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ORIGINAL ARTICLE
Ahead of print publication  

Dyadic congruence, dyadic coping, and psychopathology: Implications in dyads for patients with acute coronary syndrome


1 Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
2 Department of Criminology and Behavioural Sciences, Rashtriya Raksha University, Gandhinagar, Gujarat, India
3 Department of Cardiology, Base Hospital, New Delhi, India
4 Department of Cardiology, Military Hospital, Jalandhar, Punjab, India

Date of Submission25-Jul-2022
Date of Decision09-Aug-2022
Date of Acceptance25-Aug-2022
Date of Web Publication10-Jan-2023

Correspondence Address:
Romita Mitra,
M.Phil Clinical Psychology, Project Associate, NIMHANS, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_124_22

  Abstract 


Introduction: Along with a worldwide growth of individuals diagnosed with coronary heart disease (CHD), the number of adults affected with acute coronary syndrome (ACS) has substantially increased over a period of time. Such negative effects are not only limited to the patient but also extend to the caregiver. With this growing importance of caregiving among dyads, there comes a commensurate need to carefully exploring the impact of the relationship on the mental and possible overall health of both. The aim of this study is to examine the impact of dyadic coping as a mediator in the relationship between dyadic congruence and psychopathology of patient-caregiver dyads with acute coronary syndrome. Materials and Method: The present study was of a cross-sectional design. A total of 216 dyads (108 patients and 108 caregivers) were selected for this study. All the participants were chosen from Base Hospital and SGT Hospital, India. Data was collected through survey which included measures to test dyadic congruence, dyadic coping, depression, anxiety and somatic symptoms. Results: Correlation and mediation analysis was carried out for statistical analysis. Dyadic coping significantly mediated the relationship between dyadic congruence and psychopathology among patients with acute coronary syndrome and their caregivers. Conclusion: The findings of the present study throw a light on the impact of dyadic congruence and dyadic coping on the mental health of both patients with acute coronary syndrome and their caregivers.

Keywords: Acute coronary syndrome, anxiety, depression, dyadic congruence, dyadic coping, psychopathology



How to cite this URL:
Mitra R, Pujam S N, Jayachandra A, Sharma P. Dyadic congruence, dyadic coping, and psychopathology: Implications in dyads for patients with acute coronary syndrome. J Mar Med Soc [Epub ahead of print] [cited 2023 Feb 6]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=367486




  Introduction Top


Along with a worldwide growth of individuals diagnosed with coronary heart disease (CHD), the number of adults affected with acute coronary syndrome (ACS) has substantially increased over a period of time.[1] The prevalence of this clinical syndrome among adults in urban India has shown a considerable rise at its rate and has been found to be more common among young adults in comparison to North America and Western Europe.[1] External risk factors such as a high amount of exhaustion on a daily basis, job strains leading to excessive burnout, and poor financial conditions have detrimental effects, severely cause psychological distress, and are highly responsible for deterioration of one's cardiovascular health.[2] In addition, a plethora of epidemiological research has emphasized the severity of negative effects of psychosocial and emotional distress, difficult personality and temperament patterns, and certain psychiatric disorders on the development and prognosis of ACS.[3] Such negative effects are not only limited to the patient but also extend to the caregiver. Illness management is mainly carried out at home by the patients and their respective informal caregivers (dyads).[4] "Dyads" can be spouses, parents or their children, or any two parties who share a common involvement in each other's lives. However, in this study, only patients and their spouses who also are their caregivers have been considered as dyads and the relationship between them as "dyadic."[4] Similarly, for individuals with CHD, their caregivers share an integral involvement when it comes to managing the illness.[5] With this growing importance of caregiving among dyads, there comes a commensurate need to carefully examine factors associated with optimal dyadic care, that is exploring the impact of the relationship on the mental and possible overall health of the patient. The disagreement regarding management of illness between patients and their caregivers is termed dyadic incongruence. Dyadic incongruence among couples has been suggested to result in poorer adherence to treatment as well as medical recommendations and ultimately to worsening of coronary symptoms along with a compromise on the quality of life for both.[5] It has been established that within a dyad, informal caregivers of patients with coronary syndrome experience relatively decreased general well-being.[6],[7] Such couples often struggle when it comes to adapting to the changes which they are expected to make in their lives as a result of performing the added responsibilities of being a caregiver and often compromising or sacrificing one's own needs and desires, often ending up feeling overburdened.[8],[9],[10] Congruence or agreement between the patient and the spouse regarding management of illness is indeed an important factor in determining how the couple copes with it.[11] Illness management also involves dyadic coping. It refers to the process of communication that is initiated and exchanged between partners in the form of a coping response that happens in reaction to a stressful situation.[12] Dyadic coping is also considered essential and important to aspects pertaining to well-being as well as relationship quality of the couple. As opposed to negative dyadic coping, positive dyadic coping facilitates the fostering and nurturance of mutual trust, developing feelings of comfort and support for each other among both partners as well as being committed in their relationship.[13] The theory of dyadic illness management is based on the idea that when it comes to managing a specific sickness in a pair, it is done through a dyadic phenomenon that is the assessment and management of illness through participation and execution of behavior by the dyad.[14] The physical and mental health of both dyads are found to be closely linked and are known to fluctuate.[15] This tendency is more common in elderly marriages, particularly those in which both partners have comorbidities.[16]

Previous research has suggested that disagreement on the perception of illness management between couples leads to the development of psychological disorders among both or increase the vulnerability of such developments.[17] As a result, both dyads experience significant amount of stress from the situation, which is then exchanged in modes of hostile communication between them, further resulting in poor coping mechanisms. Often, this may lead to a decline in physical and mental health of the patient, affecting one's prognosis.[18]

Therefore, not only has the role of dyadic congruence and coping in relation to mental health not been examined in patients with ACS, but there is also a lack of understanding in their interaction and effect as a whole. In view of the above, the purpose of the study was to examine the association of dyadic congruence, dyadic coping, and psychopathology among patient–carer dyads and to further understand the impact of dyadic congruence on the psychopathology with the mediating role of dyadic coping. A hypothesized version of the mediational model can be seen in [Figure 1].
Figure 1: Hypothesized model of mediating role of dyadic coping between dyadic incongruence and psychopathology of dyads

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  Methodology Top


Study design and participants

The present research was a cross-sectional, hospital-based study. A total of 216 participants (dyads) (108 patients and 108 spouses) between the age ranges of 35 and 55 years were enrolled from outpatient centers from the cardiology department of SGT Hospital, Gurgaon and Base Hospital, Delhi in India. Purposive sampling was used in the collection of data. All participants who gave consent were 18 years of age or above and were picked from the outpatient services in the department of cardiology and had a confirmed diagnosis of ACS made by treating cardiologists based on clinical background history, echocardiogram, and by use of clinical methods, which was in accordance with evidence-based guidelines (McMurray et al., 2012). The patients had also received intervention and were in the finality of diagnosis and treatment. Participants were excluded solely on the basis of cancer, cerebrovascular stroke, chronic kidney diseases, developmental syndromes, and comorbid psychiatric conditions. The spouses who accompanied the patient and were willing to participate in the study were designated as caregivers. Data were collected through questionnaires filled in person by both patients and caregivers in a secluded private space located within the hospital.

This study was approved by the ethics committee of all institutions involved, and informed consent was obtained from all participants.

Measures

The dyadic coping inventory (DCI)[3] instrument was used to measure the level of dyadic coping among the patient–carer dyad. It is a 37-item instrument designed to measure perceived communication and dyadic coping that occurs in close relationships when one or both partners are stressed. Dyadic coping is measured through four subscales: supportive, delegated, negative, and joint. The items are rated on a 5-point Likert scale from 1 ("very rarely") to 5 ("very often"). The total DCI score is a sum of items 1 through 35 after reverse coding negatively keyed items (7, 10, 11, 15, 22, 25, 26, and 27). Recent psychometric testing supports the internal consistency reliability and concurrent validity (0.91, 0.80).

The dyadic symptom management type[19] scale was used to measure dyadic congruence between the patients and their spouses. The instrument contains 4 items out of which only one statement that best describes how the patient and their care partner take care of the patient's heart condition is supposed to be selected by both. If the responses of the patient and their caregiver match, it is interpreted as congruent, and similarly, if both mark different responses, it is interpreted to be incongruent. Psychometric evaluation of the dyadic symptom management type (DMST) scale was reported to be 0.82 for internal reliability and 0.79 for criterion validity.

Measures of psychopathology

The patient health questionnaire-9 (PHQ-9)[10] is a 9-item scale from the full PHQ which measures severity of depressive symptoms. The items are rated from 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day). Internal consistency reliability of PHQ9 was reported to be excellent with a score of 0.89 and criterion validity 0.93.

The PHQ-15[16] comprises of 15 items, each measuring severity of somatic symptoms experienced by the individual. The items are rated from 0 (not bothered at all), 1 (bothered a little), and 2 (bothered a lot). Internal reliability for this measure was reported to be 0.88 and construct validity with depression and other symptoms ranged from r = 0.68 to 0.75.

Demographic information (age, biological sex, marital status, employment, education level, living situation, and dyad relationship) was collected via questionnaire.

The generalized anxiety disorder-7 (GAD-7)[20] is a self-rated 7 item scale which was used to measure the severity of GAD among the dyads. The items are rated from 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day). The internal consistency of this scale was reported to be very high (Cronbach α = .92). The measure's Test- retest reliability also came out to be high (intraclass correlation = 0.83).

Statistical analysis

The analyses of descriptive statistics in the form of means, standard deviations, frequencies, and percentages were used to characterize the sample based on the level of measurement. Bivariate tests such as spearman's correlation and linear regression were conducted with IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp). This was followed by the four-step procedure involved in establishing the mediation effect which was performed through commands in SPSS 20.0. The mediation model was analyzed by Hayes's PROCESS macro (Model 4). In addition, the bootstrapping option was also selected during mediation analysis to denote stability of the hypothesized mediation model which generated 95% bias-corrected confidence intervals from 1000 simulated resamples of the data.


  Results Top


A total of 216 dyads with complete data were included in the analysis. Both males and females were equal in number among the patient–carer dyads (n = 216). Details are given in [Table 1].
Table 1: The descriptive statistics of the sociodemographic variable of patient-carer dyads with acute coronary syndrome

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[Table 2] and [Table 3] show a significant association found among dyadic congruence, dyadic coping, depression, anxiety, and somatic symptoms of spouses and patients with ACS (P < 0.00**).
Table 2: The correlation of dyadic congruence with dyadic coping, depression, anxiety and somatic symptoms of patients with acute coronary syndrome

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Table 3: The correlation of dyadic congruence, dyadic coping and psychopathology of spouses of patients with acute coronary syndrome

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Mediation analysis

We hypothesized whether dyadic coping would mediate the relationship between dyadic congruence and psychopathology among both patients and their spouses. All the results came out to be consistent with the hypothesis.

Dyadic congruence, dyadic coping, and psychopathology of patients

We found that dyadic coping significantly mediated the relationship between dyadic congruence and all measures for psychopathology that is depression, anxiety, and somatic symptoms (R = 0.77, 0.84, and 0.84 P < 0.00**) as mentioned in [Table 4]. Hence, not only there is a direct association between understanding of illness management and psychological distress, but this association is further affected by how the patients and their spouses coped with the illness together. In addition, negative coefficients for depression, anxiety, and somatic symptoms were found to be indicative of an inverse relationship between dyadic congruence and psychopathology (−7.77, −9.4, and − 13.01). Thus, a decrease in understanding of illness management between patients and their spouses is directly associated with an increase in mental distress among both. Therefore, decrease in dyadic congruence is related with decrease in dyadic coping and further an increase in the psychological distress in the patient.
Table 4: The effect of dyadic congruence on depression, anxiety and somatic symptoms with the mediation effect of dyadic coping of patients with acute coronary syndrome

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Dyadic congruence, dyadic coping, and psychopathology of spouses

Similar results are shown in [Table 5] for spouses. Dyadic coping significantly mediated the relationship between dyadic congruence and all three measures of psychopathology among spouses of patients with ACS (R = 0.78, 0.83, and 0.83, P < 0.00**). Negative coefficients for psychopathology (−13.86, −8.9, and − 13.81) were all indicative of an inverse relationship between dyadic congruence and psychopathology. Henceforth, not only for patients, but poor understanding of illness management and decreased coping also affects the spouse's mental health.
Table 5: The effect of dyadic congruence on depression, anxiety and somatic symptoms with the mediation effect of dyadic coping of the spouses of patients with acute coronary syndrome

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We further cross-examined the mediation effect as mentioned in [Table 6] and [Table 7] in the associations between dyadic congruence of patients with dyadic coping and psychopathology of spouses and between dyadic congruence of spouses with dyadic coping and psychopathology of patients. Dyadic coping of spouses significantly mediated the relationship between dyadic congruence of patients with all three measures of psychopathology of spouses of patients with ACS (R = 0.78, 0.83, and 0.83; P < 0.00). Similarly, it was found that dyadic coping of patients significantly mediated the relationship between dyadic congruence of spouses and psychopathology of patients with ACS (R = 0.77, 0.84, and 0.84; P < 0.00). All negative coefficients were found to be similar with the results mentioned above. Interestingly, understanding of illness management and the patient's perspective of coping together affects the mental health of the spouse and vice versa. Thus, both patients and their spouses are dependent on each other when it comes to these factors.
Table 6: The effect of dyadic congruence of patients on depression, anxiety, somatic symptoms and the mediation effect of dyadic coping of spouses

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Table 7: The effect of dyadic congruence of spouses on depression, anxiety, somatic symptoms and the mediation effect of dyadic coping of patients with acute coronary syndrome

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  Discussion Top


In this study, the mean age of the patients and the spouses was 43.62 ± 6.88 and 41.71 ± 7.49, respectively. A prevalence study found an increase in risk factors for CHD and most achieving diagnosis around the mean age of 45 for men and around 55 years for women. However, this trend has been found to be gradually declining with younger individuals getting affected.[21] Depression has been prevalent among 27% of patients with CHD, while anxiety has also been found to be common with its presence in at least 20% of patients with CHD and up to 50% in patients with myocardial infarction.[22] The average duration of marriage of patient–carer dyads was 14.11 ± 4.89. A prospective cohort study examined the association of marital status with CHD and found that higher risk of mortality was associated with unmarried patients as compared to those who were married.[23] Moreover, this association was similar in patients who were either divorced or widowed. Note worthily, marital status plays a significant role in the prognosis of heart diseases. As in previous findings, another study compared socioeconomic status among patients with CHD. It was found that among 31.2 million adults with low income and educational level, 51.3% were women, where both men and women with low socioeconomic status had suffered from myocardial infarction at double the rate as compared to patients with a higher level of income and education.[6]

Unsurprisingly, dyadic congruence, dyadic coping, and psychopathology consisting of scores on depression, anxiety, and somatic symptoms of both dyads were all significantly associated with each other. Previous research indicates that both dyadic congruence and dyadic coping were significantly associated with the psychopathology of patient–carer dyads found that dyadic congruence is associated with the development of psychological disorders such as depression and anxiety among dyads, and also increases their susceptibility to develop such conditions.[24] Subsequently, dyadic coping has also been found to be inversely related with depression and anxiety among patients and spouses, with poorer dyadic coping being related with increased symptoms of depression and anxiety in both.[25]

Results of the mediation analysis showed that dyadic coping significantly mediated the relationship between dyadic congruence and depression, anxiety, and somatic symptoms in patients as well as spouses. Moreover, this mediation was also found to be significant when patients and spouses were cross-examined. Therefore, dyadic coping of spouses mediated the relationship between dyadic congruence and psychopathology of patients. Subsequently, dyadic coping of patients also mediated the relationship between dyadic congruence and psychopathology of spouses. Moreover, there was an inverse relationship between dyadic congruence and dyadic coping with depression, anxiety, and somatic symptoms. Similar to earlier findings, it has been suggested that when it comes to dyads, patients and their informal caregivers experience a relative increase in depressive and anxiety symptoms as well as poor quality of life as compared to healthy dyads.[26],[27] Subsequent studies have also found an increase in psychiatric illnesses among dyads with decreased dyadic coping.[28]

Unlike the relationship between dyadic congruence and psychopathology, the effect of dyadic congruence on dyadic coping of patient–carer dyads was denoted through a positive coefficient. Thus, it can be understood that an increase in dyadic congruence would also lead to an increase in dyadic coping among patient–carer dyads. Previous findings have also suggested that couples where one of them is undergoing treatment for a critical illness have been found to often struggle in adapting to the changes that they are expected to make in their lives due to added responsibilities and feelings of burden. It was found that couples who reported to have better dyadic coping found relatively easier to cope with stressful situations and agree with strategies for management of illness. They also showed lesser symptoms of depression anxiety as compared to couples who reported to have poor dyadic coping.[29],[30]

Limitations and future scope

The present study has some limitations to be considered. First of all, use of cross-sectional data limits causal inferences. Second, majority of patients and their spouses belonged from an urban residence; thus, the results of this study cannot be generalized to the population belonging from other residences. Third, the present study did not look into comorbidities and its association with dyadic congruence and sociodemographic factors such as duration of marriage and education. The role of comorbid conditions can be further studied and looked into. Finally, it can be assumed that the level of understanding between couples who have been married for a long time and those who were recently married would be very different and can be explored in the future.

Recommendation

Dyadic congruence and dyadic coping can be improved in a lot of ways. Clinicians may consider a holistic approach during the evaluation and treatment of the patient. Along with the standard treatment protocol, they may suggest the importance and impact of well-being and psychological understanding among patient and caregivers for better prognosis of the condition. Mental health professionals may psychoeducate the patients and their family members about the same as well as provide resources for recognizing and understanding their issues. They may help by providing psychotherapy through offline or online modes. Recently, online portals such as "your dost.com," "betterlife.In," and "docvita.com" have gained wide national recognition in providing psychological services to those in need. The same may be suggested and integrated along with the existing treatment approach.


  Conclusion Top


The present study confirms the impact of dyadic congruence on dyadic coping as well as depression, anxiety and somatic symptoms among patient–carer dyads with ACS. Thus, both patients and their spouses are at risk for developing psychiatric illnesses. Previous literature has already established the relationship between psychiatric disorders and prognosis in CHD. Therefore, it can be assumed that poor dyadic congruence and dyadic coping can not only impact the psychological well-being of patient–carer dyads but also pose a threat to the prognosis of the patients.

Acknowledgment

I would like to thank the Department of Cardiology, Base Hospital, Delhi Cantt, for their expertise and assistance throughout all aspects of the study and for their help in writing the manuscript

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

 
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