Interactions Among a Stressor, Self-efficacy, Coping With Stress, Depression, and Anxiety in Maintenance Hemodialysis Patients

Jiro Takaki, MD, PhD; Tadahiro Nishi, MD, PhD; Hiromi Shimoyama, MD, PhD; Toshio Inada, MD; Norimasa Matsuyama, MD; Hiroaki Kumano, MD, PhD; Tomifusa Kuboki, MD, PhD

The authors purpose in this study was to assess the interactive effects of stressors, coping with stress, and self-efficacy on depression and anxiety in maintenance hemodialysis (HD) patients. Patients (n = 453) undergoing HD for more than 1 year in Japan were investigated. The regression lines illustrating significant (p < .05) interactions predict that itching HD patients with low self-efficacy will be more depressive and anxious than nonitching patients. In HD patients who report a high degree of emotion-oriented coping, itching patients will be more anxious than nonitching patients. These new findings may lead to the development of specific and focused interventions for depression or anxiety in maintenance HD patients. Index Terms: anxiety, coping with stress, depression, hemodialysis, selfefficacy

Depression and anxiety, which have been among frequently reported problems in maintenance hemodialysis (HD) patients,1 may be affected by stressors with the renal diseases and HD therapy. Self-efficacy has been defined as the belief that one is capable of executing a given course of action.2 Coping with stress has been defined as the preferred characteristic or the typical manner of confronting stressful situations and dealing with them.3 They may moderate the effect of stressors on depression and anxiety. For example, HD patients under stressful situations with low self-efficacy may be more depressive or anxious than those with high self-efficacy. Those with high degrees of emotion-oriented coping with stress may be more depressive or anxious than those with low emotion-oriented cop-

ing. However, to our knowledge, there are no published reports on the possible interactive effects of stressors, self-efficacy, and coping with stress on depression and anxiety in the maintenance of HD patients. Our aim of this study was to assess them. METHOD Eligibility criteria for inclusion in the study were uremic patients who (1) had been regularly undergoing HD therapy for more than 1 year, to omit the influence of metabolic factors in the early stage of HD on the consciousness level (eg, uremic encephalopathy), (2) had the ability to complete questionnaires, and (3) did not have apparent cerebrovascular disease or serious intellectual impairment. Eligible patients were investigated in 4 medical facilities, namely, the Yuuai Clinic in Saitama, and the Bousei Tanashi Clinic, the Tokyo Kensei Hospital, and the Nishi Clinic in Tokyo, Japan. We observed the universal ethical guidelines (the Helsinki Declaration, Edinburgh, 2000) while conducting this study. All patients in this study gave their written informed consent.

Drs Takaki, Kumano, and Kuboki are with the Department of Psychosomatic Medicine, University of Tokyo, Japan. Dr Nishi is director of the Nishi Clinic, Tokyo, Japan. Dr Shimoyama is with the Yuuai Clinic, Saitama, Japan. Dr Inada is with the Bousei Tanashi Clinic, Tokyo, Japan. Dr Matsuyama is head of the medical office at the Tokyo Kensei Hospital, Japan.

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The patients were asked about their age, gender, and duration of HD and were also requested to answer the following questionnaires. 1. Hospital Anxiety and Depression Scale (HADS). This is a self-report questionnaire for hospital outpatients in medical or surgical departments, assessing anxiety and depression on 2 dimensions.4 The score for each subscale ranges from 0 to 21. The higher the score, the more the depression or anxiety.4 The Japanese version of HADS has been established by forward and back-translation and has high construct validity and reliability.57 2. Self-efficacy on Health-Related Behavior Scale. This questionnaire has been developed as a scale of self-efficacy for health-related behavior, which is hypothesized to influence the state of health in chronic disease patients.8 We used items relating to self-efficacy on the prevention of disease and motivation to promote health.8 Factor analysis using varimax rotation based on data from 220 Japanese healthy subjects revealed that the self-efficacy scale on health-related behavior has two main factors: (1) active behavior toward coping with disease (factor I; 14 items) and (2) controllability of health (factor II; 10 items). The score for factor I ranges from 14 to 56. The score for factor II ranges from 10 to 40. The higher the score, the better the self-efficacy.8 When applied to 210 Japanese patients with a chronic disease (eg, heart disease, diabetes mellitus, or hypertension), reliabilities of each subscale using Cronbachs alpha coefficient were .83 for factor I and .87 for factor II, showing the applicability of the scale.8 3. Coping Inventory for Stressful Situations (CISS). This scale was developed to reliably and validly assess the patients coping style or method of confronting stressful situations and coping with them. This self-report questionnaire consists of three subscales with a total of 48 items: (1) task-oriented coping, (2) emotion-oriented coping, and (3) avoidance-oriented coping.3 Task-oriented coping describes purposeful task-oriented efforts aimed at problem solving, cognitively restructuring the problem, or attempting to alter the situation. The main emphasis is on the task or planning and on attempts to solve the problem. Emotion-oriented coping describes reactions that are self-oriented. The aim is to reduce stress. Reactions include emotional responses, self-preoccupation, and fantasizing. In some cases, the reaction actually increases stress. The reaction is oriented toward the person. Avoidance-oriented coping describes activities and cognitive changes aimed at avoiding the stressful situation. Avoidance-oriented coping can serve as a means of alleviating stress by distracting oneself by involving oneself in other situations or tasks (task oriented) or by social diversion (person oriented).3 The score for each

subscale ranges from 16 to 80. A higher score indicates a greater degree of coping activity.3 The Japanese version of CISS has been established by forward and back-translation and has high construct validity and reliability.9 4. We used itchiness as one of the disease-related stressors. The item was How was your itchiness this last month? Much or a little = 1. Little or none = 0. Correlations between variables were assessed by the Pearson product moment correlations. Interactive effects of a stressor and self-efficacy and/or coping with stress on depression and/or anxiety were assessed by hierarchical multiple regression analyses as follows: On the first step, variables of age, gender, duration of HD, a stressor, and a subscale of self-efficacy and/or coping with stress were entered into a multiple regression model with depression and/or anxiety as the dependent variable. On the second step, the interaction terms of the stress variables and the subscale of self-efficacy and/or coping with stress were entered into the regression.10 All variables were centered to adjust for artificially-induced multicollinearity.10 List-wise deletion was used in the multivariate analyses. All the p values were at the two-tailed level of significance. All statistical analyses were conducted using SPSS (Version 10.0J, Tokyo). RESULTS Four hundred and fifty-three patients participated in this study. Patient characteristics are shown in Table 1. All patients were Asian and residents of Japan. Although not confirmed in the Japanese version of HADS,6,7 it was suggested in the original version of HADS that for each subscale, scores of 7 or lower for noncases, scores of 810 for doubtful cases, and scores of 11 or higher for definite cases were found to best fit the data.4 In this population, for the depression subscale of HADS, 298 patients (65.9%) had scores of 7 or lower, 98 patients (21.7%) had scores of 810, and 56 patients (12.4%) had scores of 11 or higher. For the anxiety subscale, 376 patients (83.0%) had scores of 7 or lower, 58 patients (12.8%) had scores of 810, and 19 patients (4.2%) had scores of 11 or higher. Correlations are shown in Table 2. Depression correlated positively with emotion-oriented coping and itchiness and negatively with self-efficacy and task- and avoidance-oriented copings (p < 0.05). Anxiety correlated positively with emotion-oriented coping and negatively with self-efficacy (p < 0.05). All the multiple regression models, in which interaction terms of stressor and a subscale of self-efficacy and/or coping with stress contributed significantly (p < 0.05), as shown in Table 3. The regression lines and predicted values illustrating significant interactions were constructed from the unstandardized regression coefficients and are depicted in

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Figure 1. Values that were 1 SD above and below the mean were used to represent typical high and low scores for the continuous variables. In HD patients with low self-efficacy (controllability of health), itching patients were more depressive and anxious than nonitching patients, but this

was not so in those with high self-efficacy. In HD patients who reported a high degree of emotion-oriented coping, itching patients were more anxious than nonitching patients, but this was not so for those who reported low scores of emotion-oriented coping.

TABLE 1. Patient Characteristics Characteristic Age (y) Duration (mo) Depression Anxiety SE1 SE2 TOC EOC AOC n Male Itchiness 294 323 M 60.2 104.3 6.0 4.6 46.0 31.0 46.7 34.3 38.6 % 64.9 71.6 SD 11.4 74.3 3.8 3.2 7.9 5.9 13.6 10.1 9.4 n (total) 453 451 Range 21.188.7 12335 017 019 1556 1040 1680 1676 1770 n 453 453 452 453 450 449 445 445 445

Note. n may vary because of missing data. Duration = duration of hemodialysis. Depression = Hospital Anxiety and Depression Scale (HADS) category of depression. Anxiety = the HADS category of anxiety. SE1 = factor I of the Self-Efficacy on Health-Related Behavior Scale. SE2 = factor II of the SelfEfficacy on Health-Related Behavior Scale. TOC = Coping Inventory for Stressful Situations (CISS) category of task-oriented coping. EOC = CISS category of emotion-oriented coping. AOC = CISS category of avoidance-oriented coping. Itchiness = patients who have itchiness a lot or a little in the last month.

TABLE 2. Correlations Variable Depression r p n Anxiety r p n Age Gender Duration SE1 SE2 TOC EOC AOC Itchiness

.17 .0002 452 .13 .0047 453 452

.06 .1789 452 .16 .0008 453

.01 .8220 .06 .1822 453

.28 < .0001 449 .29 < .0001 450

.46 < .0001 448 .38 < .0001 449

.39 < .0001 445 .07 .1468 445

.24 < .0001 445 .45 < .0001 445

.17 .0003 445 .07 .1325 445

.10 .0405 450 .07 .1559 451

Note. r = Pearson product correlation coefficient. Gender: male = 1, female = 0. Itchiness: patients who had itchiness a lot or a little in the last month = 1, little or none = 0. Duration = duration of hemodialysis. SE1 = factor I of the Self-Efficacy on Health-Related Behavior Scale. SE2 = factor II of the Self-Efficacy on Health-Related Behavior Scale. TOC = Coping Inventory for Stressful Situations (CISS) category of task-oriented coping. EOC = CISS category of emotion-oriented coping. AOC = CISS category of avoidance-oriented coping.

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TABLE 3. Results of Hierarchial Regression Analyses Dependent variable Depression Step 1st Independent variable Age Gender Duration Itchiness SE2 Itchiness SE2 Overall model Age Gender Duration Itchiness SE2 Itchiness SE2 Overall model Age Gender Duration Itchiness EOC Itchiness EOC Overall model .14 (p = .001) .08 (p = .053) .04 (p = .293) .13 (p = .001) .48 (p < .001) .12 (p = .005) .16 (p = .001) .14 (p = .001) .03 (p = .418) .09 (p = .035) .42 (p < .001) .11 (p = .013) .14 (p = .001) .10 (p = .015) .01 (p = .829) .08 (p = .050) .47 (p < .001) .13 (p = .001) R 2 change F to test change n

2nd Anxiety 1st

.250 .013 .264

29.4 (p < .001) 7.9 (p = .005) 26.2 (p < .001)

446

2nd Anxiety 1st

.201 .011 .212

22.2 (p < .001) 6.2 (p = .013) 19.7 (p < .001)

447

2nd

.246 .017 .263

28.5 (p < .001) 10.3 (p = .001) 26.0 (p < .001)

444

Note. On the first step, variables of age, gender, duration of hemodialysis, a stressor, and a subscale of self-efficacy and/or coping with stress are entered in a multiple regression model employing depression and/or anxiety as the dependent variable. On the second step, the product term of the variables of the stressor and the subscale of self-efficacy and/or coping with stress was entered in the model. The reported in the table is for the second step. = standardized regression coefficient. R 2 = the variance accounted for. SE2 = factor II of the Self-Efficacy on Health-Related Behavior Scale. EOC = Coping Inventory for Stressful Situations category of emotion-oriented coping.

DISCUSSION One limitation of this study was its cross-sectional nature, so causal inference cannot be made. In addition, this study is vulnerable to the potential for sample bias because of our convenience sampling. Our study results may have also been influenced by self-report bias. However, to our knowledge, this is the first report that described the complex relationships between depression and anxiety with stressor, self-efficacy, and coping skills. Self-efficacy and coping skills have been investigated in end-stage renal disease patients mainly with regard to adherence.1121 Few studies investigated their relationships with depression and anxiety. In general, self-efficacy is thought to be negatively associated with depression and anxiety.22 A Canadian study of 70 end-stage renal disease patients suggested that self-efficacy was negatively associated with depression.23 In our study, self-efficacy also negatively correlated with depression and anxiety.

With respect to the relationships between depression and/or anxiety and coping skills in normal subjects, taskoriented coping with stress negatively correlated with depression and anxiety, and emotion-oriented coping with stress positively correlated with depression and anxiety.3 The relationships between avoidance-oriented coping with stress and depression and/or anxiety in normal subjects varied depending on the gender and depression scales used.3 In HD patients, we found two previous studies pertaining to the relationships between depression and/or anxiety and coping skills. An American study of 83 HD patients suggested that coping strategy predicted depression.24 Another American study of 51 HD patients suggested that avoidant coping evaluated by the Ways of Coping Inventory positively correlated with anxiety.25 In our study, emotion-oriented coping with stress positively correlated with depression and anxiety. This finding is similar to what has been found in normal subjects. Task- and avoidance-oriented copings correlated negatively with

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Itching/SE2/Depression
8.0

Non Itching/SE2/Depression Itching/SE2/Anxiety

7.0

Non Itching/SE2/Anxiety Itching/EOC/Anxiety

Depression or Anxiety

6.0

Non Itching/EOC/Anxiety

5.0

4.0

3.0

SD

+ SD

FIGURE 1. Interactive effects of itchiness and self-efficacy and/or coping skills on depression and/or anxiety. SE2 = factor II of the Self-Efficacy on Health-Related Behavior Scale. EOC = Coping Inventory for Stressful Situations Category of emotionoriented coping.

depression but not with anxiety. The inconsistency of the findings of the relationships between task- and avoidancerelated copings and depression and/or anxiety may be due to the difference in scales. Past researches have confirmed the role of depression in influencing mortality of end-stage renal disease patients.2629 There is evidence supporting the efficacy of psychotherapeutic treatment on depression and anxiety in this population.30 In this study, high self-efficacy was likely to buffer the effect of itchiness on depression and/or anxiety, and low emotionoriented coping with stress was likely to buffer the effect of itchiness on anxiety. These are consistent with our theoretical models, and, to our knowledge, these are new findings. However, this study is cross-sectional, so causal inference cannot be determined. For example, the relationship between itchiness and anxiety may imply the effect of anxiety on itchiness,

as well as the effect of itchiness on anxiety. To confirm our models more strictly, prospective studies or intervention research designed to increase self-efficacy or to decrease the degree of emotion-oriented coping with stress will be necessary. These findings may lead to the development of interventions for depression or anxiety in HD patients under stressful situations. ACKNOWLEDGMENTS
We thank Monika Spesova and other staff members at MultiHealth Systems Inc for permission to use the Japanese version of the Coping Inventory for Stressful Situations, Toshiaki Furukawa for the use of it, Woe Sook Kim for the use of the Self-Efficacy on Health-Related Behavior Scale, Mitsuo Terada, Masami Nishikawa, Shinobu Tsurugano, Kazuhiro Yoshiuchi, and Tadashi Sasaki for allowing us to use their facilities, and the staff of the facilities for their cooperation in this study.

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NOTE
For comment and further information, please address correspondence to Jiro Takaki MD, PhD, Department of Psychosomatic Medicine, Faculty of Medicine, University of Tokyo, Research staff; 73-1 Hongo, Bunkyo-ku, Tokyo, Japan (e-mail: jirosinryounaikatky@umin.ac.jp).

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