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Effects of Self-esteem, Optimism, and Perceived Control on Depressive Symptoms in Stroke Survivor-Spouse Dyads

Chung, Misook L. PhD, RN, FAHA, FAAN; Bakas, Tamilyn PhD, RN, FAHA, FAAN; Plue, Laura D. MA; Williams, Linda S. MD, FAHA, FAAN

The Journal of Cardiovascular Nursing: March/April 2016 - Volume 31 - Issue 2 - p E8–E16
doi: 10.1097/JCN.0000000000000232

Background: Depressive symptoms are common in stroke survivors and their family caregivers. Given the interdependent relationship between the members of dyads in poststroke management, improving depressive symptoms in dyads may depend on their partner’s characteristics. Self-esteem, optimism, and perceived control, all known to be associated with depressive symptoms in an individual, may also contribute to their partner’s depressive symptoms.

Purpose: The purpose of this study is to examine actor and partner effects of self-esteem, optimism, and perceived control on depression in stroke survivors and their spousal caregivers.

Methods: A total of 112 ischemic stroke survivors (78% white, 34% women; mean age, 62.5 ± 12.3 years) and their spouses (mean age, 60.6 ± 12.9 years) completed surveys in which depressive symptoms, self-esteem, optimism, and perceived control were assessed using the Patient Health Questionnaire, the Rosenberg Self-esteem Scale, the Revised Life Orientation Test, and the Sense of Control Scale. Multilevel modeling, actor-partner interdependence model regression was used to determine influences on depressive symptoms within the dyad.

Results: Individuals with lower self-esteem, optimism, and perceived control had higher levels of depressive symptoms. Stroke survivors whose spouses had lower levels of self-esteem (B = −0.338, P < .001) and optimism (B = −0.361, P < .027) tended to have higher levels of depressive symptoms. Spouses whose stroke survivors had lower levels of self-esteem (B = −0.047, P = .036) also had higher levels of depressive symptoms.

Conclusion: We found significant partner effects of self-esteem on depression for both members and partner effect of optimism on patient’s depressive symptoms. These findings suggest that further research is needed to determine if dyadic interventions may help to improve self-esteem, optimism, and depressive symptoms in both patients and their caregivers.

Misook L. Chung, PhD, RN, FAHA, FAAN Associate Professor, Codirector, RICH Heart Program, College of Nursing, University of Kentucky, Lexington.

Tamilyn Bakas, PhD, RN, FAHA, FAAN Professor and Chair, Department of Science of Nursing Care, School of Nursing, Indiana University, Indianapolis.

Laura D. Plue, MA Indiana University School of Medicine and Qualitative Research Coordinator, Stroke QUERI Center for Health Information and Communications, Richard L. Roudebusch Veterans Administration Medical Center, Indianapolis.

Linda S. Williams, MD, FAHA, FAAN Professor of Neurology, Indiana University School of Medicine and Richard L. Roudebusch Veterans Administration Medical Center, Indianapolis.

This research was funded by the National Institutes of Health, National Institute of Neurological Disorders and Stroke R01 NS39671 (Dr Williams, PI) and the National Institute of Nursing Research R01 NR010388 (Dr Bakas, PI).

The authors have no conflicts of interest to disclose.

Correspondence Misook L. Chung, PhD, RN, FAHA, FAAN, College of Nursing, University of Kentucky, 529 CON Building, 760 Rose St, Lexington, KY 40536-0232 (

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Depression is a common complication of stroke survival. Although the prevalence of depression varies depending on assessment measures, diagnostic criteria, sample selection, and time of assessment, researchers have reported up to 30% to 50% of stroke survivors with major depression and 8% to 22% with minor depression.1 Importantly, family caregivers also experience psychological distress related to their caregiving responsibility. Up to 55% of spousal caregivers have been reported to experience depression or depressive symptoms after stroke.2,3

There is substantial evidence that depression is associated with poor outcomes for stroke survivors as well as their family caregivers.1,4,5 The presence of both depressive symptoms and major depression has been associated with delayed stroke recovery, recurrent stroke, and longer hospital stays in stroke survivors.1,5 Furthermore, in a recent meta-analysis of 13 studies (n = 59 598), depressed stroke survivors had a 52% higher risk of mortality than did stroke survivors without depression.4 On the other hand, caregiver depression is also known to be a contributing factor of their poor health outcomes, including an increased risk of cardiovascular disease. In a large longitudinal cohort study with an 8-year follow-up period, spousal caregivers had a 35% higher risk of cardiovascular disease events than did spouses without caregiving responsibility, and the risk was increased to 48% when the spousal caregivers also had depression.6

Because of the high levels of depression and the severe impact of depression on health outcomes for both stroke survivors and their spousal caregivers, early recognition and treatment for depression are important for stroke survivor-spouse dyads. Identifying factors associated with depression is also important to guide development of prevention strategies for depression. Self-esteem, optimism, and perceived control are a few personal characteristics that are considered personal resources facilitating positive perceptions of stressful situations and providing inner strength to cope with chronic disease.7–9 Self-esteem is an overall personal evaluation of one’s own worth or value and involves accepting oneself.10 Negative self-esteem predicts the onset of depression, and positive self-esteem is associated with recovery of depression.7,11 Substantial evidence supports the relationship between low self-esteem and depression in various populations, including patients with heart disease.12–16 Similar findings are reported in caregivers of frail older people and cancer patients.17,18 Optimism is defined as a general expectation for positive rather than negative experiences in the future.8,19 Optimism and psychological distress have been found to be related in persons with a variety of medical conditions (eg, cancer, surgery, postpartum, stroke).8,20–27 Optimism has also played a role in psychological distress among family caregivers of patients with chronic illness (eg, cancer and Alzheimer’s disease).28,29 Sense of control is defined as a person’s real or perception of control for the conditions and events of one’s life and has been found to be associated with depression.9,30 According to control theory, sense of internal control is associated with lower levels of depression, whereas sense of external control is associated with high levels of depression.9,30 There is substantial evidence in the literature on the role of control in the stress process, and sense of control is also associated with depression in patients with cardiac disease, including stroke,31–34 and in caregivers of stroke patients.35

Most previous studies have investigated relationships between depression and the personal characteristics of self-esteem, optimism, and sense of control by focusing on the individual level of analysis, but no studies were found using the dyad level of analysis. Recently, the need for dyadic research and treatment in poststroke depression has been emphasized,36 but there is a lack of evidence about whether these individual personal factors can influence or be associated with their partner’s depression within patient-caregiver dyads. Investigating these relationships among stroke patients and their caregivers is challenging because it requires measurement of these variables from both members in a dyad. Appropriate statistical strategies like multilevel modeling techniques are needed to control for nonindependence in outcomes between stroke survivors and their family caregivers. Stroke survivors and their family caregivers are in an interpersonal dependent relationship in which they share their thoughts, beliefs, emotions, and behaviors as they receive and provide support to each other after stroke.

Given the high prevalence of depression in stroke survivors and their caregivers, and their interdependent relationship within dyads during poststroke management, it can be hypothesized that individuals’ self-esteem, optimism, and perceived control may contribute to their partner’s depression. Although this assumption may seem obvious logically, to date, researchers have not examined this association using an appropriate statistical analysis, which is dyadic analysis, in the context of depression and stroke. Therefore, the purpose of this study is to examine whether individuals’ self-esteem, optimism, and perceived control predict their own, as well as their partner’s, depressive symptoms using a multilevel dyadic analysis among stroke survivors and their spousal caregivers.

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Study Design and Sample

This study was a secondary analysis of baseline data from the randomized, controlled Active-Initiate-Monitor (AIM) study that consisted of 3 steps: (1) activating the dyads to understand and accept depression diagnosis and treatment, (2) initiating antidepressant medication, and (3) monitoring the effects of the treatment.37 The purpose of the parent AIM study was to examine the effects of a care management intervention program on poststroke depression and quality of life in stroke survivors at 6 and 12 weeks. A detailed study summary, procedures, and results from the AIM study have been previously published.37–39

After all potentially eligible subjects were identified during stroke hospitalization from 4 major hospitals in Indianapolis, they were invited to be screened for depression for possible study enrollment 1 to 2 months after stroke. Only those with scores of 5 or higher on the 9 items of the Patient Health Questionnaire (PHQ-9) or those with at least 2 symptoms on the PHQ-9, or those with the depressed mood or anhedonia item in the initial depression screening were administered the Structured Clinical Interview for Depression. Stroke survivors were included in the AIM parent study if they were diagnosed with ischemic stroke and had major or minor depression in the clinical interview for Diagnostic and Statistical Manual of Mental Disorders (4th Edition) and if they had no severe language (a score <2 on the National Institute of Health Stroke language item) and cognitive (a score >3 on the modified 6-item Mini-Mental Status Examination) impairment and if their life expectancy was at least 6 months.37–39

In the parent study AIM, caregivers, who were able to read and understand English, were also invited to complete the survey if they were an unpaid family member or significant other of the stroke survivor and providing care after discharge to the home setting. In the AIM parent study, a total of 227 stroke survivors within 2 months after stroke and their family caregivers participated. The participated caregivers were spouses (n = 122), son/daughter or son/daughter in law (n = 66), other relatives (n = 28), and others (n = 11).

In this secondary analysis, we selected only the 112 stroke survivors and their spouses who completed baseline data, which include all the main variables in this study, before randomization into either the intervention group or the usual care group. The rationale for selecting dyads with a spousal relationship was that spousal caregivers were considered to be in a more interdependent relationship with patients than other types of caregivers because a spouse is considered to play a primary caregiving role and to be engaged in active day-to-day involvement with stroke survivors. A strong interdependency between dyad members is 1 assumption in dyadic analysis. Although data were collected from patient-caregiver dyads in the AIM study,37–39 dyadic data analysis had not yet been conducted to test interdependent relationships among stroke survivors and their spousal caregivers.

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Self-esteem was defined as a global judgment and attitudes about self-worth and was assessed using the Rosenberg Self-esteem Scale.10 The Self-esteem Scale has 10 items rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The total score ranges from 10 to 50, and higher scores indicate positive global attitudes about the self. Validity has been examined in many populations, including stroke patients, and evidence of internal consistency has been reported, with a Cronbach’s α of .83 in stroke patients and .73 in stroke caregivers.15,40

Optimism was measured using the 6-item Revised Life Orientation Test,41 which assessed generalized expectancies for positive and negative outcomes. All items are rated on a 5-point Likert scale from 0 (strongly disagree) to 4 (strongly agree). Item scores are summed after 3 negative items are reverse-scored. The total scores can range from 0 to 24, and a higher score indicates greater overall optimism. The Revised Life Orientation Test has been used to assess optimism of stroke caregivers, and evidence of reliability (eg, Cronbach’s α from .73 to .82) and validity has been previously demonstrated.20,40,41

Perceived control was defined as a person’s sense of control over his/her own life and was assessed using the Sense of Control Scale.9,30 This scale has 8 items that are coded from −2 (strongly disagree) to +2 (strongly agree). The total score was computed based on the 4 different types of control factors (ie, external and internal locus of control, good and bad outcome), with higher scores indicating higher levels of perceived control.9,30 The concurrent validity with Rotter’s locus of control (r = 0.705) and construct validity using confirmatory factor analysis supported validity.30 Although the reported reliability of 8 items was low, between .574 and .633, the developers reported that this measure provided a reasonable degree of efficiency with similar reliability to other measures of control.30

Depressive symptoms were assessed using the PHQ-9.42 The PHQ-9 was developed based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria of depression. Each item is rated on a 4-point scale ranging from not at all to nearly every day. Total score ranges from 0 to 27, and higher scores indicate higher levels of depressive symptoms. The PHQ-9 is used widely among stroke survivors and caregivers, with evidence of good internal consistency reliability (Cronbach’s α from .82 to .86) and validity.20,37,40,43

The sociodemographic characteristics of all participants were collected using structured questionnaires at the baseline assessment in the parent study. In this secondary data analysis, we reported age, gender, education, race, and marital status. We also collected information about treatments of depression (ie, antidepressants use and counseling) in the past at the baseline assessment.

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Data Analysis

All analyses were conducted using SPSS for Windows, version 20. An α level of .05 was used throughout to determine statistical significance. Descriptive statistics were used to describe the sociodemographic characteristics of dyad members. Chi-square tests were used to compare education (categorical variable). Paired t tests were used to compare age, education (continuous variable), and levels of predictor and outcome variables between stroke survivors and their caregivers. Pearson correlations were used to determine bivariate associations among variables.

Multilevel dyadic modeling, called the actor-partner interdependence model (APIM) regression with distinguishable dyads, was used to determine influences of individual factors on outcomes within the dyad.44 Two dyad members are considered distinguishable based on their roles (ie, care-recipients and caregivers) in stroke rehabilitation. In the APIM for this study, the actor effect is the impact of a person’s factors (ie, self-esteem, optimism, and perceived control) on his/her own depressive symptoms, and the partner effect is the impact of a person’s factors on his/her partner’s depressive symptoms. All dyad data were restructured to a pairwise dyadic data set. We created grand-mean centered scores that were standardized using z scores to obtain unstandardized and standardized regression coefficients for actor and partner effects. The residual structure was treated as heterogeneous compound symmetry in this APIM analysis.44

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Characteristics of the dyads

Stroke survivors in this study were predominantly white and two-thirds were men (Table 1). The mean (SD) age was 62.5 (12.3) years. The poststroke duration ranged between 2 and 3 months. About two-thirds of survivors had an education level of high school graduation or less. In this secondary study, 37% of the stroke survivors were diagnosed with depression and received treatment, 33% took antidepressants, and 15% received counseling before baseline. At baseline, 27% of the stroke survivors were on antidepressants and 5% had received depression counseling. In this study, there were no same-sex marriages. Spousal caregivers were, on average, 1.9 years younger than stroke survivors (P < .05). There was no significant difference in education level between patients and caregivers. Only 39% of caregivers worked at a full- or part-time job, and 40% were retired. The rest were homemakers, unemployed, or on disability. Most caregivers (76%) reported that there was no change in their work due to their caregiving responsibilities. Before baseline, 20% of caregivers reported having a diagnosis of depression, and 26% took antidepressants and 15% received counseling. At the baseline assessment, a few caregivers reported taking antidepressants (15%) or receiving counseling for depression (5%).



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Depressive Symptoms, Self-esteem, Optimism, and Perceived Control in the Dyads

As shown in Table 2, stroke survivors had significantly higher levels of depressive symptoms and lower levels of self-esteem than caregivers did. The levels of optimism and perceived control were similar between dyad members.



The correlations among predictors and outcome variables between and within dyad members (Table 3) indicated that the depressive symptom levels of stroke survivors were positively correlated with that of caregivers (r = 0.255, P < .01). However, stroke survivor self-esteem, optimism, and perceived control levels were not significantly correlated with those of caregivers. Within stroke survivors, there were significantly moderate correlations among self-esteem, optimism, and perceived control predictors (r = 0.388 to 0.693), and these predictors were significantly correlated with their own depressive symptoms (r = −0.241 to −0.498). Within caregivers, their self-esteem, optimism, and perceived control were moderately correlated (r = 0.461 to 0.627), and these predictors were also significantly associated with their own depressive symptoms (r = −0.246 to −0.316). All correlation coefficients were less than 0.7.



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Self-esteem and Depression

The detailed results of the APIM analysis are presented in Table 4, and only the significant findings of the APIM are shown in the Figure. There were statistically significant results for the actor effects of self-esteem on depressive symptoms for both stroke survivors and spousal caregivers. This means that individuals who had higher levels of self-esteem were more likely to have lower levels of depressive symptoms. Specifically, a 1-unit increase in self-esteem was associated with a 0.434-unit decrease in depressive symptoms for stroke survivors and a 0.09-unit decrease in depressive symptoms for caregivers. There was evidence of partner effects of self-esteem on depressive symptoms for both members. Every 1-unit increase in caregivers’ self-esteem was associated with a 0.337-unit decrease in the stroke survivor’s depressive symptoms, whereas every 1-unit increase in stroke survivors’ self-esteem was associated with a 0.047-unit decrease in the caregivers’ depressive symptoms. When we compared standardized coefficients of the actor and partner effects, for stroke survivors, the partner effect of caregivers’ self-esteem was strong as 78% of actor effect on their own depressive symptoms. For caregivers, the partner effect of stroke survivors’ self-esteem was strong as 52% of the actor effect on their own depressive symptoms.





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Optimism and Depression

Optimism exerted a significant actor effect for both stroke survivors and caregivers. Individuals with higher levels of optimism were more likely to have lower levels of depressive symptoms; a 1-unit increase in optimism was associated with a 0.407-unit decrease in depressive symptoms for stroke survivors and 0.188-unit decrease in depressive symptoms for caregivers. There was only a significant partner effect of optimism on depressive symptoms for stroke survivors. That means that stroke survivors whose spouses had higher levels of optimism were more likely to have lower levels of depressive symptoms; every 1-unit increase in caregiver optimism was associated with a 0.361-unit decrease in stroke survivors’ depressive symptoms. This partner effect was 88.7% of actor effect of the optimism on depressive symptoms for stroke survivors.

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Perceived Control and Depression

Perceived control exhibited only significant actor effects for each member in the dyads. Individuals who had higher levels of perceived control had lower levels of depressive symptoms. For each 1 unit of increase in actor perceived control, there was a 2.75-unit decrease in depressive symptoms for stroke survivors and a 0.86-unit decrease in depressive symptoms for caregivers. There were no significant partner effects of perceived control on depressive symptoms. Although there was a tendency toward a decrease in stroke survivor depressive symptoms as caregiver perceived control increased, this relationship did not reach statistical significance.

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In this dyadic study, we have examined whether individuals’ self-esteem, optimism, and perceived control were associated with their own depressive symptoms as well as their partner’s depressive symptoms in stroke survivors and their spousal caregivers. We found that stroke survivors’ and spousal caregivers’ self-esteem, optimism, and perceived control were significantly associated with their own depressive symptoms. Self-esteem is known to be associated with depression in stroke survivors.16 According to research by Vickery et al,15 stroke survivors tend to have lower levels of self-esteem in the days after a stroke, and there is a strong association between self-esteem and depressive symptoms. In a 4-year prospective cohort study of stroke survivors (n = 1380), Morgenstern and colleagues20 reported that poor optimism was significantly associated with severe depression. They also reported that severe depression was associated with increased risk of mortality (hazard ratio, 1.32; 95% confidence interval, 1.02–1.72).20 A link between perceived control and depression has also been reported in stroke and cardiovascular disease and caregivers.31–34 Until this point, there has been substantial evidence of the association between these factors and depression in individuals with chronic diseases or caregivers at the individual level of analysis. Our study advanced the state of the science by specifically investigating these associations at the dyad level of analysis.

Our most compelling finding was the significant partner effects of self-esteem on depressive symptoms in both stroke survivors and caregivers that we observed in the APIM model. These findings provide strong evidence on how each member’s self-esteem within the dyad unit influences the other’s depressive symptoms during the early stages of stroke rehabilitation. Surprisingly, the partner effect of self-esteem was as strong as at least half to two-thirds of the actor effects on their own depressive symptoms. This finding is important because it suggests that intervening to increase one person’s self-esteem might simultaneously decrease depressive symptoms in the other member of the dyad. To our knowledge, this phenomenon of mutual influence has not been reported in the stroke literature. Our study provides new information on how stroke survivors and their spousal caregivers may influence each other’s depressive symptoms. The finding suggests that more research is warranted to explore the usefulness of dyadic interventions in addressing self-esteem in patients and their spouses.

We also found that the partner effect of spousal caregivers’ optimism was strong—close to the actor effect on stroke survivor’s depressive symptoms. This result indicates that only stroke survivors were more susceptible to depressive symptoms when their spouses had lower levels of optimism. This result about the partner effect of caregivers’ optimism on patient depressive symptoms has also not been reported in the literature. Patient’s optimism was not associated with caregiver’s depression.

It is important to note that the stroke survivors and their spouses reported only significant actor effects but no partner effects for perceived control on depressive symptoms. That means that the person’s depressive symptoms were affected by only his/her own score of perceived control, not by their spouses’ perceived control, and the partner is irrelevant in this context. The reason for this actor-oriented finding for perceived control is not clear. It is possible that many stroke survivors and their spouses did not display their sense of control to their partners, or it is possible that sense of control is not easy transmittable within interpersonal relationships; thus, individuals’ depression is affected only by their own perceived control, and not by their partner. Although we could not find a statistically significant mutual influence of perceived control in this study, the trend of the partner effect of perceived control on the stroke survivor’s depressive symptoms warrants further investigation.

The observed phenomena of partner effects among the dyads may be explained by the interdependence theory.45 According to the interdependence theory,45 strong interpersonal interactions exist between members of a dyad who are in a close interpersonal relationship. Individuals’ emotions, cognitions, or behaviors are easily transferred from person to person when interactions between members of a dyad are active. Eventually, individuals’ emotion, cognition, and behaviors may influence their partner’s health outcomes. The strength of individuals’ cognition, emotion, or behavioral influence on their partner may depend on the dynamic interpersonal relationship between the 2 members of the dyad. The findings from this study provide evidence of an interdependent relationship between stroke survivors and spousal caregivers during the early stage of stroke rehabilitation.

There is substantial knowledge about poststroke depression and factors associated with depression in individuals (either stroke survivors or their caregivers).15,16,20,31–33,46 The individual approach, however, underestimates the influence of dynamic, interpersonal interactions between care recipients and their caregivers. Researchers have rarely investigated whether these factors predicted depression at the dyadic level. Investigations of dyadic factors of depression in stroke survivor-caregiver couples are still in the early stages of research. In addition, most researchers have investigated dyadic factors mainly by focusing on interpersonal relationships between dyad members, including marital satisfaction, family function, and dyad coping strategies.47,48

Investigating the factors associated with depression at the dyadic level is a challenging task. Common barriers in conducting dyadic research are conceptualizing problems at the dyad level, recruiting both members of a dyad, and collecting data using same measures from dyads.36 Another challenge is the analytic approach with dyadic data. Nonindependence of observed data between individual members in dyads and measurement of dyad-level predictor variables require sophisticated statistical approaches such as multilevel dyadic analysis.36,44 Despite the importance of expanding our knowledge about dyadic approaches in poststroke depression research, few researchers have examined cross-partner effects of depression on health outcomes in stroke survivor-caregiver dyads using dyadic data.36 To the best of our knowledge, this study is the first to examine predictors (ie, self-esteem, optimism, and perceived control) of depressive symptoms at the dyadic level in stroke survivors and spousal caregivers using a multilevel model dyadic approach. The findings of this study highlight the ability of dyadic statistics to determine how an individual’s self-esteem, optimism, and perceived control influence depressive symptoms for both members of the dyad.

There are several clinical and research implications that can be generated from our study. First, healthcare providers should be aware of the presence of dynamic interpersonal relationships, the consequence of dynamic interaction between members of dyads, and the possibility of mutual influence on a partner’s outcome among stroke survivors and their spousal caregivers during early stroke rehabilitation. Stroke survivors and their spouses function as a team as well as individuals. Thus, clinicians should approach stroke survivors and their spousal caregivers as a pair in the assessment of depressive symptoms. Second, we have identified several important factors to consider at the dyadic level that will be useful to design effective interventions to reduce depressive symptoms. Although dyadic interventions may maximize the intervention effect on depressive symptoms in dyads, this assumption needs to be examined in the future.

According to a recent scientific statement by the American Heart Association/American Stroke Association,49 17 caregiver interventions and 15 dyadic interventions were critically analyzed to determine whether they improved stroke survivor and caregiver outcomes; however, none of the studies reported findings using a dyadic approach to data analysis. Of the 15 dyadic interventions, most (n = 14, 93.3%) resulted in improved outcomes for stroke survivors; however, only 9 (60%) reported significant outcomes for caregivers. None of the dyadic interventions reported significant improvements in survivor or caregiver depressive symptoms. Of the 17 caregiver interventions, 16 (94%) resulted in improved outcomes for the caregivers, but only 4 (23.5%) reported improvements in survivor outcomes.

Many of the caregiver intervention studies did not measure survivor outcomes. Only 1 caregiver intervention study reported significant improvements in depressive symptoms for both survivors and caregivers.50 This was a randomized controlled clinical trial by Kalra and colleagues50 targeting 300 stroke caregivers who received 3 to 5 inpatient sessions and 1 home visit in the intervention group. The intervention provided tailored psychoeducation and skill-building strategies (eg, hands-on training and goal setting) for the caregiver; however, most of the content of the intervention focused on the care provided to the survivor, rather than the caregiver’s own self-care. The scientific statement emphasized the need for interventions to address the needs of both survivors and caregivers49 and, when studying depressive symptoms as an outcome, ensure that survivors and caregivers exhibit sufficient depressive symptoms at baseline to demonstrate significant improvements.49 Interventions that combine skill building (eg, problem solving, stress management, goal setting) with tailored psychoeducational strategies were recommended, along with interventions that are delivered face to face and/or by telephone.50 Although only 2 studies cited in the scientific statement used Web-based interventions,49 the use of modern technology (eg, smart phones, tablets, or telehealth) is important for the future development of interventions, especially for dyads living in rural areas or dyads who experience barriers to access to care.

The significant mutual influence in this study suggests that depressed stroke survivors may benefit from interventions that improve spousal caregiver self-esteem and optimism. According to Bakas et al,40 caregiver optimism levels were significantly increased by an 8-week telephone intervention for caregivers that consisted of stroke education and skill building. The intervention addressed caregiver knowledge about stroke, providing personal care and instrumental care, managing survivor emotions and behaviors, and dealing with the caregiver’s own personal responses to providing care using skill-building strategies such as problem solving and stress management. Further research on this intervention, as well as other interventions to improve caregiver self-esteem and optimism, is warranted.

There are a few limitations to this study. First, this study is a secondary data analysis using cross-sectional data, and our results are based on a predictive regression model, not a causal model. In addition, we did not control for possible confounding variables of depression outcomes such as demographic (eg, age, gender) or clinical (eg, location of stroke, comorbidity, disability) characteristics. Another limitation is possible confounding effects of antidepressants or alternative nonpharmacological treatment for depressive symptoms. Adherence to antidepressants is crucial in improving depressive symptoms. A few participants were on antidepressants at the baseline assessment, but we did not assess their adherence behavior to antidepressants and nonpharmacological treatments. Thus, we need to be cautious in interpretation of study findings and we cannot infer direct causality based on the simple 2-variable relationships. Nevertheless, because examining the associations in this study was based on mutual influence on outcomes based on the interdependence theory,44 future replicated findings will enhance the causal relation among variables.

Second, generalizability may be limited because the selection of study dyads was purposefully narrowed to those who met the inclusion criteria for the primary intervention study of stroke survivors. For example, stroke survivors who were excluded because of language or cognitive impairment in the parent study may have severe depression or be more interdependent with their family caregivers.

Third, although we assumed that spouses were the primary caregivers and the primary sources of support, it is possible that some couples who have poor quality of marriage or conflicts in their interpersonal relationship may have different associations between personal characteristics and depression.

Finally, because this study focused only on spousal caregivers, it is not known whether nonspousal family caregivers have similar effects on patient outcomes. Stroke survivors may interact more with nonspousal caregivers (ie, son and daughters). Selecting only stroke survivors with spousal caregivers in this study may result in the sample not being representative of the stroke population. It is necessary to replicate the study in the dyads who demonstrate strong interdependent relationships rather than selecting specific types of caregivers.

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Using a multilevel dyadic statistical approach, this study highlights the important mutual contribution that individuals’ self-esteem, optimism, and perceived control can have on both their own depressive symptoms and their partner’s depressive symptoms. Specifically, the spouses’ self-esteem and optimistic view were found to be associated with stroke survivors’ depressive symptoms, and this finding suggests that depressed stroke survivors may benefit from interventions that improve spousal self-esteem and optimism.

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What’s New and Important

  • Stroke survivors and their spousal caregivers have an interdependent relationship in stroke rehabilitation.
  • Identifying predictors of depressive symptoms were investigated at the stroke survivor-caregiver dyad level using the dyadic statistical approach.
  • Spouses’ levels of self-esteem and optimism were associated with stroke survivor’s levels of depressive symptoms.
  • Stroke survivor’s levels of self-esteem were associated with their spouses’ levels of depressive symptoms.
  • The evidence of mutual influence in stroke survivors and their spousal caregivers provides a direction for future dyadic interventions.
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1. Turner-Stokes L, Hassan N. Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway, part 1: diagnosis, frequency and impact. Clin Rehabil. 2002; 16: 231–247.
2. Cameron JI, Cheung AM, Streiner DL, Coyte PC, Stewart DE. Stroke survivors’ behavioral and psychologic symptoms are associated with informal caregivers’ experiences of depression. Arch Phys Med Rehabil. 2006; 87: 177–183.
3. Denno MS, Gillard PJ, Graham GD, et al. Anxiety and depression associated with caregiver burden in caregivers of stroke survivors with spasticity. Arch Phys Med Rehabil. 2013; 94: 1731–1736.
4. Bartoli F, Lillia N, Lax A, et al. Depression after stroke and risk of mortality: a systematic review and meta-analysis. Stroke Res Treat. 2013; 2013: 862978.
5. Pohjasvaara T, Vataja R, Leppavuori A, Kaste M, Erkinjuntti T. Depression is an independent predictor of poor long-term functional outcome post-stroke. Eur J Neurol. 2001; 8: 315–319.
6. Capistrant BD, Moon JR, Berkman LF, Glymour MM. Current and long-term spousal caregiving and onset of cardiovascular disease. J Epidemiol Community Health. 2012; 66: 951–956.
7. Brown GW, Bifulco A, Andrews B. Self-esteem and depression, 4: effect on course and recovery. Soc Psychiatry Psychiatr Epidemiol. 1990; 25: 244–249.
8. Carver CS, Scheier MF, Segerstrom SC. Optimism. Clin Psychol Rev. 2010; 30: 879–889.
9. Mirowsky J, Ross CE. Control or defense? Depression and the sense of control over good and bad outcomes. J Health Soc Behav. 1990; 31: 71–86.
10. Rosenberg M. Society and the Adolescent Self image. Middletown, CT: Wesleyan University Press; 1989.
11. Brown GW, Andrews B, Bifulco A, Veiel H. Self-esteem and depression, 1: measurement issues and prediction of onset. Soc Psychiatry Psychiatr Epidemiol. 1990; 25: 200–209.
12. Cohen M, Mansoor D, Langut H, Lorber A. Quality of life, depressed mood, and self-esteem in adolescents with heart disease. Psychosom Med. 2007; 69: 313–318.
13. Lemola S, Raikkonen K, Gomez V, Allemand M. Optimism and self-esteem are related to sleep: results from a large community-based sample. Int J Behav Med. 2013; 20: 567–571.
14. Vickery CD, Evans CC, Lee JE, Sepehri A, Jabeen LN. Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation. Rehabil Psychol. 2009; 54: 372–380.
15. Vickery CD, Sepehri A, Evans CC. Self-esteem in an acute stroke rehabilitation sample: a control group comparison. Clin Rehabil. 2008; 22: 179–187.
16. Fung LC, Lui MH, Chau JP. Relationship between self-esteem and the occurrence of depression following a stroke. J Clin Nurs. 2006; 15: 505–506.
17. Bachner YG, Karus DG, Raveis VH. Examining the social context in the caregiving experience: correlates of global self-esteem among adult daughter caregivers to an older parent with cancer. J Aging Health. 2009; 21: 1016–1039.
18. Aggar C, Ronaldson S, Cameron ID. Self-esteem in carers of frail older people: resentment predicts anxiety and depression. Aging Mental Health. 2011; 15: 671–678.
19. Scheier MF, Carver CS. Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol. 1985; 4: 219–247.
20. Morgenstern LB, Sanchez BN, Skolarus LE, et al. Fatalism, optimism, spirituality, depressive symptoms, and stroke outcome: a population-based analysis. Stroke. 2011; 42: 3518–3523.
21. Achat H, Kawachi I, Spiro A 3rd, DeMolles DA, Sparrow D. Optimism and depression as predictors of physical and mental health functioning: the Normative Aging Study. Ann Behav Med. 2000; 22: 127–130.
22. Carver CS, Pozo-Kaderman C, Harris SD, et al. Optimism versus pessimism predicts the quality of women’s adjustment to early stage breast cancer. Cancer. 1994; 73: 1213–1220.
23. Giltay EJ, Geleijnse JM, Zitman FG, Hoekstra T, Schouten EG. Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly Dutch men and women. Arch Gen Psychiatry. 2004; 61: 1126–1135.
24. Nes LS, Segerstrom SC. Dispositional optimism and coping: a meta-analytic review. Pers Soc Psychol Rev. 2006; 10: 235–251.
25. Rasmussen HN, Scheier MF, Greenhouse JB. Optimism and physical health: a meta-analytic review. Ann Behav Med. 2009; 37: 239–256.
26. Scheier MF, Matthews KA, Owens JF, et al. Optimism and rehospitalization after coronary artery bypass graft surgery. Arch Intern Med. 1999; 159: 829–835.
27. Zenger M, Brix C, Borowski J, Stolzenburg JU, Hinz A. The impact of optimism on anxiety, depression and quality of life in urogenital cancer patients. Psychooncology. 2010; 19: 879–886.
28. Given CW, Stommel M, Given B, Osuch J, Kurtz ME, Kurtz JC. The influence of cancer patients’ symptoms and functional states on patients’ depression and family caregivers’ reaction and depression. Health Psychol. 1993; 12: 277–285.
29. Hooker K, Monahan D, Shifren K, Hutchinson C. Mental and physical health of spouse caregivers: the role of personality. Psychol Aging. 1992; 7: 367–375.
30. Mirowsky J, Ross CE. Eliminating defense and agreement bias from measures of the sense of control: a 2 × 2 index. Soc Psychol Q. 1991; 54: 127–145.
31. Dracup K, Westlake C, Erickson VS, Moser DK, Caldwell ML, Hamilton MA. Perceived control reduces emotional stress in patients with heart failure. J Heart Lung Transplant. 2003; 22: 90–93.
32. Ellis-Hill CS, Horn S. Change in identity and self-concept: a new theoretical approach to recovery following a stroke. Clin Rehabil. 2000; 14: 279–287.
33. Moser DK, Riegel B, McKinley S, et al. The Control Attitudes Scale–Revised: psychometric evaluation in three groups of patients with cardiac illness. Nurs Res. 2009; 58: 42–51.
34. Chung ML, Pressler SJ, Dunbar SB, Lennie TA, Moser DK. Predictors of depressive symptoms in caregivers of patients with heart failure. J Cardiovasc Nurs. 2010; 25: 411–419.
35. Molloy GJ, Johnston DW, Johnston M, et al. Extending the demand-control model to informal caregiving. J Psychosom Res. 2005; 58: 243–251.
36. McCarthy MJ, Lyons KS, Powers LE. Expanding poststroke depression research: movement toward a dyadic perspective. Top Stroke Rehabil. 2011; 18: 450–460.
37. Williams LS, Kroenke K, Bakas T, et al. Care management of poststroke depression: a randomized, controlled trial. Stroke. 2007; 38: 998–1003.
38. Schmid AA, Damush T, Tu W, et al. Depression improvement is related to social role functioning after stroke. Arch Phys Med Rehabil. 2012; 93: 978–982.
39. Schmid AA, Kroenke K, Hendrie HC, Bakas T, Sutherland JM, Williams LS. Poststroke depression and treatment effects on functional outcomes. Neurology. 2011; 76: 1000–1005.
40. Bakas T, Farran CJ, Austin JK, Given BA, Johnson EA, Williams LS. Stroke caregiver outcomes from the telephone assessment and skill-building kit (task). Top Stroke Rehabil. 2009; 16: 105–121.
41. Scheier MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J Pers Soc Psychol. 1994; 67: 1063–1078.
42. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001; 16: 606–613.
43. Williams LS, Brizendine EJ, Plue L, et al. Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke. 2005; 36: 635–638.
44. Kenny DA, Kashy DA, Cook WL. Dyadic Data Analysis. New York, NY: The Guilford Press; 2006.
45. Kelley HH, Thibaut TW. Interpersonal Relations: A Theory of Interdependence. New York: John Wiley & Sons; 1978.
46. Taylor-Piliae RE, Hepworth JT, Coull BM. Predictors of depressive symptoms among community-dwelling stroke survivors. J Cardiovasc Nurs. 2013; 28: 460–467.
47. Epstein-Lubow GP, Beevers CG, Bishop DS, Miller IW. Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors. Arch Phys Med Rehabil. 2009; 90: 947–955.
48. Visser-Meily A, Post M, van de Port I, Maas C, Forstberg-Warleby G, Lindeman E. Psychosocial functioning of spouses of patients with stroke from initial inpatient rehabilitation to 3 years poststroke: course and relations with coping strategies. Stroke. 2009; 40: 1399–1404.
49. Bakas T, Clark PC, Kelly-Hayes M, King RB, Lutz BJ, Miller EL. Evidence for stroke family caregiver and dyad interventions: a statement for healthcare professionals from the American Heart Association and American Stroke Association. Stroke. 2014; 45: 2836–2852.
50. Kalra L, Evans A, Perez I, et al. Training carers of stroke patients: randomised controlled trial. BMJ Clin Res Ed. 2004; 328: 1099.

depression; family study; stroke management

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