Coping strategies, hostility, and depressive symptoms - Springer Link

INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 10(4), 331–342 Copyright © 2003, Lawrence Erlbaum Associates, Inc.

Coping Strategies, Hostility, and Depressive Symptoms: A Path Model Wei-Chung Mao, Wayne A. Bardwell, Jacqueline M. Major, and Joel E. Dimsdale

Previous studies of coping, hostility, and depressive symptoms have highlighted the significant relations between all possible pairs of these 3 variables. To more completely explore the nature of depressive symptoms, we link them all together in this study by testing a coping→hostility→depressive symptoms path model. One hundred forty participants completed psychological questionnaires measuring coping strategies, hostility, and depressive symptoms. While controlling age and social class as covariates, SPSS stepwise regression analyses were used to examine relations among these 3 constructs. Results suggest that coping has a direct relation with depressive symptoms as well as an indirect relation mediated by hostility. Passive coping may lead to increased hostility, resulting in depressive symptoms. Active coping may have the opposite effect. These findings suggest that the inclusion of measures of both coping strategies and hostility yields a more thorough understanding of concomitants of depressive symptoms. From a clinical perspective, knowing what coping strategies a person uses and how much anger they experience and express may be useful in guiding the management of depressive symptoms. Key words: depression, hostility, anger, coping, mood

This work was supported by Grants HL36005 and RR00827 from the National Institutes of Health. Wei-Chung Mao, Department of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan; Wayne A. Bardwell and Joel E. Dimsdale Department of Psychiatry, University of California, San Diego, CA; Jacqueline M. Major, Department of Family and Preventive Medicine, University of California, San Diego, CA. Correspondence concerning this article should be addressed to Wayne A. Bardwell, UCSD, Department of Psychiatry, La Jolla, CA 92093–0804. E-mail: [email protected]

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MAO, BARDWELL, MAJOR, DIMSDALE

For many years, psychiatrists and psychologists have been interested in the links among coping, hostility, and depression (Littrell & Beck, 2001; Moreno, Selby, Fuhriman, & Laver, 1994; Parker & Brown, 1982; Pugh, 1983). However, these links were usually studied two variables at a time. It is rare that investigations looked at relations among all three domains. To consider all three together is important because recent studies have highlighted significant relations between all possible pairs of these three variables. To link them all together may more closely and completely approach the nature of depressive symptoms. By looking at all three domains, however, the question arises as to which variable mediates the relation between the other two.

COPING Coping strategies are defined as “conscious, rational ways for dealing with the anxieties of life” (Reber, 1985). They are viewed as a response to emotion and as having the function of arousal or tension reduction (Folkman & Lazarus, 1988a). Two modes of coping (problem focused [active] and emotion focused [defensive]) have been identified (Lazarus & Folkman, 1984).

COPING AND DEPRESSION Coping has two widely recognized major functions: regulating stressful emotions (emotion-focused coping) and altering the troubled person–environment relations that are causing the distress (problem-focused coping; Folkman, Lazarus, Dunkelschetter, Delongis, & Gruen 1986). Though the coping–depression literature is of course extensive, it seems pertinent to note that internal coping resources (e.g., personality characteristics) appear to play a stronger role in protecting against the onset of depressive symptomatology than do external resources (e.g., social support; Richman & Flaherty, 1985). Less use of problem-focused coping and more use of emotion-focused coping is strongly correlated with level of distress (Roy-Byrne et al., 1992), poor adaptation (Vitaliano, Maiuro, Russo, & Becker, 1987) and increased risk for higher depression score after a stressful event (Jacobs, Kasl, Schaefer, & Ostfeld, 1994). Studies of chronically ill patients have also revealed that the use of more passive and less active coping strategies is associated with higher levels of depressive symptoms in participants having HIV (Patterson et al., 1993) and breast cancer (Rowland & Massie, 1998).

HOSTILITY AND DEPRESSION The idea that depressive illness is associated with hostility is one of the major premises of psychodynamic and interpersonal theories, and was first discussed over

COPING STRATEGIES, HOSTILITY, AND DEPRESSIVE SYMPTOMS

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90 years ago (Abraham, 1911). Since Freud (Freud, 1917), some psychological theories have viewed depression as the inward turning of aggressive drives triggered by the loss of an important love object (Cohen, 1990; Meissner, 1977; Pedder, 1992). Depressed patients are reported to experience moderately abnormal levels of anger and have a tendency to suppress instead of express their anger, compared to either normal or PTSD groups (Riley et al., 1989). It is interesting to note that researchers have observed a decrease in hostility after treatment for depression (Lyketsos, Blackburn, & Tsiantis, 1978). Epidemiological evidence has given some support to the theory that depression is associated with an inhibition of aggressive responses to frustration (Kendell, 1970; Lyons, 1972), but conflicting findings are indicative of the complex nature of the hostility–depression relation (Fava, Kellner, Munari, Pavan, & Pesarin, 1982; Fernando, 1977). Numerous studies (e.g., Maiuro, Osullivan, Michael, & Vitaliano, 1989) underscore the importance of differentiating the experience and expression of hostility in depression. These findings suggest that, though we do not know the direction of causality between hostility and depression, we may better understand the mechanisms of depressive symptoms by understanding their associations with hostility.

COPING AND HOSTILITY Some research has revealed that hostility is associated with specific coping styles. Schill, Ramanaiah, & Olaughlin (1985) suggested that poor coping is characteristic of individuals who are resentful, suspicious, irritable, and guilty and who express their hostility indirectly (Schill et al., 1985). On the other hand, efficient coping was associated with a minimum of hostility. Numerous studies in diverse populations such as substance abusers and elder abusers link hostility to altered coping behaviors (Comijs, Jonker, van Tilburg, & Smit, 1999; McCormick & Smith, 1995). Chronic verbal aggression was associated with having less control over problem situations and a higher tendency to react aggressively when angry. Physical aggression was associated with a passive and avoidant coping. Such studies imply that coping and hostility may affect each other. On the one hand, effective coping is associated with lower levels of hostility; on the other, underlying hostility may also influence the choice of coping strategies. Meanwhile, both hostility and certain coping strategies may result in aggressive behavior.

HYPOTHESIZED PATH MODEL The articles reviewed show the complex separate relations between coping and hostility, hostility and depressive symptoms, and coping and depressive symptoms. Published articles studying the interplay of all three domains of coping, an-

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ger–hostility, and depression are rare: Materazzo reported headache patients who use less effective coping strategies and suppressed their anger may experience more depressive symptoms (Materazzo, Cathcart, & Pritchard, 2000). However, this study did not address the role of hostility as a mediator between coping and depressive symptoms. Although coping strategies have been previously shown to be associated with depressive symptoms, we hypothesized that hostility may partially mediate this relation. On the one hand, ineffective coping may have a direct relation with depressive symptoms. On the other, ineffective coping may cause increased hostility, resulting in higher levels of depressive symptoms. Effective coping may have the opposite effect. We propose to test a path model of these relations, which is shown in Figure 1.

METHODS Participants All participants were recruited through advertisement or word-of-mouth referral and were excluded if they had a history of major medical or psychiatric illness. This is a secondary analysis of data from a study of stress and blood pressure. When we initially designed this study, we wanted as homogenous a sample as possible. Given the effects of reproductive hormones on blood pressure, we excluded women in the following categories to be able to see a clearer stress–blood pressure relation: those on hormone replacement therapy or oral contraceptives, pregnant, postmenopausal, or with premenstrual syndrome. Participants were eligible for enrollment if they were 20 to 55 years old and 90% to 130% of ideal body weight as determined by Metropolitan Life Insurance Tables (Metropolitan Life Foundation, 1983). A psychological assessment battery was administered on the participants’ enrollment into this study and was completed before any other study interventions. The protocol was approved by the University of California, San Diego, Institutional Review Board, and written consent was obtained from all participants.

FIGURE 1 Hypothesized path model for coping strategies, hostility, and depressive symptoms.


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Measures

Ways of Coping Questionnaire–Revised (WC). The WC is used to gauge how people respond to stressful situations (Folkman & Lazarus, 1988b). Yielding eight subscales (confrontive coping, seeking social support, planned problem solving, positive reappraisal, distancing, self-control, accepting responsibility, escape-avoidance), WC data can be consolidated into approach and avoidance factors (Patterson et al., 1993). These factors can be thought of as representing active (confrontive coping, seeking social support, planned problem solving, positive reappraisal) and passive (distancing, self-controlling, accepting responsibility, escape–avoidance) coping strategies, respectively. The WC has been shown to be an adequately reliable and valid questionnaire, which has been used to assess coping strategies in a variety of general and patient populations (Clark, Bormann, Cropanzano, & James, 1995; Ntoumanis & Biddle, 2000; Sherbourne, Hays, & Wells, 1995; Wineman, Durand, & McCulloch, 1994). Buss-Durkee Hostility Scale (BD). The BD consists of 75 true–false items (Buss & Durkee, 1957) and has been shown to be reliable and valid in a variety of populations. It provides a total hostility score as well as separate scores on subscales that can be consolidated into Expression of Anger (indirect hostility, physical assaultiveness, verbal expression) and Experience of Anger (resentment, suspiciousness) (Biaggio, 1980; Mills, Dimsdale, Nelesen, & Dillon, 1996; Suarez & Williams, 1990). Center for Epidemiological Studies–Depression Scale (CES–D). The CES–D (Radloff, 1977) is a frequently used 20-item self-report scale that has been shown to be reliable and valid for assessing depressive symptoms in the general population and in a variety of community samples (Golding & Aneshensel, 1989; Knight, Williams, McGee, & Olaman, 1997; Roberts, 1980). Statistical Analysis The following categorical and quantitative variables were analyzed: age, gender, social class, body mass index (BMI), coping, hostility, and depressive symptoms. Mean values and corresponding standard errors were calculated. Pearson correlation coefficients were calculated to assess the direction and magnitude of association between variables. In three exploratory models, we used stepwise multiple regression analysis. Since age, gender, and social class have been implicated as demographic predictors of depression, we calculated their simple correlations with the CES-D, BD, and WC to determine if they should be controlled as covariates in each model. All data analyses were performed using the software program SPSS 10.0 (SPSS, Chicago, IL).

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RESULTS Participant characteristics are shown in Table 1. Participants averaged 37 years of age and were of somewhat lower social class (4.28 on a 1 to 5 scale, with 1 being the highest social class; Hollingshead, 1975). We were more successful at recruiting men than women (100 vs. 40). Also of note is the mean CES-D score of 20.70—a level higher than usually observed in the general population. Simple correlations were calculated for demographic variables (age, gender, social class) with CES-D, BD, and WC. Significant correlations were observed for CES-D with age (r = –.215, p = .008) and social class (r = .198, p = .013), for BD Experience with age (r = –.330, p < .001) and social class (r = .177, p = .024), for BD Expression with age (r = –.198, p = .013), and for WC Passive with age (r = –.204, p = .011). No significant correlations were found for gender. Therefore, age and social class but not gender were included as covariates. Table 2 shows Pearson correlations among the coping, hostility, and depressive symptom variables. All variables are significantly intercorrelated, with the exception of WC Active, which is significantly correlated only with WC Passive (r = 0.59). Table 3a–c provides the results of the stepwise regression analyses of the Coping → Hostility → Depressive Symptoms path model. In all of the analyses, covariates were entered as the first step. In Table 3a, the relation of BD Expression versus WC Active and WC Passive was assessed. In Table 3b, the relation of BD Experience versus WC Active and WC Passive was assessed. Finally, in Table 3c the direct relations of CES–D versus BD Experience, BD Expression, WC Active, and WC Passive were assessed. TABLE 1 Participant Characteristicsa Demographics Gender Age Social class Coping WC Active WC Passive Hostility BD Experience BD Expression Depressive symptoms CES–D

100 Males, 40 Females 37.49 ± 6.03 4.28 ± 0.71 8.51 ± 3.28 8.1 ± 3.39 39.91 ± 23.92 51.89 ± 17.74 20.70 ± 12.40

Note. Social class: Hollingshead Method (Hollingshead, 1975). WC = Ways of Coping; BD = Buss–Durkee Hostility Inventory; CES–D = Center for Epidemiological Studies–Depression. aN = 140.


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TABLE 2 Correlation Matrix (r)

BD Experience BD Expression WC Active WC Passive

CES–D

BD Experience

0.60** 0.37** 0.04 0.43**

0.58** 0.13 0.47**

BD Expression

–0.01 0.24**

WC Active

0.59**

Note. CES–D = Center for Epidemiological Students–Depression; BD = Buss–Durkee Hostility Inventory; WC = Ways of Coping. **p