Everyone knows that everyday unhappiness can be brought about by stressful experiences. But there is also substantial evidence that such adversity may at times result in clinically significant anxiety and depression. In this editorial we summarize the evidence for this link in relation to depression. Although much of what we describe comes from research with women, the general principles appear to apply to both sexes.
Women have been studied largely because of a consistent finding that they are 2-3 times more likely than men to experience depression in their lifetime Interestingly; this excess emerges at puberty and largely disappears after the menopause. It has been suggested that this may reflect biological differences, particularly involving the sex hormones, but puberty is not a discrete event and major psychological and social changes occur at the same time, clouding the simple biological interpretation. For example, the prevalence is greatest at the time in a woman’s life where she is most involved in caring for pre-school children and it may be this, rather than age itself, that accounts for the age-related trend among women.
In addition to female sex, national surveys have consistently identified a number of demographic factors linked to depression. For example, higher rates among financially and educationally disadvantaged populations, living in the inner city and being separated or divorced. Married men appear to do better than single men without children and vice versa for women. Lone mothers are especially vulnerable. But interesting as these observations are, they do not really explain what it is about the social environment that is ‘toxic’ or why only some of the people with these broad characteristics should become depressed.
The first and most obvious explanation is that clinical depression might be precipitated by particularly severe stressful experiences. There is considerable evidence to support this notion. Both discrete life events above a certain severity of unpleasantness, and ongoing difficulties of a similar severity have been shown to be more common in the year before onset. Further studies have refined these early observations and shown that depression is more likely following particular classes of experience – those involving disruption, losses and experiences of humiliation or entrapment. It has also been shown that some of these types of experience (e.g. children becoming involved in crime or drug dealing) are particularly common in inner-cities and may partially explain the greater prevalence of depression in these settings.
It is clear however, that while adversity may be a necessary condition for the precipitation of depression, it is seldom a wholly sufficient cause. Many people who experience the most appalling adversity do not develop depression and this suggests that there must be other factors operating that make some people more vulnerable to adversity than others. A strong candidate for such an effect is social support, long seen as providing an important buffering effect against the impact of unpleasant experience. It has emerged that women both express a greater need for emotional support than men and find it less often from their marital partners.
Reflections on the mechanism by which emotional support from the environment could have an impact on an individual’s mood state has also led to investigations of the links between such support and more psychological features of people vulnerable to depression - such as their ongoing levels of self-esteem, their way of appraising their stressful experiences, and with more or less negative automatic thoughts than normal and their other coping skills; such as problem-solving and looking on the bright side of life or rumination and feeling out of place and alientated. The links go in both directions: emotional support with confiding can improve someone’s coping skills and self-esteem, but if coping and self-esteem are too low initially a person may not risk confiding in anyone and will therefore remain without support.
Social Impacts that are linked to remission and recovery are largely a mirror-image of those implicated in onset. So, for example, recovery is more likely to occur following life events that bring fresh hope or which reduce chronic difficulties. Similarly, the presence of ongoing emotional support contributes to remission. These observations lead on naturally to a consideration of psychosocial interventions based on this causal model. There have now been a number of studies, most of which have built upon the notion of the provision of support. This may be provided through regular meetings with a group of individuals with similar issues to solve (e.g. groups of new mothers at risk of postnatal depression have proved relatively successful) or may involve meetings on a one-to-one basis only, which perhaps give greater scope for the development of the kind of intimate trust required for emotional support to be effective. This second type of intervention is the essence of volunteer befriending. Some organizations combine group and one to-one principles Some extremely persuasive evaluations of these interventions have been reported though the scale of the effort so far has been slight when compared to the investment in pharmacological therapy.
Tags: Depression pre school children psychological and social changes sex hormones
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