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Psychosomatic Medicine 66:527-532 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Role of Spousal Anxiety and Depression in Patients’ Psychosocial Recovery After a Cardiac Event

Debra K. Moser, RN, DNSc and Kathleen Dracup, RN, DNSc

From the College of Nursing, University of Kentucky (D.K.M.), Lexington, KY; and School of Nursing, University of California, San Francisco (K.D.), San Francisco, CA.

Address correspondence and reprint requests to Debra K. Moser, RN, DNSc, Professor and Gill Chair of Cardiovascular Nursing, College of Nursing, University of Kentucky, Lexington, KY 40536-0232. E-mail: dmoser{at}email.uky.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: The purposes of this study were to a) compare emotional responses and perception of control of patients and their spouses to myocardial infarction or coronary revascularization; and b) examine the relationship between spouses’ emotional distress and patients’ emotional distress and psychosocial adjustment to the cardiac event.

METHODS: A total of 417 patient–spouse pairs were recruited after the patient was hospitalized for either acute myocardial infarction or coronary revascularization. We compared emotional responses of patients and spouses. The relationship between spouse anxiety and depression, and patient psychosocial distress was then determined.

RESULTS: Spouses had higher levels of anxiety (p < .001) and depression (p < .001) than did patients, but there were no differences in level of hostility. Patients also expressed higher levels of perceived control than did spouses (p < .001). Spouse anxiety, depression, and perceived control remained correlated with patient psychosocial adjustment to illness, even when patient anxiety and depression were kept constant. Patients’ psychosocial adjustment to illness was worse when spouses were more anxious or depressed than patients, and it was best when patients were more anxious or depressed than spouses, whereas psychosocial adjustment to illness was intermediate to these 2 extremes when patient and spouse anxiety and depression levels were similar (p = .001).

CONCLUSION: Spouses often experience greater anxiety and depression and less perceived control than patients themselves. Attention to the psychological distress experienced by spouses of patients who have suffered a cardiac event may improve outcomes in patients.

Key Words: anxiety, • depression, • acute myocardial infarction, • psychosocial distress.

Abbreviations: AMI = acute myocardial infarction;; MAACL = Multiple Affect Adjective Check List;; NYHA = New York Heart Association;; PAIS = The Psychosocial Adjustment to Illness Scale.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
In patients with ischemic heart disease, anxiety and depression are predictive of adverse short- and long-term outcomes (1–7). Patients who have anxiety or depression during hospital admission are at increased risk for higher rates of in-hospital complications such as recurrent ischemia, re-infarction, and malignant arrhythmias (8). They also suffer higher mortality and reinfarction rates months to years after their initial cardiac event (2,6). Thus, it is important to determine those factors that contribute to patients’ psychological distress and intervene when possible.

A patient’s spouse is thought to be key in preventing or reducing the psychological distress that accompanies a cardiac event such as acute myocardial infarction (AMI) or cardiac surgery. In fact, many investigators and clinicians have suggested that successful recovery after a cardiac event and adaptation to living with a chronic condition may depend as much on positive support from a patient’s spouse as on patients’ own coping resources (9–15). Another variable implicated in psychosocial recovery is perceived control. Patients and spouses with higher levels of perceived control during patients’ recovery from an acute cardiac event report better psychosocial outcomes (16,17).

To date, few investigators have studied the impact of spouses’ emotional distress on cardiac patients’ psychosocial status. Thus, we conducted a study to a) compare emotional responses and perception of control of patients and their spouses in response to myocardial infarction or coronary revascularization; and b) examine the relationships between spouses’ emotional distress and patients’ emotional distress and psychosocial adjustment to the cardiac event.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
This study was conducted using a comparative design in which the emotional responses of patients and spouse were compared. The relationship between spouse anxiety and depression, and patient psychosocial distress was then determined. Patient–spouse pairs were recruited into this study after the patient experienced a hospitalization for either AMI or coronary revascularization. Data were collected from both members of the pair.

Sample
A total of 453 patient–spouse pairs was recruited for this study from six hospitals in a large metropolitan area. Two of the hospitals were academic medical centers and four were large community hospitals. Institutional review board approval was obtained from all sites. Of the 453 pairs, complete data sets were obtained from 417 and these pairs constitute the study sample. There were no significant differences between sociodemographic characteristics of those who did and those who did not return complete data sets.

The patient–spouse pairs were recruited if they met the following eligibility criteria: a) patient recovering from AMI or coronary revascularization using either coronary artery bypass grafting or percutaneous angioplasty; b) patient and spouse living together; c) no serious comorbidities such as cancer or renal failure in the patient; d) no cardiac disease or serious illness in the spouse; and e) no cognitive impairments that limited patients’ or spouses’ ability to complete study questionnaires.

Measurement
Data were collected from both patients and spouses on their sociodemographic characteristics by subject interviews. Clinical data were collected about patients by patient interview and chart abstract. Emotional responses were measured in both patients and spouses using the Multiple Affect Adjective Checklist (18). Perceived control was measured in both using the Cardiac Attitudes Scale (16,17). Patients’ psychosocial adjustment to the cardiac event was measured in patients only using the Psychosocial Adjustment to Illness Scale (19). Because quality of the marital relationship can affect psychosocial adjustment in the context of chronic illness (20), we measured marital adjustment using the Spanier Dyadic Adjustment Scale (21) to control for its potentially confounding influence.

Multiple Affect Adjective Checklist
Emotional adjustment was measured using the Multiple Affect Adjective Check List (MAACL) (18). This instrument measures state anxiety, depression, and hostility. The MAACL is a series of 132 positive and negative adjectives that are arranged in alphabetical order in columns. There are adjectives representing each of the three emotions. Subjects are asked to read through the adjectives and check all those that reflect how they are currently feeling. The instrument is scored by calculating the number of negative adjectives checked and the number of positive adjectives not checked. Subjects receive 1 point for each checked negative adjective and 1 point for each positive adjective not checked. As a result, higher scores mean that the subject has higher levels of the given emotion. Subjects receive a separate score for anxiety, depression, and hostility. The MAACL has been used extensively in research and clinical practice and reliability and validity have been demonstrated (18,22,23).

Control Attitudes Scale
Perceived control was measured using the Control Attitudes Scale (16) for patients and the Family Control Attitudes Scale for spouses (17). The Family Control Attitudes Scale measures the spouse’s perception of control related to their partner’s cardiac disease, whereas the Control Attitudes Scale measures the patients’ perception of control regarding their own disease. The instruments have parallel construction and each has established reliability and validity (16,17). Each instrument consists of 4 items to which subjects respond by rating their degree of agreement on a scale from 1 to 7. The ratings for each item are added to arrive at a total score for the instrument. Higher scores indicate greater perceptions of control.

Psychosocial Adjustment to Illness Scale
The Psychosocial Adjustment to Illness Scale (PAIS) is used by researchers to measure patients’ adjustment to illness in seven areas: health care orientation, vocational environment, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress (19). The PAIS comprises 46 questions to which patients respond by checking 1 of 4 responses. These responses form a continuum from no change or improvement related to illness as one anchor and markedly negative change related to illness as the other anchor. A total score is obtained, and there are scores for each of the subscales. In this study, the total PAIS score was used. Higher scores indicate worse adjustment to illness. Validity and reliability have been established for the PAIS in several populations including cardiac, cancer, and renal dialysis patients (19).

Spanier Dyadic Adjustment Scale
This instrument was used to measure quality of the marital relationship (21). The Spanier Dyadic Adjustment scale consists of 32 items that measure satisfaction, dyadic cohesion, consensus, and affectional expression in the context of a significant relationship. Higher scores on this instrument indicate higher satisfaction with the quality of the relationship. Criterion-related and concurrent validity have been established, as has reliability (21).

Procedure
Patients and spouses were recruited by trained cardiovascular nurse research assistants. Each patient and spouse gave informed consent and signed a consent form. Within 2 weeks of being recruited into the study, patients and spouses were mailed separate packets containing the questionnaires. They were asked to complete the questionnaires independently of each other and to return them within 2 weeks in the stamped, addressed envelopes provided. If the packets were not returned within a month of their original mailing, a research assistant called to remind the participants to return them. These methods yielded a return rate of 92%.

Data Analysis
Data are presented as means ± SDs or frequencies with percentages. Paired tests were used to compare the level of anxiety, depression, hostility, and perceived control between patient and spouse pairs. Initially, simple correlations were performed to examine the relationship between spouses’ emotional states and patients’ emotional states and psychosocial adjustment to illness. Then, partial correlations were conducted to determine the relationship between spouses’ emotional state and patients’ psychosocial adjustment to illness when patient anxiety or depression was controlled. Finally, analysis of variance (ANOVA) was used to compare patients’ psychosocial adjustment to illness among three groups of patient–spouse pairs. The groups of pairs were formed based on the comparison of their anxiety and depression levels. Namely, in group 1 the patient’s anxiety and depression were greater than the spouse’s anxiety and depression; in group 2, the patient’s and spouse’s emotion levels were similar, whereas in group 3 the spouse’s level of anxiety and depression were greater than the patient’s levels. Patients and spouses were considered similar if their scores were within 1 SD. When a significant overall group difference was found, post hoc t tests were performed to determine which group comparisons were significant using a Bonferroni adjustment. To determine whether age, gender, or marital adjustment score interacted with group status to produce an impact on patient psychosocial adjustment, separate 2-factor ANOVAs were performed using group and age, group and gender, and group and marital adjustment score. The marital adjustment score on the Spanier Dyadic Adjustment Scale was dichotomized at the median. Age was dichotomized using 65 years as the cutpoint. Age 65 was chosen as the cutpoint for age because 65 was the median age for patients in this sample and because 65 is a commonly used cutpoint for older versus younger adults.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Patient and Spouse Characteristics
The patient sample was composed of 86% males, whereas the spouse sample was composed of 86% females. The mean age of patients was 62 ± 10 years; the mean age of spouses was 59 ± 11 years. The average number of years of education was 14 ± 3 years for patients and 13 ± 3 years for spouses. The majority of patients were rated at New York Heart Association (NYHA) functional classification I (57%); 17% were rated NYHA II, and 7% each were rated NYHA III and IV. NYHA class was unavailable for the remaining (12%) patients. Patients’ mean left ventricular ejection fraction was 51 ± 16%.

Comparison of Emotional Responses
Spouses had significantly higher levels of anxiety (p < .001) and depression (p < .001) as measured on the MAACL than did patients (Figure 1). This pattern was similar regardless of the gender of the participant. There were no differences in levels of hostility between patients and spouses (Figure 1). In comparison with published norms for anxiety, depression, and hostility on the MAACL, 50% of patients and 56% of spouses were above the norm for anxiety. For depression, 57% of patients and 67% of spouses were above the norm. For hostility, 65% of patients and 64% of spouses were above the norm. Patients expressed higher levels of perceived control than did spouses (Figure 2; p < .001). Again, this pattern was the same regardless of gender.



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  		Figure 1. Comparison of mean (± SD) anxiety, depression, and hostility scores between patients and spouses. p < .001 for anxiety and depression; no significant difference in hostility scores between the 2. Higher scores indicate greater anxiety, depression, and hostility.

 


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  		Figure 2. Comparison of mean (± SD) level of perceived control between patients and spouses. p < .001. Higher scores indicate greater sense of perceived control.

 
Relationship Between Spouses’ Emotional Responses and Patients’ Emotional Response and Psychosocial Adjustment to Illness
Spouse anxiety, depression, and perceived control were significantly correlated with patient anxiety, depression, hostility, and psychosocial adjustment to illness (Table 1). When patient anxiety and depression were controlled, spouse anxiety, depression, and perceived control remained significantly correlated with patient psychosocial adjustment to illness (Table 2). Patients’ psychosocial adjustment to illness was affected by spouses’ level of anxiety in comparison to patients’ level of anxiety (Figure 3), and spouses’ level of depression in comparison with patients’ level of depression (Figure 4). Patients’ psychosocial adjustment to illness was worse when spouses were more anxious or depressed than patients, and it was best when patients were more anxious or depressed than spouses, whereas psychosocial adjustment to illness was intermediate to these two extremes when patient and spouse anxiety and depression levels were similar (p = .001). Neither age nor gender interacted with group to produce an effect in patients’ psychosocial adjustment to illness (p = .37 for depression grouping and p = .61 for anxiety grouping for age; p = .31 for depression grouping and p = .45 for anxiety grouping for gender). Although quality of the marital relationship was associated with patients’ psychosocial adjustment, controlling for quality of the marital relationship did not affect the relationship between spouse anxiety or depression and patients’ psychosocial adjustment to illness.


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  		TABLE 1. Correlations Among Spouse Anxiety, Depression and Perceived Control, and Patient Anxiety, Depression, and Psychosocial Adjustment to Illness (N = 417 Patient–Spouse Pairs)a
 

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  		TABLE 2. Correlations Between Spouse Anxiety, Depression and Perceived Control, and Patient Psychosocial Adjustment to Illness With Patient Anxiety and Depression Controlled (N = 417 Patient–Spouse Pairs)a
 


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  		Figure 3. Differences in mean (± SD) patient psychosocial adjustment to illness based on spouse level of anxiety compared with patient level of anxiety. p = .001 overall; post hoc group comparisons using Bonferroni correction, p < .01 for differences between each group. Higher scores on the psychosocial adjustment to illness scale indicate worse adjustment.

 


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  		Figure 4. Differences in mean (± SD) patient psychosocial adjustment to illness based on spouse level of depression compared with patient level of depression. p = .001 overall; post hoc group comparisons using Bonferroni correction, p < .01 for differences between each group. Higher scores on the psychosocial adjustment to illness scale indicate worse adjustment.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
We found that spouses were more anxious and depressed, and had lower perceptions of control than patients recovering from AMI or revascularization. Greater anxiety and depression in spouses was associated with poorer psychosocial adjustment to illness in patients. This association was unaffected by quality of the marital relationship, although psychosocial adjustment to illness was directly related to patients’ psychosocial adjustment. Spouses of cardiac patients recovering from AMI and revascularization appear to respond more negatively to the experience than do patients. We speculate that this finding is a result of the dynamics of care after a cardiac event. A cardiac event such as AMI or revascularization is a stressful, even life-changing event that can produce long-lasting emotional distress in some patients (24–26). Recognizing this reality, clinicians have instituted a number of strategies to reduce patients’ anxiety and depression, and increase their sense of control. The bulk of support and resources go to the patient, often at the expense of the spouse, who is subject to many caregiver demands and who may have to assume many of the patient’s roles for some time. As a consequence, spouses may develop and maintain higher levels of anxiety and depression and feel less control as their partner recovers from the cardiac event and the majority of support from health care providers is directed toward the patient.

The presence of emotional distress and loss of control may substantially hinder spouses’ ability to provide support to patients. Multiple investigators have documented the role of social support in cardiac patients’ recovery (27–30). Cardiac patients who live alone or lack a source of emotional support have a substantially higher risk of recurrent myocardial infarction, sudden cardiac death, and all-cause mortality than those with adequate sources of support (27,28). Social support from spouses is associated with faster postoperative recovery, less psychological distress, fewer and less severe cardiac symptoms, decreased fear of recurrent cardiac problems, increased adherence, and easier return to prior levels of social and recreational functioning among AMI and coronary artery bypass graft patients (9,14,31–35). However, there is also a negative side to social relationships. Myocardial infarction patients who perceive that they have received inadequate emotional support experience emotional distress and low self-esteem (12). Among AMI patients who have negative relationships with their spouse, pessimistic health perceptions and increased anxiety are common (14). Recovering cardiac patients who feel that spousal support does not meet their needs are less likely to surrender the sick role even when it is appropriate to do so (36).

An important factor that has an impact on whether a spouse will be able to provide positive support for a partner recovering from a cardiac event may be the spouse’s own psychological response and subsequent adjustment to the event. A spouse who is unable to marshal the resources to manage his or her own emotional distress may be ill-equipped to offer adequate support to their partner. However, spouses of cardiac patients commonly report feelings of anxiety, fear, depression, helplessness, sleep and appetite disturbances, and inability to concentrate (37,38). This psychological distress can persist for months (39) and may be related, in part, to caregiving demands (40) and a decreased sense of perceived control related to the spouses’ cardiac illness (17).

The differences between patients and spouses perceived control are noteworthy. In other studies, cardiac patients with high perceived control tended to have better functional status, and less anxiety, depression, and hostility than patients with low perceived control (16,41). In the current study, spouses reported both significantly lower perceived control and higher emotional dysphoria than patients did.

Our study provides evidence that emotional distress in spouses is associated with adverse psychosocial outcomes in patients, and suggests that patients’ psychological recovery may be improved by enhancing spouses’ emotional state. These findings highlight the importance of assessing spouses as well as patients for anxiety and depression after a cardiac event so that those with higher levels of these emotions can be targeted for intervention. Decreasing spouses’ anxiety and depression may also be a cost-effective way to intervene to improve patients’ psychosocial status and subsequent morbidity and mortality outcomes.

Interventions have been shown to decrease anxiety and depression in spouses of cardiac patients (42–44), but their implementation has been uneven in practice despite the relative simplicity of some interventions. Including spouses in all education and counseling of patients is a simple, yet often overlooked intervention that helps increase perception of control in both patients and spouses, and can potentially decrease anxiety and depression (17,23,42–45). An important component of these sessions is provision of information about the possible psychological responses to a cardiac event and highlighting the fact that a cardiac event has implications for both patients and spouses.

A limitation of this study is the cross-sectional design. With such a design, we were unable to confirm that spouses’ level of emotional distress predicts patients’ psychosocial adjustment in the long-term or that changes in the level of spouses’ emotional distress will predict changes in patients’ psychosocial adjustment. Longitudinal studies will help to illuminate the nature of the relationship. This study was also limited by the small number of female patients enrolled. Although we demonstrated no gender differences in the relationship between spouses’ emotional distress and patients’ psychosocial adjustment, future studies with larger samples of women are needed to confirm this finding. Future research also is needed to test interventions to improve spouse emotional status after their partners’ cardiac event. To fully demonstrate whether there is a causal relationship between spouses’ emotional distress and patients’ psychosocial recovery, intervention studies should test the impact of the intervention on spouses and patients. Finally, testing the impact on patients’ clinical outcomes is important.

In summary, spouses of patients with heart disease who have experienced a cardiac event such as AMI or revascularization experience significant anxiety, depression, and hostility as well as low perceived control. Not surprisingly, these negative emotions have an impact on patients’ psychosocial recovery. Interventions directed at supporting spouses, who often bear the new burden of being a caregiver along with other roles, should be designed and tested to determine whether they can positively affect spousal emotional status and, in turn, improve patients’ psychosocial and physical recovery.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This study was supported by a grant from the National Institutes of Health, National Heart, Lung and Blood Institute, grant number R01 HL32171.

Received for publication June 16, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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