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Depression in lung cancer patients :

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Title:
Depression in lung cancer patients : role of perceived stigma
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English
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Gonzalez, Brian
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University of South Florida
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Tampa, Fla
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Subjects / Keywords:
Psycho-oncology
Mood disorders
Thoracic oncology
Smoking
Tobacco
Dissertations, Academic -- Psychology -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: Previous research suggests that lung cancer patients are at an increased risk for depressive symptomatology; however, little is known about the possible etiology or correlates of depression among these patients. This study examined the relationship between perceived stigma and depressive symptomatology among lung cancer patients, and sought to find potential mediators of this relationship. It was hypothesized that more perceived stigma would be related to greater depressive symptomatology and that perceived stigma would contribute unique variance to depressive symptomatology above and beyond that contributed by clinical, demographic, and psychosocial variables. A sample of 95 participants receiving chemotherapy for stage II-IV non-small cell lung cancer was recruited during routine outpatient chemotherapy visits. A medical chart review was conducted to assess clinical factors and participants completed a standard demographic questionnaire as well as measures of perceived stigma, depressive symptomatology, and other psychosocial variables. As hypothesized, there was a positive association of perceived stigma to depressive symptomatology. Perceived stigma contributed significant unique variance to depressive symptomatology. In addition dyadic adjustment and dysfunctional attitudes mediated this relationship. Future research should aim to replicate and extend these findings in longitudinal analyses and attempt to ameliorate lung cancer patients' depressive symptomatology by targeting perceived stigma.
Thesis:
Thesis (M.A.)--University of South Florida, 2010.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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Statement of Responsibility:
by Brian Gonzalez.
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Title from PDF of title page.
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Document formatted into pages; contains X pages.

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ABSTRACT: Previous research suggests that lung cancer patients are at an increased risk for depressive symptomatology; however, little is known about the possible etiology or correlates of depression among these patients. This study examined the relationship between perceived stigma and depressive symptomatology among lung cancer patients, and sought to find potential mediators of this relationship. It was hypothesized that more perceived stigma would be related to greater depressive symptomatology and that perceived stigma would contribute unique variance to depressive symptomatology above and beyond that contributed by clinical, demographic, and psychosocial variables. A sample of 95 participants receiving chemotherapy for stage II-IV non-small cell lung cancer was recruited during routine outpatient chemotherapy visits. A medical chart review was conducted to assess clinical factors and participants completed a standard demographic questionnaire as well as measures of perceived stigma, depressive symptomatology, and other psychosocial variables. As hypothesized, there was a positive association of perceived stigma to depressive symptomatology. Perceived stigma contributed significant unique variance to depressive symptomatology. In addition dyadic adjustment and dysfunctional attitudes mediated this relationship. Future research should aim to replicate and extend these findings in longitudinal analyses and attempt to ameliorate lung cancer patients' depressive symptomatology by targeting perceived stigma.
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Depression in Lung Cancer Patien ts: Role of Perceived Stigma by Brian D. Gonzalez A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Psychology College of Arts & Sciences University of South Florida Major Professor: Paul B. Jacobsen, Ph.D. Jennifer Bosson, Ph.D. Thomas Brandon, Ph.D. Date of Approval: March 1, 2010 Keywords: psycho-oncology, mood disorder s, thoracic oncology, smoking, tobacco Copyright 2010, Brian D. Gonzalez

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Dedication To my loving wife Rebecca, whose support and understanding throughout this process has been invaluab le. I love you forever.

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i Table of Contents List of Tables ii List of Figures iii Abstract iv Introduction 1 Lung Cancer 1 Depression in Lung Cancer Patients 2 Correlates of Depression in Lung Cancer Patients 3 Demographic Factors 4 Clinical Factors 4 Psychosocial Factors 5 Smoking Behavior 6 Stigma and Lung Cancer Patients 7 Dyadic Adjustment and Dysfunctional Attitudes 9 Aims 10 Hypotheses 11 Method 11 Participants 11 Procedure 11 Measures 12

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ii Statistical Analyses 16 Results 20 Participants 20 Relationship of Perceived Stigma and Depressive Symptomatology 24 Relationship of Other Psychosocia l Variables with Depressive Symptomatology 25 Relationships of Demographic and Clinical Variables with Depressive Symptomatology 26 Regression Analyses of De pressive Symptomatology 29 Relationships of Demographic and Clinical Variables with Perceived Stigma 36 Mediational Analyses 40 Discussion 43 Summary of Results 43 Theoretical and Clinical Implications 45 Limitations 48 Future Directions 49 References 51

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iii List of Tables Table 1 Demographic Charact eristics of the Sample 23 Table 2 Clinical Characteristics of the Sample 24 Table 3 Mean, Standard Deviations, and Internal Consistency Reliabilities of Psychosocial Scales 25 Table 4 Correlations Between Depressi ve Symptomatology and Perceived Stigma 26 Table 5 Correlations Between Depr essive Symptomatology and Psychosocial Variables 27 Table 6 Relationships Between De pressive Symptomatology and Demographic Variables 28 Table 7 Relationships Between Depres sive Symptomatology and Clinical Variables 29 Table 8 Summary of Hierarchical Re gression Analysis for Variables Predicting Depressive Symtpomatology 31 Table 9 Summary of Hierarchical Re gression Analysis for Variables Predicting Depressive Sy mtpomatology (CES-D) Among Participants Living With a Spouse or Partner 33 Table 10 Summary of Hierarchical Re gression Analysis for Variables Predicting Depressive Symtpomatology (CES-D) 35

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iv Table 11 Summary of Hierarchical Re gression Analysis for Variables Predicting Depressive Symtpomatology (CES-D) 36 Table 12 Relationships Between Pe rceived Stigma and Demographic Variables 38 Table 13 Relationships Between Percei ved Stigma and Clinical Variables 39 Table 14 Summary of Stepwi se Regression Analysis fo r Variables Predicting Perceived Stigma (SIS) 40 Table 15 Correlations Between Per ceived Stigma and Psychosocial Variables 41

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v List of Figures Figure 1 Path Diagram for the Indire ct Effect of a Predictor on a Dependent Variable through a Mediator 18 Figure 2 Participant Flow Chart 21 Figure 3 Proposed Model of Social Support (ESSI) as a Mediator Between Perceived Stigma (SIS) and Depressive Symptomatology (CES-D) 42 Figure 4 Proposed Model of Dyadic Adjustment (DAS-4) as a Mediator Between Perceived Stigma (SIS) and Depressive Symptomatology (CES-D) 43 Figure 5 Proposed Models of Dysfunc tional Attitudes (DAS) as a Mediator Between Perceived S tigma (SIS) and Depressive Symptomatology (CES-D) 44

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vi Depression in Lung Cancer Patients: Role of Perceived Stigma Brian D. Gonzalez ABSTRACT Previous research suggests that lung cancer patients are at an increased risk for depressive symptomatology; however, little is known about the possible etiology or correlates of depression among these patient s. This study examined the relationship between perceived stigma and depressive symptomatology among lung cancer patients, and sought to find potential mediators of this relationship. It was hypothesized that more perceived stigma would be related to greater depressive symptomatology and that perceived stigma would contri bute unique variance to depressive symptomatology above and beyond that contributed by clinical, demographic, and psychosocial variables. A sample of 95 participants receiving ch emotherapy for stage II-IV non-small cell lung cancer was recruited during r outine outpatient chemothera py visits. A medical chart review was conducted to assess clinical factors and particip ants completed a standard demographic questionnaire as well as meas ures of perceived stigma, depressive symptomatology, and other psychosocial variab les. As hypothesized, there was a positive association of perceived stigma to depr essive symptomatology. Perceived stigma contributed significant unique variance to depressive symptomatology. In addition dyadic adjustment and dysfunctional attitudes mediated this relations hip. Future research should aim to replicate and extend these findings in longitudinal analyses and attempt to

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vii ameliorate lung cancer patients depressi ve symptomatology by targeting perceived stigma.

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1 Introduction It is estimated that 215,020 people will be diagnosed with lung cancer in the United States in 2009 (Jemal et al., 2008). While early-stage lung cancer patients can sometimes be cured, many patients face bouts with lung cancer that can last several years and during which they may receive surgery, ch emotherapy, radiation therapy, or all three. The effects of the illness and some of the side-effects of its treatment often make concealing ones illness from others difficu lt, leaving lung cancer patients vulnerable to stigmatization. The potential contributory role of tobacco use to the development of lung cancer is another factor that may contribute to perceived st igmatization. Patients with this illness are at increased risk for depressive symptomatology, which itself is related to poorer quality of life among cancer patients (Hyodo et al., 1999; Montazeri, Milroy, Hole, McEwen, & Gillis, 1998; Turner, Muers, Haward, & Mulley, 2007; Visser & Smets, 1998). Some correlates of depressive symptomatology in lung cancer patients have been identified; however, the potentia l contribution of illness-related perceived stigma has yet to be examined. To address this issue, the current study seeks to determine whether perceived stigma is related to de pressive symptomatology among lung cancer patients. Lung Cancer Lung cancer is one of the most common a nd deadliest forms of cancer. It accounts for 15% of new cancer cases and 29% of cancer deaths annually (Jemal et al., 2008). It is the leading cause of cancer-related death in males (31%) and females (26%), far

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2 outnumbering the rates of deaths due to prostate cancer (10%) and brea st cancer (15%) in males and females, respectively (Jemal et al., 2008). The discrepancy between the prevalence of lung cancer and the percentage of cancer-related deaths attributed to lung cancer is a testament to its lethality. This le thality is exacerbated by the late stage at which lung cancer is often detect ed, which is partly due to th e less-than-optimal detection methods (e.g. chest x-rays); newer methods (e .g., spiral CT scans) remain controversial (Kaneko et al., 1996). In addition, doctors ma y have difficulty differentiating symptoms of lung cancer from similar smoking-related problems, which may be another factor contributing to the late stage in which lung cancer is often detected. For example, in a recent qualitative study, lung cancer patients report ed that their disease-related symptoms were often ignored by medical doctors, some times for several years, and attributed instead to smokers cough (Cha pple, Ziebland, & McPherson, 2004). Depression in Lung Cancer Patients Lung cancer patients often report experi encing symptoms such as fatigue, insomnia, pain, and depression (Degner & Sloan, 1995; Sarna, 1993; Sarna, 1998). Several studies of lung cancer patients have found high rates of c linically significant depressive symptomatology shortly after diagnosis. For exampl e, in a study of patients in Japan who had recently received a lung cancer diagnosis, 31% exhibited clinically significant levels of depressive sympto matology (Hyodo et al., 1999). Similarly, a study of lung cancer patients in Scotland found that 23% endorsed c linically significant depressive symptomatology when they were informed of their diagnosis (Montazeri et al., 1998). Additionally, a study of lung cancer patients in Britain about to receive radiotherapy found a 21% rate of clinical ly significant depressive symptomatology

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3 (Turner et al., 2007). Hopwood and Stephens (2000) sampled lung cancer patients recruited into palliative therapy medica tion trials throughout the United Kingdom and reported a pre-treatment rate of clinically si gnificant depressive symptomatology of 33%. The highest reported rate of depressive symptomatology is 44%, reported in a study of lung cancer patients referred to an Italian specialist center (Buccheri, 1998). Some evidence suggests that depressive symptomatology in lung cancer patients may remain elevated after treatment comple tion For example, a postoperative study of lung cancer patients who had smoked within m onths of surgery reported a 29% rate of clinically significant depressive symptomatology (Walker, Zona, & Fisher, 2006). Hopwood and Stephens (2000) reported th at 29% of lung cancer patients assessed between three and eight weeks after treatme nt had clinically si gnificant depressive symptomatology. Rates of depressive sympto matology were 34% and 44% in two studies that assessed symptoms three months af ter the beginning of lung cancer treatment (Montazeri et al., 1998; Nakaya et al., 2006). In addition, a study of elderly lung cancer patients found that rates of c linically significant depressi ve symptomatology decreased only slightly from 39% at one month after th e beginning of treatment to 31% more than one year later (Kurtz, Kurtz, Stommel, Gi ven, & Given, 2002). The rates of depressive symptomatology in lung cancer patients exceed those reported by individuals with other types of cancer. For example, a sample of patients with breast cancer, head and neck cancer, and lymphoma reported an 8% rate of elevated depressive symptomatology (Berard, Boermeester, & Viljoen, 1998), and a sample of thyroid cancer patients reported a 17% rate (Tagay et al., 2006).

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4 Correlates of Depression in Lung Cancer Patients Demographic Factors. Research on demographic correl ates of depression in lung cancer patients is limited and results are mi xed. For example, two studies of lung cancer patients have found women to be at higher ri sk of elevated depr essive symptomatology than men (Hopwood & Stephens, 2000; Hyodo et al., 1999), but three other studies found no sex differences (Montazeri et al., 1998; Naka ya et al., 2006; Uchitomi et al., 2003). Similarly, three studies reported that older lung cancer patients were more likely to experience elevated depressive symptomato logy compared to younger patients (Hyodo et al., 1999; Walker, Zona, Larsen, & Fisher, 2004; Walker et al., 2006); however, three other studies found no age differences (Mont azeri et al., 1998; Nakaya et al., 2006; Uchitomi et al., 2003). One study found that year s of education was negatively related to depressive symptomatology in lung cancer patients (Uchitomi et al., 2003); however, two other studies found no relationship for educa tion (Montazeri et al., 1998; Nakaya et al., 2006). Neither income nor marital status has been found to be related to depressive symptomatology among lung cancer patients (Mont azeri et al., 1998; Nakaya et al., 2006; Uchitomi et al., 2003). Although female gender, older age, and fewer years of education may be positively related to depressive symptomatology in lung cancer patients, more research is needed to clarify these relationships. Clinical Factors. More definitive conclusions can be made about the relationships between clinical factors a nd depressive symptomatology in lung cancer patients, in part because there is more research in this area. Clinical factors studied include performance status (i.e., clinical ratings of overall physical functioning), disease stage, type of cancer treatment, functiona l impairment, and symptom severity. Studies

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5 have consistently found that poorer performan ce status is related to greater depressive symptomatology (Hopwood & Stephens, 2000; H yodo et al., 1999; Nakaya et al., 2006; Uchitomi et al., 2003; Walker et al., 2006). Several studies have reported no relationship between disease stage and depressive sympto matology in lung cancer patients before treatment (Montazeri et al., 1998; Nakaya et al., 2006) and as shortly as a few weeks and as long as 12 months after treatment initia tion (Montazeri et al., 1998; Uchitomi et al., 2003; Walker et al., 2006). However, one study found that two weeks after the diagnosis of lung cancer, patients with later disease stages exhibited less depressive symptomatology than those with earlier disease stages (H yodo et al., 1999). Only two studies have examined whether depressive sy mptomatology varies as a function of lung cancer treatment type. While Montazeri a nd colleagues (1998) found no relationship between type of treatment and depressive symptomatology, Hyodo and colleagues (1999) reported that patients who had not received radiotherapy were more depressed than patients who had radiotherapy. Greater functional impairment (Hopwood & Stephens, 2000) and symptom severity (Hopwood & Stephe ns, 2000; Kurtz et al., 2002) have been found to be positively related to greater de pressive symptomatology; however, these findings require further replication. Psychosocial Factors. The psychosocial correlates of depressive symptomatology in lung cancer patients have only recently be gun to be studied. Less adaptive coping (i.e., less problem-focused coping) was found to be related to greater depressive symptomatology in a sample of lung cancer patients who had recently undergone surgical resection and had smoked within three months before surgery (Walker et al., 2006). In addition, two aspects of greater social suppor t have been found to be related to less

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6 depressive symptomatology among lung cancer patients (Fisher Jr, La Greca, Greco, Arfken, & Schneiderman, 1997). In separate studies of postoperative lung cancer patients, nondirective emotiona l support (i.e., emotionally a ssisting or cooperating with the patient while allowing the responsibility fo r behavior and choices to remain with the patient) was associated with less depr essive symptomatology, while directive instrumental support (i.e., support that takes responsibility for financial and material matters) was associated with more depressi ve symptomatology (Walker, Larsen, Zona, Govindan, & Fisher, 2004; Walker et al., 2006 ). Thus, emerging evidence suggests that coping and social support merit further study as psychosocial correlates of depressive symptomatology in lung cancer patients. Smoking Behavior. To date, only three studies have investigated the relationship between smoking status and depressive sy mptomatology in lung cancer patients. One study assessed smoking status before curati ve resection of non-small cell lung cancer (NSCLC) and examined its relationship to de pressive symptomatol ogy one year later; no relationship was evident (Uchitomi et al., 2003). In another study of NSCLC patients, no relationship was found between preopera tive smoking status and depressive symptomatology assessed three months after surgery (Nakaya et al., 2006). In a third study of patients who had smoked within the three months be fore lung cancer resection, there was a trend towards a relationship between postoperative smoking status and depressive symptomatology, such that thos e who continued smoking after surgery had higher depressive symptomatology than those who had quit (Walker et al., 2004). Although all three studies reported no signi ficant relationship be tween depression and smoking status, the evidence of such a rela tionship in the general population (Goodman

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7 & Capitman, 2000) and the potential implicati ons it would carry if a similar relationship were found among lung cancer patients argue fo r additional research on this topic. Stigma in Lung Cancer Patients An important factor that might be re lated to differences in depressive symptomatology among lung cancer pa tients is perceived stigma. Modified Labeling Theory, which was first used to describe the effects of stigma on individuals with psychiatric disorders (Link, Cullen, Struen ing, Shrout, & Dohrenwend, 1989), posits that once society labels an individual, they are subject to uniform responses from others. These societal responses can constrain an indivi dual into the role to which they are being subjected, which can cause the individual to acce pt this role and incorporate it into their identity. This process can often result in psychological harm. Perceived stigma, the perception that one is subject to the uniform responses from othe rs that are to be expected for an individual with a certain label, ha s been studied in ch ronically-ill populations, primarily with HIV-positive patients and those infected with Hepatitis C. Individuals with these illnesses often perceive (accurately or inaccurately) that they are undergoing uniform responses from societ y that are a result of thei r label (e.g., HIV positive). The potential for stigma originates from the fact that these diseases are often transmitted via unsafe sexual behavior and intravenous drug use (Beyrer et al., 2005; Purcell, Parsons, Halkitis, Mizuno, & Woods, 2001). Research has examined the relationship of perceived stigma to depressive symptomatology in HIV positive individuals (B erger, Ferrans, & Lashley, 2001; Miles, Burchinal, Holditch-Davis, Wasilewski, & Christian, 1997; Simbayi et al., 2007). One such study sampled HIV positive individuals in South Africa and examined several

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8 potential demographic and psyc hosocial correlates (Simbayi et al., 2007). In addition to finding a significant positive re lationship between internalized stigma and depressive symptomatology, this study also found that internalized stigma contributed unique variance to depressive symp tomatology over and above dem ographic factors (i.e., sex, age, race, drugs and alcohol intake), clin ical factors (i.e., ta king HIV medications, presence of HIV-related symptoms), and so cial support (Simbayi et al., 2007). Similar findings were reported in a study of patients with the Hepatitis C virus visiting a clinic in Iowa (Zickmund, Masuda, Ippolito, & LaBrecq ue, 2003). Findings indicated that a majority of participants believed they had been stigmatized due to their illness and consequently reported greater depressive symptomatology than those who did not perceive stigmatization (Zickmund et al., 2003). Similarly, lung cancer patients are likely to experience stigma as a function of their disease because a particular behavior smoking, is strongly associated with lung cancer incidence. Smoking is estimated to cause about 90% of all lung cancer cases (Godtfredsen, Prescott, & Osler, 2005). Becau se it is an often preventable disease, patients and others may often blame the patien t for their lung cancer diagnosis. To date, research on perceived stigma in lung cancer patients is limite d. One of the key pieces of evidence is a qualitative st udy conducted by Chapple and co lleagues (2004). In this study, lung cancer patients in the United Kingd om were interviewed about their personal history with the disease. A common theme reported by many patients involved feeling stigmatized because of the strong associa tion between smoking and lung cancer (Chapple et al., 2004). Whereas patient s suffering from other cancers (e.g., breast, prostate) may not necessarily be blamed for their disease, these lung cancer patients reported feeling

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9 blamed for their disease by friends, loved ones, and even healthcare professionals (Chapple et al., 2004). Moreover, even patien ts who reported no hi story of smoking or had stopped smoking several years before their diagnosis reported that they felt blamed for their illness (Chapple et al., 2004). Perceived stigma may be related to depressive symptomatology in lung cancer patients, as is the case for patients with Hepatitis C ((Zickmund et al., 2003) and HIV (Berger et al ., 2001; Miles et al., 1997; Simbayi et al., 2007); however, a search of the published litera ture suggests that this hypothesis has yet to be tested. Dyadic Adjustment and Dysfunctional Attitudes In studying the relationship of stigma to depressive symptomatology in lung cancer patients, it will be important to determine whether stigma accounts for variability in depression distinct from other psychosocial variables often found to be associated with depression. Dyadic adjustment (a measure of relational satisfaction) and dysfunctional attitudes (a measure of cognitiv e vulnerability to depression) may be related to depressive symptomatology in lung cancer patients, but th ese relationships have yet to be studied. However, an association between poorer dyadic adjustment and greater depressive symptomatology has been shown in studies of healthy populations (Herr, Hammen, & Brennan, 2007; Jenewein et al., 2008; King & Arnett, 2005; Lewis, Fletcher, Cochrane, & Fann, 2008; Whisman, 2007) as well as in medically-ill populations (Brotto et al., 2008; King & Arnett, 2005). For example, a study of outpatient multiple sclerosis patients and their significan t others reported a relati onship between poorer dyadic adjustment and greater depressive symptomatology (King & Arnett, 2005). In addition, a trial of a psycho-educational interventi on aimed to reduce Female Sexual Arousal

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10 Disorder symptoms in gynecologic cancer patie nts reported a relati onship between poorer dyadic adjustment and greater depressive symptomatology (Brotto et al., 2008). Similarly, there is evidence for a rela tionship of dysfunctional attitudes to depressive symptomatology in other populations. In a study of women with and without a history of depression, more dysfunctional attit udes were associated with a greater number of previous episodes of depr ession and greater likelihood to have a future depressive episode (Otto et al., 2007). Also, in a sample of college undergradua tes with and without a history of depression, more dysfunctional atti tudes were found to be related to greater depressive symptomatology (Haffel et al ., 2005). The relationships between dyadic adjustment, dysfunctional attitudes, and depr essive symptomatology merit exploration in lung cancer patient populations. Aims The primary aim of this study was to examine the relationship between stigma, as measured by the Social Impact Scale (SIS ; Fife & Wright, 2000), and depressive symptomatology, as measured by the Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977), in people w ith lung cancer. The study also aimed to examine relationships between several psyc hosocial factors found to be related to depression in other populations (i.e., coping, social support, dyadic adjustment, and dysfunctional attitudes) and depressive symptomatology in lung cancer patients. Additionally, this study aimed to determine wh ich demographic and clinical factors are related to perceived stigma. Finally, this study also sought to determine if stigma accounts for variability in depressive sympto matology in lung cancer patients above and beyond psychosocial factors found to be relate d to depressive symptomatology in other

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11 populations, and if psychosocial factors me diate the relationship between perceived stigma and depressive symptomatology. Hypotheses 1. It was hypothesized that great er perceived stigma woul d be related to greater depressive symptomatology. 2. Also, it was hypothesized that more avoi dant coping, poorer social support, poorer dyadic adjustment, and more dysfunc tional attitudes would be related to greater depressive symptomatology. 3. In addition, it was hypothesized that perc eived stigma would explain unique variance in depression over and above that explained by other psychosocial, demographic, and clinical variables re lated to depressive symptomatology. 4. Finally, further analyses were conducted, based on the result of hypothesis testing, to determine if psychosocial factors medi ated the relationship between perceived stigma and depressive symptomatology.

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12 Method Participants Eligibility criteria for the current stud y were: 1) receiving chemotherapy for stage II, III, or IV non-small cell lung cancer 2) 18 years of age, 3) ab le to understand, speak, and read English, 4) no history of other cancers with the exception of non-melanoma skin cancer, 5) and able to provide informed consent. Procedure Study eligibility was determined via consultation with H. Lee Moffitt Cancer Center Thoracic Oncology Program team me mbers. Potential participants were approached during a routine ou tpatient visit and had the study protocol explained. Those eligible and interested provided written informed consent. Particip ants were given the option of filling out the study measures during their outpatient visit or taking them home and returning the completed measures in a self-addressed stamped envelope that was provided. Participants were not compen sated for their study participation. Measures Demographics and Background Information. Demographics and background information were collected using a standardi zed self-report form. The variables assessed were: age, sex, race, ethnicity, education, inco me, marital status, and employment status. In addition, participants current and past smoking status, number of cigarettes smoked per day, and years of smoking were assessed. Clinical Information. The following clinical information was assessed via a review of patients medical reco rds: date of lung cancer diagno sis, disease stage, previous

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13 lung cancer treatment, planned lung cancer treatment, and ECOG performance status (Oken et al., 1982). Stigma. Experienced stigma was assessed us ing the Social Impact Scale (SIS; Fife & Wright, 2000), a 24-item Likert-type scale which measures the extent to which individuals with an illness believe they are experiencing social rejection, financial insecurity, internalized shame, and social isolation as a result of their illness. In addition to a total score, the measure yields subscale scores for the four aspects of experienced stigma described above. These four subscales have been shown to have strong internal consistency reliability ( range: .85 .90), and though they are related, their relatively low zero-order correlati ons with one another (r range: .28 .66) suggest that they assess divergent aspects of ones illness-related stigma (Fife & Wright, 2000). In the current study, analyses focused on the total score. Dyadic Adjustment. Among participants who were living with a spouse or partner, relational adjustment was assessed using the Dyadic Adjustment Scale-4 (DAS4; Sabourin, Valois, & Lussier, 2005), a Like rt-type instrument designed for use with married, unmarried, and same-sex cohabitating couples. It is comprised of 4 items: How often do you discuss or have you discussed divorce, separation, or terminating your relationship?; In general, how often do you think that things between you and your partner are going well?; Do you confide in your mate?; and Pleas e circle the choice which best describes the degree of happiness, all things considered, of your relationship. The DAS-4 has been shown to have adequate convergent and divergent validity, and a cut-off score of 13 has been posited as op timal for distinguishing between individuals with dyadic distress and those w ithout (Sabourin et al., 2005).

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14 Coping. Coping strategies were assessed using the Coping Responses Inventory (CRI; Moos, 1993), a 48-item Likert-type instrument which assesses specific coping responses via eight subscales Four subscales assess appr oach coping styles; two are considered behavioral approach coping styles (seeking guidance a nd support, problem solving), and two are considered cognitive a pproach coping styles (logical analysis, positive reappraisal) (Moos, 1993). Four subscales assess avoidant coping styles; two are considered behavioral avoidant coping styl es (seeking alternativ e rewards, emotional discharge), and two are considered cognitive a voidant coping styles (cognitive avoidance, acceptance or resignation) (Moos, 1993). The ap proach and avoidant scales of the CRI have been shown to have adequate internal consistency reliability ( s = .74 and .66, respectively) in a sample of breast cancer patients (Hack & Degner, 2004). The eight individual subscales of the CRI have been validated (Moos, 1993) and been shown to have adequate internal consistency reliability ( range: .61 .74) in a sample of ovarian cancer patients (Chan, Ng, Lee, Ngan, & Wong, 2003). In the present study, analyses focused on the cognitive avoidance subscale. Social Support. Social support was assessed us ing the ENRICHD Social Support Instrument (ESSI; Mitchell et al., 2003), a 5item Likert-type instrument designed to assess emotional support. The ESSI has been shown to have strong internal consistency reliability ( = .87), good convergent validity with another measure of social support ( r = .62), and relatively weak correlati ons with measures of structural and tangible support ( r range: .20 .25), which is indi cative of divergent validity between emotional and other types of social support (Mitchell et al., 2003). Sample questions include Is there

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15 someone available to give you good advice a bout a problem? and Is there someone available to you who shows you love and affection? (Mitchell et al., 2003). Dysfunctional Attitudes. Dysfunctional attitudes were assessed via the Dysfunctional Attitudes Scale (DAS; Weissm an & Beck, 1978), a 40-item Likert-type self-report measure of cognitive distortions. Part icipants will report, on a 1 to 7 scale, the degree to which they agree or disagree with item s such as, If a person asks for help, it is a sign of weakness. In addition to face vali dity, the DAS has demonstrated concurrent validity with a measure of depressive symptomatology, including the ability to distinguish between depressed and non-depr essed individuals. Th e DAS also has good internal consistency reliability ( range: .84 .92) and test-retest reliability ( r range: .80 .84; Weissman & Beck, 1978). Depressive Symptomatology. Participants depressive symptomatology was assessed using the Center for Epidemiol ogical Studies Depression Scale (CES-D; Radloff, 1977), a 20-item Like rt-type self-report measure of depressive symptomatology. Participants answered ques tions about how they felt ove r the past week. Sample questions include, I had trouble keeping my mind on what I was doing and I had crying spells. Because it is brief and its queries focus primarily on cognitive and affective symptoms of depression rather than somatic symptoms, it is well-suited for use with the medically-ill, such as lung cancer patients (Hann, Winter, & Jacobsen, 1999). The CES-D has been shown to be a valid m easure of depressive symptomatology with excellent internal consistency reliability, as well as adequate test-retest reliability in a sample of cancer patients (Hann et al., 1999).

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16 History of Depression. Participants history of Major Depressive Disorder (MDD) prior to their lung can cer diagnosis was assessed usin g the Structured Clinical Interview for DSM-IV (SCID; Gibbon & W illiams, 2002). The SCID is a widely-used structured interview which is used to determine diagnoses of numerous mental disorders according to Diagnostic and Statistical Ma nual of Mental Disorders IV (DSM-IV; (American Psychiatric Association, 2000) criteria. Good inter-rater agreement on diagnoses of MDD ( = .80; Zanarini et al., 2000) has been demonstrated using trained raters. The mood episodes s ection of the SCID was ad ministered by trained and periodically-observed staff to assess lifetime history of MDD prior to the participants date of diagnosis of lung cancer. Statistical Analyses To test the study hypotheses, correlationa l analyses were conducted to determine the relationships between depressive sy mptomatology and each of the following: perceived stigma, social suppor t, avoidant coping responses and dysfunctional attitudes. A correlational analysis was also conducted to determine the relationship between depressive symptomatology and dyadic adjustme nt among the subset of participants who were living with a spouse or partner and were thus able to complete the measure assessing dyadic adjustment. In addition, independent samples t -tests, ANOVAs, and chi-square tests were performed, as appropriate, to examine relatio nships between demographic and clinical variables and depressive symptomatology. Two hierarchical regressi on analyses were conducted to determine whether perceived stigma accounts for unique variance in depressive symptomatology not

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17 accounted for by other psychosocial variables and by demographic, clinical, and smoking variables related to depressive symptomato logy. In the first hier archical regression analysis, depressive symptomatology was the dependent variable, and independent variables were included in the model in the following 4 steps: 1. Presence of a lifetime (before lung cancer diagnosis) history of depression 2. Any demographic, clinical, or smoking variable related to depressive symptomatology 3. Social support, coping responses, an d dysfunctional though ts, regardless of the significance of their relationshi p to depressive symptomatology 4. Perceived stigma In the second hierarchical regression analysis, dyadic adjustment was added as an independent variable in step 3. This an alysis was conducted with the subset of participants who were living with a spouse or partner and were able to complete the DAS-4. Four additional hierarchi cal regression analyses were conducted to determine which components of perceived stigma contributed unique variance to depressive symptomatology. In these analyses, the four s ubscales of the Social Impact Scale were added as the independent variable in step 4. In addition, independent samples t -tests, ANOVAs, and chi-square tests were performed, as appropriate, to examine relatio nships between demographic and clinical variables and perceived stigma. Finally, mediational analyses were conducted to determine whether social support, dyadic adjustment, coping styles, or dysfunctional attitudes mediated the

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relationship between perceived stigma and depressive symptomatology. These analyses followed the established protocol for dete rmining mediation (MacKinnon, Fairchild, & Fritz, 2007). MacKinnon, et al (2007) lay out the followi ng steps (see Figure 1): 1. The dependent variable (depressive symptomatology) is regressed on the predictor (perceived stig ma). The regression coefficient for the independent variable (IV) in this equation is termed c 2. The proposed mediator (psychosocial fact or) is regressed on the predictor. The regression coefficient for the IV in this equation is termed a. 3. The dependent variable is regressed on the predictor and mediator. The regression coefficient for the mediator is termed b, and the new regression coefficient for the predictor in this equation is termed c X b c (c) X M a Figure 1. Path diagram for the indirect effect of a predictor on a dependent variable through a mediator. In order to satisfy the requirements for mediation, c a, and b must be significant. Also, the decrease from c to c (indirect effect) must be sign ificant as tested by the Sobel test. The Sobel test divides th e value of the indirect effect by its standard error and compares the result to a standard normal distribution (Sobel, 1982). 18

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19 A power analysis using Power and Precisi on 2.0 (Biostat, 2000) indicated that for a correlational analysis with a Type I error rate of .05 (two-tailed), the sample size of the current study (N = 95) woul d yield power equal to .85 for detecting a medium-sized effect (r = .30). A second analysis was conducted to determine the power of the hierarchical multiple linear regression model de scribed above. It indicated that a model in which Step 1 (i.e., past hist ory of depression) accounts for 10% of the variance in depressive symptomatology, Step 2 (i.e., demographic and clinical variables) accounts for an additional 10% of the variance, Step 3 (i.e., psychosocial variables) accounts for an additional 20% of the variance, power is equa l to .82 with a Type I error rate of .05 and 95 participants for detecting a 5% increase in variance accounted for by stigma on Step 4.

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20 Results Participants Eight hundred thirty-nine part icipants were screened for this study; of these, 680 were ineligible based on medical record reviews (e.g., history of other cancer, not receiving chemotherapy). The remaining 159 participants were approached for participation; of these, an additional 17 were deemed ineligible before consent, 33 refused to participate, and 109 agreed to partic ipate (77% of those eligible). Of those who agreed to participate, 4 withdrew from th e study, 4 never completed the study measures and could not be reached, and 6 were found to be ineligible after they participated. Thus, analyses were conducted on th e 95 participants who had ev aluable data, 66 of whom were living with a spouse/part ner and were included in th e sub-analyses with dyadic adjustment (See Figure 2 for a participant fl ow chart). The 109 pa tients who agreed to participate in the study did not differ in terms of age, gender, or race from the 33 patients who declined to participate, ps .48.

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Assessed for eligibility (n= 839) Ineligible for participation (n = 680) Approached for consent (n = 159) 21 Figure 2. Participant Flow Chart Consented (n = 109) Completed study measures (n = 95) Refused to participate (n = 33) Ineligible before consent (n = 17) Ineligible after consent (n = 6) Withdrew from study (n = 4) Failed to complete measures (n = 4) Living with spouse/partner (n = 66)

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22 Participants ranged in age from 42 to 83 years ( M = 64.04; SD = 8.79). The majority of the participants were high school graduates (60%), married (61.1%), and White (92.6%). Mean Body Mass Index for this sample was 26.44 ( SD = 5.18), which indicates that the average participant was s lightly overweight. On average, participants were 18.14 months ( SD = 30.35) from their original l ung cancer diagnosis. Forty-five (47.4%) participants had surgery for this cancer and 41 (43.2%) had been treated with radiation therapy. The possible range of scores on the CES-D is from 0 to 60. The range of scores for this sample was 0 to 44. The mean CES-D score was 14.39 (SD = 8.26), and 38% of participants ( n = 36) met the CES-D cutoff for clinically significant depressive symptoms ( 16). Thirteen participants (13.7%) met criteria for a diagnosis of Past Major Depressive Disorder, and 16 (16.8%) were taki ng antidepressant medications at the time of the study visit. Twelve participants ( 12.6%) were never smokers, 68 (71.6%) were past smokers, and 15 (15.8%) were current smokers at the time of the study visit (see Tables 1 and 2 for complete demographic and clinical information). All measures had adequate internal consistency reliability, (Cronbachs alphas .72; see Table 3 for descriptive statistics and internal consistency reliabilities for each measure).

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Table 1 Demographic Characteristics of the Sample (N = 95) Variable M SD Age, years 64.04 (8.79) Pack Yearsa 35.43 (23.70) Variable n % Gender Males 39 (41.1%) Females 56 (58.9%) Education High school graduate 38 (40.0%) > High school graduate 57 (60.0%) Race White 88 (92.6%) Non-White 7 (7.4%) Ethnicity Hispanic 3 (3.2%) Non-Hispanic 92 (96.8%) Marital Status Currently Married 58 (61.1%) Not Married 37 (38.9%) Total household income < $ 40,000 22 (23.2%) $40,000 44 (46.3%) Declined to answer 29 (30.5%) Alcohol use in past month No 42 (44.2%) Yes 53 (55.8%) Cigarette use Never 12 (12.6%) Previous 68 (71.6%) Current 15 (15.8%) aAmong only past smokers and current smokers ( n = 83). 23

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Table 2 Clinical Characteristics of the Sample (N = 95) Variable M SD Body Mass Index 26.44 (5.18) Months Since Original Diagnosis 18.14 (30.35) Variable n % Disease Stage II 3 (3.2%) III 29 (30.5%) IV 63 (66.3%) ECOG Performance Status 0 20 (21.0%) 1 62 (65.3%) 2 3 13 (13.7%) Diagnosis of Past Major Depression No 82 (86.3%) Yes 13 (13.7%) Taking antidepressant medica tion at time of study visit No 79 (83.2%) Yes 16 (16.8%) Had Surgery for This Cancer No 50 (52.6%) Yes 45 (47.4%) Had Radiation Therapy for This Cancer Never 54 (56.9%) Before current course of chemo 33 (34.7%) Currently 8 (8.4%) Note : ECOG = Eastern Cooperative Oncology Group. 24

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Table 3 Mean, Standard Deviations, and Internal C onsistency Reliabilities of Psychosocial Scales Scale M SD Social Impact Scale 42.90 11.87 .95 Dyadic Adjustment Scale 16.94 3.55 .83 ENRICHD Social Support Instrument 22.74 3.04 .91 CRI Cognitive Avoidance 7.85 3.94 .72 Dysfunctional Attitudes Scale 103.62 25.92 .89 CES-D 14.39 8.26 .84 Note : CRI = Coping Responses Inventory; CES-D = Center for Epidemiologic Studies Depression Scale. Relationship of Perceived Stigma and Depressive Symptomatology Correlational analyses were conducted to test the hypothesi s that perceived stigma would be would be positively related to depressive sympto matology (see Table 4). As hypothesized, these correlations indicate that more social rejection, financial insecurity, internalized shame, social isola tion, and greater overall perceived stigma as a result of ones lung cancer diagnosis were significantly related to greater depressive symptomatology. 25

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Table 4 Correlations Between Depressive Symptomatology and Perceived Stigma (N = 95) Variable Depression (CES-D) p-value Perceived Stigma (SIS Total) .46 < .001 Social Rejection (SocRej) .29 .004 Financial Insecurity (FinIns) .43 < .001 Internalized Shame (IntSha) .27 .010 Social Isolation (SocIso) .58 < .001 Note : CES-D = Center for Epidemiologic Studies Depression Scale; SIS = Social Impact Scale. Relationships of Other Psychosocial Vari ables with Depressive Symptomatology A second set of correlational analyses was conducted to test the hypotheses that poorer social support, poorer dyadic adju stment, more avoidant coping, and more dysfunctional attitudes would be related to depressive symptomatology (see Table 5). As hypothesized, these correlati ons indicate that poorer so cial support, poorer dyadic adjustment, more avoidant coping, and more dysfunctional attitudes were significantly related to greater depressive symptomatology. 26

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Table 5 Correlations Between Depressive Symptomato logy and Psychosocial Variables (N = 95) Variable Depression (CES-D) p-value Social Support (ESSI) -.33 .001 Dyadic Adjustment (DAS-4)a -.48 < .001 Avoidant Coping (CRI CA) .36 < .001 Dysfunctional Attitudes (DAS) .48 < .001 Note : CES-D = Center for Epidemiologic Stud ies Depression Scale; ESSI = ENRICHD Social Support Instrument; DAS-4 = Dyadic Adjustment Scale 4; CRI CA = Coping Responses Inventory Cognitive Avoidance Subscale; DAS = Dysfunctional Attitudes Scale. aAmong only those who were living with a spouse or partner (n = 66); Relationships of Demographic and Clinical Variables with Depressive Symptomatology In order to determine if demographic and clinical variables were associated with depressive symptomatology, t -tests, ANOVAs, and correla tional analyses were conducted (see Tables 6 and 7). No demographi c variables were found to be related to depressive symptomatology ( ps > .05). In contrast, two clin ical variables were found to be related to depressive symptomatology. Those with a diagnosis of past Major Depressive Disorder reported gr eater depressive symptomatology ( M = 19.31; SD = 11.27) than those without a diagnosis of past Major Depressive Disorder ( M = 13.60; SD 27

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= 7.48) ( p = .02). Also, patients for whom more time had elapsed since their lung cancer diagnosis reported greater depressive symptomatology, r (93) = .20, p = .048. Table 6 Relationships Between Depressive Sympto matology and Demographic Variables (N = 95) Variable Depression (CES-D) p-value Age (years) r = .05 .66 Gender (m, f) t = -1.0 .32 Education (< H.S., H.S.) t = -1.26 .21 Race (White, non-White) t = -1.57 .12 Ethnicity (Hispanic, non-Hispanic) t = -0.29 .77 Marital Status (married, not married) t = -0.29 .78 Total Household Income (< $40k, $40k) t = 0.71 .48 Alcohol Use in Past Month (yes, no) t = 0.28 .78 Cigarette Use (never, previous, current) F = 0.30 .75 Pack Years r = .01 .92 aAmong only past smokers and current smokers ( n = 83). 28

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Table 7 Relationships Between Depressive Symptomatology and Clinical Variables (N = 95) Variable Depression (CES-D) p-value Diagnosis of Past Ma jor Depression (yes, no) t = 2.37 .02 BMI r = .07 .52 Months Since Original Diagnosis r = .20 .05 Months Since Recurrencea r = -.01 .98 Disease Stage (II, III, IV) F = 0.23 .80 ECOG Performance Status (0, 1, 2-3) F = 0.71 .50 Surgery (yes, no) t = -0.40 .69 Months Since Surgeryb r = .23 .12 Radiation Therapy (n ever, previous, current) F = 0.98 .38 Months Since Radiation Therapyc r = .00 .98 Chemotherapy infusions for this course r = -.12 .24 Previous chemotherapy coursesd r = .07 .63 Antidepressant medication (yes, no) t = -0.42 .67 Note: ECOG = Eastern Cooperative Oncology Group aAmong only those with a recurrence of Non-Small Cell Lung Cancer ( n = 30); bAmong only those who had surgery; cAmong only those who received radiation therapy ( n = 41); dAmong only those who received a course of chemotherapy previous to the current course ( n = 45). 29

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30 Regression Analysis of Depressive Symptomatology Based on the findings that perceived stigma was related to depressive symptomatology, a hierarchical regression an alysis was conducted to determine if perceived stigma accounted for significant vari ability in scores on the CES-D above and beyond that accounted for by relevant variable s (see Table 8). Diagnosis of past Major Depressive Disorder was specified for in clusion in the model prior to conducting analyses, time since original lung cancer diagnosis was included in the model because of its relationship with depressive sympto matology (see Table 7), and psychosocial variables were included based on the prespecified model. As shown in Table 8, diagnosis of past Major Depre ssive Disorder accounted for 5% of the variance and time since original lung cancer diagnosis accounted for 4% of the variance in depressive symptomatology. Social support, avoidant coping, and dys functional attitudes were entered into the equation in the third step. Together, they accounted for an additional 35% of the variance in depressive symptomatology. Lastly, perceived stigma was entered into the model in the fourth step. It accounted for an additional 3% of the remaining variance in depressive symptomatology. As hypothesized, perceived stigma accounted for a statistically significant amount of additiona l variance in depressive symptomatology (p = .043). Together, these variable s accounted for 47% of the variance in depressive symptomatology.

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Table 8 Summary of Hierarchical Regression Anal ysis for Variables Predicting Depressive Symtpomatology (CES-D) (N = 95) Variable R2 Step 1 .05 History of MDD .25* Step 2 .04 Time Since Diagnosis .11 Step 3 .35 Social Support (ESSI) -.11 Avoidant Coping (CRI CA) .27** Dysfunctional Attitudes (DAS) .33** Step 4 .03 Perceived Stigma (SIS) .19* Note. Overall F (6, 88) = 12.43, p < .001; CES-D = Center for Epidemiologic Studies Depression Scale; MDD = Majo r Depressive Disorder; ESSI = ENRICHD Social Support Instrument; CRI CA = Coping Responses I nventory Cognitive Avoidance Subscale; DAS = Dysfunctional Attitudes Scale; SIS: Social Impact Scale. p < .05, ** p < .01; 31

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32 A second hierarchical regression analysis was conducted with a subset of the sample ( n = 66) that was living with a spouse or pa rtner and was eligible to complete the Dyadic Adjustment Scale 4 (see Table 9). Diagnosis of past MDD was entered into the model in the first step and accounted fo r 8% of the variance in depressive symptomatology. Time since original lung can cer diagnosis was entered in the second step and accounted for an additional 5% of the variance. Social support, avoidant coping, dysfunctional attitudes, and dyadic adjustment were added in the third step and accounted for an additional 39% of variance. Perceived stigma was added in the fourth step and accounted for 4% of the remaining vari ance. As hypothesized, perceived stigma accounted for a statistically significant amount of additional variance in depressive symptomatology ( p = .028). Together, these variables accounted for 56% of the variance in depressive symptomatology.

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Table 9 Summary of Hierarchical Regression Anal ysis for Variables Predicting Depressive Symtpomatology (CES-D) Among Participants Living With a Spouse or Partner (n = 66) Variable R2 Step 1 .08 History of MDD .14* Step 2 .05 Time Since Diagnosis .18 Step 3 .39 Social Support (ESSI) -.15 Avoidant Coping (CRI CA) .11 Dysfunctional Attitudes (DAS) .30** Dyadic Adjustment (DAS-4) -.11 Step 4 .04 Perceived Stigma (SIS) .24* Note. Overall F (7, 58) = 10.42, p < .001; CES-D = Center for Epidemiologic Studies Depression Scale; MDD = Majo r Depressive Disorder; ESSI = ENRICHD Social Support Instrument; CRI CA = Coping Responses I nventory Cognitive Avoidance Subscale; DAS = Dysfunctional Attitudes Scale; DAS-4 = Dyad ic Adjustment Scale 4; SIS = Social Impact Scale. p < .05, ** p < .01 33

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34 Additional hierarchical re gression analyses were c onducted to determine which components of perceived stigma contri buted unique variance to depressive symptomatology. The Social Rejection and Internalized Shame subscales did not contribute significant variance to depressive symptomatology (ps .49); however, the Financial Insecurity and Social Isolation subscales did contri bute significant variance to depressive symptomatology (see Tables 10 and 11). Similar trends were found, in analyses which included the Dyadic Adjust ment Scale 4 among the participants who were living with a spouse or partner (not shown). These fi ndings suggest that financial insecurity and social isolati on are the components of perceived stigma that may be most associated with depressive symptomatology.

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Table 10 Summary of Hierarchical Regression Anal ysis for Variables Predicting Depressive Symtpomatology (C ES-D) (n = 95) Variable R2 Step 1 .05 History of MDD .25** Step 2 .04 Time Since Diagnosis .11 Step 3 .35 Social Support (ESSI) -.11 Avoidant Coping (CRI CA) .25** Dysfunctional Attitudes (DAS) .37** Step 4 .03 Financial Insecurity (SIS FinIns) .19* Note. Overall F (6, 88) = 12.53, p < .001; CES-D = Center for Epidemiologic Studies Depression Scale; MDD = Majo r Depressive Disorder; ESSI = ENRICHD Social Support Instrument; CRI CA = Coping Responses I nventory Cognitive Avoidance Subscale; DAS = Dysfunctional Attitudes Scale; DAS-4 = Dyad ic Adjustment Scale 4; SIS = Social Impact Scale. p < .05, ** p < .01 35

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Table 11 Summary of Hierarchical Regression Anal ysis for Variables Predicting Depressive Symtpomatology (C ES-D) (n = 95) Variable R2 Step 1 .05 History of MDD .22** Step 2 .04 Time Since Diagnosis .08 Step 3 .35 Social Support (ESSI) -.10 Avoidant Coping (CRI CA) .24** Dysfunctional Attitudes (DAS) .27** Step 4 .07 Social Isolation (SIS SocIso) .33** Note. Overall F (6, 88) = 12.53, p < .001; CES-D = Center for Epidemiologic Studies Depression Scale; MDD = Majo r Depressive Disorder; ESSI = ENRICHD Social Support Instrument; CRI CA = Coping Responses I nventory Cognitive Avoidance Subscale; DAS = Dysfunctional Attitudes Scale; DAS-4 = Dyad ic Adjustment Scale 4; SIS = Social Impact Scale. p < .05, ** p < .01 36

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37 Relationships of Demographic and Clinic al Variables with Perceived Stigma In order to determine if demographic and clinical variables were associated with perceived stigma, t -tests, ANOVAs, and correlational analyses were conducted (see Tables 12 and 13). Age was associated with perceived stigma, such that younger patients reported greater perceived stigma. Also, thos e who reported no alcohol use in the past month ( M = 45.19, SD = 11.30) reported greater perceived stigma than those who reported using alcohol in the past month ( M = 40.00, SD = 12.06). In addition, patients with a diagnosis of past Ma jor Depressive Disorder (M = 48.91, SD = 12.71) as well as those with an ECOG performance status of 2 or 3 ( M = 50.63, SD = 12.70) reported greater perceived stigma as compared to those without a history of Major Depressive Disorder ( M = 41.86, SD = 11.48) and those with performance statuses of 0 ( M = 40.69, SD = 10.35) or 1 ( M = 41.99, SD = 11.70). Although no hypotheses were offered, multiv ariate stepwise analyses were conducted to determine which of these demogr aphic and clinical variables contributed significant variance in perceived stigma (see Table 14). Age and performance status were the only variables that contri buted significant variance in perceived stigma above and beyond that contributed by one another.

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Table 12 Relationships Between Perceived Stigma and Demographic Variables (N = 95) Variable Perceived Stigma (SIS) p-value Age (years) r = -.21 .04 Gender (m, f) t = 1.14 .26 Education (< H.S., H.S.) t = -1.01 .32 Race (White, non-White) t = -1.19 .24 Ethnicity (Hispanic, non-Hispanic) t = 0.38 .71 Marital Status (married, not married) t = 0.95 .35 Total Household Income (< $40k, $40k) t = 0.68 .50 Alcohol Use in Past Month (yes, no) t = 2.16 .03 Cigarette Use (never, previous, current) F = 0.23 .80 Pack Years r = .18 .08 aAmong only past smokers and current smokers ( n = 83). 38

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Table 13 Relationships Between Perceived Stigma and Clinical Variables (N = 95) Variable Perceived Stigma (SIS) p-value Diagnosis of Past Ma jor Depression (yes, no) t = 2.09 .04 BMI r = -.15 .14 Months Since Original Diagnosis r = .12 .25 Months Since Recurrencea r = .02 .91 Disease Stage (II, III, IV) F = 0.63 .54 ECOG Performance Status (0, 1, 2-3) F = 3.46 .04 Surgery (yes, no) t = -0.60 .55 Months Since Surgeryb r = .12 .45 Radiation Therapy (n ever, previous, current) F = 0.08 .92 Months Since Radiation Therapyc r = .05 .74 Chemotherapy infusions for this course r = .02 .85 Previous chemotherapy coursesd r = .17 .26 Antidepressant medication (yes, no) t =1.38 .17 Note: ECOG = Eastern Cooperative Oncology Group aAmong only those with a recurrence of Non-Small Cell Lung Cancer ( n = 30); bAmong only those who had surgery; cAmong only those who received radiation therapy ( n = 41); dAmong only those who received a course of chemotherapy previous to the current course ( n = 45). 39

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Table 14 Summary of Stepwise Regression Analysis for Variables Predicting Perceived Stigma (SIS) (n = 95) Variable R2 Step 1 .05 ECOG Performance Status (0, 1, 2-3) .22* Step 2 .05 Age -.22* Note. Overall F (2, 92) = 4.94, p < .01; SIS = Social Imp act Scale; ECOG = Eastern Cooperative Oncology Group. p < .05 40

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Mediational Analyses In order to determine which psychosocial variables would be tested for mediation of the relationship between perceived stigma and depressive symptomatology, correlational analyses were conducted between perceived stigma and social support, avoidant coping, dysfunctional attitudes, and dyadic adjust ment (see Table 10). Social support, dysfunctional attitudes, and dyadic adju stment were all significantly correlated with perceived stigma ( ps < .01); avoidant coping was not ( p = .45). Thus, three separate mediational analyses were conducted to de termine if social support, dysfunctional attitudes, or dyadic adjustme nt mediated the relationshi p observed between perceived stigma and depressive symptomatology. The method described by MacKinnon, et al. (2007) was employed to determine if there is a direct effect ( c ) between the predictor and dependent variable which is medi ated by the proposed mediator. Table 15 Correlations Between Perceived Stigma and Psychosocial Variables (N = 95) Variable Perceived Stigma (SIS) p-value Social Support (ESSI) -.35 .001 Dyadic Adjustment (DAS-4)a -.35 .004 Avoidant Coping (CRI CA) .08 .450 Dysfunctional Attitudes (DAS) .43 < .001 aAmong only those living with a spouse or partner ( n = 66). 41

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The first model tested whether social support mediated the relationship of perceived stigma to depressive symptomatology. Perceived stigma was a significant predictor of depressi ve symptomatology ( B = .32, p < .001) as well as social support ( B = -.09, p < .001). After controlling for social support, there was a reduction in the regression coefficient for perceived stigma ( B = .28, p < .001), indicating that the effect of perceived stigma on depressive sympto matology was partially mediated by social support; however, the Sobel test was only marginally significant (z = 1.70, p = .089), suggesting no mediational relationship (see Figure 3). Social Support (ESSI) Perceived Stigma (SIS) Depressive Symptomatology (CES-D) B = -.53* B = .32** ( B = .28**) B = -.09** Figure 3 Proposed Model of Social Support (ESS I) as a Mediator Between Perceived Stigma (SIS) and Depressive Symptomatology (CES-D). ESSI: ENRICHD Social Support Instrument; SIS: Social Impact Scale; CES-D: Center for Epidemiologic Studies Depression Scale; Sobel test z = 1.70, p = .089. *p < .05, **p < .01 42 The second model tested whet her dyadic adjustment mediated the relationship of perceived stigma to depressive symptomatology. Perceived stigma was a significant predictor of depressive symptomatology, B = .40, p < .001, as well as dyadic adjustment, B = -.10, p = .005. After controlling for dyadic adjustment, there was a reduction in the

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regression coefficient for perceived stigma to B = .28, p < .001, indicating that the effect of perceived stigma on depressive sympto matology was partially mediated by dyadic adjustment. Sobels test was significant (z = 2.10, p = .036), adding further support to the mediation model (see Figure 4). Dyadic Adjustment (DAS-4) Perceived Stigma (SIS) Depressive Symptomatology (CES-D) B = .40** ( B = .32**) B = -.80** B = -.10** Figure 4. Proposed Model of Dyadic Adjustment (DAS-4) as a Mediator Between Perceived Stigma (SIS) and Depr essive Symptomatology (CES-D) aAmong only those participants who were livi ng with a spouse or partner (n = 66); DAS-4 = Dyadic Adjustment Scale-4; SIS = Social Impact Scale; CES-D = Center for Epidemiologic Studies Depression Scale; Sobel test z = 2.10, p = .036. *p < .05, **p < .01 The third model tested whether dysfunctional attitudes mediated the relationship of perceived stigma to depressive sympto matology. Perceived stigma was a significant predictor of depres sive symptomatology, B = .32, p < .001, as well as dysfunctional attitudes, B = .94, p < .001. After controlling for dysf unctional attitudes, there was a reduction in the regression coefficient for perceived stigma to B = .22, p < .001, indicating that the eff ect of perceived stigma on depressive symptomatology was partially 43

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mediated by dysfunctional attitudes. Sobels test was signi ficant (z = 2.82, p = .005), adding further support to the me diation model (see Figure 5). Dysfunctional Attitudes (DAS) Perceived Stigma (SIS) Depressive Symptomatology (CES-D) B = .32** ( B = .22**) B = .11** B = .94** Figure 5. Proposed Models of Dysfunctional Attitudes (DAS) as a Mediator Between Perceived Stigma (SIS) and Depressive Sy mptomatology (CES-D). DAS = Dysfunctional Attitudes Scale; SIS = Social Impact Scale; CES-D = Center for Epidemiologic Studies Depression Scale; Sobel test z = 2.82, p = .005. *p < .05, **p < .01 44

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45 Discussion Summary of Results The primary aim of this study was to examine the relationship between perceived stigma and depressive symptomatology in people with lung cancer. The study also sought to examine relationships between several psychosocial factors that are related to depressive symptomatology in other populations and depr essive symptomatology in people with lung cancer. Additi onally, it aimed to determine if perceived stigma accounts for variability in depressive symptomato logy in lung cancer patients above and beyond that explained by psychosocial factors that ha ve been found to be related to depressive symptomatology in other populat ions. Lastly, this study sough t to determine whether the psychosocial factors assessed mediated the relationship between perceived stigma and depressive symptomatology. Results generally supported the study hypothe ses. As expected, greater perceived stigma was significantly related to higher le vels of depressive symptomatology. More avoidant coping, poorer social support, poorer dyadic adjust ment, and more dysfunctional attitudes were also significantly related to greater depressive symptomatology. Additional analyses indicated that perceived stigma contributed unique variance in depressive symptomatology above and beyond that accounte d for by clinical (time since lung cancer diagnosis), demographic (history of past Ma jor Depressive Disorder), and psychosocial (avoidant coping, social support, dyadic adjustment, and dysfunctional attitudes) factors. Further analyses showed that financial insecurity and social isolation may be the aspects of perceived stigma that mo st contribute to depressive symptomatology. In addition, younger patients, those who reported no alcohol use in the past month, those with a

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46 history of Major Depressive Disorder, as well as those with poorer performance statuses reported greater perceived stigma; however, only age and performance status contributed significant variance to perceived stigma. Fi nally, analyses suggested that dyadic adjustment and dysfunctional attitudes mediated the rela tionship between perceived stigma and depressive symptomatology. Th e following discussion will consider the theoretical and clini cal implications of these findings describe the studys limitations, and identify future research directio ns suggested by the study findings. Theoretical and Clinical Implications As can best be determined, this is the first study to examine the relationship of perceived stigma to depressive symptomatology in lung cancer patients. This studys findings provide quantitative ev idence consistent with the qualitative evidence provided by Chapple and colleagues (2004) which suggest ed that lung cancer patients experience significant stigma from others as a result of their illness. Moreover, this study extends this finding to provide evidence for a link between perceived stigma and depressive symptomatology as well as possible mediators of this relationship. Documenting this link among lung cancer patients is important for several reasons. First, it adds further evidence to the growing body of literature suggesting a connection between illness-re lated stigma and depressive symptomatology. As noted earlier, studies have found that patients w ith other stigmatizing conditions (e.g., HIV infection) who report more stigma also report greater depressive symptomatology (Simbayi, et al., 2007). Second, it adds to knowledge about the po ssible etiology of depressive symptomatology among lung cancer patie nts, a group that is particularly likely to experience depressive symptoms (B uccheri, 1998; Nakaya et al., 2006).

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47 This studys findings are consistent w ith the Cognitive Theory of Depression, which states that ones e xperiences may contribute to depressive symptomatology by activating maladaptive schemas, or ways of thinking, from past experiences that are related to the current situ ation (Beck & Dempster, 1976; Beck, Rush, Shaw, & Emery, 1979). When activated, these maladaptive sc hemas begin to perpetuate dysfunctional attitudes, or faulty reasoning, within the in dividual that are evid ent in their automatic cognitive responses to stimuli. These automatic cognitive responses propagate negative views of oneself, the experiences one under goes, and ones outlook on the future. These negative thought patterns, the Cognitive Triad, are the most conscious manifestations of the depressive state and are theorized to result in affective and somatic depressive symptoms (Beck et al., 1979). Th is studys findings suggest that this chain reaction could be activated in lung cancer patients who perc eive they are being stigmatized because of their illness. Some lung cancer patients may in fact misperceive that they are being stigmatized because of their illness; however, the effect of misperceived stigma would likely be similar to that of actual stigma tization. Consider, Beck and colleagues explanation of the effects of misperceiving being rejected and socially alienated two expressions of stigma: For example, if the patient incorrectly thinks he is being reject ed, he will react with the same negative affect (for example, sadness, anger) that occurs with actual rejection. If he erroneously believes he is a social outcast, he will feel lonely (Beck et al., 1979, p. 11). The finding that those experi encing more stigma also reported greater depressive symptomatology provides evidence that this process may be under way in some patients

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48 with lung cancer, an illness for which patie nts are often stigmatized (Chapple et al., 2004). Moreover, this study also suggested m echanisms by which stigma may contribute to depression in lung cancer patients. Specifi cally, the mediational effect of dysfunctional attitudes on the relationship between perceived stigma a nd depressive symptomatology further suggest that Becks Cognitive Th eory of Depression may help explain the etiology of depressive symptoms often experienced by lung cancer patients. The mediational effects of dyadic ad justment on the relationship between perceived stigma and depressive symptomatology also suggest additional pathways through which perceived stigma may lead to or worsen the severity of depressive symptoms. That is, greater perceived stigma may activate the process which leads to relational problems with close others which, in turn, might worsen ones depressive symptoms. Research in the general population, as well as in chronically-ill populations, has shown that individuals experiencing poorer dyadic adjustment (B erger et al., 2001; Miles et al., 1997; Simbayi et al., 2007) re port greater depressive symptomatology. With regard to clinical implications the findings suggest psychotherapeutic approaches that might be employed to alle viate or prevent depressive symptoms among lung cancer patients. Most approaches to reducing stigma are focused on reducing the stigma that individuals feel towards people of another gr oup (Couture & Penn, 2003). They are either protests against the injust ice of stigmatizing behavior or programs to educate the public about inaccuracies of stereo types and replace these inaccuracies with facts (Corrigan, Kerr, & Knudsen, 2005). These a pproaches do not seem very applicable to reducing perceived stigma in lung cancer patients. However, other approaches such as cognitive therapy may be helpful in counteracting the effects of stigma (e.g.,

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49 dysfunctional attitudes) on the stigmatized individual (Corrigan et al., 2005). Specifically, a modified cogni tive therapy approach targ eted at altering thoughts and feelings associated with perceived stigma may prove effective in reducing depressive symptomatology. Self-blame is an important component of perceived stigma that warrants attention. One strategy might involve pointing out to pa tients that, although it is true that smoking causes many cases of lung cancer, self-blame is a maladaptive coping strategy after lung cancer is diagnosed. To help patients move beyond the self-blame they may experience as a result of perceived stigma, they might be encouraged to present exempting beliefs. For example, not everyone who smokes gets cancer and not everyone who gets cancer smoked. Thus, it is impossible to ascertain whether ones lung cancer diagnosis can be directly attributable to their smoking. K nowing that one may not necessarily have caused their cancer might help reduce self -blame. The addictiveness of cigarette smoking and the deception in early tobacco industry advertisements could also be understood by some patients to put them in the position of having been wronged rather than being a wrong-doer. Though self-blame can be targeted and reduced, it may remain in some patients. Those patients should be encouraged to acknowledge the potential for culpability, then move on to more productive us es of their energies. To help facilitate this, a psychotherapeutic approach should a ssist lung cancer patients with helping their families cope with their illness and its pres ent and future consequences. Patients could also be offered counseling to aid in th eir understanding of thei r illness and their oncologists recommended treatment plan. Th ese and other focuses within the broader

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50 framework of Cognitive Therapy for depression could help patients move past self-blame and other consequences of their illness. Limitations This study had several limitations. First, the cross-sectional nature of this study limits the conclusions that can be drawn fr om its findings. Although the results can be interpreted as suggesting that stigma contri butes to depression, the possibility that depression contributes to stigma cannot be ru led out. The use of a longitudinal design would allow the testing of temporal hypotheses. Second, the studys sample was relatively homogenous with respect to race and ethnicity, which limits the ability to generalize to the broader l ung cancer patient population. Th ird, the lung cancer patients in this study were receiving chemotherapy de signed to extend life; thus, this studys findings may not generalize to lung cancer patients receiving other types of treatments or receiving no treatment at a ll. Lastly, although use of antidepressant medication was not related to depressive symptomatology in th is study, participants use of psychotherapy and related services was not assessed. Future Directions Because this is the first quantitative study to identify the relationship between perceived stigma and depressive symptomatology among lung cancer patients, it will be important to see if these findi ngs can be replicated in futu re research. Beyond this, there is a need for longitudinal research that w ould allow for examination of the temporal relationships between perceptions of s tigma and depressive symptomatology. Based on the findings that psychosocial fa ctors mediate the relationship between perceived stigma and depressive symptoma tology, longitudinal study designs should be

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51 employed in future studies. These designs would enable examinat ions of temporal relationships and would allow stronger causal in ferences to be drawn. Also, future studies should examine the potential re lationship between the use of psychotherapy services and depressive symptomatology. Futu re studies should also aim to recruit samples of lung cancer patients that are more diverse with regard to race, ethnicity, and socioeconomic status. Additionally, the use of interventi ons to reduce depressive symptomatology among lung cancer patients and other stigma tized groups should consider targeting stigma and its direct effects.

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52 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Ameri can Psychiatric Association. Babiss, L. A., & Gangwisch, J. E. (2009). S ports participation as a protective factor against depression and suicidal ideation in adolescents as mediated by self-esteem and social support. Journal of Developmental & Behavioral Pediatrics, 30 (5), 376-384. Beck, A. T., & Dempster, R. (1976). Cognitive therapy and the emotional disorders International Universities Press New York. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive theory of depression. New York, Guilford, Berard, R. M. F., Boermeester, F., & Viljo en, G. (1998). Depressive disorders in an out­ patient oncology setting: Prev alence, assessment, and management. Psycho-Oncology, 7 (2), 112-120. Berger, B. E., Ferrans, C. E., & Lashley, F. R. (2001). Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Research in Nursing & Health, 24(6), 518-529. Beyrer, C., Sripaipan, T., Tovanabutra, S., Jittiwutikarn, J., Suriyanon, V., Vongchak, T., Srirak, N., Kawichai, S., Razak, M. H., & Celentano, D. D. (2005). High HIV, hepatitis C and sexual risks among drug-using men who have sex with men in northern thailand. AIDS, 19 (14), 1535. Biostat. (2000). Power and precision Englewood, NJ.

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53 Brotto, L. A., Heiman, J. R., Goff, B., Greer, B., Lentz, G. M., Swisher, E., Tamimi, H., & Van Blaricom, A. (2008). A psychoeducat ional intervention fo r sexual dysfunction in women with gynecologic cancer. Archives of S exual Behavior, 37(2), 317-329. Buccheri, G. (1998). Depressive reactions to lung cancer are comm on and often followed by a poor outcome. European Respiratory Journal, 11 (1), 173-178. Chan, Y. M., Ng, T. Y., Lee, P. W. H ., Ngan, H. Y. S., & Wong, L. C. (2003). Symptoms, coping strategies, and timing of presentations in patients with newly diagnosed ovarian cancer. Gynecologic Oncology, 90 (3), 651-656. Chapple, A., Ziebland, S., & McPherson, A. (2004). Stigma, shame, and blame experienced by patients with lung cancer: Qualitative study. BMJ (Clinical Research Ed.), 328 (7454), 1470. doi:10.1136/bmj.38111.639734.7C Corrigan, P. W., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: Explanatory models a nd methods for change. Applied and Preventive Psychology, 11(3), 179-190. Couture, S., & Penn, D. (2003). Interpersonal co ntact and the stigma of mental illness: A review of the literature. Journal of Me ntal Health, 12 (3), 291-305. Degner, L. F., & Sloan, J. A. (1995). Symptom distress in newly diagnosed ambulatory cancer patients and as a predic tor of survival in lung cancer. Journal of Pain and Symptom Management, 10 (6), 423-431. Fife, B. L., & Wright, E. R. (2000). The dime nsionality of stigma: A comparison of its impact on the self of persons with HIV/AIDS and cancer. Journal of Health and Social Behavior, 41 (1), 50-67.

PAGE 63

54 Fisher Jr, E. B., La Greca, A. M., Grec o, P., Arfken, C., & Schneiderman, N. (1997). Directive and nondirective social support in diabetes management. International Journal of Behavioral Medicine, 4 (2), 131-144. Frasure-Smith, N., Lesperance, F., Gravel, G., Masson, A., Juneau, M., Talajic, M., & Bourassa, M. G. (2000). Social support, de pression, and mortality during the first year after myocardial infarction. Circulation, 101(16), 1919-1924. Gibbon, M., & Williams, J. B. W. (2002). Structur ed clinical interview for DSM-IV axis I disorders, research version, non-patient edition (SCID-I/NP). New York: Biometrics Research, New York State Psychiatric Institute, Godtfredsen, N. S., Prescott, E., & Osler, M. (2005). Effect of smoking reduction on lung cancer risk. JAMA, 294 (12), 1505-1510. Goodman, E., & Capitman, J. (2000). Depr essive symptoms and cigarette smoking among teens. Pediatrics, 106(4), 748-755. Hack, T. F., & Degner, L. F. (2004). Coping responses following breas t cancer diagnosis predict psychological adjustment three years later. Psycho-Oncology, 13(4), 235-247. Haffel, G. J., Abramson, L. Y., Voelz, Z. R ., Metalsky, G. I., Halberstadt, L., Dykman, B. M., Donovan, P., Hogan, M. E., Hankin, B. L., & Alloy, L. B. (2005). Negative cognitive styles, dysfunctional attitudes, and the remitted depression paradigm: A search for the elusive cognitive vulnerabi lity to depression factor among remitted depressives. Emotion (Washington, D.C.), 5 (3), 343-348. doi:10.1037/15283542.5.3.343

PAGE 64

55 Hann, D., Winter, K., & Jacobs en, P. (1999). Measurement of depressive symptoms in cancer patients: Evaluation of the center fo r epidemiological studies depression scale (CES-D). Journal of Psychos omatic Research, 46 (5), 437-443. Herr, N. R., Hammen, C., & Brennan, P. A. (2007). Current and past depression as predictors of family functioning: A comparison of men and women in a community sample. JOURNAL OF FAMILY PSYCHOLOGY, 21 (4), 694. Hopwood, P., & Stephens, R. J. (2000). Depr ession in patients with lung cancer: Prevalence and risk factors derived from quality-of-life data. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 18 (4), 893903. Hyodo, I., Eguchi, K., Takigawa, N., Segawa, Y., Hosokawa, Y., Kamejima, K., & Inoue, R. (1999). Psychological impact of informed consent in hospitalized cancer patients. A sequential study of anxiety and depression using the hospital anxiety and depression scale. Supportive Care in Cancer : Official Jour nal of the Multinational Association of Supportive Care in Cancer, 7 (6), 396-399. Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., Murray, T., & Thun, M. J. (2008). Cancer statistics, 2008. CA: A Cancer Journal for Clinicians, 58 (2), 71-96. doi:10.3322/CA.2007.0010 Jenewein, J., Zwahlen, R. A., Zwahlen, D., Drab e, N., Moergeli, H., & Buchi, S. (2008). Quality of life and dyadic adjustment in oral cancer patients and their female partners. European Journal of Cancer Care, 17 (2), 127.

PAGE 65

56 Kaneko, M., Eguchi, K., Ohmatsu, H., Kakinuma, R., Naruke, T., Suemasu, K., & Moriyama, N. (1996). Peripheral lung cancer : Screening and detection with low-dose spiral CT versus radiography. Radiology, 201 (3), 798-802. King, K. E., & Arnett, P. A. (2005). Predictors of dyadic adjustment in multiple sclerosis. Multiple Sclerosis, 11 (6), 700. Kurtz, M. E., Kurtz, J. C., Stommel, M., Gi ven, C. W., & Given, B. (2002). Predictors of depressive symptomatology of geriatric patients with lung cancer-a longitudinal analysis. Psycho-Oncology, 11(1), 12-22. Lewis, F. M., Fletcher, K. A., Cochrane, B. B., & Fann, J. R. (2008). Predictors of depressed mood in spouses of women with breast cancer. Journal of Clinical Oncology, 26(8), 1289. Link, B. G., Cullen, F. T., Struening, E., Sh rout, P. E., & Dohrenwend, B. P. (1989). A modified labeling theory approach to ment al disorders: An empirical assessment. American Sociological Review, 54 (3), 400-423. MacKinnon, D. P., Fairchild, A. J., & Fr itz, M. S. (2007). Mediation analysis. Annual Review of Psychology, 58 593-614. Miles, M. S., Burchinal, P., Holditch-Davis, D., Wasilewski, Y., & Christian, B. (1997). Personal, family, and health -related correlates of depres sive symptoms in mothers with HIV. Journal of Family Psychology, 11(1), 23-34. Mitchell, P. H., Powell, L., Blumenthal, J., Norten, J., Ironson, G., Pitula, C. R., Froelicher, E. S., Czajkowski, S., Youngblood, M., Huber, M., & Berkman, L. F. (2003). A short social support measure for patients recovering from myocardial

PAGE 66

57 infarction: The ENRICHD so cial support inventory. Journal of Cardiopulmonary Rehabilitation, 23 (6), 398-403. Montazeri, A., Milroy, R., Hole, D., McEwen, J., & Gillis, C. R. (1998). Anxiety and depression in patients with lung cancer before and after diagnosis: Findings from a population in glasgow, scotland. Journal of Epidemiology and Community Health, 52(3), 203-204. Moos, R. H. (1993). Coping responses inventory Odessa, FL: Psychological Assessment Resources, Inc. Nakaya, N., Saito-Nakaya, K., Akizuki, N., Yoshikawa, E., Kobayakawa, M., Fujimori, M., Nagai, K., Nishiwaki, Y., Fukudo, S., & Tsubono, Y. (2006). Depression and survival in patients with non-small cell lung cancer after curative resection: A preliminary study. Cancer Science, 97 (3), 199-205. Oken, M. M., Creech, R. H., Tormey, D. C., Horton, J., Davis, T. E., McFadden, E. T., & Carbone, P. P. (1982). Toxicity and respons e criteria of the eastern cooperative oncology group. American Journal of Clinical Oncology, 5 (6), 649-655. Otto, M. W., Teachman, B. A., Cohen, L. S., So ares, C. N., Vitonis, A. F., & Harlow, B. L. (2007). Dysfunctional attitudes and episodes of major depression: Predictive validity and temporal stability in never-d epressed, depressed, and recovered women. Journal of Abnormal Psychology, 116 (3), 475. Purcell, D. W., Parsons, J. T., Halkitis P. N., Mizuno, Y., & Woods, W. J. (2001). Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. Journal of Substance Abuse, 13 (1-2), 185-200.

PAGE 67

58 Radloff, L. S. (1977). The CESD scale: A self-report depressi on scale for research in the general population. Applied Psychological Measurement, 1 (3), 385. Sabourin, S., Valois, P., & Lussier, Y. (2005) Development and validation of a brief version of the dyadic adjustment scale w ith a nonparametric item analysis model. Psychological Assessment, 17 (1), 15-27. doi:10.1037/1040-3590.17.1.15 Sarna, L. (1993). Correlates of sympto m distress in women with lung cancer. Cancer Practice, 1 (1), 21-28. Sarna, L. (1998). Effectiveness of structured nursing assessment of symptom distress in advanced lung cancer. Oncology Nursing Forum, 25 (6), 1041-1048. Simbayi, L. C., Kalichman, S., Strebel, A., Cloete, A., Henda, N., & Mqeketo, A. (2007). Internalized stigma, discrimination, a nd depression among men and women living with HIV/AIDS in cape town, south africa. Social Science & Medicine, 64 (9), 18231831. Sobel, M. E. (1982). Asymptotic confidence in tervals for indirect e ffects in structural equation models. Sociological Methodology, 13 290-312. Tagay, S., Herpertz, S., Langkafel, M., Erim, Y., Bockisch, A., Senf W., & Grges, R. (2006). Health-related quality of life, depression and a nxiety in thyroid cancer patients. Quality of Life Research, 15 (4), 695-703. Turner, N. J., Muers, M. F., Haward, R. A., & Mulley, G. P. (2007). Psychological distress and concerns of elde rly patients treated with palliative radiotherapy for lung cancer. Psycho-Oncology, 16 (8), 707-713. doi:10.1002/pon.1109

PAGE 68

59 Uchitomi, Y., Mikami, I., Nagai, K., Nishiwak i, Y., Akechi, T., & Okamura, H. (2003). Depression and psychological distress in pa tients during the y ear after curative resection of non-small-cell lung cancer. Journal of Clinical Oncology, 21 (1), 69. Visser, M. R. M., & Smets, E. M. A. (1998). Fatigue, depression and quality of life in cancer patients: How are they related? Supportive Care in Cancer, 6 (2), 101-108. Walker, M. S., Larsen, R. J., Zona, D. M., Govindan, R., & Fisher, E. B. (2004). Smoking urges and relapse among lung cancer pa tients: Findings from a preliminary retrospective study. Preventive Medicine, 39 (3), 449-457. Walker, M. S., Zona, D. M., & Fisher, E. B. (2006). Depressive symptoms after lung cancer surgery: Their relation to coping style and social support. Psycho-Oncology, 15(8), 684. Walker, M. S., Zona, D. M., Larsen, R. J., & Fisher, E. B. (2004). Multilevel analysis of social support and psychological adjustme nt during the first year following lung cancer surgery. 25th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Baltimore, MD. 27(Supplement) S022. Weissman, A. N., & Beck, A. T. (1978). Development and validation of the dysfunctional attitude scale: A preliminary investigation. Proceedings of the Meeting of the American Educational Research Association, Toronto, ON. Wells, K. J., Booth-Jones, M., & Jacobsen, P. B. (2009). Do coping and social support predict depression and anxiety in patien ts undergoing hematopoietic stem cell transplantation? Journal of Psychosocial Oncology, 27 (3), 297-315. Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116 (3), 638.

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60 Zanarini, M. C., Skodol, A. E., Bender, D., Dolan, R., Sanislow, C., Schaefer, E., Morey, L. C., Grilo, C. M., Shea, M. T., McGlashan, T. H., & Gunderson, J. G. (2000). The collaborative longitudinal personality diso rders study: Reliability of axis I and II diagnoses. Journal of Personality Disorders, 14(4), 291-299. Zickmund, S., Masuda, M., Ippolito, L., & LaBrecque, D. R. (2003). Stigmatization and the quality of life of patients with hepatitis C. Journal of General Internal Medicine, 18(10), 835-844.