Interpersonal dysfunction in depressed women: impairments independent of depressive symptoms

Abstract

Background: The study explored the generality of interpersonal impairments in depressed women and examined the extent of their independence of current depressive episodes or symptoms. Methods: 812 community women who were formerly depressed, currently depressed, or never depressed were compared on a variety of indices of interpersonal behavior and beliefs. Information was also obtained from their spouses, adolescent children, and raters. Current depressive mood and sociodemographic factors that might affect social functioning were controlled. Results: Consistent with the hypotheses that interpersonal difficulties are not just consequences of depressive symptoms, formerly but not currently depressed women were significantly more impaired than never-depressed women on nearly all measures. They were less likely to be stably married, had poorer marital satisfaction, reported more spouse coercion and physical injury, had more problematic relationships with their child, friends, and extended family, reported more stressful life events with interpersonal and conflict content, and were more insecure in their beliefs about other people. Their spouses and boyfriends also reported more problems, and were themselves more likely to have diagnosable disorders. However, the groups did not differ in their children’s perceptions of maternal warmth or hostility. Limitations: The cross-sectional design precluded conclusions about the causal direction of the relationship between interpersonal impairment and depressive disorder. Since clinical depression is more often than not followed by subthreshold symptoms that are not captured by standard diagnostic instruments, such symptoms are not easily discernable from preceding or co-existing interpersonal problems. Only women were studied. Conclusions: Interpersonal impairment is a stable feature of depression, a significant challenge to treatment, and may reflect underlying vulnerability to the onset, and recurrence, of depressive experiences.

Introduction

The interpersonal functioning of depressed individuals has often been observed to be impaired, associated with marital conflict and divorce, and problems in parent–child interactions. Overall, the social impact of depression on the person and others is enormous, and treatments may have paid inadequate attention to interpersonal dysfunction in depression (Hirschfeld et al., 2000). Increased scrutiny of interpersonal functioning in depressed individuals is warranted for several reasons. The interpersonal difficulties may be persistent, and recover more slowly than symptom changes (e.g. Tweed, 1993). Such difficulties may contribute to the recurrence of depressive episodes, and may in fact reflect underlying vulnerability factors portending risk for depression (Joiner and Coyne, 1999). Moreover, they may represent one of the mechanisms of intergenerational transmission of depression (Hammen and Brennan, 2001).

One of the first systematic studies of the lives of depressed individuals, Weissman and Paykel’s (1974) book, The Depressed Woman: A Study of Social Relationships, reported that depressed women commonly have problematic marital and family relationships that persist even when the women are not experiencing depressive episodes (see also Billings and Moos, 1985, Hammen, 1991a, Keitner and Miller, 1990). Subsequent studies have increasingly identified social difficulties in the lives of depressed people, including divorce, marital disruption, and negative partner interactions (reviewed in Gotlib and Hammen, 1992, Rao et al., 1999). Recent studies of clinical and community samples have documented self-perceived social impairment among depressed people (e.g. Evans et al., 1996, Tweed, 1993, Zlotnick et al., 2000). Moreover, there has been an increasing emphasis on interpersonal functioning as a possible vulnerability factor in initial and recurrent depression. For instance, it has been shown that depressed individuals interact maladaptively with others in ways that contribute to the occurrence of interpersonal stressful life events, that in turn may precipitate further depression (Davila et al., 1995, Hammen, 1991b). Occurrence of such stressors suggests impaired interpersonal skills and dysfunctional cognitions that reflect poor interpersonal problem-solving. Depressed people are often dependent on others, and seek reassurance in ways that distance others (Barnett and Gotlib, 1988, Joiner and Metalsky, 1995). They may often overvalue relationships as sources of self-worth, but may also have acquired negative beliefs about the availability and trustworthiness of others (Beck, 1983, Bowlby, 1980).

An additional area of intense study has been the possible role of the quality of relationships between depressed mothers and their children as a contributor to the intergenerational transmission of depression. Dysfunctional interactions between depressed mothers and their infants, toddlers, and school-age children have been extensively documented (reviewed in Cummings and Davies, 1994, Downey and Coyne, 1990, Kaslow et al., 1994). Lyons-Ruth (1995) observed that in view of the apparent role of dysfunctional parenting and marital problems among depressed women, perhaps it is not depression as such that causes children’s negative outcomes. Rather, as she speculated, perhaps the mechanism is ‘relational pathology.’

For all of these reasons, it is important to shed further light on issues about interpersonal functioning among depressed individuals. However, there are several conceptual and methodological issues that obscure conclusions about the meaning of results reported to date. One of the unresolved issues is the extent to which social impairments are mood-dependent or whether they are relatively stable features of the individual. The vast majority of studies of social functioning of depressed individuals have focused on currently depressed people, whose symptoms would be expected to impair their adjustment in all major roles, including interpersonal. Most of the research demonstrating enduring interpersonal difficulties implies that interpersonal dysfunctions are slower to resolve than depressive symptoms, but that individuals will return to a normal baseline. Or, studies have reported that ‘residual’ impairments could be related to continuing mild depressive symptoms, but presented analyses that have not controlled for the effects of persisting symptoms. Therefore, it is important to determine whether the interpersonal difficulties are independent of symptoms, examining social functioning during periods of remission and including control for current subsyndromal depressive symptoms.

Another unresolved issue concerns the nature of the interpersonal dysfunction—whether it is specific or general—e.g. whether it applies to relationships with spouses and children, or whether it is more general, and whether it includes both cognitions about relationships and actual behaviors. A related methodological shortcoming of most prior research is that studies have generally been based exclusively on self-report with the potentially biasing effect of current mood (e.g. Evans et al., 1996, Hirschfeld et al., 2000). More research is needed in which functioning measures include interviewer ratings and reports by other observers such as family members. Also, much of the previous research has been based on patient samples that are likely to be more impaired and less representative of depressive disorders as a whole (e.g. Miller et al., 2000). It would be useful to study community samples whose diagnoses and personal circumstances may reflect major depression and dysthymic disorder as they are more commonly represented.

The purpose of the present study, therefore, is to describe a variety of indicators of interpersonal functioning and social characteristics of depressed women, including both currently and formerly depressed, compared with women who have never been depressed. Additionally, the study addresses a number of the methodological limitations of some prior studies: use of a community sample, control for subclinical depressive symptoms as well as sociodemographic factors that might affect social functioning (family income and maternal educational attainment), and inclusion diverse informants—self, interviewer, spouse, and child. Assessments includes multiple measures across various relationships: marital functioning, relationships with spouse, child, friends, and extended family, as well as interpersonal life events, and interpersonal cognitions (attachment beliefs and expectations, and self-reported symptoms of two dimensions of personality pathology often noted for particularly problematic relationships, dependent and borderline personality disorder). We also present diagnostic evaluations of the husbands based on direct clinical interviews. The sample is restricted to women whose ‘target’ child is 15 years old, in order to reduce sample variability in terms of contextual factors.

Consistent with a model of ‘relational pathology’model of depression, we hypothesize that depression is associated with stable and generalized interpersonal impairments affecting interpersonal behaviors and cognitions. We specifically predict that even when current subclinical symptoms are controlled, formerly (but not currently) depressed women will show more impairment on interpersonal functioning variables compared with never-depressed women. We predict that the impairments will encompass relationships with the child, spouse/partner, friends, and extended family, that women with histories of depressive disorders will have higher rates of interpersonal conflicts reflecting relatively dysfunctional interpersonal conflict resolution skills and relationship representations. Furthermore, we predict that the spouses/partners of depressed women will have higher rates of diagnosable disorders than spouses/partners of nondepressed women.