Employment status, social ties, and caregivers’ mental health

Abstract

The purpose of this study of mid-life and older women was to assess the relation between informal care provision and depressive symptoms, taking into account concurrent demands on women's time (including multiple caregiving roles and employment outside the home) as well as participants’ access to potentially supportive social ties.

This cross-sectional study included women ages 46–71, free from major disease, who provided complete health and social information in the 1992 Nurses’ Health Study follow-up survey (n=61,383). In logistic regression models predicting depressive symptoms, we examined the interaction between employment outside the home and informal care provision for a disabled or ill spouse or parent. We also investigated level of social ties, measured with the Berkman–Syme Social Network Index, as a potential modifier of the association between informal care provision and depressive symptoms.

In all analyses, higher weekly time commitment to informal care for a spouse or parent was associated with increased risk of depressive symptoms. This relationship persisted whether women were not employed outside the home, were employed full-time, or were employed part-time. Higher weekly time commitment to informal care provision was associated with increased risk of depressive symptoms whether women were socially integrated or socially isolated. However, both informal care provision and social ties were potent independent correlates of depressive symptoms. Therefore, women who reported high spousal care time commitment and few social ties experienced a dramatic elevation in depressive symptoms, compared to women with no spousal care responsibilities and many social ties (OR for depressive symptoms=11.8; 95% CI 4.8, 28.9). We observed the same pattern among socially isolated women who cared for their parent(s) many hours per week, but the association was not as strong (OR for depressive symptoms=6.5; 95% CI 3.4, 12.7). In this cross-sectional study, employment status did not seem to confer additional mental health risk or benefit to informal caregivers, while access to extensive social ties was associated with more favorable caregiver health outcomes.

Introduction

With the aging of the population, and with women's increasing labor market participation, juggling of work and family responsibilities is increasingly common. More than 60% of all women are expected to provide care to elderly relatives at some point in their lives (Abel, 1995), and approximately 30–40% of informal caregivers in the United States are also salaried workers (Stone, Cafferata, & Sangl, 1987; Brody & Schoonover, 1986). Researchers and the popular press have debated the potential health effects of women's multiple social roles, with essentially two reigning perspectives. The first view is the “scarcity hypothesis,” which argues that multiple roles deplete women's limited energy and resources, resulting in adverse health outcomes (Barnett & Baruch, 1987; Mui, 1992). The second concept is the “expansion hypothesis,” which asserts that benefits accrue to people who operate in multiple roles or domains. With multiple roles come opportunities for prestige, recognition, and financial reward, all of which can bolster women's self-concept and wellbeing (Skaff & Pearlin, 1992).

The scientific evidence regarding multiple roles and health is equivocal. In support of the scarcity hypothesis, Barnett and Baruch (1987) found that the number of roles a woman occupies predicts both role demand overload and role strain. Those authors also reported that motherhood is rarely associated with psychological wellbeing and frequently associated with distress, and that employed women sacrifice their own leisure activities in order to meet work and family demands. In support of the expansion hypothesis, Barnett, Marshall, and Singer (1992) reported that employed women generally exhibit better mental health than do non-employed women. Ozer (1995) also offered evidence that employed mothers are healthier than non-employed mothers, although this may be an artifact of selection bias or “the healthy worker effect.” There is some empirical evidence that employed elder caregivers experience lower levels of depressive symptoms than do non-employed caregivers (Rosenthal, Sulman, & Marshall, 1993). Barnett and Rivers (1996) suggest in She Works, He Works that families are thriving in an era of multiple work and family care demands. In contrast, Taylor, Ford, and Dunbar (1995) noted no significant difference between the health effects of caregiving among non-employed vs. employed women.

An extensive literature documents the impact of social ties on health status. Social networks and support predict both short- and long-term mortality, especially from cardiovascular disease (see especially Berkman & Syme, 1979; House, Robbins, & Metzner, 1982). This finding is particularly strong and consistent among men (Berkman, Vaccarino, & Seeman, 1993). Research also points to a protective effect of supportive social ties on mental health status. In Oxman, Berkman, Kasl, Freeman, and Barrett's (1992) research in the Established Population for the Epidemiologic Study of the Elderly (EPESE) cohort, presence of a confidant, frequency of contact with family and friends, and church or other group membership all were related to lower levels of depressive symptoms. Oxman's study also demonstrated that the following factors were associated with increased depressive symptoms: loss of a spouse or confidant; decline in the number of children seen weekly; and decline in emotional or tangible support available. Although these shifts in social ties may predict mental health status, social ties and support appear fairly consistent over time (Eurelings-Bontekoe, Diekstra, & Verschuur, 1995).

There is some evidence that supportive social ties moderate the negative health effects (e.g., depressive symptoms and physical distress) of elder care (Rosenthal et al., 1993; Moritz, Kasl, & Berkman, 1995; Tausig, 1992; Lieberman & Fisher, 1995; Baumgarten et al., 1994; Gallagher, Wagenfeld, Baro, & Haepers, 1994). Cohen, Teresi, and Blum (1994) reported that 47% of a caregiver sample attended church or synagogue on a regular basis, and that religious attendance had the most potent direct and interactive effects on caregiver psychological wellbeing of any social network variable studied. Access to tangible support also may predict caregiver wellbeing. In Rosenthal's et al. (1993) study of caregivers for long-stay patients, lower depressive symptom levels (measured by the Center for Epidemiologic Studies Depression Scale) were reported by caregivers who felt that someone else could assume their role if necessary.

In the current study, we examined the association between informal care and depressive symptoms, exploring employment status and social ties as potential modifiers of that relationship. We hypothesized that employment outside the home would attenuate the association between informal care and depressive symptoms, in accordance with the expansion hypothesis. We also postulated that, compared to socially isolated caregivers, those with extensive social ties would be less likely to suffer depressive symptoms. Specific social ties may be particularly protective (e.g., large family size may represent access to tangible support and potential relief from informal care responsibilities).