Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-099Stress, Coping and Social SupportLawrence R. Landerman and Dana HughesDuke University Medical Center, Durham, NC, USAWhile a multitude of studies have examined the effects ofsocial and environmental stressors, coping behaviors andsocial support on psychological distress, relatively little isknown about their effects on neurotic disorders in the elderly.The effects of stress, support and coping on depression havebeen studied extensively in the general population and amongthose aged 65. A smaller number of studies examines theireffects on the anxiety disorders in the general population.Very little work has been done with neurotic disorders as theoutcome of interest among older persons. Recent reviewersconclude that the anxiety and panic disorders among theelderly have received little attention and that a systematicexamination of the risk factors associated with late-lifeanxiety disorders has barely begun 1–3 . This is the case despitethe fact that they are the most prevalent psychiatricconditions among the elderly, as they are among youngerpersons. Methodological problems involved with defining andoperationalizing the anxiety disorders, disentangling anxietyfrom depression, and the transience of some symptom statesaccount, in part, for the lack of attention they have receivedin epidemiologic studies 3,4 .Since the overwhelming majority of relevant studies deal withdepression rather than the neurotic disorders, we will use these toexamine the rationale and evidence for epidemiologic modelslinking stress, coping and support to psychiatric symptoms anddisorder. Next, we will review a smaller but growing number ofstudies that have begun to examine whether stress, support andcoping affect the anxiety disorders in a manner similar to theireffects on depression. Since all but three of these anxiety studiesare based on general population surveys rather than samples ofthe elderly per se, we will address the degree to which these studiesare consistent with a conclusion that similar effects of stress,coping and support on neurosis are present among the elderly.Finally, we will point out key unresolved issues and the practicalimplications of the studies reviewed.associated with an increased risk of psychiatric symptoms anddisorder 5–7 . Findings for stress and depression are based onsamples of older adults as well as the general population andinclude prospective studies where stress precedes the onset ofsymptoms 8–10 .Stressful life events are most likely to have negative healthconsequences if they are perceived as unexpected and undesirable 5 .Negatively-evaluated changes in health, family and living situations,work and finances have been shown to be strongly andpositively related to depressive symptoms and major depressiveepisodes in the general population and in samples of olderindividuals 5,11,12 . Chronic stressors include poverty, deterioratedneighborhood conditions and ill health, which have been shown topredict both the onset of depression and the course of recovery 13–17 .While cross-sectional studies show an association between cognitiveimpairment and depression 4–17 , prospective studies reportmixed and inconclusive results regarding whether dementia orcognitive impairment are risk factors for the onset or duration ofdepression 17 .While older persons experience fewer potentially stressful lifeevents 18 , they experience a ‘‘changing landscape of stressors’’ 19 ,and are more likely to experience particular events that arestrongly related to psychiatric morbidity 20 . These include poorhealth and disability, widowhood, and the death of other friendsand family members 21,22 . While retirement per se is not associatedwith an increased risk of psychiatric disorder 23 , a recent study 24reports that driving cessation is strongly associated with anincreased risk of depressive symptoms. Findings are mixedregarding whether stress associated with caring for a disabledperson is a risk factor for depression. Initial studies of those(presumably more distressed) caregivers who sought servicesfound high levels of depressive symptoms. A smaller number ofcommunity studies of caregiving and depression report inconsistentresults 17 .STRESS, COPING, SOCIAL SUPPORT ANDDEPRESSIONStressStressors refer to life experiences that may be perceived asthreatening and/or challenging. They include discrete ‘‘stressfullife events’’, such as changes in finances, health or maritalstatus. They also include more enduring or chronic problemswith regard to income, health or other areas of life. Reviewersare in accord that there is consistent evidence that stress isCopingCoping refers to steps the individual takes to avoid, solve orminimize the impact of life problems 25 . It serves two functions:problem solving and the regulation of emotions. Different copingstrategies can have different consequences for psychological wellbeinggenerally, and for the impact of stress on well-being inparticular. Rodin 26 contends that solving a problem without helpfrom others may promote well-being by enhancing feelings of selfworthand personal control. Requesting help, on the other hand,may negatively affect well-being by generating interpersonalconflict if those asked are unwilling or unable to providePrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd