Author: Gjesfjeld, Christopher D
Date published: September 1, 2010
Maternal depression is a significant public mental health problem that can negatively affect mothers and children. Besides the direct negative effects that mothers can experience, such as lowered quality of life and potential deficits in workplace and home settings (Druss, Rosenheck, & Sledge, 2000; Judd et al., 2000; Stewart, Ricci, Chee, Hahn, & Morganstein, 2003), children of depressed mothers are at greater risk for behavioral and emotional problems (Ashman, Dawson, & Panagiotides,2008;Weissmanetal., 2006). Although the mechanisms linking mothers' and children's behavioral health outcomes are not yet clearly understood, it appears that parenting is negatively affected by the symptoms of depression and that children may also model cognitions, behaviors, and affect consistent with the illness (S. H. Goodman, 2007; S. H. Goodman & Gotlib, 1999). Understanding the role of factors that may contribute to maternal depression is an important task to ultimately developing treatment and preventive strategies to alleviate this problem. This article examines the effects of economic stress and social support on maternal depressive symptoms in a group of predominantly low-income mothers whose children are receiving mental health care.
A number of important studies have documented the link between economic stress and depressive illness. Since Brown, Bhrolchain, and Harris's (1975) study of psychiatric symptoms in working-class and middle-class women, research has continued to accumulate linking economic stress and the risk of experiencing depressive illness. In a meta-analysis of 60 studies examining socioeconomic inequalities and depression, individuals in the lowest socioeconomic status (SES) group were nearly twice as likely to experience a current depressive episode as those in the highest SES group (Lorant et al., 2003). Longitudinal studies have also confirmed that sustained economic stress increases the risk of experiencing depressive symptoms (Dearing,Taylor, & McCartney, 2004; Lynch, Kaplan, & Shema, 1997). The alarming rate of depressive symptoms in lowincome community samples of mothers also suggests a link between economic stress and depression. In a variety of studies specific to low-income mothers, 35% to 52% of women were found to be at risk for clinical depression (Coiro,2001 ;Kalil,Born,Kunz,& Caudill, 2001; Pascoe, Stolli, & Ormond, 2006).
Despite the detrimental impact of economic stress, it appears that social support may provide some protection from maternal depression. Studies specifically addressing social support and maternal depression have confirmed that high levels of social support are associated with significantly lower levels of depressive symptoms and a lower risk of depressive illness (Cairney, Boyle, Offord,& Racine, 2003; Siefert, Bowman, Heflin,Danziger,& Williams, 2000; Surkan, Peterson, Hughes, & Gottlieb, 2006). Although there are a small number of longitudinal studies examining maternal depression and social support, research on postpartum mothers has found low social support to be predictive of high levels of depressive symptoms (Ritter, Hobfoll, Lavin, Cameron, & Hulsizer, 2000; Xie, He, Koszycki, Walker, & Wen, 2009).
Although both economic stress and social support have been shown to predict depressive symptoms and illness, little research has examined the interlocking relationships between economic stress and social support. The social support deterioration model (Barrera, 1986; Ensel & Lin, 1991) proposes that the relationship between stress (for example, economic stress) and psychological distress (for example, depressive symptoms) can be partially explained by the impact of stress on social support. In other words, economic stress may have a direct effect on depressive symptoms but may also negatively affect an important protective factor, social support.To our knowledge, only Schulz et al. (2006) have examined this model with a specific interest in economic stress. In their research on 679 African American mothers living in Detroit, low social support was found to be partially responsible for the relationship between the economic stress of these mothers and their depressive symptoms, supporting the social support deterioration model.
Although little research has considered social support as a mediating variable in the economic stress- depression relationship, other researchers have demonstrated that stressful events can negatively influence social support (Lepore, Evans, & Schneider, 1 99 1 ; Norris & Kaniasty, 1 996; Quittner, Glueckauf, & Jackson, 1 990) . Ensel and Lin (1991) , in their longitudinal study of 677 New York residents, examined a number of social support models. They found that weakened social support perceptions partially mediated the relationship between negative life events and depression.
Besides relationships suggested by social support deterioration, the present analysis included demographic variables previously found to be associated with depressive symptoms: marital status and employment status. Working mothers and married mothers have lower levels of depression and higher levels of social support than do unemployed and unmarried mothers (Hope, Power, & Rodgers, 1 999; Pascoe et al., 2006; Sachs-Ericsson & Ciarlo, 2000; Turner & Marino, 1994).
Our analysis examined the relationships predicted by the social support deterioration model in our sample of mothers. For this model to be confirmed, four conditions had to be met, per Baron and Kenny's (1986) criteria for mediation: (1) economic stress had to negatively predict depressive symptoms, (2) economic stress had to negatively predict social support, (3) social support had to negatively predict depressive symptoms, and (4) social support had to mediate the relationship between economic stress and depressive symptoms - that is, a significant indirect effect had to be found to demonstrate that the initial relationship between the independent and dependent variable had been reduced by the mediator's presence.
Study Design and Sample
This research used data collected for a study funded by the National Institute of Mental Health, with methods approved by the University of Pittsburgh Institutional Review Board. The initial aims of this project were the following: identification of major barriers to mental health treatment engagement of mothers and their children and assessment of the impact of social and environmental factors on mothers' psychiatric status, children's psychiatric status, and treatment attendance. Mothers were recruited through community mental health clinics that provided treatment for their children. These community mental health clinics serve mostly lowincome populations, with about 60% of mothers being publicly insured.
Participants in this study were mothers who had consented for the study at five community mental health clinics between June 2001 and August 2003. To be included in the initial study, mothers had to be the biological or adoptive parent of their child, have custody of the child, and live with the child. Children also needed to be between the ages of four and 17.
Five hundred and thirty-nine mothers meeting eligibility criteria were approached and could be contacted for scheduling; 340 mothers (63%) participated. Trained interviewers explained the project to participants and obtained written informed consent. The interview was usually conducted at the clinic at which the child was receiving services, although it could be conducted at any convenient location for the mother. Mothers received financial compensation for their participation in the study. Of the 340 mothers who participated, 99% percent (n = 336) had complete data for the three variables: economic stress, social support, and depressive symptoms.
Depression. Depression was measured using the Beck Depression Inventory (BDI). The BDI was designed to detect the severity of 21 symptoms and attitudes correlated with depression in psychiatric patients; some of these symptoms are sadness, sleep problems, and loss of energy (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The BDI is used to measure the severity of depressive symptoms, not support a formal diagnosis of major depression disorder. In a self-report questionnaire format, respondents reported the intensity of a symptom over a one-week period on a four-point scale from 0 to 3. A total depression score was determined by summing the 21 items, with the highest possible score being 63. In a meta-analysis of nine psychiatric and 15 nonpsychiatric populations, high coefficient alphas were reported for the BDI - .86 and .81, respectively (Beck, Steer, & Garbin, 1988). In our sample, the BDI had a coefficient alpha of .91.
Economic Stress. The Money subscale of the Hassles of Environmental Poverty Instrument (HOEP) was used to assess the economic stress of mothers (Wijnberg, Lagerwey, Applegate, & Reding, 2006). This scale measures the degree of difficulty, or "hassle," involved in obtaining certain material goods, such as food, housing, and clothing. A fourpoint response scale was used to determine the total score on the basis of 18 items, and an average score was derived. Wijnberg et al. (2006) found that the 1 8-item Money subscale of the HOEP had good psychometric properties, with a coefficient alpha of .93. In our sample of mothers, the HOEP Money subscale had a coefficient alpha of .88.
Social Support. Social support was measured using the Social Support Survey from the Medical Outcomes Study (MOS-SSS) (Sherbourne & Stewart, 1991). This scale was developed on the basis of data gathered from nearly 3,000 patients with chronic medical conditions. Respondents were presented with 18 items regarding the types of support that were available to them. The reliability of the MOSSSS has been demonstrated through high internal consistency (subscale and total scale alphas over .90) and test-retest reliability (.72 to .76 over a one-year period) We also found the MOS-SSS to have a high coefficient alpha in our sample: .96.
Demographic Variables. Besides the three main variables of interest, mothers were asked to complete basic demographic information: age, race, marital status, work status, education, and income. These demographic data were tested prior to being included in the hypothesized model. Being married and working outside the home predicted depressive symptoms [for marital status, t(337) = 3.48, p < .01; for working status, t(adjusted df = 287) = 5.61, p < .01], Age, race, and number of children were not found to predict depressive symptoms and were not included in the model. Given that the HOEP Money subscale measures economic stress, income was not included in the model. Educational status was also not evaluated for inclusion in the hypothesized model because there was little variation in the variable (that is, only 7% of the sample completed college) and the initial data coding was not mutually exclusive.
We hypothesized a model that included both theoretically relevant demographics and the relationships consistent with the social support deterioration model. Given that we examined all of the paths among the study variables, the path model is said to be "just-identified," or a saturated model. In other words, all paths in the model were examined in the analysis. Although a saturated model does suggest that the theorized model has a perfect fit with the observed variables (df = 0), a saturated model does not imply that every relationship in the model is statistically significant. Nonsignificant relationships among demographic variables were not removed from the model, because the exclusion of these demographic variables could influence our test of mediation. Given that the data depart from normality (Mardia's kurtosis = -3.90), robust statistics were calculated for the relationships among the hypothesized relationships to correct for nonnormal data (Satorra & Bender, 1994).
After specification of the path model, we used EQS 6.1 for Windows software (Bender, 2004) to analyze all seven hypothesized relationships in the model. Our main hypothesis involved the test of mediation. This test was performed to determine whether low social support mediated the relationship between economic stress and depressive symptoms. Although full mediation would indicate that the association between the independent and dependent variables would disappear after accounting for the mediator, partial mediation would indicate a significant reduction in the size of the relationship between the independent (economic stress) and dependent variables (depressive symptoms) when the mediator was accounted for. Social support as a partial mediator was more plausible because, as Baron and Kenny (1986) noted,
most areas of psychology, including social, treat phenomena that have multiple causes, a more realistic goal may be to seek mediators that significantly decrease |the relationship between the independent and dependent variable] rather than eliminating the relation between the independent and dependent variables altogether, (p. 1176)
This reduction in size of the independentdependent variable relationship would be reflected by economic stress having a significant indirect impact on depressive symptoms through its influence on social support.
Maternal age ranged from 20 to 61 years, with a mean age of 37.3 (SD = 7.6). Thirty-five percent (n =119) of mothers reported that they were currently married. Nearly three-quarters (n = 247) of these women reported their race as white (74%), whereas 23% (n = 78) identified themselves as African American. Three percent (n =11) identified themselves as Asian, Hispanic, American Indian, or other. Fifty-four percent (n = 180) of mothers indicated that they worked outside of their home. Only 7% (n = 23) held a college degree or better, and 70% (n = 237) had an annual household income of less than $30,000. Participants had a mean of 2.49 children.
Model Specification and Hypothesis Testing
The correlation matrix for all variables used in the analysis are presented in Table 1 , and Figure 1 illustrates the model. All hypothesized paths were suggested, thereby specifying a fully saturated model. Independent variables were allowed to covary, which is standard in testing structural equation models. Instead of dropping paths post hoc, we examined the results of all seven hypothesized relationships and performed a test of mediation to determine if social support deterioration was occurring.Table 2 reports the significance test for each of these hypothesized relationships.
As expected, economic stress was found to be a positive predictor of depressive symptoms (β = .39, z = 8.34, p < .01), and social support was a negative predictor of depressive symptoms (β = -.18, z = -3.43, p < .01). Economic stress also was found to be a negative predictor of perceived social support (β = -.43,2 = S.07,p< .01).
A key hypothesis in this study involved a test to determine whether social support mediated the relationship between economic stress and depressive symptoms. Social support was found to partially mediate the prediction of depressive symptoms by economic hardship (β = .08, z = 3.17, p < .01). Given that the direct path between economic hardship and depressive symptoms remained significant after social support was accounted for, social support acts as a partial mediator in the relationship between economic hardship and depressive symptoms.
When demographic variables were examined, married mothers were found to have higher social support scores (β = .11, z = 2.42, p = .02) than unmarried mothers, yet being married was found to have no direct relationship with depressive symptoms (β = -.05, z = -1.08, p = .28). Mothers who worked outside the home had higher levels of perceived social support than mothers not working outside the home (β = .13, z = 2.63, p < .01), and they maintained fewer depressive symptoms than mothers who were unemployed or worked within the home (β = -.22, z = -4.91, p < .01). When direct and indirect effects were considered, working outside the home accounted for a five-point (B = -4.99, z = -5.25, p < .01) decrease on the BDI.
The present research supports the relationships suggested by the social support deterioration model in a sample of mothers with children in mental health treatment. This model suggests that low social support may be one mechanism that explains the positive association between economic stress and maternal depressive symptoms. Economic stress appears to have a dual impact on depression: a direct relationship with depressive symptoms and an indirect relationship with depression through reduction of the protective qualities of social support. Our results are consistent with prior research that has found low levels of social support to be a mediator between chronic stressors and psychological distress (Ensel & Lin, 1991; Lepore et al., 1991; Noms & Kamasty, 1996; Schulz et al., 2006). Our research also appears to support the psychological benefits of maternal employment. This finding is consistent with literature on the psychological health benefits of employment for mothers (Barnett, 2004).
Despite our findings supporting key relationships in the social support deterioration model, several limitations warrant attention. First, the use of cross-sectional data makes any claims about causality problematic. Although one may speculate about the direction of causality between our three main study variables, without longitudinal data, certainty regarding causality is not possible. For example, depressive symptoms could influence how mothers report both economic hassles and social support perceptions. It is probable that negative thought patterns associated with depressive symptoms could have caused respondents to underestimate both actual and perceived social support and overestimate their economic troubles. Longitudinal data could more fully explicate these relationships. Second, other stressful experiences, such as parenting a child with behavior problems, could have had complex interactive or additive effects on study variables. Considering this possibility, we examined the bivariate correlations between child behavior scores and maternal depressive symptoms, but we found no significant relationships, suggesting that child behaviors have little influence on maternal depression. However, some unknown stressors or variable could have been influencing our key variables. Third, our response rate of 63% could complicate conclusions made about these mothers or the strength of the relationships. It is plausible that the relationships among study variables could have been different among nonresponders. Finally, the generalizability of our study is limited due to this unique characteristic of our study participants: All were mothers with children in mental health treatment. Although these mothers may be reflective of the clients served by social workers, their unique attributes make our study's results difficult to generalize to other populations.
Despite these limitations, we believe that research on psychological health specific to high-risk populations is important. Nearly half of the mothers in our study maintained a level of depressive symptoms that would be concerning to mental health treatment providers (a 14 on the BDI). Although a number of researchers have already documented the impact that maternal depression can have on mothers, their parenting practices, and child outcomes (S. H. Goodman, 2007; S. H. Goodman & Gotlib, 1999; Muzik, Marcus, Heringhausen, & Flynn, 2009), we see our research as filling an important gap in that it considers the contextual risks and protective factors associated with psychological well-being. Although some work has considered the adaptation of evidence-based models of intervention for economically stressed populations (Grote, Bledsoe, Swartz, & Frank; 2004; Miranda, Azocar, Organista, Dwyer, & Areane, 2003), we hope that both prevention and intervention efforts aimed at maternal depression consider the prime importance of basic need acquisition.
Although we found low social support to be a potential mechanism in explaining the association between economic stress and depression, our research did not give any specific insights into why this may be so.The relationship between economic stress and social support may be influenced by a number of processes at the individual, group, and societal levels. At the individual level, economic stress may make it harder for individuals to involve themselves in social activities. Mothers struggling to meet basic needs would appear to have fewer financial resources to invest in activities that could facilitate social engagement. It is interesting to note that in the evidence-based treatment for depression known as behavioral activation (Cuijpers, van Straten, & Warmerdam, 2007; Dobson et al., 2008), involvement in pleasurable activities, or activity scheduling, is vital. It seems plausible that economic stress could complicate efforts to involve oneself in such activities (for example, a gym membership, dinner with friends, a movie).
Group dynamics within a community may also be responsible for the link between economic stress and low levels of social support. Economic instability, at both the individual and community levels, may lead to individual isolation (Phan, Blumer, & Demaiter, 2009). Stack (1974), in her description of an African American community within an urban midwestern city, described the concept of swapping, defined as the trading of resources, possessions, and services within a community. Although gifts were regarded, initially, as voluntary, Stack noted that an unspoken rule obliged reciprocation. The consequences of not reciprocating had the potential to create discord in one's social circle. Besides reciprocation, it is also possible that the social circle of those with few economic resources merely lacks the types of resources that would make a difference (for example, time, money).
Finally, the social stigma of poverty may encourage self-exile from support. Nelson (2000), in her study of poor, rural mothers, found that asking for too much help created feelings of dependency in many mothers. Given their own difficulty in making ends meet and potential feelings of dependence, mothers experiencing economic stress were apt to remove themselves from important social exchanges because of their own beliefs. Mothers had felt that they had "used up" social favors from friends and family, or they perceived themselves as a burden. One potential way of preserving personal integrity that these mothers practiced was distancing themselves from supportive others. In future studies, researchers should consider how social support deterioration operates at different levels of analysis, including the individual, the social group, and society.
Given that there has been over 25 years of research on the social determinants of depression, it is unfortunate that economic concerns have not taken center stage in the development of treatment or prevention models focused on depression. In light of the strong relationship between economic stress and depressive symptoms, our research suggests one major point: Economic issues matter.They have the potential to negatively affect acquisition of social support, and they are widely discussed by clients as the cause of their emotional difficulties (Anderson et al., 2006; Falconnier & Elkin, 2008). And yet, current models of care remain fragmented in their approach to women experiencing economic disadvantage and depression (Hollon et al., 2002). Current intervention methods typically involve a two-pronged approach: (1) psychotherapy, pharmacotherapy, or both for depressive symptoms and (2) economic supports (for example, food stamps, welfare assistance) to alleviate economic stress. As a result, women receive care that is siloed into two systems of assistance - mental health care and economic support services.
Smyth, Goodman, and Glenn (2006) have argued that this siloed approach further isolates and marginalizes women, and they have developed a model known as the full-frame approach to remedy the current state of fragmented services. Four principles at the core of their model are (1) the interplay between external contexts and internal experiences, (2) the centrality of a woman's relationships, (3) the value of a woman's personal story and choices, and (4) the development of a broader community greater than one's set of "problems." ROAD (Reaching Out About Depression) (L. A. Goodman, Glenn, Bohlig, Banyard, & Borges, 2009) has used these principles in the development of a project focused on low-income women with depressive symptoms in Cambridge, Massachusetts. Women, in this project, not only converse with each other about their lives as they experience depression, they share their experiences of navigating a social service system that has been unresponsive to their concerns.
Social workers are educationally well prepared to conceptualize how internal psychological distress can be influenced by various contextual factors. And yet, we work in systems of care that prioritize specialized knowledge to the detriment of contextual understanding. It is our hope that social work professionals can deliberately aim to heal a fragmented delivery system. At the micro level, a more nuanced consideration of economic stress with our clients may enhance our understanding of their psychosocial context. At the macro level, the development of grassroots projects, such as ROAD (L. A. Goodman et al. ,2009), has the potential to influence a diversity of outcomes, such as psychological wellness, social support, and specific economic concerns. If we neglect to examine the important economic context of individuals, it is hard to imagine how the aims of mental health treatment or prevention can be realized.
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Christopher D. Gjesfjeld,PhD,LCSVyis assistant professor, Department of Social Work, University of North Dakota, 225 Centennial Drive, Stop 7135, Grand Forks, ND 58201;e-tnail: firstname.lastname@example.org. Catherine G. Greeno, PhD, is associate professor, School of Social Work, University of Pittsburgh. Kevin H. Kim, PhD, is associate professor, School of Education, University of Pittsburgh. Carol M.Anderson, PhD, is professor, Department of Psychiatry and School of Social Work, University of Pittsburgh. An earlier version of this manuscript was presented at the annual conference of the Council on Social Work Education, October 2007, San Francisco.
Original manuscript teceived Januaty 5, 2009
Final revision teceived Match 22, 2010
Accepted Match 31, 2010