Background
Infertility is medically defined as “the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse” [
1]. It is a global public health concern affecting 9% of reproductive-aged couples worldwide [
2] with negative psychological consequences. One of the most often-cited repercussions of infertility is depression disorder. For example, in two studies conducted by Maroufizadeh et al. [
3] and Omani-Samani et al. [
4] in Iran, the prevalences of depression were 33.0% and 30.5%, respectively, which are higher than what was reported in general population. Some of the demographic/fertility risk factors for depression in infertile couples include educational level, cause of infertility, duration of infertility, and having failure in previous infertility treatments [
3‐
5]. One the other hand, infertility and its treatment has also a negative impact on a person’s marital satisfaction, relationship satisfaction, and sextual functioning [
6‐
8].
Based on the Marital Discord Model of Depression (MDMD) [
9], marital discord is an important risk factor for depressive symptoms in married couples. A growing body of evidence support the MDMD. For example, in a meta-analysis of 26 cross-sectional study, the effect size of marital satisfaction on depression was − 0.42 for women and − 0.37 for men [
10]. In addition, longitudinal studies have found that marital dissatisfaction is associated with subsequent depressive disorder [
11,
12]. On the other hand, marital satisfaction is strongly influenced by sexual functioning. Satisfying marital and sexual functioning protects against the development of psychological distress but is also a factor related to depression and anxiety [
13,
14].
A fundamental assumption in behavioral and social science statistical methods is the independence of observations. Many of the phenomena studied in this context are dyadic in nature (e.g., research on man-woman dyads). The observations arising from such designs are not independent, but interdependent (i.e., the characteristics of one member of the dyad affects outcomes of the other member in the dyad) [
15,
16]. In this case, conventional statistical methods are not proper for analyzing data; Instead, the methods that take into account the interdependence is required [
16]. To address this issue, Kenny et al. [
16] developed the Actor Partner Interdependence Model (APIM), the most frequently used analytical model of dyadic data. This model simultaneously estimates the effects of an individual’s attributes on his/her own outcome variable (actor effect), as well as his/her partner’s (partner effect).
Most studies examining the effect of marital satisfaction on depression in infertile couples use the conventional statistical methods. Although valuable, these studies fail to take into account the interdependency of couples’ data, and consequently fail to show interpersonal relationships. In addition, since experience of infertility is a shared problem between members of a couple, examining the interpersonal relationship is especially relevant [
17]. Due to these reasons, in the last few years, APIM framework has been used to examine many relationship processes, including the effect of depression on quality of life in Iranian infertile couples [
18], and effects of spirituality and infertility-related stress on quality of life in Brazilian infertile couples [
19]. The aim of the present study was twofold: (a) to examine whether there were differences in the levels of marital satisfaction and depression between men and women dyads with infertility, and (b) to apply the APIM framework to elucidate and differentiate actor and partner effects of marital satisfaction on depression in infertile couples.
Discussion
To the best of our knowledge, this study is the first of its kind to use the APIM approach to examine the intrapersonal and interpersonal influences of marital satisfaction on depression in a sample of infertile couples. Although the most of studies examining the relationship between marital satisfaction and depressive symptoms focused on the intrapersonal mechanisms (actor effects), there are growing calls to examine the interpersonal mechanisms (partner effects). Since infertility is also a shared problem between spouses, both men and women need to be involved and considered as a dyad in the data analysis. According to within-dyad correlations, considerable correlations between wives’ and husbands’ scores were observed. These findings confirm that husbands and wives’ scores were adequately related to be deemed statistically interdependent, and so APIM approach would be more appropriate than conventional statistical analyses.
In keeping with some previous studies [
3,
25], we found that there was no significant difference between men and women in the depression level. However, in a two study conducted in Poland [
26] and Pakistan [
27], women had a higher level of depression than men. In this study, there was also no sex difference in the marital satisfaction, which is in line with Peterson et al. study [
28]. In a study performed by Drosdzol and Skrzypulec [
26], women had a worse marital satisfaction than their husbands. In addition, general population studies indicate that marital and psychological distress are more common among women than men [
29].
Consistent with the MDMD, the current study showed the considerable actor effect of marital satisfaction on depression, which is also consistent with previous studies conducted in USA [
30], China [
31,
32], Brazil [
33] and Israel [
12]. However, in a study conducted among Chinese older couples, neither of the actor effects was significant [
34].
The key finding of our study was the link between men’s marital satisfaction and women’s depression. In line with our expectation, we found that husband’s lower marital satisfaction was associated with greater level of wives’ depression. Contrary to our expectation, the present study does not confirm a strong partner effect of women’s marital satisfaction on their husband’s depression. In other words, regarding the partner effects, the MDMD was partly supported asymmetrically among infertile couples. This type of asymmetrical pattern of partner effects has also been reported in several previous studies [
34,
35]. However, contrary to our finding, Miller et al. [
31] reported an opposite pattern of the partner effect in a sample of middle-aged Chinese couples.
The present research offers a number of important contributions to understanding the relationship between marital satisfaction and depression. Studies regarding this relationship tend to focus on individuals, despite the obviously dyadic nature of marital satisfaction. Many researches in this area also tend to focus on general population of adolescents and couples, most of whom have probably not yet become involved in long-term, committed marital relationships or have not yet experienced a shared health problem like infertility. The present study addresses these limitations, as it sought to test the MDMD in infertile married couples from a dyadic perspective. The findings of the present study have potentially important clinical implications. Probably one of the most key findings is the importance of taking a dyadic perspective on marital satisfaction and depression. Particularly, the study indicates that men’s marital satisfaction is important to their wives’ depression. Therapists working with infertile couples should be aware of these dyadic effects; thus, psychological interventions that target an enhancement of marital satisfaction and reduction of depression symptoms should treat the couple as a unit.
Our study had several limitations that should be considered when interpreting the findings. First, this study was conducted only in one center and therefore may not be generalizable. Second, the cross-sectional nature of the study design limits inferences about the causal relationships between marital satisfaction and depression. Longitudinal research is needed to better understand the relationship between marital satisfaction and depression symptoms, as these relationships can be multi-factorial and complex [
36‐
38].
Conclusion
Despite the limitations, the study findings provide support for the MDMD among infertile couples.
Particularly, besides the actor (intrapersonal) effects for both male and female, there were partner (interpersonal) effects of male marital satisfaction on female depression symptoms. Based on these findings, interventions to reduce depressive symptoms in infertile couples should include both husbands and wives simultaneously.
Acknowledgements
The authors express their gratitude to the infertile couples who participated in this study and to the Royan Institute, Tehran, Iran for its kind cooperation in data collection.
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