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Abstract Little is known about the association between depression and the buffering effects of social support in mid-life crisis. The aim of this study is to determine the buffering effects of social support on depression concerning middle-aged individuals, while also taking reciprocity and gender differences into careful consideration. A cross-sectional survey of all middle-aged individuals (40–69 years of age) using a large sample (n = 4558) from a community-living population, who resided in Rokunohe town, Aomori prefecture in northern Japan (response rate = 69.8%), was undertaken. This town recently had a lot of suicides. Two-way anova was used to analyze the effects of stressor and social support on the Center for Epidemiologic Studies Depression scale scores. The authors found a stress buffering effect of social support on the depressive symptoms occurring in middle age, however, a significant difference in the stress buffer effect was only observed in male subjects. Moreover, when the authors take reciprocity into account, the effect of the buffer on depression was found not only in males receiving support but in males providing support as well. In conclusion, pertaining to males, social support reduces depressive symptoms under stressful circumstances in middle age, not only when they receive such support but also when they provide it. Therefore, these findings suggest that reciprocal social support is important for males in relation to community mental health.
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It is said that low levels of social connections increase the risk of death. In an Alameda County Study, California, USA, the most isolated group of men was found to have an age-adjusted relative mortality rate 2.30-fold higher than the men with the most connections, and the rate was 2.8 times higher than for the women.1 In addition, the lack of social ties is also considered to have a large influence on mental health.2
Numerous studies have shown a positive relationship between social support and mental health, especially depression.3–6 As a result, as for Public Health, it is said that social support can improve the standard of health, however, there are still many unclear factors regarding how social support influences mental health.
Two models have been used to explain how social relationships influence health,7 namely the main effect model and the stress buffering model by Cohen and Wills.8,9
According to the main effect hypothesis, people with relatively strong social support have better health than those with weak social support, irrespective of their exposure to stressors. In other words, a lack of social support or isolation tends to negatively influence health by stressors. In contrast, according to the indirect effect (buffer) hypothesis, people with strong social support tend to have better health than those with weak social support, but only with respect to exposure to stressors. In other words, support buffers protect persons from the potentially pathogenic influence of stressful events.10
The study of the stress buffering effect by social support has been researched in earnest since about 1980.11–14 There have been some community-based investigations about middle-aged individuals, however, several of them were limited studies, such as for African–American subjects, which took religion into account,15 or consisting only of married men,16 or married women.17 Moreover, research on the elderly,10,18–21 or a specific group (e.g. twin women,22,23 HIV patient,24 pregnant or postpartum women,25,26 students27,28) have been reported after the 1990s when Cohen’s theory was popular, and few such studies have been made on middle-aged individuals.29
In contrast, the reciprocity of social support should also be considered.30–32 The balance between help provided (in other words, giving or donated) and help received (e.g. instrumental support, emotional support) correlated negatively with any influence on health.33 Because, when an individual receives social support, the person feels a burden, indebtedness, or load. Recently, the study of the reciprocity has been performed, not only concerning well-being of persons,33,34 but also respecting the buffering effect. In the latter case, only older adults18,35 or students36 have so far been studied.
However, little research has previously been done for the middle-aged in a community-residing population studying the stress buffering effect, particularly in a type of social support based on reciprocity. In this article, the authors should clarify the stress buffering effect of social support on depressive symptoms in a large community sample of middle-aged individuals (40–69 years of age), by comparing males and females, and then separating them into instrumental, emotional and providing (giving) support.
In addition, these days in Japan, an increased suicide rate among middle-aged individuals remains a huge problem.37 As a result, a region with a high suicide mortality rate in Japan was selected for this investigation.38–40 To understand the actual conditions concerning mental health, establishing suicide prevention systems for farm villages was another purpose of this research. Since it is a factor in improving mental health, the social supports for middle-aged individuals in local areas were investigated.
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The mean age of the residents was 54.9 years (SD = 8.4). Female subjects comprised 53.6% of the overall subjects. Other backgrounds were as follows: married (81.5%), living alone (4.8%), farmers including as a side-job (38.9%). The grades of stressor were classified into the following four steps (n[%]); ‘heavy’ 428 (14.8%), ‘sometimes’ 1423 (49.2%), ‘not much’ 731 (25.3%) and ‘nothing’ 311 (10.8%).
The factors causing the most stressors were as follows: ‘economical problems’ 879 (31.2%), ‘work’ (superior official, contents, responsibility etc.) 595 (21.1%), ‘health and illness’ 509 (18.1%), and ‘interpersonal relations’ 495 (17.6%). Particularly, ‘work’ (male 28.2%, female 14.9%; χ2 = 74.1, P < 0.001) and ‘interpersonal relations’ (male 12.2%, female 22.3%; χ2 = 48.2, P < 0.001) showed a significant difference between males and females. (This question had multiple answers for a few items for both genders.)
The states of the CES-D score were as follows: effective answers were 55%, Cronbach’s alpha was 0.82, and the scores of light (≥16) were 33.5% male, 39.0% female; moderate (≥21) were 19.4% male, 20.8% female; and heavy (≥31) were 4.1% male, 4.6% female.
Table 2 shows the means and standard deviations (SD) of CES-D score by Kruskal–Wallis test, each item about age group, marital status, stressors, and communication with friends. The more an individual suffered from stressors, and the fewer relationships they tended to have with friends of both genders, the higher CES-D score levels. However, the CES-D score did not show a significant difference in relationship to the age group or the marital status of females.
Table 2. Related factors of Center for Epidemiologic Studies Depression scale score
Moreover, the social support score (MOSS-E) findings were as follows: effective answers were 73%, Cronbach’s alpha was 0.91 (subscale; Instrumental = 0.85, Emotional = 0.90 and Providing = 0.78). In addition, the average score (Mean ± SD total and three subscale) among genders were: male 6.60 ± 3.44 points (institute 1.98 ± 1.25, emotional 3.03 ± 1.50, providing 1.58 ± 1.24), and female 6.96 ± 3.17 points (institute 2.05 ± 1.21, emotional 3.24 ± 1.34, providing 1.65 ± 1.23).
Table 3 presents the means and SD of MOSS-E score by non-parametric test showing each item about subjective health sense, sleep, hospital visits, and the number of illnesses. Statistically significant associations were found between social support and subjective health sense, the number of illness, in both genders. However, a significant association was found for sleep in males.
Table 3. Related factors of Measurement of Social Support-Elderly
Table 4 and Fig. 1 show two-way anova results of stressor (high-low) and social support (high-low). An apparent stress-buffering effect was found only in males, as shown by the significant interactions between stressors and all of the three categories of social support such as instrumental F (1673) = 7.17 P = 0.008, emotional F (1679) = 7.21 P = 0.007 and providing support F (1635) = 12.57 P < 0.001.
Table 4. Result of two-way anova of stressor (high–low) and social support (high–low) divided by subscales
|Instrumental support Male||Instrumental support Female|
|Stressor||5 475.2||1||5475.2||103.08||<0.001||Stressor||3 710.3||1||3710.3||66.25||<0.001|
|Stressor * Institutesup.||380.9||1||380.9||7.17||0.008||Stressor * Institutesup.||108.0||1||108.0||1.93||0.165|
|Error||35 748.3||673||53.1|| || ||Error||44 802.6||800||56.0|| || |
|Total||179 951.0||677|| || || ||Total||234 531.0||804|| || || |
|Emotional support Male||Emotional support Female|
|Stressor||5 201.8||1||5201.8||100.60||<0.001||Stressor||2 925.2||1||2925.2||55.96||<0.001|
|Stressor * emo.sup.||372.8||1||372.8||7.21||0.007||Stressor * emo.sup.||131.0||1||131.0||2.51||0.114|
|Error||35 107.9||679||51.7|| || ||Error||40 719.7||779||52.3|| || |
|Total||180 731.0||683|| || || ||Total||224 760.0||783|| || || |
|Providing support Male||Providing support Female|
|Stressor||5 117.5||1||5117.5||96.73||<0.001||Stressor||3 533.0||1||3533.0||65.55||<0.001|
|Stressor * pro.sup.||664.9||1||664.9||12.57||<0.001||Stressor * pro.sup.||21.2||1||21.2||0.39||0.531|
|Error||33 596.4||635||52.9|| || ||Error||39 614.2||735||53.9|| || |
|Total||168 489.0||639|| || || ||Total||209 734.0||739|| || || |
Figure 1. Stress-buffering effects of social support on depressive symptoms divided into subscales and genders (a,c,e, men; b,d,f, women). (a,b) Instrumental support; (c,d) emotional support; (e,f) providing support. (◆), low; (●), high.
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Moreover, the main effect was observed to have a significant direct effect on depressive symptoms only for emotional support. However, neither instrumental support nor providing support was found to have a main effect in both genders.
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The social support was related to health based on the findings of this investigation (Table 3). Especially, the relationship between the social support and mental health was analyzed by those who received and provided support (Fig. 1).
The authors have shown that the stress buffering effect of social support on depressive symptoms in a community sample of middle-aged individuals, showed a significant difference and a stress buffering effect only in males. Therefore, in situations with a high amount of stress, and a high degree of social support, the depression score was lower than a low social support. This buffer was effective in male, but not in female subjects, in addition to all subscales. Moreover, when analyzing reciprocity, a buffer effect on depression was found in males by providing support. As a result, not only receiving but also giving support, is important for males. These findings are very unique, because many recent studies did not examine gender differences.18,34,36
For all that, Schieman and Meersman researched for the elderly person in both genders.35 There was neither a main effect nor a buffering effect for the depressive symptoms when the male and female provided support.
There have been several studies on gender differences concerning stressors and social support, although about stress-buffer, no significant differences have been observed. While these results are consistent with recent studies, studies on Caucasian female twins and adolescents students showed no buffering effect for female subjects.22,27 In contrast, however, few previous studies have shown that a stress-buffering effect of social support may be somewhat stronger among women than among men.46 Therefore, women’s interpersonal ties tend to be more emotional than those of men.47 Nevertheless, as for the examination of gender difference of this study, the analysis is considered to have been too crude because of very weak correlations.
Why do females not have a ‘buffering effects of social support on depression’?
This finding may be related to differences in the ‘social networks’ among the genders.
Regarding these gender differences, Deborah Belle observed that there is plentiful evidence that males tend to participate in more activity-focused relationships than do females, while female subjects at all ages maintain more emotionally intimate relationships than do male subjects.48
What is most striking about men’s mobilization of support is that it is so heavily focused on one support provider, namely the wife.48
However, social ties also bring additional stresses into women’s lives, and in many relationships women appear to provide more support to others than they receive in return.49
Furthermore, Kawachi and Berkman summarize their interpretation of an opinion of the Belle findings: (i) women maintain more emotionally intimate relationships than men; (ii) they mobilize more social supports during periods of stress than men; and (iii) provide more frequent and more effective social support to others than do men.7
As an aside, as to the fact that females did not show any relationship to the ‘buffering effects of social support on depression’, readers should think about any potentially confounding variables. About 40% of the middle-aged individuals were engaged in agriculture in Rokunohe town. However, it seemed that interpersonal relationships were very close. As a result, the frequency of interchange with friends among females was higher than in males in this study (Table 2). Possibly, there might be a ‘negative support’ in a tight interpersonal relationship.
The reason why this study is extremely important is as follows. This is a study on the stress-buffering effect about the social support for middle-aged (40–69 years) individuals in a large community sample, which was divided into genders and subscales to take reciprocity into consideration. In addition, the authors clearly demonstrated gender differences relating to the effects of social support. Moreover, these results suggest that males who not only receive but also provide social support tend to show a decrease in depressive symptoms under stressful circumstances in the middle aged. As a result, social support may be one possible prevention method in high suicide areas. Recently, a prospective cohort study of the general population in Japan confirmed that isolation (living alone, being divorced) increased the risk of suicide in men.50
Some limitations in these findings include some important factors. The measurement of stressors remains difficult to evaluate. This measure might not show the stressful life events or daily hassles, and the findings may be confounded with stress responses or strain. It is also difficult to evaluate the quantity, quality and strength of social support. In addition, the response rate of the depression scale was not high with 55% (1639 persons), therefore, analytical object of two-way anova was scarcely 1400 persons. This number of people analyzed in the study is considerably small in comparison to the study population (4558 persons). Nevertheless, both analytical objects of two-way anova (about 1400 persons) and investigation participants (3132 persons) did not differ substantially concerning backgrounds. Third, a cross-sectional survey showed a weak causal relationship between social support and depressive symptoms. Finally, these findings also are related to sociocultural factors, for example, the women’s continuing low status in farming areas or a tight interpersonal relationship. As a result, these sociocultural factors are considered to be a confounding variable. Moreover, these results may be limited to just the region in north Japan.
Readers should, therefore, keep these points in mind concerning the findings of this study, that is to say, carefully generalize the investigation result.
In conclusion, the authors herein showed a positive relationship between social support and mental health. However, when analyzing reciprocity, the authors only identified a significant difference and a stress buffering effect in males.