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. 2025 Feb 28;20(2):e0318378. doi: 10.1371/journal.pone.0318378

The relationship between family conflict resolution methods and depressive symptoms in patients with chronic diseases

Min Jeong Joo 1,2, Jisu Ko 1,2, Jae Hyeok Lim 1,2, Dan Bi Kim 1,2, Eun-Cheol Park 2,3,*
Editor: Ali A Weinstein4
PMCID: PMC11870374  PMID: 40019908

Abstract

Background

Individuals with chronic diseases are more sensitive to depressive symptoms and stress compared to the general population. The complexity and unpredictability of these diseases necessitate family involvement in their management. However, long-term disease can exhaust both patients and their families, leading to conflicts and increased stress, thus exacerbating depressive symptoms. This longitudinal study investigated the impact of family conflict resolution methods on depressive symptoms among chronic disease patients in Korea.

Methods

We used data from the Korean Welfare Panel Study, collected from 2012 to 2022, analyzing 10,969 chronically ill cohabiting or married individuals. Chi-square tests were used to compare group characteristics, and generalized estimating equation models were used for regression analysis, focusing on Center for Epidemiologic Studies Depression Scale-11 scores, family conflict resolution changes, and covariates.

Results

Participant groups that changed from positive to negative conflict resolution methods were more likely to have depressive symptoms than the group that did not change from positive methods (positive →  negative odds ratios (OR) =  1.34, confidence intervals (CI) =  1.24–1.44). In addition, participants who did not change from negative methods were significantly more depressed than those who maintained positive methods over time (negative →  negative OR =  1.48, 95% CI =  1.37–1.59). Uncollaborative discussions and domestic violence resolution methods were related to depressive symptoms in family conflict resolution methods.

Conclusion

Negative family conflict resolution methods influence depressive symptoms in individuals with chronic diseases. Even after transitioning to positive conflict resolution methods, prior negative experiences continued to impact depressive symptoms.

Introduction

People with chronic conditions have limited activity or persistent pain, which reduces opportunities for activity [1]. These characteristics of chronic disease increase the risk of physical [2], mental [3,4], and psychological distress and lower life satisfaction in people with chronic disease when compared to physically healthy people [5]. Additionally, although stress varies by individual characteristics, patients with higher stress levels due to the general characteristics of chronic disease are more likely to experience mental disorders [6]. Similarly, people with multiple chronic conditions are at a higher risk for depressive symptoms, which is the focus of our study, than people with a single chronic condition [7–9]. Managing depression and its symptom is important because depression can lead to additional risks of social isolation [10], additional psychiatric disease, and suicidal ideation [11]. Therefore, managing the condition of chronic disease patients who are more vulnerable to depressive symptoms is extremely important.

Due to the complexity and unpredictability of the disease, personal management alone has limitations; thus, involving families in disease management and providing psychological support is considered an effective alternative [12]. Family members can improve the condition of chronically ill individuals by offering support and enhancing mutual communication. However, extended periods of sickness can exhaust and frustrate both patients and their families, leading to conflicts and increasing family stress and tension [13,14]. Effective resolution of family conflicts can significantly impact the mental health of both patients and their family members. Each family member may employ various methods of resolving conflicts, including positive methods such as open communication, cooperation, support, and building family resilience [15], or negative methods such as violence, ignoring the problem, or indifference to the family.

The increasing prevalence of depression among patients with chronic diseases in Korea [16] and issues in its management [17] have propelled active research in this direction [18,19]. However, most studies focus on individual behavioral changes [20] or effective interventions by medical staff [21]. Despite the importance of the surrounding environment and family [22], research on how family conflict resolution methods for patients with chronic diseases can affect their depressive symptoms is limited. Therefore, this study aimed to determine whether family conflict resolution among chronically ill patients affects their depressive symptoms and whether changes in conflict resolution, positive or negative, impact depressive symptoms.

Methods

Data source and study population

We obtained data from the 7th to 17th waves (2012–2022) of the Korean Welfare Panel Study (KoWePS), an annual longitudinal survey initiated in 2006[23]. This survey aims to assess the living conditions and welfare needs of various demographic groups in relation to changes in work and living environments, age, income levels, and economic activity status. It also seeks to contribute to the development of welfare policies and institutional reforms. The survey is jointly conducted by the Korea Institute for Health and Social Affairs and Seoul National University. The survey employs a proportional systematic stratified cluster sampling method to select a representative sample of households in South Korea. Multiple interviews are conducted within the same household to allow all members aged 15 years or older to complete the questionnaire whenever feasible, thus maximizing participation. The survey is conducted annually with the same participants through face-to-face interviews by the surveyors. However, when the surveyor cannot meet the respondent due to unavoidable circumstances such as travel or business trips, hospitalization, military service, or prolonged absence from home due to late-night returns or extended trips, limited telephone or proxy response surveys are conducted.

For our study’s data, the presence of chronic diseases was reported by participants themselves. Participants were categorized as chronic disease patients if they reported having the condition for less than 3 months, between 3 and less than 6 months, or more than 6 months since the initial diagnosis and initiation of medication. We excluded participants from 2012 to 2022 who were younger than 20 years old, did not have chronic diseases(e.g., seasonal illnesses, which were categorized as non-chronic), were not married or did not have cohabitants, were diagnosed with depression, or showed depressive symptoms in their first entry year in the panel. At baseline, there were a total of 5,816 participants. The average participation period for the panel participants was 5.4 years. The process of participant selection is detailed in Fig 1.

Fig 1. Flow chart of participant selection.

Fig 1

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Measures

The dependent variable was depressive symptoms. The research employed the Center for Epidemiologic Studies Depression Scale (CESD-11) to assess depressive symptoms. The CESD-11, a concise version of the original 20-item scale, is a well-validated self-report screening instrument [24,25]. The CESD-11 has been applied across a wide range of Korean populations, including those with disabilities [26,27]. The total CESD-11 score is computed by summing the scores for all 11 questions and multiplying them by 20/11 [28,29]. A score of 16 or higher indicates the presence of depressive symptoms. Scores falling within the range of 16–20 indicate mild depressive symptoms, scores between 20 and 24 indicate moderate depressive symptoms, and a score of 25 or higher indicates severe depressive symptoms.

In this study, the main independent variable was the methods for managing family conflict, evaluated using the scoring and evaluation method recommended by KoWePS [23]. We evaluated how family members have interacted and resolved conflicts over the past year based on participants’ subjective responses to five items. Participants responded to the items using a scale of “Not at all,” “Somewhat disagree,” “Neutral,” “Somewhat agree,” and “Strongly agree.” Scores are assigned to each item based on the responses, and higher total scores indicate a more positive assessment. For the statements “There are frequent disagreements in my family,” “My family members get so angry that they throw things,” “My family members criticize each other,” and “My family members hit each other,” a response of “Not at all” is given 5 points, and a response of “Strongly agree” is given 1 point. For the statement “My family members discuss issues calmly,” a response of “Not at all” is given 1 point, and a response of “Strongly agree” is given 5 points. The calculated values are then divided by 5 for evaluation. The reliability of the scale was Cronbach’s α =  0.7851. In order to establish categorical thresholds for resolving family conflicts, the responses were grouped into two distinct groups based on the median of the number of responses. Similarly, categorical thresholds were determined for each question based on the median value. Responses exceeding the median were classified as positive approaches to conflict resolution, while those falling below the median were classified as negative approaches.

We controlled for potential confounding variables in our study [30]. Socio-demographic factors included sex, age (20–29/ 30–39/ 40–49/ 50–59/ ≥  60), region (metropolitan/non-metropolitan areas), household income (based on adjusted gross income below 60% of median as low/60% and above as normal), economic activities (yes/no), and education level (college or higher/high school/middle school or lower). Health-related factors included smoking (yes/no), current alcohol use (yes/no), and self-perceived health status (good/normal/bad). We also included type of chronic disease and family relationship satisfaction as variables. Chronic disease data from KoWePS were used to classify the 32 selected chronic diseases into the top 4 most frequently reported primary conditions(excluding depression) and others (hypertension/arthritis/acute conditions/diabetes/other chronic diseases). The variable for family relationship satisfaction was categorized based on personal satisfaction with family relationships over the past year (dissatisfaction/satisfaction). All responses were self-reported and collected according to the format specified by KoWePS.

Statistical analysis

Chi-square tests were utilized to assess the overall characteristics of the groups, and generalized estimating equation (GEE) models were applied for the regression analysis of CESD-11 scores, variations in family conflict resolution strategies, and additional covariates. Time variables were grouped into yearly intervals, and unique identifiers were used to recognize recurring participants in the GEE model through the application of an unstructured working correlation matrix. The findings were reported in terms of odds ratios (OR) and confidence intervals (CI). Subgroup analyses were performed to assess the relationships between individual fluctuations in family conflict resolution methods and depressive symptoms, and other pertinent factors. The analyses were performed using SAS software (version 9.4; SAS Institute, Cary, NC, USA), with statistical significance established at a p-value of less than 0.05.

Results

Table 1 presents baseline characteristics from 2013 for the 5,816 participants included in the analysis. Among them, 32.1% maintained positive family conflict resolution methods, 20.9% transitioned from negative to positive methods, and 18% shifted from positive to negative methods. Additionally, 29% maintained negative methods. Statistically significant differences in depressive symptoms among chronic disease patients were observed based on their family conflict resolution methods.

Table 1. General characteristics of the baseline population (2012 to 2013).

Variables Depressive symptoms (CESD-11 ≥  16)
Total No Yes P-value
N % N % N %
5,816 100.0 5,112 87.9 704 12.1
Family conflict resolution methods <.0001
Positive →  Positive 1,866 32.1 1710 91.6 156 8.4
Negative →  Positive 1,214 20.9 1077 88.7 137 11.3
Positive →  Negative 1,049 18.0 913 87.0 136 13.0
Negative →  Negative 1,687 29.0 1412 83.7 275 16.3
Sex <.0001
Male 2,442 42.0 2242 91.8 200 8.2
Female 3,374 58.0 2870 85.1 504 14.9
Age <.0001
20-29 133 2.3 130 97.7 3 2.3
30-39 284 4.9 275 96.8 9 3.2
40-49 557 9.6 532 95.5 25 4.5
50-59 958 16.5 881 92.0 77 8.0
60 ≤  3,884 66.8 3294 84.8 590 15.2
Region 0.2548
Metropolitan 4,348 74.8 3834 88.2 514 11.8
Non-metropolitan 1,468 25.2 1278 87.1 190 12.9
Household income <.0001
Normal 3,370 57.9 3151 93.5 219 6.5
Low 2,446 42.1 1961 80.2 485 19.8
Economic activity <.0001
No 2,498 43.0 2277 91.2 221 8.8
Yes 3,318 57.0 2835 85.4 483 14.6
Educational level <.0001
Middle school or lower 3,606 62.0 3030 84.0 576 16.0
High school 1,341 23.1 1252 93.4 89 6.6
College or higher 869 14.9 830 95.5 39 4.5
Smoking 0.0916
No 4,949 85.1 4335 87.6 614 12.4
Yes 867 14.9 777 89.6 90 10.4
Current Alcohol Use <.0001
No 3,494 60.1 2953 84.5 541 15.5
Yes 2,322 39.9 2159 93.0 163 7.0
Health status <.0001
Bad 1,895 32.6 1421 75.0 474 25.0
Normal 1,818 31.3 1674 92.1 144 7.9
Good 2,103 36.2 2017 95.9 86 4.1
Family relationship <.0001
Dissatisfaction 1,157 19.9 869 75.1 288 24.9
Satisfaction 4,659 80.1 4243 91.1 416 8.9
Chronic disease <.0001
Hypertension 1,604 27.6 1,443 90.0 161 10.0
Arthritis 1,444 24.8 1,218 84.3 226 15.7
Acute diseases 305 5.2 281 92.1 24 7.9
Diabetes 632 10.9 549 86.9 83 13.1
Other Chronic diseases 1,831 31.5 1621 88.5 210 11.5
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Table 2 displays the outcomes of the GEE examination concerning the correlation between strategies for resolving family conflicts and depressive symptoms. Model 1 represents the model without adjusting for covariates (negative →  negative OR =  1.88, 95% CI = 1.75–2.02). In Model 2, socio-demographic variables were adjusted (negative →  negative OR =  1.82, 95% CI: 1.69–1.96). In Model 3, following adjustment for all potential confounding variables, individuals who consistently employed negative conflict resolution methods demonstrated a significantly greater manifestation of depressive symptoms compared to those who consistently utilized positive conflict resolution strategies (negative →  negative OR =  1.48, 95% CI =  1.37–1.59).

Table 2. Unadjusted and adjusted modal for depressive symptoms with change of family conflict resolution methods in 2012 to 2022.

Variablesa Depressive symptoms (CESD-11 ≥  16)
OR 95%CI
Family conflict resolution methods
Model Iª
Positive →  Positive 1.00
Negative →  Positive 1.23 (1.15 – 1.32)
Positive →  Negative 1.55 (1.45 – 1.66)
Negative →  Negative 1.88 (1.75 – 2.02)
Model II b
Positive →  Positive 1.00
Negative →  Positive 1.22 (1.13 – 1.31)
Positive →  Negative 1.53 (1.43 – 1.64)
Negative →  Negative 1.82 (1.69 – 1.96)
Model III c
Positive →  Positive 1.00
Negative →  Positive 1.14 (1.05 – 1.22)
Positive →  Negative 1.34 (1.24 – 1.44)
Negative →  Negative 1.48 (1.37 – 1.59)
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aAdjusted for Sex, Age;

bAdditinally adjusted for region, household income, economic activities, education level on the base of Model 1.

cAdditinally adjusted for smoking, current alcohol use, health status, type of chronic disease, family relationship on the base of Model 2.

Table 3 displays GEE results for subgroup analysis, stratified by independent variables. Participants with normal household income showed a higher odds ratio (OR) for depressive symptoms when family conflict resolution methods changed negatively over time (positive →  negative OR =  1.31, 95% CI =  1.15–1.48; negative →  negative OR =  1.65, 95% CI =  1.46–1.86). Similarly, those engaged in economic activities (positive →  negative OR =  1.42, 95% CI =  1.25–1.62; negative →  negative OR =  1.62, 95% CI =  1.43–1.84), reporting good health status (positive →  negative OR =  1.51, 95% CI =  1.24–1.83; negative →  negative OR =  2.07, 95% CI =  1.74–2.46), or expressing dissatisfaction with family relationships (positive →  negative OR =  1.25, 95% CI =  1.08–1.45; negative →  negative OR =  1.49, 95% CI =  1.30–1.72) were at higher risk of developing depressive symptoms due to negative changes in family conflict resolution.

Table 3. Subgroup analysis using the generalized estimating equation depressive symptom among chronic patients with family conflict resolution methods in 2012 to 2022.

Variablesª Depressive symptoms (CESD-11 ≥  16)
Family conflict resolution methods
Positive → Positive Negative →  Positive Positive → Negative Negative →  Negative
OR OR 95% CI OR 95% CI OR 95% CI
Sex
Male 1.00 1.24 (1.09 – 1.42) 1.44 (1.25 – 1.65) 1.57 (1.37 – 1.80)
Female 1.00 1.09 (1.00 – 1.19) 1.29 (1.18 – 1.42) 1.44 (1.32 – 1.58)
Age
20-29 1.00 – – –
30-39 1.00 0.80 (0.45 – 1.44) 1.11 (0.58 – 2.14) 1.17 (0.66 – 2.08)
40-49 1.00 1.36 (0.89 – 2.10) 1.27 (0.83 – 1.96) 1.97 (1.31 – 2.95)
50-59 1.00 1.23 (0.95 – 1.60) 1.46 (1.14 – 1.88) 1.96 (1.55 – 2.47)
60 ≤  1.00 1.12 (1.04 – 1.22) 1.34 (1.23 – 1.45) 1.41 (1.30 – 1.53)
Region
Metropolitan 1.00 1.17 (1.07 – 1.28) 1.37 (1.25 – 1.49) 1.52 (1.39 – 1.66)
Non-metropolitan 1.00 1.07 (0.93 – 1.22) 1.28 (1.11 – 1.48) 1.38 (1.19 – 1.59)
Household income
Normal 1.00 1.13 (1.00 – 1.28) 1.31 (1.15 – 1.48) 1.65 (1.46 – 1.86)
Low 1.00 1.13 (1.03 – 1.24) 1.36 (1.24 – 1.49) 1.38 (1.25 – 1.51)
Economic activity
No 1.00 1.17 (1.07 – 1.28) 1.29 (1.17 – 1.41) 1.40 (1.28 – 1.53)
Yes 1.00 1.06 (0.93 – 1.21) 1.42 (1.25 – 1.62) 1.62 (1.43 – 1.84)
Educational level
Middle school or lower – – – – – – – – – – – – –
High school 1.00 1.22 (1.01 – 1.46) 1.21 (1.00 – 1.46) 1.53 (1.28 – 1.84)
College or higher 1.00 1.19 (0.92 – 1.54) 1.33 (1.03 – 1.72) 1.84 (1.43 – 2.37)
Smoking
No 1.00 1.13 (1.04 – 1.22) 1.37 (1.27 – 1.48) 1.48 (1.36 – 1.60)
Yes 1.00 1.15 (0.91 – 1.47) 1.06 (0.82 – 1.36) 1.41 (1.11 – 1.79)
Current Alcohol Use
No 1.00 1.12 (1.03 – 1.21) 1.31 (1.21 – 1.43) 1.41 (1.29 – 1.53)
Yes 1.00 1.21 (1.03 – 1.42) 1.47 (1.25 – 1.73) 1.68 (1.44 – 1.96)
Health status
Bad 1.00 1.08 (0.98 – 1.19) 1.30 (1.17 – 1.43) 1.28 (1.16 – 1.41)
Normal 1.00 1.21 (1.06 – 1.40) 1.31 (1.13 – 1.51) 1.49 (1.31 – 1.70)
Good 1.00 1.20 (0.98 – 1.46) 1.51 (1.24 – 1.83) 2.07 (1.74 – 2.46)
Family relationship
Dissatisfaction 1.00 1.10 (0.93 – 1.29) 1.25 (1.08 – 1.45) 1.49 (1.30 – 1.72)
Satisfaction 1.00 1.14 (1.05 – 1.24) 1.37 (1.25 – 1.49) 1.39 (1.27 – 1.52)
Chronic disease
Hypertension 1.00 – – –
Arthritis 1.00 1.13 (0.95 – 1.33) 1.37 (1.15 – 1.64) 1.46 (1.24 – 1.73)
Acute diseases 100 0.86 (0.53 – 1.41) 1.38 (0.88 – 2.17) 1.71 (1.13 – 2.57)
Diabetes 1.00 1.04 (0.81 – 1.35) 1.47 (1.15 – 1.89) 1.45 (1.15 – 1.82)
Other Chronic diseases 1.00 1.13 (1.02 – 1.25) 1.23 (1.11 – 1.36) 1.45 (1.31 – 1.61)
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ªAdjusted for all covariates

The findings of the subgroup analysis, stratified based on the variables of interest, are outlined in Fig 2. Family conflict resolution methods were categorized into five distinct items: frequent disagreements, object throwing, collaborative discussions, mutual blame, and incidents of domestic violence. Depressive symptoms increased among individuals who transitioned from negative to positive conflict resolution methods, particularly when collaborative discussions (positive →  negative OR =  1.2, 95% CI =  1.11–1.30; negative →  negative OR =  1.8, 95% CI =  1.65–1.95) and incidents of domestic violence (positive →  negative OR =  1.31, 95% CI =  1.20–1.43; negative →  negative OR =  1.37, 95% CI =  1.20–1.55) changed from positive to negative or remained negative.

Fig 2. Sensitivity analysis of depressive symptoms stratified by family conflict resolution methods in 2012 to 2022.

Fig 2

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Discussion

Understanding how to resolve conflicts that may arise during family interactions is important for enhancing the mental health status of people with chronic diseases, as they have a higher risk of developing depression compared to those without chronic diseases. Therefore, this longitudinal study examined the relationship between depression and positive and negative changes in family conflict resolution in patients with chronic diseases in Korea aged over 20.

Our study found an association between depressive symptoms and changes in how patients with chronic diseases resolve family conflicts. A change in the negative approach to resolving conflict and no change in the negative approach were linked to higher odds of experiencing depressive symptoms compared with the positive approach. By contrast, participants who changed from a negative to a positive method showed lower levels of depressive symptoms than those who continued using a negative method of conflict resolution. However, even among those who adopted positive methods, any prior experience with negative conflict resolution was still associated with depressive symptoms. While transitions from negative to positive methods were linked to lower odds of depressive symptoms compared to remaining in negative conflict styles, the odds ratios remained above one, suggesting that any exposure to negative family conflict experiences contributes to heightened depression risks. Consistent with previous studies, our results indicated that conflict within family relationships influenced depressive symptoms, and addressing conflicts is crucial for managing such symptoms [31, 32].

Our study revealed that economically active participants with chronic diseases faced higher odds of depressive symptoms when their family conflict resolution methods remained persistently negative. This finding aligns with existing research indicating that individuals with chronic diseases are more susceptible to presenteeism [33] and psychological stress in the workplace compared to healthy individuals [34], which can spill over into the home, exacerbating family relationship conflicts [35]. Therefore, addressing mental health issues for individuals with chronic diseases is crucial in both workplace and home settings [36]. This underscores the need for continuous attention and support to improve the overall mental health of individuals with chronic diseases.

Regarding family conflict resolution methods, our study identified frequent differences in opinions, object throwing, collaborative discussions, mutual blame, and incidents of domestic violence. Notably, avoiding collaborative discussions and engaging in object throwing were associated with depressive symptoms. Previous research consistently links family violence [37] or trauma [38] to higher depression risk among individuals, highlighting the need to prevent depression in vulnerable chronic disease patients in violent family environments [39], and to control family conflicts. Additionally, our study findings show that verbal conflict is as strongly linked to an increase in depression and depressive symptoms among patients with chronic diseases as physical conflict [40]. Previous research shows that frequent arguments that include negative language increase depression [41–43], whereas calm and respectful family conversations reduce depression [44, 45]. Across variables, individuals with even a single instance of negative conflict resolution experience exhibited higher levels of depressive symptoms than those who consistently used positive methods. These results reinforce the critical need to prevent negative family conflict altogether and to promote consistent use of positive conflict resolution methods to mitigate depressive symptoms and support mental health in individuals with chronic diseases.

Although the results of this study indicated the need to investigate the relationship between family conflict resolution methods and depressive symptoms in patients with chronic diseases, this study has some limitations. First, this study used the CESD-11 scale to assess depressive symptoms in individuals with chronic diseases. While the CESD-11 is widely used to identify depressive symptoms across a broad range of Korean populations, including individuals with disabilities, its validity specifically for individuals with chronic diseases has not been established. Second, to identify patients with chronic diseases, the type and duration of the disease were checked, and patients without chronic conditions were excluded. However, there may have been cases in which participants were undiagnosed. Third, family conflict resolution methods were assessed through subjective statements; however, similar situations could be interpreted differently by different participants. Fourth, the median was used as a cutoff score to categorize family conflict resolution methods into positive and negative categories; however, this was an unverified criterion. Fifth, identifying causal relationships was not possible as this was a prospective study. Sixth, while the survey primarily adheres to the principle of direct face-to-face interviews, participants who were unable to meet with the surveyors may have completed the survey through telephone or proxy responses. Although this study has some drawbacks, it also has notable strengths. First, it is based on longitudinal data gathered from diverse samples across Korea. Second, the research highlights the impact of changes in family conflict resolution strategies on depressive symptoms in individuals with chronic disease, showing that negative changes can worsen these symptoms. Additionally, we found that even after transitioning to positive conflict resolution methods, prior negative experiences could still affect depressive symptoms. Last, the study reveals a strong link between resolving verbal conflicts and an increase in depressive symptoms among patients with chronic disease, similar to the effects of physical violence.

Conclusion

Our study examined the relationship between family conflict resolution methods and depression in individuals over the age of 20 in Korea living with chronic disease. The study found that using negative methods to resolve family conflicts was associated with symptoms of depression. There was a heightened risk of depressive symptoms when negative communication or physical violence was involved. Based on these results, programs and services must be developed to promote healthy conflict resolution for individuals and families, minimize negative change, and facilitate positive change. To enhance the study’s scope, future research should incorporate different variables and effective conflict resolution strategies. Furthermore, it is important to compare and validate these findings with those of similar studies conducted in diverse cultural contexts to enhance the applicability of the research outcomes.

Supporting information

S1 Table. General characteristics of the baseline population with chronic disease.

(TIF)

pone.0318378.s001.tif (245.3KB, tif)

Acknowledgments

We express our gratitude to the Korea Welfare Panel study for providing longitudinal survey data. Additionally, we thank colleagues from Yonsei University’s Health Research Institute for their advice on drafting the manuscript.

Data Availability

The third-party data underlying the results of this study are publicly available from the KOWEPS website (http://www.koweps.re.kr). To obtain the data, users must create an account, submit a data request, and agree to the data usage terms set by the Korea Institute for Health and Social Affairs (KIHASA). The specific datasets used in this study include survey waves from 2012 to 2022. Interested researchers can fully replicate our study findings by directly obtaining the same datasets from the KOWEPS database and following the methods described in the study. The authors had no special access privileges, and all researchers who meet the KOWEPS data usage requirements can access the data under the same conditions.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Asres Bedaso Tilahune

18 Apr 2024

PONE-D-24-06786The relationship between family conflict resolution methods and depressive symptoms in patients with chronic diseasesPLOS ONE

Dear Dr. Park,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 02 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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Asres Bedaso Tilahune

Academic Editor

PLOS ONE

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Additional Editor Comments:

The study examined an important area of research, but the authors should address the suggested comments before considering publication.

Address all comments raised by both reviewers. In the methods section, use a diagram that is clear and easy for readers to understand how the sample used for the current analyses was selected from the total eligible sample. Explain more detail how the family conflict resolution method was analysed (e.g. how consecutive years were considered to decide whether family conflict resolution is positive/negative?) Clearly label outcome, exposure and confounding variables in the methods section. Also, provide more information on the instruments used to assess some of the variables, such as income (low/normal?), family life, health status, smoking (current/ever?), drinking (alcohol or what?), etc. Make major revisions to the data presented in all tables (N(%), 95%CI, age category?, p-value for age in table 1, include % for all frequencies across all rows, p-value for chronic disease?, be consistent with decimals across all tables (e.g. <.0001, 0.0007), keep journal rule for spacing, table 2 95% CI should be revised). In Table 2, what is the point of reporting the OR of other confounders when your exposure variable (EV) is family conflict resolution method? Instead, present the OR of the EV in different models (Model I (unadjusted), Model II, Model III (fully adjusted)) and report the adjusted variables as a footnote below the table. Delete a figure presented before the discussion. I think the result presented in Table 5 does not add anything to the study as the association between category of family conflict resolution method and depression is significant at almost all levels. Significantly revise the discussion, add more scientific theories to support your argument, use updated literature and include the policy and research implications of the study findings. Revise and update the conclusion accordingly.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This was a really interesting topic which addressed how family conflict resolve methods may affect depression among chronic disease patients who are likely to be more depressive than those disease-free individuals. They did careful analyses, however I have following questions, hopefully they can be addressed by investigators.

1 there are so many people excluded at baseline, I think a characteristic comparison table is needed to compare those included and excluded

2 why excluded those under 29?

3 is CESD-11 validated in Korean population with chronic diseases ?

4 the scoring method for participants’ responses to five statements are confusing: 1 point for “never “ to 5 point for “always” (line 117), so the higher the total score, the more negative resolve method is, but why the opposite is the definition being stated?

6. What was the plot for on page 13? What is the interpretation of the results?

Reviewer #2: 1. In introduction : how vulnerable people with chronic diseases are to depression, not depression.

2. In Methods : Isn't the participants for people under 30 years old? Line 101 needs to be checked.

3. In Methods : The author should further explain what chronic diseases are.

4. In Methods : Didn't investigate the duration of the prevalence of chronic diseases?

5. In Results : Please organize the tables and Figure in an easy to see. The % is missing in Table 1.

6. In Results : table 5, It would be better to present either the table or the figure, not both.

7. In discussion : I don't understand the sentence. Please organize your thoughts and write them down again. The arguments before and after do not match.

8. In discussion : Please write down the line number.

9. In Conclusion : Please check the sentence and write it down concisely.

10. In Conclusion : Please check the completion of the sentence in the first paragraph.

**********

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2025 Feb 28;20(2):e0318378. doi: 10.1371/journal.pone.0318378.r003

Author response to Decision Letter 1

13 Jul 2024

We were pleased to have the opportunity to revise our paper. In revising our paper, we have carefully considered your comments and suggestions. As instructed, we have attempted to explain the changes made in reaction to all the reviewers’ comments. The reviewers’ comments were very helpful overall, and we appreciate the constructive feedback on our original submission. After addressing the issues raised, we feel the quality of the paper has greatly improved and we hope you agree. Our response to each comment is as follows, and we attach a revision note with the highlighted, revised sections of the manuscript. Again, thank you for the valuable and helpful comments.

Attachment

Submitted filename: Response to Reviewers_PONE-D-24-06786.pdf

pone.0318378.s003.pdf (613.2KB, pdf)

Decision Letter 1

Ali A Weinstein

27 Dec 2024

PONE-D-24-06786R1The relationship between family conflict resolution methods and depressive symptoms in patients with chronic diseasesPLOS ONE

Dear Dr. Park,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR: 

Thank you for taking the time to thoughtfully revise your paper with the comments of the previous review. Your manuscript has improved greatly. One of the reviewers was "new" to your manuscript, as the previous reviewer was unavailable. That reviewer had some very helpful suggestions that you will see listed below. Please carefully consider these suggestions as you complete your revision. Looking forward to receiving your revised manuscript.

Please submit your revised manuscript by Feb 10 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Ali A. Weinstein, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:  The authors provided well prepared reply to my questions. They Addressed all my comments well. No further comments now

Reviewer #3:  This study examines the impact of family resolution methods on depressive symptoms among adults aged 20 and over in Korea. The authors utilized data from the Korean Welfare Panel Study (KoWePS), analyzing information from 5,816 participants with chronic diseases collected longitudinally from 2012 to 2022 (7th to 17th waves). Notably, participants did not have depressive symptoms upon initial entry into the panel.

I reviewed both the original and revised versions of the manuscript and observed substantial changes that significantly improved the readability and overall quality of the paper. The topic is highly relevant and engaging. Below are some suggestions for further improvement:

1. Provide more information on KoWePS:

o It would be helpful to include additional background on the Korean Welfare Panel Study. What was the study originally designed to assess? Were the same individuals followed over time, or does the dataset involve a rotation of participants from different families or households?

2. Clarify interview methods:

o What specific circumstances prevented face-to-face surveys? Additionally, please indicate the number of participants interviewed via telephone or proxy responses and discuss any potential biases this may introduce.

3. Define chronic conditions:

o The manuscript states: “Participants were reported as chronic if they had the condition for less than three months, between...” This definition is inconsistent with standard definitions of chronic conditions. Chronic diseases typically persist for a longer duration. Please revise or clarify this classification.

4. Justify the age cutoff:

o Why was the age cutoff set at 20 years? Is there a specific rationale for excluding participants aged 18 or 19? Providing an explanation will strengthen the methodology section.

5. Reassess Family Conflict Resolution Measures:

o The assessment of family resolution methods is a significant limitation of the study.

� Citations: Add a citation for KoWePS recommendations regarding the evaluation of family conflict resolution.

� Content Validity: Many of the statements used (e.g., “My family members criticize each other” or “My family members hit each other”) appear to measure conflict rather than resolution techniques. Please provide justification for using these items as measures of resolution strategies. Have they been validated in previous studies?

6. Explain family conflict groupings:

o The method section lacks details on how the family conflict resolution groups (e.g., “Positive to Positive,” “Negative to Positive,” “Positive to Negative,” “Negative to Negative”) were formed. What time intervals were used (e.g., year-to-year changes or baseline to follow-up)? Ensure this is clearly defined, as it appears prominently in Table 1.

7. Figure formatting and interpretation:

o The figure before the discussion section lacks a title and proper axis descriptions. Include these to improve clarity for readers.

8. Discussion refinement:

o The discussion appropriately highlights that “Negative to Positive” changes in conflict resolution are associated with lower odds of depression compared to “Positive to Negative” or “Negative to Negative.” However, the odds ratios never dropped below one, indicating that any negative family conflict experience increases the odds of depressive symptoms. This underscores the importance of preventing negative family conflict altogether as a key takeaway from the study.

In summary, the manuscript addresses an important and timely topic with significant implications for understanding the relationship between family dynamics and mental health. Incorporating these recommendations will strengthen the study's rigor and impact.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #3: Yes:  Mamadou Sy

**********

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PLoS One. 2025 Feb 28;20(2):e0318378. doi: 10.1371/journal.pone.0318378.r005

Author response to Decision Letter 2

11 Jan 2025

Thank you for your great efforts in reviewing our manuscript.

Attachment

Submitted filename: Response to Reviewers(2nd)_PONE-D-24-06786.pdf

pone.0318378.s004.pdf (613.2KB, pdf)

Decision Letter 2

Ali A Weinstein

15 Jan 2025

The relationship between family conflict resolution methods and depressive symptoms in patients with chronic diseases

PONE-D-24-06786R2

Dear Dr. Park,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Ali A. Weinstein, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Ali Weinstein

PONE-D-24-06786R2

PLOS ONE

Dear Dr. Park,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ali A. Weinstein

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. General characteristics of the baseline population with chronic disease.

    (TIF)

    pone.0318378.s001.tif (245.3KB, tif)
    Attachment

    Submitted filename: Response to Reviewers_PONE-D-24-06786.pdf

    pone.0318378.s003.pdf (613.2KB, pdf)
    Attachment

    Submitted filename: Response to Reviewers(2nd)_PONE-D-24-06786.pdf

    pone.0318378.s004.pdf (613.2KB, pdf)

    Data Availability Statement

    The third-party data underlying the results of this study are publicly available from the KOWEPS website (http://www.koweps.re.kr). To obtain the data, users must create an account, submit a data request, and agree to the data usage terms set by the Korea Institute for Health and Social Affairs (KIHASA). The specific datasets used in this study include survey waves from 2012 to 2022. Interested researchers can fully replicate our study findings by directly obtaining the same datasets from the KOWEPS database and following the methods described in the study. The authors had no special access privileges, and all researchers who meet the KOWEPS data usage requirements can access the data under the same conditions.

    Articles from PLOS One are provided here courtesy of PLOS

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