Gender-specific mechanisms associated with outcome of depression: perception of emotions, coping and interpersonal functioning
Introduction
Early-developing capacities for social perception (i.e. inferring feelings and tendencies from others' behaviour) are important for promoting personal relatedness and for establishing the developmental pathways that lead to interpersonal understanding (see Hobson, 1993). Interactional synchrony and coordination seem important prerequisites to establish these pathways to interpersonal relationships (Fogel, 1993). Coordination refers to the reciprocal and mutual behavioural exchange of infants and care-givers. The perception and interpretation of facial signals form an integrated part of this coordination. The face both expresses emotional states and regulates others' behaviour.
There is convincing evidence that the ability to recognize facial expressions of basic emotions such as happiness, surprise, fear, anger and sadness is universal and innate in humans (Darwin, 1965; Ekman, 1992). Therefore, humans, as all animals, have innately determined perceptual-affective sensibilities towards the behaviour of others (for more arguments, see Cappella, 1991). Studies on the interaction between care-givers and infants suggest that high levels of non-verbal coordination are related to secure attachment (Isabella et al., 1989; Isabella and Belsky, 1991). Attachment is considered a basic and biologically necessary aspect of human nature. Many studies support the suggestion that insecure attachment in early life may underlie later depression (Bowlby, 1969, Bowlby, 1981; Gotlib, 1992; Hammen et al., 1995; Main, 1996): children who have experienced insecure attachment in early life are assumed to develop `working models' (Bowlby, 1969, Bowlby, 1981) or negative cognitive `schemas' (Beck et al., 1979). These negative cognitions may form a risk (possibly via interpersonal behaviour) to later depression (Crowell et al., 1991; Gotlib and Hammen, 1992; Segal et al., 1996).
Some theories on the development and maintenance of depression have integrated cognitive and interpersonal aspects of depression (e.g. Gotlib and Hammen, 1992). It has been argued that the depression-prone person's perception of how (significant) others behave and express emotions may be relevant for both the onset and persistence of depression (McCann and Lalonde, 1993). Maladaptive cognitions about self and others and ineffective coping strategies are presumed to contribute to the occurrence of stressful events and circumstances. These are assumed to trigger depressive reactions (Hammen, 1992).
Several studies of healthy subjects support the notion that the appreciation of non-verbal signals affects interpersonal processes. Interactions between two persons who both correctly interpret non-verbal behaviours are experienced as more meaningful and are accompanied by more mutual support and emotional sharing (Hodgins and Zuckerman, 1990; Hall et al., 1995). Moreover, non-verbal decoding ability is related to better adjustment between marriage partners (Noller, 1981). People with low decoding ability are viewed as less warm, sympathetic and open than people with high decoding ability (Funder and Harris, 1986). In this reasoning, a depressed patient's impaired perception of others would be expected to generate interpersonal stress.
Although findings are not entirely consistent, adult depressed patients seem to show an impaired ability to decode facial expressions (Gur et al., 1992; Rubinow and Post, 1992; Mikhailova et al., 1996) and a decreased sensitivity to emotion-related stimuli compared with controls (Wexler et al., 1994). Apart from this impaired sensitivity to social signals, which may hamper normal interactions, depressed patients may also have a negative bias in the judgement of facial expressions (Mandal and Palchoudhury, 1985; Gur et al., 1992; Rubinow and Post, 1992). Moreover, we found that high levels of perception of negative facial expressions at admission were associated with poor outcome of depression (Geerts and Bouhuys, 1998). Hence, decoding abilities are biologically based, grounded in early experience and linked to (the etiology of) depression. Furthermore, decoding deficits are presumed to affect interpersonal relationships and to affect coping with (interpersonal) stressful events. The aim of the present study is to focus on these variables as vulnerability markers of depression maintenance.
Depression shows a 2:1 female predominance (Weissman and Klerman, 1977; Paykel, 1991). Surprisingly little attention has been devoted to possible gender differences in (cognitive) mechanisms that may underlie the development and maintenance of depression. Some authors have postulated that women and men follow different pathways to the development and maintenance of depression, with cognitive factors being more implicated in depression for women than for men (Teasdale, 1988; Nolen-Hoeksema, 1990; Butler and Nolen-Hoeksema, 1994). Furthermore, evidence exists that women and men differ in cognitive processing of non-verbal signals. Overall, women are more accurate and sensitive decoders than men (Hall, 1978; Mufson and Nowicki, 1991). Apart from these possible gender differences in information processing, some authors report that women and men may differ in coping strategies and interpersonal functioning. Gender differences have been demonstrated in styles of responding to or coping with depressed mood: women are more likely than men to ruminatively self-focus when depressed, a response style that maintains and exacerbates the depressed mood (Bruder-Mattson and Hovanitz, 1990; Nolen-Hoeksema, 1990). In addition, women seem more likely than men to attribute their depression to interpersonal problems (Robbins and Tanck, 1991; Spangler et al., 1996). Therefore, our investigation of vulnerability to persistent depression will take gender differences into account.
Above we argued that decoding of emotions may be a very basic ability. Deficits in this ability may hamper coping strategies and interpersonal processes. We hypothesize that a negative bias in decoding of emotional expressions may help determine the risk of depression persistence, via a negative influence on coping and interpersonal functioning. We investigate three related hypotheses.
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Hypothesis 1: Whether cognitions determine how coping and interpersonal functioning are linked to depression outcome. In specific, high levels of perception of negative emotions may modify the putative associations between deficient coping and interpersonal functioning at admission, on the one hand, and poor outcome of depression, on the other hand.
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Hypothesis 2: Whether the relation between cognitions and depression outcome can be explained by coping and/or social functioning. More specifically, high levels of perception of negative emotions may predict later poor outcome of depression through the mediating role of deficient coping strategies and/or interpersonal functioning.
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Hypothesis 3: Whether deficient coping and/or interpersonal functioning and high levels of perception of negative emotions are independently related to poor outcome.
Furthermore, we hypothesize that decoding abilities, coping strategies and interpersonal functioning are more likely to contribute to the prediction of depression outcome in women than in men.
Section snippets
Subjects and design
Sixty patients with major depression (DSM-IV; American Psychiatric Association, 1994) were studied at admission to an in-patient clinic (T0) and 6 weeks after admission (T1). Patients were included after they had given informed consent and had an initial severity of depression of at least 17 on the Beck Depression Inventory (BDI; Beck et al., 1961) and 16 on the 21-item Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967; mean of two independent external raters). The group of 60 patients
Patient characteristics
The average depression scores of the whole group at admission were 25.3 (S.D.=5.3; range=16.5–37.5) on the HRSD and 32.7 (S.D.=9.9; range=18–58) on the BDI. At admission, the BDI score of the 40 women was 34.9 (S.D.=9.5) and differed significantly from that of the men: 28.2 (S.D.=9.4) (analysis of variance: F=6.76, d.f.=1,58, P=0.012). The HRSD score at admission was 26.3 (S.D.=4.7) for the women compared with 23.5 (S.D.=6.0) for the men — a difference that approached significance (analysis of
Main findings
We hypothesized that perception of facial emotions, coping strategies, and interpersonal processes would be more likely to contribute to the prediction of outcome of depression among women than among men. The results confirmed this hypothesis. In contrast to men, women who were initially inclined to perceive high levels of negative emotions in schematic ambiguous facial expressions were more likely to show a less favourable outcome of depression 6 weeks later. In addition, women who reported
Acknowledgements
This research was supported by a VWS grant 92-47. The authors are very grateful to Henk Korte, Louise Dols, Gerda Bloem and Jaap Jansen for their assistance in data collection and registration.
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