T H E C O N T R I B U T I O N OF F A M I L Y C O H E S I O N A N D T H E P A I N - C O P I N G P R O C E S S T O D E P R E S S I V E S Y M P T O M S IN F I B R O M Y A L G I A 1'2'3

Perry M. Nicassio, Ph.D. California School o f Professional Psychology, San Diego/University o f California, San Diego

Vesna Radojevic, Ph.D. University o f California, San Diego Karen Schoenfeld-Smith, M.A. California School o f Professional Psychology, San Diego/University o f California, San Diego

Kathy D w y e r , P h . D . Vanderbilt University School o f Nursing

ABSTRACT

INTRODUCTION

This research evaluated a model for examining the role of family cohesion and the pain-coping process in predicting depressive symptoms in fubromyalgia, a chronic pain disorder of unknown etiology. Depressive symptoms were highly prevalent in this patient group. Fifty-nine percent of the sample met or exceeded the cutoff score of 16 for depression on the Center for Epidemiological Studies Depression Scale (CES-D), while slightly greater than 50% exceeded the cutoff score of 19, a figure that is suggested for evaluating depression in chronic pain populations. Multiple regression analyses, controllingfor demographic factors and medication use, revealed that low family cohesion (either reported by the patient or the patient's spouse), high pain, high helplessness, and high passive coping contributed independently to greater CES-D scores. Pain also was related to higher depression scores indirectly through its association with greater helplessness and passive coping. In contrast, no indirect effects of family cohesion were found on depressive symptoms through pain, helplessness, and passive coping. Structural equation modeling procedures provided confirmatory evidence of the significance of these relationships, indicating a high degree of goodnessof-fit with the model examined. The data illustrate the import of a multidimensional framework for conceptualizingphysical, psychological, and social determinants of depressive disturbance in fibromyalgia.

Fibromyalgia (FM) is a disorder o f unknown etiology characterized by diffuse museuloskeletal pain upon palpation in I 1 of 18 skeletal muscle sites that are symmetrically distributed throughout the body (1). Research has found this condition to be as painful as rheumatoid arthritis (RA) (2) and to be associated with significant disability and work impairment (3). Several aspects o f the clinical presentation o f this condition (e.g. fatigue, somatic preoccupation, functional limitations, sleep disturbance) have led investigators to speculate that depression may either be a prevalent concomitant disorder in fibromyalgia patients, or that the disorder itself m a y be a manifestation o f an atypical form o f m o o d disturbance (4). Research addressing the prevalence o f depression in fibromyalgia, however, has yielded m i x e d findings. While M M P I studies have confirmed the existence o f elevated scores on hypochondriasis, depression, and hysteria scales (5), this pattern m o r e commonly reflects general psychological distress rather than depression as a primary psychiatric disorder. In research employing the Diagnostic Interview Schedule (DIS), which provides definitive criteria for making psychiatric diagnoses, H u d s o n et al. (6) found that 71% o f a sample o f 31 fibromyalgia patients had a lifetime history of major depression, while 26% had a current diagnosis. A m o r e recent investigation with the DIS comparing the prevalence o f psychiatric disorders in 35 fibromyalgia patients and 33 rheumatoid arthritis patients found that 34% offibromyalgia patients and 33% o f rheumatoid arthritis patients met criteria for m a j o r depression (7). Although these data do not support the theoretical position that fibromyalgia s y m p t o m s are manifestations o f an affective disorder, these prevalence fndings, while based on small samples, indicate that depressive symptoms are c o m monly found in this medical condition.

(Ann Behav Med

1995, 17(4):349-356)

Preparation of this manuscript was supported in part by a Multipurpose Arthritis, Musculoskeletal, and Skin Disorders Center Grant AR40770 to the University of California, San Diego, School of Medicine and a grant from the General Clinical Centers #M012RR00827 of NCRR from NIH.

Biopsychosocial Model and Depression

2 Portions of this manuscript were presented at the meeting of the Society of Behavioral Medicine, April 1994, in Boston, MA.

Previous research on depression in fibromyalgia has lacked a conceptual framework to guide the development o f specific investigative hypotheses. The biopsychosocial model, as articulated by Engel (8,9), provides a heuristic framework for conceptualizing the origins o f depression in fibromyalgia. A basic premise o f this framework is that health outcomes, including depression, m a y be the result o f the independent and conjoint influences o f psychological, social, and biological factors in m e d ical patients.

3 The authors gratefullyacknowledge the assistance of Teresa Krall, Jung Kim, and Catherine Schuman with data collection and management, and the contribution of Amy Culbertson with statistical analyses.

Reprint Address: P. M. Nicassio, Ph.D., Health Psychology Programs, California School of Professional Psychology, 6212 Ferris Square, San Diego, CA 92121. 9 1995 by The Society of Behavioral Medicine. 349

350

ANNALS OF BEHAVIORAL MEDICINE Family System a be

External

i"-. I i /

Nocice )ciceptio

Pain ~ Experience ~

Pain ~ Appraisal ~

be

Pain-Coping _ Response ~

Pain Outcomes c

Internal

a = Encompasses structural features, modeling influences, reinforcement contingencies b t = Either facilitation or inhibition by the family of the experience of pain, adaptive pain appraisal, pain coping or pain outcomes in the patient b e = Effect of the experience of pain,pain appraisal, pain coping and pain outcomes of the patient on structural features and reactions of the family c = Changes in subjective pain, psychological functioning, disability

FIGURE 1: Relationship between Family Functioning and the Pain-Coping Process in the Patient. The relevance of the biopsychosocial model for understanding the impact of pain on depression and disability in rheumatoid arthritis and other conditions involving chronic pain has already been dearly documented (10,11). For example, whereas pain has proven to contribute to an exacerbation of depressive symptoms over time in rheumatoid arthritis (10), patients" perceived helplessness in the face of the illness (12) and their use of passive pain coping strategies (13) also have independently predicted depression in this medical condition. Furthermore, Smith et al. (14) found that the relationship between pain and depression in rheumatoid arthritis was mediated by perceived helplessness, accounting for the mechanism by which pain and depression were linked. This research evaluates the mediational role of helplessness in explaining depressive symptoms in FM, and also examines the association between helplessness and passive pain coping strategies, testing the specific proposition that passive coping may mediate the relationship between helplessness and depression. Lazarus and Folkman (15) have noted that appraisals reflecting lack of control or helplessness in the face of stress may lead to avoidant or passive forms of coping which may have untoward health consequences when the source of stress is potentially controllable. As background for the present research, Smith and Wallston (16), in a longitudinal study with RA patients, reported that helplessness contributed to passive coping. This, in turn, led to greater functional impairment, providing evidence of a cycle of dysfunction involving negative illness appraisals, maladaptive coping, and negative health outcomes. Social/Familial Conditions Affecting Pain and Depression In addition to the foregoing studies which illustrate the important role of psychological reactions and behaviors of the patient in explaining depressive symptomatology, the family of the pain patient may have a significant impact on adaptational outcomes, including the manifestation of depressive symptoms. The family system constitutes a major social environment for the learning of health behaviors which may lead to different health outcomes for the patient (17). According to Turk and Kerns (18), a transactional, cognitive-behavioral framework is a useful model for examining the relationship between family reactions and the adjustment of chronic pain patients. A major implication of this model is that the family may influence several different aspects of the pain-coping process in chronic pain patients (19). We have developed a hypothetical model depicting the manner in which the family may affect the pain-coping

Nicassio et al. process (see Figure 1). After pain-producing stimuli (nociception) give rise to the perception and experience of pain, patients appraise the pain along a number of important dimensions including its severity, location, and their ability to control it. Such appraisals are then associated with attempts to cope with the pain to minimize its impact. Depending on their efficacy, such coping mechanisms may contribute to various outcomes including changes in subjective pain, pain behaviors, or affective symptoms. Through modeling influences or direct reactions to the patient (e.g. reinforcement contingencies, extinction), family members may affect all components of this process and thus influence pain outcomes indirectly, or they may influence pain outcomes directly and independently of this process. Patients are not passively affected by the reactions of the family; rather, they actively process the behavior of family members and appraise the resources available to assist with the process of coping. As such, the model takes into account reciprocal influence processes between patients and family members. The patient's paincoping process may affect structural features of the family and family reactions to the patient, which in turn, may influence the adjustment of the patient. The Present Research The major objective of this research was to examine the empirical support for this theoretical model in a sample of fibromyalgia patients evaluated in an outpatient clinic setting. Considerable evidence has shown that social support from family and friends is associated with less depression in rheumatoid arthritis patients (20,21); yet, the role o f family and social influences on the psychosocial adjustment offibromyalgia patients has received sparse research attention (19). Family cohesiveness was examined as a potentially important measure of family functioning in our model for the following reasons. First, greater social support may be available to patients whose families are cohesive and have stronger emotional ties. Cohesive families may thus enhance the stress-resistance of patients and contribute to beneficial health outcomes. Secondly, family cohesion has been associated with fewer psychosomatic complaints and lower depressive affect in normal populations (22). Whether family cohesion is related to components of the pain-coping process has not been explored nor has its role been explored in the psychosocial adjustment of FM patients. In this research, family cohesiveness reflected the degree of perceived support in the patient's family and was evaluated for its potential indirect and direct influences on depressive symptoms in the sample. METHODS Subjects The sample consisted of 122 fibromyalgia patients (109 females and 13 males) between the ages of 19 and 78, with an average age of 52.04 years. Subjects reported having been diagnosed with fibromyalgla for an average of 11.92 years. Sixtythree percent of the sample reported being married, 16% were single, 19% were either separated or divorced, and 2% were widowed. Eighty-six percent of this sample had completed some college, an undergraduate or graduate degree, or some postgraduate education. The vast majority of subjects were Cancasian (88%), with the remainder indicating their ethnic origins to be either Hispanic, Asian, or from other backgrounds. All subjects resided in San Diego or neighboring areas in Southern California. Medication use to regulate fibromyalgla symptoms was common in the sample. While subjects took a range of

Depression in Fibromyalgia medications, antidepressants and analgesics were the m o s t frequently used drugs. Thirty-nine percent and 89 percent o f the patients, respectively, reported using these medications.

Procedures The current F M sample was recruited from the community, private rheumatology clinics a n d practices, and a universitybased rheumatology clinic to participate in a treatment outcome study assessing the efficacy o f behavioral and educational interventions for this disorder. The measures for this study constituted a portion o f the baseline assessment for the parent investigation. Subjects and designated support persons (e.g. a spouse or another adult family m e m b e r or friend who had frequent and consistent contact with the patient) recruited for the intervention study completed a battery o f self-report measures under the supervision o f research assistants at the Clinical Research Center o f the University o f California, San Diego. The present research focuses primarily on data obtained from the F M subjects themselves. Data on spouses' perceptions o f family cohesion are also reported. All subjects had received the diagnosis o f fibromyalgia by their rheumatologist or p r i m a r y care physician before entering the study. A physical exam conducted by a rheumatology nurse under the supervision o f a clinical rheumatologist confirmed the diagnosis o f F M according to criteria as delineated by Wolfe et al. (1). These criteria stipulate that patients have diffuse upper and lower body pain for at least three months and 11 o f 18 tender points. Subjects were excluded from the research i f they reported at the initial telephone screening that they h a d concomitant rheumatologic conditions (Hashimoto's syndrome, rheumatoid arthritis, scleroderma, systemic lupus erythematosus) or were found to have these illnesses when they were physically examined.

Measures Measures were selected which assessed the various components o f the model presented in Figure 1. The pain-coping process included measures o f pain, helplessness, and passive coping, and depression as a pain outcome. Family cohesion constituted the measure o f family context, hypothetically related to both aspects o f the pain-coping process and depression.

Family Support: The Cohesion subscale o f the F a m i l y Env i r o n m e n t Scale (FES) (23) was used to assess the perceived availability o f social support within the family o f the patient. The subscale is comprised o f nine items (e.g. " F a m i l y m e m b e r s really help and support one another," "There is a feeling o f togetherness in our family," " F a m i l y members really back each other up") and is a component o f the Relationship Dimension o f the FES which also includes the subscales o f Family Expressiveness and Family Conflict. The FES also assesses dimensions o f personal growth (the extent to which the family promotes independence, cultural pursuits, and involvement in recreational and leisure activities) and system maintenance (the degree to which the family is able to adapt to internal and external changes while preserving a sense o f unity). The reliability and construct validity of the FES have been established across a variety o f populations in more than 50 studies (23). Subjects are instructed to complete the FES based on their description o f the current functioning o f their family. Pain Experience (Subjective Pain): A pain index reflecting the composite score o f four measures was used to assess the

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construct o f pain in this research. Each of the following pain measures was standardized, given equal weight, and s u m m e d to compute the pain index: (a) the Pain subscale o f the Fibromyalgia I m p a c t Assessment Questionnaire (24) which is comprised o f four items pertaining to the patient's report o f the intensity and severity o f pain over the previous week; (b) the number o f painful body sites identified by the patient on a human figure drawing from the McGill Questionnaire (25) (this score was derived by summing the number o f discrete sites marked by the patient on the drawing as painful either internally or externally on the drawing); (c) the Pain Rating Index from the McGiU Questionnaire which is a s u m m a t i o n of the ranked values associated with adjectives selected by the patient as describing current pain; and (d) a two-item flare-up index, in which the patient's reported frequency o f flare-ups (sudden, intense increases in pain) was multiplied by the square o f the reported average intensity o f flare-ups over the past m o n t h (13).

Pain Appraisal." The five-item Helplessness subscale (26) o f the Rheumatology Attitude Index (RAI) (27), a measure adapted from the Arthritis Helplessness Index (AHI) developed by Nicassio et al. (12), was used to assess patients' perceived helplessness to control pain and other symptomatology o f F M (e.g. " M y condition is controlling m y life," "I would feel helpless i f I couldn't rely on other people for help with m y condition"). Recent research has shown the factor structure o f the Rheumatology Attitude Index (26) to correspond very closely to the factor structure o f the Arthritis Helplessness Index (28) from which the original scales o f Helplessness and Arthritis Internality were derived. The alpha o f the R A I Helplessness subscale has been reported to be .67 (26), while the alpha and test-retest reliabilities o f the Helplessness subscale o f the A H I have been reported to be .63 and .64, respectively (28). Furthermore, the 5-item Helplessness subscales o f both the R A I and A H I have proven to be internally consistent and more strongly associated with a variety o f health status measures than the 15-item R A I or A H I (26,28). Pain Coping: The Passive Coping subscale o f the Pain Management Inventory (PMI) (29) assessed the pain coping construct in our model. In contrast to the Active Coping subscale which assesses attempts to control pain or to function in spite o f pain, the Passive Coping subscale o f the Pain Management Inventory measures the tendency o f patients with chronic pain to restrict functioning due to pain, to take pain medication, or to rely on health professionals or others when pain reaches a moderate level o f intensity or greater. Both subscales are highly reliable and demonstrate opposite relationships with pain, depression, and physical functioning in R A patients (29). The Active and Passive subscales are analogous to Lazarus and Folkman's conceptions o f problem-focused versus emotion-focused coping (15). Examples o f Passive Coping items include the following: "Praying for relief, . . . . Taking medication for purposes o f immediate pain relief," and "Calling or seeing the doctor or nurse for help or advice." Depression: The Center for Epidemiological Studies Depression Scale (CES-D) was used to evaluate depressive symptoms in the sample (30). The CES-D is a self-report measure o f depression that was designed for studies detecting depressive symptomatology in the general population. The CES-D consists o f 20 items (4 reverse scored) and evaluates the existence o f depressive cognitions, dysphoric mood, and vegetative signs over the past week. Subjects are asked to indicate how frequently

352

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OF BEHAVIORAL

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TABLE 1 Means and Standard Deviations of Variables in the Model

Variable Family Cohesion Pain a Helplessness Passive Coping Depression

Mean

SD

6.47 .07 17.90 31.10 20.13

2.58 2.91 4.81 6.30 10.74

a This variable reflects a composite score of four standardized pain measures: Pain Rating Index and Body Area Score of the McGill, Pain Suhscale of the Fibromyalgia Impact Questionnaire, and a flare-up index. they experienced each s y m p t o m with scores ranging from 0 (less than one day) to 3 (five to seven days). The measure has received widespread use in community a n d epidemiological research, has proven to be internally consistent and reasonably stable over time, and has been effectively adopted in research studies evaluating the factors associated with depressive s y m p t o m s in a variety o f medical populations, including those with chronic pain (31) and chronic illnesses such as rheumatoid arthritis (13,32). The cutoffscore indicative o f the existence o f depressive disorder in a community sample is 16; however, Turk and Okifuji (31) have provided evidence that a cutoff score o f 19 m a y be more appropriate for a chronic pain population. Scores of 16 were shown to lack specificity (i.e. to identify chronic pain patients as depressed who d i d not receive clinical diagnoses of depression based on a clinical interview). RESULTS Descriptive Findings

Table 1 presents descriptive data on the variables in the model. The patients' scores on the CES-D ranged from 2 to 49, with a mean of 20.13 and standard deviation o f 10.74. These data reflect both a high-average degree o f depressive s y m p t o m s as well as significant variability in depression scores in the sample. Fifty-nine percent o f the sample had scores above 16, and with the more stringent cutoff score o f 19, 50.4% o f the sample would be classified as depressed. This sample shows a much higher magnitude of depressive symptoms than a group o f 287 R A outpatients reported by Brown et al. (13) to have a mean o f 12.98 and standard deviation o f 10.5. In addition, helplessness scores are higher than those found in a sample o f R A outpatients reported by Stein et al. (28) based on the A H I Helplessness factor (M = 15.3, SD = 5.1). However, passive paincoping scores are very similar to those reported by Brown et al. (13) (M = 31.65, SD = 7.53), and FES Cohesion scale scores correspond very closely to the data on this measure reported by Moos and Moos (23) on a n o r m a l sample (M = 6.61, SD = 1.36).

Correlations tend to be in the moderate range, indicating convergence between several o f the constructs in the m o d e l (see Table 2). Pain, helplessness, and passive coping were significantly and positively correlated with each other and with depression. In contrast, family cohesion was negatively related to CES-D scores. Evaluation of the M o d e l

A series of hierarchical multiple regression analyses were conducted to evaluate the hypothesized model presented in Figure 1. This framework allows for an evaluation o f the direct

N i c a s s i o et al. TABLE 2 Zero-Order Correlations among Variables in the Model

Family Cohesion (FC) Pain (P) Helplessness (H) Passive Coping (PC) Depression (D)

FC

P

- . 10 -.05 -.04 -.35*

.46* .39* .56*

H

PC

-.49* .54*

.44*

D

-m

* p < .001, two-tailed.

relationship between family cohesion a n d depression, as well as the indirect relationship between these two variables by the association o f family cohesion with specific components o f the pain-coping process involving pain, helplessness, and passive coping. Furthermore, the model describes indirect relationships between pain and depression through helplessness and passive coping. An analysis o f the direct effects o f all variables in the model on depression was conducted first, followed by analyses o f indirect relationships between family cohesion and the different aspects o f the pain-coping process in explaining depression. In all analyses, the demographic variables o f age, illness duration, and socioeconomic status were entered into the regression equation first, followed by medication status variables, and finally, the specific variables depicted in the model. Medication status was comprised o f two separate variables scored dichotomously to indicate the use or non-use of analgesics (both prescription and non-prescription) and antidepressants. Structural equation modeling procedures were employed to confirm the regression findings and to examine the goodness-of-fit of the derived model. Direct Predictors of Depression

In the analysis predicting directly to depression, demographic factors accounted for 10% o f the variance in CES-D scores (F[3, 119] = 4.47, p < .01). Lower socioeconomic status, t(119) = 2.50, p < .05, and lower age, t(119) -- - 3 . 2 5 , p < .01, were related to higher depression. On the next step, medication use did not significantly contribute to depression scores, adding only 1% unique variance (F[5, 117] = .79). Thus, patients' use o f either analgesics or antidepressants was unrelated to depressive symptoms. When entered as a block on the final step o f the analysis, family cohesion, pain, helplessness, and passive coping contributed significantly to depression, adding 44.2% unique variance (F[9, 113] = 28.06, p < .001). Lower family cohesion, t(113) = - 4 . 5 1 , p < .001, higher pain, t(113) = 4.64, p < .001, higher helplessness, t(l13) = 3.43, p < .001, and higher passive coping, t(113) = 2.00, p < .05, were uniquely associated with more depression. Together, all variables in the regression m o d e l accounted for greater than 55% o f the variance in depression scores, with family cohesion and pain proving to be the strongest individual predictors, each contributing 8% unique variance. After the latter group o f variables entered the regression equation, socioeconomic status and age were no longer predictive o f depression scores, indicating that their contribution to depression was largely explained by other factors in the model. To counter the argument that patients' perceptions o f the cohesiveness o f their families could be the result o f their depressive symptomatology rather than a contributing factor to it, reports o f family cohesion from all the spouses in the study

Depression in Fibromyalgia

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TABLE 3 Hierarchical Multiple Regression of Predictors of Depression Scores Predictor

Step

Demographic Factors Age Illness Duration Socioeconomic Status

1

Medication Use Analgesics Antidepressants Variables in Model Family Cohesion Pain Helplessness Passive Coping

R2

R 2 change

F changeb

Fa

df

.10

4.47***

3,119

2

.11

2.99*

5,117

.01

.79

3

.56

15.67"*

9,113

.44

28.06***

Note: a = F ratio indicative of significance of overall regression equation; b = F ratio reflecting significance of variables entered on that step of the regression equation. *p < .05, **p < .01, ***p < .001.

(N = 73) were evaluated for their contribution to explaining depressive symptoms in patients. These subjects were included because their descriptions o f family functioning corresponded to the same family system as that o f the patient. Other support persons were not asked to provide their observations o f the family functioning o f the patient, and therefore, were not included in this analysis. I f the spouses' depiction o f family cohesion independently would predict patients' depression scores, the position that patients' depression is contributing to the perception that their families are less cohesive would be less tenable. A separate regression analysis adopting the same framework as above was conducted to test this proposition. After removing the effects o f demographic factors and medication use, spouses' family cohesion scores were uniquely, inversely related to patients' CES-D scores (B = - . 2 1 , t = - 2.1, p < .05) when entered on the same step as patients' pain, helplessness, and passive coping. Further, patients' and spouses' FES scores were m o d erately, yet significantly correlated (r = .52, p < .001). Thus, family cohesion, whether reported by patients or their spouses, had the same relationship with reports o f depressive s y m p t o m s in the patient.

Indirect Mechanisms Indirect relationships were explored in the m o d e l by conducting a series o f partial regression analyses in order to evaluate the predictors o f pain, helplessness, and passive coping in the sequence specified in the model. The first analysis evaluated whether family cohesion predicted pain scores; the second analysis focused on the contribution o f family cohesion and pain to helplessness; and the third analysis examined the contribution o f family cohesion, pain, and helplessness to passive coping. In the first o f these analyses, sociodemographic factors accounted for 8.1~ o f the variance in pain scores (F[3, 119] = 3.49, p < .05) with age being the only significant individual predictor, t(119) = - 3.09, p < .05. Younger subjects scored higher on this composite variable than older subjects. Neither medication use nor family cohesion, entered on subsequent steps, contributed to pain, and d i d not alter the relationship between age a n d pain. The second analysis predicting helplessness revealed no effect o f demographic factors, medication use, or family cohesion; however, a highly significant effect o f pain, t(115)

= 5.21, p < .001, was demonstrated, with higher pain being associated with greater helplessness. In the third analysis, demographic factors accounted for 7.4% o f the variance in passive coping (F[3, 119] = 3.17, p < .05) with lower age, t(119) = - 2 . 2 4 , p < .05, and lower socioeconomic status, t(119) = 2.48, p < .05, being associated with greater passive coping. Medication use was unrelated to passive coping scores as was family cohesion on the final step o f the analysis. In contrast, high pain, t(114) = 2.42, p < .05, and high helplessness, t(114) = 4.07, p < .0 l, each contributed independently to greater passive coping. Combined with the earlier finding that passive coping independently predicted depression, these analyses revealed that passive coping mediated the effects o f pain and helplessness on depression scores. After the latter group o f variables entered the regression equation, age and socioeconomic status no longer pred i c t e d p a s s i v e c o p i n g scores, d e m o n s t r a t i n g that t h e i r contribution to passive coping was primarily accounted for by pain and helplessness, the most robust individual predictors o f passive coping tendencies.

Structural Equation Modeling The next step in the analysis was to evaluate the overall fit of the derived model. Structural equation modeling was selected as the analytic technique because it allows all o f the relationships depicted in the derived model to be evaluated simultaneously. A number o f measures were used to evaluate the adequacy o f the model, including chi-square, the adjusted goodness-of-fit index, the root mean square residual, the chi-square/df ratio, the modification indices, and significance tests for each path coefficient (33-36). M a x i m u m likelihood estimates were computed using the sample covariance matrix and LISREL VII. Table 3 presents a s u m m a r y o f several measures o f overall model goodness-of-fit. The chi-square value was not significant, X 2 = .47, p = .79, which suggested an overall good fit. In addition, the adjusted goodness-of-fit index was almost equal to one (.99), an indication o f excellent fit. A n examination o f the residuals, which were relatively small, provided additional support for the model ( R M R = .43). Further, the chi-square/dfratio was .24, providing evidence o f strong convergence between the overall model and the sample variance-covariance matrix.

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Nicassio et al.

TABLE 4

Family Cohesion

Goodness-of-Fit Summary Statistics from Structural Equation Modeling Measure

X2 (df = 2) Adjusted Goodness-of-Fit Index Root Mean Square Residual x2/df ratio

Statistic .47" .99 .43 .24

...... ,41=" I~ = .44 Pain . .~9 s r , = .1~***

"a'.o. ~ "'" ~ 13= .36 .''uO po = .15 Helplessness ~ Passive C o p i n g ~ Depression - sr = = .lU'** sr 2 = .02"

* p = .79. * = p < .05

In order t o f u l l y evaluate the model, individual components also were examined. This step involved an evaluation o f each o f the path coefficients in the derived model. Each path was tested and found to be significantly different from zero. Modification indices were examined to identify possible model misspecification errors. These indices were all less than five, indicating that all significant pathways had been included. Thus, the structural equation modeling findings provided significant support for the validity o f the derived model and the path analytic results revealed through the multiple regression procedures. Summary of Model

In summary, direct and indirect mechanisms affecting depression are graphically depicted in Figure 2. Data on the unique contribution (sr 2) of each variable to relevant components specified in the various paths o f the model are also presented. The model clearly demonstrates highly significant, direct relationships between family cohesion, pain, helplessness, and depression, and a more modest, yet significant contribution to depression by passive coping. Family cohesion, however, was not related to the pain-coping process, as suggested by the model. Pain and helplessness have central roles in this framework. In addition to its direct relationship with depression, pain was also indirectly related to depression through its association with helplessness and passive coping. While also being directly related to depression, helplessness served as an important mediational mechanism linking greater pain with higher levels o f passive coping and depressive symptoms. The model thus provides evidence that the social environment and pain-coping process o f the patient constitute important sources of variability in depressive symptoms in this medical condition. DISCUSSION This study has provided evidence consistent with other investigations (4-7) that depressive disturbance is c o m m o n in fibromyalgia syndrome. Whether using a traditional cutoff score of 16 or 19, as recommended by Turk and Okifuji (31) for use in chronic pain populations, over half of the sample in this research scored in the depressed range on the CES-D, a measure that has been used to detect depressive symptomatology in both community samples and medical populations. These findings reflect a higher suggested prevalence of symptoms of depression in fibromyalgia than that found in studies reported by Ahles et al. (7) and Hudson (6); however, disparity in prevalence may be a function o f the mode of measurement. Recent findings indicate that self-report measures may overestimate the presence of clinical depression in fibromyalgia, as lower estimates are obtained from interview-based approaches such as the DIS (6,31). In this regard, Turk and Okifuji (31) have noted that while the CES-D may be a sensitive measure, it may lack spec-

"* = p < . 0 1

significant path

.....

"'" = p < .001

~

nonsignificant path

FIGURE 2: Derived Model Evaluating the Relationship between Family Cohesion, the Pain-Coping Process, and Depression.

ificity and thus lead to false positive diagnoses of clinical depression in some instances. Thus, it is possible that the results pertaining to the probable existence of clinical depression may be biased in this direction. Nonetheless, the conclusion that depressive symptoms are c o m m o n in this medical condition, and thus constitute an important factor in its management, is highly warranted. This research strongly supports the utility of the biopsychosocial framework as a conceptual paradigm for understanding the various factors associated with the existence of depression in this population. Pain, appraisal, coping, and perceptions o f family cohesion were found to contribute uniquely to depressive symptoms after demographic factors and analgesic and antidepressant medication use were statistically controlled. These findings suggest that pain and other psychosocial factors contribute to depression in FM, and affirm the potential value of intervention approaches which address such factors in the management of this illness. These findings are not meant to supplant biological theories of FM based on serotonin deficiency or H P A axis dysfunction (4), but they do suggest that multiple sources of influence may contribute to depressive disturbances in FM. This research demonstrated that pain was a significant correlate of depression, a finding which is consistent with other evidence showing pain to predict depressive disturbances in other painful conditions, particularly rheumatoid arthritis (2,10,13). Moreover, fibromyalgia pain has been found to be correlated with work impairment, hospitalizations, and other forms of disability in this medical condition (3). In the present research, while pain had a unique relationship with depression, it also was associated indirectly with depression through its relationship with helplessness and passive coping. This latter finding suggests that when pain contributes to appraisals of helplessness in the face of fibromyalgia and greater passive coping attempts, depression is greater than when considering the role of pain alone. Earlier research by Smith et al. (14) found that helplessness explained the relationship between pain and depression in rheumatoid arthritis, accounting for the majority of the variance between these two variables. A later investigation by Smith and Wallston (16) indicated that passive coping mediated the relationship between helplessness and functional impairment in RA. Our results revealed that passive coping mediated the effects o f both pain and helplessness on depressive symptomatology. Moreover, while helplessness and passive coping share some conceptual overlap, they contributed uniquely to depressive symptoms when they competed with each other

Depression in Fibromyalgia and with other variables in the model. However, based on the a m o u n t o f unique variance accounted for by each variable to CES-D scores, helplessness appears to be a more significant and robust marker for depression, and an important variable to consider in future research a n d clinical investigations o f fibromyalgia. In sum, helplessness a n d passive coping provide important insight into the mechanisms by which the pain o f F M is related to depressive s y m p t o m s in this illness. The importance o f this framework was further evident in the finding that family cohesion was inversely related to depression in this sample o f patients. Patients' and spouses' family cohesion scores were significantly correlated with one another, and each contributed uniquely to depression in separate regression equations when competing with all other variables tested in the model. Although it is conceivable that depression in the patient could contribute to the perception by the spouse o f less cohesiveness in the family, it does not appear that the relationship between patients' depression and family cohesion was solely the result o f a negative cognitive bias on the part o f the patient. These results corroborate earlier preliminary findings on the role o f family variables in pain outcomes in both r h e u m a t o i d arthritis and fibromyalgia (19), a n d indicate that social a n d interpersonal processes m a y potentially play significant roles in the psychosocial adjustment o f fibromyalgia patients. It is particularly noteworthy that family cohesion contributed an equal a m o u n t o f variability to depression as that contributed by pain, and was a highly significant predictor o f scores falling in the clinically depressed range. However, while family cohesion was directly related to depression, it was not associated with other variables in the pain-coping process which did contribute to depression. Thus, regardless o f levels o f pain, helplessness, or pain-coping tendencies, depression is lower when patients perceive their families to be cohesive and supportive social units. Social support processes may be particularly important to fibromyalgia patients due to the vagaries o f their illness a n d the burdensome impact that the illness may have on others, including health care providers. In this regard, recent evidence has demonstrated, albeit with small numbers o f patients, that the social networks o f fibromyalgia patients are more restricted than the social networks o f rheumatoid arthritis patients (37). Future research should explicitly examine the impact o f different forms o f social support received by fibromyalgia patients on depression and related health outcomes, and whether other dimensions of family functioning m a y be related to the paincoping process in the patient. CONCLUSIONS The potential utility o f a theoretical model evaluating the independent and conjoint influences o f family variables and the pain-coping process as contributing to depressive s y m p t o m s in fibromyalgia has been demonstrated in this research. It should be noted, however, that the subjects in this research were drawn from a volunteer population who had chosen to participate with a support person in a treatment outcome study designed to ameliorate fibromyalgia symptoms. Therefore, it is possible that these data m a y not be generalizable to other clinic and comm u n i t y populations where such support may be less attainable. Moreover, caution is warranted in interpreting the findings due to the cross-sectional, correlational nature o f the design o f the study. W e acknowledge that, while depression was postulated as a major health outcome in the model evaluated and the pattern o f findings converged with data obtained from other

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disease populations, depression itself m a y alter pain perception, increase perceptions o f helplessness, and fuel passive coping efforts. Further, we did not examine reciprocal influence processes between patients and family m e m b e r s since this is an issue that can only be meaningfully addressed in longitudinal research or in controlled laboratory settings. Prospective studies, using the framework proposed, are therefore recommended which evaluate predictive relationships between family variables, the pain-coping process, and pain outcomes in patients afflicted with this troublesome and enigmatic medical condition. REFERENCES (1) Wolfe F, Smythe HA, Yunus MB, ct al: The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis and Rheumatism. 1990, 33:160-172. (2) Leavitt F, Katz R, Golden H, et al: Comparison of pain properties in fibromyalgia patients and rheumatoid arthritis patients. Arthritis and Rheumatism. 1986, 29:775-781. (3) Cathey M, Wolfe F, Kleinheksel S, et al: Functional ability and work status in patients with fibromyalgia. Arthritis Care and Research. 1988, 1:85-98. (4) Hudson JI, Pope HG: Fibromyalgia and psychopathology: Is fibromyalgia a form of "affective spectrum disorder?" Journal of Rheumatology. 1989, 19(Suppl. 16):15-22. (5) Payne TC, Leavitt F, Garron DC, et al: Fibrositis and psychological disturbance. Arthritis and Rheumatism. 1982, 25:213-217. (6) Hudson JI, Hudson MS, Pliner LF, et al: Fibromyalgia and major affective disorder: A controlled phenomenology and family history study. American Journal of Psychiatry. 1985, 142:441--446. (7) Ahles TA, Khan SA, Yunus MB, Spiegel DA, Masi AT: Psychiatric status of patients with primary fibromyalgia, patients with rheumatoid arthritis, and subjects without pain: A blind comparison of DSM-III diagnoses. American Journal of Psychiatry. 1991,148: 1721-1726. (8) Engel GL: The need for a new medical model: A challenge for biomedicine. Science. 1977, 196(4286): 129-I 36. (9) Engel GL: The clinical application of the biopsychosocial model. American Journal of Psychiatry. 1980, 137:535-544. (10) Brown GK: A causal analysis of chronic pain and depression. Journal of Abnormal Psychology. 1990, 99:127-137. (11) Keefe FJ, Brown GK, Wallston KA, Caldwell DS: Coping with rheumatoid arthritis pain: Catastrophizing as a maladaptive strategy. Pain. 1989, 37:51-56. (12) Nicassio PM, Wallston KA, Callahan LF, Hervert M, Pincus T: The measurement of helplessness in rheumatoid arthritis. The development of the arthritis helplessness index. Journal of Rheumatology. 1985, 12(3):462-467. (13) Brown GK, Nicassio PM, Wallston KA: Pain coping strategies and depression in rheumatoid arthritis. Journal of Consulting and Clinical Psychology. 1989, 57(5):652-657. (14) Smith TW, Peck JR, Ward JR: Helplessness and depression in rheumatoid arthritis. Health Psychology. 1990, 2:377-389. (15) Lazarus RS, Folkman S: Stress, Appraisal, and Coping. New York: Springer Publishing Company, 1984. (16) Smith CA, Wallston KA: Adaptation in persons with chronic rheumatoid arthritis. Application of a general model. Health Psychology. 1992, 11:151-162. (17) Litman TJ: The family as a basic unit in health and medical care: A social-behavioral overview. Social Science and Medicine. 1974, 8:495-519. (18) Turk DC, Kerns RD: The family in health and illness. In Turk DC, Kems RD (eds), Health, Illness, and Families: A Life Span Perspective. New York: Wiley Interscience, 1985, 1-22. (19) Nicassio PM, Radojevic V: Models of family functioning and their contribution to patient outcomes in chronic pain. Motivation and Emotion. 1993, 17:295-316.

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