- Email: [email protected]
Do stressful life-events or sociodemographic variables associate with depression and alexithymia among a general population?—a 3-year follow-up study
Do Stressful Life-Events or Sociodemographic Variables Associate With Depression and Alexithymia Among a General Population?—A 3-Year Follow-Up Study Kirsi Honkalampi, Heli Koivumaa-Honkanen, Jukka Hintikka, Risto Antikainen, Kaisa Haatainen, Antti Tanskanen, and Heimo Viinama¨ki This 3-year follow-up study examined background factors, stressful life-events, and changes in alexithymia and depression scores in four groups of subjects from a general population (N ⴝ 1,339): alexithymic (A), depressed (D), simultaneously alexithymic/depressed (AD), and non-alexithymic/non-depressed (O). Alexithymia was assessed using the 20-item version of the Toronto Alexithymia Scale (TAS) and depression using the 21-item Beck Depression Inventory (BDI). A questionnaire screening sociodemography and stressful life-events was also used. The results showed that alexithymia was associated with male gender and blue-collar working, whereas depressive symptoms associated with female gender, older age, poor subjective health, poor financial situation, and
low life satisfaction. During the follow-up the sum of stressful life-events was higher among groups AD and D than in groups A and O. The most common stressful life-events were the death of a close relative or friend, a negative change in the health of a family member, and financial problems. The TAS scores decreased only in groups A and AD. The BDI scores decreased in group AD but remained relatively unchanged in group D. Interestingly, if only those without depressive symptoms are considered, alexithymia appears to be a rarer phenomenon than has been reported previously. Furthermore, it seems that depressive symptoms were chronic and long-lasting among the general population. © 2004 Elsevier Inc. All rights reserved.
D
including somatoform disorder16 and certain personality disorders, such as avoidant, schizotypal, and dependent personality disorders.17,18 Previously, the alexithymia construct was suggested to encompass a cluster of cognitive and affective characteristics, and it has even been agreed that, in some situations, alexithymia could be a state-related phenomenon secondary to the emotional distress evoked by an illness.19 Recent studies11,18 have shown that many depressed patients are simultaneously alexithymic and that alexithymia could also be a situational reaction to depression. However, it is not known whether other specific factors, for example, stressful lifeevents, could affect the stability of alexithymia. The aim of this 3-year follow-up study was to compare alexithymic, depressed, simultaneously alexithymic/depressed and non-alexithymic/nondepressed subjects with respect to their sociodemographic background factors, stressful lifeevents, and changes in their alexithymia and depression scores.
EPRESSION IS relatively common among the general population.1 The average prevalence of depressive disorders was reported to be 8.6% among adults in the general population of five European countries,1 and has been found to be higher among women than men.1,2 Somatic depression in particular is more common among women.3 Factors that have been related to the depression in both genders include stressful life-events,4,5 poor health status,6,7 and age.8,9 In addition, alexithymia10-13 has been often, but not unambiguously,14 associated with depression. Alexithymia originally consisted of four facets: (1) difficulty in identifying and describing subjective feelings to others, (2) difficulty in distinguishing between feelings and the bodily sensations of emotional arousal, (3) a constricted imaginal capacity, such as a paucity of fantasies, and (4) an externally oriented thinking or cognitive style.15 Earlier studies have shown alexithymia to be significantly associated with many DSM disorders,
METHOD From the Department of Psychiatry, Research and Development Unit, Kuopio University Hospital, Kuopio, Finland. Address reprint requests to Kirsi Honkalampi, Ph.D., Department of Psychiatry/4977, Kuopio University Hospital, PO Box 1777, FIN-70211 Kuopio, Finland. © 2004 Elsevier Inc. All rights reserved. 0010-440X/04/4504-0013$30.00/0 doi:10.1016/j.comppsych.2004.03.014 254
Study Population This study was a part of the ongoing Kuopio Depression Study (KUDEP),12,18,20,21 which was approved by the Ethics Committee of Kuopio University Hospital and the University of Kuopio. All of the general population subjects were randomly selected from the National Population Register and were living in the District of Kuopio in the eastern part of Finland.
Comprehensive Psychiatry, Vol. 45, No. 4 (July/August), 2004: pp 254-260
ALEXITHYMIA, DEPRESSION AND LIFE EVENTS
Data were collected three times, in 1998 (T1), 1999 (T2), and 2001 (T3). At baseline in 1998 (T1), 3,004 questionnaires were mailed and a total of 2,050 questionnaires were returned, corresponding to a response rate of 68.2%. Due to incompletely filled questionnaires, 17 (0.7%) subjects were rejected from the analysis and the final sample at baseline (T1) therefore comprised 2,033 subjects (67.7%) (1,135 women, 898 men).12 The second data collection took place 1 year later, in 1999 (T2). In this phase, 1,767 (60.0%) subjects responded, but six (0.3%) questionnaires were rejected due to incomplete information.20 The majority of the respondents on T2 follow-up (89.7%, n ⫽ 1,584) participated in both study phases (T1 and T2). In the third data collection in 2001, questionnaires were sent only to those who had responded at least once before (N ⫽ 2,200). In this phase, 1,618 (936 women, 682 men) subjects responded (73.5%). A total of 1,347 subjects (795 women, 552 men) participated in all three study phases (T1- T3). Eight of these subjects (0.6%) were excluded from the study due to incomplete information in any of the Toronto Alexithymia Scale with 20 items (TAS-20) or Beck Depression Inventory (BDI). The final sample of this study therefore consisted of 1,339 subjects (793 women, 546 men).
Methods At baseline in T1, the subjects completed questionnaires relating to their sociodemographic background (classification in parentheses): age, gender, years of education (high v low: ⱖ12 v ⬍ 12 years), occupation (white-collar worker v blue-collar worker), marital status (married or cohabiting v single, divorced, or widowed), subjective working capacity (good v reduced or unable to work), employment status (employed v unemployed), subjective financial situation (good or fairly good v fairly poor or poor), and subjective general health status (good or fairly good v fairly poor or poor). Alexithymia was screened using the Finnish version22 TAS20.23,24 Each TAS-20 item was rated on a 5-point Likert scale, with total scores ranging from 20 to 100. The baseline cut-off point used for alexithymia was ⱖ61.25 In the other study phases, only mean TAS-20 scores were used. Depressive symptoms were assessed using the 21-item BDI.26 The items of the BDI contain four statements each, and reflect the intensity of a particular depressive symptom, with total scores ranging from 0 to 63. The BDI was used as a class variable with four groups, a cut-off score of ⱕ9 indicating no depression and greater than 9 indicating depression. If the response for one or two items of the TAS-20 or BDI was missing for a particular subject, the missing item was replaced with the subject’s own mean; in the case of more missing items, the scale for that subject was regarded as incomplete data. In addition, life satisfaction was estimated by means of a structured four-item scale27 at baseline and on follow-up in 2001. The total score was used to classify the subjects as either satisfied with their life (score 4 to 11) or dissatisfied (score 12 to 20).27,28 Life events within the 2 preceding years (from T2 to T3) were charted with 12 questions.29 Twelve stressful life-events were recorded: the death of a spouse, the death of a close relative or friend, a negative change in the state of health of a family member, sexual difficulties, considerable difficulties in a working relationship, considerable financial difficulties, divorce, the breaking off of a long-term relationship, the loss of a job or bankruptcy, significantly more conflicts with the spouse, illness
255
causing work disability for over 3 weeks, and some other heavy ordeal. Responses of the subjects to each event were classified as “yes” (⫽ 1; i.e., “has happened and its meaning to me is quite great/extremely great”) or “no” (⫽ 0; i.e., “has not happened/ has happened and its meaning to me is minor”). Moreover, the total sum of all stressful life-events was calculated for multinomial logistic regression analysis.
Drop-out Analysis Of those subjects in the baseline sample (N ⫽ 2,033), women more frequently participated in all follow-up phases than men (69.9%, N ⫽ 793 v 61.0%, N ⫽ 548; 2 ⫽ 17.5, df ⫽ 1, P ⬍ .001). In addition, there were significant differences between those who participated in all phases and the first or second phase dropouts in age (mean age ⫾ SD: 45.7 ⫾ 10.5 years v 41.8 ⫾ 10.7 years; t ⫽ 2.6, df ⫽ 2,031, P ⬍ .001) and baseline TAS-20 score (43.6 ⫾ 11.5 v 45.1 ⫾ 12.2; t ⫽ 1.9, df ⫽ 2,031, P ⬍ .01). However, there was no significant difference in the baseline BDI score between participants and dropouts (5.8 ⫾ 6.7 v 6.4 ⫾ 7.4, not significant).
Statistical Methods Subjects were divided into four groups according to their TAS-20 and BDI scores at baseline (T1). Group A consisted of those subjects who were alexithymic (TAS-20 score ⱖ61) but not depressed (BDI score ⱕ9) at baseline; group D consisted of those who were depressed (BDI score ⬎9) but not alexithymic (TAS-20 score ⬍61) at baseline; group AD consisted of those subjects who were both alexithymic and depressed at baseline; and the fourth group, the “others” (group O), were subjects who were neither alexithymic nor depressed at T1. The statistical methods used included the Pearson chi-square test for categorical variables and one-way analysis of variance (ANOVA) for continuous variables. Repeated-measures ANOVA was used for repeated variables such as TAS-20 and BDI. The normal distribution of variables and residuals (standardized and unstandardized) was verified in each analysis of variance. If residuals were not normally distributed, nonparametric analysis, the Friedman test, and Wilcoxon’s signed ranks test were used instead of repeated-measures ANOVA. Multinomial logistic regression analysis was used to identify the factors that were associated with each group. All data analysis was conducted with SPSS 10.0 (SPSS Inc, Chicago, IL). All statistical tests were two-tailed and a P value less than .05 was considered statistically significant in all analyses.
RESULTS
At baseline a total of 3.0% (n ⫽ 40) of the subjects were alexithymic but not depressed (group A) and 14.9% (n ⫽ 200) were depressed but not alexithymic (group D). Seventy-nine (5.9%) subjects were simultaneously alexithymic and depressed at the baseline (group AD). The largest group comprised subjects who were neither alexithymic nor depressed at T1 (group O) (n ⫽ 1,020, 76.2%). There were many differences in sociodemo-
256
HONKALAMPI ET AL Table 1. Background Characteristics of the Studied Groups at Baseline Variable
Group A
Group D
Group AD
Group O
Age in years, mean (SD)a Gender (male), % (N) Married/cohabiting, % (N) Low level of education, % (N) Blue-collar worker, % (N) Retired or on sick leave % (N) Consider themselves unhealthy, % (N) Consider themselves work-disabled, % (N) Poor financial situation, % (N) Low life satisfaction, % (N)
47.4 (9.9) 67.5 (27) 72.5 (29) 82.5 (33) 43.61 (17) 30.0 (12) 10.0 (4) 17.5 (7) 17.5 (7) 20.0 (8)
47.7 (10.0) 33.5 (67) 67.0 (134) 74.6 (147) 27.2 (53) 25.1 (50) 33.7 (66) 20.5 (41) 40.1 (79) 51.5 (103)
49.6 (9.7) 44.3 (35) 72.2 (57) 81.0 (64) 40.3 (31) 37.2 (29) 41.8 (33) 27.8 (22) 39.2 (31) 70.9 (56)
44.9 (10.6) 40.9 (417) 75.6 (770) 67.7 (689) 23.1 (232) 13.8 (140) 5.9 (59) 5.9 (60) 16.4 (165) 6.9 (70)
2 (df ⫽ 3), P Value
— 16.6† NS 12.2† 18.9‡ 43.5‡ 186.4‡ 75.7‡ 71.8‡ 392.6‡
NOTE. Group A: subjects with alexithymia (TAS-20 score ⱖ 61) but not depression (BDI score ⱕ 9) at baseline (n ⫽ 40, 3.0%). Group D: subjects with depression (BDI score ⬎ 9) but not alexithymia (TAS-20 score ⬍ 61) at baseline (n ⫽ 200, 14.9%). Group AD: subjects with both alexithymia and depression at baseline (n ⫽ 79, 5.9%). Group O: subjects neither alexithymic nor depressed at baseline (n ⫽ 1,020, 76.2%). Abbreviation: NS, not significant. *P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001. a F(3,1335) ⫽ 8.7, P ⬍ .001.
graphic background between the studied groups. Subjects in groups A, D, and AD were more often low educated, retired, or on a sick leave and their subjective assessments of their health, working ability, financial situation, or life satisfaction were more often negative compared to group O (Table 1). The sum of stressful life-events was significantly higher among groups AD (2.1 ⫾ 2.1) and D (1.9 ⫾ 1.9) compared to group A (1.4 ⫾ 1.3) or O (1.0 ⫾ 1.4) [F(3,1221) ⫽ 26.4, P ⬍ .001]. The
death of a close relative or friend and a negative change in the state of health of a family member were quite common stressful life-events, and in groups A, D, and AD these occurred more often than in group O (Table 2). In addition, subjects in groups D and AD often reported sexual difficulties and considerable financial difficulties, while those in group AD quite often reported having more conflicts with the spouse. There were statistical differences in TAS-20 and
Table 2. Stressful Life-Events of the Studied Groups Stressful Life-Events
Death of a close relative or friend Negative change in the state of health of a family member Sexual difficulties Considerable difficulties in a working relationship Considerable financial difficulties Divorce Breaking off of a long-term relationship Loss of a job or bankruptcy Significantly more conflicts with the spouse Illness causing work disability for over 3 weeks Some other heavy ordeal *P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001.
2 (df ⫽ 3), P Value
Group A % (N)
Group D % (N)
Group AD % (N)
Group O % (N)
30.8 (12)
32.5 (64)
32.9 (26)
21.8 (220)
14.5†
25.6 (10) 7.7 (3)
28.4 (56) 24.0 (47)
26.3 (20) 25.3 (19)
17.9 (179) 10.3 (102)
14.0† 38.0‡
2.6 (1) 10.3 (4) 10.3 (4)
12.2 (24) 26.4 (52) 3.6 (7)
13.2 (10) 35.1 (27) 8.0 (6)
6.4 (64) 9.3 (93) 3.3 (33)
12.9† 74.9‡ 8.7*
10.3 (4) 2.6 (1)
8.1 (16) 8.1 (16)
17.3 (13) 9.3 (7)
5.3 (53) 3.8 (38)
18.6‡ 10.9*
10.0 (4)
10.2 (20)
21.3 (16)
6.7 (67)
21.6‡
7.7 (3) 17.9 (7)
19.4 (38) 27.1 (52)
17.1 (13) 22.9 (16)
9.5 (95) 11.8 (117)
19.0‡ 34.1‡
ALEXITHYMIA, DEPRESSION AND LIFE EVENTS
257
Table 3. TAS-20 and BDI Scores in Studied Groups at Baseline (T1) and on Follow-up After 1 and 3 Years (T2-T3)
TAS-20 score T1 mean (95% CI) T2 mean (95% CI) T3 mean (95% CI) BDI score T1 mean (95% CI) T2 mean (95% CI) T3 mean (95% CI)
Group A
Group D
Group AD
Group O
F (df ), P Value
63.6 (62.7-64.6) 58.3 (56.2-60.3) 57.1 (54.6-59.6) F(1,39) ⫽ 23.5‡
47.7 (46.4-48.9) 48.0 (46.4-49.5) 47.0 (45.3-48.6) —
66.6 (65.7-67.6) 61.8 (59.5-64.1) 61.1 (58.9-63.3) F(1,75) ⫽ 24.1‡
40.3 (39.7-40.8) 40.8 (40.2-41.4) 40.6 (40.0-41.2) —
307.0 (3,1,335)‡ 156.3 (3,1,330)‡ 140.8 (3,1,330)‡
5.5 (4.6-6.3) 5.6 (4.4-6.8) 7.0 (5.8-8.2) F(1,38) ⫽ 4.2*
14.7 (13.9-15.5) 12.8 (11.6-13.9) 12.6 (11.2-13.9) —
20.3 (18.5-22.0) 18.5 (16.1-21.0) 16.8 (14.6-19.0) F(1,77) ⫽ 8.5†
3.0 (2.8-3.1) 3.7 (3.5-4.0) 3.8 (3.5-4.1) —
935.6 (3,1,353)‡ 295.9 (3,1,329)‡ 207.0 (3,1,333)‡
Abbreviation: CI, confidence interval. *P ⬍ .05; †P ⬎ .01; ‡P ⬍ .001.
BDI scores between groups in each study phase. The TAS-20 scores decreased significantly during the follow-up in groups A and AD (Table 3). BDI scores decreased significantly in group AD, but slightly increased in group A during the follow-up phases. In group D the BDI scores decreased only during the first year of follow-up (T1 to T2) (Z ⫽ ⫺3.9, P ⬍ .001). Multinomial logistic regression analysis was performed to determine whether subjects in groups A, D, or AD had different sociodemographic backgrounds or stressful life-events compared to group O. The analysis simultaneously compared groups A, D, and AD to group O. Sociodemographic factors that differed significantly between groups (Table 1) were age, gender (female ⫽ 0, male ⫽ 1), level of education (ⱖ12 years ⫽ 0, ⬍12 years ⫽ 1), occupation (other occupations ⫽ 0, blue collar ⫽ 1), being retired or on sick-leave (no ⫽ 0, yes ⫽ 1), subjective health status (healthy ⫽ 0, unhealthy ⫽ 1), subjective working ability (good working ability ⫽ 0, work-disabled ⫽ 1), and subjective financial situation (good ⫽ 0, poor ⫽ 1).
These variables were included in the model. Life satisfaction at T3 (life satisfaction score 4 to 11 ⫽ 0, life satisfaction score 12 to 20 ⫽ 1) and the sum of stressful life-events were also included, because they were found to differ significantly between the groups. Compared to group O, those who were male and had a low life satisfaction had a greater likelihood of belonging to group A (Table 4). Being older, female, and subjectively work-disabled increased the probability of belonging to group D. Low life satisfaction, poor subjective financial situation, poor health status, and high sum of stressful lifeevents increased the likelihood of belonging to groups D or AD compared with group O. DISCUSSION
This study provides evidence that certain sociodemographic factors, as well as stressful lifeevents, are common among alexithymic and depressed subjects in the general Finnish population. Moreover, our findings indicate that alexithymia without depressive symptoms is a rarer phenome-
Table 4. Results of Multinomial Logistic Regression Analysis Variable
Group A v Group O OR (95% CI)
Group D v Group O OR (95% CI)
Group AD v Group O OR (95% CI)
Age Gender (male) Low level of education Blue-collar worker Retired or on sick leave Consider themselves unhealthy Consider themselves work-disabled Poor financial situation The sum of negative life-events Low life satisfaction at T3
1.0 (1.0-1.1) 2.8 (1.3-6.0)† 1.5 (0.6-3.8) 1.6 (0.8-3.5) 1.6 (0.5-5.2) 0.7 (0.2-2.8) 2.2 (0.6-8.3) 0.9 (0.4-2.2) 1.8 (0.9-3.8) 3.2 (1.3-7.5)†
1.0 (1.0-1.1)* 0.6 (0.4-0.8)† 1.1 (0.7-1.8) 1.1 (0.7-1.8) 0.8 (0.4-1.6) 3.7 (2.1-6.3)‡ 2.5 (1.1-5.5)* 2.1 (1.4-3.3)‡ 2.4 (1.5-3.6)‡ 6.0 (3.9-9.3)‡
1.0 (1.0-1.1) 0.8 (0.4-1.4) 1.1 (0.6-2.2) 1.3 (0.7-2.6) 1.1 (0.4-2.9) 5.8 (2.8-11.7)‡ 2.0 (0.7-5.8) 2.0 (1.1-3.7)* 2.1 (1.1-4.0)* 8.1 (4.4-15.0)‡
*P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001.
258
non than has earlier been reported among general populations.30-32 Interestingly, the majority of alexithymic subjects were simultaneously depressed, and this group had the greatest number of stressful life-events and the highest TAS and BDI scores in all study phases. Moreover, the sociodemographic background of the AD group was more similar to the background of depressed than alexithymic subjects. This might suggest that simultaneous alexithymia and depression can also be augmented by other factors. In this study, alexithymic subjects were more often male, whereas depressed subjects were more often female than in other groups. In other samples of the Finnish general population, men were found to be alexithymic almost twice as often as women (17% v 10%30 and 9.4% v 5.2%31). Similarly, depression has found to be more common among women than men.1,2 Interestingly, no gender difference was found within the AD group. The only similarity in sociodemographic factors between AD and A groups was in the proportion of blue-collar workers, which is often found to be associated with alexithymia.33,34 As in earlier studies,8,9 age was a risk factor for depression. In addition, a low level of education was common among depressed subjects, whereas a poor financial situation and poor subjective health were common in both D and AD groups. West et al.35 showed that poor health and physical disability relate to depressive symptoms among older people, and suggested that a person’s subjective estimate of their health may reflect their overall lowered well-being due to financial problems and depressive symptoms, which also seems to have been possible in our sample. Both depression and alexithymia associated with low life satisfaction and subjective working disability. Subjects from the A, D, and AD groups were also often retired or on sick leave. An earlier study36 has shown that depressive disorders are likely to cause more disabilities than many other chronic diseases. Subjective life dissatisfaction has also been shown to be a long-term predictor of psychiatric morbidity27 and even mortality.37 Interestingly, in a meta-analysis, Mintz et al.38 found that work recovery took considerably longer than recovering from the symptoms of depression. In groups A, D, and AD the study subjects more frequently reported stressful life-events than those in group O. However, in logistic regression analy-
HONKALAMPI ET AL
sis the sum of stressful life-events was associated with depression and AD but not with alexithymia itself. Sexual and financial difficulties, as well as a negative change in the state of health of a family member, were reported more often in groups D and AD. In some studies, depression has also been found to be related to high rates of sexual dysfunction,39 financial losses,6 and taking care of a seriously ill family member.40 Any of these events could cause high levels of life stress, which has been found to be a predictor for a depressive episode.41 Kendler et al.4 found that stressful lifeevents actually have a causal relationship with the onset of depression, although one third of this association is noncausal. Even if the highest TAS-20 and BDI scores were found among the AD group, the TAS mean scores decreased in groups AD and A during the study phases, whereas no differences were found in other groups. These results are in line with earlier studies from patient samples showing that the alexithymia score may decline during psychotherapeutic treatment42 or the follow-up period.11,18 The BDI scores also decreased in group AD. Importantly, among depressed subjects depressive symptoms remained quite unchanged. In earlier studies from three separate general population surveys, the percentage of subjects remaining depressed after 1 year of follow-up was between 24% and 65%.43-45 These findings were supported by our results in that depressive symptoms among depressed subjects seemed to be long lasting and stable. Several limitations in the study design should be considered when interpreting these results. First, women and older subjects more frequently participated in all follow-up phases than men and younger subjects. Second, participants had lower TAS-20 scores at baseline than dropouts; however, no difference in the BDI baseline scores was found. Even though stressful life-events and many background variables were measured by single questions, subjects were also asked to rate the significance of each stressful life-event. In summary, our results suggest that stressful life-events associated mainly with depression. Both alexithymia and depression seemed to relate to lowered subjective well-being. In addition, the alexithymia score declined during the follow-up, whereas depressive symptoms were more chronic and long lasting in our sample of the general population.
ALEXITHYMIA, DEPRESSION AND LIFE EVENTS
259
REFERENCES 1. Ayuso-Mateos JL, Vazques-Barquero JL, Dowrick C, Lehtinen V, Dalgard OS, Casey P, et al. Depressive disorders in Europe: prevalence figures from the ODIN study. Br J Psychiatry 2001;179:308-316. 2. Ohayon MM, Schatzberg AF. Prevalence of depressive episodes with psychotic features in the general population. Am J Psychiatry 2002;159:1855-1861. 3. Silverstein B. Gender differences in the prevalence of somatic versus pure depression: a replication. Am J Psychiatry 2002;159:1051-1052. 4. Kendler KS, Karkowski LM, Prescott CA. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry 1999;56:837-841. 5. Cassano P, Fava M. Depression and public health. J Psychosom Res 2002;53:849-857. 6. Judd LL, Paulus MP, Wells KB, Rapaport MH. Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. Am J Psychiatry 1996;153:1411-1417. 7. Saarija¨ rvi S, Salminen JK, Toikka T, Raitasalo R. Healthrelated quality of life among patients with major depression. Nord J Psychiatry 2002;56:261-264. 8. Kivela¨ SL, Luukinen H, Sulkava R, Viramo P, Koski K. Marital and family relations and depression in married elderly Finns. J Affect Disord 1999;54:177-182. 9. Stordal E, Bjartveit Kruger M, Dahl NH, Kruger O, Mykletun A, Dahl AA. Depression in relation to age and gender in the general population: the Nord-Trondelag Health Study (HUNT). Acta Psychiatr Scand 2001;104:210-216. 10. Gunzelmann T, Kupfer J, Brahler E. Alexithymia in the elderly population. Compr Psychiatry 2002;43:74-80. 11. Saarija¨ rvi S, Salminen JK, Toikka TB. Alexithymia and depression: a 1-year follow-up study in outpatients with major depression. J Psychosom Res 2001;51:729-733. 12. Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinama¨ ki H. Depression is strongly associated with alexithymia in the general population. J Psychosom Res 2000;48:99104. 13. De Groot JM, Rodin G, Olmsted MP. Alexithymia, depression, and treatment outcome in bulimia nervosa. Compr Psychiatry 1995;36:53-60. 14. Luminet O, Bagby RM, Taylor GJ. An evaluation of the absolute and relative stability of alexithymia in patients with major depression. Psychother Psychosom 2001;70:254-260. 15. Sifneos PE. The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychother Psychosom 1973; 22:255-262. 16. Bankier B, Aigner M, Bach M. Alexithymia in DSM-IV disorder. Psychosomatics 2001;42:235-240. 17. Bach M, Zwaan M, Ackard D, Nutzinger DO, Mitchell JE. Alexithymia: relationship to personality disorders. Compr Psychiatry 1994;35:239-243. 18. Honkalampi K, Hintikka J, Antikainen R, Lehtonen J, Viinama¨ ki H. Alexithymia in patients with major depressive disorder and comorbid cluster C personality disorders: a 6-month follow-up study. J Personal Disord 2001;15:245-254. 19. Taylor GJ. Recent developments in alexithymia theory and research. Can J Psychiatry 2000;45:134-142. 20. Honkalampi K, Koivumaa-Honkanen H, Tanskanen A,
Hintikka J, Lehtonen J, Viinama¨ ki H. Why do alexithymic features appear to be stable?—A 12-month follow-up study of a general population. Psychother Psychosom 2001;70:247-253. 21. Hintikka J, Honkalampi K, Lehtonen J, Viinama¨ ki H. Are alexithymia and depression distinct or overlapping constructs? A study in a general population. Compr Psychiatry 2001;42:234-239. 22. Joukamaa M, Miettunen J, Kokkonen P, Koskinen M, Julkunen J, Kauhanen J, et al. Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nord J Psychiatry 2001;55:123-127. 23. Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale-I: item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23-32. 24. Bagby RM, Taylor GJ, Parker JDA. The twenty-item Toronto Alexithymia Scale-II. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33-40. 25. Bagby RM, Taylor GJ. Measurement and validation of the alexithymia construct. In: Taylor GJ, Bagby RM, Parker JDA (eds). Disorders of Affect Regulation. Alexithymia in Medical and Psychiatric Illness. Cambridge, UK: Cambridge University Press, 1997:60-66. 26. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-571. 27. Koivumaa-Honkanen H-T. Life Satisfaction as a Health Predictor. Kuopio, Finland: Kuopio University Publications D. Medical Sciences 143, 1998. 28. Koivumaa-Honkanen H, Honkanen R, Viinama¨ ki H, Heikkila¨ K, Kaprio J, Koskenvuo M. Self-reported life satisfaction and 20-year mortality in healthy Finnish adults. Am J Epidemiol 2000;152:983-991. 29. Romanov K, Varjonen J, Kaprio J, Koskenvuo M. Life events and depressiveness—the effect of adjustment for psychosocial factors, somatic health and genetic liability. Acta Psychiatr Scand 2003;107:25-33. ¨ a¨ rela¨ E, Toikka T, Kauhanen 30. Salminen JK, Saarija¨ rvi S, A J. Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland. J Psychosom Res 1999;46:75-82. 31. Kokkonen P, Karvonen JT, Veijola J, La¨ ksy K, Jokelainen J, Ja¨ rvelin MR, et al. Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Compr Psychiatry 2001;42:471-476. 32. Posse M, Hallstro¨ m T, Backenroth-Ohsako G. Alexithymia, social support, psycho-social stress and mental health in a female population. Nord J Psychiatry 2002;56:329-334. 33. Kauhanen J, Kaplan GA, Julkunen J, Wilson TW, Salonen JT. Social factors in alexithymia. Comp Psychiatry 1993; 34:330-335. 34. Valkamo M, Hintikka J, Honkalampi K, Niskanen L, Koivumaa-Honkanen H, Viinama¨ ki H. Alexithymia in patients with coronary heart disease. J Psychosom Res 2001;50:125130. 35. West CG, Reed DM, Gildengorin GL. Can money buy happiness? Depressive symptoms in an affluent older population. J Am Geriatr Soc 1998;46:1328-1329. 36. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K. Functioning and well-being outcomes of patients with de-
260
pression compared with chronic general medical illnesses. Arch Gen Psychiatry 1995;52:11-19. 37. Koivumaa-Honkanen HT, Honkanen R, Viinama¨ ki H, Heikkila¨ K, Kaprio J, Koskenvuo M. Life satisfaction and suicide, a 20-year follow-up study. Am J Psychiatry 2001;158: 433-439. 38. Mintz J, Mintz LI, Arruda MJ, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry 1992;49:761-768. 39. Zajecka J, Dunner DL, Gelenber AJ, Hirschfeld AJ, Kornstein SG, Ninan PT, et al. Sexual function and satisfaction in the treatment of chronic major depression with nefazodone, psychotherapy, and their combination. J Clin Psychiatry 2002; 63:709-716. 40. Carter PA, Chang BL. Sleep and depression in cancer caregivers. Cancer Nurs 2000;23:410-415. 41. Michalak EE, Wilkinson C, Hood K, Srinivasan J, Dowrick C, Dunn G. Prevalence and risk factors for depres-
HONKALAMPI ET AL
sion in a rural setting. Results from the North Wales arm of the ODIN project. Soc Psychiatry Psychiatr Epidemiol 2002; 37:567-571. 42. Beresnevaite M. Exploring the benefits of group psychotherapy in reducing alexithymia in coronary heart disease patients: a preliminary study. Psychother Psychosom 2000;69: 117-122. 43. Sargeant JK, Bruce ML, Florio LP, Weissman MM. Factors associated with 1-year outcome of major depression in the community. Arch Gen Psychiatry 1990;47:519-526. 44. Spijker J, Bijl RV, de Graaf R, Nolen WA. Determinants of poor 1-year outcome of DSM-III-R major depression in the general population: results of the Netherlands Mental Health Survey and Incidence Study. Acta Psychiatr Scand 2001;103: 122-130. 45. Kadam UT, Croft P, Lewis M. Use of a cross-sectional survey to estimate outcome of health care: the example of anxiety and depression. J Clin Epidemiol 2001;54:1112-1119.
low life satisfaction. During the follow-up the sum of stressful life-events was higher among groups AD and D than in groups A and O. The most common stressful life-events were the death of a close relative or friend, a negative change in the health of a family member, and financial problems. The TAS scores decreased only in groups A and AD. The BDI scores decreased in group AD but remained relatively unchanged in group D. Interestingly, if only those without depressive symptoms are considered, alexithymia appears to be a rarer phenomenon than has been reported previously. Furthermore, it seems that depressive symptoms were chronic and long-lasting among the general population. © 2004 Elsevier Inc. All rights reserved.
D
including somatoform disorder16 and certain personality disorders, such as avoidant, schizotypal, and dependent personality disorders.17,18 Previously, the alexithymia construct was suggested to encompass a cluster of cognitive and affective characteristics, and it has even been agreed that, in some situations, alexithymia could be a state-related phenomenon secondary to the emotional distress evoked by an illness.19 Recent studies11,18 have shown that many depressed patients are simultaneously alexithymic and that alexithymia could also be a situational reaction to depression. However, it is not known whether other specific factors, for example, stressful lifeevents, could affect the stability of alexithymia. The aim of this 3-year follow-up study was to compare alexithymic, depressed, simultaneously alexithymic/depressed and non-alexithymic/nondepressed subjects with respect to their sociodemographic background factors, stressful lifeevents, and changes in their alexithymia and depression scores.
EPRESSION IS relatively common among the general population.1 The average prevalence of depressive disorders was reported to be 8.6% among adults in the general population of five European countries,1 and has been found to be higher among women than men.1,2 Somatic depression in particular is more common among women.3 Factors that have been related to the depression in both genders include stressful life-events,4,5 poor health status,6,7 and age.8,9 In addition, alexithymia10-13 has been often, but not unambiguously,14 associated with depression. Alexithymia originally consisted of four facets: (1) difficulty in identifying and describing subjective feelings to others, (2) difficulty in distinguishing between feelings and the bodily sensations of emotional arousal, (3) a constricted imaginal capacity, such as a paucity of fantasies, and (4) an externally oriented thinking or cognitive style.15 Earlier studies have shown alexithymia to be significantly associated with many DSM disorders,
METHOD From the Department of Psychiatry, Research and Development Unit, Kuopio University Hospital, Kuopio, Finland. Address reprint requests to Kirsi Honkalampi, Ph.D., Department of Psychiatry/4977, Kuopio University Hospital, PO Box 1777, FIN-70211 Kuopio, Finland. © 2004 Elsevier Inc. All rights reserved. 0010-440X/04/4504-0013$30.00/0 doi:10.1016/j.comppsych.2004.03.014 254
Study Population This study was a part of the ongoing Kuopio Depression Study (KUDEP),12,18,20,21 which was approved by the Ethics Committee of Kuopio University Hospital and the University of Kuopio. All of the general population subjects were randomly selected from the National Population Register and were living in the District of Kuopio in the eastern part of Finland.
Comprehensive Psychiatry, Vol. 45, No. 4 (July/August), 2004: pp 254-260
ALEXITHYMIA, DEPRESSION AND LIFE EVENTS
Data were collected three times, in 1998 (T1), 1999 (T2), and 2001 (T3). At baseline in 1998 (T1), 3,004 questionnaires were mailed and a total of 2,050 questionnaires were returned, corresponding to a response rate of 68.2%. Due to incompletely filled questionnaires, 17 (0.7%) subjects were rejected from the analysis and the final sample at baseline (T1) therefore comprised 2,033 subjects (67.7%) (1,135 women, 898 men).12 The second data collection took place 1 year later, in 1999 (T2). In this phase, 1,767 (60.0%) subjects responded, but six (0.3%) questionnaires were rejected due to incomplete information.20 The majority of the respondents on T2 follow-up (89.7%, n ⫽ 1,584) participated in both study phases (T1 and T2). In the third data collection in 2001, questionnaires were sent only to those who had responded at least once before (N ⫽ 2,200). In this phase, 1,618 (936 women, 682 men) subjects responded (73.5%). A total of 1,347 subjects (795 women, 552 men) participated in all three study phases (T1- T3). Eight of these subjects (0.6%) were excluded from the study due to incomplete information in any of the Toronto Alexithymia Scale with 20 items (TAS-20) or Beck Depression Inventory (BDI). The final sample of this study therefore consisted of 1,339 subjects (793 women, 546 men).
Methods At baseline in T1, the subjects completed questionnaires relating to their sociodemographic background (classification in parentheses): age, gender, years of education (high v low: ⱖ12 v ⬍ 12 years), occupation (white-collar worker v blue-collar worker), marital status (married or cohabiting v single, divorced, or widowed), subjective working capacity (good v reduced or unable to work), employment status (employed v unemployed), subjective financial situation (good or fairly good v fairly poor or poor), and subjective general health status (good or fairly good v fairly poor or poor). Alexithymia was screened using the Finnish version22 TAS20.23,24 Each TAS-20 item was rated on a 5-point Likert scale, with total scores ranging from 20 to 100. The baseline cut-off point used for alexithymia was ⱖ61.25 In the other study phases, only mean TAS-20 scores were used. Depressive symptoms were assessed using the 21-item BDI.26 The items of the BDI contain four statements each, and reflect the intensity of a particular depressive symptom, with total scores ranging from 0 to 63. The BDI was used as a class variable with four groups, a cut-off score of ⱕ9 indicating no depression and greater than 9 indicating depression. If the response for one or two items of the TAS-20 or BDI was missing for a particular subject, the missing item was replaced with the subject’s own mean; in the case of more missing items, the scale for that subject was regarded as incomplete data. In addition, life satisfaction was estimated by means of a structured four-item scale27 at baseline and on follow-up in 2001. The total score was used to classify the subjects as either satisfied with their life (score 4 to 11) or dissatisfied (score 12 to 20).27,28 Life events within the 2 preceding years (from T2 to T3) were charted with 12 questions.29 Twelve stressful life-events were recorded: the death of a spouse, the death of a close relative or friend, a negative change in the state of health of a family member, sexual difficulties, considerable difficulties in a working relationship, considerable financial difficulties, divorce, the breaking off of a long-term relationship, the loss of a job or bankruptcy, significantly more conflicts with the spouse, illness
255
causing work disability for over 3 weeks, and some other heavy ordeal. Responses of the subjects to each event were classified as “yes” (⫽ 1; i.e., “has happened and its meaning to me is quite great/extremely great”) or “no” (⫽ 0; i.e., “has not happened/ has happened and its meaning to me is minor”). Moreover, the total sum of all stressful life-events was calculated for multinomial logistic regression analysis.
Drop-out Analysis Of those subjects in the baseline sample (N ⫽ 2,033), women more frequently participated in all follow-up phases than men (69.9%, N ⫽ 793 v 61.0%, N ⫽ 548; 2 ⫽ 17.5, df ⫽ 1, P ⬍ .001). In addition, there were significant differences between those who participated in all phases and the first or second phase dropouts in age (mean age ⫾ SD: 45.7 ⫾ 10.5 years v 41.8 ⫾ 10.7 years; t ⫽ 2.6, df ⫽ 2,031, P ⬍ .001) and baseline TAS-20 score (43.6 ⫾ 11.5 v 45.1 ⫾ 12.2; t ⫽ 1.9, df ⫽ 2,031, P ⬍ .01). However, there was no significant difference in the baseline BDI score between participants and dropouts (5.8 ⫾ 6.7 v 6.4 ⫾ 7.4, not significant).
Statistical Methods Subjects were divided into four groups according to their TAS-20 and BDI scores at baseline (T1). Group A consisted of those subjects who were alexithymic (TAS-20 score ⱖ61) but not depressed (BDI score ⱕ9) at baseline; group D consisted of those who were depressed (BDI score ⬎9) but not alexithymic (TAS-20 score ⬍61) at baseline; group AD consisted of those subjects who were both alexithymic and depressed at baseline; and the fourth group, the “others” (group O), were subjects who were neither alexithymic nor depressed at T1. The statistical methods used included the Pearson chi-square test for categorical variables and one-way analysis of variance (ANOVA) for continuous variables. Repeated-measures ANOVA was used for repeated variables such as TAS-20 and BDI. The normal distribution of variables and residuals (standardized and unstandardized) was verified in each analysis of variance. If residuals were not normally distributed, nonparametric analysis, the Friedman test, and Wilcoxon’s signed ranks test were used instead of repeated-measures ANOVA. Multinomial logistic regression analysis was used to identify the factors that were associated with each group. All data analysis was conducted with SPSS 10.0 (SPSS Inc, Chicago, IL). All statistical tests were two-tailed and a P value less than .05 was considered statistically significant in all analyses.
RESULTS
At baseline a total of 3.0% (n ⫽ 40) of the subjects were alexithymic but not depressed (group A) and 14.9% (n ⫽ 200) were depressed but not alexithymic (group D). Seventy-nine (5.9%) subjects were simultaneously alexithymic and depressed at the baseline (group AD). The largest group comprised subjects who were neither alexithymic nor depressed at T1 (group O) (n ⫽ 1,020, 76.2%). There were many differences in sociodemo-
256
HONKALAMPI ET AL Table 1. Background Characteristics of the Studied Groups at Baseline Variable
Group A
Group D
Group AD
Group O
Age in years, mean (SD)a Gender (male), % (N) Married/cohabiting, % (N) Low level of education, % (N) Blue-collar worker, % (N) Retired or on sick leave % (N) Consider themselves unhealthy, % (N) Consider themselves work-disabled, % (N) Poor financial situation, % (N) Low life satisfaction, % (N)
47.4 (9.9) 67.5 (27) 72.5 (29) 82.5 (33) 43.61 (17) 30.0 (12) 10.0 (4) 17.5 (7) 17.5 (7) 20.0 (8)
47.7 (10.0) 33.5 (67) 67.0 (134) 74.6 (147) 27.2 (53) 25.1 (50) 33.7 (66) 20.5 (41) 40.1 (79) 51.5 (103)
49.6 (9.7) 44.3 (35) 72.2 (57) 81.0 (64) 40.3 (31) 37.2 (29) 41.8 (33) 27.8 (22) 39.2 (31) 70.9 (56)
44.9 (10.6) 40.9 (417) 75.6 (770) 67.7 (689) 23.1 (232) 13.8 (140) 5.9 (59) 5.9 (60) 16.4 (165) 6.9 (70)
2 (df ⫽ 3), P Value
— 16.6† NS 12.2† 18.9‡ 43.5‡ 186.4‡ 75.7‡ 71.8‡ 392.6‡
NOTE. Group A: subjects with alexithymia (TAS-20 score ⱖ 61) but not depression (BDI score ⱕ 9) at baseline (n ⫽ 40, 3.0%). Group D: subjects with depression (BDI score ⬎ 9) but not alexithymia (TAS-20 score ⬍ 61) at baseline (n ⫽ 200, 14.9%). Group AD: subjects with both alexithymia and depression at baseline (n ⫽ 79, 5.9%). Group O: subjects neither alexithymic nor depressed at baseline (n ⫽ 1,020, 76.2%). Abbreviation: NS, not significant. *P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001. a F(3,1335) ⫽ 8.7, P ⬍ .001.
graphic background between the studied groups. Subjects in groups A, D, and AD were more often low educated, retired, or on a sick leave and their subjective assessments of their health, working ability, financial situation, or life satisfaction were more often negative compared to group O (Table 1). The sum of stressful life-events was significantly higher among groups AD (2.1 ⫾ 2.1) and D (1.9 ⫾ 1.9) compared to group A (1.4 ⫾ 1.3) or O (1.0 ⫾ 1.4) [F(3,1221) ⫽ 26.4, P ⬍ .001]. The
death of a close relative or friend and a negative change in the state of health of a family member were quite common stressful life-events, and in groups A, D, and AD these occurred more often than in group O (Table 2). In addition, subjects in groups D and AD often reported sexual difficulties and considerable financial difficulties, while those in group AD quite often reported having more conflicts with the spouse. There were statistical differences in TAS-20 and
Table 2. Stressful Life-Events of the Studied Groups Stressful Life-Events
Death of a close relative or friend Negative change in the state of health of a family member Sexual difficulties Considerable difficulties in a working relationship Considerable financial difficulties Divorce Breaking off of a long-term relationship Loss of a job or bankruptcy Significantly more conflicts with the spouse Illness causing work disability for over 3 weeks Some other heavy ordeal *P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001.
2 (df ⫽ 3), P Value
Group A % (N)
Group D % (N)
Group AD % (N)
Group O % (N)
30.8 (12)
32.5 (64)
32.9 (26)
21.8 (220)
14.5†
25.6 (10) 7.7 (3)
28.4 (56) 24.0 (47)
26.3 (20) 25.3 (19)
17.9 (179) 10.3 (102)
14.0† 38.0‡
2.6 (1) 10.3 (4) 10.3 (4)
12.2 (24) 26.4 (52) 3.6 (7)
13.2 (10) 35.1 (27) 8.0 (6)
6.4 (64) 9.3 (93) 3.3 (33)
12.9† 74.9‡ 8.7*
10.3 (4) 2.6 (1)
8.1 (16) 8.1 (16)
17.3 (13) 9.3 (7)
5.3 (53) 3.8 (38)
18.6‡ 10.9*
10.0 (4)
10.2 (20)
21.3 (16)
6.7 (67)
21.6‡
7.7 (3) 17.9 (7)
19.4 (38) 27.1 (52)
17.1 (13) 22.9 (16)
9.5 (95) 11.8 (117)
19.0‡ 34.1‡
ALEXITHYMIA, DEPRESSION AND LIFE EVENTS
257
Table 3. TAS-20 and BDI Scores in Studied Groups at Baseline (T1) and on Follow-up After 1 and 3 Years (T2-T3)
TAS-20 score T1 mean (95% CI) T2 mean (95% CI) T3 mean (95% CI) BDI score T1 mean (95% CI) T2 mean (95% CI) T3 mean (95% CI)
Group A
Group D
Group AD
Group O
F (df ), P Value
63.6 (62.7-64.6) 58.3 (56.2-60.3) 57.1 (54.6-59.6) F(1,39) ⫽ 23.5‡
47.7 (46.4-48.9) 48.0 (46.4-49.5) 47.0 (45.3-48.6) —
66.6 (65.7-67.6) 61.8 (59.5-64.1) 61.1 (58.9-63.3) F(1,75) ⫽ 24.1‡
40.3 (39.7-40.8) 40.8 (40.2-41.4) 40.6 (40.0-41.2) —
307.0 (3,1,335)‡ 156.3 (3,1,330)‡ 140.8 (3,1,330)‡
5.5 (4.6-6.3) 5.6 (4.4-6.8) 7.0 (5.8-8.2) F(1,38) ⫽ 4.2*
14.7 (13.9-15.5) 12.8 (11.6-13.9) 12.6 (11.2-13.9) —
20.3 (18.5-22.0) 18.5 (16.1-21.0) 16.8 (14.6-19.0) F(1,77) ⫽ 8.5†
3.0 (2.8-3.1) 3.7 (3.5-4.0) 3.8 (3.5-4.1) —
935.6 (3,1,353)‡ 295.9 (3,1,329)‡ 207.0 (3,1,333)‡
Abbreviation: CI, confidence interval. *P ⬍ .05; †P ⬎ .01; ‡P ⬍ .001.
BDI scores between groups in each study phase. The TAS-20 scores decreased significantly during the follow-up in groups A and AD (Table 3). BDI scores decreased significantly in group AD, but slightly increased in group A during the follow-up phases. In group D the BDI scores decreased only during the first year of follow-up (T1 to T2) (Z ⫽ ⫺3.9, P ⬍ .001). Multinomial logistic regression analysis was performed to determine whether subjects in groups A, D, or AD had different sociodemographic backgrounds or stressful life-events compared to group O. The analysis simultaneously compared groups A, D, and AD to group O. Sociodemographic factors that differed significantly between groups (Table 1) were age, gender (female ⫽ 0, male ⫽ 1), level of education (ⱖ12 years ⫽ 0, ⬍12 years ⫽ 1), occupation (other occupations ⫽ 0, blue collar ⫽ 1), being retired or on sick-leave (no ⫽ 0, yes ⫽ 1), subjective health status (healthy ⫽ 0, unhealthy ⫽ 1), subjective working ability (good working ability ⫽ 0, work-disabled ⫽ 1), and subjective financial situation (good ⫽ 0, poor ⫽ 1).
These variables were included in the model. Life satisfaction at T3 (life satisfaction score 4 to 11 ⫽ 0, life satisfaction score 12 to 20 ⫽ 1) and the sum of stressful life-events were also included, because they were found to differ significantly between the groups. Compared to group O, those who were male and had a low life satisfaction had a greater likelihood of belonging to group A (Table 4). Being older, female, and subjectively work-disabled increased the probability of belonging to group D. Low life satisfaction, poor subjective financial situation, poor health status, and high sum of stressful lifeevents increased the likelihood of belonging to groups D or AD compared with group O. DISCUSSION
This study provides evidence that certain sociodemographic factors, as well as stressful lifeevents, are common among alexithymic and depressed subjects in the general Finnish population. Moreover, our findings indicate that alexithymia without depressive symptoms is a rarer phenome-
Table 4. Results of Multinomial Logistic Regression Analysis Variable
Group A v Group O OR (95% CI)
Group D v Group O OR (95% CI)
Group AD v Group O OR (95% CI)
Age Gender (male) Low level of education Blue-collar worker Retired or on sick leave Consider themselves unhealthy Consider themselves work-disabled Poor financial situation The sum of negative life-events Low life satisfaction at T3
1.0 (1.0-1.1) 2.8 (1.3-6.0)† 1.5 (0.6-3.8) 1.6 (0.8-3.5) 1.6 (0.5-5.2) 0.7 (0.2-2.8) 2.2 (0.6-8.3) 0.9 (0.4-2.2) 1.8 (0.9-3.8) 3.2 (1.3-7.5)†
1.0 (1.0-1.1)* 0.6 (0.4-0.8)† 1.1 (0.7-1.8) 1.1 (0.7-1.8) 0.8 (0.4-1.6) 3.7 (2.1-6.3)‡ 2.5 (1.1-5.5)* 2.1 (1.4-3.3)‡ 2.4 (1.5-3.6)‡ 6.0 (3.9-9.3)‡
1.0 (1.0-1.1) 0.8 (0.4-1.4) 1.1 (0.6-2.2) 1.3 (0.7-2.6) 1.1 (0.4-2.9) 5.8 (2.8-11.7)‡ 2.0 (0.7-5.8) 2.0 (1.1-3.7)* 2.1 (1.1-4.0)* 8.1 (4.4-15.0)‡
*P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001.
258
non than has earlier been reported among general populations.30-32 Interestingly, the majority of alexithymic subjects were simultaneously depressed, and this group had the greatest number of stressful life-events and the highest TAS and BDI scores in all study phases. Moreover, the sociodemographic background of the AD group was more similar to the background of depressed than alexithymic subjects. This might suggest that simultaneous alexithymia and depression can also be augmented by other factors. In this study, alexithymic subjects were more often male, whereas depressed subjects were more often female than in other groups. In other samples of the Finnish general population, men were found to be alexithymic almost twice as often as women (17% v 10%30 and 9.4% v 5.2%31). Similarly, depression has found to be more common among women than men.1,2 Interestingly, no gender difference was found within the AD group. The only similarity in sociodemographic factors between AD and A groups was in the proportion of blue-collar workers, which is often found to be associated with alexithymia.33,34 As in earlier studies,8,9 age was a risk factor for depression. In addition, a low level of education was common among depressed subjects, whereas a poor financial situation and poor subjective health were common in both D and AD groups. West et al.35 showed that poor health and physical disability relate to depressive symptoms among older people, and suggested that a person’s subjective estimate of their health may reflect their overall lowered well-being due to financial problems and depressive symptoms, which also seems to have been possible in our sample. Both depression and alexithymia associated with low life satisfaction and subjective working disability. Subjects from the A, D, and AD groups were also often retired or on sick leave. An earlier study36 has shown that depressive disorders are likely to cause more disabilities than many other chronic diseases. Subjective life dissatisfaction has also been shown to be a long-term predictor of psychiatric morbidity27 and even mortality.37 Interestingly, in a meta-analysis, Mintz et al.38 found that work recovery took considerably longer than recovering from the symptoms of depression. In groups A, D, and AD the study subjects more frequently reported stressful life-events than those in group O. However, in logistic regression analy-
HONKALAMPI ET AL
sis the sum of stressful life-events was associated with depression and AD but not with alexithymia itself. Sexual and financial difficulties, as well as a negative change in the state of health of a family member, were reported more often in groups D and AD. In some studies, depression has also been found to be related to high rates of sexual dysfunction,39 financial losses,6 and taking care of a seriously ill family member.40 Any of these events could cause high levels of life stress, which has been found to be a predictor for a depressive episode.41 Kendler et al.4 found that stressful lifeevents actually have a causal relationship with the onset of depression, although one third of this association is noncausal. Even if the highest TAS-20 and BDI scores were found among the AD group, the TAS mean scores decreased in groups AD and A during the study phases, whereas no differences were found in other groups. These results are in line with earlier studies from patient samples showing that the alexithymia score may decline during psychotherapeutic treatment42 or the follow-up period.11,18 The BDI scores also decreased in group AD. Importantly, among depressed subjects depressive symptoms remained quite unchanged. In earlier studies from three separate general population surveys, the percentage of subjects remaining depressed after 1 year of follow-up was between 24% and 65%.43-45 These findings were supported by our results in that depressive symptoms among depressed subjects seemed to be long lasting and stable. Several limitations in the study design should be considered when interpreting these results. First, women and older subjects more frequently participated in all follow-up phases than men and younger subjects. Second, participants had lower TAS-20 scores at baseline than dropouts; however, no difference in the BDI baseline scores was found. Even though stressful life-events and many background variables were measured by single questions, subjects were also asked to rate the significance of each stressful life-event. In summary, our results suggest that stressful life-events associated mainly with depression. Both alexithymia and depression seemed to relate to lowered subjective well-being. In addition, the alexithymia score declined during the follow-up, whereas depressive symptoms were more chronic and long lasting in our sample of the general population.
ALEXITHYMIA, DEPRESSION AND LIFE EVENTS
259
REFERENCES 1. Ayuso-Mateos JL, Vazques-Barquero JL, Dowrick C, Lehtinen V, Dalgard OS, Casey P, et al. Depressive disorders in Europe: prevalence figures from the ODIN study. Br J Psychiatry 2001;179:308-316. 2. Ohayon MM, Schatzberg AF. Prevalence of depressive episodes with psychotic features in the general population. Am J Psychiatry 2002;159:1855-1861. 3. Silverstein B. Gender differences in the prevalence of somatic versus pure depression: a replication. Am J Psychiatry 2002;159:1051-1052. 4. Kendler KS, Karkowski LM, Prescott CA. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry 1999;56:837-841. 5. Cassano P, Fava M. Depression and public health. J Psychosom Res 2002;53:849-857. 6. Judd LL, Paulus MP, Wells KB, Rapaport MH. Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. Am J Psychiatry 1996;153:1411-1417. 7. Saarija¨ rvi S, Salminen JK, Toikka T, Raitasalo R. Healthrelated quality of life among patients with major depression. Nord J Psychiatry 2002;56:261-264. 8. Kivela¨ SL, Luukinen H, Sulkava R, Viramo P, Koski K. Marital and family relations and depression in married elderly Finns. J Affect Disord 1999;54:177-182. 9. Stordal E, Bjartveit Kruger M, Dahl NH, Kruger O, Mykletun A, Dahl AA. Depression in relation to age and gender in the general population: the Nord-Trondelag Health Study (HUNT). Acta Psychiatr Scand 2001;104:210-216. 10. Gunzelmann T, Kupfer J, Brahler E. Alexithymia in the elderly population. Compr Psychiatry 2002;43:74-80. 11. Saarija¨ rvi S, Salminen JK, Toikka TB. Alexithymia and depression: a 1-year follow-up study in outpatients with major depression. J Psychosom Res 2001;51:729-733. 12. Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinama¨ ki H. Depression is strongly associated with alexithymia in the general population. J Psychosom Res 2000;48:99104. 13. De Groot JM, Rodin G, Olmsted MP. Alexithymia, depression, and treatment outcome in bulimia nervosa. Compr Psychiatry 1995;36:53-60. 14. Luminet O, Bagby RM, Taylor GJ. An evaluation of the absolute and relative stability of alexithymia in patients with major depression. Psychother Psychosom 2001;70:254-260. 15. Sifneos PE. The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychother Psychosom 1973; 22:255-262. 16. Bankier B, Aigner M, Bach M. Alexithymia in DSM-IV disorder. Psychosomatics 2001;42:235-240. 17. Bach M, Zwaan M, Ackard D, Nutzinger DO, Mitchell JE. Alexithymia: relationship to personality disorders. Compr Psychiatry 1994;35:239-243. 18. Honkalampi K, Hintikka J, Antikainen R, Lehtonen J, Viinama¨ ki H. Alexithymia in patients with major depressive disorder and comorbid cluster C personality disorders: a 6-month follow-up study. J Personal Disord 2001;15:245-254. 19. Taylor GJ. Recent developments in alexithymia theory and research. Can J Psychiatry 2000;45:134-142. 20. Honkalampi K, Koivumaa-Honkanen H, Tanskanen A,
Hintikka J, Lehtonen J, Viinama¨ ki H. Why do alexithymic features appear to be stable?—A 12-month follow-up study of a general population. Psychother Psychosom 2001;70:247-253. 21. Hintikka J, Honkalampi K, Lehtonen J, Viinama¨ ki H. Are alexithymia and depression distinct or overlapping constructs? A study in a general population. Compr Psychiatry 2001;42:234-239. 22. Joukamaa M, Miettunen J, Kokkonen P, Koskinen M, Julkunen J, Kauhanen J, et al. Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nord J Psychiatry 2001;55:123-127. 23. Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale-I: item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23-32. 24. Bagby RM, Taylor GJ, Parker JDA. The twenty-item Toronto Alexithymia Scale-II. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33-40. 25. Bagby RM, Taylor GJ. Measurement and validation of the alexithymia construct. In: Taylor GJ, Bagby RM, Parker JDA (eds). Disorders of Affect Regulation. Alexithymia in Medical and Psychiatric Illness. Cambridge, UK: Cambridge University Press, 1997:60-66. 26. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-571. 27. Koivumaa-Honkanen H-T. Life Satisfaction as a Health Predictor. Kuopio, Finland: Kuopio University Publications D. Medical Sciences 143, 1998. 28. Koivumaa-Honkanen H, Honkanen R, Viinama¨ ki H, Heikkila¨ K, Kaprio J, Koskenvuo M. Self-reported life satisfaction and 20-year mortality in healthy Finnish adults. Am J Epidemiol 2000;152:983-991. 29. Romanov K, Varjonen J, Kaprio J, Koskenvuo M. Life events and depressiveness—the effect of adjustment for psychosocial factors, somatic health and genetic liability. Acta Psychiatr Scand 2003;107:25-33. ¨ a¨ rela¨ E, Toikka T, Kauhanen 30. Salminen JK, Saarija¨ rvi S, A J. Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland. J Psychosom Res 1999;46:75-82. 31. Kokkonen P, Karvonen JT, Veijola J, La¨ ksy K, Jokelainen J, Ja¨ rvelin MR, et al. Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Compr Psychiatry 2001;42:471-476. 32. Posse M, Hallstro¨ m T, Backenroth-Ohsako G. Alexithymia, social support, psycho-social stress and mental health in a female population. Nord J Psychiatry 2002;56:329-334. 33. Kauhanen J, Kaplan GA, Julkunen J, Wilson TW, Salonen JT. Social factors in alexithymia. Comp Psychiatry 1993; 34:330-335. 34. Valkamo M, Hintikka J, Honkalampi K, Niskanen L, Koivumaa-Honkanen H, Viinama¨ ki H. Alexithymia in patients with coronary heart disease. J Psychosom Res 2001;50:125130. 35. West CG, Reed DM, Gildengorin GL. Can money buy happiness? Depressive symptoms in an affluent older population. J Am Geriatr Soc 1998;46:1328-1329. 36. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K. Functioning and well-being outcomes of patients with de-
260
pression compared with chronic general medical illnesses. Arch Gen Psychiatry 1995;52:11-19. 37. Koivumaa-Honkanen HT, Honkanen R, Viinama¨ ki H, Heikkila¨ K, Kaprio J, Koskenvuo M. Life satisfaction and suicide, a 20-year follow-up study. Am J Psychiatry 2001;158: 433-439. 38. Mintz J, Mintz LI, Arruda MJ, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry 1992;49:761-768. 39. Zajecka J, Dunner DL, Gelenber AJ, Hirschfeld AJ, Kornstein SG, Ninan PT, et al. Sexual function and satisfaction in the treatment of chronic major depression with nefazodone, psychotherapy, and their combination. J Clin Psychiatry 2002; 63:709-716. 40. Carter PA, Chang BL. Sleep and depression in cancer caregivers. Cancer Nurs 2000;23:410-415. 41. Michalak EE, Wilkinson C, Hood K, Srinivasan J, Dowrick C, Dunn G. Prevalence and risk factors for depres-
HONKALAMPI ET AL
sion in a rural setting. Results from the North Wales arm of the ODIN project. Soc Psychiatry Psychiatr Epidemiol 2002; 37:567-571. 42. Beresnevaite M. Exploring the benefits of group psychotherapy in reducing alexithymia in coronary heart disease patients: a preliminary study. Psychother Psychosom 2000;69: 117-122. 43. Sargeant JK, Bruce ML, Florio LP, Weissman MM. Factors associated with 1-year outcome of major depression in the community. Arch Gen Psychiatry 1990;47:519-526. 44. Spijker J, Bijl RV, de Graaf R, Nolen WA. Determinants of poor 1-year outcome of DSM-III-R major depression in the general population: results of the Netherlands Mental Health Survey and Incidence Study. Acta Psychiatr Scand 2001;103: 122-130. 45. Kadam UT, Croft P, Lewis M. Use of a cross-sectional survey to estimate outcome of health care: the example of anxiety and depression. J Clin Epidemiol 2001;54:1112-1119.