قضاوت از حالات چهره و پشتکار افسردگی

Abstract In research it has been demonstrated that cognitive and interpersonal processes play significant roles in depression development and persistence. The judgment of emotions displayed in facial expressions by depressed patients allows for a better understanding of these processes. In this study, 48 major depression outpatients and healthy control subjects, matched on the gender of the patients, judged facial expressions as to the emotions the expressions displayed. These judgments were conducted at the patients' outpatient admission (T1). The depression severity of the patients was measured at T1, 13 weeks later (T2) and at a 6-month follow-up (T3). It was found that the judgment of negative emotions in the facial expressions was related to both the depression severity at T1 and depression persistence (T2 and T3), whereas the judgment of positive emotions was not related to the patients' depression. The judgment of the emotion of sadness was the best predictor of the patients' depression persistence. Additionally, it was found that the patients judged significantly more sadness in the facial expressions than the control subjects. These findings are related to previous data of facial expression judgments of depressed patients and future research directions are discussed.

Introduction The role cognitive and interpersonal processes play in the development and persistence of depression is a topic of much study. Cognitive researchers, such as Beck et al. (1979)and Lewinsohn et al. (1981), have found that depressed individuals have the tendency to appraise themselves, others and their daily events with negative expectancies. Additionally, it has been shown that depressed people tend to attribute negative events (Sweeney et al., 1986) and negative self-evaluations to themselves (Giesler et al., 1996). In addition to negative cognitions of depressed persons, interpersonal processes, such as the giving and receiving of social support, have been found to be problematic (McNaughton et al., 1992), and a lack of social support has been related to increased risk of depression chronicity (Brown et al., 1994). Coyne et al. (1991)has suggested that depression is a process of dysfunctional interpersonal interactions. Coyne contends that the depressed-prone person elicits support behaviors, intermixed with rejection attitudes, from persons in his or her general surroundings. Sensitive to this underlying rejection attitude, the depression-prone person increases his or her support-seeking behavior in order to elicit more supportive behaviors from others until these others eventually withdraw. It is along these lines that Gotlib and Hammen (1992)have suggested that the negative expectancies (cognitions) of depressives, a readiness to perceive and attend to negative aspects of their social surroundings, may lead to decreased social support. In order to better understand the negative cognitive processes and interpersonal interaction behaviors of depressed patients, attention has been given to the facial emotional expressions of depressed patients and their judgments of facial expressions. The reasons for employing facial expressions in the study of negative cognitive processes and interpersonal interactions are twofold: First, it has been demonstrated that facial expressions are used to judge the emotional state of others, as well as to display one's own emotional state. In addition, individuals are less able to disguise their actual affective state in their display of their facial expressions than they are with other modes of emotional communication, such as their verbal report of their affect (Ekman et al., 1980). Secondly, cross-cultural studies have demonstrated the universal similarity in the recognition and expression of basic emotions in facial expressions (Ekman et al., 1987 and Ekman, 1993). Given that emotional expressions are outcomes of one's cognitions and interpersonal interactions, research of facial expressions is helpful in obtaining a better understanding of the (culture-free) principles underlying depressed patients' cognitive appraisal of situations and interpersonal interactions with others in these situations, with a relative degree of freedom from patient demand characteristics. Research into the display of facial expression has shown that depressed individuals have a general impairment in displaying emotional facial expressions (Wexler et al., 1994), particularly positive expressions (Jaeger et al., 1986), and a tendency to display more sad facial expressions than healthy control subjects (Brown, 1982). Depressives have also been found to have a negative bias in the judgment of facial expressions (Nandi et al., 1982 and Gur et al., 1992) and a general deficit in facial judgment accuracy (Feinberg et al., 1986), leading some to suggest that this may help explain the poor interpersonal interactions depressives have with others (Persad and Polivy, 1993). However, a negative bias has not found support in all studies. In a study by Bouhuys et al. (1996), it was found that a hyposensitivity in the judgment of facial expressions by depressed patients was related to their depression persistence. Additionally, in the study of facial expression judgment, specific attention has been given to the judgment of ambiguous (i.e. mixed emotions) expressions. In studies which have used mood induction procedures with normal subjects, it has been shown that judgments of ambiguous facial expressions are sensitive to the subject's depressed mood (Bouhuys et al., 1995). However, while much attention has been given to the characteristics of the judgment of facial expressions by depressives, less attention has been given to the relationship between depressed patients' judgment of facial expressions and depression persistence, and how the judgments of patients compare to the judgments of healthy control subjects. Therefore, in the present study, depressed out-patients and healthy control subjects judged facial expressions in terms of the emotions they felt the facial expressions displayed. In the light of both cognitive theories and interpersonal theories of depression, it was anticipated that depressed patients would judge facial expressions negatively. It was expected that negative judgment of facial expression would be related to the patients' depression severity (as assessed at out-patient admission) and would be predictive of depression persistence (as assessed 13 weeks and 6 months after outpatient admission). In respect to the finding that the judgment of ambiguous facial expressions is more mood dependent than the judgement of general facial expressions, it was expected that negative judgment of facial expressions by patients would be more pronounced for their judgment of ambiguous facial expressions. Additionally, it was anticipated that the patients' judgment of facial expressions would be more negative than the judgment of facial expressions by healthy control subjects.

. Results 3.1. Depression severity course Over the course of the patients' treatment at the out-patient clinic, their depression severity scores decreased. The average depression severity (BDI) of the 48 depressed patients at outpatient admission (T1) was 27.7 (S.D.=7.1; range 17–47). At T2, two patients failed to return their BDI questionnaires, reducing the patient group from 48 patients to 46; the average depression severity was 20.7 (S.D.=12.0; range 0–52). At T3, all 48 patients participated and the average depression severity was 17.2 (S.D.=11.6; range 1–51). Significant differences between the BDI scores were found for both the T1 and T2 measurements (F1,93=12.3, P=0.00) and the T1 and T3 measurements (F1,95=29.3, P=0.00). Of the 48 patients, 28 patients (58.3%) were invited back for re-testing before six months, and the remaining 20 (41.7%) were invited back 6 months after T1; the former patients did not differ from the latter in T1 depression scores (F1,47=0.03, P=0.85). It should also be noted that in analysis of variance tests, it was found that the patients who were invited back before 6 months did not significantly differ in their judgment of facial expressions from the patients invited back 6 months after T1. 3.2. Judgment of general facial expressions and depression severity prediction The correlations of the judgment of the 12 general facial expressions at T1 to the BDI depression scores, as assessed at T1, T2 and T3, are presented in Table 2. Table 2. Correlations of the judgments by depressive patients at T1 of the emotions expressed by the general facial expressions and the BDI depression severity scores (T1, T2 and T3) Judged Admission 13-week 6-month emotions BDI (T1) BDI (T2) BDI (T3) Sadness 0.473** 0.450** 0.410** Anger 0.493** 0.394** 0.285** Disgust 0.544** 0.386** 0.262 Fear 0.298* 0.229 0.239 Rejection 0.473** 0.351* 0.308* Negative 0.519** 0.410** 0.343* Invitation −0.066 −0.138 −0.262 Happiness 0.092 −0.004 −0.109 Positive 0.010 −0.081 −0.208 *P≤0.05; **P≤0.01 Table options As can be seen in the table, the negative emotions correlated significantly with depression severity at T1 and depression persistence at T2 and T3, whereas none of the positive emotions correlated significantly. Multiple stepwise regression tests revealed that the sadness emotion best predicted both the T2 (Adjusted R2=0.18, P=0.00; sadness: β=0.45) and T3 depression severity scores (Adjusted R2=0.15, P=0.00; sadness: β=0.41). 3.3. Judgment of ambiguous facial expressions and depression severity prediction The correlations of the judgment of the ambiguous facial expressions at T1 to the BDI depression scores, as assessed at T1, T2 and T3, are presented in Table 3. Table 3. Correlations of the patients' judgment at T1 of the emotions expressed by the ambiguous facial expressions and the BDI depression severity scores (T1, T2 and T3) Judged Admission 13-week 6-month emotions BDI (T1) BDI (T2) BDI (T3) Sadness 0.532** 0.479** 0.523** Anger 0.398** 0.278 0.243 Disgust 0.555** 0.412** 0.329* Fear 0.451** 0.389** 0.414** Rejection 0.544** 0.280 0.317* Negative 0.637** 0.466** 0.467** Invitation −0.164 −0.084 −0.175 Happiness 0.118 0.090 −0.030 Positive −0.034 −0.001 −0.120 *P≤0.05; **P≤0.01. Table options As with the general facial expressions, the negative emotions correlated significantly with depression severity at T1 and the depression persistence at T2 and T3, whereas none of the positive emotions correlated significantly. Additionally, the judgment of the sadness emotion was the best predictor of the T2 (adjusted R2=0.21, P=0.00; sadness: β=0.48) and the T3 depression severity scores (adjusted R2=0.26, P=0.00; sadness: β=0.52). 3.4. Relationship of gender and medication to judgment of facial expressions Analyses of variance were conducted to explore if a relationship existed between the patients' gender and judgment of both the general and ambiguous facial expressions. For both the general and ambiguous facial expressions, no significant relationship was found (see Table 4Table 5). Table 4. Analyses of variance of T1 patient judgments of the emotions of the general facial expressions by gender and medication treatment (d.f.=1,47) Judged Gender Antidepressant Benzodiazepine emotions F (P) F (P) F (P) Sadness 0.11 (0.74) 0.05 (0.82) 0.24 (0.63) Anger 0.02 (0.88) 0.02 (0.87) 0.97 (0.33) Disgust 0.07 (0.79) 0.56 (0.46) 0.33 (0.57) Fear 0.64 (0.43) 0.06 (0.81) 0.56 (0.46) Rejection 3.47 (0.08) 0.13 (0.72) 0.72 (0.40) Negative 0.33 (0.57) 0.01 (0.94) 0.66 (0.42) Invitation 0.05 (0.83) 0.39 (0.53) 0.16 (0.69) Happiness 0.63 (0.43) 0.02 (0.88) 0.12 (0.73) Positive 0.08 (0.78) 0.19 (0.66) 0.17 (0.68) Table options Table 5. Analyses of variance of the T1 patient judgments of the emotions of the ambiguous facial expressions by gender and medication treatment (d.f.=1,47) Judged Gender Antidepressant Benzodiazepine emotions F (P) F (P) F (P) Sadness 0.87 (0.36) 0.13 (0.72) 0.41 (0.52) Anger 0.05 (0.83) 0.69 (0.41) 3.07 (0.09) Disgust 0.17 (0.68) 0.55 (0.46) 0.53 (0.47) Fear 0.95 (0.33) 0.62 (0.43) 0.47 (0.49) Rejection 1.54 (0.22) 0.16 (0.69) 0.38 (0.54) Negative 0.35 (0.56) 0.61 (0.44) 1.18 (0.28) Invitation 0.07 (0.79) 0.16 (0.69) 1.57 (0.22) Happiness 0.42 (0.52) 0.07 (0.79) 0.05 (0.83) Positive 0.04 (0.85) 0.01 (0.93) 0.73 (0.39) Table options In the same fashion, analyses of variance were performed to investigate if a relationship existed between the patients' medication prescriptions and judgment of both the general and ambiguous facial expressions. For both the general and ambiguous facial expressions, no significant relationship was found (see Table 4 and Table 5). 3.5. Judgments of facial expressions by patients and control subjects Analysis of variance revealed that the patients judged significantly more sadness in the general facial expressions than did the control subjects (F1,93=6.87, P=0.01; Patients: mean=1.92, S.D.=0.53; Control subjects: mean=1.66, S.D.=0.42). For the ambiguous faces, the patients also judged more sadness than the control subjects (F1,93=8.91, P=0.00; Patients: mean=1.68, S.D.=0.58; Control subjects: mean=1.36, S.D.=0.45). Additionally, the patients judged the ambiguous faces more negatively than the control subjects (F1,93=3.95, P=0.05; Patients: mean=1.71, S.D.=0.42; Control subjects: mean=1.54, S.D.=0.41). The means and standard deviations of the patients' and the control subjects' judgments of the facial expressions are presented in Table 6 Table 7. Table 6. Means and standard deviations of the patients and control subjects' judgments of the emotions expressed by the general facial expressions Judged emotions Patients Control subjects Mean (S.D.) Mean (S.D.) Sadness 1.9 (0.5) 1.6 (0.4)** Anger 2.0 (0.4) 1.9 (0.3) Disgust 1.9 (0.5) 1.8 (0.5) Fear 1.9 (0.5) 1.8 (0.5) Rejection 2.0 (0.5) 1.9 (0.5) Negative 2.0 (0.4) 1.8 (0.4) Invitation 1.6 (0.3) 1.7 (0.3) Happiness 1.7 (0.3) 1.7 (0.2) Positive 1.6 (0.3) 1.7 (0.2) **P≤0.01. Table options Table 7. Means and standard deviations of the patients and control subjects' judgments of the emotions by the ambiguous facial expressions Judged emotions Patients Control subjects Mean (S.D.) Mean (S.D.) Sadness 1.6 (0.6) 1.3 (0.4)** Anger 1.7 (0.5) 1.7 (0.5) Disgust 1.7 (0.6) 1.5 (0.6) Fear 1.6 (0.4) 1.5 (0.5) Rejection 1.8 (0.5) 1.7 (0.6) Negative 1.7 (0.4) 1.5 (0.4)* Invitation 1.7 (0.6) 1.8 (0.5) Happiness 1.8 (0.6) 1.9 (0.6) Positive 1.8 (0.5) 1.9 (0.5) *P≤0.05; **P≤0.01.