Journal of Affective Disorders 58 (2000) 79–86

www.elsevier.com / locate / jad

Preliminary communication

Social support and self-esteem predict changes in bipolar depression

but not mania

Sheri L. Johnson*, Bjorn Meyer, Carol Winett, Juan Small

Department of Psychology, University of Miami, PO Box 249229, Coral Gables, FL 33124 -0721, USA

Received 13 April 1999; accepted 29 June 1999

Abstract

Introduction: Our own and other research has suggested that social support predicts course of bipolar disorder, with
particularly strong effects on depressive symptoms. Within this paper, we examine which components of social support
appear most powerful. Methods: Thirty-one individuals with Bipolar I disorder were followed longitudinally for 9 months.
Participants completed a standardized symptom severity interview monthly, and at a 2-month follow-up, they completed the
Interpersonal Support Evaluation List. At a 6-month follow-up, they completed the Rosenberg Self-Esteem Inventory.
Results: Self-esteem support appeared to the most important predictor of change in depression across a 6-month follow-up,
and multiple regression analyses suggested that social support effects were mediated through self-esteem. Limitations and
implications: Although the small sample size suggests a need for replication, current results highlight the importance of
psychosocial variables in the course of bipolar depression. Self-esteem may be a particularly important target for clinical
interventions.  2000 Elsevier Science B.V. All rights reserved.

Keywords: Social support; Self-esteem; Bipolar depression; Mania

1. Introduction found to die from suicide (Isometsa, 1993). Al-

Bipolar disorder is one of the most challenging of
psychiatric disorders. Even with adequate medication
treatment, individuals tend to relapse within 3 years
(Keller et al., 1992). As many as a quarter of
individuals fail to return to work in the year after
hospitalization (Harrow et al., 1990) and in one
study, 19% of individuals with bipolar disorder were
*Corresponding author.
E-mail address: sjohnson@miami.edu (S.L. Johnson)
though only 1% of the population suffers from this
disorder, bipolar disorder ranks as the sixth leading
cause of disability among physical and psychiatric
disorders (Murray and Lopez, 1996).
Although genetic factors determine who develops
bipolar disorder (Goodwin and Jamison, 1990), the
psychosocial environment plays a powerful role in
predicting the course of disorder. Recent findings
suggest that life events (Hammen et al., 1992;
Johnson and Roberts, 1995; Johnson and Miller,
1997), expressed emotion (Miklowitz et al., 1987;

0165-0327 / 00 / $ – see front matter  2000 Elsevier Science B.V. All rights reserved.
PII: S0165-0327( 99 )00133-0
80 S.L. Johnson et al. / Journal of Affective Disorders 58 (2000) 79 – 86
Priebe et al., 1989; O’Connell et al., 1991; Miklowitz
et al., 1996), and psychotherapy (Miklowitz, 1996)
predict course.
Individuals with bipolar disorder tend to receive
less support than medical or nondisturbed popula-
tions (Kennedy et al., 1983), and recent studies
suggest that social support does influence course.
O’Connell et al. (1991) reported that low social
support was tied to greater number of weeks of
symptoms across the year following hospitalization,
and we found that that social support robustly
predicted the timing of recovery as well as changes
in depression (Johnson et al., in press).
Despite evidence for the importance of social
support in bipolar disorder, little is known about
which components are most protective. By examin-
ing specific aspects of social support, one might
learn about the mechanisms through which social
support operates. For example, higher levels of
belonging, or availability of individuals who will
engage in joint activities, might help by increasing
pleasant activities and social reinforcement, whereas
self-esteem support might buffer an individual
against dangerous downturns in self-evaluations.
Recent investigations of depression in pregnant
women and individuals with arthritis have suggested
that social support effects may be mediated by self-
esteem (Hall et al., 1996; Druley and Townsend,
1998). Little is known about whether similar models
are applicable to bipolar disorder.
In this paper, we examine which components of
social support are tied to changes in manic and
depressive symptoms. Additionally, we examine
whether self-esteem is a mediator of social support
effects on symptoms.
2. Methods
2.1. Design
In this naturalistic study, we followed 31 indi-
viduals with Bipolar I disorder with monthly inter-
views of depression and mania. Results specific to
social support as a stress buffer have been published
elsewhere (Johnson et al., in press).
2.2. Participants
Participants who met criteria for bipolar disorder
as assessed by the Structured Clinical Interview for
DSM (SCID, First et al., 1996) were recruited from
hospitals, outpatient clinics, support groups, and
community advertising in South Florida. Only in-
dividuals between the age of 18 and 65 were
included. Potential participants were excluded for:
(1) mood symptoms secondary to a general medical
condition; (2) substance abuse or dependence in the
past year; and (3) inability to speak English or
independently complete self-report measures.
Ages ranged from 31 to 65, with a mean of 42.29
(SD 5 9.36). The number of years of education
varied from 9 years through advanced degrees, with
a mean of 15.37 (SD 5 2.86). Approximately 47%
were employed full or part-time, 8% were students,
38% were on disability or unemployed, and 8% were
retired. According to Hollingshead (1957) occupa-
tional criteria, 43% of the participants had most
recently held a job meeting criteria for higher
executives, business managers, and administrative
personnel. Fifty-five percent of the sample was male.
Of the sample, 33.3% entered the study in a manic
episode, 43.3% in a depressed episode, 16.6% cy-
cling from one polarity to another without recovery,
and 3.3% in a mixed episode, and 3.3% were not in a
full-blown episode. At baseline, 42.9% were ex-
periencing mild or moderate episodes (met major
depression or mania criteria, yet little evidence of
social impairment above that mandated by the
criteria), 42.9% had severe episodes without psycho-
sis, 10.7% had mood-congruent psychosis, and 3.6%
had mood-incongruent psychosis. On average, par-
ticipants had experienced more than 20 lifetime
episodes, and no person in this study was experienc-
ing their first episode.
2.3. Procedures
For all participants approached in treatment cen-
ters, attending physicians provided permission. Writ-
ten informed consent was obtained from all in-
dividuals screened. The SCID was administered to
determine if participants met study criteria. Indi-
viduals were followed for up to a 2-year period. The
 S.L. Johnson et al. / Journal of Affective Disorders 58 (2000) 79 – 86
current sample included participants who were fol-
lowed for a minimum of 9 months. Although addi-
tional follow-up data were available for some par-
ticipants (median length of follow-up 5 18 months),
only data from months 2 through 8 were used for
current analyses. Symptom severity and pharmaco-
therapy adequacy measures were completed monthly
either by telephone or face-to-face, if preferred.
Social support measures were completed at a 2-
month follow-up and self-esteem measures were
completed at a 6-month follow-up. Any individual
experiencing severe symptoms completed assess-
ments at a later date, so that psychotic, tangential, or
disorganized thinking would not compromise the
quality or validity of assessments. Our decision to
wait 2 months to assess social support was empirical-
ly based, since symptom severity scores in previous
studies were substantially reduced by 2-month fol-
low-ups. Within this study, acute symptoms had
remitted for the vast majority of participants by 2
months. Whereas most individuals completed their
self-reports in a timely fashion, some individuals
were slow in completing these measures. Participants
who completed the self-reports on time did not differ
from others on any of our independent or dependent
variables, P values . 0.05.
Follow-up success has been comparable to other
naturalistic studies of bipolar disorder. Attrition
occurred with two voluntary dropouts, five particip-
ants who moved from the area, and two individuals
who were unreachable. Eight individuals were ruled
out because of diagnostic changes (three), mental
status (two), and language difficulties (three). These
individuals are not included in the current sample
description or analyses. Individuals who did not
complete follow-up assessments did not differ from
those who did complete assessments on demographic
or illness characteristics, including number of life-
time episodes or hospitalizations.
2.4. Measures
2.4.1. Diagnosis
Diagnosis was determined using the SCID. Previ-
ous studies have found strong inter-rater reliability
for bipolar disorder (k 5 0.84) (Williams et al.,
1992). Our inter-rater reliability has been high as
81
well (k 5 1.0 for mania in seven interviews evalu-
ated by two raters, r 5 0.94 for the specific symp-
toms of mania, n 5 74, P , 0.0001).
2.4.2. Symptom severity
The Modified Hamilton Rating Scale for Depres-
sion (MHRSD; Miller et al., 1985) was administered
monthly to evaluate the severity of depressive symp-
toms. This modification was developed to increase
the reliability of ratings by including a standardized
interview and behavioral reference points for ratings.
The 17-item index achieves strong correlations with
the original HRSD and was used for current analy-
ses. The MHRSD is sensitive to fluctuations in
clinical status. Inter-rater reliability for the scale is
high, with intra-class correlations of 0.93. Our inter-
rater reliability, calculated using procedures defined
by Shrout and Fleiss (1979), was also high (intra-
class correlation 5 0.95).
Severity of manic symptoms was measured with
the Bech–Rafaelsen Mania Scale (BRMS; Bech et
al., 1979), a standardized interview. The BRMS has
strong inter-rater reliability, reflected in Spearman
correlation coefficients at 0.97. Our inter-rater re-
liability was high (intraclass correlations 5 0.92).
Both the MHRSD and BRMS assessed symptoms
during the most severe week within each month.
Interviewers were trained with didactic materials,
role-plays, and co-interviews. All interviewers were
required to meet initial standards of inter-rater
reliability, which included both correlation coeffi-
cients and percent agreements with gold standard
interviews of above 0.90. Audiotaped interviews
were periodically consensually rated to maintain
reliability and protect against rater drift.
For our symptom follow-up indices, we con-
structed averages of symptom severity scores over
time. That is, each participant’s MHRSD scores from
months 3 through 8 were summed and then divided
by number of months (6) to form the depression
follow-up index. Similarly, each participant’s BRMS
scores for this 6-month time period were averaged to
form a mania follow-up index. To examine whether
this strategy might obscure symptom severity
changes across months, we conducted two repeated
measures analyses of variance. No significant within-
subjects effects emerged for MHRSD scores and
82 S.L. Johnson et al. / Journal of Affective Disorders 58 (2000) 79 – 86
BRMS scores over time, F values , 1.00, P values
. 0.50. The mean of the depression follow-up index
was 8.03 (SD 5 4.94), and the mean of the mania
follow-up index was 4.10 (SD 5 4.21). Depression
and mania did not correlate significantly with each
other, r 5 0.14, P 5 0.45.
2.4.3. Interpersonal support evaluation list ( ISEL;
Cohen et al., 1985)
The ISEL is a 40-item self-report questionnaire
that was developed to assess social support. A
comprehensive theoretical review of the functions of
social support formed the basis for scale develop-
ment; this review emphasized components of social
support likely to have direct and stress-buffering
effects (Cohen and Wills, 1985). The ISEL captures
perceptions of resources provided by others. A total
index is comprised of four subscales: tangible assis-
tance (material aid), appraisal (availability of some-
one to talk to about one’s problems), self-esteem
(positive appraisal of self from others and positive
comparison when comparing one’s self with others),
and belonging (people with whom one can do
things). Items from each subscale include, respec-
tively, ‘‘If I was stranded 10 miles from home, there
is someone I could call who would come and get
me’’; ‘‘When I feel lonely, there are several people I
can talk to’’; ‘‘Most people I know think highly of
me’’; and ‘‘I feel like I’m not always included by my
circle of friends’’. Responses for each item are coded
on a four-point Likert scale ranging from definitely
false to definitely true.
The ISEL has obtained high internal consistency
(a 5 0.90) and moderately high 6-month test–retest
stability coefficients (r 5 0.74), and has been demon-
strated to predict longitudinal changes in psychiatric
symptoms and well-being (Cohen et al., 1985).
Within the current sample, the ISEL demonstrated
strong internal consistency (a of total scale 5 0.93, a
values of four subscales $ 0.74, see Table 1). ISEL
scales were more strongly intercorrelated than dem-
onstrated in community samples (r values ranging
from 0.53 to 0.75, P values , 0.002). For a smaller
pool of the sample, the ISEL total scale exhibited
high 4-month test–retest stability (r 5 0.85; N 5 20,
P # 0.0005) and no significant change across time in
means (dependent t 5 1.55, df 5 19, P 5 0.14), in-
dicating that participants remain consistent in their
appraisals of social support across time.
2.4.4. Self-esteem
Self-esteem was assessed with the Rosenberg Self-
Esteem Scale (RSE; Rosenberg, 1965, 1979), de-
veloped to measure trait global self-esteem. The RSE
contains 10 items rated on a Likert scale from 1 (I
agree a lot) to 7 (I disagree a lot). RSE scores were
missing on two participants. Alpha internal consis-
tency of the 10-item RSE was 0.94 within our
sample. The mean of the RSE among this subset of
29 participants was 44.10 (SD 5 16.42), suggesting
that individuals tended on average to have neutral
responses to items such as ‘‘I feel that I have a
number of good qualities.’’ Whereas the ISEL mea-
sures how much esteem others hold for the particip-
ant, the RSE measures how much esteem the in-
dividual holds for him or herself.
2.4.5. Pharmacotherapy adequacy
Information on medications was obtained from
medical records of blood serum levels, when avail-
able, and during monthly interviews that covered the
types, dosages, and compliance for each medication.
Adequacy of outpatient treatment was rated on a
six-point scale using the Somatotherapy Index, a
refinement for evaluating bipolar disorder treatment,
based on the Pharmacotherapy Adequacy Scale
utilized in the NIMH Collaborative Program on the
Psychobiology of Depression Clinical Studies Pro-
ject. The scale has achieved high inter-rater reliabili-
ty (intraclass correlation using a 5 0.96; Bauer et al.,
1997). Atypical or complex treatments were con-
sensually rated. Adequate pharmacotherapy was
defined as demonstrated blood serum levels of
$ 0.50 mEq of lithium, $ 50 mg / dl of depakote,
$ 4 mg / dl of tegretol, or $ 200 mg / day of imi-
pramine or an equivalent antidepressant dosage for
four consecutive weeks. Within this sample, 61.2%
of individuals maintained adequate pharmacotherapy.
3. Results
The focus in the present study was on examining
prospective associations of mania and depression
symptoms with social support and self-esteem, after
 S.L. Johnson et al. / Journal of Affective Disorders 58 (2000) 79 – 86 83

controlling for initial symptom severity. We first follow-up depression scores, F(1,29) 5 10.66, b 5
examined the potentially confounding influence ex- 0.34, P 5 0.003. The incremental effect of ISEL
erted by illness and treatment parameters. Social scales—after accounting for initial depression
support subscales and self-esteem were not predicted severity—was also significant, F-change (4,25) 5
by severity of index episode, number of previous 3.20, P 5 0.03. Initial depression accounted for
hospitalizations, number of manic episodes, number 26.9% of the variance in follow-up depression
of depressions, age of first depression or mania, or scores, and ISEL scales raised this estimate by
medication adequacy. As a single exception, an 24.8% to a total of 51.7%. Inspection of regression
inverse correlation emerged between number of coefficients revealed that of the ISEL scales, only the
previous hospitalizations and the Rosenberg self- self-esteem scale uniquely predicted depression over
esteem scale, r 5 2 0.41, P , 0.05. Because number time, b 5 2 0.42, t 5 2 2.84, P 5 0.009, when con-
of hospitalizations was not associated with either the trolling for initial depression levels. Regression
mania or depression follow-up index, it was not coefficients of all three other ISEL scales did not
included as a covariate in subsequent analyses. attain significance, P values $ 0.25.
Bivariate correlations between symptom follow-up A parallel hierarchical regression analysis was
indices and ISEL subscales were inspected next. As performed to examine the effect of social support on
shown in Table 1, three of the four ISEL scales follow-up mania symptoms. To control for the
(self-esteem, tangible, and belonging) were inversely effects of initial mania severity, the BRMS 2-month
related with follow-up depression. Social support score was entered in a first step. In the second step,
was not linked to follow-up mania symptoms. These the four ISEL scales were again entered in a joint
zero-order correlations do not permit conclusions set. As expected, initial mania severity was strongly
regarding the unique effects exerted by social sup- related to follow-up mania severity, F(1,29) 5 25.79,
port components. b 5 0.47, P , 0.0005. The incremental effect of
ISEL scales—after accounting for initial mania
3.1. Regression analyses severity—did not attain significance, F-change
(4,25) 5 0.97, P 5 0.44. Initial mania scores ac-
To examine the effect of social support on follow- counted for 47.1% of the variance in the mania
up depression symptoms after controlling for follow-up index.
baseline depression, a hierarchical regression analy-
sis was conducted. Participants’ 2-month MHRSD 3.2. Rosenberg Self-esteem Scale
score was entered as a first step. In a second step, the
four ISEL subscales were entered jointly as a set. To examine the role of self-esteem in the predic-
This strategy yields information regarding the joint tion of follow-up mania and depression symptoms,
effect of ISEL scales as well as the unique contribu- we conducted analyses using the Rosenberg Self-
tion of each subscale. esteem Scale (RSE). Bivariate correlation analyses
Initial depression severity was strongly linked with revealed substantial overlap between the RSE and
ISEL self-esteem scale, r 5 0.72, P , 0.01. The RSE
also correlated significantly with the ISEL belonging
Table 1
Bivariate correlations of symptom indexes with ISEL scales, and scale, r 5 0.46, P , 0.05. In contrast, the ISEL
ISEL means, standard deviations, and internal consistency co- tangible support and appraisal scales were uncorre-
efficients (n 5 31) lated with the RSE at the 0.05 level of significance, r
Self-esteem Tangible Appraisal Belonging valuess 0.35 and 0.24, respectively. The RSE was
a 5 0.84 a 5 0.74 a 5 0.91 a 5 0.87 further strongly and inversely linked with follow-up
MHRSD 2 0.58** 2 0.36* 2 0.25 2 0.49* depression scores, r 5 2 0.68, P , 0.01, but no link
BRMS 2 0.11 0.00 0.02 0.05 was detected between RSE and follow-up mania
M 18.99 19.23 21.13 18.25 scores, r 5 2 0.22, P 5 0.26. Thus, both self-esteem
SD 6.05 5.92 7.74 7.22 (as measured by the RSE) and social support for
**P , 0.01; *P , 0.05. self-esteem (ISEL) were associated with follow-up
84 S.L. Johnson et al. / Journal of Affective Disorders 58 (2000) 79 – 86
depression symptoms but unrelated to follow-up
mania symptoms.
We further tested whether the effect of social
support on follow-up depression could be mediated
by self-esteem (cf. Baron and Kenny, 1986). To do
so, we examined whether the effect of social support
(as measured by the ISEL total score) would de-
crease in magnitude when self-esteem (as measured
by the RSE) was entered simultaneously as a predic-
tor. Indeed, the significant inverse correlation be-
tween the ISEL and follow-up depression scores,
r 5 2 0.45, P 5 , 0.01, reduced to a nonsignificant
semipartial correlation coefficient, sr 5 2 0.12, P 5
0.42, when controlling for the effects of self-esteem.
The significant link between the RSE and depression
follow-up, r 5 2 0.68, P , 0.01, however, remained
significant even when controlling for social support,
sr 5 2 0.52, P , 0.01. These results are consistent
with a mediational model, indicating that the effects
of social support on depression over time can be
explained by the intervening mechanism of self-
esteem. We also investigated whether the effects of
the ISEL self-esteem subscale on depression was
mediated by the Rosenberg self-esteem scale, utiliz-
ing a parallel regression model. Results were entirely
comparable. That is, the significant inverse correla-
tion between ISEL self-esteem and follow-up depres-
sion, r 5 2 0.56, P , 0.01, reduced to nonsignifi-
cance, sr 5 2 0.10, P 5 0.48, when simultaneously
controlling for Rosenberg self-esteem. The signifi-
cant correlation between RSE and depression follow-
up, however, remained significant even when con-
trolling for ISEL self-esteem, sr 5 2 0.40, P , 0.01.
A similar mediation model was supported for the
ISEL belonging subscale, but not for the appraisal
and tangible subscales, which were uncorrelated with
RSE.
4. Discussion
Social support components and self-esteem were
not linked with follow-up mania symptoms. Of the
social support scales, support for self-esteem was
uniquely and inversely linked to depression severity
over time, even after controlling for initial depres-
sion symptoms. The Rosenberg Self-Esteem scale
was tied to depressive symptoms as well. Results
were consistent with a mediational model, in which
self-esteem may be one mechanism whereby social
support influences depression over time. Individuals
who felt that their friends evaluated them positively
were likely to report higher self-esteem, which was
then associated with less depression at follow-up. As
a first study of the components and mediators of
social support in bipolar disorder, these findings add
to previous literature suggesting that social support is
an important predictor of outcome.
Although these results suggest that psychosocial
factors are important in the course of bipolar depres-
sion, they also add to growing evidence that many
psychosocial variables do not impact mania. Psycho-
therapy, life events, social support, and neuroticism
impact depressive symptoms more powerfully than
manic symptoms of bipolar disorder (Johnson et al.,
in press; Lozano and Johnson, in preparation;
Simoneau et al., in press). Mania appears to be more
specifically predicted by psychosocial variables re-
lated to sleep and behavioral activation (Meyer et al.,
in press; Sandrow et al., in preparation). Differentiat-
ing manic and depressive outcomes appears requisite
for understanding the role of the psychosocial en-
vironment in bipolar disorder.
Several methodological limitations in the current
study should be acknowledged. The high correlations
between social support, self-esteem, and depression
may reflect overlapping content as well as common
method variance. We attempted to control for some
of these methodological confounds by utilizing an
interview-based symptom measure. More important-
ly, our analyses examined how social support and
self-esteem predicted changes in depression above
and beyond baseline symptoms. Despite this, rela-
tions among these intricately related phenomena
cannot be clarified by these methods alone, for
several reasons. First, one would expect self-esteem
and social support to relate to depression in a bi-
directional fashion across the broader lifespan. Sec-
ond, unmeasured aspects of symptoms and illness
history may influence both self-esteem and social
support. Third, variables such as biology (Kendler,
1997), cognitive style, and personality traits likely
influence all three variables. Social support can not
be conceptualized as an exogenous independent
variable without experimental provision of support
within laboratory studies and clinical interventions
 S.L. Johnson et al. / Journal of Affective Disorders 58 (2000) 79 – 86
(cf., Helgeson and Cohen, 1996; Uchino et al.,
1996). Fourth, the theoretical constructs of depres-
sion, self-esteem, and perceived social support con-
tain a certain amount of overlap.
Finally, fluctuations in self-esteem may predict
unipolar depression more robustly than low self-
esteem (Roberts and Monroe, in press). Unstable
self-esteem is an intriguing construct within this
disorder, in which individuals experience extreme
mood shifts. Within this context, stable relationships
may have increased meaning.
Current findings suggest windows for clinical
intervention, such as enhancing positive aspects of
relationships. Interestingly, improvements in positive
communication appear to mediate family therapy for
bipolar disorder (Simoneau et al., in press).
Pychotherapies that increase positive communication
in important relationships may provide self-esteem
and depression protection for bipolar individuals.
Acknowledgements
We wish to gratefully acknowledge the contribu-
tions of Dena Rosenberg, Randy Fingerhut, William
Greenhouse, Ruben Perczek and Jennifer Strauss for
their help in rating and interviewing. This study was
supported by grants from the National Alliance for
Research on Schizophrenia and Depression and from
the National Institute of Mental Health grant
MH55950.
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