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Predictors of distress in cancer

patients and their partners: The role
of optimism in the sense of coherence
construct
a a b a
M. Gustavsson-Lilius , J. Julkunen , P. Keskivaara , J.
a c
Lipsanen & P. Hietanen
a
Institute of Behavioural Sciences , University of Helsinki , PO Box
9 (Siltavuorenpenger 20 D), 00014 Helsinki , Finland
b
Rehabilitation Foundation , Helsinki , Finland
c
Finnish Medical Journal , Finnish Medical Association , Helsinki ,
Finland
Published online: 03 Mar 2011.

To cite this article: M. Gustavsson-Lilius , J. Julkunen , P. Keskivaara , J. Lipsanen & P.

Hietanen (2012) Predictors of distress in cancer patients and their partners: The role of
optimism in the sense of coherence construct, Psychology & Health, 27:2, 178-195, DOI:
10.1080/08870446.2010.484064

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 Psychology and Health
Vol. 27, No. 2, February 2012, 178195

RESEARCH ARTICLE
Predictors of distress in cancer patients and their partners:
The role of optimism in the sense of coherence construct
M. Gustavsson-Liliusa*, J. Julkunenab, P. Keskivaaraa,
J. Lipsanena and P. Hietanenc
a
Institute of Behavioural Sciences, University of Helsinki, PO Box 9 (Siltavuorenpenger
20 D), 00014 Helsinki, Finland; bRehabilitation Foundation, Helsinki, Finland;
c
Finnish Medical Journal, Finnish Medical Association, Helsinki, Finland
(Received 22 April 2009; final version received 5 April 2010)
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Aim: The aim of this study was to clarify the associations between sense
of coherence (SOC), dispositional optimism and distress (i.e. anxiety and
depression) in cancer patients and their partners. Methods: The associations
between SOC, dispositional optimism (Life Orientation Test-Revised,
LOT-R), depression (Beck Depression Inventory-14, BDI-14) and anxiety
(Endler Multidimensional Anxiety Scales, EMAS-State) were studied in
147 cancer couples. The data were collected with self-report questionnaires
at the time of diagnosis (2 months) and after 6 months. Path analysis was
used to analyse the predictors of follow-up distress and crossover effects
in the longitudinal data. Results: Optimistic patients and patients with
strong SOC as well as their partners reported fewer symptoms of depression
and anxiety than less optimistic subjects and subjects with weaker SOC.
Optimism partially explained the effect of SOC on distress and SOC seemed
to be an independent factor in predicting distress. Patient and partner
distress at baseline and at 8-month follow-up correlated positively.
In addition, high partner optimism at baseline seemed to predict low
patient anxiety at follow-up. Conclusions: The beneficial effects of SOC
seem to include also other elements beyond optimism. In clinical practice,
enhancing optimistic expectations of the future and promoting SOC could
be expected to reduce distress in cancer patients and their partners.
Keywords: optimism; SOC, distress; cancer; oncology; couples

Introduction
For most people, receiving a cancer diagnosis is extremely frightening and often
leads to elevated levels of psychological distress, increased anxiety and depression
being the most common symptoms (Hagedoorn, Sanderman, Bolks, Tuinstra,
& Coyne, 2008; Miovic & Block, 2007). In addition to the individual, cancer affects
the whole family. Cancer patients family members, especially female caregivers,
often suffer from elevated levels of emotional distress (Hagedoorn, Buunk, Kuijer,
Wobbes, & Sanderman, 2000; Pitceathly & Maguire, 2003), although the mean
scores seem to be below clinical cutpoints (Hagedoorn et al., 2008).

*Corresponding author. Email: mila.gustavsson@helsinki.fi

ISSN 08870446 print/ISSN 14768321 online

2012 Taylor & Francis
http://dx.doi.org/10.1080/08870446.2010.484064
http://www.tandfonline.com
 Psychology and Health 179

Family members, especially partners, are usually the main source of support
for cancer patients. In addition to within-person effects, there seems to be great
interdependence in the impact of the cancer disease on patients and their partners
emotional and everyday life (Giese-Davis, Hermanson, Koopman, Weibel, &
Spiegel, 2000; Hagedoorn et al., 2008).

Partners influence on each other and adjustment to cancer

Growing literature has provided a general consensus that patients and partners
are involved in each others support processes by influencing the experience of one
another. This so-called crossover or transitive effect has been studied earlier in
non-clinical samples (Westman, Vinokur, Hamilton, & Roziner, 2004), and recently
in clinical samples as well (Hagedoorn et al., 2008; Ruiz, Matthews, Scheier,
& Schulz, 2006). Previous literature on personality resources in stressful life events
provide evidence that patient-perceived partner support and partners positive
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general expectancies enhance patients adjustment (Baider, Cooper, & Kaplan

De-Nour, 2000; Ben-Zur, Gilbar, & Lev, 2001), coping and quality of life
(Gustavsson-Lilius, Julkunen, & Hietanen, 2007a; Northouse et al., 2002;
Schroeder & Schwartzer, 2001), and predict lower levels of depression (Knoll,
Schwartzer, Pfuller, & Kienle, 2009).
Recently, researchers have demonstrated significant correlations in emotional
distress and similar trajectories in distress (Segrin et al., 2005), as well as in levels
of adjustment within cancer dyads, irrespective of cancer type or illness stage
(Hagedoorn et al., 2008; Pitceathly & Maguire, 2003). It seems that alleviating cancer
patients and partners distress is better achieved by focusing on both patient and
partner characteristics than on individual factors. Consequently, a more detailed
investigation of this issue is needed.

Sense of coherence and dispositional optimism in stressful life events

Over the past decades, the researchers of health psychology as well as behavioural
medicine have adopted a more salutogenic approach, exploring factors which
promote health and physical well-being in stressful situations, instead of the
traditional pathogenic orientation. One key construct of the salutogenic model is
sense of coherence (SOC), developed by Antonovsky (1987). Research evidence
has supported Antonovskys views of the SOC construct as a health-promoting
factor, for both physical (Kivimaki, Vahtera, Elovainio, Lillrank, & Kevin, 2002;
Surtees, Wainwright, Luben, Khaw, & Day, 2006) and mental well-being (Julkunen
& Ahlstrom, 2006; Karlsson, Berglin, & Larsson, 2000).
SOC has been defined as a global orientation based on a persons pervasive
feeling of confidence that the stimuli causing stress are structured, predictable
and explicable, that resources are available to meet the effects of the stimuli, and
the demands and challenges are ameliorable to the persons effort. Moreover,
Antonovskys (1987) theory on salutogenesis suggests that SOC is a factor
comparable to several general resistance resources, a phenomenon combating or
buffering against a variety of stressors.
Dispositional optimism, i.e. generalised expectations that good things will
happen, is another positive resource construct in this area. Previous evidence has
indicated that optimism may act as a stress buffer and protect one from experiencing
 180 M. Gustavsson-Lilius et al.

distress in stressful situations. In several reports, dispositional optimism has been

shown to have beneficial effects on mental and physical health (Carver, Smith,
Petronis, & Antoni, 2006; De Moor et al., 2006; Schou, Ekeberg, Ruland, Sandvik,
& Karesen, 2004). Optimism has also been found to be a predictor of good
adjustment to a variety of somatic illnesses, including different types of cancers
(Carver, Lehman, & Michael, 2003; Friedman et al., 2006).

Dispositional optimism, SOC and symptoms of distress in cancer couples

Only few studies have investigated the stress buffering effects of dispositional
optimism on distress symptoms (i.e. anxiety and depression) among dyads.
For example, a negative association between dispositional optimism and distress
in chronically ill people and their spouses has been found earlier by Ruiz et al. (2006).
Also, Schroeder and Schwartzer (2001) have reported that dispositional optimism
was associated with less depression in a sample of heart patients and their partners.
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Studies reporting associations between dispositional optimism and distress among

couples in psycho-oncology, however, are rare.
Previous research has also shown a strong relationship between SOC and distress,
particularly between SOC and depression (Karlsson et al., 2000; Kivimaki et al.,
2002). Furthermore, in our previous sub-study we found that strong SOC alleviated
the development of distress (i.e. anxiety and depression) during 14 months in 123
newly diagnosed cancer patients and their partners. In this earlier sub-study,
however, no crossover effect between patient and partner SOC and distress was
found, neither were any other positive resistance resources, such as optimism,
investigated (Gustavsson-Lilius, Julkunen, Keskivaara, & Hietanen, 2007b).

Associations between dispositional optimism and SOC

In some previous studies, SOC and dispositional optimism have been found to
correlate positively (Ebert, Tucker, & Roth, 2002; Pallant & Lae, 2002). However,
as far as we know, the reciprocal relationship between these factors has previously
been overlooked. For example, in a comprehensive text book on optimism by Chang
(2001), SOC is mentioned only once in a footnote as a related construct to
dispositional optimism. And particularly, Antonovskys (1987) conceptualisation
of SOC relies on constructs such as comprehensibility, manageability and
meaningfulness, and he does not use the term optimism explicitly.
In his latest report, however, Antonovsky (1996) states that optimism is a related
concept to SOC, but he emphasises that the particular combination of cognitive,
behavioural and motivational components is unique to the SOC construct.
Obviously, dispositional optimism and SOC originate from very different theoretical
backgrounds, and have not been sufficiently investigated in the same context.
Consequently, it can be asked to what extent the health-promoting effects of SOC
would be based on optimism as an important element in the SOC construct?

Aim of this study

Cancer patients and their partners offer an interesting and clinically important
context for investigating generalised positive resistance resources. During the recent
 Psychology and Health 181

years, evidence on dyadic transitive effects has been rapidly increasing and the role
of the cancer patients partner is nowadays generally recognised (Hagedoorn et al.,
2008; Segrin et al., 2005). To date, however, very few reports have investigated the
crossover pathways between cancer patients and their partners optimism, SOC
and distress. Moreover, research into the relationship between partners optimism
and their own distress in the context of cancer has been rare. In addition, most
studies on couples with cancer are conducted with breast cancer patients and their
spouses. Obviously, the dyadic interplay between the personal characteristics of the
patient and the partner and their impact on couples psychological reactions, in a
serious illness such as cancer, needs more attention.
Furthermore, whether dispositional optimism and SOC have some shared health-
promoting effects is an interesting theoretical question which has not been studied
previously. Therefore, the aim of this sub-study was to explore further the
salutogenic factors, i.e. optimism and SOC in cancer patients and their spouses.
The hypotheses (illustrated in Figure 1) were as follows:
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(1) Optimism predicts lower levels of distress (i.e. symptoms of anxiety and
depression) among cancer patients and their spouses at the time of diagnosis
and 8-month follow-up (Model 1).
(2) Patient and partner optimism have a crossover effect on distress at follow-up.
Patient optimism predicts lower levels of partner anxiety and depression,
and partner optimism predicts lower levels of patient anxiety and depression
at 8-month follow-up (Model 1).
(3) Strong SOC is associated with high dispositional optimism, which in turn
predicts lower distress at the time of diagnosis and after 8 months (Model 2).

(c)

Dispositional (a) Distress/patient Distress/patient

SOC
optimism Depression Depression
/patient
/patient Anxiety Anxiety

(b) Stage of cancer

Dispositional Distress/partner Distress/partner

SOC
optimism Depression Depression
/partner
/partner Anxiety Anxiety

T1 T2

(a) Model 1, (b) Model 2, (c) Model 3

Figure 1. Theoretical models linking relationships between (a) optimism, depression and
anxiety (Model 1, paths shown in solid line), (b) SOC, optimism, depression and anxiety
(Model 2, new included paths shown in dashed line) and (c) SOC, optimism, depression and
anxiety, optimism explaining the effect of SOC only partially (Model 3, new included paths
shown in dashed and dotted line).
 182 M. Gustavsson-Lilius et al.

(4) Because the SOC construct also includes elements other than optimism, an
alternative hypothesis can be proposed implying that, dispositional optimism
only partially explains the association of SOC with distress (Model 3).

Methods
This sub-study is part of a larger research project aiming to investigate the
psychosocial consequences of cancer in Finnish cancer patients and their immediate
families. The original sample was recruited from the Helsinki University Central
Hospital in 19972000 using a longitudinal study design. Research nurses delivered
self-report questionnaires to patients as well as their family members visiting the
hospital during the time of diagnosis (T1). Follow-up questionnaires were sent to
the participants after 6 (T2) and 12 (T3) months after returning the questionnaires
at T1 (approximately 2 months), i.e. 8 and 14 months post diagnosis. Informed
written consent was requested from the participants and ethical approval of the
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hospital committee was obtained before the study was begun.

Sample
The original data were limited to the 10 most common cancers. A consecutive series
of 394 patients and 269 family members were in the original baseline sample.
Participants who did not return the baseline questionnaires within a 6-month period
were excluded. At the baseline, 172 couples were identified. Of the couples,
49 dropped out until T3. Complete data of the present sub-study variables at baseline
(T1) and at first follow-up (T2) were available for 147 couples. These 147 patients
and their partners formed the final sample of this sub-study. No statistically
significant differences in the study variables were found between the dropout couples
and the final sample (all p-values 4 0.10)
The sample consisted of 81 female and 66 male patients and their spouses.
The couples had been married or living together for 31 years (range 052 years)
on average, and 79% of the patients had completed cancer treatment at the time
of the first follow-up (8 months). The basic clinical information, collected from the
hospital records, and socio-demographic data of the sample is given in Table 1.

Measures
Dispositional optimism was measured at T1 with a Finnish adaptation of the Life
Orientation Test-Revised (LOT-R) (Scheier, Carver, & Bridges, 1994). The LOT-R
consists of three items measuring positive and three items measuring negative
outcome expectancies (plus four filler items). In the previous studies (Scheier et al.,
1994), the LOT-R has been proved to be reliable and valid in measuring dispositional
optimism. The Cronbachs alphas were as follows: patients  0.71 and partners
 0.67. In other Finnish samples, the LOT-R has established a good internal
reliability and validity (Heinonen, Raikkonen, & Keltikangas-Jarvinen, 2005).
SOC was assessed at baseline using a 12-item Finnish short version of the original
29-item Orientation to Life Questionnaire (OLQ) developed by Antonovsky (1987).
OLQ items are assessed using a seven-point Likert scale in which higher scores
indicate higher SOC (score range for SOC-12 is from 12 to 84). Four items are
 Psychology and Health 183

Table 1. Demographic and medical data, means and SDs of the psychological variables.

Patients Partners

M SD M SD t (df ) / 2 (df ) p

Age (years)a 58 8.7 59 9.4 1.7 (146) 0.083

Psychological variablesa
Depression T1 4.9 4.5 5.2 5.0 0.660 (146) 0.510
Depression T2 4.4 4.8 4.8 5.0 0.675 (146) 0.501
Anxiety T1 34.7 13.6 36.2 16.2 0.949 (146) 0.344
Anxiety T2 29.8 11.5 32.4 13.9 2.040 (146) 0.043*
Dispositional optimism 17.5 3.6 17.3 3.3 0.471 (146) 0.639
SOC 63.9 9.6 63.1 9.2 0.756 (146) 0.451
n (%) n (%)
Educationb 61.8 (4) 0.000***
Primary 59 40.7 57 39.3
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Secondary 42 29.0 32 22.1

Upper secondary 44 30.3 56 38.6
Men Women
Diagnostic categoriesb 1.29 (5) 0.000***
Breast cancer 60 74.1
Gynaecological cancers 15 18.5
Prostate cancer 41 62.1
Lung cancer 4 6.1 2 2.5
Gastrointestinal cancer 13 19.7 1 1.2
Other cancers 8 12.1 3 3.7
Stage of cancerb 13.5 (2) 0.001**
Local 48 72.7 36 44.4
Regional 9 13.6 31 38.3
Advanced 9 13.6 14 17.3
Treatmentb 75.4 (4) 0.000***
Combination therapy 10 15.2 65 80.2
Operation only 54 85.7 9 11.1
Radiation only 1 1.5 5 6.2
Chemotherapy only 1 1.5 1 1.2
Endocrine therapy only 1 1.2
Aim of treatmentb 0.48 (1) 0.488
Curative 58 87.9 74 91.4
Palliative 8 12.1 7 8.6

Notes: at-test for difference in the continuous variables.

b 2
 test in the categorical variables (n 147).
*p 5 .05; **p 5 .01; ***p 5 .001.

scored inversely. The widely used short form (SOC-13) of the scale consists of five
comprehensibility, four manageability and four meaningfulness items.
In the Finnish 12-item adaptation, one item measuring manageability (number 25
on the original scale) has been left out due to translation difficulty. The internal
consistency of the original short version of the scale in previous research has been
good or excellent (Antonovsky, 1993; Pallant & Lae, 2002). In this study, the
Cronbach coefficient alpha for the SOC-12 scale was good (patients, a 0.88 and
partners, a 0.87).
Depression was assessed at two assessment points with a 14-item short form of
the Beck Depression Inventory (BDI) (Beck, Steer, & Garbin, 1988). The original
 184 M. Gustavsson-Lilius et al.

21-item scale has been the most widely accepted measure of depression, and has
been used in numerous studies of depression in seriously ill people as well as in
psycho-oncological studies (Berard, Boermeester, & Viljoen, 1998; Clarke, Smith,
& Herrman, 1993). In Finland, the BDI-14 has been used in studies of coronary
and bypass patients (Julkunen, Saarinen, Idanpaan-Heikkila, & Sala, 2000), and has
been proven to have good internal consistency. The depression scores could range
from a low of 0 to a high of 42. The reliabilities of the BDI-14 in this study were
a 0.79 for patients and a 0.85 for partners.
Anxiety was assessed at T1 and at T2 with the state-anxiety sub-scale of the
Endler Multidimensional Anxiety Scales (EMAS-State) (Endler, Parker, Bagby,
& Cox, 1991). The state-anxiety sub-scale consists of 20 items evaluated on a five-
point Likert scale (score range 20100). In previous research, the EMAS has shown
good or excellent validity and reliability (Endler et al., 1991). The Cronbach
coefficient alphas for our patients and partners were excellent (patients, a 0.95 and
partners, a 0.96).
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Statistical analyses
The mean values of the psychological measures in the different study groups
(patients/partners) were compared with t-tests for continuous variables and chi-
squared test (2) for the categorised variables using SPSS 16.0 software. Patient and
partner psychological measures were compared with paired-samples t-tests. Partial
correlations, addressing the association of the study variables after controlling
for the effect of the dyad, were used to analyse the relationships between the study
variables. Finally, the models were analysed using path analysis with structural
equation modelling (SEM).
As a comprehensive test and illustration of the study hypotheses, path models
were calculated using an Mplus version 5.0 program. A chi-squared test (2), root
mean square error of approximation (RMSEA), comparative fit index (CFI) and
TuckerLewis index (TLI) were used to evaluate the goodness-of-fit of the model.
The RMSEA 5 0.05, CFI 4 0.95, TLI 4 0.90 and a non-significant ( p 4 0.05) 2
test indicate an acceptable model (Kline, 2005). Path models testing the crossover
effect between patient and partner variables and mediation were adapted from
similar previous models (Gustavsson-Lilius et al., 2007b; Westman et al., 2004).
Preliminary descriptive analyses of depression and anxiety showed moderate
positive skewness in patients and their partners (skewness statistics varying from
1.0 to 1.6). Therefore, direct, indirect and total effects, were evaluated in the full
structural model that included all the direct and indirect paths, and estimated the
significance of the effects by using the bootstrap method (MacKinnon, Lockwood,
& Williams, 2004; Shrout & Bolger, 2002). A total of 1000 bootstrap re-samples were
generated to estimate 95% confidence intervals. A maximum likelihood estimation
(ML) was used in testing the path analyses (Muthen & Muthen, 2007). According
to the previous studies of distress in cancer patients (Stark & House, 2000), stage
of cancer and gender were controlled for in the statistical analyses in association with
symptoms of depression and anxiety. Categorical variables were used as dummy
variables and non-independence of the exogenous variables in the path analysis was
confirmed using Kenny, Kashy, and Cooks (2006) guidelines.
 Psychology and Health 185

Table 2. Partial correlations between the model variables within subjects (n 294) and
cross-partners (n 147).

Anxiety Depression Anxiety Depression

Variable Optimism SOC T1 T1 T2 T2

Optimism Z0.00 0.10 0.07 0.07 0.11 0.07

SOC 0.58*** 0.22*** 0.12* 0.19** 0.12* 0.11
Anxiety T1 0.37*** 0.49*** 0.24*** 0.22*** 0.18** 0.13*
Depression T1 0.52*** 0.59*** 0.73*** 0.24*** 0.19** 0.19**
Anxiety T2 0.39*** 0.48*** 0.65*** 0.60*** 0.23*** 0.22***
Depression T2 0.41*** 0.52*** 0.56*** 0.71*** 0.75*** 0.25***

Notes: Overall cross-partner correlations are presented on and above the diagonal (bold
values); overall within-subject correlations below the diagonal. Interdependence of the dyad
has been controlled for.
*p 5 0.05; **p 5 0.01; ***p 5 0.001.
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Results
Descriptive analyses
The means and standard deviations (SDs) for dispositional optimism, SOC, anxiety
and depression in patients and partners are given in Table 1. The overall within-
subject and cross-partner partial correlations between optimism, SOC, anxiety
and depression are presented in Table 2. The within-subject correlations indicated
a statistically significant negative association between optimism and depression/
anxiety as well as SOC and depression/anxiety. Also, significant cross-partner
correlations were found between the study variables. Nevertheless, patient optimism
was not related with partner optimism. SOC and optimism correlated positively,
r 0.58.
The t-tests comparing mean values of the study variables in patients and partners
revealed no statistically significant differences (all p-values 4 0.344), except for
follow-up anxiety. Partners reported more anxiety symptoms at T2 as compared
to patients (t(146) 2.04, p 0.043). Stage of cancer was not significantly
associated with optimism (F(2, 147) 0.777, p 0.462 and 2 0.11) or SOC
(F(2, 147) 2.488, p 0.087 and 2 0.33). Decrease in symptoms of depression
and anxiety and effects of the illness on these distress variables have been reported
earlier in our previous sub-study (Gustavsson-Lilius et al., 2007b).

Dispositional optimism and SOC as predictors of depression and anxiety

Path analyses were used to test the initial theoretical models which included both
patient and partner distress variables at T1 and T2, as well as SOC and dispositional
optimism (Figure 1). The final path models are shown in Figure 2, goodness-of-fit
statistics and direct and indirect effects in Table 3.

Model 1
First, we tested the basic model in which only dispositional optimism was a predictor
of depression and anxiety (Model 1). Since the theoretical model did not fit the data
 186 M. Gustavsson-Lilius et al.
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Figure 2. The final path models: Model 1 (values shown in parentheses) and Model 3 (paths
shown in dashed and dotted line).
Notes: The values along the paths are standardised regression coefficients (betas). Results
of the marginally significant paths ( p 5 0.06) are shown in italics. For clarity of the
presentation, associations between anxiety T1 and depression T1 among patients and partners
as well as statistically insignificant paths are not displayed in the figures (for partial
correlations, see Table 2).

well, insignificant paths from stage of cancer to patient/partner depression and

anxiety and gender to patient distress variables were omitted. After these
modifications, the fit indices indicated an acceptable fit of the model (Figure 2
and Table 3). This model explained 28% of the variance of patient anxiety at T2,
and 32% of the variance of patient depression at T2. In the partners, 53% of
variance of T2 anxiety and 58% of depression were explained.
The results of Model 1 indicated that high dispositional optimism was associated
with less anxiety and depressive symptoms in cancer patients and their partners.
In addition, there was a statistically significant direct link between optimism and
T2 anxiety in partners and a nearly significant ( p 0.055) direct link between
optimism and T2 anxiety in patients (Table 3). We also detected a marginally
significant ( p 0.053) crossover association between partner dispositional optimism
and patient anxiety at T2. Moreover, patient and partner anxiety and depression
8 months after diagnosis were associated, and gender was related to partner anxiety
and depression at T1, indicating that female partners displayed more symptoms
of depression and anxiety than male partners.

Model 2
In testing Model 2, both SOC and dispositional optimism were used as predictors
of depression and anxiety. With this model, we wanted to test whether optimism
 Downloaded by [UQ Library] at 23:59 02 November 2014

Table 3.. The goodness-of-fit indices of the proposed Models (1, 2 and 3), and indirect and direct effects of the paths.

Model specification df 2 p-value RMSEA CFI TLI

M1 hypothesised 25 43.83 0.01 0.072 0.98 0.95

M1 alternative 22 30.54 0.11 0.051 0.99 0.98
M2 44 117.70 0.00 0.107 0.93 0.88
M3 36 38.60 0.35 0.022 1.00 0.99
Depression T1 Anxiety T1 Depression T2 Anxiety T2
Model 1
Patients Total 0.46 (0.11)*** 0.75 (0.26)**
Psychology and Health

Optimism Direct 0.63 (0.08)*** 0.93 (0.30)** 0.15 (0.10) 0.44 (0.23)y
Total indirect (via T1) 0.31 (0.07)*** 0.31 (0.12)**
Partners Total 0.68 (0.13)*** 2.0 (0.36)***
Optimism Direct 0.75 (0.11)*** 0.21 (0.38)*** 0.17 (0.09)y 1.0 (0.25)***
Total indirect (via T1) 0.51 (0.09)*** 1.0 (0.25)***
Model 3
Patients Total 0.27 (0.04)*** 0.51 (0.11)*** 0.25 (0.04)*** 0.42 (0.08)***
SOC Direct 0.19 (0.04)*** 0.43 (0.13)*** 0.13 (0.05)** 0.24 (0.10)*
Total indirect 0.08 (0.03)** 0.08 (0.08) 0.12 (0.04)** 0.18 (0.07)*
Specific indirect
Via optimism 0.001 (0.02) 0.02 (0.06)
Via baseline 0.08 (0.02)*** 0.13 (0.05)**
Via optimism and T1 0.035 (0.02)* 0.03 (0.10)
187
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Patients Total 0.16 (0.14) 0.22 (0.30)

188

Optimism Direct 0.01 (0.11) 0.10 (0.25)

Total indirect (via T1) 0.16 (0.06)** 0.12 (0.12)
Partners Total 0.31 (0.03)*** 1.01 (0.12)*** 0.30 (0.04)*** 0.86 (0.12)***
SOC Direct 0.23 (0.04)*** 0.85 (0.13)*** 0.09 (0.04)* 0.26 (0.11)*
Total indirect 0.08 (0.03)** 0.17 (0.09)y 0.21 (0.04)*** 0.59 (0.12)***
Specific indirect
Via optimism 0.01 (0.02) 0.14 (0.06)*
Via baseline 0.14 (0.03)*** 0.37 (0.09)***
Via optimism and T1 0.05 (0.02)** 0.07 (0.04)y
Partners Total 0.31 (0.08)** 1.0 (0.36)**
Optimism Direct 0.06 (0.09) 0.68 (0.28)**
Total indirect (via T1) 0.25 (0.08)*** 0.35 (0.19)y

Notes: n 147. RMSEA, root-mean-square error of approximation; CFI, comparative fit index; TLI, TuckerLewis index. M1 hypothesised Model 1.
M1 alternative Model 1 modified, paths from stage of cancer to patient/partner distress excluded. M2 Model 2. M3 model 3. The values are
unstandardised regression coefficients (betas) and standardised errors.
***p 5 0.001; **p 5 0.01; *p 5 0.05; yp 5 0.10.
M. Gustavsson-Lilius et al.
 Psychology and Health 189

explained the impact of SOC on symptoms of depression and anxiety. However,

Model 2 did not fit the data and the fit indices were poor (Table 3).

Model 3
In Model 3, we tested whether dispositional optimism explained the association
of SOC with symptoms of depression and anxiety only partially. Paths from SOC
to baseline anxiety and depression, and follow-up anxiety and depression were
added. The fit indices indicated clearly that this was the best model (Table 3).
The results showed that SOC was statistically significantly associated with optimism,
anxiety and depression at T1 and T2. However, in this model, optimism was not
associated with patient/partner anxiety at T1, while optimism was still significantly
associated with T1 depression in patients and partners (Figure 2, Table 3).
Also with Model 3, as with Model 1, we found a marginally significant
( p 0.051) crossover effect between partner optimism and patient anxiety.
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Moreover, partner distress symptoms were associated with patient distress symptoms
at T1 and T2. Also in Model 3, gender was associated with partner anxiety/
depression at T1. SOC, dispositional optimism and baseline anxiety/depression
explained 33% of the variance of patient anxiety at T2, and 39% of the variance of
patient depression at T2 in Model 3. In the partners, 56% of variance of T2 anxiety,
and 60% of depression at follow-up was explained by their own SOC, dispositional
optimism and baseline anxiety depression.

Discussion
In this study, the relationships between dispositional optimism and SOC, and their
impact on distress (i.e. depression and anxiety) in cancer patients and their partners
were investigated as presented in the proposed models (Figure 1).
Supporting our hypothesis, optimism seemed to act as a distress buffering factor
at the time of cancer diagnosis, i.e. cancer patients and their partners who were more
optimistic at the time of diagnosis reported less distress symptoms after 8 months
than did patients and partners with less optimism. Also, the results indicated that
optimism predicted decrease in symptoms of anxiety during the 8-month follow-up,
especially in partners.
Our results regarding distress-protecting effects of dispositional optimism are
congruent to the findings of prior psycho-oncological studies (Carver et al., 2006;
De Moor et al., 2006; Friedman et al., 2006). Psycho-oncological reports that have
investigated health-promoting effects of dispositional optimism in dyadic designs
and in larger samples of cancer patients are rare. In this study, a sample consisting
of patients diagnosed with 10 most common cancers and their caregivers was used.
The aim of this study was also to investigate the crossover or transitive effects
of one partners dispositional optimism on other partners symptoms of distress.
The results, however, did not show a strong crossover effect between patient and
partner optimism and depression and anxiety as was expected. Nevertheless, a
relatively weak, marginally statistically significant crossover effect between partner
dispositional optimism and patient anxiety at T2 was found. In addition, patient and
partner distress symptoms at T1 and at T2 were associated, suggesting an emotional
interdependence or even a direct emotional contagion among the partners.
 190 M. Gustavsson-Lilius et al.

While we could not detect a prior similar study, including patient and partner
optimism with anxiety and depression in the same model, our findings are
comparable to the results reported by Knoll et al. (2009), who demonstrated
a positive transmission of depressive symptoms from one partner to another in
couples going through assisted reproductive treatments. Our results are also in line
with the findings from Ruiz et al. (2006), who found that higher presurgical patient
optimism predicted lower postsurgical depression in coronary artery bypass graft
(CABG) patients as well as in their caregivers. However, in this study, patient
optimism was not associated with partner depression/anxiety. Also, the crossover
effect was obtained only between partner optimism and patient anxiety, not patient
depression. Nevertheless, our findings on crossover give further support to the
previously reported results (Hagedoorn et al., 2008; Ruiz et al., 2006; Schroeder &
Schwartzer, 2001).
It has been previously suggested that, for example, partners emotional social
support, constructive expression of anger and open communication in the dyad
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might be associated with patients psychological well-being and may act as a second
process mediator between optimism and mental health (Julkunen, Gustavsson-
Lilius, & Hietanen, 2009; Manne et al., 2006). One can speculate that the crossover
effect found in this study is explained by a second process mediator. It is reasonable
to assume that emotional support given from the partner is affected by their
optimistic expectations of the future, and therefore boosts patients stress buffer and
reduces patients anxiety symptoms. In this study, however, the mediating processes
between optimism and depression/anxiety were not investigated, and these plausible
mediating factors, e.g. communication between the partners, need more detailed
investigation in the future psycho-oncological research.
In this study we were also interested in investigating the role of optimism in the
SOC construct. We wanted to explore to what extent the possible health-promoting
effects of SOC would be based on optimism. According to Antonovskys theory on
SOC, as a common factor of generalised resistance resources, we hypothesised that
the distress-protecting impact of SOC could be fully or partly based on dispositional
optimism. To our knowledge, this is the first psycho-oncological study to investigate
the interplay of optimism, SOC and distress symptoms in cancer patients and their
partners.
Consistent with Antonovskys description of SOC, we found that strong SOC
was associated with more optimistic expectations of future. Our results indicated
more than 30% of shared variance between optimism and SOC, which is comparable
with previous results (Ebert et al., 2002; Pallant & Lae, 2002). However, we found
that optimism explained the impact of SOC on depression/anxiety only partially
(Figure 2, Model 3). This finding might indicate that optimism partially mediates
the impact of SOC on distress. On the other hand, a valid testing of mediation
would need three separate follow-up waves (Spencer, Zanna, & Fong, 2005)
and therefore, mediation between these concepts waits for future research to be
confirmed.
In his conceptualisation of SOC, Antonovsky argues that SOC has a
motivational, behavioural, and a cognitive component. On the other hand, Carver
and Scheier (2001) have conzeptualised dispositional optimism only as a motiva-
tional structure. Nevertheless, if SOC is seen as a higher order construct of
generalised resistance resources, as Antonovsky has suggested, one might assume
that people with strong SOC have more optimistic generalised expectancies of the
 Psychology and Health 191

future and experience less distress in a stressful situation, such as cancer, than people
with weak SOC.
In our previous sub-study based on a longer follow-up and smaller, partly
overlapping sample (Gustavsson-Lilius et al., 2007b), we could not find a crossover
effect between patient and partner SOC and patient/partner distress symptoms.
However, the results of this study indicated a weak crossover effect between partner
optimism and patient follow-up anxiety. It seems possible that dispositional
optimism comes across in social interaction of the dyads more evidently than
possibly hierarchically higher construct, SOC. On the other hand, SOC predicted
lower levels of anxiety and depression at both assessment times even when
dispositional optimism was included in the model (Figure 2). The results obtained
here further support the notion that SOC and dispositional optimism are not
analogous constructs and that the construct of SOC includes other important
elements besides optimism. Moreover, these results support Antonoskys theory on
SOC as a higher order, common factor.
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As also several prior studies (e.g. Hagedoorn et al., 2000, 2008) have found,
partners of this study reported more distress symptoms as compared to patients.
Directing attention to patientpartner roles in psycho-oncological research seems
reasonable. Finally, the path models explained about one-third of the variance
of depression and anxiety in patients and nearly two-thirds in partners. These results
might indicate that the psychological situation of the partners is more stable as
compared to the patients, whose emotional reactions are more prone to fluctuate
during the course of illness. Although SOC, optimism and baseline distress
symptoms explained a significant part of follow-up distress symptoms, other
variables such as social support and coping obviously need to be included in future
studies.

Limitations
There are a number of limitations to this study that should be considered. While
in this study the most common cancers in Finland were included, our sample was
in fact heavily biased towards breast cancer and prostate cancer patients. The small
number of patients in the other diagnostic categories did not permit valid
comparisons between the diagnostic groups. Although the effects of the clinical
factors on the study variables were tested, it is difficult to rule out the possibility that
different cancers or different medical treatments may have distorted the results
somewhat. On the other hand, this study including several diagnostic categories
extends previous results based mainly on breast cancer, and most importantly dyadic
samples in this research field are rare.
Furthermore, since the data at T1 were limited to respondents answering within
6 months of diagnosis, some of the participants may have returned the
questionnaires after the most critical post-diagnostic period. We are inclined to
speculate that the present sample is biased towards patients coping psychologically
better than average cancer patients. In addition, SOC and optimism were assessed
only at baseline. Therefore, despite of the longitudinal design of this study,
conclusions on causality should be drawn cautiously, and the pathways indicated
here need to be confirmed with other samples in the future with repeated
measurements.
 192 M. Gustavsson-Lilius et al.

Finally, recently there has been active debate on the pitfalls of testing mediation
in non-experimental settings. It has been stated that statistical analyses may support
mediation hypothesis if the psychological are not theoretically distinct (Spencer
et al., 2005). Therefore, interpreting results as causal mediation chain must be
considered cautiously. However, testing mediation as suggested earlier by Baron
and Kenny (1986) is often recommended in examining psychosocial processes
(Spencer et al., 2005), and a detailed discussion on pitfalls of partial mediation goes
beyond the scope of this article.

Conclusions
The results of this study suggest that cancer patients and their partners who are
optimistic and view the world coherently report less distress symptoms, particularly
symptoms of anxiety. In addition, the findings on our study suggest that effects
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of positive resources, not just stress and strain, may transfer to the spouse and have
a positive impact on his or her well-being and interactions with the partner.
It seems important in clinical practice to give special attention not only to the
cancer patients but also to the partners because of their elevated levels of anxiety and
depression. Moreover, the results of this study give further support to the previously
discussed notion (Kayser, 2005) that taken account the frequency and intensity of the
interaction between the spouses, empirically based dyadic interventions instead of
individual or peer support are needed in the future.
The results of this study also suggest that in clinical interventions enhancing
optimistic expectations of the future and promoting SOC could be expected to
reduce distress in cancer couples, especially in partners. There are empirical findings
indicating that personal characteristics and positive general expectancies are more
susceptible to change as previously assumed (Antoni et al., 2001; Gustavsson-Lilius
et al., 2007b). Several randomly controlled trials have shown that clinical
interventions using, positive modification, personal and group guidance, and
relaxation may also enhance dispositional personal characteristics, such as SOC
and optimism (Vastamaki, Moser, & Paul, 2009; Weissbecker et al., 2002). For
example, the study of Antoni et al. (2001) showed that cognitive behavioural stress
management intervention increased dispositional optimism among women with early
stage breast cancer, especially among those participants who were less optimistic at
the start of the study.
Although optimism seems to be significant in coping with a serious illness, the
present results indicate that SOC is a major predictor of symptoms of depression and
anxiety in cancer patients and their partners and also includes other health-
promoting elements in addition to optimism. To clarify the constructs of SOC and
optimism, future research should include both SOC and dispositional optimism
in the same studies. Moreover, studying dyads or families instead of individual
patients seems to offer new insights for psycho-oncological practice.

Acknowledgements
This study was supported by a grant from the Cancer Society of Finland, Cultural Foundation
of Finland and Yrjo Jahnsson Foundation.
 Psychology and Health 193

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