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- SUBJECTS AND METHODS
People with rheumatoid arthritis (RA) are at risk for experiencing depressive symptoms (1–3). Understanding factors that may benefit psychological adjustment of individuals with RA is critical to developing interventions that may prevent depression. Social support may be particularly significant in adjustment to RA given the limitations that physical disability may create for both informal social contacts and intimate relationships with family members (4, 5). Social support has been found to have beneficial effects on both physical health and psychological well being of individuals coping with chronic illness (6–9), and has specifically been found to minimize the effects of physical limitations resulting from RA on psychological adjustment (10–14).
Social support is a complex construct that has been defined and measured in a variety of ways. Distinctions have been made concerning the functional aspects of support (e.g., emotional, instrumental, or informational support), the structural aspects of support (e.g., size of social networks, diffuse versus intimate relationships), and the adequacy of support (e.g., amount of support received, perceived availability of support, satisfaction with support) (6, 7, 15, 16). Social support measures are often composite in nature (13, 17, 18), limiting the interpretations that can be made about the specific impact of different support functions on adjustment. When distinctions are made, research suggests that emotional support may be more strongly associated with depression and well being than instrumental support (11, 14), and satisfaction with support is consistently found to be more strongly associated with psychological well being than amount of support received or perceived availability of support (12, 13, 19).
Although consistently associated with adjustment, support measures have been consistently unrelated to health status measures or disease severity (10, 12–14, 19). However, research indicates that social support moderates the impact of disease severity on psychological adjustment to RA. For individuals experiencing greater disease severity or physical disability, greater social support is associated with better psychological adjustment (10, 11, 18).
This article assesses the unique impact of individuals' satisfaction with the amount of instrumental and emotional support on 2 outcomes: valued life activity (VLA) disability and depressive symptoms. We hypothesize that instrumental support will be associated with VLA disability, whereas emotional support will be associated with depression.
Disability in VLAs has been found to be more strongly associated with increases in depressive symptoms than are general functional limitations (5, 20). It is expected that individuals who report more satisfaction with instrumental support (i.e., help with daily tasks) will be better able to maintain the valued activities, and that receiving adequate instrumental support will moderate the impact of poor physical function on VLA disability (Figure 1).
Emotional support is expected to be associated with depressive symptoms, such that individuals reporting more emotional support are expected to report fewer depressive symptoms. Furthermore, it is expected that emotional support will lessen the impact of VLA disability on depressive symptoms (6). For individuals who experience greater VLA disability, greater satisfaction with emotional support will be associated with fewer depressive symptoms (see Figure 1). Establishing these relationships will allow for further examination of the pathways through which both social support and activity loss affect depressive symptoms. In addition, examining these relationships both cross-sectionally and longitudinally may help clarify the causal nature of the relationship between social support and psychological adjustment.
- Top of page
- SUBJECTS AND METHODS
This study examined the impact of instrumental and emotional support on valued activity disability and depressive symptoms. Results indicate that instrumental support is associated with development of less disability in valued activities. Individuals who received adequate help with daily tasks during year 1 reported fewer valued activities newly affected by RA from year 1 to year 2. Although not significant, a statistical trend suggests that instrumental support may moderate the impact of basic function on VLA disability. In other words, the worse an individual's function, the more important receiving adequate help with daily tasks may be to minimize VLA disability.
In addition, analyses revealed that both VLA disability and emotional support were strongly associated with concurrent depressive symptoms. Individuals who had fewer newly affected activities from year 1 to year 2 and who received adequate emotional support in year 2 reported fewer depressive symptoms in the same year.
A significant relationship between emotional support and depressive symptoms was only found in the primary (short-term) analyses. Results failed to support the hypothesis that emotional support would be associated with future depression. Limitations in this study's measurement of social support may explain the insignificant longitudinal relationship between emotional support and depressive symptoms. Each type of social support was assessed with a single item, and the variability in responses to these items was limited. For example, in the analysis sample, 73% of participants responded that they received adequate support, both instrumental and emotional. Therefore, additional research is needed using a more sensitive multidimensional social support scale designed to independently assess both instrumental and emotional support, as well as different aspects of support (e.g., quantity of support and satisfaction with the quality of support) (38, 39). In addition, some research has shown negative effects of some types of support; future measures should consider this as well (19, 40).
In addition to the limitations posed by the social support measure, other limitations are also noted for this study. There were differences between the panel members who remained in the panel and those who did not. It is possible that attrition of panel members biased the results of this study by differential inclusion of persons with better function or psychological status. However, the individuals who have remained in the study have experienced a variety of outcomes over the course of the study, including progression of functional impairment (e.g., the mean HAQ in year 1 was 0.99, and ranged from 0 to 2.88), so by no means could all of the panel members be considered to have experienced a favorable disease course. It is possible that individuals who visit rheumatologists for their RA may be systematically different from those who visit general internists. It is also possible the persons treated by the study rheumatologists did not represent the full spectrum of persons with RA, treatments, or other independent variables. The average duration of RA among these individuals is quite long, primarily due to the length of time they have been in the panel. Although this panel includes persons as young as age 27 years, the mean age of this group is 61 years, again primarily due to the duration of the panel study. In general, though, this study sample is similar to other large panel studies of persons with RA (41) and reflects the population of persons with RA as a whole in many ways (e.g., demographic characteristics). Finally, because these analyses excluded individuals who were already depressed, these results may not be relevant to this group.
The interpretations and implications from this study concerning the impact of instrumental and emotional support on both VLA disability and depressive symptoms are clear. Receiving help with daily tasks enables individuals to maintain more of their valued activities over time. VLA disability has been identified as a significant predictor of future depressive symptoms (5, 20). Therefore, clinical interventions geared at improving the instrumental support received by individuals with RA should help them maintain more of their valued activities and thus benefit their long-term psychological adjustment. In contrast to emotional support, it may be easier to increase the amount of instrumental support individuals receive by providing them with access to resources and services to help with such daily tasks as cleaning, shopping, and cooking. Such access would then provide individuals more opportunity to stay involved in activities that more directly affect their psychological well being, such as involvement in recreational activities and social interactions (20).
The lack of a relationship between emotional support and later depressive symptoms may simply indicate that the benefit of receiving adequate emotional support is a short-term effect and may not have long-term implications for adjustment. Other longitudinal studies have failed to find a relationship between emotional support and depression (11), although consistent evidence of a cross-sectional association exists (11, 14). Therefore, interventions targeting emotional support may need to focus on the immediate impact of such efforts rather than concentrating on long-term implications. Otherwise, the significant benefits of receiving adequate emotional support may be overlooked.
Results from this study highlight the need to assess the relationship between different types of support and various aspects of adjustment to RA. Receiving adequate instrumental support is beneficial to the maintenance of valued activities over time, a critical factor in the psychological adjustment of individuals with RA. This support may be particularly important for individuals experiencing poorer physical function. Instrumental support is not directly associated with depressive symptoms. However, both receiving adequate emotional support and maintaining valued activities are beneficial to the short-term psychological adjustment of individuals with RA. This study thus illustrates that instrumental and emotional social support serve different functions in the lives of individuals with RA and that these different functions have unique effects on both psychological and physical outcomes.