East Asian Arch Psychiatry 2016;26:22-9

ORIGINAL ARTICLES

Gender Differences in Perceived Social Support and Stressful Life Events in Depressed Patients
S Soman, SM Bhat, KS Latha, SK Praharaj

Dr Savitha Soman, MBBS, MD, Assistant Professor, Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India 576104.
Dr Shripathy M. Bhat, MBBS, MD, DPM, MNAMS, Professor, Department of
Psychiatry, Kasturba Medical College, Manipal, Karnataka, India 576104.
Dr K. S. Latha, MA, DPSW (MPhil), DHRL, PhD, Professor and Psychosocial Consultant, Department of Psychiatry, Dr A. V. Baliga Memorial Hospital, Doddanagudde, Udupi, Karnataka, India 576102.
Dr Samir Kumar Praharaj, MBBS, MD, DPM, Associate Professor, Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India 576104.

Address for correspondence: Dr Samir Kumar Praharaj, MBBS, MD, DPM, Associate Professor, Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India 576104.
Tel : 91-8971026304; E-mail : samirpsyche@yahoo.co.in

Submitted: 23 June 2015; Accepted: 5 October 2015


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Abstract

Objective: To study the gender differences in perceived social support and life events in patients with depression.

Methods: A total of 118 patients aged 18 to 60 years, with depressive disorder according to the DSM- IV-TR, were evaluated using the Multidimensional Scale of Perceived Social Support and Presumptive Stressful Life Events Scale.

Results: The perceived social support score was significantly higher in males than females (p < 0.001). Males perceived significantly higher social support from friends than females (p < 0.001), whereas support from significant others was higher in females. There was a higher mean number of total life events as well as specific type of life events in males that became apparent after controlling for education (p < 0.05). Financial loss or problems was the most commonly reported life event in both males and females. Work-related problems were more commonly reported by males, whereas family and marital conflict were more frequently reported by females.

Conclusion: Perceived social support and stressful life events were higher in males with depression than females.

Key words: Depression; Life change events; Social support

Introduction

Depressive disorders are a common public health problem across the world, including India. A female preponderance in depression is almost universal.1-3 Several explanations including biological factors such as neuroticism, stress responsiveness, or limbic system hyperactivity have been proposed for this gender difference; nevertheless, the role of psychosocial factors is important in the stress-diathesis model.4-6 The role of social support and life events in the development and maintenance of depression has long been of interest. Studies report that people with spouses, friends, and family members who provide support in terms of psychological and material resources have better health in comparison with those with fewer supportive social contacts.6-8 It has been suggested that social support reduces the risk of psychiatric disorder by providing a buffer against the adverse effects of stressful events.7,9 Other studies have found that social support is beneficial irrespective of life stress.10,11

Gender differences in level of social support have varied; Ross and Mirowsky12 found higher levels of perceived social support among women than men, whereas several studies have reported little or no difference across gender.13 It has been suggested that females have a stronger affiliative style than males (i.e. more attachments and a wider social network) as they require greater social support for maintenance of their psychological health. Therefore, they are more vulnerable to events that affect their close emotional ties (e.g. death of spouse, marital conflict, or family conflict), and possibly are more likely to develop depression  in response to them.6,14   This increased risk of depression because of ‘caring about’ others has been known as the ‘cost of caring’ hypothesis.6,14 Research on the association between social support and depression in males and females has provided controversial findings, with some studies reporting that social support is equally important to males and females, and others showing greater beneficial effects or even a detrimental action for depression in either gender.4,6 In one large study, neighbourhood disadvantage (poor cohesion with neighbourhood) was associated with depressive symptoms in women only (odds ratio = 1.25, 95% confidence interval = 1.01-1.55).15 In contrast, in the elderly population, low social support and a high need for affiliation were related to depression, with men being more affected than women.16,17 In another large study, self-rated perceived functional social support was associated with depression; in those lacking social support, women seemed to need more emotional support and men tangible support.18 In a study from slum areas in India, local social support was found to reduce the risk of depression among women.19

An increased rate of life events has been reported to be associated with various psychiatric disorders including depression,20,21 mania,22 obsessive-compulsive disorder,23,24 and schizophrenia.25 Kumar et al26 reported life events in 87% of depressive and 81% of manic patients; there was no significant difference in the quantitative and qualitative profile of life events and no correlation between the severity of life events or magnitude of illness. Latha et al27 found that suicide attempters experienced more life events than depressives or controls, specifically, marital discord, conflicts with in-laws, problems with love affairs, illness or death of a relative, and alcohol abuse of a close relative. The assumption that females might be at higher risk of depression owing to higher rates of adverse life events has received inconsistent support, with some studies showing gender differences in the expected direction and others finding similar levels of life events in males and females.6 In any case, the excess of life events in females has not been found to account entirely for their higher frequency of affective disorders.6,14 Wilhelm et al28 found no gender differences in the frequency of life events or in anticipated impact of pleasant and unpleasant events, whereas the actual impact of unpleasant events was rated higher by females.

The study findings are mixed as to the gender differences in social support and life events in depression and has led to the current study. This study aimed to examine the gender differences in perceived social support and life events in patients with depression. The hypothesis was that there would be no difference in perceived social support and life events in the past year between male and female patients with depression.

Methods

Participants

This was a cross-sectional, observational study carried out at the Department of Psychiatry, Kasturba Hospital, Manipal, which is a tertiary care centre in South India. The study was approved by the institutional ethics committee. The sample comprised consecutive male and female patients aged 18 to 60 years, who were attending an outpatient clinic or were admitted to hospital as an inpatient and diagnosed by a consultant psychiatrist to have major depressive disorder (mild, moderate, or severe) as per the DSM-IV-TR29 criteria. Those with co-morbid major psychiatric or medical disorders, and with a Mini-Mental State Examination (MMSE)30 score of ≤ 23 were excluded from the study. Written informed consent was obtained from all subjects.

Tools

A socio-demographic and clinical proforma designed for the study was used to collect patient details. The Mini- International Neuropsychiatric Interview, English Version 5.0.0 (MINI Plus),31   a structured diagnostic interview, was used to make the DSM-IV-TR diagnosis. To evaluate life events, the Presumptive Stressful Life Events Scale (PSLES)32 was used. It is based on the stressful life events scale of Holmes and Rahe.33 The PSLES comprises 51 items and has been designed for the Indian population. The items are ranked from the most stressful, i.e. death of spouse, to least stressful, i.e. going on a pleasure trip or pilgrimage. The items on the scale are further divided into personal (e.g. marital separation, suspension from job), impersonal (e.g. death of friend, crop damage), desirable (e.g. getting married, expansion in business), undesirable (e.g. marital conflict, robbery, or theft), and ambiguous (e.g. retirement, prophecy of astrologer). The scale has been standardised to assess life events in 2 time frames: in the past year and lifetime. The scores were calculated on 2 formats: the number of life events and weighted stress score. Based on data derived from the PSLES, an adult person in India is likely to have experienced an average of 2 events in the past year and 10 events in a lifetime without suffering any physical or psychological disturbance.32  Test-retest reliability for the scale is 0.73.34

The 17-item Hamilton Depression Rating Scale (HAM-D)35 was used to measure severity of depression. A score of ≤ 7 is considered no depression, 8 to 13 as mild depression, 14 to 18 as moderate, and ≥ 19 as severe. The Psychiatry Online Insight Rating Scale version 1.0 (PoLIRS 1),36 an observer-rated instrument, was used to measure insight. It has 6 levels of insight based on a hierarchy that ranges from appreciating that a personal experience or symptom is different to that expected in the normal range of experience (level 1), to appreciating the need for continued compliance or follow-up by formal treatment provider (level 6). It is based on the conceptualisation of insight into 3 components: awareness of illness, need for treatment, and attribution of symptoms.37 The Multidimensional Scale of Perceived Social Support,38 a 12-item scale, was used to assess the level of social support that each person perceives he / she has. The items in this scale were divided into factor groups related to the source of social support, namely family (e.g. I can talk about my problems with my family), friends (e.g. my friends really try to help me), and significant others (e.g. there is a special person who is around when I am in need). There were 4 questions devoted to each source and each was rated on a 7-point Likert scale (‘1’ for ‘very strongly disagree’ to ‘7’ for ‘very strongly agree’). The higher the score, the greater was the social support. The scale has been shown to have high internal consistency, as well as good reliability and validity.39 The MMSE,30  a 19-item instrument, was used to measure cognitive state.

Procedure

Three subjects were excluded from the study as they did not give consent. A total of 118 subjects were assessed over an 8-month period. The diagnosis was confirmed using MINI Plus. All subjects were subsequently rated on HAM-D, PoLIRS 1, Multidimensional Scale of Perceived Social Support, and PSLES (in the past year).

Statistical Analysis

Data were analysed using the Statistical Package for the Social Sciences Windows version 16.0 (SPSS Inc., Chicago [IL], US). The categorical and continuous variables across gender were compared using Pearson’s Chi-square test and independent t test, respectively. Effect size for categorical variables was reported as phi or Cramer’s V, and for continuous variables as Cohen’s d. Analysis of covariance(ANCOVA) was used to control the effects of education that differed across gender; the effect sizes were reported as partial eta squared (ηp2). Exploratory correlational analysis (Pearson’s r) was carried out between perceived social support and socio-demographic and clinical variables separately for males and females. Level of significance was set at p < 0.05 (2-tailed).

 

Results

Socio-demographic and Clinical Variables

The socio-demographic and clinical variables are summarised in Table 1. There was no significant difference in age, marital status, occupation, residence, family type, illness duration, HAM-D or insight scores across gender. Among females, 14 (21%) had no formal education compared with 1 (2%) in male, whereas 17 (25%) females had a higher education compared with 24 (47%) males; the difference was significant (p = 0.01), with medium effect size (Cramer’s V = 0.32). Melancholic symptoms were present in a higher proportion of males (71%) than females (57%) but the difference was not significant. Also, psychotic symptoms were present in a higher proportion of males (14%) than females (8%); the difference was not statistically significant.

Perceived Social Support and Life Events

The gender differences in perceived social support and life events are summarised in Table 2. The perceived social support scale score was significantly higher in males than in females (p < 0.001) with large effect size (Cohen’s d = 0.88). After controlling for education, ANCOVA showed a significant difference in perceived social support scale score (F = 17.99, degrees of freedom [df] = 2/115, p < 0.001) across gender. There was no difference in the perceived social support from family members across gender, even after controlling for education. Males perceived significantly higher social support from friends than females (p < 0.001) with large effect size (Cohen’s d = 1.31), whereas support from significant others was higher in females, with small effect size (Cohen’s d = 0.42). After controlling for education, ANCOVA showed significantly higher perceived social support from friends in males (F = 31.12, df = 2/115, p < 0.001), but the higher support from significant others in females became non-significant (F = 2.36, df = 2/115, p = 0.10).

There was a higher mean number of total life events as well as specific type of life events in males compared with females, but the differences were not statistically significant. In the ANCOVA model, after controlling for education, there was a significantly higher mean number of total life events in males (F = 5.30, df = 2/115, p = 0.01), with small effect size (ηp2 = 0.084). Also, after controlling for education in ANCOVA, there was a significantly higher mean impersonal life events in males (F = 6.94, df = 2/115, p = 0.001, ηp2 = 0.108), but the difference in personal life events was not significant across gender. The ANCOVA after controlling for education showed higher mean number of desirable life events (F = 3.60, df = 2/115, p = 0.004, ηp2 = 0.093) and ambiguous life events in males (F = 5.48, df = 2/115, p = 0.01, ηp= 0.087), but the difference in undesirable life events was not significant. Hence, in the ANCOVA model, after controlling for education, there was no difference in personal or undesirable life events, but the impersonal and other life events were higher in males (F = 9.68, df = 2/115, p < 0.001, ηp2 = 0.144). Figures 1 and 2 summarise the frequency of common life events reported by male and female patients, respectively. Financial loss or problems was the most commonly reported life event in both males and females. Work-related problems were more commonly reported by males, whereas family and marital conflict were more frequently reported by females.

Correlation of Perceived Social Support with Socio- demographic and Clinical Variables

Among males, total perceived social support significantly and positively correlated with desirable life events (p = 0.01, r = 0.36) and negatively correlated with illness duration (p = 0.03, r = –0.30). Social support from family significantly and negatively correlated with undesirable life events (p = 0.002, r = –0.42), whereas social support from friends significantly and positively correlated with desirable life events (p = 0.04, r = 0.29). Perceived social support from significant others significantly positively correlated with total life events (p = 0.05, r = 0.27), impersonal life events (p = 0.002, r = 0.42), and desirable life events (p = 0.04, r = 0.29), and negatively correlated with age (p = 0.05, r = –0.28). The HAM-D score positively correlated with ambiguous life events (p = 0.04, r = 0.29), and insight score negatively correlated with total life events (p = 0.003, r = –0.41), personal life events (p = 0.01, r = –0.38), desirable life events (p = 0.04, r = –0.29), and undesirable life events (p = 0.003, r = –0.41).

Among females, total perceived social support significantly and positively correlated with total life events (p = 0.04, r = 0.25), personal life events (p = 0.02, r = 0.29), desirable life events (p = 0.01, r = 0.32) and insight (p = 0.01, r = 0.32), and negatively correlated with age (p = 0.004, r = –0.35). Social support from family did not correlate with life events, but significantly and positively correlated with insight (p = 0.02, r = 0.28). Social support from friends did not correlate with life events, but significantly negatively correlated with age (p = 0.001, r = –0.39). Perceived social support from significant others significantly and positively correlated with personal life events (p = 0.03, r = 0.39). The HAM-D score positively correlated with total life events (p = 0.03, r = 0.27).

Discussion

The major finding in our study was that males with depression had higher perceived social support overall, and specifically from friends, compared with females with depression, with a large effect. The difference remained significant even after controlling for education; both of which differed across gender. In contrast, females had higher perceived social support from significant others than males although this was not significant after controlling for education. Interestingly, there was no difference in perceived social support from family members across gender. The findings are in contrast to previous studies that report women with depression to have a larger and more intimate social network.12,40 In a study on twins, Kendler et al40 found that women reported higher levels of global social support than their twin brother, but levels of social support did not explain the gender difference in risk for major depression. Our results echo the findings of Walen and Lachman41 who examined the association of social support and strain with psychological wellbeing and health and whether these associations depended on type of relationship (partner, family, friends), and the extent to which these associations differed by age and gender. They found that positive and negative social exchanges were more strongly related to psychological wellbeing than to health. For both sexes, partner support and strain and family support were predictive of wellbeing measures; further, supportive networks were found to buffer the detrimental effects of strained interactions; friends and family served a buffering role more often for women than for men. Yang42 found that only perceived social support, not objective measures of support, acts as a significant stress reducer and mediates the detrimental effects of disability on increments in depressive symptoms. With regard to the findings related to social support in our study, we would like to consider the possibility that since women were aged 18 to 60 years and mostly married, they were more likely to be involved in household and childcare responsibilities and hence would have less contact with their friends than the men. Hence, the support from friends would be less.

Another finding was that the mean number of life events experienced by males and females was similar and there was no difference in desirable or undesirable life events. Nonetheless after controlling for education, males reported a higher number of total life events, impersonal life events, desirable life events, and ambiguous life events. This is similar to previous research that reported higher rates of life events in males and females with depression.43  Slopen et al44 investigated gender differences in the association between stressful life events and major depression and alcohol dependence in a large national sample of adults in the US (n = 32,744) using a prospective design. Logistic regression analysis showed that number of stressful life events was predictive of first-onset major depression and alcohol dependence. This was true for both males and females, and gender-by-stress interaction terms did not support the hypothesis that gender-specific responses to stressful life events lead to gender differences in first onset of major depression and alcohol dependence among adults. In contrast, in a multinational community survey, Dalgard et al45  found that women reported slightly more negative life events than men, mainly related to the social network, but more social support in general  and in connection with reported life events. They concluded that in general, women were not more vulnerable to negative life events than men. Nonetheless women with no social support, who are exposed to life events, are more vulnerable than men without support. Another study46 reported on a combined sample of 375 individuals in which all participants were diagnosed with major depressive disorder and assessed with the Life Events and Difficulties Schedule. Women reported significantly more severe and non-severe, independent and dependent, and other-focused and subject-focused life events prior to onset of depression than did men. Furthermore, these relationships were significantly moderated by age, such that gender differences in rates of most types of events were found primarily in young adulthood. In our study, females with a higher number of life events had higher perceived social support, with small-to-medium effect size. Craig47  reported that experiences of  defeat, humiliation, and entrapment were at the heart of depressive episodes in males and females,  though females  were far more likely to report such experiences, possibly because of their distinctive social circumstances. In our study, financial loss or problems were the most common life events reported by both male and female depressed patients, and is similar to the study by Kumar et al.26  Among females, life events related to loss of emotional ties were more common than in male patients and is in accordance with the cost of caring hypothesis,6,14 i.e. females experiencing such life events are more vulnerable to develop depression. In contrast, males have more work-related problems, rather than affiliative life events. In females, depression severity was higher in those who perceived a higher number of life events; in males it was associated with ambiguous life events only.

The limitations of our study include recall bias that is associated with retrospective assessments. Also, the hospital-based sample precluded generalisation to the community where milder illnesses are common. Future longitudinal studies could focus on the relationship between social support and life events and clarify whether there is any stress-buffering role of social support in the development of depression.

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