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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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8 We used items relating to self-efficacy on the prevention of disease and motivation to promote health. The aim is to reduce stress. The score for factor I ranges from 14 to 56. gender. 376 patients (83.87 for factor II. The main emphasis is on the task or planning and on attempts to solve the problem. For the anxiety subscale. or attempting to alter the situation. and duration of HD and were also requested to answer the following questionnaires.8 3. Tokyo). 298 patients (65. (2) emotion-oriented coping. showing the applicability of the scale. All the p values were at the two-tailed level of significance. cognitively restructuring the problem. and (3) avoidance-oriented coping. and 56 patients (12.4 In this population. 10 items). 58 patients (12. reliabilities of each subscale using Cronbach’s alpha coefficient were . The regression lines and predicted values illustrating significant interactions were constructed from the unstandardized regression coefficients and are depicted in 108 Behavioral Medicine .4 The Japanese version of HADS has been established by forward and back-translation and has high construct validity and reliability.3 Task-oriented coping describes purposeful task-oriented efforts aimed at problem solving. a stressor. Correlations are shown in Table 2.10 All variables were centered to adjust for artificially-induced multicollinearity. assessing anxiety and depression on 2 dimensions. Depression correlated positively with emotion-oriented coping and itchiness and negatively with self-efficacy and task. Hospital Anxiety and Depression Scale (HADS). scores of 7 or lower for noncases.3 The score for each subscale ranges from 16 to 80.” Correlations between variables were assessed by the Pearson product moment correlations. 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).10 List-wise deletion was used in the multivariate analyses. We used itchiness as one of the disease-related stressors. the interaction terms of the stress variables and the subscale of self-efficacy and/or coping with stress were entered into the regression. in which interaction terms of stressor and a subscale of self-efficacy and/or coping with stress contributed significantly (p < 0. The higher the score. and scores of 11 or higher for definite cases were found to best fit the data. This self-report questionnaire consists of three subscales with a total of 48 items: (1) task-oriented coping.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. Self-efficacy on Health-Related Behavior Scale. and fantasizing. the more the depression or anxiety. which is hypothesized to influence the state of health in chronic disease patients. self-preoccupation.7%) had scores of 8–10. Avoidance-oriented coping describes activities and cognitive changes aimed at avoiding the stressful situation. scores of 8–10 for doubtful cases. All statistical analyses were conducted using SPSS (Version 10. This scale was developed to reliably and validly assess the patient’s coping style or method of confronting stressful situations and coping with them.83 for factor I and .4 The score for each subscale ranges from 0 to 21. 14 items) and (2) controllability of health (factor II. or hypertension). Coping Inventory for Stressful Situations (CISS). Patient characteristics are shown in Table 1.and avoidance-oriented copings (p < 0. This is a self-report questionnaire for hospital outpatients in medical or surgical departments. The score for factor II ranges from 10 to 40.05). The reaction is oriented toward the person. AND ANXIETY The patients were asked about their age.7 it was suggested in the original version of HADS that for each subscale.2%) had scores of 11 or higher. All patients were Asian and residents of Japan. All the multiple regression models. This questionnaire has been developed as a scale of self-efficacy for health-related behavior. RESULTS Four hundred and fifty-three patients participated in this study.STRESS. for the depression subscale of HADS. 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.9%) had scores of 7 or lower. 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.8 When applied to 210 Japanese patients with a chronic disease (eg. and 19 patients (4.8%) had scores of 8–10. 98 patients (21. variables of age. diabetes mellitus.5–7 2.9 4.6. heart disease. In some cases. 1. Emotion-oriented coping describes reactions that are self-oriented. The item was “How was your itchiness this last month? Much or a little = 1. as shown in Table 3. On the second step.0J. the reaction actually increases stress. the better the self-efficacy.0%) had scores of 7 or lower. Anxiety correlated positively with emotion-oriented coping and negatively with self-efficacy (p < 0.4%) had scores of 11 or higher. Little or none = 0.3 The Japanese version of CISS has been established by forward and back-translation and has high construct validity and reliability. Although not confirmed in the Japanese version of HADS. A higher score indicates a greater degree of coping activity. gender. duration of HD. Reactions include emotional responses. The higher the score.05).05). DEPRESSION.

13 .1 9. Itchiness = patients who have itchiness a lot or a little in the last month. Fall 2003 109 . Duration = duration of hemodialysis.29 < .0001 450 –. itching patients were more depressive and anxious than nonitching patients.45 < .4 n (total) 453 451 Range 21. TOC = Coping Inventory for Stressful Situations (CISS) category of task-oriented coping. EOC = CISS category of emotion-oriented coping.9 13.24 < .8220 .0001 445 .38 < .0001 445 –. female = 0. TOC = Coping Inventory for Stressful Situations (CISS) category of task-oriented coping. Correlations Variable Depression r p n Anxiety r p n Age Gender Duration SE1 SE2 TOC EOC AOC Itchiness . In HD patients who reported a high degree of emotion-oriented coping. Itchiness: patients who had itchiness a lot or a little in the last month = 1.1468 445 .0002 452 –.0405 450 .0001 449 –.7 34. Vol 29.1325 445 .9 5.28 < .8 3.0 4. Patient Characteristics Characteristic Age (y) Duration (mo) Depression Anxiety SE1 SE2 TOC EOC AOC n Male Itchiness 294 323 M 60.6 SD 11. SE2 = factor II of the SelfEfficacy on Health-Related Behavior Scale.0 31. Gender: male = 1.0003 445 . TABLE 2. TABLE 1.07 .07 .0008 453 . but this was not so for those who reported low scores of emotion-oriented coping.1822 453 –.0001 448 –.3 38.2 104.0001 449 –.6 46.46 < .07 .17 . little or none = 0.06 .39 < . SE1 = factor I of the Self-Efficacy on Health-Related Behavior Scale. r = Pearson product correlation coefficient.1789 452 –.1559 451 Note. SE2 = factor II of the Self-Efficacy on Health-Related Behavior Scale. Values that were 1 SD above and below the mean were used to represent typical high and low scores for the continuous variables. itching patients were more anxious than nonitching patients.16 .6 10. Depression = Hospital Anxiety and Depression Scale (HADS) category of depression.01 .6 % 64.4 74.1–88. Duration = duration of hemodialysis. AOC = CISS category of avoidance-oriented coping.0 46.7 12–335 0–17 0–19 15–56 10–40 16–80 16–76 17–70 n 453 453 452 453 450 449 445 445 445 Note.2 7.9 71.0047 453 452 .10 . AOC = CISS category of avoidance-oriented coping.3 6.06 .3 3. Anxiety = the HADS category of anxiety. EOC = CISS category of emotion-oriented coping. but this was not so in those with high self-efficacy. In HD patients with low self-efficacy (controllability of health).17 . n may vary because of missing data. SE1 = factor I of the Self-Efficacy on Health-Related Behavior Scale.TAKAKI ET AL Figure 1.0001 445 –.

9 (p = . On the second step. 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 β . emotion-oriented coping with stress positively correlated with depression and anxiety. SE2 = factor II of the Self-Efficacy on Health-Related Behavior Scale. taskoriented coping with stress negatively correlated with depression and anxiety.015) .2 (p = .16 (p = .04 (p = . EOC = Coping Inventory for Stressful Situations category of emotion-oriented coping.STRESS.001) 26.017 .001) –. to our knowledge.13 (p = .7 (p < .001) –. However. Our study results may have also been influenced by self-report bias.03 (p = . An American study of 83 HD patients suggested that coping strategy predicted depression.001) 7. R 2 = the variance accounted for.08 (p = . 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.13 (p = .14 (p = .11 (p = .001) .25 In our study.42 (p < .013) –.050) . this is the first report that described the complex relationships between depression and anxiety with stressor.013) 19.14 (p = . DISCUSSION One limitation of this study was its cross-sectional nature. The β reported in the table is for the second step.201 . this study is vulnerable to the potential for sample bias because of our convenience sampling. β = standardized regression coefficient.212 22. variables of age.001) 446 2nd Anxiety 1st .001) 6.001) –.001) . gender.0 (p < . In general.001) –. Task.23 In our study.12 (p = .001) –. This finding is similar to what has been found in normal subjects. and coping skills. and emotion-oriented coping with stress positively correlated with depression and anxiety.48 (p < .035) –. duration of hemodialysis. DEPRESSION.250 .14 (p = . With respect to the relationships between depression and/or anxiety and coping skills in normal subjects.013 .11–21 Few studies investigated their relationships with depression and anxiety.246 .09 (p = .47 (p < .10 (p = . self-efficacy is thought to be negatively associated with depression and anxiety.053) .001) 447 2nd . we found two previous studies pertaining to the relationships between depression and/or anxiety and coping skills. Self-efficacy and coping skills have been investigated in end-stage renal disease patients mainly with regard to adherence.22 A Canadian study of 70 end-stage renal disease patients suggested that self-efficacy was negatively associated with depression. AND ANXIETY TABLE 3.293) .2 (p < .and avoidance-oriented copings correlated negatively with 110 Behavioral Medicine . self-efficacy also negatively correlated with depression and anxiety.24 Another American study of 51 HD patients suggested that avoidant coping evaluated by the Ways of Coping Inventory positively correlated with anxiety. a stressor.011 . self-efficacy.4 (p < .001) 10.005) 26.2 (p < .829) . On the first step.5 (p < .001) . so causal inference cannot be made.01 (p = .263 28.264 29.001) 444 Note. In addition.001) R 2 change F to test change n 2nd Anxiety 1st .005) –.418) .3 In HD patients.3 (p = .08 (p = .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. 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.

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.0 Non Itching/SE2/Anxiety Itching/EOC/Anxiety Depression or Anxiety 6. and the staff of the facilities for their cooperation in this study. Interactive effects of itchiness and self-efficacy and/or coping skills on depression and/or anxiety. Past researches have confirmed the role of depression in influencing mortality of end-stage renal disease patients.0 3. However. Woe Sook Kim for the use of the Self-Efficacy on Health-Related Behavior Scale. Toshiaki Furukawa for the use of it. These findings may lead to the development of interventions for depression or anxiety in HD patients under stressful situations. prospective studies or intervention research designed to increase self-efficacy or to decrease the degree of emotion-oriented coping with stress will be necessary. For example.30 In this study. high self-efficacy was likely to buffer the effect of itchiness on depression and/or anxiety.and avoidancerelated copings and depression and/or anxiety may be due to the difference in scales. so causal inference cannot be determined. These are consistent with our theoretical models. and. as well as the effect of itchiness on anxiety.0 Non Itching/EOC/Anxiety 5.0 4. this study is cross-sectional.26–29 There is evidence supporting the efficacy of psychotherapeutic treatment on depression and anxiety in this population. depression but not with anxiety. Vol 29. the relationship between itchiness and anxiety may imply the effect of anxiety on itchiness. and Tadashi Sasaki for allowing us to use their facilities. Fall 2003 111 . Masami Nishikawa.0 Non Itching/SE2/Depression Itching/SE2/Anxiety 7. SE2 = factor II of the Self-Efficacy on Health-Related Behavior Scale.0 – SD + SD FIGURE 1. Mitsuo Terada. to our knowledge. The inconsistency of the findings of the relationships between task. these are new findings.TAKAKI ET AL Itching/SE2/Depression 8. Kazuhiro Yoshiuchi. and low emotionoriented coping with stress was likely to buffer the effect of itchiness on anxiety. EOC = Coping Inventory for Stressful Situations Category of emotionoriented coping. To confirm our models more strictly. Shinobu Tsurugano.

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