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Running Head: DEPRESSION and SOCIAL SUPPORT 1 Running head: DEPRESSION AND SOCIAL SUPPORT 1 Depression and social support: Why social support may help those who are depressed? Anastasiia Onatskaia ANR 517209 Supervisor: Dr. Yvette van Osch Second supervisor: Dr. Rob Nelissen DEPRESSION AND SOCIAL SUPPORT 2 Abstract Social support is well known to have negative effect on depression. However, relatively few studies focus on why social support is beneficial for mental health. Those who do, offer a few possible explanations for the relationship: (1) stress-buffering approach (enhancing coping performance and appraising life events as less stressful) and (2) behavioral change approach (health improvement through health-promoting behaviors: choosing a healthy diet and exercising). The stress-buffering approach is the only theoretical concept that has an empirical evidence, the behavioral change approach has never been examined before. Therefore, the current study is the first empirical test of the behavioral change approach, and it is also the first study that investigates more than one approach. The data (N=205) showed main effect of social support on depression; however no significant results confirming either explanation of social support effectiveness were found. In the exploratory analysis, social support moderated relationship between stress and depression for the group of participants that were not previously diagnosed with depression (no/no group); however failed to do the same in two other groups, consisted of participants who were previously diagnosed with depression, and did (yes/yes group) or did not (yes/no group) take medication at the moment of the study. Overall, I found very little evidence for suggested explanations of the relationship between social support and depression. Keywords: depression, social support, stress, diet, physical activity. DEPRESSION AND SOCIAL SUPPORT 3 Depression and social support: Why social support may help those who are depressed? Major Depressive Disorder is one of the main causes of morbidity worldwide (World Health Organization, 2001). The number of people affected by Major Depressive Disorder during their lifetime is in the range between 5 and 17% (Sadock, Sadock & Ruiz, 2017). DSM-5 operationalizes Major Depressive Disorder in the following way: depressed mood; markedly diminished interest or pleasure in activities, significant weight loss when not dieting or weight gain; sleep disturbance; fatigue; feelings of worthlessness; diminished ability to think or concentrate; recurrent suicidal ideation, a suicide attempt or a specific plan for committing suicide (American Psychiatric Association, 2013, p.160). Despite the prevalence of depression even in countries with well-organized health care systems it was estimated that between 44% and 70% of patients with Major Depressive Disorder do not receive treatment (American Association of Suicidology, 2014). If left untreated, depression can lead to comorbid (emerging at the same time) mental disorders, recurrent episodes and higher rates of suicide (American Association of Suicidology, 2014). However, depression is curable; the recovery probability during first six months is more than 50%, within 1 year is 70% and within 5 years is 88% (Keller et al., 1992). There are many methods that are used to cope with depression, including medicines, psychotherapy, electroconvulsive therapy (Gelenberg et al., 2010) and also tools such as yoga (Streeter, Gerbarg, Saper, Ciraulo & Brown, 2012) and meditation (Chiesa & Serretti, 2010), etc. Kraemer, Wilson, Fairburn and Agras (2002) questioned why and under what circumstances treatment of psychiatric disorder results in recovery. Researchers indicated that social support may be an important extra-therapeutic condition of successful depression treatment (Linville, 1987; Park, Cuijpers, van Straten & Reynolds, 2014). The link between social support and depression is well established; many studies have shown a negative effect of social support on depression (e.g., Aneshensel & Frerichs, 1982; DEPRESSION AND SOCIAL SUPPORT 4 Brown et al., 1986; George, Blazer, Hughes & Fowler, 1989; Gottlieb & Bergen, 2010; Grav, Hellzèn, Romild, & Stordal, 2012; Holahan & Holahan, 1987; Lin, Dean & Ensel, 2013; Wang, Cai, Qian, & Peng, 2014). However, relatively few studies focus on why social support is beneficial for health (Cohen, 1988). It was suggested that there are multiple psychological pathways by which social support may influence both onset (Brown & Andrews, 1986; Thoits, 1982) and progression (George, Blazer, Hughes & Fowler, 1989) of depression. Articles offering classifications of approaches that can potentially explain relationship between social support and depression are mainly theoretical; they are great for understanding multiple approaches one can use but they lack empirical evidence. To get a clear picture on why social support has significant effect on depression, multiple studies should be conducted to test all approaches, and then meta-analyses of the studies might help to understand how much of the relationship between social support and depression can be explained by each approach. In this paper, I examine the two main approaches to influence of social support on health: the stress-buffering approach (e.g., change in the appraisal of stressful events, boost in coping performance) and the behavioral change approach (health improvement through health-promoting behaviors: choosing a healthy diet and exercising) (Cohen, 1988; Lakey & Cohen, 2000). First of all, I want to replicate result of previous studies (Brown et al., 1986; Grav, Hellzèn, Romild, & Stordal, 2012; George, Blazer, Hughes & Fowler, 1989; Wang, Cai, Qian, & Peng, 2014) that shown significant negative correlation between social support and depression. H1. Social support is negatively related to depression (figure 1). Social support Depression Figure 1. Effect of social support on depression Stress-buffering approach DEPRESSION AND SOCIAL SUPPORT 5 The stress-buffering approach is the most influential theoretical perspective on why social support is beneficial for one’s health (Lakey & Cohen, 2000). It states that social support decreases the negative influence of stressful life events on mental health by enhancing coping performance and appraising life events as less stressful (Cohen, 1988). There is a lot of empirical support for the relationship between stress and depression (Aneshensel & Frerichs, 1982; Aneshensel & Stone, 1982; Billings & Moos, 1984; Hammen, 2005; Lechin, Van Der Dijs & Benaim, 1996). Some studies (Husaini, Newbrough, Neff & Moore, 1982; Raffaelli, 2013; Takizawa, 2006) have found not only the main effect of the stress on depression (as did studies mentioned above), but also a buffering effect of social support on the relationship between stress and depression: people with a high quality and quantity of social support were less susceptible to stressful events and, therefore, had lower prevalence of depressive disorders. H2. Social support will moderate the relationship between stress and depression (figure 2). Social support Stress Depression Figure 2. Moderation of the relationship between stress and depression by social support Although the stress-buffering hypothesis is central in studies of the effects of social support (Lin, Dean & Ensel, 2013) and has some empirical evidence (Husaini, Newbrough, Neff & Moore, 1982; Raffaelli, 2013; Takizawa, 2006), it could not be applied to all cases of mood disorders. The stress-buffering hypothesis assumes that stress is required for depression to develop whereas Lakey and Cohen (2000) stated that it is not always the case: sometimes negative thoughts are enough to provoke negative emotions. Therefore, if stress is not always required for the depression onset (depression may develop without any stressful events), DEPRESSION AND SOCIAL SUPPORT 6 stress-buffering approach could not be the sole explanation of social support being beneficial for mental health. Alternative rationalization of the relationship between social support and depression can be the behavioral change approach. Behavioral change approach In this approach social support is believed to stimulate behaviors beneficial for one’s health such as exercising and eating a healthy diet (Uchino, Cacioppo, & Kiecolt-Glaser, 1996). Therefore, negative effect of social support on depression is executed through diet and exercising. Behavioral change approach have never been tested empirically, however there are studies that showed significant relationships between the variables (social support – diet/physical activity and diet/physical activity – depression). Researches (Aggarwal, Liao, Allegrante & Mosca, 2010; Kara, Caglar & Kilic, 2007) found that patients with low social support show poor adherence to the diet while people with high social support tend to stick to the diet. Tamers et al. (2011) demonstrated that people with higher social support had 14.3% higher physical activity and 4% higher fruit and vegetable consumption compared to participants with lower social support. Appelhans et al. (2012) have shown that greater depression severity was associated with poorer diet quality whereas healthy diet (e.g., Mediterranean diet) correlates with lower levels of depression (Sanchez-Villegas, Henriquez, Bes-Rastrollo & Doreste, 2006). Physical activity can reduce symptoms of depression (Dunn, Trivedi & O'Neal, 2001) and decrease the risk of subsequent depression (Strawbridge, Deleger, Roberts, & Kaplan, 2002). To sum up, there is an empirical evidence that higher
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