Low perceived social support predicts later depression but not social phobia in middle adolescence

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rhpb20 Download by: [Tampere University] Date: 20 September 2016, At: 00:01 Health Psychology and Behavioral Medicine ISSN: (Print) 2164-2850 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpb20 Low perceived social support predicts later depression but not social phobia in middle adolescence Juha-Matti Väänänen, Mauri Marttunen, Mika Helminen & Riittakerttu Kaltiala-Heino To cite this article: Juha-Matti Väänänen, Mauri Marttunen, Mika Helminen & Riittakerttu Kaltiala-Heino (2014) Low perceived social support predicts later depression but not social phobia in middle adolescence, Health Psychology and Behavioral Medicine, 2:1, 1023-1037, DOI: 10.1080/21642850.2014.966716 To link to this article: http://dx.doi.org/10.1080/21642850.2014.966716 © 2014 The Author(s). Published by Taylor & Francis. Published online: 28 Oct 2014. Submit your article to this journal Article views: 542 View related articles View Crossmark data Low perceived social support predicts later depression but not social phobia in middle adolescence Juha-Matti Väänänen a *, Mauri Marttunen b,c,d , Mika Helminen e,f and Riittakerttu Kaltiala-Heino g,a a Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland; b Department of Psychiatry, University of Helsinki, Helsinki, Finland; c Department of Adolescent Psychiatry, Helsinki University Central Hospital, Helsinki, Finland; d Department of Mental Health and Substance Use Services, National Institute for Health and Welfare, Helsinki, Finland; e Science Center, Pirkanmaa Hospital District, Tampere, Finland; f Tampere School of Public Health, University of Tampere, Tampere, Finland; g Medical School, University of Tampere, Tampere, Finland (Received 20 November 2013; accepted 4 September 2014) Social phobia and depression are common and highly comorbid disorders in adolescence. There is a lack of studies on possible psychosocial shared risk factors for these disorders. The current study examined if low social support is a shared risk factor for both disorders among adolescent girls and boys. This study is a part of the Adolescent Mental Health Cohort Study’s two-year follow-up. We studied cross-sectional and longitudinal associations of perceived social support with social phobia, depression, and comorbid social phobia and depression among girls and boys. The study sample consisted of 2070 15-year-old adolescents at baseline. Depression was measured by the 13-item Beck Depression Inventory, social phobia by the Social Phobia Inventory (SPIN), and perceived social support by the Perceived Social Support Scale-Revised (PSSS-R). Girls reported higher scores on the PSSS-R than boys in total scores and in friend and significant other subscales. Cross-sectional PSSS-R scores were lower among adolescents with social phobia, depression, and comorbid disorder than among those without these disorders. Low PSSS-R total score and significant other subscale were risk factors for depression among both genders, and low support from friends among girls only. Low perceived social support from any source was not a risk factor for social phobia or comorbid social phobia and depression. As conclusion of the study, low perceived social support was a risk factor for depression, but not a shared risk factor for depression and social phobia. Interventions enhancing perceived social support should be an important issue in treatment of depression. Keywords: social anxiety; phobia; depression; social support; adolescents; gender differences; family support; peer support Introduction Social phobia and depression are common disorders among adolescents. The point prevalence estimates of social phobia in adolescence range from 1.6% to 6%, and lifetime prevalence estimates from 7% to 14% (Essau, Conradt, & Petermann, 1999; Gren-Landell et al., 2009; Ranta, Kaltiala-Heino, Rantanen, & Marttunen, 2009; Shields, 2004; Väänänen et al., 2011; Wittchen, Stein, & Kessler, 1999). Prevalence estimates of depression in adolescence range from 3% to © 2014 The Author(s). Published by Taylor & Francis. *Corresponding author. Email: juha.vaananen@pshp.fi This is an open-access article distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/ licenses/by/3.0/, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The moral rights of the named author(s) have been asserted. Health Psychology & Behavioural Medicine, 2014 Vol. 2, No. 1, 1023–1037, http://dx.doi.org/10.1080/21642850.2014.966716 10% (Kessler, Avenevoli, & Merikangas, 2001; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Lewinsohn, Rohde, & Seeley, 1998; Roberts, Lewinsohn, & Seeley, 1995) and from 15% to 25% (Kessler & Walters, 1998; Lewinsohn et al., 1993), respectively. Comorbidity between social phobia and depression is common, and these two disorders have been a focus for quite many comorbidity studies (Beesdo et al., 2007; Bittner, Goodwin, & Wittchen, 2004; Lewinsohn, Zinbarg, Seeley, Lewinsohn, & Sack, 1997; Väänänen et al., 2011; Wittchen et al., 1999). Based on several studies on the comorbidity of social phobia and depression, it has been hypothesized that social phobia may cause psychological and functional deterioration leading to depression (Kessler, Stang, Wittchen, Stein, & Walters, 1999; Merikangas et al., 1996)or there may be shared risk factors for both disorders leading to different phenotypes, which may vary over time (Angold, Costello, Farmer, Burns, & Erkanli, 1999). Among adolescents who suffer from social phobia, risk factors for subsequent depression have been found to be a number of feared situations, and pervasiveness, severity, and earlier onset of social phobia (Beesdo et al., 2007; Bittner et al., 2004; Chavira, Stein, Bailey, & Stein, 2004). Low social support has been reported as a risk factor for adolescent psychiatric problems (Aseltine, Gore, & Colten, 1994; Ezzell, Swenson, & Brondino, 2000; Ritakallio, Luukkala, Marttunen, Pelkonen, & Kaltiala-Heino, 2010; Sheeber, Hops, Alpert, Davis, & Andrews, 1997). Blumenthal et al. (1987) reported in their original study using Perceived Social Support Scale (PSSS) that among adults probability to coronary artery disease was inversely related to the level of social support and that social support moderated the long-term health consequences for type As behavioural pattern (Blumenthal et al., 1987). Parental support has found to be a predictor of identity achievement in adolescent development (Sartor & Youniss, 2002). The interaction with social network may directly produce positive or negative psychological states being supportive or deprivating (Kawachi & Bergman, 2001). Low social support has shown to be associated with adolescent depression in many studies (Bettge et al., 2008; Kaltiala-Heino, Rimpelä, Rantanen, & Laippala, 2001; Lewinsohn, Gotlib, & Seeley, 1997; Newman, Newman, Griffen, O’Connor, & Spas, 2007; Schraedley, Gotlib, & Hayward, 1999) and high social support has been found to have a buffering effect against the emergence of adolescent depression (Denny, Clark, Fleming, & Wall, 2004; Piko, Kovacs, & Fitzpatrick, 2009). Studies concerning the association between social support and social phobia are much less common. Theoretically, low perceived social support may lead an adolescent to insecurity in social situation and, thus, to social phobia. Perceiving high social support from family and low social support from friends may also lead an adolescent to turn more to home from social situations possibly leading to social phobia. Adolescents with social anxiety have shown to experience lower support from friends and classmates in a study about perceived support from friends, classmates, and family (La Greca & Lopez, 1998), and less support from friends in a study about perceived support from mother, father, and friends (McDonald, Bowker, Rubin, Laursen, & Duchene, 2010). During adolescent development adolescents turn to seek support from peers instead of their family. In childhood, families are the strongest source of support followed by peers and teachers (Ezzell et al., 2000). Among children in prospective study from 1st grade to 10th grade, most common support provider was biological father followed by grandparents (Appleyard, England, & Sroufe, 2007). During adolescence, the perception of source of support has reported to turn from family to peers (Garnefski, 2000). The sources of social support have been found to have different impacts on risk for social phobia and depression. Both low family and low peer support have been linked to depression in middle and late adolescence in most studies (Denny et al., 2004; Lewinsohn, Gotlib, et al., 1997; McDonald et al., 2010), while school-related support has played only a modest role in relation to depression (Piko et al., 2009). High social support from friends but not from family 1024 J.-M. Väänänen et al. or teachers has been found to protect against social phobia (La Greca & Lopez, 1998; McDonald et al., 2010). Previous research has reported gender differences in social phobia, depression, and social support. In epidemiological studies, the prevalence of social phobia has found to be higher among girls than boys (Gren-Landell et al., 2009; Shields, 2004; Wittchen et al., 1999). The prevalence of depression is higher among girls from adolescence onwards, and risk factors for depression differ by gender. Conflicts with family, negative cognitive style, and rumination have been found to be risk factors among females only (Hankin, 2009; Hankin & Abramson, 2001; Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2000). Females have a higher risk for recurrence of depression (Lewinsohn et al., 2000). Among females with earlier social phobia the onset of subsequent comorbid depression takes place in a shorter interval than among males (Beesdo et al., 2007). Females report higher levels of perceived social support than males (Bettge et al., 2008), especially received from outside the family (Katainen, Räikkönen, & KeltinkangasJärvinen, 1999; La Greca & Lopez, 1998). Stress and social support have been more strongly associated with depression among girls than boys in some studies (Bettge et al., 2008; Kaltiala-Heino et al., 2001), but not in all (Denny et al., 2004). Low social support has been shown to have a more deleterious effect on social functioning among girls than among boys (La Greca & Lopez, 1998). Social phobia and depression are highly comorbid with each other, but there is a lack of prospective population-based studies among adolescents about possible psychosocial shared risk factors for these disorders. To better understand the development of social phobia and depression and thus to improve preventive interventions and treatment for these under-recognized and undertreated disorders (Kessler et al., 2001; Lewinsohn et al., 1998; Shields, 2004; Wittchen et al., 1999), prospective population studies on the psychosocial risk factors for these disorders and their comorbidity are needed. Further, more research on gender-specific patterns of risk factors is needed to develop earlier and more precise identification of social phobia, depression, and comorbid social phobia and depression, and to develop specific interventions of these disorders for girls and boys. The aims of our study were (1) to explore if low perceived social support from different sources is a risk factor for social phobia, depression, and comorbid social phobia and depression in two-year follow-up separately among boys and girls; (2) to identify cross-sectional associations between depression and social phobia and perceived social support among girls and boys aged 15 and 17 years; and (3) to analyse gender differences in perceived social support, and its associations with social phobia and depression in middle adolescence. Based on previous literature we expected that (1) low perceived social support –particularly from peers –is a risk factor for both depression and social phobia; (2) low perceived social support from family is an additional risk factor for depression; (3) low perceived social support is associated with current social phobia and depression, being most evident among those with comorbid disorders; and (4) the above mentioned effects are more prominent among girls than boys. Materials and methods Study samples and procedures This study is part of an ongoing prospective cohort study, the Adolescent Mental Health Cohort (AMHC) Study, conducted in two Finnish cities, Tampere (200,000 inhabitants) and Vantaa (180,000 inhabitants). These cities were chosen because they represent well Finnish urban population. Tampere is the largest provincial centre outside the capital city area, and Vantaa is about the same sized site in the capital city area of Finland. Data collection, procedures, and measures of the Health Psychology & Behavioural Medicine 1025 study have been reported in detail elsewhere (Fröjd, Marttunen, Pelkonen, von der Pahlen, & Kaltiala-Heino, 2006,2007). Briefly, at baseline survey 2002–2003 (T1), data were collected from all ninth graders (age 15) in all Finnish-speaking secondary schools in the two cities. Subjects completed a person-identifiable survey during a school lesson under the supervision of a teacher. Another opportunity to participate was offered in the school within a couple of weeks for students absent from school on the original survey day. For students not present on either occasion the questionnaires were sent by post twice, and if no reply was received, it was concluded that the student was not willing to participate. Thus, the participation rate for T1 data collection was excellent (94.4%), consisting 3278 adolescents (mean age = 15.5 years, SD = 0.39; 1609 girls, 1669 boys, 69% living in two-parent families). Follow-up data collection was conducted in 2004– 2005 (T2). Eligible participants at T2 were students who had participated at T1. We organized school-based surveys as T1 in upper secondary schools and vocational schools. Surveys were sent by post to adolescents not reached through schools and to those who did not respond even by post, the same survey was offered by Internet (Fröjd et al., 2006). A total of 2070 adolescents completed the survey at both T1 and T2. The response rate of the final sample was 63.1% (2070/3278). Of the respondents 56.6% were girls. The mean age at T2 was 17.6 years (SD 0.4). At T2 over 80% of the adolescents were full-time students (girls 89.6%, boys 82.0%, p< .001). Cases were excluded if more than three items of our measures were unanswered. If only three or less items were unanswered, missing values were replaced with the mean value of the subject’s responses to the other items of the scale. Because of too many unanswered items, 32 subjects were excluded from the analyses, and the final sample consisted of 2038 subjects, 1154 girls and 884 boys. In the analyses, we always used all data available on the issues of interest, and therefore, the number of subjects varies slightly between separate analyses. Measures Depression (DEP). A Finnish modification of the 13-item Beck Depression Inventory (R-BDI) (Raitasalo, 2007) was used to assess depression (Beck & Beck, 1972; Beck, Rial, & Rickels, 1974). The R-BDI is a widely used self-report scale measuring the severity of depressive symptoms, and its reliability and validity are good (Bennet et al., 1997). The R-BDI has been shown to be appropriate for measuring depression in Finnish adolescents in population studies (KaltialaHeino, Rimpelä, Rantanen, & Laippala, 1999; Raitasalo, 2007). Each item is scored 0–3 according to the severity of the symptom. Sum scores of 13 items (range 0–39) were dichotomized to non/mild depression (scores 0–7), and moderate/severe depression (scores 8–39) (Beck & Beck, 1972). A cut-off score of 8 predicts a diagnosis of depression by structured interview Schedules for Clinical Assessment in Neuropsychiatry with good sensitivity (0.93) and specificity (0.88) (Fountoulakis et al., 2003). Social phobia (SP). To measure social phobia we used the Social Phobia Inventory (SPIN) (Connor et al., 2000). SPIN is a 17-item self-report questionnaire for measuring symptoms of social phobia. It is constructed on a five-point Likert-type scale which has previously shown good reliability and construct validity (Johnson, Inderbitzen-Nolan, & Anderson, 2006; Ranta, Kaltiala-Heino, Rantanen, Tuomisto, & Marttunen, 2007) for use among English-speaking and Finnish adolescents. For the Finnish translation of SPIN, a cut-off of 24 points has resulted in 81.8% sensitivity and 85.1% specificity in relation to a diagnosis of social phobia based on the Schedules for Affective Disorders and Schizophrenia for school-aged children –Present and Lifetime version (Kiddie-SADS-PL) diagnostic interview (Ranta et al., 2007). Social support.The Perceived Social Support Scale-Revised (PSSS-R) was used to measure perceived social support from multiple sources. The PSSS-R was first presented by Blumenthal et al. (1987) in their study on the impact of social support to moderate the association between 1026 J.-M. Väänänen et al. behaviour type and coronary artery disease. The PSSS-R measures people’s subjective perceptions of social support and emotional closeness (Blumenthal et al., 1987). It contains 12 items on a 5-point Likert-type scale. Factor-analytically derived sum scores were used for addressing perceived support from family, friends, and significant others (each ranging 4–20). High sum scores indicate high perceived social support. PSSS-R sum scores were used as a continuous variable. The PSSS-R has been shown to be a useful method for assessing perceived social support among Finnish adolescents (Katainen et al., 1999). Reliabilities for the subscales were for girls and boys, respectively, α= 0.91 and α= 0.82 for family support; α= 0.93 and α= 0.91 for significant other support; and α= 0.89 and α= 0.84 for support from friends (Fröjd et al., 2006). Covariates In the statistical analyses, the controlled covariates were age (calculated from the date of survey and date of birth), family structure (asked to select from items in questionnaire on question ‘do your family include?’: mother and father; mother and stepfather; father and step mother; only mother; only father; someone else caretaker; who. For present study we dichotomized the answers to living with both biological parents, if the first item was selected/living in some other family structure, if some of the other items was selected), both parents’highest educational qualification (asked to select from items in questionnaire on question: what is the highest educational level your father has completed/‘what is the highest educational level your mother has completed?’Items to select were comprehensive school only, comprehensive school and vocational school, college and vocational school, and university examine. For the present study we dichotomized the answers to comprehensive school only, if the first item was selected/higher education, if some of the other items were selected), and externalizing symptoms, measured by Finnish version of the Youth Self Report (YSR) (Achenbach, 1991), at T1. We used externalizing scale of YSR as continuous sum scores. These covariates were chosen since previous studies have suggested that they have an impact on the main variables of interest in the present study (Costello, Swendsen, Rose, & Dierker, 2008; DeWit et al., 2005; Hankin, 2009; Hankin & Abramson, 2001; Kendler, Gardner, & Prescott, 2002,2006; Wittchen & Fehm, 2001). Attrition Compared to responders at both surveys, there were more boys (63.4% vs. girls 36.6%; p< .001) and subjects with depression at T1 (11.7% (dropouts) vs. 9.1% (responders), p= .020) among dropouts. There were no differences in response rate at T2 among those with or without social phobia at T1 (65.1% vs. 63.1%, p= .523). Dropout boys’perceived support from family at T1 was significantly lower than that perceived by boys also responding at T2 (Mann–Whitney test, p= .015). Social support from family among girls, and social support from friends and from significant other among both genders did not differ significantly between responders and dropouts. Father’s or mother’s highest educational status was more often comprehensive school only or lower among dropouts at T2 (father 18.9% vs. 15.1, p= .005%; mother 16.1% vs. 12.2%, p= .002). Statistical analysis We formed four groups of our sample according to disorder status: adolescents without social phobia or depression (no SP/DEP) (SPIN score < 24, R-BDI score < 8), with social phobia and without depression (SP) (SPIN ≥24, R-BDI < 8), with depression and without social phobia Health Psychology & Behavioural Medicine 1027 (DEP) (SPIN < 24, R-BDI ≥8), and with both social phobia and depression (comorbid SP/DEP) (SPIN ≥24, R-BDI ≥8). To explore current social support according to disorder status, because the distribution of scores of the PSSS-R was non-Gaussian, the Kruskal–Wallis test at a significance level of p= .05 was used. To analyse one-to-one differences between disorder groups, we used the Bonferroni-corrected Mann–Whitney test. Because we had 4 groups, we had 6 paired comparisons, meaning that statistical significance of p-level 0.05/6 = 0.008333 was used. The statistical significance of gender differences was tested by the Mann–Whitney test at p= .05 level. We used medians instead of means as the parameter, because of the non-Gaussian distribution of PSSS-R scores. In analyses of longitudinal associations between social support at T1 and disorder status at T2, we selected the sub-samples free of both disorders at T1 to control the possible confounding effect of baseline SP and DEP to the results. For analyses we used the Kruskal–Wallis test. To control for the effects of covariates –age, family structure, both parents’highest educational qualification, and external symptoms –we used binomial logistic regression analysis. Statistical significance was tested two-tailed. Data analyses were made using SPSS, version 16.0 (SPSS Inc., Chicago, Illinois, USA). Results Cross-sectional associations between current SP, DEP, or comorbid SP/DEP and perceived social support at age 15 and 17 years In the Kruskal–Wallis test, low scores of all subscales of PSSS-R, family, friends, and significant others, as well as total scores on the PSSS-R were associated with having DEP, SP, or comorbid SP/DEP at both T1 and T2 among both genders (p< .001) (Tables 1 and 2). In the Bonferroni-corrected Mann–Whitney test among girls at ages 15 and 17 years, perceived social support scores, both total score and all subscale scores, were highest in the no SP/DEP group, and lowest in the comorbid SP/DEP group. Perceived social support from family at both T1 and T2 surveys, and total score and significant other subscale of the PSSS-R at T2 were lower in the DEP group than in the SP group (Tables 1 and 2). Similarly, in the Bonferroni-corrected Mann–Whitney test among boys at both ages, perceived social support was highest in the no SP/DEP group and lowest in the comorbid SP/ DEP group. Among boys perceived support from family was lower in the DEP group than in the SP group at T1 and T2, but perceived social support from significant other at T2 was lower in the SP group than in the DEP group (Tables 1 and 2). Longitudinal associations between perceived social support at age 15 years and incidence of SP, DEP, or comorbid SP/DEP during follow-up In analyses made by the Kruskal–Wallis test among adolescents in no SP/DEP group at T1, low perceived social support at T1 predicted DEP at T2 but not SP or comorbid SP/DEP at T2. Among girls a statistically significant association was found between low total score (p= .004), family subscale (p= .008), and friend subscale (p= .008) of PSSS-R and subsequent DEP. Among boys the same association was found between low total score (p= .005), family subscale (p= .008), and significant other subscale (p= .001) and subsequent DEP. In logistic regression after controlling for covariates (age, family structure, both parents’ highest educational qualification, and external symptoms), low total score of PSSS-R (odds ratio (OR) = 0.944, 95% confidence interval (C.I.) 0.906–0.984, p= .006), low perceived 1028 J.-M. Väänänen et al. Table 1. Current PSSS-R scores according to disorders at age 15 years among girls and boys. Girls Boys pof gender difference (1) (2) (3) (4) (1) (2) (3) (4) No SP/ DEP SP DEP Comorbid SP/DEP No SP/ DEP SP DEP Comorbid SP/DEP n= 945 n=56 n=73 n=60 n= 759 n=49 n=35 n=18 PSSS-R scores Total score M= 55.00 M= 53.00 M= 47.00 M= 42.23 M= 48.00 M= 41.00 M= 40.00 M= 25.00 (1) <.001 SD = 7.00 SD = 8.70* SD = 10.04** SD = 11.81** ,++,¤ SD = 10.72 SD = 11.90** SD = 14.45** SD = 12.18** ,++ (2) <.001 (3) =.002 (4) <.001 Family subscale M= 18.00 M= 16.50 M= 13.00 M= 12.50 M= 18.00 M= 16.00 M= 12.00 M= 11.36 (1) n.s. SD = 3.29 SD = 3.91 SD = 4.60** ,++ SD = 4.65** ,++ SD = 3.57 SD = 4.14* SD = 5.03** ,+ SD = 5.18** ,++ (2) n.s. (3) n.s. (4) n.s. Friend subscale M= 19.00 M= 18.00 M= 17.00 M= 14.05 M= 16.00 M= 13.00 M= 13.00 M= 7.50 (1) <.001 SD = 2.95 SD = 3.37* SD = 4.27 SD = 4.86** ,+,¤¤ SD = 4.17 SD = 4.62* SD = 5.76** SD = 4.65** ,+ (2) <.001 (3) =.001 (4) =.001 Significant other subscale M= 20.00 M= 18.50 M= 19.00 M= 16.00 M= 16.00 M= 13.00 M= 10.64 M= 6.50 (1) <.001 SD = 2.70 SD = 3.48* SD = 4.50 SD = 4.96** ,¤¤ SD = 4.48 SD = 4.74* SD = 6.22 SD = 4.31** ,+ (2) <.001 (3) <.001 (4) <.001 Note: SP = Social phobia (SPIN ≥24, R-BDI < 8), DEP = depression (SPIN < 24, R-BDI ≥8), and comorbid SP/DEP (SPIN ≥24, R-BDI ≥8). M= median, SD = standard deviation. Statistical significance by the Bonferroni-corrected Mann–Whitney test: disorder groups vs. no SP/DEP group: **p< .001, *p< .00833; DEP or comorbid SP/DEP groups vs. SP group: ++ p< .001, + p< .00833; comorbid SP/DEP group vs. DEP group: ¤¤ p< .001, ¤ p<.00833. pof gender difference: (1), in no SP/DEP; (2), in SP; (3), in DEP; and (4), in comorbid SP/DEP groups. Health Psychology & Behavioural Medicine 1029 Table 2. Current PSSS-R scores according to disorders at age 17 years among girls and boys. Girls Boys pof gender difference (1) (2) (3) (4) (1) (2) (3) (4) No SP/ DEP SP DEP Comorbid SP/DEP No SP/ DEP SP DEP Comorbid SP/DEP n= 940 n=79 n=57 n=62 n= 755 n=48 n=22 n=34 PSSS-R scores Total score M= 57.00 M= 52.00 M= 42.00 M= 44.50 M= 51.00 M= 46.00 M= 43.50 M= 37.00 (1) <0.001 SD = 6.61 SD = 7.85** SD = 11.74** ,++ SD = 10.61** ,++ SD = 9.51 SD = 8.01* SD = 11.94* SD = 12.90** ,++ (2) = 0.006 (3) n.s. (4) = 0.001 Family subscale M= 18.00 M= 16.00 M= 12.00 M= 14.00 M= 18.00 M= 17.00 M= 12.50 M= 12.00 (1) =0.015 SD = 3.42 SD = 3.07** SD = 4.97** ,++ SD = 3.98** ,++ SD = 3.53 SD = 2.85 SD = 5.31** ,++ SD = 4.59** ,++ (2) =0.036 (3) n.s. (4) n.s. Friend subscale M= 20.00 M= 17.00 M= 15.00 M= 15.00 M= 17.00 M= 15.00 M= 16.00 M= 12.00 (1) <0.001 SD = 2.74 SD = 3.53** SD = 5.12** SD = 4.72** ,+ SD = 3.72 SD = 3.47** SD = 4.22** SD = 5.41** (2) =0.001 (3) n.s. (4) =0.014 Significant other subscale M= 20.00 M= 19.00 M= 16.00 M= 17.00 M= 18.00 M= 15.50 M= 17.50 M= 12.00 (1) <0.001 SD = 2.30 SD = 3.23* SD = 4.60** ,++ SD = 4.35** ,+ SD = 3.90 SD = 3.80* SD = 5.33** ,++ SD = 5.39** ,+,¤ (2) <0.001 (3) n.s. (4) <0.001 Note: SP = Social phobia (SPIN ≥24, R-BDI < 8), DEP = depression (SPIN < 24, R-BDI ≥8), and comorbid SP/DEP (SPIN ≥24, R-BDI ≥8). M= median, SD = standard deviation. 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