520 Journal of Pain and Symptom Management IU. 9 No. 8 November 1994

Depression in Painful Chronic The Role of Pain and Conflict About Pain Julia A. Faucett, PhD School of Nursing, University of CalifMnia, San Francisco, Cali$ornia

Abstmct Chmnic pain severity, the responses of the signifia?&t other to the putient ‘s pain, and social rzetwork re~tio~h~ps were in.v~tig~ed for their ~ont~.butio~ to d~ession among patients with myofascial pain disordm (N = 67) and arthritis (N = 83). Interview data were gathered using the Beck Depression Inventory, McGill Pain Inventory, Multidimensional Pain Inventory, and interpersonal Wationships Inventory. Patients with myofzscialpain disorders reported si~~~~a?~t~ mure severe vision and pain, more convict lout thaw- Paine and

moTe netwo& conflict than those with arthritis. They also repmtd less networ-k social support. A@ controllingfm the type of painful chronic disorder, multi@ linear regression. analyses indicated that more sarere w&on was ~.~~~can.tly associated with more severe pain, conflict a&out pain, and less n&work social suck. Co~t~i&t ant pain may increase the risk of aT+ression fm pat&ts with chronic painful d&rders. Patients with myofascial pain d&-&s, however, may experience m.ore conflict about their pain because of the absence of ob~~~.ve phys~al~ndin~ that &~obora~ the report 0fpain.J Pain Symptom Manage 1 PP4;9:520-526.

A~h~t~, chronic w-n, ~on~i&t, vision, myof~cial pain disorders, social supp~

Depression is a common and potentially serious complication of chronic medical illness that may compound physical ~sabili~ and threaten emotional well-being.1,z The depres- sion that occurs in chronic disorders has previously been associated with social isolation and lack of support% Because of this associa- tion, supplementation and mobilization of the patient’s support network have been suggested as potential interventions.78 Other investiga-

Address repr&t requests to: Julia A. Faucett, PhD, School of Nursing, Center of Occupational and Environ- mental Health, Box 0608, ~Tnive~i~ of California, San Francisco, CA 941430608, USA.

Acceptedf~publication: April 13,1994.

tions, however, have shown that stress or conflict in social relationships is more strongly associated with depression than low levels of social support. D-12 Moreover, the associations between affective ~ptomatolo~ and social support or conflict have been found to vary with the type of disorder and the nature of the social relationship studied.12-I7

Relationships with spouses, partners, or con- fidants differ from less intimate relationships because of the type of support they provide and their importance in preventing depres- sion.13p1g*‘” Marital conflict and dissatisfaction, in particular, have been linked to poor patient adaptation to chronic disorders.zh*2 Although there is generally a rallying of support from family members and others as the severity of a chronic disorder increases,25,24 long-term de-

0 U.S. Cancer Pain Relief Committee, 1994 Published by Elsevier, New York, New York 08&E-3924/94/$7.00

Vol. 9 No. 8 Mxentber 1994 ISepessian and Cltronic Pain 521

mands or li~i~tio~s caused by the chronic disorder may jeopardize suppo~ and increase COMliCt iI3 ClOStT reHalioilships.l~~,““~~!“-”

Hn chronic disorders cbamcterized by pain, conflict may arise about the impact of the patient’s pain on others in the famiiy and also about the patient’s ways of expressing pain or coping with it.” If objective physical fmdings that corroborate the subjective expression of pain are absent, others may also question the legitimacy of the patient‘s pain compiaint.‘” Thus, patients -4th Taipei chronic disorders may have unique problems garnering appro- priate family support. The increased risk for depression posed by chronic pain S*sOmay be due in part to its effects on the patient’s close relationships.

Once ide~ti~ed, depression is a treatable disorder. The recommended treatments for chnicai depression are pharmacological and co~itive-beha~o~ and may require consufta- tion and referraLSI Most health-care providers, holvever, are able to provide adjunct&e coun- seling and teaching to support and sustain the emotional well-being of their patients with chronic painful disorders. In addition to pro- viding emotional support, providers may help patients and their families resolve misunder- standings about chronic pain or its manage- ment in daily life and increase the family’s ability to provide long-term support to the patient. Pain treatment centers, for example, often teach patients about pain and its manage- ment, the operant conditioning of pain behav- ior and patterns of expression, and assertive styles of interaction.

This study investigated the severity of chronic pain, responses of the significant other to the patient’s pain, and nenvork support and confhct for their contributions to depression among patients ‘with common chronic m~culoskele~ disorders. To investigate the effect of the presence or absence of objective findings that corroborate the report of pain, patients with myofascial pain disorders (MPDs) were con- trasted to those with pain from arthritis. MPDs are c&&ally diagnosed based on subjective reports of pain and the palpation of “tender” points or “trigger” points.s2~33 The diagnosis of arthritis, on the other hand, rests not only on subjective reports, but also on Iaboratory and ~~010~~~ evidence. The lack of objective findings has raised questions about both the

etiology and the appropriate dearest of .Q4 For this study, it was rized that

ict about pain and its man em would be associated with increases in depression re- gardless of the painful disorder. but that such conflict lvould be more common among MPD palely.

Patients were recruited from uni~e~i~-~~i- ated rhe~mato~o~ clinics, private rheumatol- ogy practices, and a community-based arthritis self-management course to participate in a structured telephone interview. Patients eligi- ble for the study (N = 185) lvere currently experiencing pain from MPDs or from rbeuma- toid arthritis or osteoarthritis (arthritis), as diagnosed by their rheumatologists. No patient had pain from any other type of acute or chronic disorder. Criteria for a diagnosis of chronic MPD were (a) diffuse and persistent muscular aching for 3 moues or more, (b) deep tenderness at localized sites (tender or trigger points), and (c) no obsenable laboratory or radio’iogic evidence of organic pathology. 52+ss Common MPD diagnoses in- cluded fibromyalgia and regional or trigger point myofascial pain syndromes. The arthritis diagnoses were based on abloom Iabomtory findings and evidence ofjoint inflammation or destruction.

A total I59 patients agreed to participate in the study. However, four prosided incomplete data, four were found to be ineligible at the time of the inteniew, and one was excluded because of severe bipolar disorder, leaving a total sample of 150 (MPD, N= 67; and arthritis, N= 83).

The sample was broadly representative of age and income, with the average respondent haying at feast some cohege education (Table 1). Women were more frequently represented than men, as is common for these types of rheumatic disorders. Arthritis patients were signi~cand~ older and better educated than MPD patients.

Measures

DC$WSSZ?W. Depression \vas measured using the 13item short form of the Beck Depression Inventory (BDI).ss The BDI has performed well

FOZ&%& vol. 9 NCX 8 Nov~b~ 1994

T&k? 1 Demographics of the Sample

Variables

MPD Arthritis Total N= 67 N= 83 N= 150

Mean (S@ Mean (sr>) Mean (SD)

Age “(years) 47.8 (12.0) 58.3 (13.5) 53.6 (13.8)

Education b(years) 13.8 (2.8) 14.8 (2.5) 14.4 (2.7)

Income ($l~s) 39.0 (31.4) 36.8 (25.5) 37.8 (28.2)

Gender (% women) 92% 82% 87%

MPD, myofascial pain disorders. vko.05. WO.O1.

in comparison with clinical examination for depression among patients with chronic pain.3637 The short form demonst~ted ade- quate reliability among the subjects of this study (o-coe@&xt = 0.86). Moderate depression is defined by scores between 4 and 8 and severe depression is defined by a score of 8 or more.s6

Pain. The McGill Pain Questionnaire (MPQ) was used to evaluate the patient’s recent pain severity.s* The main section of the MPQ consists of 20 clusters of adjectives, each comprising 3-6 pain descriptors ranked by intensity, Scale scores are obtained by adding the ranks of the adjectives selected by the patients. The total scale score (PRI) of the MPQ was used as the measure of pain for this study.

Social support and confiti. To gather data on the responses of a significant other to the patient’s pain, patients were asked to report on a spouse or other adult with whom they lived, or, if they lived alone, on an adult they felt close to, whom they saw frequently (preferably more than twice a week), and who they felt would help them if their chronic pain flared. All patients were able to report on the responses of a significant other to their pain.

Patients reported on the supportive re- sponses of the significant other to their pain using the Solicitous Responses subscale (six items) of the Multidimensional Pain Inventory (MPI) Fg Conflict with the significant other that was specifically related to the patient’s pain was evaluated using the MPI Punishing Responses subscale (four items). These two subscales are comprised of behavior-based items, such as

“Gets my pain medication for me,” “Brings me food and drink,” and “Gets angry with me,” that are endorsed as true or false by the respondent.

The availability of social support and the presence of conflict in the patient’s social network relationships were measured using the Support and Conflict subscales of the Interper- sonal Relationships Inventory (IPRI).40 Each subscale has 13 items such as “There is someone I can turn to for helpful advice about a problem,” “ Someone I care about stands by me through good times and bad times,” “There is tension between me and someone I care about,” and “Some people I care about are a burden to me.” Items are scored using a 5-point Likert scale.

The MPI and IPRI have both had extensive psychometric testing to establish their reliabil- ity and validity.sg~40 cL-Coefftcients for the MPI and IPRI measures of social support and conflict in this study ranged from 0.79 to 0.89.

The MPD and arthritis groups were com- pared, using Student’s t test, in terms of depression and pain severity, the responses of the significant other to pain, and network support and conflict. Data were also analyzed using multiple linear regression. In these analyses, depression was regressed hierarchi- cally on {a) the type of painful disorder fMPD vs arthritis), (b) pain severity, (c) the responses of the significant other to the patient’s pain, and (d) network support and conflict.

Descriptive information about the patients’ scores on the study scales is shown in Table 2. Depression, as well as pain scores, tended to be mild to moderate for this sample. Depression scores ranged from 0 to 22 (MPD, O-22; and arthritis, O-19) and pain scores ranged from 3 to 56 (MPD, 5-49; and arthritis, 3-56).

MPD patients reported signi~~ndy more severe depression and pain than arthritis patients (Table 2). They also reported a greater number of punishing responses from the significant other in response to their pain and more conflict from the social network in general. Social support from the network was also significantly lower for the MPD group.

Vol. 9 No. 8 Nouember 1994 Depression and Chronic Pain s. 5.23 -.--s_I

n+?w&x& (Beck Depression ~nveuto~)

Pain (McGill Pain Inventory)

Ffespoiws t5pain (M~ddi~e~sion~ Fain tovento~)

Solicitous responses

Punishing responses

Nelwwk &&ionrhzps (~nte~e~on~ ~e~ad~nships ~nvenco~}

sttpport

Conilict

em&? 2 83 (Nz 67) atId tis (N= 8%)

Natalie (scales)

MPD ArthritiS

Mean (SD) Mean (SD) F&n-Max M~n-.~~

7.6 (5.1) 4.9 (3.9) o-22 O-19

27.8 (9.8) 20.7 (Ia 5) !S-49 3-56

3.3 (1.7) 3.7 (1.4) 0.0-6.0 0.0-6.0 2.0 (2.0) 1.0 (1.0) 0.0-6.0 0.6-5.0

3.6 (0.8) 4.2 (0.6) 1.7-5-o 2.r;5.0

3.1 (0.8) 2.7 (0.6) 1.8-%8 1.2-4.3

_-

t value

3.w

4.08a

1.28

3.78”

2.w

2.99

MPD. myofascial pain disorders; and Min-Max, minimum and maximum scores.

The multiple regression model accounted After the type and severity of pain were for 35% (F= 12.86, PC 0.001) ofthe ~~a~~~ in controlled, the responses of the si~i~cant depression severity (Table 3). MPD was associ- other to pain additionally contributed signifi- ated with more severe depression than arthritis. candy to depression. This contribution was due After controlling for the type of painful disor- mainly to the unique sign~~a~t co~~ibutio~ der, however, more severe depression was of the punishing responses of the significant associated with more severe pain. Together, other to the patient’s pain. Network relation- tne type of painful disorder and the severitv of ships contributed an additional 11% toward the pain accounted for approximately half of ex~~a~~~~g the variance in depression, 6% of the explained variance in depression. which came from network support alone.

2X&? 3 Hiemrchicd Multiple Regression Arudyses of Depression (IV = 150)

Dependent variable: depression

Step 1: Trpe of disorder MPD vs arthritis

Degrees of freedom

1,148

Cum& R2

0.f.w

R‘J change

o.oaa

step

sr2 p weight

0.28

Step 2: Pain severity McGill Pain Questionnaire

Step 3: Responses to pain Solicitous responses Punishing responses

2,147 0.1F 0.W 0.32

4,145 0.24a 0.07a 0.01 -0.10 0.04= 0.23

Step 4: Network relationships support Conflict

6,143 0.35’1 rl.11” 0.06= -0.32 0.01 0.13

MPD, myofascial pain disorders; and s$, squared semipartial correlations. =Ro.61

524 Fu~tt

Intemction terms were entered at the final step of the regression equation, using the foward technique:tto determine whether the relationship between depression and punish- ing responses was modified by the type of painful disorder or by support from the network. Neither of these interaction terms proved to be significant, and both failed to enter the model.

Correlates of depression were investigated in a sample of patients with painful chronic musculoskeletal disorders that differ on the presence or absence of underlying organic pathology. Half of the explained variance of depression was accounted for by social relation- ship factors and half by illne~-related factors. The results suggest that depression severity is associated with the quality of the patient’s close relationships, regardless of the type of painful disorder or the severity of pain. Specifically, conflict with the si~i~cant other about pain and low overall support from the social net- work predicted more severe depression. Pa- tients with MPD, as compared to those with arthritis, may have an increased risk for depres- sion because of greater conflict with the significant other about pain and less social network support.

Patients reported moderate ‘depression on average. Patients with MPD, however, reported significantly more severe depression, more problems with their social relationships, and, in particular, more conflict with the significant other about pain. Family members’ responses to the patient who is in pain are likely to be influenced by their causal explanations of the patient’s pain behavior.27*4* If the responder finds reason to suspect the legitimacy of the patient’s pain complaint, pain behavior may be met with suspicion and anger instead of sympathy and support. 43 Such a situation may be more likely to exist for MPD patients than for arthritis patients, whose report of pain is frequently substantiated by observable inflam- mation and laboratory or radiological findings. Others have shown that chronic pain without accompanying organic pathology can lead to sti~ati~tion, greater dependence on family as other supporters withdraw, and eventual impairment of family relationships.*s Further-

more, previous work suggests that increases in conflict in general and negative responses to pain specifically are more likely to accompany increases in MPD pain than arthritis pain.*”

The association of pain-related conflict with depression suggests that assessment of and intervention for family misunderstandings about pain, pain expression, and coping with pain may be worthwhile, particularly for MPD patients. Interpersonal conflict has previously been found to contribute significantly to de- pression in arthritis. t7 The finding that pain- related conflict, but not network conflict, contributed significantly to depression in this study suggests that patients may need assistance to resolve illness-specific controversies with others. The finding that depression varied with network support, on the other hand, a finding replicated in the social support literature,“,” reaffirms the importance of determining the breadth of social resources available to patients with chronic medical disorders. Kerns and colleagues, for example, have argued that although pain-specific conflict with the spouse may be predictive of depression, the overall quality of support in a marriage establishes an important context. 44 Likewise, in a study of arthritis patients, the supportive aspects of close relationships tended to buffer the stress- ful or problematic aspects of those relation- ships.45

Although social relationships may affect depression, the alternative explanation that depression impairs social relationships, as well as amplifies the pain complaint, must be considered.4s Additionally, other investigators have argued for the overriding role of personal- ity in determining the likelihood of depression, the quality of social relationships, and the nature of the pain complaint.33+47 The investi- gation of causal relationships is not possible with the cross-sectional design of this study.

Arthritis and myofascial pain disorders pre- dominantly affect women, and the gender proportions of the sample reflected this bias. The relationship of pain-related conflict and social support to depression among patients with painful chronic disorders may differ with gender. Women, for example, receive more social support, are more likely to have close reladonships, and are generally more socially active.4R Women are also more prone to depression than men. In this study of a

Vol. 9 No. 8 Ahember 199G Depression and Chronic Pain 5.25

predominantly female sample, convict with others about pain made a significant contribu- tion to the severity of depression. In a study of men with chronic Ipain, the responses of others to pain also contributed significantly to the severity of depression, but only among men with low, in contrast to high, levels of instru- mental acti~ity.~~ ~~rthe~ore~ Zautra and colleagues have suggested that, for patients with rheumatoid arthritis, heightened estrogen and prolactin responsiveness may increase the association of conflict and depression with disease activity. I5 The in~~estigation of gender- related differences among patients wieh chronic pain will be ari important area for further research.

In summary, close relationships provide needed support for patients with chronic painful disorders. The findings from this study suggest that the responses of others to the patient’s pain may be influenced when the causes of pain are unexplained. Conflict about pain and low support from the social network in addition to pain severity may increase the risk for depression. The clinical assessment of patients with chronic pain may be enhanced by including a psychosocial history of the patient’s family and other close relationships.

Funding was provided by the National Center for Nursing Research-NE+ (T32-NR07034); the School of Nursing, Univ~rsi~ of ~ifornia, San Francisco; and the Arthritis Foundation. At the time of the study* the author was an NEZF Margaret Tyson Fellow and UC Kegents’ Fellow. The assistance of the following individuals, for their advice and help in finding study subjects, is sincerely appreciated: John Levine, MD, Kate Lorig, RN, Ch~stopher I.&sh, PhD, Kenneth Sack, MD, Paul Davidson, MD, Kenneth Fye, MD, Thomas Jamison, MD, Stephen Nimelstein, MD, and ~i~iarn Seaman, MD.

1. Cavanaugh S. Diagnosing depression in the hospitalized patient with chronic medical illness. J Clin Psychiatry 1984;45:13-16.

2. Wells KB, Stewart A, Hays RI), Buram MA, et al. The functioning and well-being of depressed pa- tien?s. JAMA 1989;262:914-919.

3. Aflleck C, ~fei~~~r C, Tenneco viscid J. Social support and psychosocial adjustme& to rb~umatoid arthritis: quantitative and qualitative findil,g. or_ thritis Care Res 1988;1:71-77.

4. Newman SP, Fitzpatrick R, Lamb R Shipley aa. The origins of depressed mood in rheumatoid arthritis. J ~eunlato~ 198~~~749-744.

5. htrkk E)k., Morgan MI, Charlton JRH. Fsychoso- cial support and change in the health status of physically disabled people. Sot Sci Med 1986;22: 1347-1354.

6. Turner RJ, Nob S. Physical disability and depres sion: a longitudinal analysis. J Health Sot B&m 1988;29:2%37.

7. Stewart MJ. Social support intervention studies: a review and prospectus of nursing contributions. Int

J Nurs Stud 1989;26:93-114.

8. Tilden VP, Weinert C. Social support and the chronically ill individual. Nurs Gin North Am 198~2~61~20.

9. Kieholt-Glaser JK, Dyer CS, Shuttleworth EC. Upsetting social interactions and distress among Alzheimer’s disease family caregivers: a replication and extension. Am J Community Psycho1 1988; 16332~837.

10. Page1 MD, Erdly Ww, Becker J. Social networks: we get by with (and in spite of) a little help from our friends. J Fers Sot Psycho1 1987;53:793-804.

i 1. Rook KS. The negative side of social interaction: impact on psychological well-being. J Pers Sot Psycho1 1984;~1097-1108.

12, Schuster TL, Kessler RC, Aseltine RH. Supportive inte~ctions, negative interactions, and depressed mood. Am J Community Psycho1 1990;18:42%438.

13. Primomo J, Yates BC, Woods NF. Social support for women during chronic illness: the relationship among sources and types to adjustment. Res Nurs Wealth ~990;1~15~161.

14. Anderson LP, Rehm LP. The relationship between strategies of coping and perception of pain in three chronic pain groups. J Clin Psycho1 1984; 4&l 170-l 177.

15. Faucett JA, L.evine JD. The contributions of interpersonal conflict to chronic pain in the pres- ence or absence of organic pathology. Pain 1991; 44:35-43.

16. Lin N, Woelfel MW, Light SC. The buffering effect of social support subsequent to an important life event. J Health Sot Behav 1985;26:247-263.

17. Zautra AJ, Burleson MH, Watt KS, Roth S, Burrows LB. Interpersonal stress, depression, and disease activity in arthritis Health Psycho1 199* l&l-10.

18. Brown CW, Harris T. Social origiats of depres sion: a study of psychiatric disorder in rvomen. London: Tavistock, 1978.

19. fitw& E, Szelenyi I. Primary ~TOUP StmctureS and && functions: kin, neighbors, and friends. Am Social Rev 1969;34:465-481.

20. Manne SL, Zautra AJ. Couples coping with chronic illness: women with rheumatoid arthritis and their healthy husbands. J Behav Med 199% 13:327-342.

21. Kerns RD, Turk DC. Depression and chronic pain: the mediating role of the spouse. J Marriage 1984;46:845-852.

22. Waltz M, Badura B, Pfaff H, Schott T Marriage and the psychological consequences of a heart attack: a longitudinal study of adaptation to chronic illness after 3 years, Sot Sci Med 1988;27:149-158.

23. Corbin JM, Strauss A. Unending work and care: rn~a~ng chronic illness at home. San Francisco: Jossey-Bass, 1988.

24. Grant I, Patterson TL, Yager J. Social supports in relation to physical health and symptoms of depres- sion in the elderly. Am J Psychiatry 1988;145:1254- 1257.

25. Dura JR, Beck SJ. A comparison of family functioning when mothers have chronic pain. Pain 1988;35:79-89.

26. Fitzpatrick R, Newman S, Lamb R, Shipley M. Social reladonships and p~cholo~cal well-being in rheumatoid arthritis. Sot Sci Med 1988;27:399-403.

27. Rowat KM, Knafl K Living with chronic pain: the spouse’s perspective. Pain 1985;25:25Q-271.

28. Iennon MC, Link BG, Mar~ch JJ, Dohrenwend BP. The stigma of chronic facial pain and its impact on social relationships. Sot Probl 1989,36:117-134.

29. Anderson KO, Bradley LA, Young LD, McDaniel LK, Wise CM. Rheumatoid arthritis: review of psychological factors related to etiology, effects, and treatment. Psycho1 Bull 198~9~35~387.

30. Roman0 JM, Turner JA. Chronic pain and depression: does the evidence support a relation- ship? Psycho1 Bull 1985;97:1&34.

31. Depression Guideline Panel. Depression in primary care. US Pub1 930550. Washington, DC: Department of Health and Human Services, Agency for Health Care Policy and Reform, 1993.

32. Simons DG. Myofascial pain syndromes due to trigger points. In: Osterweis M, Kleinman A, Me- chanic D, eds. Pain and disability, Washington, DC: National Academy, 1987.

33. Smythe HA. “Fibrositis” and other diffuse muscu- loskeletal syndromes. in: Kelley WN, Harris ED Jr, Ruddy S, Sledge CB, eds. Textbook of rheumatology, 2nd ed. PhiIadelphia: WB Saunders, 1985.

34. Potts MK, Silverman SL. The importance of aspects of treatment for flbromyalgia (flbrositis): differences be?.veen patient and physician views. Arthritis Care Res 1990;3:1 l-18.

35. Beck AT, Beck RW. Screening depressed patients in family practice: a rapid technique. Postgrad Med J 1972;52:81-85.

36. Turner JA, Roman0 JM. Self-report screening measures for depression in chronic pain patients. J Clin Psycho1 1984;40:909--913,

37. Gold+rg GM, Kerns RD, Rosenberg R. Pain- relevant support as a buffer from depression among chronic pain patients low in instrumental activity. Clin J Pain 1993;9:34-40.

38. Melzack R. The McGill pain questionnaire. In: Melzack R, ed. Pain measurement and assessment. New York: Raven, 1983.

39. Kerns PD, Turk DC, Rudy TE. The West Haven-Yale multidimensional pain inventory (WHYMPI) . Pain 1984;23:345-356.

40. Tilden VP, Nelson CA, May BA. The IPR Inventoty: development and psychometric charac- teristics. Nurs Res 1990;39:337-343.

41. Munro BH, Visintainer MA, Page EB. Statistical methods for health care research, Philadelphia: JB Lippincott, 1986,

42. Taylor AG, Skeleton JA, Butcher J. Duration of pain condition and physical pathology as determi- nants of nurses’ assessments of patients in pain, Nurs Res 1984;33:4-8.

43. Reid J, Ewan C, Lowy E. Pilgrimage of pain: the illness experiences of women with repetition strain injury and the search for credibility. Sot Sci Med 1991;32:601-612.

44. Kerns RD, Haythorn~w~te JA, Southwick S, Giller EL. The role of marital interaction in chronic pain and depressive symptom severity. J Psychosom Res 1990;34:401-408.

45. Revenson TA, Schiaffmo KM, Majerovitz SD, Gibofsky A. Social support as a double~dged sword: the relation of positive and problematic support to depression among rheumatoid arthritis patients. Sot Sci Med 1991;33:807-813.

46. Coyne JC. Depression and the responses of others. J Abnorm Psycho1 197~8~:18~193.

47. Henderson S, Byrne DG, Duncan-Jones P. Neurosis and the social environment. New York: Academic, 1981.

48. Vaux A. Variations in social supoort associated with gender, ethnic&y, and age. J %c Issues 1985; 41:89-110.