Full text of DOI:10.1053/ajkd.2001.27704

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Depression and Marital Dissatisfaction in Patients With End-Stage
Renal Disease and in Their Spouses
Beth Daneker, PhD, Paul L. Kimmel, MD, Tedine Ranich, MD, and Rolf A. Peterson, PhD
● Little research has been performed assessing patients with end-stage renal disease (ESRD) as parts of marital
dyads or within family structures. Recent findings suggest patient interactions within such systems are associated
with patient outcomes. To evaluate the relationship between level of patient depression and spouse psychosocial
status, 55 couples in which one partner was undergoing chronic hemodialysis therapy for ESRD were interviewed.
Two variables that alone and in interaction with one another were expected to relate to the spouse’s level of
depression and marital satisfaction were investigated: patient depression level and spouse’s perceived social
support. Depression was assessed using the Beck Depression Inventory (BDI). Spouses’ levels of depressive affect
correlated directly with patient BDI scores. A significant two-way interaction for spousal depression (patient
depression and spousal support) supported viewing spouses’ adjustment as a function of the interaction between
spouse and patient factors. Additionally, a main effect of perceived spousal social support on spousal marital
satisfaction indicated that spouses reporting high levels of social support had the least marital strain. The severity
of the patient’s illness did not correlate with any of the predictor variables or measures of spousal adjustment, but
spouses reported significantly lower functional status for patients than did nephrologists. Spouse and patient
levels of depression are related, although causal relationships cannot be determined by these studies. Moreover,
spouse perception of marital satisfaction is related to depression scores. These findings suggest the patient with
ESRD functions in a psychosocial dyad. Spouse psychosocial status could impact on the level of patient
depression, and the spouse might be amenable to interventions that could improve patient outcome.
© 2001 by the National Kidney Foundation, Inc.
INDEX WORDS: Depression; marriage; marital satisfaction; marital conflict; social support; functional status;
Karnofsky performance status scale.
VARIETY OF psychological disorders and
viewed as taking place within the context of such
A stresses complicate the course of patients larger social subsystems as the marital dyad,12,15
with renal disease.1-4 Spouses of chronically ill
patients are also at risk for both psychological
distress and compromised physical health.5-7 End-
stage renal disease (ESRD) provides an example
of a chronic illness that can be debilitating for
both marital partners. As with many chronic
illnesses, the spouse, like the patient with ESRD,
must accommodate to an intrusive illness and its
treatment demands and is frequently called on to
contend with a series of crises that may at times
be unpredictable and burdensome.Although mod-
erate to excessive levels of depression or subjec-
tive stress have been documented in healthy
spouses of patients with ESRD,8-13 some spouses
show few adverse reactions to living with a
husband or wife treated with dialysis. Previous
studies have not adequately explored this variabil-
ity in spousal reactions and have given little
consideration to factors related to psychological
outcomes of members of the marital dyad. Few
studies have assessed patient perceptions in the
context of marital, familial, and treatment sys-
tems, linking adjustment to patient medical and
marital status, but some data suggest these may
be associated with clinically significant out-
comes.2,14 Because individual adjustment can be
the degree of the nonpatient spouse’s emotional
distress and marital dissatisfaction may impact
critically on the patient. Recently, we showed
that perception of marital discord was associated
with increased mortality in a population of Afri-
can-American women with ESRD,14 but the con-
tribution of the spouse to marital adjustment was
not assessed in that study.
Although estimates of the prevalence of depres-
sion in dialysis patients are varied, there appears
to be a high frequency of moderate to severe
levels of depression among this patient popula-
From the Departments of Psychology and Medicine,
George Washington University, Washington, DC; and the
Division of Kidney, Urologic and Hematologic Diseases,
National Institute of Diabetes and Digestive and Kidney
Diseases, The National Institutes of Health, Bethesda, MD.
Received February 8, 2001; accepted in revised form May
18, 2001.
Address reprint requests to Paul L. Kimmel, MD, Division
of Renal Diseases and Hypertension, Department of Medi-
cine, George Washington University Medical Center, 2150
Pennsylvania Ave NW, Washington DC 20037. E-mail:
domplk@gwumc.edu
© 2001 by the National Kidney Foundation, Inc.
0272-6386/01/3804-0014$35.00/0
doi:10.1053/ajkd.2001.27704
American Journal of Kidney Diseases, Vol 38, No 4 (October), 2001: pp 839-846
839

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840
DANEKER ET AL
tion.2,16-18 Depression may detract substantially
from the quality of life of patients with
ESRD1,2,14,16,19,20 and is particularly problematic
given that dialysis patients are at increased risk
for suicide2,16,21 and may have greater rates of
mortality associated with increased depressive
affect.2,16,22,23 Thus, a patient with a high level of
depressive symptoms can be viewed as a signifi-
cant source of stress for the spouse with whom
he or she lives. Studies of a variety of chronically
ill populations have shown associations between
levels of depressive affect in patients and their
spouses6,24-26; however, correlations have gener-
ally been only in the moderate range.25,27 It is
clear that in investigating the nonpatient spouse’s
response to chronic illness, one must consider
more than the patient’s reaction to the illness.
Similarly, although depressive affect in spouses
of chronically ill patients has been linked to
some degree to perceived illness demands,28 ob-
jective measures of the severity of the patient’s
illness are by themselves not necessarily predic-
tive of either partner’s psychosocial status or
level of adjustment. The influence of spousal
social support on spousal and patient psychoso-
cial status within the context of patient severity
of illness and depression has rarely been studied
in ESRD populations.
Chronic illness may have a profound effect on
a marriage, often creating new sources of marital
tension or amplifying existing marital problems.
Strains may include, among other factors, changes
in the sexual relationship,1-3,8 communication
problems,29 and perceptions of decreased inti-
macy.30 Disruptions in the marriage brought on
by illness and treatment demands may lead to
spousal distress, although the converse may also
be true. The nonpatient spouse’s level of depres-
sive affect may negatively impact on the marital
relationship and affect the patient and his or her
medical course. Identification of variables re-
lated to both outcomes can be used in designing
effective interventions for both the healthy spouse
and chronically ill partner.
sive affect and severity of the patient’s illness
may function as stressors for the spouse. We
hypothesized that patient depressive affect would
correlate with spouse psychosocial status, and
the most adverse stress reactions would be re-
ported by spouses who perceived low levels of
social support and were married to or cohabiting
with patients with high depression scores.
METHODS
Subjects
Couples in which one partner was being treated for ESRD
were invited to participate in the study. Couples were re-
cruited from four medical centers in the Washington, DC,
metropolitan area at which the ill partners were undergoing
in-center hemodialysis (HD) treatment on a regular thrice-
weekly schedule. Couples in which the patient showed signs
of dementia, failed to pass a Mini–Mental Status Examina-
tion,31 or was infected with human immunodeficiency virus
were excluded from the study. In addition, only couples in
which the patient had been undergoing HD for at least 6
months were recruited for participation, as previously de-
scribed.14 All subjects provided informed consent for the
study, and the study was approved by the institutional review
boards of the medical centers providing dialysis.
Measures
Comorbidity
ESRD severity coefficient. A severity coefficient was
calculated for each patient based on the criteria of Plough et
al,32 using the patient’s age and additional concurrent ill-
nesses. The coefficient was determined by multiplication of
the patient’s relative mortality risk based on age and the risk
of additional comorbid illnesses present, described in our
previous studies.17,22,33 Pretreatment blood urea nitrogen
(BUN) levels were abstracted from patients’ medical charts
during the month in which patients were interviewed.
Perceived Patient Functional Status
The Karnofsky Performance Status Scale. The Karnof-
sky score, assessed by healthcare workers, has been used
frequently as a measure of the degree to which HD patients
are physically rehabilitated.1,2,20,34-36 The Karnofsky score
provides a rating of the patient’s functional capacities rang-
ing from normality (100) to death (zero) in 10-point decre-
ments. Intermediate ratings focus on the patient’s ability to
work, ability to care for self, and the need for hospitalization
or institutionalization. The scale has been extensively used
in studies of patients with ESRD (reviewed in20,35). Both
physician Karnofsky ratings and ratings from the nonpatient
spouses were collected. Physician and spousal Karnofsky
ratings were used to assess the relationship between percep-
tions of the patient’s physical state and the nonpatient
spouse’s adjustment.
The purpose of the present study is to investi-
gate two sets of specific factors (patient and
spouse depression level and spousal perception
of social support and marital satisfaction) that
alone and in interaction with one another might
relate to emotional and marital adjustment among
ESRD dyads. Both the patient’s level of depres-
A battery of questionnaires that included the following
measures was administered to the subjects by a trained
psychologist.

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ESRD SPOUSE DEPRESSION AND MARITAL CONFLICT
841
and good internal consistency and test-retest reliability for
the three subscales and overall test.42 It has been used by us
previously in studies of patients with chronic renal dis-
ease2,14,33,35 and predicted survival in patients with ESRD
treated with HD.33
Depressive Affect
Beck Depression Inventory. The Beck Depression Inven-
tory (BDI)37 is a 21-item index that assesses both somatic
and emotional aspects of depression. Items on the BDI are
presented in a four-point Likert scale format. Zero on the
scale represents the absence of a problem, and 3 represents
an extreme problem, with total scores ranging from zero to
63. Adiagnosis of depression is made for a score greater than
10, and severe depression, for a score of 16 or higher.38
Craven et al39 showed that a BDI score of 15 or higher had
high diagnostic sensitivity and specificity in dialysis patients
with ESRD. The scale shows excellent reliability and valid-
ity37,38 and has been used extensively in patients with chronic
renal disease.2,23,39
Typically, the somatic aspects of depression are included
in diagnostic evaluations and scoring systems,2,16,17,22 al-
though symptoms of medical illness can make the diagnosis
of depression more difficult in patients with a chronic
medical illness.2,16,17,22 To assess this issue, several years
ago, we devised the Cognitive Depression Index
(CDI),2,16,17,22 a 15-item scale in which somatic items of the
BDI have been deleted. We used this measure in several
populations of patients with ESRD.17,22,23,33 Unfortunately,
except in early studies,17,22 the CDI has not provided discrimi-
native power compared with the BDI. The meaning of the
CDI in people in the absence of medical illness is unclear.
The CDI was assessed in all patients in this study.
Procedure
Patients were interviewed individually in the dialysis
units by one of the authors (B.D.), a trained psychologist.
The BDI was read to the patients, and interviews were paced
according to patients’ comfort and energy levels. Karnofsky
Performance Status Scale scores were obtained from staff
nephrologists. Patients were asked at the time of their
interviews for permission to contact their spouses. The
following questionnaires were administered by the psycholo-
gist to nonpatient spouses during scheduled telephone inter-
views: the Karnofsky Scale for assessment of the patient by
the spouse and the spouse’s response to the BDI, DAS-S,
and MSPSS. Couples were mailed a small monetary compen-
sation for participating in the study.
Statistical Considerations
Correlations were assessed using Pearson’s correlation
coefficient. Interactions were assessed using two-way analy-
sis of variance. To examine two-way interaction effects,
median splits were used to determine high versus low group
status for both predictor variables (patient depression and
spouse’s perceived total social support). Spouses with MSPSS
scores of 62.5 or higher were assigned to a high-support
group, whereas a low-support group consisted of subjects
with MSPSS scores less than 62.5. Subjects married to or
cohabiting with patients with BDI scores of 9 or higher made
up a high–patient-depression group, whereas subjects mar-
ried to or cohabiting with patients with BDI scores les than 9
were assigned to a low–patient-depression group. Data are
presented as mean Ϯ SD. P less than 0.05 is considered the
level of statistical significance.
Marital Satisfaction and Conflict
Dyadic Adjustment Scale and Dyadic Satisfaction Sub-
scale. The Dyadic Adjustment Scale (DAS)40 is a 32-item
self-report measure intended for use with either married or
unmarried cohabiting couples. The DAS contains four sub-
scales of dyadic adjustment: dyadic consensus, dyadic satis-
faction, dyadic cohesion, and affectional expression. The
Dyadic Satisfaction Subscale (DAS-S) was used in this
study, as in our previous studies.14,35 Items 1 to 7 on the
DAS-S address the frequency of marital conflict and percep-
tions of the marriage. They are presented in a six-category
Likert scale format, with responses ranging from “always”
to “never.” The remaining items present similar rating scales
and address the frequency of physical affection between the
partners, overall happiness with the relationship, and their
feelings about its future success. Good internal consistency
and initial validity data have been reported,40,41 and the scale
has been used in patients with ESRD treated with HD.14,35
Higher scores signify greater perception of marital satisfac-
tion.
RESULTS
Four dyads were excluded before invitation to
the study because of the presence of acquired
immunodeficiency syndrome or known human
immunodeficiency virus infection in the patient.
Four dyads were excluded before invitation to
the study because patients were disoriented or
demented or had psychiatric illnesses. Thirteen
of the 68 couples invited to take part in the study
declined, yielding 55 couples and a recruitment
rate of 80.1%. Mean patient age was 56.0 Ϯ 12.6
years (range, 32 to 79 years; Table 1), 76.4% of
patients were men (n ϭ 42), 23.6% were women
(n ϭ 13), 89.1% of patients were black (n ϭ 49),
and 7.3% were white (n ϭ 4). Mean duration of
time since patients first underwent HD treatment
was 34.8 Ϯ 39.8 months (range, 6 to 152 months).
Of the 55 couples, 48 couples were married
Social Support
The Multidimensional Scale of Perceived Social Support.
The Multidimensional Scale of Perceived Social Support
(MSPSS)42 is a 12-item questionnaire that measures per-
ceived social support from friends, family, and a special
person (a confidant, such as a spouse, spiritual pastor, or
medical staff member) and their sum, the total perceived
social support. Four items pertaining to each area of support
are presented. Items are answered using a seven-point rating
scale that ranges from “very strongly disagree” (1) to “very
strongly agree” (7). The MSPSS shows excellent validity

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842
DANEKER ET AL
Table 1. Patient and Spouse Characteristics
spouse assessment of patient Karnofsky score
(r ϭ –0.40; P Ͻ 0.003 and r ϭ –0.37; P Ͻ 0.005,
respectively). Spouses’ perceptions of perceived
total social support and spouses’ assessments of
patients’ Karnofsky scores correlated (r ϭ 0.31;
P Ͻ 0.03; Table 2) with greater spousal levels of
perceived social support associated with spousal
perception of better patient functional status.
Patient mean BDI score was 30.4% higher
than the mean BDI of the nonpatient spouse
(10.3 Ϯ 7.0 versus 7.9 Ϯ 5.7; P Ͻ 0.0l), signify-
ing a greater level of depressive affect. The
overall mean score for patients was in the range
of mild depression. Seven patients (12.7%) and
six spouses (10.9%) had total BDI scores of 16
or higher, consistent with clinical depression.
The mean CDI score of patients was 6.2 Ϯ 5.2,
similar to that found in previous studies.14,16,23,33
There was no difference between mean CDI
scores of male and female patients. There was no
difference in mean psychological assessments of
male and female spouses. Patient BDI and CDI
scores correlated with spouse BDI scores (r ϭ
0.49; P Ͻ 0.01 and r ϭ 0.51; P Ͻ 0.001; Tables 2
and 3) and inversely correlated with spousal
measures of perceived social support (r ϭ –0.27;
P Ͻ 0.05 and r ϭ 0.51; P Ͻ 0.001). Thus, the
greater the social support reported by spouses,
the lower the level of depressive affect reported
by patients.
No. of
Variable
Subjects Mean
SD
Patient age (y)
55
55
55
55
55
55
55
55
55
55
55
55
56.0
34.8
72.6
2.6
51.9
13.1
25.5
2.5
12.6
39.8
15.7
1.1
13.3
2.9
13.2
1.8
1.1
Patient duration of ESRD (mon)
Patient predialysis BUN (mg/dL)
Patient Severity Index
Spouse age (y)
Spouse education (y)
Years married or cohabiting
No. of children per couple
No. of children in household
Patient BDI score
0.84
10.3
6.2
7.1
5.2
5.7
Patient CDI score
Spouse BDI score
7.9
Spouses’ marital satisfaction
(DAS-S)
Spouses’ social support
(total MSPSS)
54
54
35.6
60.9
7.0
16.3
NOTE: N ϭ 55 couples.
(87.3%) and 7 couples were cohabiting (12.7%).
Couples had been married or cohabiting for a
range of 2 to 55 years. The modal number of
children in the family was two, with a mode of
zero children residing in the household at the
time of the interview.
Of the spouses, 85.5% were black (n ϭ 47),
l0.9% were white (n ϭ 6), and 3.6% (n ϭ 2)
were of a different ethnicity than the patient. The
mean age of nonpatient spouses was 51.9 Ϯ 13.3
years (range, 29 to 78 years), 76.4% of spouses
were women (nϭ42), and 23.6% were men (n ϭ
13). The average education of spouses was 13.1 Ϯ
2.9 years of school. The majority of spouses
(56.4%; n ϭ 31) were employed on a full-time
basis.
Mean spouse MSPSS score for perception of
Table 2. Correlations Between Patient Medical
Characteristics and Level of Depressive Affect and
Spouse Psychosocial Variables
R
Spouses rated the patients’ Karnofsky func-
tional status almost 10 points less than physi-
cians (69.1 Ϯ 17.0 versus 77.6 Ϯ 16.61; P Ͻ
0.001). There was no difference in mean patient
Karnofsky ratings reported by male and female
spouses. Spouse Karnofsky ratings correlated
with nephrologists’ assessments (r ϭ 0.40; P Ͻ
0.002). According to physicians’ ratings, the av-
erage patient was functioning at a level at which
he or she was able to care for himself or herself,
but was unable to carry on “normal activity” or
do “active work.” Spousal ratings indicated a
lower level of function, with the patient requiring
“occasional assistance.” There was a significant
inverse correlation of patient and spouse age and
Patient
BDI
Spouse
BDI
Spouse
MSPSS
Variable
Patient severity coefficient
Patients BUN
Patient duration of treatment
for ESRD
Patient BDI
Patient CDI
Karnofsky rating by spouse
Karnofsky rating by
nephrologist
0.01
0.01
0.06
0.03
0.01
0.14
0.06 Ϫ0.10
0.03
0.49* Ϫ0.27†
0.51‡ ؊0.26†
0.23
Ϫ0.23
0.31§
Ϫ0.14 Ϫ0.11
0.10
*P Ͻ 0.01.
†P Ͻ 0.05.
‡P Ͻ 0.001.
§P Ͻ 0.03.