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INTERPERSONAL RELATIONS AND GROUP PROCESSES

Does Who You Marry Matter for Your Health? Influence of Patients’ andSpouses’ Personality on Their Partners’ Psychological Well-Being

Following Coronary Artery Bypass Surgery

John M. Ruiz and Karen A. MatthewsUniversity of Pittsburgh

Michael F. ScheierCarnegie Mellon University

Richard SchulzUniversity of Pittsburgh

Research suggests that presurgical personality attributes influence postsurgical well-being in bothpatients and their spouses in the context of coronary artery bypass grafting (CABG) surgery. Theauthors hypothesized that a spouse’s characteristics would influence a partner’s psychologicalwell-being, regardless of whether he or she was the patient or the caregiver. In this study, 111 malepatients and their caregiver spouses completed measures of neuroticism, optimism, perceived maritalsatisfaction, and depression prior to elective CABG. Follow-up was conducted at 18 months. Asexpected, higher caregiver presurgical neuroticism predicted higher patient depressive symptoms atfollow-up, with caregiver’s concurrent 18-month affect controlled for. Likewise, higher patientpresurgical neuroticism predicted higher caregiver depressive symptoms at follow-up. Additionally,higher patient presurgical depressive symptoms and lower presurgical optimism contributed togreater caregiving burden. Relationship satisfaction moderated these effects. These results suggestthat partners’ personality traits are important determinants of both patients’ and their caregivingspouses’ well-being.

Keywords: marital satisfaction, neuroticism, optimism, depression, coronary artery bypass grafting

Coronary heart disease is the leading cause of death in theUnited States and most industrialized Western nations (AmericanHeart Association, 2002). With more than 570,000 proceduresperformed annually, coronary artery bypass grafting (CABG) isthe most common invasive treatment with a procedural mortalityrate of 1%–2% (American Heart Association, 2002). A host offactors including age at time of surgery, left ventricular function,time of intervention, number of grafts, and comorbid medical

conditions are predictive of subsequent morbidity and mortality(Eagle et al., 1999).

Health quality of life following CABG is significantly improvedin the majority of patients (Eagle et al., 1999; Herlitz et al., 2001;Wahrborg, 1999). Although distress is common prior to sur-gery, with nearly half of all patients reporting moderate tosevere levels of fear and anxiety (Koivula, Paunonen-Ilmonen,Tarkka, Tarkka, & Laippala, 2001), psychological well-being isunderstandably improved following successful intervention(Brorsson, Bernstein, Brook, & Werko, 2001; Herlitz et al.,2001). Despite these improvements, clinically significant levelsof depressive symptoms are reported in 20%–30% of patients 6months following surgery (Boudrez & DeBacker, 2001; Pirra-glia, Peterson, Williams-Russo, Gorkin, & Charlson, 1999).Depression is increasingly recognized as an important riskfactor for cardiac morbidity and all-cause mortality (Smith &Ruiz, 2002; Suls & Bunde, 2005). For example, prospectiveresearch has demonstrated that following myocardial infarction,depressive symptoms are predictive of future myocardial in-farction and mortality (Bush et al., 2001; Carney et al. for theENRICHD Investigators, 2004; Frasure-Smith, Lesperance, &Talajic, 1993; Ladwig, Kieser, Konig, Breithardt, & Borggrefe,

John M. Ruiz and Karen A. Matthews, Department of Psychiatry,University of Pittsburgh; Michael F. Scheier, Department of Psychology,Carnegie Mellon University; Richard Schulz, University Center for Socialand Urban Research, University of Pittsburgh.

Portions of this article were presented at the 2003 meeting of theAmerican Psychosomatic Society, Phoenix, Arizona. This research wassupported in part by National Institutes of Health Grants HL07560,HL065111, HL065112, HL076852, and HL076858.

We thank the participants, without whom this research would not havebeen possible.

Correspondence concerning this article should be addressed to John M.Ruiz, who is now at the Department of Psychology, Washington State Uni-versity, P.O. Box 644820, Pullman,WA 99164-4820. E-mail: [email protected]

Journal of Personality and Social Psychology, 2006, Vol. 91, No. 2, 255–267Copyright 2006 by the American Psychological Association 0022-3514/06/$12.00 DOI: 10.1037/0022-3514.91.2.255

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1991). In addition, CABG patients who report more depressivesymptoms after surgery appear to be at higher risk of mortalitythan those patients reporting fewer symptoms (Blumenthal et al.for the NORG Investigators, 2003; Borowicz et al., 2002;Connerney, Shapiro, McLaughlin, Bagiella, & Sloan, 2001;Peterson et al., 2002; Ruiz, Matthews, Scheier, Wortman, &Schulz, 2005). Hence, postsurgical depressive symptoms are animportant measure of quality of life as well as risk of futuremorbidity and mortality.

Influence of Patients’ Presurgical Characteristics on TheirOwn Postsurgical Well-Being

Patients’ premorbid emotional status is increasingly recognizedas an important predictor of mental and physical outcomes afterCABG. Presurgical distress and poor quality of life prior to surgerypredict increases in postsurgical depressive symptoms, lower qual-ity of life, greater functional impairment, and slower return towork at follow-up (Duits, Boeke, Taams, Passchier, & Erdman,1997; Perski et al., 1998; Rumsfeld et al., 1999; Soderman, Lis-spers, & Sundin, 2003). Presurgical depressive symptoms areparticularly relevant to postsurgical cardiovascular health, as mea-sured by subsequent cardiac events (Burg, Benedetto, Rosenberg,& Soufer, 2003; Perski et al., 1998; Saur et al., 2001) and post-

surgical mortality (Baker, Andrew, Schrader, & Knight, 2001;Burg, Benedetto, & Soufer, 2003). In addition to premorbid emo-tional status, patients’ presurgical personality traits, particularlyneuroticism, are associated with higher levels of presurgical dis-tress and with increases in depression and anxiety over a 6-monthpostsurgical follow-up (Duits et al., 1999). Moreover, neuroticismalso appears to moderate the strength of the relationship betweenpresurgical anxiety and later depressive symptoms, such that peo-ple with more neuroticism experience greater acute distress, whichpredicts later depression (Duits et al., 1999). In contrast to negativepersonality traits, higher optimism is associated with lower rehos-pitalization rates following difficult medical procedures such asCABG (Scheier et al., 1999). Hence, patients’ neuroticism, opti-mism, and distress appear to be important determinants of presur-gical emotional distress as well as postsurgical physical and psy-chological outcomes. These relationships are noted in Figure 1,Pathway A.

Spouse Adaptation to CABG Surgery

The emotional impact of illness extends beyond patients toinclude close social network members, particularly spouses (De-lon, 1996; Fengler & Goodrich, 1979; Han & Haley, 1999).Spouses routinely experience significant emotional distress in re-

Figure 1. The transitive model illustrates three types of effects. First, individuals’ own presurgical traitsinfluence their own postsurgical well-being (within-person effects; Pathways A and B). Second, the currentaffect of one spouse influences the current affect of the partner (Pathway C). Third, caregivers’ presurgical traitsinfluence their partners’ postsurgical well-being (transitive effects; Pathways D and E). Finally, presurgicalmarital satisfaction is hypothesized to moderate the within-person and transitive effects of presurgical person-ality traits (Pathway F).

256 RUIZ, MATTHEWS, SCHEIER, AND SCHULZ

sponse to patients’ CABG (Artinian, 1991, 1992; Karmilovich,1994; Langeluddecke, Tennant, Fulcher, Barid, & Hughes, 1989;Stanley & Frantz, 1988). Spouses commonly report anxiety, de-pressive symptoms, increased irritability, and difficulties withsleep prior to CABG (Bengtson, Karlsson, Wahrborg, Hjalmarson,& Herlitz, 1996; Langeluddecke et al., 1989) and experiencesignificant distress during the acute rehabilitation phase (O’Farrell,Murray, & Hotz, 2000). Moreover, spousal distress often remainselevated 12 months postsurgery while perceived caregiving burdenincreases during the 1st year (Artinian, 1992). Spouses reportworries about prognosis, follow-up care, patient distress, changesin roles, changes in social relationships, financial concerns, sexualconcerns, and patient helplessness or apathy (Artinian, 1992;Bengtson et al., 1996; Cozac, 1988; O’Farrell et al., 2000).

Influence of Spouses’ Presurgical Characteristics on TheirOwn Postsurgical Well-Being

Like patients, spouses’ personality traits influence their ownpresurgical distress as well as postsurgical adaptation to patients’CABG surgery (Patrick & Hayden, 1999). Numerous studiesacross illness domains support that spouses’ trait neuroticismpredicts their own caregiving burden and distress (Bookwala &Schulz, 1998; Hooker, Monahan, Shifren, & Hutchinson, 1992;Nijboer, Tempelaar, Triemstra, van den Bos, & Sanderman, 2001;M. F. Reis, Gold, Andres, Markiewicz, & Gauthier, 1994;Vedhara, Shanks, Wilcock, & Lightman, 2001). Conversely,more optimistic spousal caregivers report greater resilience tothe demands of caregiving including less depressive symptomsover time (Given et al., 1993; Hooker et al., 1992; Kurtz, Kurtz,Given, & Given, 1997). These relationships are noted in Fig-ure 1, Pathway B.

Influence of One Spouse’s Affect on Partner’s ConcurrentAffect

In addition to within-person effects, spouses may also influencethe experience of one another. Relationship experts suggest notonly that interpersonal influences occur between individuals butthat the frequency and magnitude of these effects are greaterbetween people who share a close relationship such as with maritalcouples (i.e., interdependence theory; cf. Rusbult & Van Lange,2003). For example, research supports the idea that the currentaffect of one spouse may influence the current affect of his or herpartner—so-called contagion effects (Nieboer et al., 1998; Schulz,Bookwala, Knapp, Scheier, & Williamson, 1996). In a study of1,040 older couples, Bookwala and Schulz (1996) found that thecurrent affect of one spouse was associated with the partner’saffect. These results suggest that if one spouse is distressed fol-lowing CABG surgery, the partner is likely to be distressed aswell. Although the mechanisms for this phenomenon are not clear,contagion effects may be an additional important determinant ofpost-CABG depressive symptoms in both patients and theirspouses. These relationships are noted in Figure 1, Pathway C.

Transitive Influence of Couples’ PresurgicalCharacteristics on Their Partners’ Adaptation

Although contagion effects support a cross-sectional influenceof one spouse on the partner’s experience, spousal influences may

also take place longitudinally. However, less is known about thepotential influence of one person’s presurgical personality on thespouse’s postsurgical well-being. We propose the transitive modelto illustrate these potential cross-sectional and longitudinal inter-personal influences among couples in the context of illness (seeFigure 1).

Derived from the clinical and interpersonal literature, the termtransitive refers to the influence one person has on a second person(Benjamin, 1996; Kiesler, 1996; Sullivan, 1953). For example,someone smiling at us may shift our mood from neutral to positive.The person’s smile is transitive in that it causes our change inmood. Moreover, if that person’s positive personality motivatedthe smile, we might say that the person’s personality had a tran-sitive influence on our experience. It is notable that this transitivemodel does not abandon the traditional within-person relationshipwhereby we expect that our affect and experience are influencedby our own personality (see Figure 1, Pathways A and B). Rather,the transitive model emphasizes an interpersonal framework inwhich each individual also influences the experience of the otherdyad member (see Figure 1, Pathways D and E).

Support for the Transitive Perspective

Research examining transitive interpersonal effects is sparse inthe health literature and more generally. Despite interest in inter-personal processes among social psychologists, few prospectivestudies independently assess both an individual and members ofthe social network. Rather, researchers often rely on structuralmeasures of social environments (e.g., size of one’s social networkor marital status) and a perception of interpersonal attributes andinfluence (e.g., perceived characteristics, perceived support andsupport quality). However, the few studies that have examinedsuch relationships appear to support the transitive hypothesis. Forexample, Beach and colleagues found that lower marital satisfac-tion in one spouse predicted later depressive symptoms in thepartner (Beach, Katz, Kim, & Brody, 2003), although a similarstudy of newlyweds did not find such a relationship (Fincham,Beach, Harold, & Osborne, 1997). In another line of research,Agnew, Loving, and Drigotas (2001) found that in a sample ofcollege-age couples, individual perceptions of relationship close-ness predicted future relationship breakups. In the context ofcaregiving and health, a literature review of caregivers of patientswith Alzheimer’s disease concluded that patient depression wasstrongly associated with distress and depression in their caregivers(Teri, 1997). Subsequent findings across several illness domainsalso support patient distress as a significant source of caregiverburden (Dyck, Short, & Vitaliano, 1999; Fang, Manne, & Pape,2001; Northouse, Templin, & Mood, 2000; Scholte op Reimer, deHaan, Rijnders, Limburg, & van den Bos, 1998). However, wefound no prospective studies examining spousal characteristics aspredictors of patients’ health and well-being, no studies examiningthese relationships in the context of a discrete event such as CABGsurgery (vs. longitudinal studies of cancer or dementia), and nostudies looking at dispositional characteristics such as personality,as opposed to disease severity or emotional distress.

Marital Satisfaction as a Potential Moderator

Presurgical relationship quality is an important predictor ofpostsurgical well-being for couples facing CABG (Kulik &

257DOES WHO YOU MARRY MATTER FOR YOUR HEALTH?

Mahler, 1989, 1993; Lindsay, Hanlon, Smith, & Wheatley, 2000;Pirraglia et al., 1999). For example, Elizur and Hirsh (1999) foundthat patients who reported higher preoperative marital qualitydisplayed better psychological recovery 2 months followingCABG procedures. Allen, Young, and Xu (1998) found that fe-male patients who reported better marital quality prior to CABGdisplayed better functional status 6 and 12 months post-CABG.Because of a lack of research examining both constructs as simul-taneous predictors, it is not clear that marital satisfaction predictshealth independent of personality. Interpersonal theories alongwith supporting evidence suggest that personality traits impacttrajectories of marital quality (cf. Karney & Bradbury, 1997;Kiecolt-Glaser & Newton, 2001). This evidence suggests thatpersonality supersedes marital satisfaction with implications forhealth. A plausible alternative to both as predictors is that maritalsatisfaction may moderate the relationship between personalityand health. H. T. Reis and Collins (2004) and H. T. Reis, Collins,and Berscheid (2000) hypothesized that the relational context ofinterpersonal behavior influences the impact of such behavior onthe interpersonal target. For example, in two studies of couplescoping with kidney transplants, Frazier, Tix, and Barnett (2003)demonstrated that unsupportive spousal-caregiver behaviors wereassociated with higher patient distress but only when the patientwas less satisfied with the relationship. Thus, we hypothesized thatthe degree to which a person is satisfied or dissatisfied with his orher relationship moderates the extent to which that person isinfluenced by the spouse’s personality (Figure 1, Pathway F). Thatis, the impact of one person’s personality on the partner’s out-comes may be more or less strong depending on the level ofsatisfaction that the person experiences.

In summary, CABG surgery is an efficacious intervention foradvanced coronary heart disease. However, the stress of the procedureand the underlying disease is associated with significant distress inboth patients and caregivers. Characteristics such as neuroticism,optimism, presurgical distress, and relationship quality predict adjust-ment in both patients and their caregivers. In addition, interpersonaltheories coupled with sparse evidence suggest that presurgical char-acteristics may have transitive interpersonal effects such that thecharacteristics of one person affect the partner’s adaptation, particu-larly when illness occurs in the context of close relationships such asmarriage. However, no published studies have prospectively exam-ined these relationships in a discrete medical event context such asCABG surgery nor have studies examined these relationships as afunction of dispositional characteristics. In addition, we are unawareof any published studies having examined both marital satisfactionand personality traits as concurrent predictors or studies examiningmarital satisfaction as a possible moderator of transitive relationshipsbetween personality and health. Given the importance of close rela-tionships such as marriage, particularly during an individual’s time ofneed, transitive interpersonal effects of personality may be a funda-mental part of adjustment to major life stressors.

Current Study

One hundred and eleven male patients and their caregiverspouses completed measures of neuroticism, optimism, depressivesymptoms, and perceived marital satisfaction prior to electiveCABG surgery. Follow-up was conducted at 18 months postsur-gery. For the current study, postsurgical well-being was concep-

tualized as depressive symptoms for both patients and caregivers,and caregivers’ well-being also encompassed caregiving burdenand strain. Our major expectations were as follows: We expectedpatients’ depressive symptoms at follow-up to be associated with(a) higher presurgical depressive symptoms and neuroticism aswell as lower optimism; (b) higher caregiver presurgical depres-sive symptoms, higher neuroticism, and lower optimism; and (c)the interaction between patients’ presurgical marital satisfactionand their caregivers’ personality.

Caregiver-spouse predictions were analogous to patient hypoth-eses. In addition, caregivers completed measures of caregivingburden and strain. Thus, we expected caregivers’ postsurgicalburden to be associated with (a) higher presurgical burden, neu-roticism, and depressive symptoms as well as lower optimism; (b)higher patient presurgical depressive symptoms, higher neuroti-cism, and lower optimism; and (c) the interaction between care-givers’ presurgical marital satisfaction and patients’ personality.Parallel predictions were made for caregiver strain.

Method

Sample

Participants for this study were drawn from a larger pool of patientsparticipating in the Pittsburgh Bypass Project. Participants were recruitedfrom 528 consecutive patients scheduled for elective CABG surgery atAllegheny General Hospital in Pittsburgh, Pennsylvania, between June1992 and January 1994 (Scheier et al., 1999). Eligibility criteria were (a)first-time referral for coronary artery bypass surgery with no concurrentprocedures, (b) no acute chest pain at the time of the initial interview, (c) 1-dayminimum between time of scheduled procedure and actual procedure, (d) notadmitted to the intensive care unit, (e) English speaking, and (f) residencewithin 125 miles (201.17 km) of Allegheny General Hospital. The baselinepatient sample consisted of 309 participants (215 men, 69.6%).

The caregiver was identified by the patient as someone who would helpor take care of him when he returned home. Of the original patient sample,287 reported having a caregiver, of whom 206 were contacted, with 144(128 women, 88.9%) participating at baseline.

Participants for the present study consisted of the 111 married couples inwhich the husband was the patient and the wife participated as the care-giver. There were insufficient numbers of female patients/husbands ascaregiver dyads to perform any meaningful analyses (n � 13). Husbandswere generally older than their wives (see Table 1). Of the original 111

Table 1Participant Baseline Characteristics

Variable Patient Caregiver

N 111 111Age (years)

M 61.05 57.55SD 10.32 10.84

Education�HS diploma 25 16HS diploma or some college 55 75College degree 31 16Missing 0 4

EmployedYes 46 47No 65 64

Note. Difference between patient and caregiver mean baseline age wassignificant, t(110) � 8.31, p � .001. HS � high school.


husband/patient couples, 97 participated in the 18-month data collection(11 couples either could not be located or declined further participation,and 3 patients had died, resulting in the loss of the dyad).

Procedure

The office of the cardiothoracic surgeon made all referrals. Face-to-facebaseline interviews were scheduled and conducted by trained interviewersbetween 1 and 20 days before the scheduled surgery. During the course ofthis study, surgical practices changed so that elective surgeries werescheduled within 1 or 2 days of diagnosis as opposed to 7–10 days,accounting for the variability in time for administration of the presurgicalinterviews. In all cases, informed consent was obtained prior to conductingthe interviews. Follow-up interviews were conducted at 6–8 days, 6months, and 18 months postoperatively. Caregivers were followed up at 6months and 18 months postoperatively.

Psychosocial Measures

All participants completed measures of dispositional optimism, depres-sive symptoms, neuroticism, and relationship satisfaction. Optimism wasmeasured with the 6-item Revised Life Orientation Test (Scheier, Carver,& Bridges, 1994). Higher total score was interpreted as greater traitoptimism. Neuroticism was measured with a 10-item version of the Neu-roticism scale of the Eysenck Personality Questionnaire (Eysenck, 1958;Goh, King, & King, 1982). Depressive symptoms were measured with a10-item version of the Center for Epidemiologic Studies Depression Scale(Radloff, 1977). The current version excluded somatic symptoms becausethese could be influenced by differences in cardiac/medical symptoms.These exclusions limit interpretation of scores with respect to their clinicalsignificance. However, the measure is useful as an index of depressivesymptoms. Alpha reliabilities for this version have been reported in therange of .82–.93 (Nieboer et al., 1998; Scheier et al., 1999). Finally, theDyadic Relationship Scale (Skinner, Steinhauer, & Santa-Barbara, 1983) isa 14-item self-report measure of relationship satisfaction with a specificother. Individuals rate the degree to which they agree with statementsregarding their partner’s communication, affective expression, and affec-tive involvement. Example items include “Even if this person disagrees, heor she listens to my point of view” and “When I am upset, I know thisperson really cares.” Items are rated on a 4-point Likert scale (1 � stronglydisagree, 4 � strongly agree) and are totaled to yield an overall score. Inthe current study, husbands and wives completed the measure with respectto each other, which was interpreted as a measure of marital satisfaction.Alpha reliabilities for patients and spouses ranged from .88 to .90.

Caregivers also completed measures of caregiver burden and strain priorto surgery and at 6 and 18 months post-CABG. The Burden scale is basedon the Zarit Burden Interview (Zarit, Reever, & Bach-Peterson, 1980) andassesses how often the individual feels oppressed by various aspects ofcaregiving. Participants responded using a 3-point Likert scale rangingfrom 1 (never) to 3 (often). Example items include “I feel useful in myinteractions with this person” and “I feel resentful of other relatives whocould but who do not do things with or for this person.” Alpha reliabilitieswere .81 for presurgical burden and .84 at the 18-month follow-up. TheZarit Burden scale assesses the frequency with which spouses experiencecertain feelings. To complement this frequency scale, a 20-item CaregiverStrain Scale was developed for this project to assess the magnitude ofburden associated with common aspects of caregiving. Participants weregiven the stem “Please indicate how much strain each of these has causedfor you in the past month” and asked to respond to 20 items on a 3-pointLikert scale (1 � none, 3 � a great deal). Items included “lack ofgratitude,” “social isolation,” and “insurance concerns.” Alpha reliabilitieswere .90 for presurgical strain and .94 at the 18-month follow-up. Pearsoncorrelations between the Burden and strain scales were .77 (p � .001) priorto surgery and .69 (p � .001) at the 18-month follow-up.

Medical Information

Medical information was gathered from several sources including thecardiac catheterization report, the operative report, and inpatient medicalrecords. The catheterization report yielded the following information: (a)number of grafts, (b) number of coronary vessels occluded 50% or more,and (c) ejection fraction less than 40%. Hospital medical records yielded(a) current smoking status (smoker or not), (b) history of hypertension, (c)history of diabetes mellitus, and (d) presurgical serum cholesterol. Aseparate record contained the patient’s preoperative New York HeartAssociation classification as well as current or immediately preoperativeepisodes of acute myocardial infarction, congestive heart failure, or unsta-ble angina.

Analysis Strategy

Linear regression was used to test hypotheses regarding the influence ofeach person’s presurgical traits (optimism, depressive symptoms, neuroti-cism, and relationship satisfaction) on the spouse’s 18-month well-being(e.g., depressive symptoms). First, simple correlations were performedbetween presurgical and postsurgical outcome variables. Second, we cal-culated partial correlations in order to identify candidate presurgical pre-dictors for inclusion in the overall multivariate analyses. Postsurgicaloutcomes were correlated with each patient and spouse presurgical predic-tor, with presurgical values of the outcome controlled for. For patients,none of the eight medical (five preoperative and three postoperative) or twodemographic (age and income) variables were associated with 18-monthdepressive symptoms and, thus, were not included in the regression mod-els. Similar null results were found for patient medical covariates andspouse-caregiver demographics on caregivers’ 18-month depressive symp-toms and measures of caregiving burden.1

In the third analysis phase, we regressed each significant presurgicalpredictor to emerge from the second phase of analysis onto the 18-monthpostsurgical outcome. Linear regressions were conducted in steps. First, theoutcome-matched presurgical term along with any of the individual’s ownsignificant presurgical predictors were regressed simultaneously. This ap-proach allowed us to account for as much variance in the postsurgicaloutcome as could be predicted by the individual’s own presurgical char-acteristics prior to examining any additional variance explained by thespouse’s presurgical characteristics. In the second step, any significantspouse presurgical predictors were entered in a stepwise manner to deter-mine the best partner predictors of additional variance. In describing theanalyses, we report the unstandardized (B), standard error, and standard-ized (�) regression coefficients. We also report the overall multiple cor-relation squared (R2) for the final model as well as the R2 for the modelreflecting the individual’s own predictors and the �R2 for each additionalmodel.

In separate analyses, linear regression was used to examine maritalsatisfaction as a potential moderator of transitive relationships on bothpatient and caregiver outcomes. First, all predictors were centered. Next,four sets of interaction terms were created, two for examining caregivereffects on patients’ well-being (patients’ perceived marital satisfaction withcaregiver traits and caregivers’ perceived marital satisfaction with theirown traits) and two for examining patient effects on caregivers’ well-being(caregivers’ perceived marital satisfaction with patient traits and patients’marital satisfaction with their own traits). Consistent with the preceding

1 One medical/demographic covariate was correlated with caregiveroutcomes. Partial correlations revealed that higher caregiver age wasassociated with lower 18-month perception of burden when we controlledfor presurgical burden (r � �.22, p � .05). Caregiver age was entered intothe first step of the regression model but did not remain significant whenadditional caregiver traits were added. Thus, caregiver age was droppedfrom the final model.


analytic methodology, patient and caregiver predictors were identifiedthrough partial correlations. Centered terms were created for these analy-ses. Regressions were performed in three steps: (a) the individual’s owntraits, (b) the partner’s traits, and (c) the interaction terms entered stepwise.Variables in the first two steps were forced in using the “enter” method inorder to account for their variance before the interaction terms wereexamined (Aiken & West, 1991). Significant interactions were plotted andexamined using Aiken and West’s (1991) approach.

Results

Spousal Comparison on Traits and Outcomes

Table 2 reports the means and standard deviations for thepsychosocial measures at baseline and at 18 months for patientsand spouse-caregivers. Table 2 also reports the results of paired-sample t tests conducted to assess whether significant differencesexisted between dyad pairs on these measures as well as thecorrelations between the dyad pairs on the measures assessed. Asshown, patient and caregiver traits were similar, with the exceptionof depressive symptoms. Prior to surgery, caregivers reportedsignificantly more depressive symptoms as compared with theirpatients but reported similar levels of optimism, neuroticism, andmarital satisfaction. After surgery, couples reported similar levelsof depressive symptoms. Finally, with the exception of optimism,for each of the variables assessed, a significant positive correlationexisted between the ratings made by the dyad pairs.

Patient Outcomes

We hypothesized that patient and caregiver traits measured priorto surgery would predict patients’ postsurgical depressive symp-toms. In univariate analyses, patients’ presurgical and postsurgicaldepressive symptoms were positively correlated (r � .47, p �.001). However, patients’ depressive symptoms did not changesignificantly between presurgical levels and the 18-monthfollow-up (see Table 2). Partial correlations controlling for pre-surgical depressive symptoms revealed significant associationsbetween patient 18-month depressive symptoms and both patientand caregiver presurgical predictors. Specifically, higher patient18-month depressive symptoms were significantly associated withlower patient presurgical optimism, lower marital satisfaction, and

higher neuroticism (see Table 3). In addition, lower caregiverpresurgical optimism and higher presurgical neuroticism were alsosignificantly associated with higher patient 18-month depressivesymptoms. Hence, these patient and caregiver predictors wereincluded in the overall regression model.

Multivariate analyses showed that higher 18-month depressivesymptoms were predicted by patients’ higher presurgical depres-sive symptoms and lower presurgical optimism, accounting for34% of the variance in scores. As expected, higher caregiverpresurgical neuroticism accounted for an additional 6% of thevariance (Table 4, Model 1). Thus, we found some support for thetransitive hypothesis for patient depressive symptoms. Next, weexamined patient and caregiver presurgical marital satisfaction aspotential moderators of caregiver traits on patient depressivesymptoms. Multivariate analyses showed that patient but not care-giver presurgical marital satisfaction emerged as a moderator ofcaregiver presurgical neuroticism on patient postsurgical depres-sive symptoms (Table 4, Model 2; see Figure 2A). Post hocanalyses revealed that postsurgical depressive symptoms werehigher among patients who were less satisfied in their marriageprior to surgery and whose caregiving spouse was higher in pre-surgical neuroticism (B � 1.13, p � .001).

Caregiver Outcomes

For caregivers, we hypothesized that patient and caregiver traitsmeasured prior to surgery would predict caregivers’ postsurgicaldepressive symptoms and caregiving burden and strain.

Depressive symptoms. In univariate analyses, caregivers’ pre-surgical and postsurgical depressive symptoms were positivelycorrelated (r � .52, p � .001). In contrast to patient findings,caregivers reported a significant improvement in depressive symp-toms over time, t(83) � 5.96, p � .001 (see Table 2). Partialcorrelations controlling for presurgical depressive symptoms re-vealed significant associations between spouse 18-month depres-sive symptoms and both caregiver and patient presurgical predic-tors. Specifically, higher caregiver 18-month depressive symptomswere significantly associated with lower caregiver presurgical op-timism and marital satisfaction and higher caregiver neuroticism(see Table 3). Higher patient presurgical neuroticism, higher de-

Table 2Mean Comparisons of Patient and Caregiver Psychosocial Measures and Their Associations

Time of assessment andmeasure Scale Patient Caregiver df t r

PresurgicalDepressive symptoms CES-D 16.5a (5.9) 19.8b (6.7) 99 4.13*** .23*Marital satisfaction DRS 45.2 (5.8) 45.4 (6.6) 100 �0.22 .39***Optimism LOT 21.9 (3.6) 21.9 (3.7) 104 �0.04 .17Neuroticism Eysenck 2.6 (2.5) 2.9 (2.4) 102 �1.11 .31***

18-month follow-upDepressive symptoms CES-D 15.1a (5.4) 15.6b (5.4) 86 �0.90 .37***

Note. Standard deviations are in parentheses. CES-D � Center for Epidemiologic Studies DepressionScale; DRS � Dyadic Relationship Scale; LOT � Life Orientation Test; Eysenck � Eysenck PersonalityQuestionnaire.a Comparison between patients’ presurgical and 18-month depressive symptoms, t(90) � 1.54, ns. b Compari-son between caregivers’ presurgical and 18-month depressive symptoms, t(83) � 5.96, p � .001.* p � .05. *** p � .001.


pressive symptoms, and lower marital satisfaction were also asso-ciated with higher caregiver depressive symptoms at 18-monthfollow-up. Hence, these patient and caregiver predictors wereincluded in the overall regression model.

Multivariate analyses showed that higher caregiver 18-month de-pressive symptoms were predicted by their own higher presurgicaldepressive symptoms and higher neuroticism, accounting for 47% ofthe variance in scores. Consistent with our hypotheses, higher patientpresurgical neuroticism accounted for an additional 12% of the vari-ance (Table 5, Model 1). Multivariate analyses revealed that therelationship between patients’ presurgical traits and caregivers’ post-surgical depressive symptoms was not moderated by either patient orcaregiver presurgical marital satisfaction.

Caregiving burden. In univariate analyses, caregivers’ presur-gical and postsurgical caregiving burden were positively correlated(r � .60, p � .001). No significant change was found betweenpresurgical and 18-month postsurgical burden. Partial correlations

controlling for presurgical burden revealed no significant associ-ations between caregiver 18-month burden and any other of theirown presurgical predictors. Higher caregiver 18-month burden wassignificantly associated with higher patient depressive symptoms,higher neuroticism, and lower optimism (see Table 3). Hence,these patient predictors were included in the overall regressionmodel.

In multivariate analyses, higher 18-month burden scores werepredicted by higher presurgical burden, accounting for 38% of thevariance in burden scores (Table 5, Model 2). Consistent withexpectations, higher patient presurgical depressive symptomsemerged as a significant predictor, accounting for an additional13% of the variance. Finally, lower patient optimism also emergedas a significant predictor, accounting for an additional 5% of thevariance in caregivers’ 18-month burden scores.

Multivariate analyses showed that both patient (Table 5, Model3; see Figure 2B) and caregiver (Table 5, Model 4; see Figure 2C)

Table 3Partial Correlations Between Patient and Caregiver Presurgical Traits and 18-Month Patientand Caregiver Outcomes, Controlling for Presurgical Levels of the Outcome Variable

VariablePatient depressive

symptomsCaregiver depressive

symptoms Caregiver burden Caregiver strain

Patient presurgicalDepressive symptoms .24* (77) .48*** (78) .42*** (77)Optimism �.38*** (87) �.09 (78) �.43*** (80) �.07 (79)Marital satisfaction �.24* (84) �.23* (76) �.15 (78) �.23* (77)Neuroticism .37*** (86) .47*** (77) .38*** (78) .30** (77)

Caregiver presurgicalDepressive symptoms .16 (85) .05 (79) �.05 (78)Optimism �.27** (87) �.34** (80) �.14 (82) �.25* (82)Marital satisfaction �.06 (86) �.25* (80) �.13 (81) �.35*** (80)Neuroticism .30** (85) .46*** (78) .14 (80) .24* (79)

Note. Numbers of couples are in parentheses.* p � .05. ** p � .01. *** p � .001.

Table 4Multiple Regression Models Predicting Patient 18-Month Well-Being by Patient and CaregiverPresurgical Traits

Model and patient 18-month depressive symptoms B SE B �

Model 1a

Patient presurgical depressive symptoms 0.34 0.09 .36***Patient presurgical optimism �0.51 0.15 �.33**Caregiver presurgical neuroticism 0.57 0.20 .25**

Model 2b

Patient presurgical depressive symptoms 0.41 0.10 .41***Patient presurgical optimism �0.44 0.17 �.29**Patient presurgical neuroticism �0.09 0.28 �.04Patient presurgical marital satisfaction �0.14 0.10 �.15Caregiver presurgical optimism �0.04 0.16 �.03Caregiver presurgical neuroticism 0.46 0.26 .20Caregiver presurgical marital satisfaction 0.16 0.09 .19Caregiver Presurgical Neuroticism � Patient Presurgical

Marital Satisfaction �0.12 0.04 �.31***

Note. Only models demonstrating a significant transitive effect are shown. All coefficient values reflect thefinal regression model.a Overall R2 � .40; patient predictors, R2 � .34; caregiver predictor, �R2 � .06, p � .01. b Overall R2 � .47;interaction term, �R2 � .08, p � .001.** p � .01. *** p � .001.


marital satisfaction emerged as moderators of patient traits oncaregiver burden. Post hoc analyses revealed that caregiving bur-den was higher among caregivers who were less satisfied in theirmarriage prior to surgery and who were caring for a patient-spousehigher in presurgical neuroticism (B � 0.56, p � .05). Caregivingburden was also higher among caregivers who were caring forpatient-spouses who themselves were less satisfied in their mar-riage and who reported higher presurgical depressive symptoms(B � 0.43, p � .001).

Caregiving strain. Univariate analyses revealed caregivers’presurgical and postsurgical strain were positively correlated (r �.65, p � .001). No significant change was found between presur-gical and 18-month postsurgical strain. Partial correlations con-trolling for presurgical strain revealed significant associations be-

tween caregivers’ 18-month strain and both caregiver and patientpresurgical predictors. Specifically, higher 18-month strain wassignificantly associated with lower caregiver presurgical optimism,lower marital satisfaction, and higher neuroticism (see Table 3).Higher patient presurgical depressive symptoms and neuroticismas well as lower marital satisfaction were also associated withhigher caregiver strain at 18-month follow-up. Hence, these care-giver and patient predictors were included in the overall regressionmodel.

Multivariate analyses showed that higher 18-month caregivingstrain scores were predicted by higher caregiver presurgical strain,higher neuroticism, and lower marital satisfaction, accounting for56% of the variance in scores (Table 5, Model 5). In addition,higher patient presurgical depressive symptoms also predicted

Figure 2. Interactions between presurgical traits and marital satisfaction on patient and caregiver outcomes. A:Interaction between patients’ presurgical marital satisfaction and caregivers’ presurgical neuroticism for patientpostsurgical depressive symptoms. B: Interaction between caregivers’ presurgical marital satisfaction andpatients’ presurgical neuroticism for caregivers’ postsurgical burden. C: Interaction between patients’ presurgicalmarital satisfaction and their own presurgical depressive symptoms for caregivers’ postsurgical burden. D:Interaction between caregivers’ presurgical marital satisfaction and patients’ presurgical neuroticism for care-givers’ postsurgical strain.


higher caregiver strain at 18 months, accounting for an additional10% of the variance. Finally, patient presurgical neuroticism in-teracted with caregivers’ presurgical marital satisfaction, suggest-ing that among caregivers who reported higher presurgical maritalsatisfaction, higher patient presurgical neuroticism was associatedwith lower post-CABG caregiving strain (Table 5, Model 6; seeFigure 2D). Post hoc analyses revealed a paradoxical relationshipsuch that caregiving strain was higher among caregivers who weremore satisfied in their marriage prior to surgery and who were

caring for a patient-spouse lower in presurgical neuroticism (B ��0.85, p � .05).

Spouses’ Current Versus Prospective Factors inPredicting Partner Depressive Symptoms

Current affect of one spouse may influence the current affect ofthe partner—contagion effects (Figure 1, Pathway C). Contagioneffects argue for congruent affective experiences among dyad

Table 5Multiple Regression Models Predicting Caregiver 18-Month Well-Being by Patient andCaregiver Presurgical Traits

Model and presurgical trait B SE B �

Caregiver 18-month depressive symptomsModel 1a

Caregiver presurgical depressive symptoms 0.15 0.08 .18*Caregiver presurgical neuroticism 1.05 0.24 .43***Patient presurgical neuroticism 0.93 0.21 .37***

Caregiver 18-month burdenModel 2b

Caregiver presurgical burden 0.45 0.09 .44***Patient presurgical depressive symptoms 0.23 0.07 .30***Patient presurgical optimism �0.33 0.12 �.25**

Model 3c

Caregiver presurgical burden 0.27 0.10 .27**Caregiver presurgical marital satisfaction �0.12 0.07 �.17Patient presurgical depressive symptoms 0.25 0.08 .29**Patient presurgical optimism �0.22 0.12 �.17Patient presurgical neuroticism 0.11 0.19 .06Patient presurgical marital satisfaction �0.04 0.07 �.06Patient Neuroticism � Caregiver Presurgical Marital Satisfaction �0.07 0.02 �.26**

Model 4d

Caregiver presurgical burden 0.34 0.10 .33***Caregiver presurgical marital satisfaction �0.02 0.07 �.03Patient presurgical depressive symptoms 0.27 0.08 .32**Patient presurgical optimism �0.26 0.13 �.20*Patient presurgical neuroticism 0.16 0.19 .09Patient presurgical marital satisfaction �0.11 0.07 �.14Patient Presurgical Depressive Symptoms � Patient Presurgical

Marital Satisfaction �0.03 0.01 �.20*Caregiver 18-month strain

Model 5e

Caregiver presurgical strain 0.38 0.10 .39***Caregiver presurgical marital satisfaction �0.28 0.09 �.23**Caregiver presurgical neuroticism 0.81 0.30 .25**Patient presurgical depressive symptoms 0.50 0.11 .33***

Model 6f

Caregiver presurgical strain 0.36 0.10 .37***Caregiver presurgical optimism �0.10 0.19 �.05Caregiver presurgical neuroticism 0.75 0.35 .23*Caregiver presurgical marital satisfaction �0.30 0.10 �.25**Patient presurgical depressive symptoms 0.56 0.13 .37***Patient presurgical neuroticism �0.35 0.30 �.11Patient presurgical marital satisfaction �0.07 0.11 �.05Patient Presurgical Neuroticism � Caregiver Presurgical Marital

Satisfaction �0.08 0.04 �.16*

Note. Only models demonstrating a significant transitive effect are shown. All coefficient values reflect thefinal regression model.a Overall R2 � .59; caregiver predictors, R2 � .47; patient predictor, �R2 � .12, p � .001. b Overall R2 � .56;caregiver predictors, R2 � .38; patients’ presurgical depressive symptoms, �R2 � .13, p � .001; patients’presurgical optimism, �R2 � .05, p � .01. c Overall R2 � .62; interaction term, �R2 � .05, p � .005. d Over-all R2 � .61; interaction term, �R2 � .04, p � .05. e Overall R2 � .66; R2 for individuals’ own predictors �.56; patient predictors, �R2 � .10, p � .001. f Overall R2 � .69; interaction term, �R2 � .02, p � .05.* p � .05. ** p � .01. *** p � .001.


members. Hence, as an alternative to our prospective findings, weexamined the possibility that 18-month outcomes were betteraccounted for by partners’ 18-month depressive symptoms.2

In univariate analyses, patients’ and caregivers’ 18-month de-pressive symptoms were positively correlated (r � .37, p � .001).In addition, partial correlations revealed significant associationsbetween patients’ and spouses’ 18-month depressive symptomswhen either patients’ (r � .27, p � .05) or caregivers’ (r � .29,p � .01) presurgical depressive symptoms were controlled for.These findings are consistent with Figure 1, Pathway C.

Linear regression was used to test concurrent affect versusprospective factors of one spouse on the partner’s 18-month de-pressive symptoms. The regression model, including predictorsand order of entry, was identical to those previously used forpatient and caregiver 18-month depressive symptoms. To testwhether the presurgical factors or concurrent affect of one spousewas a better predictor of the partner’s 18-month depressive symp-toms, we also entered the predictor spouse’s concurrent 18-monthdepressive symptoms in the first step of the regression model.Concurrent affect was not a significant predictor for either patientor caregiver outcomes and did not significantly alter previouslyobserved prospective findings. These findings suggest that presur-gical factors and not concurrent affect are the stronger predictorsof partner 18-month depressive symptoms among couples facingCABG surgery.

Discussion

The current study supports the hypothesis that personality char-acteristics are important prospective risk factors for the well-beingof both individuals and their spouses. First, the findings demon-strate the importance of presurgical personality traits as within-person predictors of postsurgical adaptation. For patients, lowerpresurgical optimism predicted higher postsurgical depressivesymptoms. For caregiver spouses, higher presurgical neuroticismpredicted more postsurgical depressive symptoms and, along withlower presurgical marital satisfaction, contributed to greater post-surgical caregiving strain. Second, and perhaps more interesting,the current study demonstrates the importance of personality traitsas independent predictors of partner’s adaptation in the context ofmarriage and illness. As predicted, partner’s presurgical neuroti-cism predicted higher postsurgical depressive symptoms for bothpatients and caregivers after we accounted for the individual’s ownpersonality characteristics. It is important that we demonstratedthat these transactional effects were not better explained by theconcurrent affect of the spouse. In addition, higher patient presur-gical depressive symptoms predicted higher caregiver postsurgicalburden and strain, whereas higher patient optimism was associatedwith lower postsurgical caregiver burden. Together, these findingssuggest that over and above a patient’s own risk factors, spouses’psychosocial characteristics contribute unique risk to patientwell-being.

Consistent with expectations, marital satisfaction emerged as aconsistent moderator of transitive neuroticism effects. We gener-ally found that the more dissatisfied people were with their mar-riage prior to surgery, the more damaging was their spouses’neuroticism to their own well-being after surgery. These findingssuggest that for couples who are less happy in their marriage andwho are facing CABG surgery, higher neuroticism in one spouse

is predictive of more postsurgical difficulties in the partner. Curi-ously, we found one exception to this pattern: Caregivers whowere more satisfied in their marriage and who were caring formore neurotic patient-spouses reported less postsurgical strain.Future research should investigate whether this is a replicablefinding or simply an anomaly in the data. Despite this finding,higher neuroticism emerged as an important interpersonal riskfactor, either alone or as moderated by lower marital satisfaction,for all patient and caregiver outcomes examined here. These find-ings also clarify the role of presurgical marital satisfaction as amoderator of transitive personality influence rather than as aunique predictor of later well-being. Finally, analyses revealed thatthe prospective effects of personality remained significant afterconcurrent affect was accounted for. This finding suggests thatpersonality is the more important predictor of partner depressivesymptoms, at least in this data set, perhaps due to the stability ofpersonality traits compared with the more transitive nature ofmood variables such as depressive symptoms. In the absence ofprior examples comparing such effects, our finding is somewhatexploratory. However, our rationale for the prediction was basedon the idea that in established relationships, personality representsnot only a consistent pattern of overt affect and behavior but ahistory of interacting with that pattern. This is not to say thattransient mood is not important, but, at least in these data, expe-rience outweighed the episodic.

Our results support a broader transitive conceptualization of thepatient/caregiver-spouse relationship and, particularly, the role ofpersonality traits within the model. Extending findings of neurot-icism as an important predictor of individual depressive symptoms,the quality of caregivers’ neuroticism appears to be a criticalcontributor to their partners’ well-being for both patients and theircaregivers in the context of a stressful event such as CABGsurgery. Prior research suggests that more distressed individualshave more difficulty adapting. Perhaps neuroticism activates orexacerbates partner distress through greater interpersonal expres-sions of worry, communicating cause for concern, and pulling forgreater attention from the caregiver. Higher patient depressionprior to surgery was associated with more within-person depres-sive symptoms at follow-up and also with greater perceived burdenand strain among caregiving spouses. It is conceivable that patientdepressive symptoms may communicate to the caregiver cause forconcern and pull for the spouse to assist in the patient’s recovery.Future research should attempt to explicate these factors. Regard-less of the transitive mechanism, clinical interventions aimed atreducing depressive symptoms are likely to benefit the health andwell-being of both spouses.

We should note that these findings also speak to the controversyregarding dispositional optimism and neuroticism as possibly twosides of the same coin (Scheier et al., 1994; Smith, Pope, Rhode-walt, & Poulton, 1989). Previously, Scheier et al. (1994) demon-strated that optimism accounted for a significant amount of vari-ance in depressive symptoms, when they controlled forneuroticism. Our findings broaden this support by demonstrating

2 Analyses focused only on 18-month depressive symptoms because ofthe clear partner-matched variable (concurrent 18-month depressive symp-toms). Caregiver burden and strain were not examined because of the lackof a patient-matched variable.


that when examined together, optimism and neuroticism displayunique as opposed to redundant interpersonal effects, at leastwithin the context of marital relationships and health.

More broadly, these findings support the transitive interpersonalmodel as an important concept for studying close relationships inthe context of illness. This model has the potential to advanceunderstanding of the complexities of individual health and well-being outcomes by considering the common social context inwhich they occur. The explicit emphasis on the transitive proper-ties of personality traits may yield far more accurate predictionsabout patient–caregiver relationships than reliance on traditionalassumptions of caregiver spouses as inherently supportive andpatients as burdensome and instead suggests that each individualcan improve as well as make more difficult the experience of hisor her dyadic partner. Finally, in addition to considering theindividual attributes of two people, the model also emphasizes theimportance of relationship quality, with our findings supporting itsrole as a moderator of partner’s attributes on future well-being.

Despite these advances, the current study is not without itslimitations. Although sufficient for demonstrating the interper-sonal properties of personality traits in coping with illness, futureresearch should use a wider taxonomy of traits or target traits withknown interpersonal consequences such as hostility (McCrae &Costa, 1987; Trapnell & Wiggins, 1990; cf. Smith, Glazer, Ruiz, &Gallo, 2004). In addition, the current study was limited to dyads inwhich the patient was the husband, leaving open the question as towhether the observed effects are truly representative of patient/spouse-caregiver relationships, an effect of gender, or the interac-tion between gender and illness roles. Although unlikely, it is alsopossible that our findings are a result of a shared reporting stylespecific to couples facing a crisis such as CABG surgery. Com-parisons with a control group not facing a crisis may have helpedto examine this issue. We also used a number of nonindependenttests, which although based on a priori hypotheses may haveinflated the risk of Type I error.

Finally, it is unclear whether transitive processes are specificallya health phenomenon, a shared-challenge phenomenon, or a moregeneral relationship phenomenon. It is possible that health chal-lenges motivate couples to interact more intensely in order to meetshared goals and responsibilities and that these acute interactionperiods expose couples to more (frequent, duration) transitiveeffects. However, most couples are faced with various sharedchallenges at one time or another that require greater interaction(Karney & Bradbury, 1995; Kiecolt-Glaser & Newton, 2001).Hence, it may be the case that any period of heightened interactionincreases exposure to transitive effects. Alternatively, establishedrelationships represent repeated interpersonal interactions with thesame person that may extol cumulative effects independent of anyspecific challenge. Clearly, these issues were beyond the scope ofthe current study but warrant future research to explore the gen-eralizability of transitive processes.

These qualifications aside, this study supports the transitivemodel as an important step in understanding adaptation to disease.In addition to addressing the aforementioned limitations, futureresearch should examine the interpersonal influence of a widerrange of caregivers. For example, the patient’s primary physician,surgeon, and health care staff may engender confidence or worrywith implications for the trajectory of physical and emotionalrecovery of both the patient and the spouse. Similar attention

should also be given to important social network members includ-ing family, friends, and coworkers as each group may influence theindividual’s self-perception of recovery and a return to normal lifeor a need for continued concern. In addition, transactional pro-cesses also deserve more direct attention. For example, do patientshigher in neuroticism transactionally create their own depressionby overburdening their caregivers, causing them to be less sup-portive? Additional research on the transitive processes may facil-itate a more complete understanding of psychosocial influences inthe illness process and guide the development of appropriateinterventions.

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Received August 5, 2004Revision received November 30, 2005

Accepted December 11, 2005 �


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