Indian set up and has been used before.Citation13,14
Quality of Life
A simple rating of QOL was performed: patients were asked how they rated their QOL along a five-category Likert scale from poor to excellent. The scale although subjective has been used previously to assess the QOL in ESRD patients and gives a fair judgment as it is based on the patient’s own personal assessment.Citation2,15
Social Support
Couples were divided into those having a nuclear family or joint family. The concept of joint family in which more than one family shares the same kitchen is not unusual in India, and joint families are believed to have stronger ties and social support system.Citation16
PROCEDURE
After taking consent, patient and spouse were interviewed in two separate rooms by the same interviewer. Both were given the pro forma for the BDI and the revised-DAS. They were also asked to rate their QOL on a five-point Likert scale. Other details regarding patient and spouse were filled in predesigned pro forma. Finally, they were made to sit together and the Kuppuswamy socioeconomic scale was calculated.
STATISTICS
Statistical analysis was performed on SPSS version 15.0 (SPSS, Inc., Chicago, IL, USA). Data are presented as mean ± standard deviation wherever applicable (mean ± SD). Comparisons between patient and spouses and between male and female spouses were made using the t-test. t-Test was also used to compare patients and spouses who were depressed and had marital stress compared with those who were not depressed and had no marital stress. Similarly comparison between the patients living in nuclear family versus joint family was made using the t-test. Correlations were assessed using Pearson’s correlation coefficient. Besides this, individual stepwise multiple regression analysis was applied for finding predictors of depression and degree of marital dissatisfaction in patients and spouses by including in individual model all the variables having significance of <0.05. A p-value of <0.05 was considered significant.
RESULTS
Forty-nine couples were enrolled for the study. There were 32 male patients and 17 female patients with corresponding number of spouses. The mean age of patients was 43.7 ± 11.4 years with average duration of illness and dialysis being 40.4 ± 36.9 and 14.1 ± 10.6 months, respectively. There were no differences observed between the mean age, hemoglobin concentrations, serum albumin levels, and duration of illness between male and female patients (). The reported incidence of depression was 57.1% (28 patients, of which 6 had severe depression) and mean BDI score was 16.6 ± 11.4. Self-reported QOL score averaged 2.6 ± 1.1. Marital stress as assessed by RDAS was present in 36.7% patients with average score of 26.7 ± 17.5. Among all the subscales of RDAS, the satisfaction subscale was most affected. Also, female patients were found to be more depressed than males but had similar QOL and equal degree of marital strain (). Depressed patients had a significantly higher RDAS scores and poorer QOL compared with nondepressed patients. Similarly, patients having marital stress also had higher BDI scores compared with those who did not have marital stress ().
Table 1. Baseline and study parameters in maintenance hemodialysis patients.
Table 2. Comparison of study parameters with patients’ means of score for Beck Depression Inventory and Revised Dyadic Adjustment Scale study.
The mean age of spouse was 41.9 ± 12.5 years, with average duration of marriage being 9.4 ± 1.2 years. About 44.9% of spouses were employed. Mean BDI scores were 12.8 ± 9.8, with reported incidence of depression being 42.8% (21 spouses, of which 3 had severe depression). The reported QOL score averaged 2.8 ± 1.2. Mean RDAS scores were 25.3 ± 16.2 with marital stress being reported in 24.4% spouses. Among all the subscales of RDAS, the cohesion subscale was most affected. Male spouses of female patients reported more marital stress compared with female spouses of male patients (RDAS scores of 28.6 ± 17.7 and 19.4 ± 13.6, respectively, p = 0.04), although they were equally depressed and there was no difference in their perceived QOL (). Depressed spouses had significantly higher RDAS scores and poorer QOL compared with nondepressed spouses. Similarly, spouses who had marital stress also had significantly higher BDI scores and lower reported QOL when compared to those spouses who did not had marital stress (). On comparing patients with ESRD with their spouses, we found no significant difference in reported incidence and severity of depression, QOL, and marital stress.
Table 3. Baseline and study parameters in spouses of maintenance hemodialysis patients.
Table 4. Comparison of study parameters with spouses’ means of score for Beck Depression Inventory and Revised Dyadic Adjustment Scale.
Patients living in joint families had lower BDI scores, higher QOL, and lower marital stress (p < 0.01 for all) compared with those living in nuclear families ().
On Pearson’s correlation, patients’ BDI scores correlated positively with spouses’ BDI and RDAS scores and negatively with serum albumin and their perceived QOL. Whereas patients’ RDAS scores correlated positively with spouses’ BDI and RDAS scores and negatively with socioeconomic status. When individual stepwise multiple regression analysis was applied including in model all variables having significance, patients’ BDI score correlated with spousal BDI and RDAS scores (r = 0.572 and 0.623, respectively, p < 0.01 for both) and QOL (r = −0.56 p < 0.01), while RDAS score correlated with spousal BDI and RDAS scores (r = 0.668 and 0.76, respectively, p < 0.01 for both). BDI scores in spouses correlated negatively with their perceived QOL and positively with their RDAS scores besides patients’ BDI and RDAS scores. While spouses’ RDAS scores correlated negatively with their QOL, besides their BDI scores and patients’ BDI and RDAS scores. On similar stepwise multiple regression analysis, spouses’ BDI and RDAS scores correlated significantly with each other (r = 0.885, p < 0.001), their QOL (r = −0.563 and −0.574, respectively), besides patients’ BDI and RDAS scores (). Our results therefore indicate that spouses less happy with their marriages were more depressed and this correlated with more depression and marital stress among patients.
DISCUSSION
Psychosocial variables like depression, social support, and patient’s perception of QOL and well being are underestimated, but are an important concern in dialysis patients as they are related to the outcome of these patients.Citation4,17,18 In this study, for the first time, we have looked at depression, QOL, and marital stress in patients of ESRD and their spouses in the Indian subcontinent through face-to-face interview and RDAS. We have also excluded common comorbidities like diabetes and cardiovascular diseases in patients and any chronic illness in spouses to see the independent effect of ESRD on these parameters. We found that majority of our patients were depressed and significant patients (36.7%) reported marital dissatisfaction. In these patients, higher BDI scores had a negative impact on their perceived QOL and were associated with higher degree of marital stress. We also noted similar level of depression and perception of marital conflict in spouses of these patients. The incidence of marital strain in our patients is much less than that reported from a study in the United States.Citation8 This could be due to difference in patient profile and exclusion of patients with comorbidities, besides differences in dyadic adjustments in different socioeconomic environment. We also found that depressed spouses reported more marital stress. It is therefore important for the physicians to not assume spouses as providers of natural support without making an assessment of the same.
Table 5. Comparison of patients living in nuclear family with those living in joint family.
Table 6. Pearson’s correlation coefficient between various factors between spouse and patient (paired t-test).
Also the patient’s depressive affect correlated with spousal depression and marital stress. These findings confirm that couples with one spouse having ESRD with depression should be viewed as a depressive dyad. Our results are in accordance with previous few studies,Citation8,19 although one of these studiesCitation19 did not examine the psychological status of patients and spouses in relation to other variables. It has been suggested that the adjustment of both partners in this dyad is interdependentCitation20,21 and therefore the depressive status of patient can bring about changes in the psychological status of healthy spouses.
Social support refers to a social network’s provision of psychological and material resources intended to benefit an individual’s capacity to cope with stress.Citation22 Social support may improve outcomes in chronic diseases by increased compliance and access to healthcare, improvements in nutritional status, overall QOL, and modulation of immune system.Citation22 Several studies among different ethnic groups in dialysis patients have shown a negative relationship between patients’ perceived social support and survival. Kimmel et al.Citation18 showed that an increased perception of social support in dialysis patients predicted their survival even after adjusting for age, comorbid illness, serum albumin, and type of dialysis membrane. Traditionally, a multidimensional scale of perceived social support has been used to assess the social support system in patients of chronic renal diseaseCitation8,18,23,24; this scale measures perceived social support from friends, family, and a confidant. In Asian and African countries, more people live in joint families compared with the Europeans and Americans. People living in joint families are believed to have stronger social ties and support system.Citation16 We found that patients living in joint families were less depressed and reported higher QOL. Although not using the scale is a limitation of our study, we believe that a simple classification of family into nuclear and joint gives a fair idea of the available support network especially in India.
Although there was no difference in the mean BDI scores between the male and female spouses, male spouses were noted to have significantly more marital stress. This is in accordance with a study from Israel in which the authors also noted higher distress among male spouses compared with female spouses.Citation25 This supports the hypothesis of “nurturing role” of females.Citation26 If the woman is ill and her role as a nurturer is reduced, it translates into more severe social-psychological dysfunction in healthy husbands. It could also be that social support might be different for male or female patient with ESRD. In a Canadian study, it was noted that among couples in which woman developed ESRD, family support declined while no perceived change in the social support was noted for the male ESRD patients,Citation27 thus contributing to greater marital distress in male spouses of female patients. Although we have not assessed the same formally, we believe a similar trend might be there in the Indian society.
Our study however has a few limitations. Since ours is a predominantly transplant-oriented center, the patients undergoing dialysis are predominantly male, are younger, and have shorter duration of dialysis. Therefore, the results might not be representative of all the dialysis patients in our country. However, the high incidence of depression and marital conflict found even in these patients would suggest that the problem would only be magnified in the overall dialysis population. Second, although the demographic and medical profile of the study population was representative of the dialysis population at our center, convenience sampling used may lead to bias as the final sample may not be typical of the population. Also the cross-sectional design of the study and small patient numbers limits the establishment of cause–effect relationship between the study parameters, which highlights the need for multi-centric longitudinal studies.
To conclude, married patients and their spouses function in a complex psychosocial dyad with significant two-way interactions. Spouses should not be assumed by the healthcare professionals to always be able to provide a natural support to the patients as they may also have significant degree of depression and marital stress. Conjoint therapy of patient and the spouses appears more meaningful wherein the simultaneous assessment of various psychosocial factors should be undertaken. Also appropriate measures should be taken by social welfare agencies to enhance the social support system of these families, especially in patients living in depressed dyad. Future studies are needed to clarify the role of gender differences in the adaptation of spouses to patient’s chronic disease and the role of intervention in spouses of patients with ESRD on long-term patient outcome.
ACKNOWLEDGMENT
We acknowledge the help provided by Dr. Guresh Kumar, Department of Biostatistics, All India Institute of Medical Sciences.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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