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Psychosomatics 46:123-130, April 2005
© 2005 The Academy of Psychosomatic Medicine

Levels of Depressive Symptoms in Spouses of People With Lung Cancer: Effects of Personality, Social Support, and Caregiving Burden

Youngmee Kim, Ph.D., Paul R. Duberstein, Ph.D., Silvia Sörensen, Ph.D., and Mark R. Larson, Ph.D.

Received Oct. 15, 2003; revision received April 12, 2004; accepted May 26, 2004. From the Behavioral Research Center, American Cancer Society; and the University of Rochester School of Medicine and Dentistry, Rochester, N.Y. Address correspondence and reprint requests to Dr. Kim, Behavioral Research Center, American Cancer Society, 1599 Clifton Rd., N.E., Atlanta, GA 30329-4251; youngmee.kim{at}cancer.org (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors sought to identify the personality correlates of depressive symptoms in 120 spouses of people with lung cancer. Spouses completed questionnaires, including measures of personality (neuroticism, extraversion, and interpersonal self-efficacy), social support, and caregiving burden. Their level of depressive symptoms was measured with self-report (Center for Epidemiologic Studies Depression Scale) and interviewer (Hamilton Depression Rating Scale) ratings. Structural equation modeling showed that neuroticism was directly associated with greater depressive symptoms and indirectly associated with less social support and greater caregiving burden. Interpersonal self-efficacy was indirectly associated with the severity of depressive symptoms through both social support and caregiving burden. These findings have implications for identifying spouses of individuals with lung cancer who are vulnerable to depression and could inform the design of programs to reduce depressive symptoms in the context of cancer caregiving.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Lung cancer is the third most common cancer and the leading cause of cancer deaths in the U.S.1 Although the 1-year survival rates have steadily risen over the past two decades, the 5-year survival rate is still only 15%.1 Spouses often provide home care for their ill husband or wife.2–3 Although many spousal caregivers report high levels of depression, there is significant variability in depressive symptoms.4 For example, several studies have reported little mood disturbance and relatively low depression scores among caregivers of cancer outpatients,2,5 whereas others have shown that up to 30% of cancer caregivers have significant psychological distress.6,7 Treating and preventing severe levels of depression in the spouses of individuals with cancer is important. Depression in caregivers may diminish the quality and quantity of home health care provided,8 leading to impaired quality of life, physical morbidity, and premature mortality of the caregivers.9

It is possible that those who are more likely to become depressed can be identified early on and referred to mental health providers. Despite interesting clinical observations about lung cancer patients and their families,10 few studies have attempted to identify characteristics of spouses that make them more vulnerable to depression. Given that personality traits are associated with depression in spouses of patients with other cancers and chronic illnesses,11–19 it is possible that spouses who are at risk for depression can be identified on the basis of their personality traits.

We examined the relationships between personality (neuroticism, extraversion, and interpersonal self-efficacy) and depressive symptoms in the spouses of lung cancer patients. The rationale for selecting these variables was as follows. Neuroticism is associated with depression in the spouses of cancer patients,11,12 Alzheimer’s and Parkinson’s patients,13 and cardiovascular patients14; in family caregivers of people with dementia;15 and in parental caregivers of patients with chronic mental disability.16 Extraversion may be salient in the caregiving context because extraverted people tend to be optimistic and feel comfortable in the presence of others. One study of the caregivers of cancer patients12 showed that lower levels of extraversion were associated with higher levels of depression. Interpersonal self-efficacy may also have important implications17 because those with higher levels reported a greater sense of personal control and competence and more adequate support from close relationships.18 They may be more adept at recruiting and mobilizing assistance in times of need, both from their social support network and from healthcare professionals. Caregivers with high interpersonal self-efficacy report less strain and depression associated with caregiving than those with low self-efficacy.17,19

Because we assumed that personality traits were associated with depression in this study group, mediational analyses examining the potential mechanisms by which the severity of depression is amplified or mitigated ought to be conducted. We proposed two plausible mediators: social support and caregiving burden. Neuroticism, extraversion, and interpersonal self-efficacy are each related to social support.12–14 For example, among caregivers of cancer patients, individuals with lower neuroticism and higher extraversion were more likely to consider the amount of social support provided as sufficient.12 Given that increases in perceived social support during times of stress may reduce the severity of depression,20 social support might mediate the relationship between personality and depressive symptoms.

Whereas social support appears to have beneficial effects, caregiving burden may have negative effects on psychological outcomes for caregivers.12,13 Caregivers with higher levels of neuroticism and lower levels of extraversion or interpersonal self-efficacy tend to experience higher levels of stress and caregiving burden.12,13,15 Those lower in neuroticism and higher in extraversion and interpersonal self-efficacy, in contrast, may be less burdened in part because of their more optimistic outlook and ability to recruit support. Thus, caregiving burden might mediate the relationship between personality and depressive symptoms.13

We hypothesize that neuroticism, extraversion, and interpersonal self-efficacy are each associated with depressive symptoms in individuals caring for a spouse with lung cancer (hypothesis 1). In addition, we hypothesized that the relation between personality and depressive symptoms is mediated by social support (hypothesis 2a), caregiving burden (hypothesis 2b), or a combination of the two (hypothesis 2c).


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
All English-speaking spouses of patients who had been diagnosed with and treated for lung cancer within the last 5 years were eligible to participate. Of the 340 spouses of lung cancer patients who were approached, 159 (47%) provided written consent for participation, and complete data were available for 120. Most of the cancer patients (79%) had already completed some form of treatment at the time of the spouse’s participation. Surgery (56%) was the most common treatment; other patients received a combination of surgery, radiation, and chemotherapy (35%), radiation only (6%), or chemotherapy only (3%). Proportions of cancer stages for the patients were the following: stage I (47%), stage II (12%), stage III (25%), and stage IV (16%). The average age of the participants was 63.1 years (SD=10.0, range=26–82), more than half were female (66%), and most were Caucasian (97%) and married to and living with the patients (98%). The mean level of education for the participants was 13.0 years.

Procedure
A member of our research team, based in the Department of Psychiatry, identified eligible spouses. In general, the treating surgeon or oncologist introduced the research team member to the spouse. The research team member then explained the nature of the study and invited the spouse to participate. Informed consent was obtained at the time of the research interview with a consent form approved by the research subjects review board at the University of Rochester. Research assistants administered the self-report questionnaires and conducted interviews after extensive training in structured interviewing. On average, the interviews lasted between 2 and 3 hours. Researcher training sessions were conducted throughout the study to monitor rater drift and ensure the methodological integrity of the data collection process. As part of the training process, monthly meetings were convened where raters observed and scored live and videotaped interviews. Coding conventions were established and reviewed in these meetings, and formal interrater reliability exercises were conducted.

Measures
There were three indicators of personality: neuroticism, extraversion, and interpersonal self-efficacy. Neuroticism and extraversion were measured with 12 internally consistent items ({alpha}=0.84 and 0.63, respectively, in the current study) from the NEO Five-Factor Inventory,21 with a 5-point Likert response format (1=strongly disagree and 5=strongly agree). The NEO-FFI has been used in prior research on spouses and family members of chronically ill people.13,16 Individuals scoring higher in neuroticism are prone to worry, nervousness, and feelings of insecurity. People who are introverted are relatively shy and avoidant and may have social skills deficits. Interpersonal self-efficacy was measured by five internally consistent items ({alpha}=0.80) from the Self-Efficacy Scale22 with a 4-point Likert response format (1=strongly disagree and 4=strongly agree). Individuals with higher interpersonal self-efficacy scores are able to effectively ask for assistance and set interpersonal limits.22 The validity of the scale has been documented.22,23

An abbreviated 7-item version of the Duke Social Support Index24 was used to assess two dimensions of social support: perceived social support (six items) and satisfaction with social support (one item). (The Duke Social Support Index assesses three dimensions of social support: perceived, satisfaction, and instrumental. Instrumental social support assesses whether individuals need tangible support, which clearly depends on certain situations and times. Because this dimension is not relevant to our study, we excluded it.) Both dimensions are measured with a 3-point Likert response format (1=hardly ever and 3=most of the time). The scale has been validated in mixed age samples.25 Although spousal support has been studied most frequently, other sources of support, such as adult children and friends, may also be important.25 Thus, consistent with previous recommendations,26 participants were asked to respond to each item in reference to 1) spouse, 2) children, and 3) other close family and friends. The summed scores of the two dimensions of social support (perceived and satisfaction) were labeled spouse, child, and friend. Because the social support scores referred to sources of support (i.e., spouse, children, and family/friends) and not dimensions (e.g., instrumental or perceived satisfaction), calculating internal consistency across dimensions was not appropriate.26

The 18-item Burden Interview27,28 was used to assess stressors and amount of perceived burden experienced by caregivers with a 5-point Likert response format (1=never and 5=nearly always). The measure has two subscales: personal strain, which refers to how personally stressful the experience is (12 items), and role strain, which refers to stress due to role conflict or overload (six items). The scale has been validated with elderly cancer patients, their primary caregiving spouses, and their adult children.29 Each subscale score was determined by summing the responses of relevant items, with higher scores indicating more caregiver distress. Both subscales have good internal consistency in the current study ({alpha}=0.80 and 0.87, personal and role strain, respectively).

The 20-item Center for Epidemiologic Studies Depression Scale (CES-D)30 was used to measure the overall level of depressive symptoms experienced more days than not in the most recent week with a 4-point Likert response format (0=rarely or none of the time and 3=most or all of time). This measure has been used with older adults31 as well as spousal caregivers32 and was found to have good reliability and validity ({alpha}=0.92 in the current study). We also used the 24-item observer-rated Hamilton Depression Rating Scale.33 The Hamilton depression scale is a structured assessment of the presence and severity of depressive symptoms in the week before the interview. This measure was administered by trained clinical interviewers. Scores are based on self-report and nonverbal presentation. Higher scores reflect greater levels of depressive symptoms.

Statistical Analyses
The hypotheses were tested with structural equation modeling, which is a comprehensive statistical approach to testing hypothesized relationships among manifest and latent variables. The software package used was AMOS 4.0.34 Each of the three personality traits (neuroticism, extraversion, and interpersonal self-efficacy) was assessed by corresponding manifest variables. Social support, caregiving burden, and depression were included in the study model as latent variables. The patient’s stage of cancer was included as a covariate. After the structure of the study model was evaluated and the hypotheses were tested, a supplementary model was tested to rule out bias due to the use of self-report measures for both neuroticism and depression.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Descriptive statistics of study variables are reported in Table 1. They indicate that the current group of participants consisted of individuals relatively low in neuroticism, average in extraversion, and high in interpersonal self-efficacy.21,23 This group of caregivers appears to perceive their social support as satisfactory and seems to be mildly strained from providing care for their spouse with cancer. The majority of the participants’ levels of depressive symptoms are below the clinical cutoff (70% of the participants scored less than 16 on the CES-D).


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TABLE 1. Descriptive Characteristics for Personality, Social Support, and Caregiving Burden on Depression in Spouses of People With Lung Cancer



The measurement properties of the three proposed latent variables were examined with confirmatory factor analysis, which established that all three latent variables were measured as satisfactory (p<0.001). Loadings for social support were as follows: spouse (ß=0.61), child (ß=0.66), and friend (ß=0.80), indicating that all three sources of support were important. The caregiving burden latent variable was loaded by personal strain (ß=0.82) and role strain (ß=0.91), and the depression latent variable was loaded by the CES-D (ß=0.78) and the Hamilton Depression Rating Scale (ß=0.91) (the correlation between the CES-D and Hamilton Depression Rating Scale scores was 0.67 [p<0.001]). When we tested the hypothesis that personality traits would be directly associated with the depression latent variable, the fit of the specified structural model was satisfactory35 after allowance for error terms among the three personality traits to be correlated: {chi}2=11.9, df=6, goodness of fit index=0.97, comparative fit index=0.96, and root mean squared error of approximation=0.09. As shown in Table 2 (see the column titled "Partial Study Model"), the paths from neuroticism and interpersonal self-efficacy to depression were significant, but the path from extraversion to depression was not.


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TABLE 2. Comparison of Models Derived From Structural Equation Modeling of the Effects of Personality, Social Support, and Caregiving Burden on Depression in Spouses of People With Lung Cancera



Next, we examined hypotheses 2 (2a to 2c), which stated that caregivers’ personality traits would indirectly predict their levels of depressive symptoms through social support and/or caregiving burden (see the column titled "Full Study Model" in Table 2). For the model depicted in Figure 1, the fit was acceptable ({chi}2=53.4, df=32, goodness of fit index=0.93, comparative fit index=0.95, and root mean squared error of approximation=0.07). When the proposed mediators were entered, the magnitude of the direct path from neuroticism to depression was reduced but remained significant, while the direct path from interpersonal self-efficacy to depression became nonsignificant (see Table 2).



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FIGURE 1.  Full Study Model of the Effects of Personality, Social Support, and Caregiving Burden on Depression in Spouses of People With Lung Cancer

Paths in solid-bold lines are significant at p<0.001; a path in broken-bold line is significant at p<0.10; paths in dot-lines are not significant. Stage=stage of cancer of the patient.


Both neuroticism and interpersonal self-efficacy were associated with social support, but social support was not directly related to depression. Thus, the hypothesized mediating effect of social support (hypothesis 2a) was not supported. Rather, the effect of social support on depression was mediated by caregiving burden. Individuals who scored high on neuroticism or who scored low on interpersonal self-efficacy tended to report lower levels of social support, and those reporting lower levels of social support were, in turn, more likely to experience greater caregiving burden, which brought about higher levels of depressive symptoms. This pattern supported hypothesis 2c.

In addition, the paths from interpersonal self-efficacy to caregiving burden and from caregiving burden to depression were significant, supporting hypothesis 2b; caregiving burden mediates the relationship between personality and depression. Individuals who scored high on interpersonal self-efficacy were less likely to experience caregiving as burdensome. Lower burden, in turn, was related to lower levels of depressive symptoms.

A supplementary model was tested to rule out bias in the relationship between neuroticism and depression due to shared method variance of self-report measurement between the two constructs. The fit of this model, which excluded the CES-D from the depression latent variable, was satisfactory and not significantly different from the proposed full study model ({chi}2 difference=14.1, df=8, p>0.10. All paths that were significant in the full model remained significant, and the path from social support to depression remained nonsignificant. Findings from the supplementary model suggest that shared method variance did not bias the full model. Thus, the study model is valid not only for self-report measures of depression but also for observer-rated depression.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This study advances understanding about the levels of depressive symptoms in the spouses of individuals with lung cancer both theoretically and empirically. Two major findings warrant attention. First, the results underscore the importance of both neuroticism and interpersonal self-efficacy in caregiver depression while casting doubt on the importance of extraversion. Second, concerning the proposed mediators, the data support the idea that lower levels of social support and increased caregiving burden are themselves products of longstanding personality traits that in turn serve to engender or exacerbate depressive symptoms. Individuals higher in neuroticism or lower in interpersonal self-efficacy perceive less available social support and report a greater degree of personal and role strain. Such strains are, in turn, strongly associated with higher levels of depressive symptoms. Poorer social support and caregiving burden both mediate the link between neuroticism, interpersonal self-efficacy, and depression.

Caregiving burden by itself was a significant and direct correlate of depressive symptoms, which is consistent with previous research.4 Moreover, caregiving burden fully mediated the effect of social support on levels of depressive symptoms in the present study. The significant association between social support and depression became nonsignificant when caregiving burden was included in the model as a mediator. These findings suggest that future studies of the health effects of social support need to consider both plausible antecedents (e.g., personality traits) and mechanisms (e.g., caregiving burden).

Implications for Theory and Practice
Our findings have implications for both theory and practice. From a theoretical perspective, consequences of cancer caregiving appear to depend on longstanding traits of the caregivers as well as specific coping processes used in stressful situations. For example, neuroticism was directly associated with depression. The association became indirect, although still significant, when mediated by the perceived availability of and satisfaction with social support coupled with caregiving strains. Similarly, the impact of interpersonal self-efficacy on depressive symptoms was dependent upon perceived social support, satisfaction with social support, and strain from providing care. Some researchers study the effects of personality while ignoring social support or strain; others ascribe too much significance to social support and acute stressors and ignore longstanding personality traits. There is a need for conceptual integration.13,36

Family care has not been fully incorporated into typical oncology systems.37 In a thorough review of family care for cancer patients, Given and colleagues37 highlighted the importance of understanding the nature of the caregivers’ personal and social resources as well as the patients’ physical and psychological needs to provide efficient support to the family. From a pragmatic perspective, the present findings suggest that it might be possible to develop tailored, family-focused support programs targeted to vulnerable caregivers who could be identified by virtue of their personality traits. Caregivers high in neuroticism may suffer more than others from the stress of providing care for an ill spouse. Additionally, those who lack adequate resources or are insufficiently prepared for a caregiving role are at greater risk for experiencing burden. If one had to choose between intervening in the social support system or reducing caregiver burden, our findings suggest that the latter may be preferable in terms of reducing the severity of depressive symptoms among spousal caregivers of individuals with lung cancer. Interventions that emphasize education and information about medical treatment and disease processes,38 focus on improving problem-solving skills, and provide respite services, such as adult day care or in-home personal support services,38 have been found to be effective in reducing caregiving burden39 and could be integrated into comprehensive cancer programs.

Limitations and Future Directions
Findings must be interpreted in the context of the study design’s weaknesses and strengths. First, our study group was too small for structural equation modeling to examine either gender or cancer stage differences in the associations among study variables. Larger groups are needed to replicate the current findings and to examine if the current framework holds within each gender or cancer stage. In addition, interpreting the relationship between neuroticism and social support should be done with caution because the statistical significance of the relationship was marginal with our group. Second, the cross-sectional design prevented the inference of causal relations among study variables. Third, we studied a homogeneous group of spouses who were mostly Caucasian. Attempts to replicate the current findings with groups of caregivers from different disease, racial, or social groups are warranted. Fourth, we did not include an assessment of axis I disorders; depression was assessed as a continuous, not as a dichotomous, variable in the current study. Cautious interpretation of the current findings should be applied to the individuals whose levels of depressive symptoms are above the cutoff scores on the CES-D and Hamilton depression rating scales. Finally, although social support and caregiving burden mediated the relationship between neuroticism, interpersonal self-efficacy, and depressive symptoms, other mediators must be identified.

Despite these limitations, the present study suggests that personality characteristics, particularly neuroticism and low interpersonal self-efficacy, may serve to engender or exacerbate depressive symptoms in the context of caregiving. Identifying vulnerable caregivers and referring them for preventive interventions could improve the quality of care that they provide to their ill spouses, while potentially decreasing their own risk for depression and other adverse health outcomes.


  ACKNOWLEDGMENTS

 
Presented in part at the 22nd annual meeting of the Society of Behavioral Medicine, Seattle, March 21–24, 2001.

Data collection for this project was supported by Public Health Service grant K07-MH-01135.

The authors thank Jill Guary, Susan Jackson, and Nathan Franus for their assistance with data collection; Dr. Richard Feins, Dr. David Johnstone, and other Cancer Center physicians for providing access to patients; all the families who participated in this investigation; and Dr. Kenneth Conner, Nathan Franus, Cindy Hutton, and other members of the Laboratory of Personality and Development, anonymous reviewers for their comments, and Heekyoung Kim for her inspiration.


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 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
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