Full text of DOI:10.1093/geronb/56.1.P35

Journal of Gerontology: PSYCHOLOGICAL SCIENCES
001, Vol. 56B, No. 1, P35–P45
Copyright 2001 by The Gerontological Society of America
2
Social Support and Treatment Response in Older
Depressed Primary Care Patients
Thomas E. Oxman and Jay G. Hull2
1
1Departments of Psychiatry and Community and Family Medicine, Dartmouth Medical School, Dartmouth-Hitchcock Medical
Center, Lebanon, New Hampshire.
2
Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire.
A previously tested theoretical model that specifies relationships among depression, activities of daily living
(ADL) impairment, and social support components was validated with 307 patients aged 60 and older from a
multisite effectiveness trial of 3 treatments (antidepressant, placebo, Problem-Solving Treatment) for dysthymia
or minor depression in primary care. Participants completed interviews and self-reports at baseline and at 6 and
1
2 weeks. The short-term, longitudinal data were analyzed with covariance structure modeling techniques. Con-
sistent with the previous model, impairment in ADLs was associated with subsequent increases in depression, a
larger emotionally close network that made frequent visits was associated with subsequent increases in perceived
support, and perceived support was associated with subsequent decreases in depression. This last effect was sig-
nificant only among participants randomly assigned to receive placebo with clinical management. The similar re-
sults in 2 different studies are a substantial validation of the theoretical model. The effect of perceived support
primarily in the placebo group suggests that those with greater perceived social support and subsyndromal de-
pression may be more likely to have a positive response to nonspecific clinical treatment components.
ANY researchers have identified an association between
social support and depression in older persons (Bowling
Browne, 1991; Henderson, Byrne, & Duncan-Jones, 1981;
treated by primary care physicians (Regier et al., 1993).
There is substantial evidence that patients with major de-
pression will respond to pharmacological or psychothera-
peutic treatment (Gloaguen, Cottraux, Cucherat, & Blackburn,
1998; Reynolds, 1997; Schneider & Olin, 1995; Schulberg,
Katon, Simon, & Rush, 1998). However, in older primary
care patients, subsyndromal depressions, such as minor de-
pression or dysthymia, are the most common types (Barrett,
Barrett, Oxman, & Gerber, 1988; Blazer, Hughes, & George,
1987; Johnson, Weissman, & Klerman, 1992; Olfson et al.,
1996), and the effectiveness of treatments for these other
depressive types is less certain (Coyne, Klinkman, Gallo, &
Schwenk, 1997; Katon et al., 1995; Kendrik, 1996; Oxman,
1997; Public Health Service Agency for Health Care Policy
and Research, 1993). Spontaneous remission without phar-
macotherapy or psychotherapy (Malt, Robak, Madsbu, Bakke,
& Loeb, 1999; Rapp, Parisi, & Wallace, 1991) and response
to clinical management alone (Miller, Frank, & Reynolds,
1999) may be higher in minor depression than in major de-
pression. Social support may play a significant role in pro-
moting such responses.
Because of the uncertainty of effective treatments for
these common conditions in primary care, we have previ-
ously evaluated two primary-care-based-treatments in an
11-week multicenter randomized trial (Barrett, Williams,
Oxman, Katon, Frank, Hegel, et al., 1999) comparing pla-
cebo, the antidepressant paroxetine, and Problem-Solving
Treatment for Primary Care (PST-PC; Mynors-Wallis,
1996), a cognitive behavioral therapy for primary care. All
three treatment groups received clinical management (Mil-
ler et al., 1999). In the overall results for the study (Barrett,
Williams, Oxman, Katon, Frank, Cornell, et al., 1999), par-
oxetine showed a small but significant treatment effect
compared to placebo but not to PST-PC. PST-PC showed a
M
&
Krause, Liang, & Yatomi, 1989; Matt & Dean, 1993; Oxman,
Berkman, Kasl, Freeman, & Barrett, 1992). In addition, social
support is frequently associated with less impairment in activi-
ties of daily living (ADLs) in elderly persons (Cummings et al.,
1
988; King, Reis, Porter, & Norsen, 1993; Wilcox, Kasl, &
Berkman, 1994). The interrelation of social support, ADLs,
and depression is particularly relevant in older medical patients
because of the greater likelihood of functional impairment (dif-
ficulty in performing ADLs; Oxman et al., 1992; Oxman,
Barrett, Freeman, & Manheimer, 1994; Schulz & Decker,
985; Siegal, Calsyn, & Cuddihee, 1987; Turner & Noh, 1988).
Notwithstanding these important lines of research, few
studies have simultaneously examined the relationship of
social support, depression, and ADLs. ADL impairment is
consistently a more powerful predictor of depression in el-
derly persons than is social support (Bowling & Farquhar,
991; Oxman et al., 1992). In addition, ADL impairment as
a consequence of illness is often associated with changes in
social support (Bloom & Kessler, 1994; Stoller & Pugliesi,
1
1
1
991; Wilcox et al., 1994). Unless depression, social sup-
port, and ADL impairment are analyzed simultaneously and
longitudinally, researchers cannot determine the extent to
which their interrelations are independent and which do-
main warrants priority for targeting interventions. This is
particularly relevant for the primary care physician faced
with a depressed patient. The primary care physician is con-
stantly facing competing demands that limit his or her time
and the health care system’s resources to simultaneously ad-
dress all three domains (Klinkman, 1997; Rost et al., 2000).
If treated for depression, the majority of older patients
with depression and functional impairment are likely to be
P35

P36
OXMAN AND HULL
faster response than placebo but not a significantly better re-
sponse at the end of the trial. The relatively small differences
suggest that clinical management, regardless of additional de-
pression-specific treatment, appears to be a reasonably effec-
tive treatment for many patients. Primary care physicians have
long been using “watchful waiting” as a treatment approach
for mild depression. Clinical management in this study was
more intense than the watchful waiting of usual care, but it is
less costly than a commitment to antidepressants or psycho-
therapy. An enhanced watchful waiting by primary care physi-
cians, along with predictors of patients who are not likely to
respond to clinical management alone, seems indicated. Social
support may be one such important predictor.
Given the number of studies examining the relationships
between social support and depression in elderly persons or
social support and ADLs, we have previously described a
theoretical framework that emerges from this literature and
propose that it applies to older medical patients. Research
supporting this model in a short-term (7-month) longitudi-
nal study of older adults undergoing heart surgery is re-
ported in Oxman and Hull (1997). In brief, our framework
was organized around three sets of relationships.
3. Social support and ADL impairment. The association of
social support with ADL impairment may diminish or
change direction unless new events occur (Fontana,
Kerns, Rosenberg, & Colonese, 1989; Glass & Maddox,
1992; Marottoli, Berkman, & Cooney, 1992). Because
we have been examining older patients with a mixture of
chronic and acute conditions, we hypothesized overall,
direct, unidirectional relationships from perceived sup-
port and network size to ADLs. The greater the per-
ceived adequacy of support, the lower will be the level of
impairment in ADLs. In turn, the lower the level of ADL
impairment, the lower will be the level of depression. So-
cial support thus can have both direct and indirect effects
to reduce depression severity.
In this study, we tested the generalizability of these rela-
tionships by evaluating the relationship of social support to
depression in older patients undergoing treatment for dys-
thymia or minor depression.
METHODS
Participants
1
. Components of social support. Social support is multidi-
mensional (Barrera, 1986; Heller, Swindle, & Dunsen-
bury, et al., 1986; Oxman & Berkman, 1990; Schaefer,
Coyne, & Lazarus, 1981; Seeman & Berkman, 1988;
Tardy, 1988). Three major components of social support
are (a) the network of support providers, (b) the type and
amount of support provided through that network, and
The details of the study design have been described in de-
tail elsewhere and are summarized here (Barrett, Williams,
Oxman, Katon, Frank, Hegel, et al., 1999). Primary care pa-
tients aged more than 60 were recruited for a comparative
treatment trial from patients currently enrolled in primary
care practices (family medicine or general internal medi-
cine) in four communities (Lebanon, NH, Pittsburgh, PA,
San Antonio, TX, and Seattle, WA). The four participating
centers were chosen for geographic diversity and diversity
of clinical populations. Patients aged 60 and older were re-
cruited through referral and screening at community, Veter-
ans Affairs, and academic-affiliated primary care clinics. To
be included, a participant needed to have had three or four
of the DSM-IV symptoms of depression for at least 1
month, one of which was depressed mood or anhedonia as
assessed by clinical interview, and to have a 17-item Hamil-
ton Rating Scale for Depression HAM-D; (Hamilton, 1960)
score of 10 or greater. Patients with dysthymia were also re-
quired to have had symptoms for at least 2 years. Depres-
sion diagnoses were made by a research psychiatrist or psy-
chologist using the PRIME-MD, a diagnostic instrument
designed for use in primary care (Spitzer et al., 1994). Pa-
tients were excluded if, within the past 6 months, they had
had major depression, active substance abuse, uncompli-
cated bereavement, parasuicidal behavior, or antisocial per-
sonality. Patients currently taking psychotropic drugs or
seeing a psychotherapist were also excluded because the
study was a treatment trial. Patients with cognitive impair-
ment (a Mini-Mental State Examination score of less than
23; Folstein, Folstein, & McHugh, 1975) or a terminal ill-
ness (less than 6 months to live) were also excluded.
(
&
c) the adequacy of that support (George, 1989; Oxman
Berkman, 1990). The components of social support
are interrelated. With respect to depression, the most im-
portant interrelationship is that types and frequency of
network contacts (Kessler, Kendler, Heath, Neale, &
Eaves, 1994; Oxman et al., 1992) are strongly associated
with the perceived adequacy of support. Persons who
have more frequent contact with network members to
whom they feel emotionally close perceive their support
as being more adequate (Oxman & Hull, 1997).
. Social support and depression. One of the consequences
of a severe mood disorder can be social withdrawal and a
more negative perception of social support. The support
may be more adequate than severely depressed persons
perceive it to be. However, severely depressed persons
may be difficult to be around and may indeed drive their
support away. In other words, their perception of inade-
quate support may be accurate. In contrast, participants
with less severe levels of depression are more likely to
have diminished social support precede the onset of de-
pressive symptoms (Alloway & Bebbington, 1987;
Brown, Bifulco, & Harris, 1987; Brugha et al., 1982).
Because we have been examining participants with the
less severe diagnoses of minor depression or dysthymia,
our framework included the hypothesis of a unidirec-
tional relationship from social support components to de-
pression. The greater the number of emotionally close
network members making frequent contact or the greater
the perceived adequacy of support, the less severe will be
the level of depressive symptoms.
2
Design
We randomly assigned patients giving consent to pla-
cebo, paroxetine, or PST-PC using a computer-generated
random allocation table. Randomization was blocked and
stratified by site and diagnosis. Treatment assignments were

SOCIAL SUPPORT AND TREATMENT
P37
held by a pharmacist and were available to study personnel
only in the event of emergent medical need.
For the overall study, 415 patients met eligibility criteria
and were randomized to placebo (n ϭ 140), paroxetine (n ϭ
relative scale values for each item responded yes within the
category, dividing by the maximum possible score for that
category, and then multiplying by 100. The potential range
for each category is 0 to 100. Three categories—ambula-
tion, mobility, and body care and movement—are summed
to form the physical dimension, a basic ADL measure. In
this study we used only the physical dimension score be-
cause the full SIP score contains items that overlap with so-
cial support and depression. Although the majority of the
work on reliability and validity has been done with the total
score, in other studies (e.g., Ott et al., 1983; Oxman, Free-
man, Manheimer, & Stukel, 1994) reliability of the physical
dimension score of the SIP has been sufficiently high.
To understand better how social support relates to im-
proved outcomes, several investigators have described mul-
tidimensional models of social support (Barrera, 1986;
Heller et al., 1986; Oxman & Berkman, 1990; Schaefer et
al., 1981; Seeman & Berkman, 1988; Tardy, 1988). Three
major components of social support are (a) the network of
support providers, (b) the type and amount of support pro-
vided through that network, and (c) the adequacy of that
support (George, 1989; Oxman & Berkman, 1990). In pre-
vious work we found that the dimension of the type and
amount of support was not relevant to depressive symp-
toms. Accordingly, because this was an effectiveness trial
with a limited number of measures, in this project we in-
cluded only the dimensions of the network and the ade-
quacy of support. To assess social networks we used the in-
terview-based Social Network Questionnaire from the New
Haven site of the Established Populations for the Epidemio-
logic Study of the Elderly (Seeman & Berkman, 1988). As a
summary measure we used the total number of emotionally
close network members (children, relatives, friends) who
were seen regularly, that is, at least once per month. To as-
sess perceived adequacy of support we used the Multidi-
mensional Scale of Perceived Social Support (MSPSS;
Zimet, Dahlem, Zimet, & Farley, 1988). The MSPSS is a
12-item self-report measure with a 7-point scale from “very
strongly disagree” to “very strongly agree.” Item scores are
averaged for a total ranging from 1 to 7. The MSPSS pro-
vides a summary score as well as three subtype scores for
perceived adequacy of support from a significant other,
family, and friends. Internal and test-retest reliability are
high, and validity has been demonstrated in older medical
patients (Hann, Oxman, Ahles, Furstenberg, & Stukel 1995;
Oxman, Freeman, et al., 1994).
1
37), or PST-PC (n ϭ 138). Patient characteristics were dis-
tributed equally among groups (mean age 71, 59% male,
8% White). Diagnoses were dysthymia (n ϭ 211) or minor
7
depression (n ϭ 204). Participants were included in the
analyses for this study only if they completed the 11-week
trial and had complete data for baseline, mid-treatment
(
6-week), and end of treatment (11-week) interviews. The
method of analysis we used—structural equation model-
ing—was designed to deal with complete data only (Bentler
&
Chou, 1988, p. 180).
These restrictions resulted in a sample of 307 patients
randomized to placebo (n ϭ 110), paroxetine (n ϭ 93), or
PST-PC (n ϭ 104). The mean age was 71; 61% of partici-
pants were male and 76% were White. Diagnosis sample
sizes were 161 persons with dysthymia and 146 persons
with minor depression.
Procedures
At each site, we used a variety of methods to educate par-
ticipating primary care providers about referral. We also
used brief depression screening instruments at some sites to
bring potential patients to the attention of their provider for
referral. Participants thus were identified in the primary care
practice setting as potentially having either dysthymia or
minor depression and were referred for a research evalua-
tion. A two-phase evaluation took place within 1 week of
identification. The initial phase was a semi-structured clini-
cal interview to determine eligibility. For patients meeting
criteria, a complete description of the study was provided
and written informed consent obtained. Those who agreed
to participate were then administered additional measures,
including social support, and randomized to one of the three
treatment arms. Participants in all three arms were offered
six subsequent treatment visits at 1, 2, 4, 6, 8, and 10 (for
PST-PC) or 11 (for paroxetine and placebo) weeks.
Measures
The semi-structured interview included mood, anxiety,
and alcohol modules from the Prime-MD (Spitzer et al.,
1
994), the 17-item HAM-D (Hamilton, 1960), and portions
of the Structured Clinical Interview for Diagnosis (SCID;
Spitzer, Williams, Gibbon, & First, 1992).
To assess depression severity, we used the interview-
based 17-item HAM-D (Hamilton, 1960), ranging from 0 to
Analysis
53 for the single-rater version used in this study. The HAM-D
has shown reliability and validity in measuring depression
in elderly patients (McDowell & Newell, 1987; Oxman,
Barrett, et al., 1994).
We used the interview-administered Sickness Impact Pro-
file (SIP) (Bergner, 1978) to measure ADLs. The SIP mea-
sures functional impairments from illness and consists of
Hypotheses.—The following groups of hypotheses were
incorporated into a single structural equation model that we
tested using data obtained from older patients in the treat-
ment trial of dysthymia or minor depression. The perceived
adequacy of social support at 6 weeks, after three treatment
visits, is a positive function of the number of emotionally
close network members seen regularly before the start of
treatment. A similar relationship exists between the 6-week
assessment and the end of treatment assessment at 11
weeks. The theoretical framework we are testing includes a
unidirectional path from social support to depression. We
1
36 statements in 12 categories. All items concentrate on
changes in performance. Participants are instructed to re-
spond yes to a statement only if they are sure it describes
them at the time of questioning and is related to health sta-
tus. Category scores are calculated by adding predetermined

P38
OXMAN AND HULL
hypothesized that depressive symptoms at the 6-week as-
sessment are a negative function of the perceived adequacy
of support pretreatment and the number of network mem-
bers seen regularly pretreatment, and a positive function of
the amount of impairment in pretreatment ADLs. Similar
relationships exist between predictors assessed at the 6-week
assessment and depression at the 11-week assessment. Im-
pairment in ADLs at the 6-week assessment is a negative
function of the perceived adequacy of support and the num-
ber of network members seen regularly pretreatment. Simi-
lar relationships exist between the 6-week assessment and
the 11-week assessment.
paths depicted in Figure 2 to the paths included in the base
model. Once again, a multigroup analysis was conducted in
which this model was simultaneously applied to all three
treatment groups. In addition to the constraints applied to
the base model, all paths depicted in Figure 2 were con-
strained to be equal across groups. This model also provided
2
a reasonable fit to the data, ␹ (192, n ϭ 307) ϭ 365.18,
CFI ϭ .91, NFI ϭ .82, NNFI ϭ .90, and a significantly bet-
2
ter fit than the base model, difference ␹ (12, n ϭ 307) ϭ
21.57, p Ͻ .05. Conceptually, this improvement in the fit of
the model is equivalent to an omnibus demonstration that
the theorized short-term, longitudinal relationships (de-
picted in Figure 2) have predictive validity over and above
the cross-sectional correlation of the variables at Time 0 and
their longitudinal stability over Time 1 and 2 (depicted in
Figure 1).
Covariance structure models.—We conducted all cova-
riance structure models using the statistical program EQS
(Bentler, 1989) applied to the covariance matrix of the ob-
served variables for participants without missing data.
Whereas usual test statistics are appropriate when listwise
deletion is used for missing data, pairwise deletion or sub-
stituting estimates for missing values raises questions re-
garding the appropriateness of standard error estimates and
goodness of fit statistics (Bollen, 1989). To test the ade-
quacy of our theorized model, we used the recommended
As an explicit test of the hypothesis that the theorized as-
sociations varied as a function of treatment, a set of models
was specified in which the equality constraints specified in
the initial theoretical model were systematically lifted. The
fit of each resultant model was then compared against the
fully constrained, initial theoretical model. In all, six addi-
tional models were specified. These models differed in
terms of the paths they allowed to vary across groups. Con-
ceptually, each of these models represents a test of a spe-
cific interaction or moderation in the strength of a relation-
ship between variables as a consequence of treatment group.
If a particular model fits better than the initial theoretical
model, then the paths being tested vary in strength across
groups.
(
e.g., Anderson & Gerbing, 1988) procedure of specifying
nested models: (a) a rudimentary base model and (b) a theo-
rized model that includes all of the paths in the base model
plus a set of additional paths that were theorized a priori. To
demonstrate the utility of one’s theorized model, one must
show that (a) it fits significantly better than the base model
and (b) the theorized paths that distinguish it from the base
model are statistically significant on an individual basis.
Among the six models, Model A was of greatest interest
insofar as it allowed the perceived support to depression
paths to vary across treatment groups. Model B allowed the
ADL impairment to depression paths to vary across groups.
Model C allowed the perceived support to ADL impairment
paths to vary across groups. Model D allowed the network
size to perceived support paths to vary across groups. Model
E allowed the network size to depression paths to vary
across groups. Finally, Model F allowed the network size to
ADL impairment paths to vary across groups. In all cases,
constraints were released for both the Time 0 to Time 1 and
Time 1 to Time 2 paths. Of these six models, only Model A
fit better than the fully constrained initial theoretical model,
RESULTS
The mean HAM-D scores pretreatment and after 6 weeks
of treatment were 13.5 (SD 2.65), range 10–22, and 8.96
(
SD 4.95), range 0–25, respectively. The mean HAM-D
score at 11 weeks was 7.25 (SD 4.92), range 0–27. Mean
SIP physical dimension pretreatment was 12.1 (SD 12.7),
range 0–68.0. The most common medical conditions were
hyperlipidemia (29.3%), arthritis (25.4%), diabetes mellitus
(19.2%), benign prostatic hypertrophy (18.9%), and hyper-
tension (17.9%). Ninety-eight percent of participants had at
least one comorbid medical diagnosis, and 46.3% had five
or more diagnoses. Mean SIP physical dimension score af-
ter 6 weeks of clinical management was 11.5 (SD 12.7) and
at 11 weeks was 10.4 (SD 12.3), range 0–80.1. Tables 1–3
display the means, standard deviations, and correlation ma-
trix for each treatment group (paroxetine, PST-PC, placebo)
across the three time points.
2
difference ␹ (4, n ϭ 307) ϭ 9.85, p Ͻ .05. This finding
supports the hypothesis that the association of perceived so-
cial support with subsequent depression varies as a function
of treatment group. Inspection of the effects within groups
revealed that perceived support at Time 0 is predictive of
decreased depression at Time 1 and perceived support at
Time 1 is predictive of decreased depression at Time 2 in
the placebo group (standardized path coefficients ϭ Ϫ.18,
z ϭ Ϫ2.03, p Ͻ .05, and Ϫ.22, z ϭ Ϫ2.79, p Ͻ .01, respec-
tively), but not in the antidepressant group (standardized
path coefficients ϭ Ϫ.02, z ϭ Ϫ.22, ns, and .11, z ϭ 1.23,
ns, respectively) or the PST-PC group (standardized path
coefficients ϭ Ϫ.02, z ϭ Ϫ.25, ns, and Ϫ.09, z ϭ Ϫ1.09,
ns, respectively).
An initial model was specified in which all exogenous
variables were allowed to intercorrelate and only autore-
gressive structural effects were included (Figure 1). A mul-
tigroup analysis was conducted in which this model was si-
multaneously applied to all three treatment groups (placebo,
paroxetine, PST-PC) with the depicted paths, the variances
of the exogenous variables, and the errors for the endoge-
nous variables constrained to be equal across groups. This
2
model provided a reasonable fit to the data, ␹ (204, n ϭ 307) ϭ
Values for the standardized coefficients in Model A are
depicted in Figure 3. In order to reduce clutter, we do not
depict values for the base paths shown in Figure 1, values
3
86.75, CFI ϭ .89, NFI ϭ .80, NNFI ϭ .90.
We developed an initial theoretical model by adding the

SOCIAL SUPPORT AND TREATMENT
P39
Table 1. Means, Standard Deviations, and Correlations of Social Support, Depression, and ADL Variables for Paroxetine Group (n ϭ 93)
Time 0
Time 1
Time 2
Variables
1
2
3
4
5
6
7
8
9
10
11
12
Time 0, baseline
1
2
. Perceived adequacy of support
. No. of close network members
1.00 0.28* Ϫ0.03 Ϫ0.04
0.66****
0.30**
0.36***
0.60****
Ϫ0.05
Ϫ0.17
Ϫ0.01
0.05
0.71****
0.18
0.33***
0.47**** Ϫ0.01
Ϫ0.09
Ϫ0.01
0.13
1.00
Ϫ0.09
0.07
seen Ն1/month
3
4
. HAM-D
. SIP physical dimension
1.00
0.19 Ϫ0.01
Ϫ0.01
0.09
0.21*
0.31*
0.09
0.82****
Ϫ0.05
0.08
0.05
0.35***
0.02
0.43****
0.07
0.86****
1.00
0.01
Time 1, 6 weeks of treatment
5
6
. Perceived adequacy of support
. No. of close network members
1.00
0.41****
1.00
Ϫ0.07
Ϫ0.07
Ϫ0.01
0.09
0.72****
0.45****
0.34***
0.70****
0.10
0.02
0.05
0.18
seen Ն1/month
7
8
. HAM-D
. SIP physical dimension
1.00
0.38**** Ϫ0.06
0.05
0.37***
0.46****
0.40****
0.31**
0.88****
1.00
0.04
Time 2, 11 weeks of treatment
. Perceived adequacy of support
9
1.00
0.40****
1.00
0.09
0.16
0.07
0.42****
1
0. No. of close network members
seen Ն1/month
1
1
1. HAM-D
2. SIP physical dimension
1.00
0.48****
1.00
M
SD
4.69 4.24
1.14 3.36
14.0
2.88
13.2
13.9
5.02
1.21
4.68
3.13
8.27
4.52
13.18
14.86
5.00
1.20
4.60
3.57
6.16
4.23
11.18
13.21
Notes: ADL ϭ activities of daily living; HAM-D ϭ Hamilton Rating Scale for Depression; SIP ϭ Sickness Impact Profile.
p Յ .05; **p Յ .01; ***p Յ .001; ****p Յ .0001.
*
for the network size to ADL impairment paths (Time 0 to
Time 1 standardized path coefficient ϭ Ϫ.00, z ϭ Ϫ.01, ns;
Time 1 to Time 2 standardized path coefficient ϭ .04, z ϭ
three values for the perceived support to depression paths
varied depending on treatment group and reflected those ob-
served in the placebo, antidepressant, and PST-PC groups,
respectively.
1
.31, ns), and values for the perceived support to ADL im-
pairment paths (Time 0 to Time 1 standardized path coeffi-
cient ϭ Ϫ.01, z ϭ Ϫ.44, ns; Time 1 to Time 2 standardized
path coefficient ϭ .00, z ϭ .10, ns), although these values
were included in the specification of the model. Finally, the
The basic conclusions to be drawn from the effects de-
picted in Figure 3 are (a) ADL impairment was associated
with subsequent increases in depression, (b) larger network
size was associated with subsequent increases in perceived
Table 2. Means, Standard Deviations, and Correlations of Social Support, Depression, and ADL Variables for PST-PC Group (n ϭ 104)
Time 0
3
Time 1
Time 2
Variables
1
2
4
5
6
7
8
9
10
11
12
Time 0, baseline
1
. Perceived adequacy of
support
. No. of close network
1.00 0.36**** Ϫ0.02 Ϫ0.11
0.69****
0.36***
0.31***
Ϫ0.07
Ϫ0.10
Ϫ0.06
0.66****
0.36***
0.26**
Ϫ0.12
Ϫ0.08
Ϫ0.05
2
1.00
Ϫ0.16 Ϫ0.05
0.48**** Ϫ0.09
0.55**** Ϫ0.18
members seen Ն1/month
3
4
. HAM-D
1.00
0.34*** Ϫ0.01
1.00 Ϫ0.22*
0.03
0.42****
0.32***
0.80****
Ϫ0.02
Ϫ0.04
Ϫ0.13
0.28**
0.36***
0.81****
. SIP physical dimension
Ϫ0.03
0.25**
0.19
0.21*
Time 1, 6 weeks of treatment
5
. Perceived adequacy of
support
. No. of close network
1.00
0.38**** Ϫ0.12
Ϫ0.18
0.72****
0.39****
0.33***
Ϫ0.16
Ϫ0.09
6
1.00
Ϫ0.20*
0.04
0.54**** Ϫ0.12
0.04
members seen Ն1/month
7
8
. HAM-D
1.00
0.34***
1.00
Ϫ0.21*
Ϫ0.26**
Ϫ0.05
0.57****
0.23*
0.39****
0.85****
. SIP physical dimension
Ϫ0.14
Time 2, 11 weeks of treatment
9
. Perceived adequacy of
support
1.00
0.46**** Ϫ0.24**
Ϫ0.09
Ϫ0.03
1
0. No. of close network
1.00
Ϫ0.13
members seen Ն1/month
1
1
1. HAM-D
1.00
0.40****
1.00
2. SIP physical dimension
M
4.51 4.66
1.16 4.79
13.4
2.54
11.5
12.0
4.62
1.18
4.64
4.13
9.56
5.28
11.1
11.8
4.68
1.26
4.93
4.02
7.60
5.36
10.1
12.0
SD
Notes: ADL ϭ activities of daily living; PST-PC ϭ Problem-Solving Treatment for Primary Care; HAM-D ϭ Hamilton Rating Scale for Depression; SIP ϭ Sick-
ness Impact Profile.
p Յ .05; **p Յ .01; ***p Յ .001; ****p Յ .0001.
*

P40
OXMAN AND HULL
Table 3. Means, Standard Deviations, and Correlations of Social Support, Depression, and ADL Variables for Placebo Group (n ϭ 110)
Time 0
3
Time 1
Time 2
Variables
1
2
4
5
6
7
8
9
10
11
12
Time 0, baseline
1
. Perceived adequacy of
support
. No. of close network
1.00 0.18* Ϫ0.01
Ϫ0.02
0.70****
0.18
0.34***
Ϫ0.20*
Ϫ0.01
Ϫ0.10
0.67****
0.13
0.34***
Ϫ0.23**
Ϫ0.06
2
1.00
0.18* Ϫ0.12
0.42**** Ϫ0.11
0.40**** Ϫ0.14
Ϫ0.09
members seen Ն1/month
3
4
. HAM-D
. SIP physical dimension
1.00
0.22* Ϫ0.19*
0.08
Ϫ0.11
0.45****
0.07
0.28**
0.85**** Ϫ0.07
Ϫ0.08
0.03
Ϫ0.02
0.11
0.18*
0.20*
0.79****
1.00
0.01
Time 1, 6 weeks of treatment
5
. Perceived adequacy of
support
. No. of close network
members seen Ն1/month
. HAM-D
1.00
0.34**** Ϫ0.30**
Ϫ0.07
0.74****
0.27**
0.30**
Ϫ0.35***
Ϫ0.12
Ϫ0.12
0.10
6
1.00
Ϫ0.17
Ϫ0.18
0.73**** Ϫ0.14
7
8
1.00
0.19*
1.00
Ϫ0.23*
Ϫ0.07
Ϫ0.23*
0.05
0.50****
0.22*
. SIP physical dimension
0.83****
Time 2, 11 weeks of treatment
9
. Perceived adequacy of
support
1.00
0.29**
1.00
Ϫ0.35**** Ϫ0.17
1
0. No. of close network
Ϫ0.10
0.03
members seen Ն1/month
1
1
1. HAM-D
2. SIP physical dimension
1.00
0.23*
1.00
M
SD
4.75 5.05
1.09 4.61
13.3
2.51
11.6
12.3
4.80
1.15
5.16
4.19
8.99
4.94
10.5
11.5
4.88
1.21
5.06
4.39
7.85
4.91
9.96
11.8
Notes: ADL ϭ activities of daily living; HAM-D ϭ Hamilton Rating Scale for Depression; SIP ϭ Sickness Impact Profile.
p Յ .05; **p Յ .01; ***p Յ .001; ****p Յ .0001.
*
social support, and (c) perceived support was associated
with subsequent decreases in depression, although this last
effect varied as a function of treatment group in that it was
only the case among participants randomly assigned to re-
ceive a placebo drug.
a function of diagnosis. A multigroup analysis was con-
ducted in which the initial theoretical model was simulta-
neously applied to data from each diagnosis group (minor
depression, dysthymia) with all paths, exogenous variances,
and endogenous errors constrained to be equal across diag-
2
nosis. This model provided a good fit to the data, ␹ (114, n ϭ
Subsidiary Analyses
307) ϭ 251.30, CFI ϭ .92, NFI ϭ .87, NNFI ϭ .91. As in
the treatment group analyses, we specified six additional
Qualification of model by diagnosis.—We performed a
set of analyses to determine if the fit of the model varied as
Figure 1. Base structural model for relationships among depres-
sion, ADL impairment, and social support components.
Figure 2. Theoretical structural model for relationships among
ADL impairment, depression, and social support components.

SOCIAL SUPPORT AND TREATMENT
P41
paths of principal theoretical interest (i.e., those that appear
in Figure 2) varied as a function of location. These six mod-
els parallel in form Models A–F described previously. None
of these models resulted in an improvement in fit over the
initial theoretical model. Inspection of the univariate modi-
fication statistics (Lagrange Multiplier Tests) revealed that
we could improve the model by relaxing several constraints
on equivalent stabilities and correlations across sites (i.e.,
the paths that appear in Figure 1) and equivalent exogenous
variances and endogenous errors. Indeed, simply relaxing the
constraints on equivalent variances and errors (while main-
taining the constraint that all paths that appear in Figures 1
and 2 be equal across groups) yielded a model with a rea-
2
sonable fit to the data, ␹ (234, n ϭ 307) ϭ 430.24, CFI ϭ
.
88, NFI ϭ .78, NNFI ϭ .87. However, for both this model
and the previous model, univariate modification statistics
revealed that none of the equality constraints of theoretical
interest (i.e., those related to paths that appear in Figure 2)
significantly degraded the model. In terms of the substan-
tive interests of the present research, it can be concluded
that the fit of the model did not vary as a function of data
collection site.
Figure 3. Trimmed structural model for relationships among de-
pression, ADL impairment, and social support components. Num-
bers are standardized coefficients. The three values for perceived
support are those observed in the placebo, antidepressant, and PST-
PC groups, respectively. All parameters associated with the base
model were estimated but for clarity are not depicted. Similarly, the
nonsignificant coefficients for network size to ADL impairment and
for perceived support to ADL impairment are not shown. *p Ͻ .10;
DISCUSSION
From the broadest perspective, the results of this study
replicate a short-term, longitudinal model relating social
support, ADL impairment, and depression, suggesting that
the proposed theoretical model is quite robust. In this
model, ADL impairment is associated with subsequent in-
creases in depressive symptoms, but depressive symptoms
are not associated with increases in ADL impairment. A
larger, emotionally close network that makes frequent visits
is subsequently associated with higher perceived adequacy
of social support. In turn, perceived social support is associ-
ated with subsequent decreases in depression, but only
among participants randomly assigned to treatment with
placebo plus clinical management.
*
*p Ͻ .05.
models to test the hypothesis that the paths of principal the-
oretical interest (i.e., those that appear in Figure 2) varied as
a function of diagnosis. These six models parallel in form
Models A–F described previously. None of these models re-
sulted in an improvement in fit over the initial theoretical
model. Inspection of the univariate modification statistics
(
Lagrange Multiplier Tests) revealed that we could improve
The participants in the present study were different in nu-
merous ways from the sample of heart surgery patients on
which the original model was tested (Oxman & Hull, 1997).
Participants in the earlier study were seen because they
were undergoing the same intensive surgical procedure at
the same hospital. They were not all depressed. Participants
in the present study were all depressed, were all primary
care outpatients suffering sufficiently to enter a randomized
controlled trial for depression, had more impairment in
ADLs than did the heart surgery patients, and came from
four geographically diverse regions. Despite these differ-
ences, there was substantial replication of the theoretical
model across these samples. Particularly encouraging for
the stability of the model is that in the present study there
was internal replication of findings from Time 0 to Time 1
in the findings from Time 1 to Time 2.
The unidirectional nature of the relationships is helpful in
better understanding the significance and mechanisms of
social support. The perception of adequate support appears
to be related to having contact with persons with whom one
feels emotionally close. The confirmation of a unidirec-
tional path from adequate support to depression suggests
that the perception of adequate support is not a secondary
the model by relaxing several constraints on equivalent sta-
bilities and exogenous correlations across diagnosis (i.e.,
the paths that appear in Figure 1) and equivalent exogenous
variances and endogenous errors. However, univariate mod-
ification statistics revealed that none of the equality con-
straints of theoretical interest (i.e., those related to paths that
appear in Figure 2) significantly degraded the model. In
terms of the substantive interests of the present research, it
can be concluded that the fit of the model did not vary as a
function of diagnosis group.
Qualification of model by site.—We performed a set of
analyses to determine if the fit of the model varied as a
function of data collection site. A multigroup analysis was
conducted in which the initial theoretical model was simul-
taneously applied to data from each of the four sites (Leba-
non, Pittsburgh, San Antonio, Seattle) with all paths, exoge-
nous variances, and endogenous errors constrained to be
equal across sites. This model provided a poor fit to the
2
data, ␹ (270, n ϭ 307) ϭ 731.05, CFI ϭ .73, NFI ϭ .63,
NNFI ϭ .73. As in the treatment group analyses, we speci-
fied six additional models to test the hypothesis that the

P42
OXMAN AND HULL
effect of mood on perception. In addition, the present results
replicate the earlier finding of a unidirectional relationship be-
tween impairment in ADLs and depression. Impairment in
ADLs leads to more depressive symptoms, but depressed
mood does not contribute significantly to impairment in ADLs.
In the present study, conducted in participants with more
severe and chronic depression and ADL impairment, the
relative replication of the model, especially in the context of
a mental health intervention rather than a surgical interven-
tion, suggests that key aspects of the model are firm and
meaningful. Despite replication of multiple associations,
some aspects of the model were not confirmed in this sam-
ple. There was no direct effect of the social network size on
lower depression or less ADL impairment as there was in
the heart surgery sample. In addition, there was no effect of
adequate perceived support on less ADL impairment as
there was for the heart surgery patients. Such differences
raise a question as to whether there were different events in
the surgical sample (presurgical anticipation, acute postsur-
gical recovery, longer term improvement in function) with
different psychological impacts. These events suggest that
part of the earlier model may have been an effect of those
particular stimuli and events.
positive conditioning can evoke better mood in the presence
of emotionally supportive contacts. Having close confidants
to turn to during stressful times can reduce the surge of neg-
ative emotions that occurs with depression. There are also
subtle but potentially powerful nonverbal interactions that
occur between persons that influence mood both positively
and negatively (Coyne & Downey, 1991; Geerts, Bouhuys,
& Van den Hoofdakker, 1996; Gerin, Milner, Chawla, &
Pickering, 1995; Levenson, Carstensen, Friesen, & Ekman,
1991). Put simply, feeling cared for leads persons to feel
good about themselves.
ADL Impairment
ADL impairment is a powerful predictor of depression in
elderly persons (Beekman et al., 1997; Bowling & Farqu-
har, 1991; Koenig, 1998; Oxman et al., 1992; Sherbourne et
al., 1995). This relationship may be stronger for minor de-
pressions or for the chronicity of major depression than for
acute major depressions (Beekman et al., 1997; Hays,
Wells, Sherbourne, Rogers, & Spritzer, 1995). In our analy-
ses, a comparison of the standardized coefficients for ADL
impairment and depression to those of perceived adequacy
of support and depression suggests that for subsyndromal
depressions the magnitude of effects are equivalent.
Our finding of no effect of social support on ADL impair-
ment is consistent with a longer term temporal model (Stol-
ler & Pugliesi, 1991; Wilcox et al, 1994). Acute events af-
fecting ADLs such as those surrounding heart surgery are
more likely to show a relationship with social support. The
most frequent illnesses in our participants were chronic con-
ditions (e.g., diabetes mellitus, arthritis) or findings that
lead to illness (e.g. hyperlipidemia, hypertension). In the
present study primary care physicians followed participants
who were outpatients rather than hospitalized for an acute
event. With chronicity social support is associated with
weaker and conflicting effects on the incidence (Seeman et
al., 1995) and course (Glass & Maddox, 1992; Wilcox et al.,
Social Support
Two key issues arise in understanding the validity of
these results: (a) the specificity of the effect of social sup-
port to the placebo group and (b) the mechanisms by which
social support has these effects.
Specificity.—Depression has different components such
as mood, cognition, and somatic symptoms. Antidepres-
sants such as paroxetine have direct effects on these features
and, at least in milder depression, do not seem to be aug-
mented by social support. In cognitive-behavioral ap-
proaches such as PST-PC, patients develop strategies to
cope and successfully implement these strategies. Imple-
mentation has been explicitly theorized to be linked to
changes in cognition and mood (Mynors-Wallis, 1996). Use
of active coping strategies has also been related to improve-
ments in mental health (Sherbourne, Hays, & Wells, 1995)
and is different than the specific focus on symptoms, side
effects, and adherence that occurs in clinical management.
Thus, for active, specific depression treatments like parox-
etine or PST-PC, naturalistic, social support appears to be
redundant and without additive benefit. In contrast, in the
placebo group social support appears to be additive to the
benefits of attention from clinical management and the ex-
pectations of positive benefit from placebo.
1
994) of ADL impairment. Theories to explain this include
unbalanced exchange theory (Dowd, 1975) and network at-
trition (Lewis & Meredith, 1988). Thus, for longer periods
the associations of social support with ADL impairment ap-
pear to diminish or even change direction unless new events
occur (Fontana et al., 1989; Glass & Maddox, 1992; Marot-
toli et al., 1992).
Limitations
There are several limitations of this study that qualify in-
terpretation or generalizability. First, we had to rely on a sub-
set of participants with no missing data. This can result in
outcomes that are less conservative than analyses in which
the last value obtained is carried forward. Second, because of
the relatively small sample size we did not include latent vari-
able representations. Third, these findings cannot necessarily
be extrapolated to older persons with major depressive disor-
der. The associations between social support and depression
may be weaker in persons with more severe depression (An-
drew, Hawton, Fagg, & Westbrook, 1993; Brugha et al.,
1987; Ezquiaga, Garcia, Bravo, & Pallares, 1998).
Mechanisms.—The experience of adequate (or inade-
quate, Coyne & Downey, 1991) social support can have ef-
fects on depression through biological, psychological, or so-
cial mechanisms. It is likely that indirect, if not direct,
effects of social support are mediated through the central
nervous system, even if these mechanisms are poorly under-
stood. For example, just as negative conditioning can result
in anticipatory vomiting during chemotherapy for cancer,

SOCIAL SUPPORT AND TREATMENT
P43
Implications
with minor depression or dysthymia. International Journal of Psychia-
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These longitudinal results from a randomized trial
strongly confirm the importance of both social support and
ADL impairment to depression in elderly persons. These re-
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change social network contacts or perceived adequacy in
milder depressions. These results, along with others (e.g.,
Beekman et al., 1997; Kendrik, 1996), support a cost-effec-
tive watchful waiting approach coupled with more selective
use of depression-specific treatments. For older primary
care patients with minor depression or dysthymia, it would
appear reasonable for physicians to pursue an initial strat-
egy of “watchful waiting” as long as the person is embed-
ded in an emotionally close network that makes regular con-
tact, particularly if ADL impairment is low. Watchful
waiting is an approach with which primary care physicians
are familiar for conditions such as depression (Williams et
al., 1999). Although watchful waiting is usually not as in-
tense as clinical management (three to six visits over 3
months), it would appear to deserve increased use in milder
depressions.
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In contrast, for patients without emotionally close network
contact, particularly when coupled with more severe ADL
impairment, beginning depression-specific treatments sooner
would seem to be indicated. Treatment for such individuals
will also be improved if physicians incorporate a diathesis-
stress model of depression (Coyne & Whiffen, 1995). Treat-
ment and future research for such individuals need simulta-
neously to address the possibility of enduring personality
traits that lead to smaller supportive networks as well as mod-
ification of the current social and life cycle context that might
result in less support (Coyne & Downey, 1991).
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From the broadest perspective, characterizing patients
along dimensions of social support and ADL impairment
could lead to a more cost-effective use of resources, includ-
ing learning how to improve inadequate social support.
Acknowledgments
This work was supported by the John D. and Catherine T. MacArthur
Foundation and the John A. Hartford Foundation.
Address correspondence to Thomas E. Oxman, MD, Department of
Psychiatry, Dartmouth-Hitchcock Medical Center, 1 Medical Center
Drive, Lebanon, NH 03756. E-mail: t.oxman@dartmouth.edu
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Received December 2, 1999
Accepted April 11, 2000
Decision Editor: Toni C. Antonucci, PhD