بدهی، نقطه ضعف اجتماعی و افسردگی مادر

Abstract Depression is common among women with young children, and is strongly associated with financial adversity. Debt is a common feature of such adversity, yet its relationship with depression has not been examined before. We have used longitudinal data, collected over six months, on 271 families with young children, to examine this relationship. Multiple regression was used to identify independent predictors of the total Edinburgh Post-natal Depression Scale score from a range of socioeconomic, demographic, social support and child health related variables. Worry about debt was the strongest independent socioeconomic predictor of the depression score at both initial and follow-up occasions. To account for the possibility of reverse causation, i.e. depression causing worry about debt, alternative regression models are reported which show that owing money by itself predicts depression and earlier debt worries predicts depression six months later. We were unable to show that earlier debt worries independently predicted subsequent depression scores after the initial depression score had been taken into account in the analysis. Although debt has not been shown to be an independent prospective predictor of depression, our results suggest it has a central place in the association between socioeconomic hardship and maternal depression. Evidence from qualitative studies on poverty and from studies on the causes of depression support this hypothesis. The implications for policy are that strategies to enable families to control debt should be an explicit part of wider antipoverty measures which are designed to reduce depression and psychological distress among mothers of young children.

Introduction Depression is an important cause of morbidity in women and is estimated to affect between 10 and 30 percent of mothers of young children (Cox, Connor, & Kendall, 1982; Cox, Murray, & Chapman, 1993; Kumar & Robson, 1984; Cooper, Campbell, Day, Kennerley, & Bond, 1988). This causes suffering among women, affects relationships within their families, and their children's developmental progress is impaired in the longer term (Murray, 1992; Sharp et al., 1995; Murray & Cooper, 1997). Maternal depression is not purely a postnatal problem; although there are some specific characteristics of depression in the months after giving birth (Murray, Cox, Chapman, & Jones, 1995; Cooper & Murray, 1995), the similarities in incidence, prevalence, clinical features and associated factors suggests there is little to distinguish depression among mothers of young children regardless of their age (Cooper et al., 1988; Cox et al., 1993; Murray et al, 1995). Despite conventional biomedical treatments being effective (Appleby, Warner, Whitton, & Faragher, 1997), there is little evidence for a purely biological mechanism of maternal depression. Instead, combinations of various factors have been suggested as precipitating depression in women who are already psychologically vulnerable. Broadly, these fall into three categories: those indicating poor quality or unsupportive relationships, those related to the pregnancy, life events and acute stressors, and those associated with socioeconomic disadvantage and financial hardship. This study examines the association between depression and a specific aspect of socioeconomic adversity, namely debt. Causal explanations of maternal depression The first broad category of precipitating factors concern the quality of interpersonal relationships. Many studies have shown that marital problems, poor quality couple relationships or absence of a confidante are strongly associated with depression (Brown & Harris, 1978; Kumar & Robson, 1984; Brown, Andrews, Harris, Adler, & Bridge, 1986; Stein, Cooper, Campbell, Day, & Altham, 1989; Murray et al., 1995; Escriba, Mas, Romito, & Saurel-Cubizolles, 1999; Hope, Power, & Rodgers, 1999; Romito, Saurel-Cubizolles, & Lelong, 1999; Stretch, Nicol, Davison, & Fundudis, 1999). Brown et al. (1986) and Brown and Bifulco (1990) have shown that lack of support during a crisis, or being “let down” by the woman's partner predicts the subsequent onset of depression. Family disruption (Sheppard, 1997) and relationship difficulties with the extended family also predispose to depression, particularly if these include problems with the woman's own mother (Kumar & Robson, 1984; Murray et al., 1995; Lambrenos, Weindling, Calam, & Cox, 1996). Lack of social support is also a risk factor, while good quality social support is a protective factor (Brown et al., 1986). It would seem from these studies that the quality of interpersonal relationships, particularly between the woman and her partner, is an essential aspect of the causal pathway to maternal depression. A second category of precipitating factors are related to the pregnancy, life events and psychosocial stresses. With respect to the pregnancy, increased risk of depression has been found in association with unplanned pregnancy (Kumar & Robson, 1984; Warner, Appleby, Whitton, & Faragher, 1996), preterm birth (Kumar & Robson, 1984), stillbirth (Kumar & Robson, 1984; Thorpe, Golding, MacGillivray, & Greenwood, 1991) and not breastfeeding (Warner et al., 1996). Risk factors related to the stress of managing a family include family size (Murray et al., 1995; Sheppard, 1997), twins or multiple births (Thorpe et al., 1991), close spacing of births (Thorpe et al., 1991), ill health of the child (Romito et al., 1999; Escriba et al., 1999), and behavioural difficulties or developmental delay in the child (Sheppard, 1997; Stretch et al., 1999). In this context, it is interesting that neither childhood disability nor the prospect of the child developing a disability appear to increase the risk of depression (Lambrenos et al., 1996). Studies on external life stresses have focussed largely on employment, and complex relationships have been found. While many studies have shown that maternal or paternal unemployment is likely to increase the risk of maternal depression (Stein et al., 1989; Lambrenos et al., 1996; Warner et al, 1996; Saurel-Cubizolles, Romito, Ancel, & Lelong, 2000), full time employment has also been shown to be a risk factor, particularly among lone parents (Brown & Bifulco, 1990; Macran, Clarke, & Joshi, 1996; Baker & North, 1999). The explanation appears to be that unemployment is an indicator of poverty, while full time employment indicates the stress of extra workload which is added to women's responsibilities for care. This is supported by Murray et al. (1995), who showed that occupational dissatisfaction increased the risk of depression. Conversely, part time work may be a protective factor because of the social support it offers (Brown & Bifulco, 1990). The third type of precipitating factor is socioeconomic adversity. This was identified in the pioneering study by Brown and Harris (1978). Subsequent studies have shown associations with a range of socio-economic factors such as low income, financial problems and money worries, receipt of benefits, maternal and paternal unemployment, housing tenure, and manual social class (Stein et al., 1989; Thorpe et al., 1991; Murray et al., 1995; Warner et al., 1996; Brown & Moran, 1997; Sheppard, 1997; Graham & Blackburn, 1998; Escriba et al., 1999; Romito et al., 1999). The interpretation of most of these studies is that socioeconomic adversity, however it is measured, is not simply an additional contributory factor but has a specific and pervasive influence. The body of research on depression among lone mothers has been important in unravelling the effects of economic hardship from other possible causes. A high proportion of families headed by a lone parent live in poverty (Judge & Benzeval, 1993; Oppenheim & Harker, 1996). Women heading a lone parent family have a much greater risk of depression than mothers with a partner (Macran et al., 1996; Sheppard, 1997; Benzeval, 1998). There are a number of possible explanations apart from the direct effect of poverty; greater stress, less social support, the effect of unemployment, and social selection, but most of the studies set up to unravel the causes have concluded that financial hardship is the most important underlying feature (Macran et al., 1996; Benzeval, 1998; Baker & North, 1999; Hope et al, 1999). Although social support and psychological stress undoubtedly have an effect, they are simply part of the web of disadvantage endured by women living in poverty. Two carefully controlled longitudinal studies enable this web of disadvantage to be teased out. The first, a large population based study among residents of New Haven, Connecticutt (Bruce, Takeuchi, & Leaf, 1991), examined the role of poverty in determining risk of various psychiatric conditions, carefully controlling for other factors such as sex, age, race and history of psychiatric illness. Previously well adults living in poverty had over twice the risk of depression than those not living in poverty, with the population attributable risk being 10% (i.e. 10% of new cases of depression were directly attributable to the effect of poverty). This study therefore demonstrates that poverty has a direct causal influence on development of new episodes of depression. The second was a detailed multifactorial study of the determinants of depression among the original Islington sample of inner city mothers (Brown & Moran, 1997). Their model of a causal pathway began with pre-existing vulnerability factors such as childhood adversity and lack of self-esteem. Poor social support and lack of a supportive partner contributed more proximally to the underlying vulnerability. Onset of depression was triggered by severe life events within the family, particularly those involving humiliation or entrapment. However, over and above all these, the most important factor was financial hardship. This was both the strongest independent predictor of depression and it also adversely affected all the other predisposing and risk factors. Socioeconomic disadvantage and depression One potential criticism of this conceptual framework of the causes of depression is that socioeconomic hardship is simply another cause of stress and does not need to be distinguished on its own. However, there are three reasons for considering it separately. First, measures of socioeconomic disadvantage consistently predict depression, whereas other aspects of stress show inconsistent and distinctly different associations between different studies. Several of the studies quoted above, particularly those with more robust methods, show the overarching influence of poverty and socioeconomic adversity, and how this can influence other aspects of stress and social relationships (e.g. Brown & Moran, 1997). Also, from a theoretical point of view poverty is a more chronic and insidious cause of stress than the other factors which are either acute, contingent on the pregnancy or arise as a result of chance or unexpectedly (for instance a sick child, twin pregnancy or a severe life event). The second reason for considering poverty as a specific risk factor is that it signifies depression among mothers as a feature of the social inequalities in health found in all modern developed countries (Whitehead & Diderichsen, 1997; Acheson et al., 1998). Given the adverse effects on family relationships and child behaviour and development, this in turn provides a possible mechanism for the social inequalities in child mental health and well being. The third reason is that it has important policy implications. Maternal depression is not just a problem for primary health care and mental health services, it requires a social policy response. To an extent this has been recognised in the government's drive to end child poverty but attempts to tackle depression and other aspects of maternal health have concentrated on ‘problem’ groups, for instance teenage mothers, lone parents, and those who have not returned to work. A variety of approaches are being tried by the current UK government, targeted on these vulnerable groups. However, if financial hardship is the primary problem, then many of these policies may be missing the mark. It is more appropriate to address the problem of poverty than to implement policies aimed at reducing the numbers of high risk women, for example lone mothers. Furthermore, interventions targeted on specific groups may miss large numbers of other women who suffer the same underlying social disadvantages and who therefore run a similarly high risk of depression. Debt and depression Families may move into and out of poverty over time, particularly after the birth of an infant when changes may occur in income, housing circumstances, demands on material and financial resources, employment and benefit eligibility. One of the more ubiquitous features of social disadvantage among families with young children in recent years has been the presence and effect of debt (Oppenheim & Harker, 1996; Kempson, 1996). Low-income families headed by young people, particularly those with larger numbers of children, run a high risk of debt (Berthoud & Kempson, 1992). The relationship between debt and maternal depression has not been studied in a quantitative way. Given that debt seems such an overarching feature of life among families living in or at the margins of poverty, this is an issue which deserves examination. Qualitative studies of the experience of poverty provide rich evidence that anxiety about debt may trigger or potentiate depression among mothers of young children (Kempson, Bryson, & Rowlingson, 1994; Kempson, 1996), particularly in circumstances in which their economic resources may have changed. As part of a study on the effects of Citizen's Advice Bureau services on the health of mothers and young children, we have data which provides an opportunity to examine this hypothesis. We collected extensive social and demographic information on families with children under one year of age, including two Edinburgh Postnatal Depression Scale (EPDS) questionnaires about six months apart, data indicating access to social networks, and measures of child and family stressors. In terms of the model of the causes of depression discussed above, we are able to examine in detail the associations between socioeconomic disadvantage and depression. We have used regression modelling to investigate the following research questions. Firstly, to confirm that maternal depression is associated with socioeconomic disadvantage among our sample. Secondly, to identify which aspects of socioeconomic disadvantage have the strongest relationship with depression, with a particular emphasis on the part played by debt and worries about debt. Thirdly to investigate whether debt and worries about debt prospectively influence the onset or worsening of depression over time