A Case–Control Study of Social Risk Factors for Depression in American Patients

Alec Roy, MD¹

Objective: To describe the social risk factors for depression and their interaction with recent life events in depressed American patients.

Methods: Forty patients with a major depressive episode were compared with 40 normal controls. Risk factors for depression were assessed, recent life events recorded, and their interaction examined.

Results: Significantly more depressed patients than controls had a poor marriage before the onset of depression and were unemployed. The depressed patients had also recently experienced significantly more life events. The only significant interaction was that employed depressed patients had experienced more recent life events than unemployed depressed patients.

Conclusion: In addition to recent life events, having a poor marriage and being unemployed may be social risk factors for depression in American patients.

(Can J Psychiatry 1997;42:307–309)

Key Words: depression, risk factors, Americans

Brown and Harris (1) described 4 vulnerability factors for depression: lack of full-time or part-time employment, a poor marital relationship, parental loss before 17 years of age, and having 3 or more children under 14 years of age at home. English and Canadian clinical studies also found that these risk factors were present significantly more often among depressed patients than controls (2–7). To date, however, no clinical study has examined these risk factors—and their interaction with life events—among depressed American patients.

Methods

A consecutive series of 40 white American depressed patients, 30 inpatients and 10 outpatients, meeting DSM-III-R criteria for a major depressive episode (MDE) was examined. Excluded from the study were depressed patients with any other major Axis I psychiatric disorder other than phobic or anxiety disorder. A consecutive series of 40 white American normal controls was recruited. Controls were inter- viewed with the Schedule for Affective Disorders and Schizophrenia—Lifetime version (SADS-L) (8) and were without past or current Axis I psychiatric disorder. All subjects were interviewed about risk factors and life events using previously reported methods (5,7). Most of these life event data have been reported previously (5) and are included here to examine for interactions with risk factors. In the statistical analysis, 2-tailed Fisher’s exact and Student’s t tests were used. Hypotheses assessing group differences with interactions between life events and risk factors were assessed using within-risk-factor Student t tests.

Results

There were no significant differences between depressed patients and controls for sex, marital status, social class, or age (Table 1). The depressed patients had a mean Hamilton Depression Rating Scale score of 23.9 ± 6.7, mean Beck Depression Inventory score of 31.5 ± 10.7, and mean duration of depression of 7.2 ± 5.8 months.

Risk Factors

Significantly more depressed patients than controls had a poor marriage in the year before the onset of depression (P < 0.0001) and were unemployed at the onset of depression (P < 0.03) (Table 2).

Life Events and Their Interaction

Depressed patients had experienced significantly more recent life events (t = 2.22, df 78, P < 0.03) (see Table 2) and had a higher undesirable life event score (mean 0.30 ± 0.51 versus 0.10 ± 0.30, t = 2.11, df 78, P < 0.04) than controls. The only significant interaction was that employed depressed patients (n = 23) had recently experienced significantly more life events than unemployed depressed patients (n = 17) (mean 2.00 ± 1.16 versus 0.94 ± 1.20, t = 2.80, df 38, P = 0.008).

Discussion

There were significant differences for 2 of the 4 risk factors: having a poor marriage before the onset of depression and being unemployed. The depressed patients had also experienced significantly more life events in the 6 months before the onset of depression. The same pattern of results was found when either depressed women or men were compared with women or men in the control group.

A poor marriage before the onset of depression has been well documented as a risk factor for depression (1,9–16). In the present study, there were no significant differences for either poor marriage or unemployment between patients with 0 to 1 previous episode and those with 2 or more previous episodes, and no married patient had a previous episode during the year before the index episode. A poor marriage rating, therefore, did not appear to be directly due to the deleterious effects of past depression.

Community studies have also reported an association between unemployment and lower levels of psychological well-being and depression (1,17–22). Unemployment may increase the chance of having interpersonal difficulties (23) and a poor marriage (24). In the present study, however, the only significant interaction between life events and risk factors was that employed depressed patients had experienced significantly more life events before the onset of depression than unemployed depressed patients. This suggests the possibility that more antecedent stress may be needed to precipitate depression in an employed individual than in an unemployed individual.

Acknowledgement

Thanks are due to Haftan Eckholdt, PhD, for statistical help.

References

1. Brown G, Harris T. Social origins of depression. London: Tavistock; 1978.

2. Roy A. Vulnerability factors and depression in women. Br J Psychiatry 1978;133:106–10.

3. Roy A. Vulnerability factors and depression in men. Br J Psychiatry 1981;138:75–7.

4. Roy A. Risk factors for depression in Canadian women. J Affect Disord 1981;3:65–70.

5. Roy A, Breier A, Doran A, Pickar D. Life events in depression. J Affect Disord 1985;9:143–8.

6. Roy A. Early permanent separation and adult depression. Arch Gen Psychiatry 1985;42:987–91.

7. Roy A. Five risk factors for depression. Br J Psychiatry 1987;150:536–41.

8. Endicott J, Spitzer R. A diagnostic interview—the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1979;35:837–44.

9. Waring E, Patton E. Marital intimacy and depression. Br J Psychiatry 1984;145:641–4.

10. Goering P, Wasylenki D, Lancee W, Freeman SJJ. Social support and post hospital outcome for depressed women. Can J Psychiatry 1983;28:612–7.

11. Weissman M, Paykel E. The depressed women: a study of social relationships. Chicago: University of Chicago Press; 1974.

12. Leaf F, Weissman M, Myers J, Holzer C, Tischler G. Psychosocial risks and correlates of major depression in one United States urban community. In: Barrett J, Rose R, editors. Mental disorder in the community: progress and challenge. New York: Guilford; 1986. p 47–73.

13. Weissman M. Advances in psychiatric epidemiology: rates and risks for major depression. Am J Public Health 1987;77:445–51.

14. Hickie L, Wilhelm K, Parker G, Boyce P, Hadzi-Pavlovic D, Brodaty H, and others. Perceived dysfunctional intimate relationships: a specific association with the non-melancholic depressive subtype. J Affect Disord 1991;19:99–107.

15. Birtchnell J. Negative modes of relating, marital quality and depression. Br J Psychiatry 1991;158:648–57.

16. Roy A, Kennedy S. Risk factors for depression in Canadians. Can J Psychiatry 1984;29:11–3.

17. Jahoda M. Work, employment and unemployment: a social psychological analysis. Cambridge (UK): Cambridge University Press; 1982.

18. Beiser M, Johnson P, Turner J. Unemployment, underemployment and depressive affect among Southeast Asian refugees. Psychol Med 1993;23:731–43.

19. Shams J, Jackson P. The impact of unemployment on the psychological well-being of British Asians. Psychol Med 1994;24:347–55.

20. Eales M. Depression and anxiety in unemployed men. Psychol Med 1988;18:935–45.

21. Dew M, Bromet E, Penkower L. Mental health effects of job loss in women. Psychol Med 1992;22:751–64.

22. Weissman M, Bruce M, Leaf P, Florio L, Holzer C. Affective disorders. In: Robins L, Regier D, editors. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: Free Press; 1991. p 53–80.

23. Warr P. Twelve questions about unemployment and health. In: Roberts B, Finnegan R, Gallie D, editors. New approaches to economic life. Manchester (UK): Manchester University Press; 1987. p 302–18.

24. McKee L, Bell C. Marital and family relations in times of male unemployment. In: Roberts B, Finnegan R, Gallie D, editors. New approaches to economic life. Manchester (UK): Manchester University Press; 1985. p 387–99.

Résumé

Objectif : Décrire les facteurs de risque social de dépression et leur interaction avec des événements récents de la vie de patients américains.

Méthodes : Quarante patients ayant subi un épisode de dépression majeure ont été comparés à 40 sujets témoins normaux. On a évalué les facteurs de risque de dépression, enregistré les événements de la vie et examiné leur interaction.

Résultats : Beaucoup plus de patients déprimés que de sujets témoins vivaient un mariage insatisfaisant avant le début de la dépression et étaient en chômage. Les patients déprimés venaient aussi de vivre beaucoup plus d’événements marquants que les sujets témoins. La seule interaction significative tenait au fait que les patients déprimés ayant un emploi venaient de vivre davantage d’événements marquants que les patients déprimés en chômage.

Conclusion : En plus des événements récents de la vie, un mariage insatisfaisant et le chômage peuvent constituer des facteurs de risque social de dépression chez les patients américains.

Manuscript received June 1996, revised January 1997.

¹Department of Psychiatry, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey.

Address for correspondence: Dr A Roy, Department of Veterans Affairs, Medical Center, 385 Tremont Avenue, East Orange, NJ 07018-1095 USA

Can J Psychiatry, Vol 42, April 1997