Journal of Abnormal Psychology 1990, Vol. 99, No.

3, 264--271

Copyright 1990 by the American Psychological Association, Inc. 0021-843X/90/$00.75

Are People Changed by the Experience of Having an Episode of Depression? A Further Test of the Scar Hypothesis
Paul Rohde, Peter M. Lewinsohn, and John R. Seeley
Oregon Research Institute, Eugene, Oregon

The purpose of this study was to identify characteristics of individuals before and after their first depressive episode. Subjects were 49 older persons assessed before and after their first depressive episode on depression-related psychosoeial variables. The control group consisted of 351 never-depressed individuals. Consistent with previous findings, patients were more likely to be younger, female, and mildly depressed both before and after the episode. In addition, they were more likely to be employed. Following an episode of depression, the recovered patients described their social skills and health as poorer and their interpersonal dependency as greater than the controls. However, on an experiment-wise basis, the number of significant differences were no greater than expected by chance. The stress activation model was examined but did not appreciably enhance the results. Results suggest that most of the psyehosocial variables associated with depression are state dependent.

Individuals who have been depressed in the past are at greater risk for developing a future episode of depression compared with those who have never been depressed (Amenson & Lewinsohn, 1981; Gonzales, Lewinsohn, & Clarke, 1985; Keller, Shapiro, Lavori, & Wolfe, 1982). For example, Amenson and Lewinsohn (1981) found that a previous history of depression was associated with an approximately two-fold increase in probability of developing a future episode of depression during a one-year period (from. 12 to.22 for women and from .05 to. 13 for men). Therefore, it may be hypothesized that (a) formerly depressed individuals possess distinguishing characteristics that contribute to this increased vulnerability, and (b) that these characteristics are present even when the individuals are not depressed. Assuming that these distinguishing characteristics can be identified, it remains to be determined whether the vulnerability to becoming depressed is a characteristic of the person before the occurrence of their first episode of depression or whether the vulnerability comes into existence during the first episode. If the characteristic, which could be psychological, environmental, or biological, is present before the first depressive episode, then it may be said to be a trait marker for becoming depressed. The trait marker hypothesis requires that variables that discriminate formerly depressed individuals from never-depressed individuals discriminate between the two groups even before the onset of the first depressive episode. Alternatively, individuals may not manifest the vulnerability before their first episode but acquire a"scar" during or after the

This project, which complied with American Psychological Association's ethical standards in the treatment of human subjects, was partially supported by National Institute of Mental Health Research Grant MH 35672. Correspondence concerning this article should be addressed to Paul Rohde, Oregon Research Institute, 1715 Franklin Boulevard, Eugene, Oregon 97403-1983. 264

first depressive episode, which predisposes them to future depressive episodes. The scar hypothesis was first introduced by Lewinsohn, Steinmetz, Larson, and Franklin (1981). A sear is defined as a relatively permanent residual deficit that is created by the episode o f depression much in the same way that a cut or surgical operation may leave a physical sear. The question o f whether an episode of depression leaves relatively permanent residuals or deficits (i.e, sear hypothesis) or whether persons who are prone to becoming depressed differ from those who are not as vulnerable even before they first become depressed (ie, trait marker hypothesis) is important both theoretically and clinically. Identifying such characteristics and their temporal relationship to the onset o f depression may provide clues about the mechanisms that render people more vulnerable to becoming depressed and clarify the sequelae of depression. Clinicallg such information could facilitate the development of interventions to ameliorate characteristics or conditions that contribute to the increased vulnerability among the formerly depressed. Relevant to the issues just mentioned is the literature in which formerly depressed individuals have been compared with never-depressed controls. Both the scar and trait marker suppositions require that these groups differ on some variables. Unfortunatel~ no clear answers as to the nature or magnitude of such differences have emerged from previous studies. On the basis o f their results and conclusions, these studies may be sorted into three general groups. The first group consists of those studies in which no significant differences between the formerly depressed and never-depressed groups were found among a large number of cognitive (Blackburn & Smyth, 1985; Hamilton & Abramson, 1983; Lewinsohn et aL 1981; Wilkinson & Blackburn, 1981) and behavioral (Lewinsohn & Talkington, 1979; MacPhillamy & Lewinsohn, 1974; Youngren & Lewinsohn, 1980; Zeiss & Lewinsohn, 1988) concomitants of depression. These studies suggest that the psychosocial variables assessed (e.g, dysfunctional atti-

SCARS OF DEPRESSION tudes, irrational beliefs, frequency of pleasant events) are not contributing to the increased vulnerability to depression relapse. A second group of studies has reported more equivocal resuits, which demonstrated that formerly depressed individuals differed, albeit in relatively small ways, from the never-depressed control group (Billings & Moos, 1985; Hirschfeld, Klerman, Clayton, & Keller, 1983; Paykel & Weissman, 1973). For instance, Billings and Moos (1985) concluded that although some differences, primarily in the area of social resources (e.g. smaller number of friends, less family support), remained after recovery, in most respects the formerly depressed patients returned to a level of functioning close to that of the never-depressed controls. The third group of studies has reported large differences between the never-depressed and formerly depressed groups (e.g, Airman & Wittenborn, 1980; Cofer & Wittenborn, 1980; Perris, Eisemann, Von Korring, & Perris, 1984). One such study (Eaves & Rush, 1984) found that upon remission a formerly depressed group of 24 women still reported significantly greater use of dysfunctional attitudes and negative attributional style, while their reported level of automatic negative thoughts was comparable to the 17 never-depressed controls. Such studies suggest that formerly depressed individuals continue to show differences on basic measures o f symptomatology and personality. These contradictory findings make it difficult to draw firm conclusions about the existence and nature of any potential scar or trait marker variables. Several possible explanations for the discrepant findings may be offered. First, those studies that reported significant group differences may have included formerly depressed subjects who were in varying degrees o f recovery, with some subjects still mildly depressed. Second, studies that reported significant differences tended to assess formerly depressed subjects who had experienced more severe and/or more numerous past episodes of depression. Both Aneshensel (1985) and Depue and Monroe (1986) emphasized the importance o f differentiating individuals who are persistently depressed from those for whom a depressive episode represents an isolated event different from their usual way of functioning. Third, individuals who have more recently recovered from a depressive episode may be more likely to show residual deficits than those who have been depression-free for many years. Fourth, scars may not always be observable; rather, they become notable only in the presence of elevated levels of stress (ie, the stress activation model). Fifth, more substantial scars may have emerged in studies involving the subset of depressed individuals who seek treatment. Present Study As part of a longitudinal study aimed at identifying the characteristics of people at risk for depression, 742 individuals aged 50 years or older were assessed by diagnostic interview and self-report questionnaire at two time points. The two-panel design provided a unique opportunity to study a group of 49 older individuals who developed their first depressive episode between the two assessment points of our study (new cases). We were able to compare this group of individuals with a never-depressed control group on a large array of psychosocial charae-

265

teristics relatively close to the onset and remission o f their first episode. Given the fact that all the subjects were older, the likelihood that we included individuals with a depression trait marker in our never-depressed control group was quite low. Several variables broadly categorized as demographics, stress, social support and interaction, personality characteristics, coping style, health, and pathology were assessed. Variables were chosen for inclusion if they had been found in previous cross-sectional and longitudinal studies to be predictors or concomitants of depression. It was among this set o f measures that the scars of depression were thought most likely to be found. The data set provided a unique opportunity to test the scar hypothesis in that (a) depression was rigorously assessed using both diagnostic interview and self-report measures before and after the first episode; (b) the study was longitudinal and prospective (i.e. the new cases had been measured before and after their first episode on a large array of psychosocial characteristics, thus providing a direct test o f the scar hypothesis); and (c) the subjects were gathered from the general community and thus were more representative than a treatment sample. Method

Participants
Between May, 1982, and November, 1983, 4,133 individuals over the age of 50 residing in Eugene-Springfield, Oregon, were randomly selected from a list of licensed drivers and invited to participate in psycholngical research. A total ofl,008 subjects completed both the Time 1 (TI) self-report questionnaire and diagnostic interview. Of the 1,008 subjects, 742 (74%) completed participation in the entire study (e.g, completed the Time 2 IT2 ] questionnaire and interview) until its conclusion in March, 1986. The average time elapsed between TI and T2 was 29 months. Inspection of the demographic characteristics of the 742 participants revealed that, compared with United States census data for the area, participants were better educated and more likely to he women. Older individuals were slightly more likely to discontinue participation; no other assessed demographic differences were associated with attrition in this study. Approximately 2% of the T2 sample reported receiving concurrent counseling forsome type of problem (e.g, alcoholism, marital discord). Subjects received no financial reimbursement for participation and signed a statement of informed consent, which ensured confidentiality.

Subject Finding
Our primary goal was to record all first episodes of depression that occurred between TI and T2. To achieve this goal, subjects were mailed the Center for Epidemiolngieal Studies Depression Scale (CESD) (Radloff, 1977), a self-report measure of 20 depressive symptoms, approximately every two months. Completion rates were high, averaging 80% (ofthe 1,008 TI subjects) across the nine mailings. Any subject not diagnosed as depressed at TI who scored above 11 on any subsequent CES-D administration was considered for a post-Tl follow-up interview to determine whether he or she had become depressed. Because of administrative and financial constraints, not all eligible subjects were interviewed and higher priority was given to subjects with higher CES-D scores. Six-huudred post-Tl interviews were conducted with 386 of the TI subjects (214, or 55.4%, of these 386 subjects had multiple post-Tl interviews).

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a. ROHDE, E LEWINSOHN, AND J. SEELEY Table 1

During the T2 phase of the study (between November, 1984, and March, 1986), 749 of the TI subjects (74%) were again interviewed and administered the self-report measures assessed at TI. Resource constraints prevented follow-up of the entire TI sample. Highest priority for T2 interviews was therefore given to subjects who (a) had been depressed at TI, (b) had become depressed at any time during the post-Tl period, (c) had a history of depression, or (d) reported an elevated level of depressive symptoms on the final post-Tl CES-D questionnaire. These criteria identified 391 subjects. In addition, a random sample of 358 (66%) of the 540 T1 subjects who had reported no evidence of past or current depression were also reinterviewed as control subjects. Data for 7 subjects were excluded from analyses because of missing information, evidence of organicity, or deviant or random responding. A group of 49 individuals (new cases) were identified who were diagnosed at the TI interview as never having been depressed and later diagnosed at the T2 interview as having experienced and recovered from their first depressive episode during the course of the study. The first depressive episode for the new eases had a mean duration of 16.1 weeks (range: 2-117 weeks).

Demographic Information for New Cases, Subjects Depressed at Time 1, and Never-Depressed Control Subjects
Variable n Women New cases 49 71.4% 61.7 8.3 49.0% 32.7% 14.3% 4.1% 79.6% 6.1% 14.3% 0.0% 8.1% 14.3% 40.8% 22.4% 14.3% 45.8% 6.3% 47.9% Depressed at Time I 73 61.6% 62.9 7.9 38.4% 42.5% 15.1% 4.1% 65.8% 19.2% 15.1% 0.0% 8.2% 26.0% 38.4% 19.2% 8.2% 26.4% 12.5% 6 I. 1% Never-depressed controls 351 49.0% 64.9 7.0 22.8% 53.0% 21.9% 2.3% 82.5% 4.3% 11.7% 1.4% 4.2% 22.6% 41.1% 19.4% 12.6% 25.7% 7.8% 66.5%

Age
M

SD
50-59 years 60--69 years 70-79 years 80+ years Marital status Married Divorced/separated Widow/widower Never married Education level 8th grade High school Some college/ vocational school College degree Professional degree Employment status Employed Unemployed Retired

Diagnostic Classifications
The diagnosis of depression and other psychopathological syndromes was based on information gathered from participants at T1 and post-Tl in two-hour semistructured interviews using the Schedule for Affective Disorders and SchizophrenianLifctime (SADS-L) (Endicott & Spitzer, 1978) and Change (SADS-C) (Spitzer & Endicott, 1977) versions, with decision rules specified by the Research Diagnostic Criteria (RDC) (Spitzer, Endicott, & Robins, 1978). At T2 the Longitudinal Interview Follow-Up Evaluation (LIFE) (Shapiro & Keller, 1979) was conducted. The LIFE interview provided detailed information about the longitudinal course of psychiatric symptoms and disorders since the last interview (T1 or post-Tl) with rigorous criteria for recovery from a disorder (i.e, symptom-free for eight or more weeks). Diagnostic interviewers were a carefully selected group of graduate and advanced undergraduate students enrolled in a year-long didactic and experiential diagnostic interviewing course. Interrater reliability for the diagnosis of depression and other psychiatric disorders was evaluated by means of the kappa statistic (Cohen, 1960). On the basis of joint ratings, the kappa coefficient was.81 for 193 TI SADS-L interviews, .81 for 101 post-Tl SADS-C interviews, and .82 for 147 T2 LIFE interviews, indicating acceptable levels of reliability for the diagnoses. Three subject groups were of interest in the present study: (a) 49 individuals comprising the new cases group, (b) 73 individuals diagnosed as depressed at TI, and (c) 351 never-depressed control group individuals who reported no past or current depressive episodes at both T1 and T2. Table 1 contains demographic information for the three groups.

Assessment of Independent Variables

The following measures were contained in the self-report questionnaires administered at T1 and T2. Demographic variables. Subjects reported their gender, age, marital status (married, divorced/separated, widow/widower, never married), educational level (grade school, 8th grade, high school, some college/ vocational school, college degree, professional degree), and employment status (employed, unemployed, retired). Self-rated health. Ten items assessing overall self-perceived health status as well as specific items regarding vision, hearing, physical disabilities, the occurrence of a serious illness during the past six months, and the use of medications. TI alpha was.71 and the TI-T2 correlation was .69 (p < .001).

Macrostress. Two measures probing for the occurrence of macrostressors were assessed on the basis of a subset ofl 8 negative/undesired items from the Social Readjustment Rating Scale (Holmes & Rahe, 1967). Subjects rated the total number of events that occurred during the past six months to them (stress to self) and to their spouse, close relative, or friend (stress to others). The TI-T2 correlations for stress to self and stress to others were .09 (nonsignificant) and .21 (nonsignificant), respectively. Microstress. Forty-four items were used from the Mood-Related Events scale of the Unpleasant Events Schedule (Lewinsohn, Mermelstein, Alexander, & MacPhillamy, 1983) describing aversive experiences from everyday life such as having arguments with one's spouse or having to do things one does not enjoy. Items were rated on a 3-point scale for frequency of occurrence during the past 30 days. Coefficient alpha at TI was .85 and the TI-T2 correlations was .68 (p < .001). Social support network. The subject's social support network was assessed with three items dealing with the frequency of contacts by the subjects with the members of their network (e.g., "How many close friends do you have?"). TI coefficient alpha was .60 and test-retest reliability was .70 (p < .001). Perceivedsocial support-family and friends. Abbreviated versions of two scales from the Perceived Social Support Questionnaire (Procidano & Heller, 1983) assessed the degree to which subjects felt that they were supported by family members (10 items) and by friends (I0 items) (e.g, "My friends give me the moral support I need"). TI coefficient alphas were .87 and .90 and T1 -T2 correlations were .45 and .55, respectively (p < .001 for both). Satisfaction with relationships. Seven items ascertained the subject's satisfaction with the quality and the quantity of their interactions with relatives and friends (e.g, "Would you like to see your friends more often than you do?"). Coefficient alpha at T1 was .68 and the TI-T2 correlation was .60 (p < .001 ).

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267

Availability of help. Six items assessed the potential availability of help from members of the subject's social network (e.g., "Is there someone who could take care of you whenever you needed help?"). TI coefficient alpha was .70 with TI-T2 correlation of.46 (p < .001). Helping others. Eleven items assessed whether the subject provided help to their children and/or grandchildren (if present) in a number ways (e.g, "help out with money"). TI coefficient alpha was .74 and test-retest reliability was .61 (p < .001). Social skill. Subjects rated themselves, using a 6-point scale, on 16 adjectives (e.g, "popular") designed to elicit the subject's self-rated social competence. These items were selected from a previous study (Lewinsohn, Mischel, Chaplin, & Barton, 1980). TI coefficient alpha was .86 and test-retest reliability was .80 (p < .001). Recreationalactivity. Five items were included to provide a measure of engagement in recreational activities. Because of low coefficient alpha (.30), each item was examined separately. The items included caring for plants (TI-T2 r = .59, p < .001), watching television (T1-T2 r= .76, p ~ .001), hobbies (TI-T2 r = .57, p < .001), educational or recreational activities (TI-T2 r = .42, p < .001), and exercising regularly (TI-T2 r = .47, p < .001). Enjoyment of activities. Seven pleasant activities (e.g, "being with friends") from the Mood-Related scale of the Pleasant Events Schedule (MacPhillamy & Lewinsohn, 1982) were rated for enjoyability. Coefficient alpha was .76 and test-retest reliability was .67 (p < .001). Life satisfaction. Ten items assessed on a 5-point scale the subjects' degree of satisfaction with the frequency and quality of their activities, accomplishments, family life, marital interaction, and recreatioit (e.g. "How do you feel about how much fun you are having?"). These items were chosen from the items used by Andrews and Withey (1976) and Cambell, Converse, and Rogers (1976). T1 coefficient alpha was .88 and TI-T2 correlation was .76 (p < .001). Emotional reliance and social self-confidence. The Emotional Reliance and Social Self-Confidence scales of the Interpersonal Dependency Questionnaire (Hirschfeld, Klerman, Chodoff, Korchin, & Barret, 1976) were included. The Emotional Reliance scale is assumed to measure the need for attachment and dependency (e.g, "I would feel helpless if deserted by someone I love"). TI coefficient alpha was .83 and the TI-T2 correlation was .71 (p < .000). The Social Self-Confidence scale is assumed to measure the wish for help in decision making and in those situations requiring initiative (e.g, "I would rather be a follower than a leader"). TI coefficient alpha of this score was .79 and the TI-T2 correlation was .80 (p < .001). Perceivedmaste~ Three items assessed perceptions ofcontrol over social outcomes (e&, "In my experience, loneliness comes from not trying to be friendly"). These items had been used in a previous study (Amenson & Lewiusohn, 1981). TI coefficient alpha was .64 and the T1-T2 correlation was .49 (p < .001). Self-control scale. The Self-Control Scale (Rosenbanm, 1980) was included as a measure of learned resourcefulness (Meichenbaum, 1977; Rosenbaum, 1980). Learned resourcefulness refers to the repertoire of cognitive and behavioral skills used to regulate one's thoughts and feelings.Tl coefficient alpha was .80 and test-retest reliability was .76 (p < .001). Effective and ineffective antidepressive behaviors. Twenty-three items from measures developed by Rippere (1976, 1977) and Parker and Brown (1979), which describe behaviors used by people to deal with stressful life situations, were included to represent "effective" antidepressive behaviors (N = 12) (e.g, "Plan something pleasant") and "ineffective" antidepressive behaviors (N = 11) (e.g, "Do something rather dangerous"). For the effective antidepressive behaviors TI coefficient alpha was .79 and test-retest reliability was .53 (p ~ .001), and for the ineffective antidepressive behaviors TI coefficient alpha was .81 and test-retest reliability was .58 (p < .001). Passivity behaviors. Six items indicative of passivity in the face of

stress (e~, "Wait to see what will happen ~) were selected from the Ways of Coping Questionnaire (Foikman & Lazarus, 1980). The TI coefficient alpha was .50 and test-retest reliability was .48 (p ~ .001). Cognitive dysfunction. Six items were selected from the Inventory of Psychic and Somatic Complaints-Elderly Scale (Raskin, 1979) to measure the perceived presence or absence of difficulties with memory, confusion, concentration, and thinking (e.g, "Do you have trouble remembering thing#'). TI coefficient alpha was .71 and test-retest reliability was .68 (p < .001). Dysphoria. Using four items from a previously developed scale (Lewinsohn et al, 1980), the subjects rated their negative affect level. TI coefficient alpha was .67 and the TI-T2 correlation was .75 (p ~ .001). Use of caffeine, tobacco, andaicohol. Three items were used tO assess the previously mentioned addictive behaviors. TI coefficient alpha was .37 and the test-retest correlation was .83 (p ~ .001). Social desirability. Ten items from the Crowne-Marlowe Social Desirability Scale (Crowne & Marlowe, 1960) were included. Tl coefficient alpha was .68 and test-retest reliability was .74 (p ~ .001). lnfrequency. Five items were included from the Infrequency scale (e.g, "At times when I was ill or tired, I have felt like going to bed early") of the Personality Research Form (Jackson, 1974) to identify subjects who might have responded randomly to the questionnaire.

Interview Measures
A number of other measures were administered at the Tl, post-Tl, and T2 interviews. The following items were of interest in the present study. Health screening questionnaire. A brief interview assessed the presence and severity of significant health problems (e.g, inflammatorY joint disease, lung disease, thyroid or glandular disease). The total number of health problems subjects had experienced, labeled "diseases," had a T1-T2 correlation of .62 (p ~ .001). In addition, the interviewer rated"global health" on a 6-point scale ranging from excellent to totally impaired. This rating was based on overall pattern and severity of illness, limitations on activity, amount of exercise, and degree of disability or functional impairment. The TI-T2 correlation of this second variable was .46 (p ~ .001). Brown lntimacy Scale. This scale (Brown & Harris, 1978) assessed the presence of a close and confiding relationship in terms of degree of intimacy, physical proximity, and frequency of contact. Subjects were asked three questions regarding who they would first discuss a problem with, additional confiding relationships, and the extent and ease of communication with these individuals. Ratings were made on a 4point scale and the T1-T2 correlation was .47 (p ~ .001). Interpersonal Attraction Measure. The social impact of the subject in face-to-face interaction was assessed by having the interviewer complete the Interpersonal Attraction Measure (McCroskey & McCain, 1974). This instrument consisted of 17 items that measured physical attraction, task attraction, and friendship attraction (e.g, "I think he/ she could be a good friend of mine") rated on a 7-point scale. T1 coefficient alpha was .94 and the TI-T2 correlation was .20 (p ~ .001). Mental Status Questionnaire. This standard brief mental status screening (Kahn & Miller, 1978) assessed orientation for place and time, recent and remote memorY, and general information. Two subjects were deselected based on performance on the Mental Status Questionnaire and the Halstead-Wepman Aphasia Screening Test. Halstead-Wepman /4~hasia Screening Test. This standard 6-point aphasia screening instrument (Halstead & Wepman, 1949) assessed the presence of apraxias and agnosias.

Results

Overview of Analyses
Data analyses were sequential. To identify the set o f depression-related variables a m o n g which scars or trait markers would

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P. ROHDE, P. LEWINSOHN, AND L SEELEY Table 2

most likely be found, the correlation of all variables with the CES-D score at T1 and a d u m m y variable (0,1) based on whether a subject was never depressed (n = 351) or depressed at TI (n = 73) was computed. The new cases (n = 49) and the never-depressed group were then compared on demographic variables, self-reported depression levels at TI and T2, and on all depression-related variables at T2 (controlling for age, gender, and self-reported depression level). Because of the possibility that scars or trait markers would be measurable only in those subjects experiencing high levels of stress, the depressionrelated variables were examined for both significant main effects and interactions with stress in predicting diagnostic group. Because of missing data, group size varied slightly across analyses. The absence of a significant difference between the new cases and the never-depressed group at T2 on a depression-related variable would be inconsistent with both the scar and the trait marker hypotheses. All variables that significantly differentiated between the two diagnostic groups at T2 were then examined at TI. In addition, variables that distinguished the two diagnostic groups at T2 were investigated using repeatedmeasures analysis of covariance to note whether a significant change in the characteristic had occurred from T1 to T2. Theoretically, a scar should not distinguish the new cases from neverdepressed controls at T1, should distinguish the two groups at T2, and should significantly change in individuals as a result of being depressed (i.e., the variable should show significant change from T1 to T2 for the new cases). On the other hand, a trait marker should significantly distinguish new cases from never-depressed controls at both T1 and T2.

Correlation of Variables With CES-D Score at Time 1 and the Diagnosis of Depression at Time I
Variable
Stress

CES-D .16"** .02 .17*** - . 19*** - . 17*** -.10.** - . 19*** - . 13*** -.03 -.25*** .21"** - . 13*** .03 .06" .03 .12*** .06* .16"** .29*** -.35"** -.48"** -.21 *** .14*** - . 18*** -.05* -.20*** -.22*** -.33*** .12*** .24*** -.03 .44*** -.34***

Diagnosis .14* .004 .27*** -.20"** -.20"** -.10. -.22"* - . 17"** -.01 - . 10. .32*** -.09* -.03 -.01 .10. .10" .10. .15*** .24*** - . 16*** -.51"** - . 17*** .14** - . 17*** .01 - . l 7*** - . 16*** -.32*** .18*** .18*** .08 .37*** -.33***

Selection of Variables for Further Analysis and Demographic Differences

All variables were first correlated with CES-D at T1 and with a dummy variable based on diagnostic status at TI (never depressed = 0, depressed at TI = 1). These correlations are shown in Table 2. To be included for further consideration, the variable had to be significantly(p < .05) correlated with both CES-D and diagnosis at T1. As expected, almost all of the variables met this criterion. The exceptions were occurrence of major stressful events to significant others, providing assistance to one's children and grandchildren, caring for houseplants, amount of television viewing, number of hobbies, reported use of effective antidepressant behaviors, and use of cigarettes, alcohol, and caffeinated beverages. A set of 26 depression-related variables remained available for further study. Next, the new cases and never-depressed groups were compared on demographic variables and the CES-D at both TI and T2. The new cases tended to be younger (61.7 vs. 64.9), F(I, 398) = 8.64, p < .004, and were more likely to be women (71.4% vs. 49.0%) 2(1, N = 400) = 7.79, p < .005. The new cases were also more likely than the never-depressed controls to be employed rather than retired (45.8% vs. 25.7%), 2(1, N = 400) = 7.46, p < .01. This employment status difference was significant even after controlling for the effects of age (partial r, controlling for age = -.09, p < .040). Differences in CES-D scores between the two diagnostic

Stress to self Stress to others Microstress Social support and interaction Social support network Support from family Support from friends Relationship satisfaction Availability of help Helping others Social skill Brown Intimacy Scale Interpersonal attractiveness Recreational activity Care for plants Time spent watching television Hobbies Educational/recreational activity Regular exercise Personality Perceived mastery Emotional reliance Social self-confidence Life satisfaction Enjoyment of activities Social desirability Coping style Self-control scale Effective behaviors Ineffective behaviors Passive behaviors Health and pathology Self-rated health Diseases Global health Caffeine, tobacco, and alcohol use Dysphoria Cognitive dysfunction *=p~.05. **=p<.01. ***=p<.001.

Note. CES-D = Center for Epidemiological Studies Depression Scale.

groups were significant both at Tl (8.7 vs. 6.2), F(l, 396) = 9.34, p < .002, and at T2 (9.2 vs. 5.6), F(I, 396) = 17.10, p < .001; the new cases tended to endorse more symptoms of depression. The two groups did not differ on occupation, F(I, 399) = 3.01, ns, education, F(I, 397) = .14, ns, or marital status, x2(l, N = 399) = .09, ns. None of the new cases or never-depressed controls reported receiving psychological treatment at the time of the T2 interview. Since the new cases were younger, were more likely to be women, and reported more depressive symptoms on the CES-D at both T1 and T2, all three factors were statistically controlled in subsequent analyses.

Differences Between the New Cases and Never-Depressed Controls at T2 on Depression-Related Variables and the Impact of Stress
The new cases and never-depressed controls were compared at T2 using analysis of covariance (ANOVA). To examine the

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possibility that T2 differences between the new cases and never-depressed controls might be observable only in those subjects experiencing high levels of stress, a single comprehensive measure of stress was computed for each subject by standardizing and summing measures assessing macrostress and microstress; the median was used to define high- and low-stress groups. No significant difference was present in the proportion of high-stress individuals within the new cases versus never-depressed groups, x2(l, N = 400) = 2.43 ns. Two (New Cases, Never Depressed) two (High, Low stress) ANCOVAS were computed; age, gender, and T2 CES-D were entered as covariates. For three variables a significant main effect for diagnostic group was present, and one of the variables also had a significant Diagnostic Group Stress interaction. Compared with the never-depressed controls, new cases at T2 rated themselves as lower on health, F(1,360) = 7.01, p = .008, and social skill, F(I, 376) = 4.45, p = .036, and higher on emotional reliance on others, F(I, 376) = 4.94, p = .027. The only interaction with stress that attained statistical significance was emotional reliance on others, F(I, 376) --- 6.71, p = .010. Examination of group means indicated that in the low-stress condition the new cases and never-depressed controls had similar emotional reliance scores, but in the high-stress condition the new cases attained higher scores compared with the never-depressed group. Given the number of comparisons and the Type I error rate per comparison (17 < .05), one or more significant findings were expected solely by chance. Using the Bonferroni correction for an experiment-wide Type I error rate of.05, each comparison would need to be significant at approximately p < .002. With this more restrictive criterion, none of the variables would be considered to significantly differentiate between the new cases and the never-depressed controls at T2. Consequently, while we chose to proceed with further analyses, the findings need to be interpreted with caution pending cross-validation.

gender, and CES-D as covariates examined whether the variables significantly changed across time. As expected, the Group Time interaction was nonsignificant for both selfrated health, F(I, 385) = . 18, ns, and emotional reliance, F(1, 387) = .41, ns, while this interaction attained significance for self-perceived social skill, F(1,384) = 4.07, p = .044. Visual examination of the group means indicated that the never-depressed individuals were essentially unchanged across time and similar to the new cases at TI, while the new cases tended to rate themselves as less socially competent after the depressive episode. Discussion The present study examined the sequelae of depression, attempting to distinguish consequences of depression from concomitants in a sample of older individuals from the general community. We reasoned that differences between formerly depressed and nondepressed individuals could represent either scars (not present before the first episode and therefore interpreted as a result of having been depressed) or trait markers (present before the first depressive episode). As expected, the majority of assessed variables discriminated between currently depressed and nondepressed individuals; however, only three of these variables continued to differentiate individuals who had recovered from their first depressive episode from neverdepressed controls. Before reviewing these findings in greater detail, aspects of the study that limit the generalizability of the findings should be noted. The primary diagnostic group of interest, the new cases, was comprised of individuals who developed their first episode of depression relatively late in life. This sample thus represents a relatively unique group in that most depressed individuals experience their first episode between the ages of 20 and 40 (Lewinsohn, Hautzinger, & Duncan, 1984). In contrast to the present findings, formerly depressed adolescents were found to differ from never-depressed controls on a number o f psychosocial characteristics (Lewinsohn, Hops, Roberts, & Seeley, 1988). It is possible that, compared with younger individuals, the trait markers for depression in older individuals who become depressed for the first time later in life are less evident or even absent. Another aspect of the study that potentially limits generalizability is the less than optimal reliabilities of some of the measures developed specifically for this study. Thus, our predominantly negative results may be partially attributable to psychometric limitations of the measures. Nonetheless, it should be emphasized that the study was restricted to only variables that were first found to be associated with concurrent depression. In addition, while a variety of depressed-related variables were examined, other possible constructs could have been assessed as potential scars. As expected, the new cases were more likely to be younger, female, and already mildly dysphoric. These differences replicated earlier findings (Amenson & Lewinsohn, 1981; Aneshensel, 1985; Depue & Monroe, 1986; Lewinsohn, Hoberman, & Rosenbaum, 1988; Rohde, I.~winsohn, Tilson, & Seeley, 1990) and are conceptualized as risk factors for depression. The finding that the new cases reported significantly higher CES-D

Differences Between the New Cases and Never-Depressed Controls at T1 on Potential Scars or Trait Markers and Change in Variables Across Time
To discriminate scars from trait markers, the three variables that significantly differentiated the new cases from never-depressed controls at T2 were examined at TI, again using ANCOVAcontrolling for T1 CES-D, age, and gender. These analyses suggest that self-perceived social skill fit the scar pattern, whereas self-rated health and excessive emotional reliance fit the trait marker pattern. At TI, new cases did not significantly differ from never-depressed controls on self-perceived social skill, either as a main effect, F(l, 387) = .5 l, ns, or in interaction with stress, F(I, 387) = 2.34, ns. On the other hand, the new cases at Tl reported poorer self-rated health, F(l, 387) = I 1.27, p = .001, and greater emotional reliance on others, F(I, 387) = 8.53, p = .004. The interaction between emotional reliance and stress level again attained significance, F(l, 387) = 5.79, p = .017, suggesting that new cases at T1 experiencing low stress were similar to the never-depressed controls, whereas highstress new cases reported a significantly greater need for attachment and dependency on others compared with the high-stress never-depressed controls. Group (New Cases, Never Depressed) Time (TI, T2) repeated-measures ANCOVAS with age,

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P. ROHDE, P. LEWINSOHN, AND J. SEELEY consistently report an elevated number o f depressive symptoms, even though not in a diagnosable episode. Perhaps this moderate, chronic demoralization represents the principal risk factor for future depression. Once it is statistically controlled, any differences between formerly and never-depressed groups are negligible.

score at both TI and T2 emphasizes the importance of careful measurement and control o f depression in "recovered" subjects. A new risk factor----employment as opposed to retirement --was identified in the present study, suggesting that being employed places the elderly at greater risk for being depressed. Being employed in the elderly could be either causally related to depression or associated with an third factor that contributes both to be future depression and being employed (e.g. financial necessity). A large number of statistical comparisons were made, and the most conservative interpretation of the results is that once the effects of age, gender, and mild depression are controlled no psychosocial scars are present as a consequence of being depressed. Compared with the never depressed, the formerly depressed group did not differ on such depression-related psychosocial variables as stress, social support and social network, and coping style. While this is consistent with our previous findings (e.g, Lewinsohn et al~ 1981; Zeiss & Lewinsohn, 1988) that formerly depressed individuals do not differ from nondepressed controls, as indicated earlier, the interpretation o f these negative results needs to be tempered by the characteristics of the sample and the nature of the measures. However, it also needs to be emphasized that incorporating the stress activation model into the analyses had little impact on the findings, with one exception. A less conservative interpretation of our findings is that one consequence of having been depressed is that individuals view themselves as less socially skilled. In addition, the new cases rated their health as poorer both before and after the episode. Given the lack o f differences between the new cases and the controls on more objective measures ofhealth and social skill, poorer health and social incompetence most likely are attributable to a more negative self-appraisal. In addition, as suggested by others (Hirschfeld et al, 1983; I-Iirschfeld, Klerman, Clayton, Keller, & Andreason, 1984; Reich, Noyes, Hirschfeld, Coryell, & O'Gorman, 1987), individuals prone to depression may have a greater need for contact with and emotional support from others, both before and after being depressed. The present study is the only one, to our knowledge, that provides prospective evidence that excessive emotional reliance on others may be a trait marker for depression. A number of directions for future research are suggested. It is possible that residual effects o f having been depressed are more evident in individuals with an earlier age of first depression onset or among individuals with more numerous depressive episodes in the past. Future studies comparing persons with an early onset or multiple episodes with relevant control groups are recommended. It is also possible that differences in the formerly depressed are mood-state dependent (Miranda & Persons, 1988). To the extent that differences can be reliably identified, such knowledge can assist in the development o f preventative interventions, which, by modifying these factors, may reduce the probability o f future relapse. It may also be important to include other variables in studies o f this nature, especially in the areas of interpersonal dependence, introversion, marital distress, and social integration, as suggested by Barnett and Gotlib (1988). While the psychosocial scars of depression appear to be rather elusive, individuals who have been depressed in the past and those at elevated risk o f becoming depressed

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