YEBEH-04259; No of Pages 4 Epilepsy & Behavior xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Brief Communication
Gender differences in social support in persons with epilepsy Silke Burkert a,⁎,1, Friederike Kendel a,1, Henriette Kiep b, Martin Holtkamp b, Verena Gaus b a b
Institute of Medical Psychology, Charité-Universitätsmedizin Berlin, Luisenstr. 57, 10117 Berlin, Germany Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
a r t i c l e
i n f o
Article history: Received 29 October 2014 Revised 12 February 2015 Accepted 28 February 2015 Available online xxxx Keywords: Epilepsy Gender Stress Perceived social support Social integration
a b s t r a c t The present study focused on social support as a key feature of the enhancement and maintenance of mental health. So far, literature on gender differences in social support and its effects on the experience of stress in individuals with epilepsy is scarce. We hypothesized that in individuals with epilepsy, social support buffers detrimental effects of stressors (e.g., unpredictable occurrence of seizures) on mental health. Additionally, we explored the role of gender in this process. In 299 individuals with epilepsy, data from validated questionnaires on seizures in the last 3 months, perceived support, social network size, and depressive symptoms were analyzed. Women reported higher depressive symptoms (t = 2.51, p b .01) and higher perceived support (t = 2.50, p b .01) than men. Women and men did not differ in social network size (t = −0.46, p = 64), nor in experiencing seizures (χ2 = 0.07, p = .82). Regression analyses revealed no buffer effects. Perceived support was negatively associated with depressive symptoms (B = −0.49, p b .001, 95% CI [−0.67; −0.32]). With regard to depressive symptoms, social integration was slightly more beneficial for women (Bcond. = − 0.06, p b .001; 95% CI [−0.09; −0.03]) than for men (Bcond. = −0.02, p = .09; 95% CI [−0.04; 0.01]). Findings present perceived support and social integration as general health resources in individuals with epilepsy regardless of previously experienced seizures. They also encourage further research on gender-specific effects in individuals with epilepsy and move towards recommendations for practitioners and gender-specific interventions. Future aims will be to enhance social integration in order to support adjustment to the chronic condition of epilepsy and to improve individuals' confidence in support interactions. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is a chronic medical condition with major impacts on various aspects of daily life. In addition to biomedical diagnostic and therapeutic demands, treatment of individuals with epilepsy equally requires the psychosocial perspective [1]. The present study focuses on the influence of psychosocial issues on how individuals handle their disease. In general, psychosocial adjustment may be complicated by both disease characteristics and comorbid depressive symptoms. Within this process, interacting with people, especially social support, also seems to play an important role. The few previous studies provide only an incomplete picture, for instance: lack of social support is associated with poor mental health (e.g., depressive symptoms) in individuals with epilepsy [2,3]. However, men and women with epilepsy are often socially isolated [4] and less satisfied with their social support interactions [5]. In the present study, we explored whether social support is either generally relevant in individuals with epilepsy regarding mental health ⁎ Corresponding author at: Charité-Universitätsmedizin Berlin, Institute of Medical Psychology, Luisenstr. 57, 10117 Berlin, Germany. Tel.: +49 30 450 529 218. E-mail address: [email protected] (S. Burkert). 1 Both authors contributed equally to this paper.
or merely in the presence of stressors, e.g., unpredictable occurrence of seizures [5]. Social support can be seen as a general health resource, including quantitative and qualitative aspects. A commonly used quantitative indicator of social support is social integration, e.g., number of network partners [6]. It describes whether an individual is part of a social network; however, no information about the quality of social interactions is conveyed. In contrast, qualitative indicators refer to retrospective reports covering the recipient's perspective, i.e., whether social support from network partners was mobilized and received and the provider's perspective, i.e., whether social support was provided [6]. Additionally, perceived support refers to a prospective belief that social support is available if needed [6]. As a general resource, social support would enhance or maintain health, independent of current stress experiences. In contrast, Cohen and Wills postulated a stress-buffering effect of social support which implies less detrimental effects of stressful (e.g., diseases-related) events on individuals' mental health in case of higher social support (buffer hypothesis) [7]. While a general effect would be statistically indicated by main effects of social support, a buffer effect would be indicated by an interaction of social support and epilepsy-related stress indicators (e.g., seizures in the last 3 months). Men and women generally differ with regard to social support. Women commonly rely on more elaborated social networks than
http://dx.doi.org/10.1016/j.yebeh.2015.02.041 1525-5050/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
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S. Burkert et al. / Epilepsy & Behavior xxx (2015) xxx–xxx
men [8]. In contrast, perceived support, which refers to subjective expectations that, e.g., support from others is available if needed, is not known to differ between men and women [9]. Data on general gender differences in epilepsy are scarce, and to our knowledge, no studies have specifically dealt with gender differences in social support. We hypothesize two buffer effects with regard to perceived support and social integration taking gender into account: on the one hand, experiencing seizures is not related to depressive symptoms in individuals with higher confidence that support will be available (i.e., higher perceived support) in contrast to those with lower perceived support. On the other hand, experiencing seizures is not related to depressive symptoms in individuals with a larger number of network partners (i.e., higher social integration) in contrast to those reporting a lower social integration. Because literature on social support in the context of epilepsy does not allow deriving gender-specific hypotheses, gender effects were investigated in an exploratory way. 2. Method 2.1. Design A total of 319 individuals with epilepsy were invited to participate in a questionnaire and semistructured interview study in the outpatient clinic of the Department of Neurology, Charité-Universitätsmedizin Berlin between February 2011 and March 2012. Seven patients declined to participate; all other patients signed informed consent. Six participants did not meet inclusion criteria (i.e., epilepsy diagnosis not verified). Participants with missing data (n = 7) were excluded from the current analyses. These 13 participants did not differ significantly from the final sample analyzed here (data not shown). About half (53.8%) were female. The majority (63.5%) reported a maximum of 9 or 10 years of schooling as well as living with a partner (67.5%). Only 17.1% of the participants were currently certified as unfit or incapacitated for work; 40.8% of participants were employed. Almost all patients (91%) had experienced generalized tonic– clonic seizures. Generalized epilepsy syndromes were found in 23.5% and partial epilepsy syndromes in 70.9%. Further sample characteristics are reported in Table 1. The study was approved by the local ethics committee (EA2/133/10). 2.2. Measures As an indicator of mental health, depressive symptoms were measured by nine depression items from the highly reliable and valid Patient Health Questionnaire (PHQ-9) [10], reflecting diagnostic criteria from the Diagnostic and Statistical Manual-5 (DSM-5) for major depression (range: 0–27; Cronbach's α = .80). Perceived support was
measured by five items of the highly reliable and valid German version [11] of the ENRICHD Social Support Inventory (ESSI; range: 5–25; Cronbach's α = .75) [12]. To assess social integration, participants indicated the total number of network partners (i.e., living in their household, family, close friends, colleagues, neighbors, leisure contacts and others) assessed by multidimensional social contact cycle (MUSK) [13]. Additionally, self-reported seizures in the last 3 months and gender were considered as moderators. Further continuous variables such as age and duration of epilepsy in years as well as dichotomous variables (0 = no/1 = yes) including current relationship, generalized epilepsy, antiepileptic drug polytherapy, and potentially mood-enhancing antiepileptic medication were considered as covariates. 2.3. Statistical procedures For the sample description, group comparisons for dichotomous variables were calculated by means of χ2-tests, and those for continuous variables were calculated by means of t-tests. Main hypotheses, i.e., predictions of continuous variables by multiple predictors, were tested by means of linear regressions. Moderation analyses were conducted using the PROCESS macro based on linear regression analyses (version 2.041) [14]. In a first model, depressive symptoms were predicted by perceived support, seizures in the last 3 months, and gender as well as the respective 2-way and 3-way interactions, controlling for covariates mentioned above. In the second and third models, perceived support was replaced by social integration. All predictors were centered around their grand means, and interaction terms were computed by the multiplication of the predictor and moderator in each model [15]. Significant interactions were plotted with values of M + 1SD (high) and M − 1SD (low) [15]. Conditional effects, i.e., distinct effects of perceived support or social integration, respectively on depressive symptoms for men or women, were calculated by means of simple slope analysis [15]. Data were screened for statistical outliers. 3. Results As depicted in Table 1, in the sample of 299 patients with epilepsy, participants showed on average mild severity of depressive symptoms with significantly higher values in women than men. On average, perceived support was very high, with women perceiving significantly more support than men. Women and men did not differ significantly in their reported network size of about 33 network partners. Hypotheses were tested by means of moderation analyses. In both men and women, perceived support was associated with less depressive symptoms, regardless of seizures in the past 3 months (see Table 2). In contrast to our hypothesis, no buffer effect of perceived
Table 1 Sample characteristics and gender differences. Total sample N (%) Gender Living in partnership Antiepileptic drug polymedication Potentially mood-enhancing AED Generalized epilepsy Seizures in the last 3 months
Age (in years) Duration of disease (in years) PHQ-9 (0–27) Perceived support (ESSI; 0–25) Social integration (MUSK)
– 202 (67.6) 121 (40.5) 106 (35.5) 70 (23.4) 165 (55.2)
Women N (%) 161 (53.8) 111 (68.9) 55 (34.2) 65 (40.4) 55 (34.2) 90 (55.9)
Men N (%)
χ2
138 (43.2) 91 (65.9) 66 (47.8) 41 (29.7) 15 (10.9) 75 (54.3)
p
0.31 5.76 3.69 22.48 0.07
.62 .02 .07 b.001 .82
M (SD)
M (SD)
M (SD)
t
p
44.4 (16.5) 20.3 (16.8) 6.72 (5.17) 22.41 (3.38) 33.4 (29.7)
40.4 (14.9) 20.0 (16.5) 7.40 (5.02) 22.87 (2.94) 32.6 (5.02)
49.0 (17.1) 20.5 (17.2) 5.91 (5.26) 21.88 (3.78) 34.3 (5.3)
−4.59 −0.23 2.51 2.50 −0.46
b.001 .82 .01 .01 .64
Note: N = sample size, M = mean, SD = standard deviation; dichotomous covariates (0 = no, 1 = yes): partner, antiepileptic drug polymedication, potentially moodenhancing antiepileptic drug (AED), generalized epilepsy, seizures in the last 3 months; PHQ = Patient Health Questionnaire, ESSI = ENRICHD Social Support Inventory, MUSK = multidimensional social contact cycle, number of contacts.
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
S. Burkert et al. / Epilepsy & Behavior xxx (2015) xxx–xxx
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Table 2 Interactions of seizures in the last three months, social support, and gender. DV: depressive symptoms Social support: perceived support (ESSI)
Age Living in partnership Duration of disease Antiepileptic drug polymedication Potentially mood-enhancing AED Generalized epilepsy Seizures in the last 3 months Social support Gender Seizure ∗ social support Seizure ∗ gender Social support ∗ gender Seizure ∗ social support ∗ gender
Social support: social integration (MUSK)
B
SE
t
p
95% CI
B
SE
t
p
95% CI
−0.03 −0.50 0.02 −0.78 −1.77 −0.96 1.19 −0.49 −2.02 0.14 −2.31 0.21 0.11
−0.02 0.62 0.02 0.77 0.75 0.70 0.60 0.09 0.60 0.18 1.14 0.17 0.35
−1.49 −0.81 0.78 −1.01 −2.37 −1.39 −1.97 −5.44 −3.35 0.82 −2.03 1.20 0.31
.14 .42 .44 .31 .02 .17 .05 b.001 b.001 .42 .04 .23 .75
[−0.07; 0.01] [−1.72; 0.72] [−0.02; 0.05] [−2.29; 0.73] [−3.24; −0.30] [−2.33; 0.40] [0.01; 2.37] [−0.67; −0.32] [−3.20; −0.83] [−0.20; 0.49] [−4.56; −0.07] [−0.13; 0.54] [−0.57; 0.79] R2 = .22
−0.03 −1.31 0.02 −1.09 −2.58 −0.79 1.27 −0.04 −1.43 0.01 −2.63 0.03 0.02
0.02 0.61 0.02 0.79 0.77 0.72 0.60 0.01 0.61 0.02 1.14 0.02 0.04
−1.463 −2.16 1.17 −1.38 −3.34 −1.10 2.11 −3.80 −2.35 0.48 −2.30 1.53 0.60
.10 .03 .24 .17 b.001 .27 .04 b.001 .02 .63 .02 .13 .55
[−0.07; 0.01] [−2.51; −0.12] [−0.02; 0.06] [−2.64; 0.47] [−4.10; −1.06] [−2.19; 0.62] [0.08; 2.46] [−0.05; −0.02] [−2.63; −0.23] [−0.03; 0.05] [−4.88; −0.38] [−0.01; 0.07] [−0.05; 0.10] R2 = .18
Note: N = 202; DV = dependent variable; B = unstandardized regression weight indicating the strength of predictor-specific associations with DV, SE = standard error, t = significance test, p = error probability/level of significance; social support indicators: perceived support or social integration; gender (1 = women, 2 = men); dichotomous covariates (0 = no, 1 = yes): living in partnership, potentially mood-enhancing antiepileptic drug (AED), psychotropic effects of medication, generalized epilepsy, seizures in the last 3 months; ESSI = ENRICHD Social Support Inventory, MUSK = multidimensional social contact cycle, number of contacts; main effect of perceived support and 2-way interaction of social integration and gender confirmed by post hoc analyses without further interactions.
support was detected indicated by a nonsignificant 2-way interaction of perceived support and experiences of seizures and a nonsignificant 3-way interaction of perceived support, experiences of seizures, and gender (see Table 2). In a post hoc regression analysis with a single interaction, we tested the significant 2-way interaction of experiencing seizures in the last 3 months and gender, controlling for all other predictors. It did not reach significance. Also, social integration did not buffer detrimental effects of seizures in the last 3 months on depressive symptoms (see Table 2), which is in contrast to our hypothesis. Independent of seizures and gender, social integration was related to less depressive symptoms. Again, we tested the significant 2-way interaction of gender and social integration in a post hoc regression analysis. Social integration turned out to be especially beneficial in women, regardless of seizures in the last 3 months. Women with larger social networks reported slightly less depressive symptoms (conditional effect of − 0.06 in women: t = − 3.66, p b .001; 95% CI [− 0.09; − 0.03]) whereas social integration was not associated with depressive symptoms in men (conditional effect of −0.02 in men: t = −1.73, p = .09; 95% CI [−0.04; 0.01]). 4. Discussion The main finding of the present study was that in patients with epilepsy, the perception of available support (perceived support) was associated with beneficial effects with regard to depressive symptoms. This is true for men and women and independent of the experience of disease-related stressors, i.e., seizures in the last 3 months. Even though this is in line with previous studies on other populations (e.g., patients with chronic cardiac disease) [11], this finding is remarkable since perceived support is based on previous social interactions which are commonly experienced to be less satisfying by individuals with epilepsy [5]. Perceived support additionally depends on individual appraisals which are influenced by personality traits like optimism; this might explain our findings and point to opportunities for interventions. Another indicator, more specific, and antecedent of social support is integration into a social network. Surprisingly, men and women with epilepsy did not differ in the number of network partners. This is noteworthy since commonly, women report larger networks than men [8]. This raises the question of whether and how they differ in how they use and benefit from their social networks. In the present study, we used a quantity measure, i.e., the number of network partners, as well as a quality measure, i.e., the subjective appraisal that social support is available in times of need. These indicators do not reflect actual support interactions
in terms of mobilized, provided, and received support [6,16], which should be considered in future research. Moreover, women benefited slightly more from their networks than men. This finding extends the existing literature by a gender-sensitive perspective on epilepsy. Consequently, knowledge about the quality of social support and the effectiveness of specific support providers will allow for developing successful gender-specific support interventions for individuals with epilepsy [17]. In the present study, we could not provide evidence for a buffering effect of perceived support or social integration. This might be due to our choice of an epilepsy-related stress indicator, i.e., seizures in the last 3 months, which is only one stressor among many others in this patient population. Taking epilepsy as a stressor per se, future studies should compare individuals with epilepsy and healthy controls in order to test whether social support buffers disease-related stress. However, on the one hand, higher reports of perceived support were associated with less depressive symptoms in both men and women, pointing to a general health resource. On the other hand, women reported higher amounts of perceived support and depressive symptoms than men. These gender differences in depression are a well-known phenomenon in the depression literature [18] and are, for instance, explained either by a higher vulnerability in women [19] or a response bias, i.e., underreporting of symptoms in men [20]. With regard to perceived support, gender differences are less investigated in clinical samples; however, literature indicates that women generalize different kinds of available support whereas men differentiate between different kinds of support [21]. Gender-specific appraisals might also lead to a higher amount of perceived support in women. Consequently, perceived support interventions can be developed to change individuals' cognitive appraisals to more positive expectations in terms of concretizing and differentiating between different kinds of anticipated support. In addition to limitations regarding sample and study methods mentioned above, some further limitations must be addressed. First, a causal interpretation of our findings is not possible because findings are based on cross-sectional and self-reported data. Thus, we cannot rule out that self-reported social indicators might be affected by depressive symptoms. Second, generalizability is limited due to data from a monocenter study. Third, with regard to depression, the present sample of patients with epilepsy was characterized by only a mild severity of symptoms. Thus, in future studies, this research question should be investigated in patients with epilepsy who are more strongly affected by symptoms of depression. Our study complements previous data focusing on biomedical and psychosocial issues of epilepsy by a gender-specific perspective. The
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
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findings encourage further research on gender-specific effects in the context of epilepsy. They may help to develop recommendations for practitioners and for interventions to improve individuals' confidence in support interactions as well as gender-specific needs of interventions. This may help to enhance social integration in order to support adjustment to the chronic condition of epilepsy. Author contributions Study concept and design: Gaus, Kiep, and Holtkamp. Data collection: Gaus, Kiep, and Holtkamp. Statistical analysis: Burkert. Interpretation of data: Burkert and Kendel. Drafting of the manuscript: Burkert. Critical revision of the manuscript for important intellectual content: Kendel, Kiep, Gaus, and Holtkamp. Disclosure None of the authors has any conflict of interest to disclose that is related to the content of this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. References [1] Elliot JO, Richardson VE. The biopsychosocial model and quality of life in persons with active epilepsy. Epilepsy Behav 2014;41:55–65. [2] Lu B, Elliott JO. Beyond seizures and medications: normal activity limitations, social support, and mental health in epilepsy. Epilepsia 2012;53(2):e25–8. [3] Reisinger EL, Dilorio C. Individual, seizure-related, and psychosocial predictors of depressive symptoms among people with epilepsy over six months. Epilepsy Behav 2009;15(2):196–201.
[4] McCagh J, Fisk JE, Baker GA. Epilepsy, psychosocial and cognitive functioning. Epilepsy Res 2009;86(1):1–14. [5] Kobau R, Luncheon C, Zack MM, Shegog R, Price PH. Satisfaction with life domains in people with epilepsy. Epilepsy Behav 2012;25(4):546–51. [6] Schwarzer R, Knoll N. Functional roles of social support within the stress and coping process: a theoretical and empirical overview. Int J Psychol 2007;42(4):243–353. [7] Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull 1985;98(2):310–57. [8] Helgeson VS. Psychology of gender. 2nd ed. Upper Saddle River, NJ: Pearson; 2005. [9] Verhofstadt LL, Buysse A, Ickes W. Social support in couples: an examination of gender differences using self-report and observational methods. Sex Roles 2007; 57(3–4):267–82. [10] Kroehnke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16(9):606–13. [11] Kendel F, et al. Ein deutsche Adaptation des ENRICHED Social Support Inventory (ESSI). Diagnostica 2011;57(2):99–106. [12] ENRICHD-Investigators. Enhancing Recovery in Coronary Heart Disease (ENRICHD) study intervention: rationale and design. Psychosom Med 2001;63(5):747–55. [13] Linden M, Lischka AM, Popien C, Colombek J. Der multidimensionale Sozialkontakt Kreis (MUSK) – ein Interviewverfahren zur Erfassung des sozialen Netzes in der klinischen Praxis (The multidimensional social contact cycle). Z Psychol 2007; 16(2):135–43. [14] Hayes AF. Introduction to mediation, moderation, and conditional process analysis. New York: The Guilford Press; 2013. [15] Cohen J, Cohen P, West SG, Aiken LS. Applied multiple regression/correlation analysis for the behavioral sciences. 3rd ed. Hillsdale: Erlbaum; 2003. [16] Walker ER, et al. A mixed methods analysis of support for self-management behaviors: perspectives of people with epilepsy and their support providers. Epilepsy Behav 2014;31:152–9. [17] Elliott JO, Charyton C, Sprangers P, Lu B, Moore JL. The impact of marriage and social support on persons with active epilepsy. Epilepsy Behav 2011;20(3):533–8. [18] Martin A, Rief W, Klaiberg A, Braehler E. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry 2006;28(1):71–7. [19] Nolen-Hoeksema S, Larson J, Grayson C. Explaining the gender difference in depressive symptoms. J Pers Soc Psychol 1999;77(5):1061–72. [20] Sigmon ST, et al. Gender differences in self-reports of depression: the response bias hypothesis revisited. Sex Roles 2005;53(5/6):401–11. [21] Matud PM, Ibánez I, Bethencourt JM, Marrero R, Carballeira M. Structural differences in perceived support. Pers Indiv Differ 2003;35(8):1919–29.
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Brief Communication
Gender differences in social support in persons with epilepsy Silke Burkert a,⁎,1, Friederike Kendel a,1, Henriette Kiep b, Martin Holtkamp b, Verena Gaus b a b
Institute of Medical Psychology, Charité-Universitätsmedizin Berlin, Luisenstr. 57, 10117 Berlin, Germany Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
a r t i c l e
i n f o
Article history: Received 29 October 2014 Revised 12 February 2015 Accepted 28 February 2015 Available online xxxx Keywords: Epilepsy Gender Stress Perceived social support Social integration
a b s t r a c t The present study focused on social support as a key feature of the enhancement and maintenance of mental health. So far, literature on gender differences in social support and its effects on the experience of stress in individuals with epilepsy is scarce. We hypothesized that in individuals with epilepsy, social support buffers detrimental effects of stressors (e.g., unpredictable occurrence of seizures) on mental health. Additionally, we explored the role of gender in this process. In 299 individuals with epilepsy, data from validated questionnaires on seizures in the last 3 months, perceived support, social network size, and depressive symptoms were analyzed. Women reported higher depressive symptoms (t = 2.51, p b .01) and higher perceived support (t = 2.50, p b .01) than men. Women and men did not differ in social network size (t = −0.46, p = 64), nor in experiencing seizures (χ2 = 0.07, p = .82). Regression analyses revealed no buffer effects. Perceived support was negatively associated with depressive symptoms (B = −0.49, p b .001, 95% CI [−0.67; −0.32]). With regard to depressive symptoms, social integration was slightly more beneficial for women (Bcond. = − 0.06, p b .001; 95% CI [−0.09; −0.03]) than for men (Bcond. = −0.02, p = .09; 95% CI [−0.04; 0.01]). Findings present perceived support and social integration as general health resources in individuals with epilepsy regardless of previously experienced seizures. They also encourage further research on gender-specific effects in individuals with epilepsy and move towards recommendations for practitioners and gender-specific interventions. Future aims will be to enhance social integration in order to support adjustment to the chronic condition of epilepsy and to improve individuals' confidence in support interactions. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is a chronic medical condition with major impacts on various aspects of daily life. In addition to biomedical diagnostic and therapeutic demands, treatment of individuals with epilepsy equally requires the psychosocial perspective [1]. The present study focuses on the influence of psychosocial issues on how individuals handle their disease. In general, psychosocial adjustment may be complicated by both disease characteristics and comorbid depressive symptoms. Within this process, interacting with people, especially social support, also seems to play an important role. The few previous studies provide only an incomplete picture, for instance: lack of social support is associated with poor mental health (e.g., depressive symptoms) in individuals with epilepsy [2,3]. However, men and women with epilepsy are often socially isolated [4] and less satisfied with their social support interactions [5]. In the present study, we explored whether social support is either generally relevant in individuals with epilepsy regarding mental health ⁎ Corresponding author at: Charité-Universitätsmedizin Berlin, Institute of Medical Psychology, Luisenstr. 57, 10117 Berlin, Germany. Tel.: +49 30 450 529 218. E-mail address: [email protected] (S. Burkert). 1 Both authors contributed equally to this paper.
or merely in the presence of stressors, e.g., unpredictable occurrence of seizures [5]. Social support can be seen as a general health resource, including quantitative and qualitative aspects. A commonly used quantitative indicator of social support is social integration, e.g., number of network partners [6]. It describes whether an individual is part of a social network; however, no information about the quality of social interactions is conveyed. In contrast, qualitative indicators refer to retrospective reports covering the recipient's perspective, i.e., whether social support from network partners was mobilized and received and the provider's perspective, i.e., whether social support was provided [6]. Additionally, perceived support refers to a prospective belief that social support is available if needed [6]. As a general resource, social support would enhance or maintain health, independent of current stress experiences. In contrast, Cohen and Wills postulated a stress-buffering effect of social support which implies less detrimental effects of stressful (e.g., diseases-related) events on individuals' mental health in case of higher social support (buffer hypothesis) [7]. While a general effect would be statistically indicated by main effects of social support, a buffer effect would be indicated by an interaction of social support and epilepsy-related stress indicators (e.g., seizures in the last 3 months). Men and women generally differ with regard to social support. Women commonly rely on more elaborated social networks than
http://dx.doi.org/10.1016/j.yebeh.2015.02.041 1525-5050/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
2
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men [8]. In contrast, perceived support, which refers to subjective expectations that, e.g., support from others is available if needed, is not known to differ between men and women [9]. Data on general gender differences in epilepsy are scarce, and to our knowledge, no studies have specifically dealt with gender differences in social support. We hypothesize two buffer effects with regard to perceived support and social integration taking gender into account: on the one hand, experiencing seizures is not related to depressive symptoms in individuals with higher confidence that support will be available (i.e., higher perceived support) in contrast to those with lower perceived support. On the other hand, experiencing seizures is not related to depressive symptoms in individuals with a larger number of network partners (i.e., higher social integration) in contrast to those reporting a lower social integration. Because literature on social support in the context of epilepsy does not allow deriving gender-specific hypotheses, gender effects were investigated in an exploratory way. 2. Method 2.1. Design A total of 319 individuals with epilepsy were invited to participate in a questionnaire and semistructured interview study in the outpatient clinic of the Department of Neurology, Charité-Universitätsmedizin Berlin between February 2011 and March 2012. Seven patients declined to participate; all other patients signed informed consent. Six participants did not meet inclusion criteria (i.e., epilepsy diagnosis not verified). Participants with missing data (n = 7) were excluded from the current analyses. These 13 participants did not differ significantly from the final sample analyzed here (data not shown). About half (53.8%) were female. The majority (63.5%) reported a maximum of 9 or 10 years of schooling as well as living with a partner (67.5%). Only 17.1% of the participants were currently certified as unfit or incapacitated for work; 40.8% of participants were employed. Almost all patients (91%) had experienced generalized tonic– clonic seizures. Generalized epilepsy syndromes were found in 23.5% and partial epilepsy syndromes in 70.9%. Further sample characteristics are reported in Table 1. The study was approved by the local ethics committee (EA2/133/10). 2.2. Measures As an indicator of mental health, depressive symptoms were measured by nine depression items from the highly reliable and valid Patient Health Questionnaire (PHQ-9) [10], reflecting diagnostic criteria from the Diagnostic and Statistical Manual-5 (DSM-5) for major depression (range: 0–27; Cronbach's α = .80). Perceived support was
measured by five items of the highly reliable and valid German version [11] of the ENRICHD Social Support Inventory (ESSI; range: 5–25; Cronbach's α = .75) [12]. To assess social integration, participants indicated the total number of network partners (i.e., living in their household, family, close friends, colleagues, neighbors, leisure contacts and others) assessed by multidimensional social contact cycle (MUSK) [13]. Additionally, self-reported seizures in the last 3 months and gender were considered as moderators. Further continuous variables such as age and duration of epilepsy in years as well as dichotomous variables (0 = no/1 = yes) including current relationship, generalized epilepsy, antiepileptic drug polytherapy, and potentially mood-enhancing antiepileptic medication were considered as covariates. 2.3. Statistical procedures For the sample description, group comparisons for dichotomous variables were calculated by means of χ2-tests, and those for continuous variables were calculated by means of t-tests. Main hypotheses, i.e., predictions of continuous variables by multiple predictors, were tested by means of linear regressions. Moderation analyses were conducted using the PROCESS macro based on linear regression analyses (version 2.041) [14]. In a first model, depressive symptoms were predicted by perceived support, seizures in the last 3 months, and gender as well as the respective 2-way and 3-way interactions, controlling for covariates mentioned above. In the second and third models, perceived support was replaced by social integration. All predictors were centered around their grand means, and interaction terms were computed by the multiplication of the predictor and moderator in each model [15]. Significant interactions were plotted with values of M + 1SD (high) and M − 1SD (low) [15]. Conditional effects, i.e., distinct effects of perceived support or social integration, respectively on depressive symptoms for men or women, were calculated by means of simple slope analysis [15]. Data were screened for statistical outliers. 3. Results As depicted in Table 1, in the sample of 299 patients with epilepsy, participants showed on average mild severity of depressive symptoms with significantly higher values in women than men. On average, perceived support was very high, with women perceiving significantly more support than men. Women and men did not differ significantly in their reported network size of about 33 network partners. Hypotheses were tested by means of moderation analyses. In both men and women, perceived support was associated with less depressive symptoms, regardless of seizures in the past 3 months (see Table 2). In contrast to our hypothesis, no buffer effect of perceived
Table 1 Sample characteristics and gender differences. Total sample N (%) Gender Living in partnership Antiepileptic drug polymedication Potentially mood-enhancing AED Generalized epilepsy Seizures in the last 3 months
Age (in years) Duration of disease (in years) PHQ-9 (0–27) Perceived support (ESSI; 0–25) Social integration (MUSK)
– 202 (67.6) 121 (40.5) 106 (35.5) 70 (23.4) 165 (55.2)
Women N (%) 161 (53.8) 111 (68.9) 55 (34.2) 65 (40.4) 55 (34.2) 90 (55.9)
Men N (%)
χ2
138 (43.2) 91 (65.9) 66 (47.8) 41 (29.7) 15 (10.9) 75 (54.3)
p
0.31 5.76 3.69 22.48 0.07
.62 .02 .07 b.001 .82
M (SD)
M (SD)
M (SD)
t
p
44.4 (16.5) 20.3 (16.8) 6.72 (5.17) 22.41 (3.38) 33.4 (29.7)
40.4 (14.9) 20.0 (16.5) 7.40 (5.02) 22.87 (2.94) 32.6 (5.02)
49.0 (17.1) 20.5 (17.2) 5.91 (5.26) 21.88 (3.78) 34.3 (5.3)
−4.59 −0.23 2.51 2.50 −0.46
b.001 .82 .01 .01 .64
Note: N = sample size, M = mean, SD = standard deviation; dichotomous covariates (0 = no, 1 = yes): partner, antiepileptic drug polymedication, potentially moodenhancing antiepileptic drug (AED), generalized epilepsy, seizures in the last 3 months; PHQ = Patient Health Questionnaire, ESSI = ENRICHD Social Support Inventory, MUSK = multidimensional social contact cycle, number of contacts.
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
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Table 2 Interactions of seizures in the last three months, social support, and gender. DV: depressive symptoms Social support: perceived support (ESSI)
Age Living in partnership Duration of disease Antiepileptic drug polymedication Potentially mood-enhancing AED Generalized epilepsy Seizures in the last 3 months Social support Gender Seizure ∗ social support Seizure ∗ gender Social support ∗ gender Seizure ∗ social support ∗ gender
Social support: social integration (MUSK)
B
SE
t
p
95% CI
B
SE
t
p
95% CI
−0.03 −0.50 0.02 −0.78 −1.77 −0.96 1.19 −0.49 −2.02 0.14 −2.31 0.21 0.11
−0.02 0.62 0.02 0.77 0.75 0.70 0.60 0.09 0.60 0.18 1.14 0.17 0.35
−1.49 −0.81 0.78 −1.01 −2.37 −1.39 −1.97 −5.44 −3.35 0.82 −2.03 1.20 0.31
.14 .42 .44 .31 .02 .17 .05 b.001 b.001 .42 .04 .23 .75
[−0.07; 0.01] [−1.72; 0.72] [−0.02; 0.05] [−2.29; 0.73] [−3.24; −0.30] [−2.33; 0.40] [0.01; 2.37] [−0.67; −0.32] [−3.20; −0.83] [−0.20; 0.49] [−4.56; −0.07] [−0.13; 0.54] [−0.57; 0.79] R2 = .22
−0.03 −1.31 0.02 −1.09 −2.58 −0.79 1.27 −0.04 −1.43 0.01 −2.63 0.03 0.02
0.02 0.61 0.02 0.79 0.77 0.72 0.60 0.01 0.61 0.02 1.14 0.02 0.04
−1.463 −2.16 1.17 −1.38 −3.34 −1.10 2.11 −3.80 −2.35 0.48 −2.30 1.53 0.60
.10 .03 .24 .17 b.001 .27 .04 b.001 .02 .63 .02 .13 .55
[−0.07; 0.01] [−2.51; −0.12] [−0.02; 0.06] [−2.64; 0.47] [−4.10; −1.06] [−2.19; 0.62] [0.08; 2.46] [−0.05; −0.02] [−2.63; −0.23] [−0.03; 0.05] [−4.88; −0.38] [−0.01; 0.07] [−0.05; 0.10] R2 = .18
Note: N = 202; DV = dependent variable; B = unstandardized regression weight indicating the strength of predictor-specific associations with DV, SE = standard error, t = significance test, p = error probability/level of significance; social support indicators: perceived support or social integration; gender (1 = women, 2 = men); dichotomous covariates (0 = no, 1 = yes): living in partnership, potentially mood-enhancing antiepileptic drug (AED), psychotropic effects of medication, generalized epilepsy, seizures in the last 3 months; ESSI = ENRICHD Social Support Inventory, MUSK = multidimensional social contact cycle, number of contacts; main effect of perceived support and 2-way interaction of social integration and gender confirmed by post hoc analyses without further interactions.
support was detected indicated by a nonsignificant 2-way interaction of perceived support and experiences of seizures and a nonsignificant 3-way interaction of perceived support, experiences of seizures, and gender (see Table 2). In a post hoc regression analysis with a single interaction, we tested the significant 2-way interaction of experiencing seizures in the last 3 months and gender, controlling for all other predictors. It did not reach significance. Also, social integration did not buffer detrimental effects of seizures in the last 3 months on depressive symptoms (see Table 2), which is in contrast to our hypothesis. Independent of seizures and gender, social integration was related to less depressive symptoms. Again, we tested the significant 2-way interaction of gender and social integration in a post hoc regression analysis. Social integration turned out to be especially beneficial in women, regardless of seizures in the last 3 months. Women with larger social networks reported slightly less depressive symptoms (conditional effect of − 0.06 in women: t = − 3.66, p b .001; 95% CI [− 0.09; − 0.03]) whereas social integration was not associated with depressive symptoms in men (conditional effect of −0.02 in men: t = −1.73, p = .09; 95% CI [−0.04; 0.01]). 4. Discussion The main finding of the present study was that in patients with epilepsy, the perception of available support (perceived support) was associated with beneficial effects with regard to depressive symptoms. This is true for men and women and independent of the experience of disease-related stressors, i.e., seizures in the last 3 months. Even though this is in line with previous studies on other populations (e.g., patients with chronic cardiac disease) [11], this finding is remarkable since perceived support is based on previous social interactions which are commonly experienced to be less satisfying by individuals with epilepsy [5]. Perceived support additionally depends on individual appraisals which are influenced by personality traits like optimism; this might explain our findings and point to opportunities for interventions. Another indicator, more specific, and antecedent of social support is integration into a social network. Surprisingly, men and women with epilepsy did not differ in the number of network partners. This is noteworthy since commonly, women report larger networks than men [8]. This raises the question of whether and how they differ in how they use and benefit from their social networks. In the present study, we used a quantity measure, i.e., the number of network partners, as well as a quality measure, i.e., the subjective appraisal that social support is available in times of need. These indicators do not reflect actual support interactions
in terms of mobilized, provided, and received support [6,16], which should be considered in future research. Moreover, women benefited slightly more from their networks than men. This finding extends the existing literature by a gender-sensitive perspective on epilepsy. Consequently, knowledge about the quality of social support and the effectiveness of specific support providers will allow for developing successful gender-specific support interventions for individuals with epilepsy [17]. In the present study, we could not provide evidence for a buffering effect of perceived support or social integration. This might be due to our choice of an epilepsy-related stress indicator, i.e., seizures in the last 3 months, which is only one stressor among many others in this patient population. Taking epilepsy as a stressor per se, future studies should compare individuals with epilepsy and healthy controls in order to test whether social support buffers disease-related stress. However, on the one hand, higher reports of perceived support were associated with less depressive symptoms in both men and women, pointing to a general health resource. On the other hand, women reported higher amounts of perceived support and depressive symptoms than men. These gender differences in depression are a well-known phenomenon in the depression literature [18] and are, for instance, explained either by a higher vulnerability in women [19] or a response bias, i.e., underreporting of symptoms in men [20]. With regard to perceived support, gender differences are less investigated in clinical samples; however, literature indicates that women generalize different kinds of available support whereas men differentiate between different kinds of support [21]. Gender-specific appraisals might also lead to a higher amount of perceived support in women. Consequently, perceived support interventions can be developed to change individuals' cognitive appraisals to more positive expectations in terms of concretizing and differentiating between different kinds of anticipated support. In addition to limitations regarding sample and study methods mentioned above, some further limitations must be addressed. First, a causal interpretation of our findings is not possible because findings are based on cross-sectional and self-reported data. Thus, we cannot rule out that self-reported social indicators might be affected by depressive symptoms. Second, generalizability is limited due to data from a monocenter study. Third, with regard to depression, the present sample of patients with epilepsy was characterized by only a mild severity of symptoms. Thus, in future studies, this research question should be investigated in patients with epilepsy who are more strongly affected by symptoms of depression. Our study complements previous data focusing on biomedical and psychosocial issues of epilepsy by a gender-specific perspective. The
Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
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findings encourage further research on gender-specific effects in the context of epilepsy. They may help to develop recommendations for practitioners and for interventions to improve individuals' confidence in support interactions as well as gender-specific needs of interventions. This may help to enhance social integration in order to support adjustment to the chronic condition of epilepsy. Author contributions Study concept and design: Gaus, Kiep, and Holtkamp. Data collection: Gaus, Kiep, and Holtkamp. Statistical analysis: Burkert. Interpretation of data: Burkert and Kendel. Drafting of the manuscript: Burkert. Critical revision of the manuscript for important intellectual content: Kendel, Kiep, Gaus, and Holtkamp. Disclosure None of the authors has any conflict of interest to disclose that is related to the content of this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. References [1] Elliot JO, Richardson VE. The biopsychosocial model and quality of life in persons with active epilepsy. Epilepsy Behav 2014;41:55–65. [2] Lu B, Elliott JO. Beyond seizures and medications: normal activity limitations, social support, and mental health in epilepsy. Epilepsia 2012;53(2):e25–8. [3] Reisinger EL, Dilorio C. Individual, seizure-related, and psychosocial predictors of depressive symptoms among people with epilepsy over six months. Epilepsy Behav 2009;15(2):196–201.
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Please cite this article as: Burkert S, et al, Gender differences in social support in persons with epilepsy, Epilepsy Behav (2015), http://dx.doi.org/ 10.1016/j.yebeh.2015.02.041
