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Problematic andPositive Support inRelation toDepression in Peoplewith RheumatoidArthritis

ROBERT P. RIEMSMAUniversity of York, UKERIK TAAL & OENE WIEGMANUniversity of Twente, the NetherlandsJOHANNES J . RASKERMedisch Spectrum Twente and University of Twente, the Netherlands

GEORGE A.W. BRUYNMedisch Centrum Leeuwarden, the Netherlands

HENK C. VAN PAASSENSt Franciscus Gasthuis, Rotterdam, the Netherlands

AC K N OW L E D G E M E N T S. This study was supported by grants from theDutch League against Rheumatism, and the Ministry of Health,Welfare and Sports of the Netherlands. We wish to thank all ourrespondents. We also gratefully acknowledge the cooperation of therheumatologists: H. J. Bernelot Moens MD; J. J. M. Festen MD; E. N.Griep MD; P. M. Houtman MD; M. W. M. Kruijsen MD; M. A. F. J.van de Laar MD; J. C. M. Oostveen MD; and J. M. G. W. WoutersMD. We would like to thank Ms W. Burke for correcting the English.

A D D R E S S. Correspondence should be directed to:R. P. R I E M S M A PhD, University of York, NHS Centre for Reviewsand Dissemination, Heslington, York YO10 5DD, UK.[Tel. 44 (0)1904 434576; Fax 44 (0)1904 433661; email: [email protected]]

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Journal of Health PsychologyCopyright 2000 SAGE PublicationsLondon, Thousand Oaks and New Delhi,[13591053(200004)5:2]Vol 5(2) 221230; 012237

Abstract

This study focuses on theassociations of both positive andproblematic aspects of socialsupport with depression inpatients with rheumatoidarthritis. In a hierarchicalmultiple regression analysis wefound that stressors such asfunctional limitations and painare strongly related todepression. Positive andproblematic support eachexplain an additional significantportion of the variance indepression. More positivesupport is associated with fewerfeelings of depression and moreproblematic support isassociated with more feelings ofdepression. An interaction effectbetween positive andproblematic social supportindicates that the negativeaspects of problematic supportmay be partly diminished bypositive support (bufferingeffect). Patients receiving moreproblematic support and lesspositive support experience themost feelings of depression.

Keywords

depression, problematic support,rheumatoid arthritis, socialsupport

at Alexandru Ioan Cuza on May 28, 2015hpq.sagepub.comDownloaded from

R H E U M ATO I D A RT H R I T I S (RA) is a chronic,disabling disease characterized by chronicinflammation of joints, in most patients resultingin progressive joint destruction with deformitiesand various degrees of incapacitation (Rasker &Cosh, 1989). Disease activity can vary consider-ably, even from day to day. The disease may startat any age and women are two to three timesmore likely to be affected than men. The cause isunknown.

The unpredictable and painful course of thedisease causes a lot of stress for patients, whichhas great impact on their quality of life (Taal,Rasker, & Wiegman, 1995). Patients are con-fronted with physical consequences, such aspain, stiffness, fatigue and deformities of thejoints, and functional limitations, for example,regarding mobility and problems with activitiesof daily living, such as dressing, washing, walk-ing and household activities.

The psychosocial well-being of RA patientsoften decreases seriously during the course of thedisease. Feelings of depression are very oftenmentioned as psychological consequences ofRA. Frank et al. (1988) found that 17 percent ofRA patients meet the criteria for majordepression. This level of depression is far higherthan that normally found among the generalpopulation, and similar to that of patients withother chronic disease (Cassileth et al., 1984).Anxiety, as well as uncertainty about the futureand consequences of the disease, are often men-tioned as problems by RA patients (Creed, 1990;Rasker, Bronner, & Verzijden, 1984; Taal,Rasker, Seydel, & Wiegman, 1993).

Social support, for example from family andfriends, may play an important role in the waypatients cope with their disease. In general popu-lations it has been shown that more social sup-port is related to improved mood (Cohen &Wills, 1985; Moos, 1991; Sarason, Sarason, &Pierce, 1994). Thus social support may have adirect effect on patients mood: more social sup-port may lead to improved mood and thereforefewer feelings of depression. This direct effect ofsocial support on mood has also been demon-strated among RA patients (Doeglas et al., 1994;Goodenow, Reisine, & Grady, 1990).

Social support can also have a moderating orbuffering effect on stress (Cohen & Wills, 1985).This means that patients with greater stress levelsbenefit more from social support in comparison

to those with less stress. For instance, when apatient with RA experiences a period ofincreased disease activity, involving consider-able pain and functional limitations, social sup-port will, according to the stress-bufferinghypothesis, have more influence on the patientsmood than when he or she experiences less painand limitations.

Social interactions do not just have positiveeffects on well-being: negative aspects of socialinteractions can lead to a decline in well-being.Manne and Zautra (1989) found, in a study offemale RA patients, that critical remarks fromtheir spouses were related to maladaptive copingstrategies by the patients, which in turn lead topoorer psychological well-being. Kraaimaat, vanDam-Baggen, and Bijlsma (1995) also found thata high degree of criticism from spouses andlimited social support were accompanied bypoorer psychological well-being of both maleand female RA patients.

Revenson, Schiaffino, Majerovitz, andGibofsky (1991) studied the relationshipbetween both positive and negative aspects ofsocial support, and feelings of depression. Theyused the term positive support to refer to socialinteractions that provide affect, affirmation oraid, and the term problematic support todescribe instances of support that are perceivedas non-supportive, even though the providersactions may have been well intended. Supportmay be perceived as problematic, for example,when it is neither desired nor needed, or whenthe type of support offered does not match therecipients needs. Moreover, some social interac-tions may be less than supportive in intent, suchas criticism of a patients coping efforts.Revenson et al. (1991) found that these problem-atic aspects of support were related to increasedfeelings of depression among RA patients, whilepositive support was associated with fewer feel-ings of depression. They found no significantrelationship between positive and problematicsupport, which means that receiving a largeamount of positive support does not automati-cally preclude people from receiving negativesupport. A significant interaction effect of posi-tive and negative support suggested that positivesupport operated in a stress-buffering fashion:the negative effects of problematic support areminimized within the context of positive support.

In our study we will first examine whether

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there is a relationship between stressors, such aspain and functional limitations, and depression.Our first hypothesis is therefore as follows: Themore pain and functional limitations RA patientshave, the more depressed they will be (hypothe-sis 1).

This relationship can be influenced by socialsupport; both positive and negative aspects ofsocial support may be of relevance. In accor-dance with Revenson et al. (1991) we will usethe term positive support for positive aspects ofsocial support and the term problematic supportfor negative aspects of social support. The directrelationship between social support anddepression is examined, therefore the followinghypotheses are formulated: The more positivesupport RA patients experience, the lessdepressed they will feel (hypothesis 2a); andThe more problematic support RA patientsexperience the more depressed they will feel(hypothesis 2b).

To examine whether social support has a mod-erating effect on the relationship between physi-cal functioning and pain on the one hand, anddepression on the other, we formulated the fol-lowing hypothesis: RA patients with greaterfunctional limitations and pain have more feel-ings of depression when they have less positivesupport, while among RA patients with few func-tional limitations and pain there is no relation-ship between positive support and feelings ofdepression (hypothesis 3a). In this last hypothe-sis we assume that the negative effects ondepression of stressors, such as pain and func-tional limitations, will be buffered or diminishedby positive support. It can also be assumed thatthe negative effects on depression of stressors,such as pain and functional limitations, will beheightened by problematic support, because RApatients with more pain and functional limi-tations may be more sensitive to negative socialinteractions. We therefore formulated the follow-ing hypothesis: RA patients with greater func-tional limitations and pain have more feelings ofdepression when they experience more problem-atic support, while among RA patients withfewer functional limitations and pain there is norelationship between problematic support andfeelings of depression (hypothesis 3b).

In both the last hypotheses, pain and func-tional limitations were considered to be the stres-sors; however, we can also, like Revenson et al.

(1991), assume that problematic support is itselfa stressor and positive support has a moderatingeffect on the relationship between problematicsupport and depression. The hypothesis is there-fore as follows: RA patients with greater prob-lematic support experience more feelings ofdepression when they receive less positive sup-port, while among RA patients with less prob-lematic support there is no relationship betweenpositive support and feelings of depression(hypothesis 4).

Method

Participants and procedureOur study was performed among 229 RApatients, from the outpatient clinics of 10rheumatologists from three hospitals in diverseparts of the Netherlands: one serves an urbanpopulation; one a largely rural population; andone a mixed population. The rheumatologistsinvited outpatients satisfying at least four of the1987 ACR criteria for RA (Arnett et al., 1988),and not excluded by the following criteria, toparticipate in a survey on informal care for arthri-tis patients. The exclusion criteria were: resi-dence in a nursing home; disease duration of lessthan 5 years; and age less than 16 years. In eachof the three rheumatological units, consecutivemale and female patients were asked to partici-pate until 40 women had agreed, after which onlyconsecutive male patients were asked until a totalof 40 men had agreed. In total 252 RA patientsagreed to participate. A composite questionnairewas posted to each participating patient. Twoweeks later the questionnaires were collected byan assistant, who helped with their completion ifnecessary. The assistant was not informed aboutthe purposes of the study, and was not allowed todiscuss questions with the patients. Twelverespondents informed us by telephone that theydid not want to participate, 5 could not bereached, 4 were not able to fill out the question-naire because of health problems and 2 did notmeet the inclusion criteria.

A total of 229 respondents returned the ques-tionnaires. In the analyses, only the data from 197RA patients who completed all relevant questionsfor this study were used. The 32 respondentsomitted from the analyses did not differ signifi-cantly from the remaining 197 respondents inage, gender, disease duration, comorbidities,

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level of education or marital status. Nor werethere significant differences in any of the depend-ent variables: depression, pain, functional limi-tations, positive and problematic support.

In one hospital it was not possible to enrol thedesired number of male participants, therefore 61percent of the respondents were female. Thehighest level of education completed was pri-mary school (612 years) for 36 percent, juniorvocational school (1316 years) for 46 percent,while 18 percent had been educated to seniorvocational school level or higher. The mean ageof the patients was 62.7 years ( 11.8) with arange between 25 and 86 years, 75 percent of thepatients were married or living with a partner andmean self-reported disease duration was 18 years( 10.3) with a range between 2 and 70 years.Although rheumatologists asked only patientswith a disease duration of 5 years or longer toparticipate in this study, 1 patient reported a dis-ease duration of 2 years and 2 patients reported adisease duration of 4 years.

Measures

Depression Depression was measured using themood scale from the Dutch-AIMS2 (Meenan,Mason, Anderson, Guccione, & Kazis, 1992;Riemsma et al., 1996). This scale comprised fiveitems and had good internal consistency(Cronbachs .78). The items were: Duringthe past month, how often have you enjoyed thethings you do?; During the past month, howoften have you been in low or very low spirits?;During the past month, how often did you feelthat nothing turned out the way you wanted itto?; During the past month, how often did youfeel that others would be better off if you weredead?; and During the past month, how oftendid you feel so down in the dumps that nothingwould cheer you up?. Possible answers to eachof the five items were: always, very often, some-times, almost never and never. To obtain a scalescore the scores on the individual items were firstadded together and the result was then convertedinto a score ranging from 0 (slight feelings ofdepression) to 10 (very strong feelings ofdepression).

Functional limitations To measure functionallimitations we used the combined physical func-tion scale of the Dutch-AIMS2 (Meenan et al.,

1992; Riemsma et al., 1996). The physical func-tion scale of the Dutch-AIMS2 comprises 6 sub-scales: Mobility, i.e. the ability to move aroundin the community (5 items, .79); Walkingand Bending, i.e. the lower extremity functions(5 items, .76); Hand and Finger Function,i.e. dealing with functions such as writing, turn-ing keys and opening jars (5 items, .86);Arm Function, i.e. the upper extremity functions(5 items, .84); Self-care Tasks, i.e. basicself-care tasks like washing and dressing (4items, .85); and Household Tasks, i.e. rou-tine household tasks like cooking, washing andcleaning (4 items, .86). All items have 5response categories ranging from every day tonever or always to never. The scores on the6 subscales were derived as the mood subscale,then the scores of the 6 subscales were addedtogether and divided by 6. The score on thiscombined physical function scale ranges from 0(good health) to 10 (poor health).

Pain Pain was measured using the pain scalefrom the Dutch-AIMS2. This scale comprises 5items, each having 5 response categories, rang-ing from every day to never. The scaleshowed good internal consistency ( .82). Anexample of the items is: During the past month,how often did your pain make it difficult for youto sleep?. The scores on the pain subscale werederived as the mood subscale, ranging from 0 (nopain) to 10 (great deal of pain).

Positive support To measure positive support weuse the Social Support ListInteractions(SSL12-I). Internal consistency and constructvalidity of the SSL12-I and its subscales werefound satisfactory (van Eijk, Kempen, & vanSonderen, 1994). The scale comprises 12 ques-tions on daily support (e.g. How often do peoplevisit you at home?), support in connection withproblems (e.g. How often do people give yougood advice?) and support for self-esteem (e.g.How often do people ask you for help oradvice?). The 4 response categories are: seldomor never, sometimes, regularly and often. Theinternal reliability of the scale was good ( .82). The scale score ranged from 1 (little positivesupport) to 4 (large amount of positive support).

Problematic support To measure problematicsupport we used a Dutch translation of a scale


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developed by Revenson et al. (1991). This scalecomprises 4 items: Do people become annoyedwhen you dont accept their advice?; Do peopletry to change the way you are coping with yourillness in a way you dont like?; Do people giveyou information or make suggestions that youfind unhelpful or upsetting?; and Do peoplefind it hard to understand the way you feel?. The4 response categories are: seldom or never,sometimes, regularly and often. The internal reli-ability of the scale was good ( .78). The scalescore ranged from 1 (little problematic support)to 4 (large degree of problematic support). Thusboth positive and problematic support scoresrange from 1 (low support) to 4 (high support).

Results

The 197 RA patients had a mean score of 3.15(SD 1.52) for depression measured with themood scale of the Dutch-AIMS2, which is rela-tively low on a scale ranging from 0 to 10, andreflects few feelings of depression. The scoresranged between 0.5 and 7.5; 17 percent ofrespondents had scores between 5.0 and 7.5,indicating that this group of RA patients had con-siderable levels of depressive symptoms.Depression did not correlate significantly withlevel of education and the mean score of womenfor depression (M 3.28) was not significantlydifferent to that of men (M 2.95). We did finda significant correlation between depression andage (r[197] .17, p .009); older patients wererelatively more depressed than younger patients.The correlation between depression and agemight be due to disease duration, because olderpatients have often suffered longer from RA(r[195] .18, p .006). There is a significantcorrelation between depression and disease dura-tion (r[195] .16, p .015), but the partial cor-relation between depression and age, controlled

for disease duration, is still significant (r[192] .14, p .026), which means that the relationshipbetween depression and age cannot totally beexplained by disease duration. The mean scoreand standard deviations of the variables, and thecorrelations between them, are presented inTable 1.

Both physical functioning and pain correlatedsignificantly with depression. RA patients withmore functional limitations and more pain hadhigher scores for depression compared to RApatients with fewer functional limitations andless pain. The first hypothesis is therefore sup-ported: that there is a direct relationship betweenthe stressors, functional limitations and pain, anddepression. We found that positive social supportwas not significantly correlated with depression,but problematic support had a direct relationshipwith depression. RA patients experiencing moreproblematic support had more feelings ofdepression compared to RA patients who experi-enced less problematic support. The correlationaldata do not support hypothesis 2a, but they dosupport hypothesis 2b.

Both physical functioning and pain had sig-nificant correlations with problematic support.RA patients experiencing more problematic sup-port had relatively more functional limitationsand pain compared to RA patients experiencingless problematic support. The level of positivesupport was significantly related only to physicalfunctioning. RA patients who experienced morepositive support had significantly more func-tional limitations compared to RA patients whoexperienced less positive support. This relation-ship is not very strong. There was no significantrelationship between positive and problematicsupport.

Hierarchical multiple regression analysis wasused to examine the moderating effects of posi-tive and problematic aspects of social support.


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Table 1. Mean scores and standard deviations for the main variables and their correlations

M SD 1 2 3 4 5

1. Depression 3.15 1.52 .45*** .52*** .10 .33***2. Physical Functioning 3.98 2.07 .48*** .12* .18**3. Pain 6.02 2.05 .01 .19**4. Positive Support 2.27 0.46 .035. Problematic Support 1.76 0.57

* p .05, ** p .01, *** p .001.


Sex, age and level of education were entered inthe first block as covariates, to control for demo-graphic variables. Functional limitations andpain were entered in the second block, followedby positive and problematic support in the thirdblock. In the fourth block the interaction of painand functional limitations on the one hand, andpositive and problematic support on the other,were entered, as well as the interaction betweenpositive and problematic support. We used cen-tred scores, which were calculated by subtractingthe mean score from respondents raw scores(xM

x), a process known as centring (Finney,

Mitchell, Cronkite, & Moos, 1984; see Table 2).Sex, age and level of education together

accounted for 4 percent of the variance in symp-toms of depression. Functional limitations andpain add another 29 percent to the explanation ofdepression, thus, in our study, functional limi-tations and pain are the main predictors ofdepression in RA patients. In the third block,positive and problematic support were entered.Both were significantly related to depression, andtogether they explained an additional 6 percentof the variance in depression. Thus both hypothe-ses 2a and 2b are supported.

The interactions between functional limi-tations and pain on the one hand, and bothaspects of social support on the other, wereentered in the final block, together with the inter-action between positive and problematic support.The interactions between functional limitations

and pain on the one hand, and both aspects ofsocial support on the other, appeared not to besignificantly related to depression. Social sup-port, whether it is perceived as positive or prob-lematic, did not have a moderating effect on therelationship between disease severity and feel-ings of depression.1 Thus both hypotheses 3a and3b are rejected.

The interaction between positive and problem-atic support did appear to be significantly relatedto depression, suggesting a moderating effect ofpositive support on the relationship betweenproblematic support and depression. This sup-ports hypothesis 4. To determine whether theinteraction indeed reflects a buffering effect, wedichotomized both aspects of social support, by amedian split, into either much or little posi-tive (Med 2.25) or problematic (Med 1.75)support. Next, for each of the four combinations(large degree of positive support and largeamount of problematic support, little positivesupport and large amount of problematic sup-port, etc.), the mean scores on depression arecalculated (see Figure 1).

For RA patients experiencing little problem-atic support we found no relationship betweenpositive support and feelings of depression.When RA patients experienced a greater degreeof problematic support, the amount of positivesupport experienced did influence their level ofdepression. We then found that RA patients withlittle positive support had more feelings of


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Table 2. Hierarchical regression analysis with depression as the dependent variable

Model 1 Model 2 Model 3 Model 4 R2 R2 R2 R2

Step 1: Sex .11 .03 .03 .01Age .17* .04 .04 .02Level of education .03 .04* .02 .02 .02

Step 2: Physical Functioning (FYS) .25*** .25*** .26***Pain (PYN) .40*** .33*** .36*** .35***

Step 3: Positive Support (POS) .14* .15*Problematic Support (PROBL) .22*** .39*** .23***

Step 4: FYS POS .02FYS PROBL .05PYN POS .08PYN PROBL .10POS PROBL .13* .42***

* p .05, *** p .001.


depression than those with more positive sup-port. These results support our fourth hypothesis:that positive social support does indeed producea buffering effect on depression.

Discussion

In this study we investigated the influence ofstressors, such as functional limitations and pain,on feelings of depression and the role of positiveand problematic support within this. Our firsthypothesis was confirmed by the study: RApatients with more functional limitations andpain experience more feelings of depression thanRA patients with fewer functional limitationsand pain.

The second hypothesis was only partly con-firmed by our study. Positive support appearednot to be related directly to depression, althoughproblematic support was. However, when welook at the results from the regression analysis,both positive and problematic aspects of socialsupport appeared to be related directly to feelingsof depression in RA patients. In other words, RApatients who experience more positive supporthave lower depression scores compared to RApatients experiencing less positive support; andRA patients experiencing more problematic sup-port have higher depression scores compared toRA patients experiencing less problematic sup-port. The fact that we did find a direct relation-ship between positive support and depressionbased on the regression analysis, while the corre-lation between the two showed no direct relation-ship, is due to the fact that this relationship in the

regression analysis is controlled for sex, age,level of education, functional limitations andpain. The regression analysis probably presentsthe clearest picture. The relationship betweenpositive support and depression is clouded by thehigh correlations between the stressors, func-tional limitations and pain, and depression.When the relationship between positive supportand depression is controlled for functional limi-tations and pain, it becomes clearer.

Our finding that problematic support is morestrongly related to depression than to positivesupport was also demonstrated in previousstudies among older adults, widows and cancerpatients (Finch, Okun, Barrera, Zautra, & Reich,1989; Rook, 1984; Tempelaar, de Haes, van denHeuvel, van Nieuwenhuijzen, & Pennink, 1987).Problematic support is not only more stronglyrelated to depression than positive support, it isalso more strongly related to other stressors, suchas pain and functional limitations. Our resultsindicate that problematic support is morestrongly related to the perceived consequences ofthe rheumatic disease (like depression, func-tional limitations and pain) than positive support.

The fact that we did not find a significant cor-relation between positive and problematic sup-port indicates that both concepts are independententities. A patient could receive only positivesupport from certain people, and from othersonly problematic supportor positive and prob-lematic support could be received from the samepersons. We cannot make further conclusionsbecause we did not go into further details aboutthe providers of support (both positive and prob-lematic aspects). Revenson et al. (1991) firstmade an inventory of the most important peoplein the social network, and then asked how muchpositive and problematic support the patientreceived from each person. They found no corre-lation between positive and problematic supporteither. It appeared that patients had both positiveand problematic interactions with the same per-sons from the social network.

The interactions between physical functioningand pain on the one hand, and both aspects ofsocial support on the other hand, were not sig-nificantly related to depression. Social support,whether perceived as positive or problematic,does not have a moderating effect on therelationship between disease severity (pain andfunctional limitations) and depression. Revenson


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Figure 1. The interaction between problematic andpositive support.


et al. (1991) found comparable results, which isalso in accordance with earlier studies into thebuffering effects of social support among RApatients: Doeglas et al. (1994) and Fitzpatrick,Newman, Lamb, and Shipley (1988) found nobuffering effect at all, and Affleck, Pfeiffer,Tennen, and Fifield (1988) found only a verylimited buffering effect of social support on therelationship between functional limitations andpsychological well-being. Brown, Wallston, andNicassio (1989) did find a buffering effect ofsocial support on the relationship between painand mood in a cross-sectional study, but in long-itudinal analyses over a 6-month period, theycould no longer find any buffering effect.

In our study positive support did appear tohave a buffering effect on the relationshipbetween problematic support and depression. InRA patients receiving more problematic support,we found a greater degree of depression whenthey also received less positive support; whileamong RA patients receiving less problematicsupport, we found no relationship between posi-tive support and depression. These results arealso comparable to those of Revenson et al.(1991). The buffering effect of positive supportindicates that, although problematic support isalways associated with increased levels ofdepression, the negative influence of problematicsupport may be reduced when a patient receivesmore positive support.

In our study functional limitations and pain arethe main predictors of depression in RA patients,adding another 29 percent to the explanation ofdepression. However, our model explains 42 per-cent of the variance in symptoms of depression,leaving 58 percent unexplained. There may beother measures of disease severity (e.g. fatigue),health beliefs and health behaviours, etc. thatcontribute to the explanation of depression.

In our study we included RA patients with dis-ease duration of at least 5 years, which meansthat our patients will be a little older, and there-fore probably more impaired because of theirrheumatic condition, compared to a representa-tive group of RA patients. Revenson et al. (1991)showed comparable findings among RA patientswith disease duration of a maximum of 2 years.Revenson found low scores on problematic sup-port among their respondents, ascribed by themto the short duration of the disease. Negativesocial interactions may increase as pain and

functional disability become more apparent. Ourresults do not support this assumption. Ourrespondents have longer disease duration and yetthe mean score on problematic support is rela-tively low. However, it is also possible thatrespondents do not want to admit that theyexperience a lot of problematic support, whichmeans that the low score on problematic supportmay be influenced by social desirability bias.Revenson et al. (1991) found no evidence ofsocial desirability bias in their measures, becausethe scores on problematic support did not signifi-cantly correlate with scores on an abbreviatedversion of the Marlowe-Crowne SocialDesirability scale. In studies among elderlypeople and elderly widows few negative interac-tions were also found (Finch et al., 1989; Rook,1984).

The age of the RA patients in our study was onaverage 3 years higher than would be expected ina representative group of RA patients, and dis-ease duration was on average 4 years higher(Taal, Jacobs, Seydel, Wiegman, & Rasker,1989). Scores on marital status were comparableto those of a representative group and scores onlevel of education were slightly lower than thoseof a representative group.

We have to be careful in the interpretation ofour results. First of all, it is important to remem-ber that the AIMS-Depression scale which weused to assess depression was developed as partof the AIMS to assess the overall impact of RA.Although it reflects the mood of the patient to adegree, its ability to measure a multidimensionalconstruct like depression and to distinguish clin-ically depressed from non-depressed individualshas not yet been examined in a clinical setting(Abdel-Nasser et al., 1998). The AIMS-Depression scale assesses depressive symptomswhich, while measuring an important outcomeaspect, does not presume a clinical diagnosis. Inour study the overall level of depressive symp-toms was rather low (M 3.15), but there was aconsiderable group of patients (17 percent) withhigh levels ( 5.0) of depressive symptoms.Second, the results are based on a single meas-urement and therefore we cannot draw conclu-sions about causality of the relationships. It couldbe that when RA patients are more depressed,they are more likely to consider support from thesocial network as problematic. We can con-clude, however, that we found, like Revenson et


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al. (1991), that social support does not only havepositive sides. In analysing the effects of psy-chosocial factors on the functioning of chronicpatients we should look not only at the positiveaspects of social support, but also at its problem-atic aspects and the relationships between thetwo. In interventions aimed at improving thepsychological health of RA patients, patientsshould also be taught how to cope with the prob-lematic aspects of social interactions. Theinvolvement of partners and family members inpatient education programmes could help pre-vent the deterioration in the psychosocial well-being of RA patients that so often accompaniesthe disease.

Though functional limitations and pain areseen to be the primary predictors of depression inRA patients, the contribution of support, whetherpositive or problematic, cannot be underesti-mated. By increasing awareness of patients sup-port requirements, to enable spouses and familymembers to allocate appropriate support, quanti-tatively and qualitatively, the risk of problem-atic support being given, and depression beingexperienced by the patient, can be substantiallyreduced.

Note

1. Two more regression analyses were performed: onein which positive support was entered in the thirdblock and the interactions between disease severityand positive support in the fourth block; and one inwhich problematic support was entered in the thirdblock and the interactions between disease severityand problematic support in the fourth block. Inneither of these regression analyses did we find anysignificant interaction effects.

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