Correlates and predictors of recurrent depression 1 Correlates and Predictors of Recurrent Depression Kathryn Fox Research Mentors: Judy Garber, Ph.D., Matt Morris, M.S., and Chrystyna Kouros, Ph.D. Correlates and predictors of recurrent depression 2 Abstract Depression is a recurrent and debilitating disorder affecting nearly 340 million people worldwide. The present study examined what differentiates individuals with a history of one or more major depressive episodes (MDEs) from individuals who have never been depressed as well as examine which of these differentiating factors predict subsequent depressive symptoms during a six-month follow-up. Participants were 108 young adults, ages 18-30 years old. No participant was in a current MDE at time one; 56 individuals had a history of one or more MDE and 46 had no history of psychiatric diagnoses. Those with a history of depression had higher rates of physical abuse in childhood, maladaptive coping styles, and stressors than the neverdepressed controls. At the follow-up, number of stressors, dysfunctional attitudes, maladaptive coping, and some forms of early childhood maltreatment interacting with stress predicted depressive symptoms. Correlates and predictors of recurrent depression 3 Depression is a pervasive and debilitating disorder affecting nearly 340 million people worldwide (Greden, 2001). The experience of one major depressive episode (MDE) is associated with a variety of problems including absenteeism and decreased productivity at work, increased mental health care costs, and familial problems. Major depression also is quite recurrent; at least 60% of people who have suffered from one episode of depression will have a second, 70% of those who have had two depressive episodes will have a third, 90% of individuals who have had three depressive episodes will have a fourth, and many of these individuals then go on to experience repeated episodes throughout their lifetimes (DSM–IV–TR; American Psychiatric Association, 2000). Moreover, this pattern of recurrence is frequently accompanied by increased severity over time (Greden, 2001). Evidence of an association between the experience of stressful life events and the onset and recurrence of major depressive disorder (MDD) has been reported consistently (e.g., Kendler, Karkowski, & Prescott, 1999; Monroe & Harkness, 2005; Stroud, Davila, & Moyer, 2008). First episodes of MDD tend to be strongly associated with stressful life events (SLEs), whereas the relation between SLEs and depression changes over the course of the disorder (Monroe & Harkness, 2005; Morris, Ciesla, & Garber, 2010; Stroud et al., 2008). Several explanations have been proposed to account for these alterations in the relation of stressful life events to depression including the kindling hypothesis, stress autonomy, and stress sensitization (Monroe & Harkness, 2005). The kindling hypothesis stems from the “consistent empirical finding that the association between major life stress and episode onset weakens from a first episode over successive recurrences” (Monroe & Harkness, 2005, p. 420). In their meta-analysis of thirteen previous Correlates and predictors of recurrent depression 4 studies examining the role of stress in precipitating MDEs, Stroud and colleagues (2008) found that severe stressful life events were more likely to precipitate the first depressive episode as compared to recurrences. Monroe & Harkness (2005) suggested two explanations for this phenomenon: stress autonomy and stress sensitization. The stress autonomy hypothesis proposes that the relation between stress levels and depression progressively diminishes with each MDE, such that eventually depressive episodes occur seemingly unrelated to any known stressors. In contrast, the stress sensitization hypothesis asserts that stressful events become increasingly more capable of activating depressive symptoms, leading to the negative correlation between number of depressive episodes experienced and the level of stress necessary to trigger an episode. Therefore, the results from the meta-analysis by Stroud et al. (2008) can be explained either by the diminishing association between stress and depression (i.e., stress autonomy) or by the increased ability of minor stressors to predict depressive episodes (i.e. stress sensitization). Morris and colleagues (2010) found evidence consistent with the stress sensitization hypothesis through a “stress activation model.” According to this model, the relation between stress and depressive symptoms strengthens with repeated episodes, such that the activation threshold is lower at all levels of stress, ranging from major stressors to daily hassles. Morris et al. reported a stronger positive correlation between stress levels and depressive symptoms as a function of number of prior MDEs. That is, following the stress activation model, adolescents who had experienced one or more prior MDEs became increasingly sensitized to both major and minor stressors, leading to a greater number of potential depression-triggering events and a higher level of depressive symptoms. The relation between stress and depressive symptoms is not necessarily uni-directional (Liu & Alloy, 2010). Not only do stressors affect depressive symptoms, but depressive Correlates and predictors of recurrent depression 5 symptoms also affect the amount of stress experienced. That is, depressed individuals have been found to generate some of the stressors they encounter (Hammen, 1991), possibly as a result of maladaptive coping, personality characteristics, and dysfunctional social networks (Hankin & Abramson, 2001; Harkness et al., 1999). Stressful life events can be categorized as independent or dependent upon the individual’s behaviors. For example, an independent event might be “a family member getting sick,” whereas a dependent event might be “getting fired from a job for being late too often.” Harkness and colleagues (1999) found that both recurrently depressed and never depressed individuals experienced the same number of independent SLEs, whereas recurrently depressed participants experienced more dependent stressful events than the nondepressed controls. Interestingly, they found that only daily hassles, but not severe, dependent SLEs occurred more frequently in the recurrent depressives. Whether the stressors are dependent or independent, longitudinal studies are needed to explore the prospective link between stressors and depression are needed to determine how these relations unfold over time. A few studies have examined the longitudinal relation of stressful events and depressive episodes (e.g., Kendler, Karkowsi, & Prescott, 1998; Morris et al., 2010). In a sample of adult females, Kendler and colleagues (1998) found a significant temporal association between the occurrence of stressful life events and the onset of major depression. They examined the timing of the stressors to the nearest month, but did not examine the duration. Furthermore, they only examined the onset of major depression in the month in which the stressor occurred, due to the assumption that the depressogenic impact of stressful life events occurs shortly after the event, thus not examining the time in which the stressors impact is strongest as well as leaving out the possibility for a longer-lasting effect. Correlates and predictors of recurrent depression 6 Adjusting for these problems, Morris et al. (2010) examined the predictive association of total stress levels to depressive symptoms, on a week-to-week basis, avoiding the use of a fixed risk period for the effect of the stressor on depressive symptoms. They found that the effect of stressors on depressive symptoms peaked at two weeks and lasted up to 26 weeks. One aim of the current study was to replicate these findings in a different sample. A particularly salient negative life event is the experience of maltreatment during childhood (Harkness, Bruce, & Lumley, 2006), including physical, emotional, and sexual abuse and emotional or material neglect. These early life experiences likely create a diathesis that leaves these individuals vulnerable to depression after future encounters with stress (Harkness, et al., 2006; Morris et al., 2010). For example, in the retrospective study, Harkness and colleagues found that participants with a history of child abuse experienced less threatening life events prior to their first depressive episode than did controls, or those without this abuse experience. Moreover, those with a history of child maltreatment reported higher threat levels to chronic difficulties than others. Thus, this study demonstrated increased sensitivity to future stressors among individuals with a history of maltreatment. For those without an abuse history, this increased vulnerability only occurred after the occurrence of their first depressive episode. Interestingly, Harkness et al. noted a stronger sensitization to independent than dependent life events, highlighting that not only the generation of stressful events predicted recurrence, but also sensitivity to independent life events. Although Harkness and colleagues (2006) noted that previously abused individuals evidenced a higher vulnerability to stressful events, they did not examine whether these individuals also differed with regard to other factors such as coping or cognitions. Investigating the interplay among maladaptive coping, cognitions, and childhood Correlates and predictors of recurrent depression 7 maltreatment could further differentiate those individuals who do and do not develop subsequent depressive episodes. Maladaptive coping responses to stress also have been found to be associated with depression, particularly disengagement and involuntary engagement coping strategies (Compas et al, 2001; Connor-Smith et al., 2000). Disengagement coping (e.g., avoidance, denial) tends to reinforce individuals’ negative expectations by preventing the acquisition of counter-evidence through experience. Involuntary engagement coping, characterized by rumination or emotional numbing, also has been found to be positively correlated with depression severity and recurrence (Nolen-Hoeksema, 2000). In contrast, primary control coping, involving problem solving and other active coping strategies aimed at taking control of a stressful event, is related to lower levels of internalizing and externalizing symptoms (Compas et al., 2001; Connor-Smith et al., 2000). Similarly, secondary control coping, in which individuals try to adapt to a situation through cognitive reframing, acceptance, or distraction, is negatively correlated with levels of both internalizing and externalizing symptoms (Connor-Smith et al., 2000). Although prior research has demonstrated significant concurrent relations among these various forms of coping and depressive symptoms, longitudinal designs are needed to explore the direction of association between coping and adjustment (Compas et al., 2001). Finally, dysfunctional attitudes are a cognitive vulnerability, which also correlate with depression and recurrence. Beck (2008) has argued that early adverse events foster negative attitudes and biases that are then assimilated into self-schemas, which consist of various attitudes and beliefs about the self, the world, and future. Examples of dysfunctional attitudes linked with depression include “I am nothing if a person I love doesn’t like me” or “If I fail at my work, then Correlates and predictors of recurrent depression 8 I am a failure as a person.” These maladaptive attitudes can affect how individuals appraise and process new information and consequently increase the likelihood of subsequent depression. Over time, such beliefs are reinforced through repeated use and eventually become resistant to change. Accordingly, people with dysfunctional attitudes who react negatively to life events are at increased risk for depression. Although dysfunctional attitudes are correlated with depression severity (Scott et al., 1995), when individuals with this cognitive vulnerability are not experiencing depressive symptoms, they are indistinguishable from those without the vulnerability (Monroe & Harkness, 2005). Once confronted with a stressor, however, these individuals are more likely to develop depressive symptoms. The current study examined the following research questions and hypotheses. First, what differentiates individuals who have experienced a prior major depressive episode (MDE) from those without a history of depression? In particular, we compared individuals with and without a history of depressed with regard to the number of stressful life events in the last six months, coping styles, dysfunctional attitudes, and history of maltreatment during childhood. We predicted that individuals with a history of mood disorders would report significantly more negative life events, greater use of both disengagement and involuntary engagement coping and less primary and secondary control coping, more dysfunctional attitudes, and greater maltreatment during childhood. Second, we were explored whether there was a predictive relation between stress and depression severity? Following the methodology used by Morris et al. (2010), we examined the relation of total level of stressors to depressive symptoms over time to determine when the predictive relation between the two was strongest. We expected that high levels of stress would Correlates and predictors of recurrent depression 9 significantly predict elevations in depression severity, and would be strongest at around seven to eight weeks, as had been found previously. Finally, what variables will predict depressive symptoms over time? We hypothesized that history of childhood abuse, use of maladaptive coping styles, and high levels of dysfunctional attitudes, would predict higher levels of depressive symptoms at the six-month follow-up, controlling for Time 1 depressive symptoms. Method Participants. Participants were 108 young adults ages 18-30 years old (mean age = 22.97, SD = 3.87) who were involved in a larger study examining the relations among stress, cortisol, and history of depression. Of the 108 participants, 56 (52%) had a history of at least one MDE and 46 had no history of psychiatric diagnoses; in the prior history group, 17 were males (15.7%) and 39 were females (36.11%); the never depressed group consisted of 20 males (18.5%) and 26 females (24%). Participants were recruited through the Vanderbilt University subject pool, and flyers around campus and in the local community. Potential participants were screened regarding their current and past psychiatric disorders using the Mood Disorders and PTSD sections of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First et al., 1996). Inclusion criteria were either a history of one or more prior major depressive episodes or no history of an MDE. Exclusion criteria were: (a) currently meets criteria for an MDE, (b) current or past post-traumatic stress disorder (PTSD) or bipolar disorder. These were assessed using the relevant sections of the SCID. Eligible individuals then were asked to complete a battery of questionnaires and to come to the lab to participate in an experiment. Only those measures used in the present study are described here. Correlates and predictors of recurrent depression 10 Measures. Participants completed the following measures at the first assessment (Time 1): (a) the Response to Stress Questionnaire (RSQ; Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000) consisting of 57 items assessing what participants do, think, and feel in response to stressors (i.e., assessing utilization of voluntary and involuntary coping strategies) on a 4-point scale of “not at all” to “a lot,” the measure received a Cronbach’s alpha of .862 in our sample; (b) the Events Scale (ES; Compas, Davis, Forsythe, & Wagner, 1987) assessing 90 events, both positive and negative, experienced in the previous six months as well as their perceived valence, on a 7-point scale ranging from very negative to very positive; (c) the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994) a 28 item self-report retrospective measure assessing the frequency of different types of abuse on a 5-point scale from “never true” to “very often true” and demonstrates good reliability and validity, the measure received a Cronbach’s alpha of .690 in our sample; (d) the Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978), a 40-item self-report measure of attitudes and beliefs about the self and others, the measure received a Cronbach’s alpha of .764 in our sample; (e) the Structured Clinical Interview for the DSM (SCID-1; Mood Disorders Section; PTSD); (f) Beck Depression Inventory, second edition (BDI-II; Beck, Steer, & Brown, 1996) a 21 assessing self-reported depressive symptoms in the two weeks prior to baseline the measure received a Cronbach’s alpha of .845 in our sample; and (g) the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) a 21-item clinician-administered questionnaire assessing the severity of participants’ depressive symptoms in the week prior to the baseline, the measure received a Cronbach’s alpha of .728 in our sample. Follow-up. All participants were contacted approximately eight months (mean = 35.6 weeks; SD = 9.03) after their Time 1 assessment. They then filled out two online questionnaires: Correlates and predictors of recurrent depression 11 the Events Scale (ES) and the Beck Depression Inventory, second edition (BDI-II). The ES was measured the number of life events experienced since the Time 1 assessment and the perceived valence of those events. We then conducted phone interviews in which we asked participants about all events that they had rated as negative on the ES and inquired about the onset and the duration of the event. In contrast to previous studies assessing the time period of stressors (e.g., Kendler et al., 1999), we did not merely look at the month of the stressor, but rather, we assessed the specific week so that we could get a more accurate indication of when the stressor occurred in relation to subsequent depressive symptoms. We then administered the mood, mania, and PTSD sections of the SCID-I (First et al., 1996). Participants were compensated $10 for their time. To assess participants’ depressive symptoms, we utilized the Depression Symptom Rating (DSR) scale from the Longitudinal Interval Follow-up Evaluation (LIFE, Keller et al., 1987). DSR scores are based on the number of depressive symptoms and the extent of impairment, and can range from few or no depressive symptoms (DSR score of 1-2) to a full diagnosis of a major depressive episode (DSR score of 5 or 6), thus providing an index of depression that is both dimensional and categorical. Examining changes in DSR scores allowed us to analyze weekly fluctuations in depressive symptoms and to better track the disorder in participants. Subthreshold depressive episodes have been shown to be associated with increased experience of prior and future MDEs (Sherbourne et al., 1994). Results What differentiates young adults who have and have not experienced a past major depressive episode (MDE) from never depressed individuals? We conducted a multivariate analysis of covariance (MANCOVA) using current depressive symptoms as the covariate. Correlates and predictors of recurrent depression 12 Separate analyses were conducted for the measures of life events (negative, positive), abuse (e.g., physical, sexual, neglect), coping (e.g., primary, secondary, disengaged), and an ANCOVA on dysfunctional attitudes. The groups differed significantly on current depressive symptoms as measured by both self-report and clinical interview (see Table 1). Controlling for current level of depressive symptoms, previously depressed participants reported significantly lower total desirability scores for both negative [F(1, 98) = 7.98, p = .006] and positive life events [F(1, 98) = 4.52, p = .036] occurring in the previous 6 months. They also reported significantly lower levels of secondary control coping, greater levels of involuntary engagement and involuntary disengagement coping, and greater levels of childhood physical abuse compared to the never depressed controls. No significant difference was found for dysfunctional attitudes [F(1, 98) = .98, p = .324]. However, when not controlling for current depressive symptoms, previously depressed participants reported significantly more dysfunctional attitudes than controls. Follow-Up: Preliminary analyses. Of the 102 young adults assessed at baseline, 68 (67%) were reassessed at follow-up; 17 participants could not be located and 16 declined to participate in the follow-up. Of the 102 follow-up participants, 32 (47%) had a prior history depression at baseline; 43 (63%) were female. The mean age of this follow-up sample was 23.39 (SD = 3.88) and mean SES level was 54.05 (SD = 12.10). The mean number of weeks spent in the study was 35.16 (SD = 9.03). By the end of the follow-up, 8 participants had experienced one MDE and 1 participant had experienced two MDEs. To address the hypotheses regarding within- and between-individual change simultaneously, we specified a series of multilevel models using SAS PROC MIXED (SAS Institute, 1996) consisting of a within-person (i.e., level-1) submodel describing how each Correlates and predictors of recurrent depression 13 individual changed over time and a between-person (i.e., level-2) submodel describing how these changes varied across individuals (see Bryk & Raudenbush, 1992; Singer & Willett, 2003). Before fitting models including substantive predictors, we ran an unconditional means model with no predictors to describe and partition the outcome variation across participants without regard to time. This model stipulates that an individual’s DSR score at a given time point deviates from their true mean by a level-1 residual, and that this true mean deviates from the population average true mean by a level-2 residual. Results revealed that DSR scores had a nonzero intercept (B = 1.24, t = 21.11, p <.001), and that there was significant variation in DSR scores within (B = .49, z = 34.12, p < .001) and between (B = .22, z = 5.43, p < .001) individuals. The intraclass correlation coefficient indicated that 31% of the total variation in DSR scores could be explained by differences between participants, suggesting empirical nesting of the data. Next, we ran an unconditional growth model with time (a within-subject variable indicating number of weeks in the study) as a predictor to determine whether there was significant variation in DSR scores across both individuals and time. This model stipulates that an individual’s DSR score at a given time point deviates from their true linear change trajectory by a level-1 residual, and that this true linear trajectory deviates from the population average true trajectory by a level-2 residual. Results revealed that the average trajectory for DSR scores during the follow-up period had a significant positive slope (B = .001, t = 9.14, p < .001), indicating that participants’ DSR scores increased over time. Moreover, there was significant variation within individuals around their true change trajectories (B = .47, z = 34.11, p < .001) as well as significant inter-individual variation in slopes (B = .22, t = 5.45, p < .001). Taken together, these results point to nesting of the data and suggest that sufficient heterogeneity exists to examine substantive level-1 and level-2 predictors. Ignoring individual Correlates and predictors of recurrent depression 14 characteristics that contribute to response patterns over time as well as the effects of state dependence would result in biased variability estimates and inflated Type I error rates. In this situation, a multilevel analytic approach is warranted. All time-varying predictors were personcentered (i.e., the means of these variables equaled zero for each person) at Level 1 for this and all subsequent analyses, This decision was made on both theoretical and statistical grounds (Kreft, de Leeuw, & Aiken, 1995); this centering approach was intended to remove any betweenperson variance and prevent them from correlating with individual intercepts or between-person factors (Schwartz & Stone, 1998). Including person-centered predictors allows the estimate of the individual intercepts to be treated as a random effect by ensuring that the estimates of timevarying predictors represent purely within-person effects. Preliminary analyses of covariates revealed risk (number of prior MDEs experienced assessed at baseline) was significantly correlated with DSR scores (B = .04, t = 2.97, p = .004) but not total stress levels. In addition, week significantly correlated with DSR scores (B = .001, t = 9.14, p < .001) and total stress levels (B = .16, t = 19.62, p < .001). Sex, age, and SES were not significantly correlated with DSR scores or total stress levels. All covariates were included in subsequent analyses. Is there a predictive relation between stress levels and depressive symptoms? The specification of time-varying predictors such as lagged effects helps to clarify the temporal ordering of events. To test whether and to what extent stress levels predicted subsequent depressive symptoms, we ran a series of lagged effects models varying the lag interval n. The full model was as follows: Dep ti 00 10 Dep (t n )i 20 Stress (t n )i u 0i rti Correlates and predictors of recurrent depression 15 In this equation, the term Dep denotes an individual’s DSR score and Stress denotes that individual’s total level of stress. Thus, Depti indicates the DSR score at time t for person i. Terms with subscript (t - n) were effects of the nth week prior to Depti. To protect against Type I error, we only interpreted results if they were significant at the p < .01 level. Results indicated that the optimal lag (i.e., strongest predictive association) between total stress level and depressive symptoms was seven weeks. At this interval, the effect of stress levels on depressive symptoms was estimated as 0.03 (p < .001). Stress remained a significant predictor of higher levels of DSR scores up to a lag of 14 weeks (see Figure 1). For all subsequent analyses, Level 1 predictors (i.e., stress and DSR scores) were lagged 7 weeks behind the dependent variable (i.e. DSR scores). Predictors of DSR scores. Multilevel modeling was used to assess the predictive ability of each of the variables. We examined each of the key predictors on change in DSR scores over the follow up, controlling for the following covariates [i.e., sex, age, SES, prior MDEs, total stress levels (lagged at 7 weeks), DSR scores (lagged at 7 weeks)]. Theses analyses, therefore, are testing whether the key predictors (e.g., dysfunctional attitudes, coping, trauma) moderated the rate of change in DSR scores over the follow-up period. The key predictors also were included as moderators of the relation between DSR scores and stress levels (lagged 7-weeks). Dysfunctional attitudes significantly predicted DSR trajectories B = .0004, t(1858) = 5.89, p < .0001; that is, DSR scores increased at a faster rate at higher levels of dysfunctional attitudes. Dysfunctional attitudes also significantly moderated the relation between DSR scores and stress levels 7-week prior, B = .001, t (1858) = 4.24, p < .0001. Coping predicted the slope of depressive symptoms. Secondary control coping negatively predicted change in depressive symptoms [B = -0. 21, t(1858) = -6.46, p = .0001], whereas Correlates and predictors of recurrent depression 16 voluntary disengagement coping, [B = .26, t (1858) = 4.08, p < .001], involuntary engagement coping [B = .14, t(1858) = 3.62, p = .0003], and involuntary disengagement coping [B = .02, t(1858) = 3.92, p < .0001] predicted faster rates of change in depressive symptoms during the follow-up, above and beyond the covariates. Primary control coping did not significantly predict DSR scores after including the covariates. Secondary control coping and involuntary disengagement coping also moderated the relation between total stress levels and DSR scores 7 weeks later. The relation between stress and depressive symptoms was weaker at higher levels of secondary control coping [B = -.41, t (1858) = -4.74, p < .0001]. In contrast, the relation between stress and depressive symptoms was stronger (i.e., more positive) at higher levels of involuntary disengagement coping [B = .77, t (1858) = 5.84, p < .0001]. With regard to early childhood maltreatment, none of the trauma subscales showed a significant direct association with changes in DSR scores after including covariates. We next examined whether early maltreatment moderated the relation between total stress levels and DSR scores 7 weeks later; these analyses examined whether childhood trauma functioned as a relatively stable vulnerability factor that predicted depressive symptoms when triggered by ongoing life stress. The Emotional Abuse X Stress Level interaction significantly predicted DSR scores, B = .01, t (1834) = 7.37, p < .0001. That is, the relation between stress and depressive symptoms 7-weeks later was stronger (i.e., more positive) at higher levels of emotional abuse. This interaction is depicted in Figure 2. Simple slope analyses revealed that higher stress levels were associated with higher DSR scores for participants who reported more emotional abuse during childhood (B = .06, t = 9.40, p < .0001). For those who reported low emotional abuse during childhood, the relation of stress levels to DSR scores was not significant. Correlates and predictors of recurrent depression 17 We next examined whether the Stress X Week interaction significantly predicted DSR scores as a function of different types of maltreatment. The Stress X Week X Emotional Abuse interaction was significant. Simple slope analyses revealed that the Stress X Week interaction was significant for both higher [B = .003, t(1832) = 4.06, p < .0001] and lower levels of emotional abuse [B = -.003, t(1832) = -5.36, p < .0001]. Among individuals with greater emotional abuse, higher stress levels were associated with increases in DSR scores over time [B = .02, t(1832) = 5.71, p < .0001]; lower stress levels were not associated with change in DSR scores over time. Among individuals who experienced less emotional abuse, lower stress levels were associated with change in DSR scores over time [B = .02, t(1832) = 6.54, p < .0001], whereas higher stress levels were not associated with change in DSR scores (see Figure 3). The Stress X Week X Emotional Neglect interaction also was significant. Simple slope analyses revealed that the Stress X Week interaction was significant at lower levels of emotional neglect [B = -.002, t(1832) = -4.12, p < .0001], but not at higher levels of emotional neglect (see Figure 4). Among individuals with higher levels of emotional neglect, both higher [B = .01, t(1832) = 2.80, p = .005] and lower stress levels (B = .02, t(1832) = 4.83, p < .0001) were associated with increases in DSR scores over time. Among individuals with lower levels of emotional neglect, lower stress levels were associated with increases in DSR scores over time (B = .02, t(1832) = 4.92, p < .0001), whereas higher stress levels were not associated with change in DSR scores over time. Finally, we found a significant Stress X Week X Sexual Abuse interaction. The Stress X Week interaction was significant at higher levels of sexual abuse [B = -.002, t(1832) = -5.01, p < .0001], but not at lower levels of sexual abuse. Among individuals with a history of more sexual abuse, both higher [B = .01, t(1832) = 2.61, p = .009] and lower stress levels [B = .03, t(1832) = Correlates and predictors of recurrent depression 18 7.77, p < .0001] were associated with increases in DSR scores over time. Among individuals with a history of less sexual abuse, neither lower nor higher stress levels were associated with increases in DSR scores over time. This interaction is depicted in Figure 5. Discussion Several interesting findings emerged regarding correlates and predictors of depression in young adults. The first aim of this study was to examine what differentiated people with and without a history of mood problems. We found that individuals who had previously experienced a major depressive episode (MDE) reported a higher incidence of early physical abuse, more recent stress, and more maladaptive coping styles. Other studies similarly have shown that individuals with a history of abuse are more vulnerable to depression than those in the general population (e.g., Harkness et al., 2006). Additionally, previously depressed individuals rated life events as more negative and less positive than never-depressed controls. This finding is consistent with the notion that previously depressed individual perceive events more negatively than do others, suggesting that stressors may pose a greater threat for those individuals. With regard to coping responses to stress, previously depressed individuals also reported significantly higher levels of involuntary engagement and involuntary disengagement responses to stress and lower levels of primary control coping. These results are consistent with the findings of Compas and colleagues (2001) that primary control coping was correlated with lower levels of internalizing symptoms, whereas disengagement coping strategies (e.g., avoidance or withdrawal) were associated with higher levels of internalizing symptoms. Regarding dysfunctional attitudes, individuals with a prior history of depression had significantly higher scores on the DAS compared to never depressed controls, although this difference was no longer significant when current level of depressive symptoms were controlled. Correlates and predictors of recurrent depression 19 Thus, the residual depressive symptoms of those with a history of depression may serve to maintain dysfunctional attitudes even when they are not experiencing a full depressive episode. Although some studies have shown that residual depressive symptoms are linked with more negative cognitions even after the depressive episode has remitted, other studies have found that the attitudes and beliefs of these individuals return to “normal” between episodes (Abela & Hankin, 2008). The current results are more consistent with the view that in formerly depressed individuals, levels of residual depressive symptoms are associated with levels of dysfunctional attitudes. The direction of this relation, however, cannot be determined from these crosssectional analyses. Predicting Depressive Symptoms The second purpose of this study was to explore predictors of depressive symptoms during a six to eight month follow-up. Results indicated that risk, defined by the number of prior MDEs experienced before the baseline assessment, predicted subsequent depressive symptom rating (DSR) scores. This finding is consistent with other studies showing that depression is a recurrent disorder (e.g., Harkness et al., 1999; Kendler et al., 1998; Monroe & Harkness, 2005). We then examined the predictive relation between total stress levels and depressive symptoms using lagged effects models. Following the method used by Morris et al. (2010), we did not make assumptions about the time period in which stress would have the strongest relation to DSR scores. Rather, we explored at which time period the association between stress and depressive symptoms was strongest, and found that the prediction of depressive symptoms from total stress levels was strongest at seven weeks, and continued to predict DSR scores for up to 14 weeks. In addition, week significantly correlated with DSR scores and total stress levels. Correlates and predictors of recurrent depression 20 These timing results differed somewhat from those of Morris et al. (2010) who found that the predictive relation between stress and depressive symptoms peaked ta two weeks and remained significant for up to 26 weeks. This difference may be due to the methods used to assess life events. Whereas Morris and colleagues used a Life Events Interview and assessed events occurring during the previous year, the present study used a self-report checklist, which assessed events occurring between Time 1 and the follow-up evaluation, which was about 35 weeks, or about 8 months after the initial assessment. Whereas the relatively shorter time period in the current study may have allowed for better memory and dating of events, the interview method used by Morris et al. was based on the composite memory of two people (i.e., adolescent, mother) for recalling stressors and their time periods. Additionally, time, specified by one-week intervals, significantly predicted DSR scores and total stress levels, although it is possible that this correlation was partially due to memory of participants for the time closest to the interview. Next, we examined whether variables assessed at Time 1 predicted depressive symptoms over the follow-up period. Consistent with the literature (e.g., Abela & Hankin, 2008), we found that high levels of dysfunctional attitudes significantly predicted a faster increase in DSR scores. Moreover, dysfunctional attitudes moderated the relation between DSR scores and stress levels, such that the relation between stress and depression was stronger at higher levels of dysfunctional attitudes. Given that dysfunctional attitudes were present both at the baseline and follow-up, however, it is not possible to determine the direction of this relation; that is, we do not know if dysfunctional attitudes preceded the first episode or if they resulted from a “scar” from the prior episode (Zeiss & Lewinsohn, 1987). Nevertheless, the presence of these dysfunctional attitudes predicted DSR scores over time. Correlates and predictors of recurrent depression 21 Additionally, the coping subscales significantly predicted change in DSR scores in the expected direction. Consistent with Compas et al. (2001), secondary control coping predicted a decrease in depressive symptoms over time. In contrast, involuntary engagement and disengagement strategies significantly predicted faster rates of change (i.e., growth) in DSR scores. Furthermore, secondary control coping and involuntary disengagement coping both acted as moderators of the relation between total stress and depressive symptoms. At higher levels of secondary control coping, the relation between stress and depression was weaker, whereas at higher levels of involuntary disengagement, the relation between stress and depression was stronger. With regard to history of maltreatment, no main effects of childhood abuse predicted subsequent depressive symptoms, but the interaction of emotional abuse and recent stressful events significantly predicted DSR scores. That is, the relation between stress and depression was significant for those with a history of emotional abuse, but not for those without an emotional abuse history. Thus, consistent with Harkness and colleagues (2006), we found that some forms of early childhood maltreatment were related to subsequent depressive symptoms Finally, we found that the interactions of stress and week on DSR scores were significantly moderated by different types of abuse. Among children who had experienced high levels of emotional abuse, high levels of stress predicted change in DSR score over time. In contrast, among those with less emotional abuse, only lower levels of stress were associated with increases in DSR scores over time. Second, our findings show that among those experiencing high levels of emotional neglect, both high and low levels of stress predicted increases in DSR scores over time. However, among those with lower levels of emotional neglect, only lower stress levels were associated with increases in DSR scores over time, whereas higher stress levels Correlates and predictors of recurrent depression 22 were not associated with change. Third, the stress by week interaction significantly predicted increases in DSR scores over time at both high and low levels of stress among those with high levels of sexual abuse; yet, among those with lower levels of sexual abuse, neither lower nor higher stress levels were associated with increases in DSR scores over time. Thus, consistent with Harkness and colleague (2006), we found that some forms of early childhood maltreatment were related to depressive symptoms as young adults. It appears that experiencing abuse may differentially affect the experience of both high and low levels of stress, having different consequences for future depressive symptoms. The current study contributed to the literature on recurrent depression in a several ways. First, we affirmed previous research noting the association between depression, dysfunctional attitudes, stressful life events, maladaptive coping styles, and history of abuse. We also noted the role of stress, dysfunctional attitudes, involuntary engagement coping, involuntary disengagement coping, and the interaction of emotional abuse and stress in predicting subsequent depressive symptoms. Although previous studies have examined the relation of these variables to depressive symptoms, the current prospective study highlighted their predictive value, and possible points for intervention. Limitations of the current study provide directions fur future research. First, the time frame between completion of the self-report measures and the interview was not always consistent across participants. Second, although participants knew that they had experienced certain stressors, some were uncertain of the exact start or duration of the event, resulting in their guessing or choosing an arbitrary date. Future studies might have participants keep a daily or weekly diary to record the stressors they encounter, and to rate how negative those stressors are (Liu & Aloy, 2010). Correlates and predictors of recurrent depression 23 Third, life events checklists tend to be less informative than stress interviews regarding the onset and offset of events (Hammen et al., 2005). The use of these scales limits our ability to thoroughly assess important aspects of stressful events including the type of events, dependence/independence of the events, acute versus chronic, major versus minor, and the objective impact of the event on participants. Therefore, future studies of stress and recurrent depression should consider using life events interviews rather than or in addition to checklists. Fourth, the current prospective study examined subthreshold levels of depressive symptoms. This allowed us to better examine the full continuum of depression over time. 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Paper presented at the annual meeting of the American Educational Research Association, Toronto, Ontario, Canada. Zeiss, A. M., and Lewinsohn, P. M. (1987). Enduring deficits after remissions of depression: A test of the scar hypothesis. Behavior Research and Therapy, 26 (2) 151-158. Zobel, A. W., Nickel, T., Sonntag, A., Uhr, M., Holsboer, F., & Ising, M. (2001). Cortisol response in the combined dexamethasone/CRH test as predictor of relapse in patients with remitted depression: A prospective study. Journal of Psychiatric Research, 35, 83-94. Correlates and predictors of recurrent depression 28 Table 1. Means and standard deviations of study variables of individuals with a prior major depressive episode (MDE) and those who were never depressed Prior Depression Never Depressed M (SD) M (SD) F Beck Depression Inventory 8.23 (5.94) 3.22 (3.32) 6.05* Hamilton Depression Rating Scale 5.86 (4.24) 2.22 (2.35) 24.49*** M (SD) M (SD) Fa Negative Events -36.64 (17.84) -23.89 (13.02) 7.98** Positive Events 57.65 (15.13) 66.76 (20.40) 4.52* Primary Control .20 (.04) .22 (.04) 7.36** Secondary Control .23 (.06) .27 (.04) 3.76~ Voluntary Disengagement .14 (.03) .13 (.02) .62 Involuntary Engagement .27 (.05) .23 (.04) 6.78* Involuntary Disengagement .17 (.03) .15 (.03) 5.09* Physical Abuse 6.38 (2.29) 5.59 (1.09) 6.79* Sexual Abuse 5.50 (1.55) 5.41 (2.24) .47 Emotional Abuse 7.87 (4.03) 7.15 (2.15) .51 Emotional Neglect 7.64 (3.08) 7.41 (2.83) .05 Physical Neglect 5.95 (1.74) 5.65 (1.29) 1.37 131.47 (27.63) 117.91 (22.99) .98 Life Events Desirability Scores Responses to Stress (Coping) History of Maltreatment Dysfunctional Attitudes ~p < .10; *p < .05; **p < .01; ***p < .001; a Results of ANCOVAs with depressive symptoms as the covariate. Correlates and predictors of recurrent depression 29 Variable 1 2 3 4 5 6 7 8 1. MDD Hx 2. Sex .14 3. Age .08 -.02 4. SES .14 .13 -.21 5. BDI-II .46*** .07 .01 -.05 6. HRSD 7. Primary Control 8. Secondary Control 9. Disengage .46*** .19 -.08 .01 .70*** -.32*** .14 -.12 .03 -.44*** -.20* -.39*** -.07 .03 -.004 -.59*** -.52*** .36*** -.09 .08 .13 .29** -0.001 -.56*** -.26* .07 9 10 11 12 13 14 15 16 17 18 10. Invol Eng .43*** .09 .003 -.01 .50*** .51*** -.47*** -.84*** .02 11. Invol Disengage .35*** -.12 0.02 -.12 .56*** .35*** -.70*** -.65*** .29** .49*** 12. Emotion Abuse .11 0.04 0.18 .02 .20* .10 -.03 -.26** .19 .14 .11 13. Physical Abuse .21* .01 -.14 .07 .03 -.03 .45*** -.19 .08 .16 .01 .45** 14. Sexual Abuse .02 .10 .05 .02 .04 .18 -0.03 .13 -.07 -.13 .12 -.11 -.03 15. Emotion Neglect .04 .03 -.12 .14 .04 .12 .59*** .42*** .17 .11 .04 .59*** .42*** 0.17 16. Physical Neglect .10 .04 -.23* .05 .00 -.02 .52*** .60*** .20* .55*** -.09 .52*** .60*** .20* .55*** .26** -.07 -.29** .18 -.23* .58*** - .38*** -.60*** .34*** .49*** .46*** .36*** .20* -.03 .23* .13 18. Negative Events -.45*** -.06 .03 .02 -.56*** -.51*** .44*** .58*** -.18 -.57*** -.50*** -.18 -.04 -.18 -.26* -.16 -.47*** 19. Positive Events -.25* .06 -.27** .06 -.24* -0.14 .28** .32** -.35*** -.18 -.34** -.02 .03 -.03 -.05 .11 -.21* .11 Mean 0.55 0.64 22.97 54.89 5.97 4.22 0.21 0.25 0.14 0.25 0.16 4.22 7.54 6.02 5.46 7.53 -32.47 61.8 S.D. 0.50 0.48 3.87 11.24 5.51 3.94 0.04 0.05 0.03 0.05 0.03 3.94 3.31 1.88 1.89 2.95 17.61 18.21 17. DAS MDD = Major Depressive Disorder; SES = Socioeconomic Status; Beck Depression Inventory; HRSD = Hamilton Rating Scale for Depression; Invol = Involuntary; Eng or Engage = Engagement; Disengage = Disengagement; Emotion = Emotional; DAS = Dysfunctional Attitudes Scale; S.D. = Standard Deviation Correlates and predictors of recurrent depression 30 Table 3. Dysfunctional attitudes significantly predicted (p < .05) DSR scores over the follow-up, controlling for covariates [sex, age, SES, week, Prior MDEs, total stress levels (lagged 7 weeks), DSR scores (lagged 7 weeks)]. Predictors B (SE) Intercept 1.30 (.63)* Sex .13 (.12) Age .02 (.02) SES -.01 (.01) Week -.04 (.01)*** Prior MDEs .03 (.01)* Prior Stress -.06 (.02)** Prior Depression -.14 (.03)*** Dysfunctional Attitudes -.003 (.002) Week X Dysfunctional Attitudes .0004 (.00)*** Prior Stress X Dysfunctional Attitudes .0006 (.0001)*** *p < .05; ** p < .01; ***p< .001. Note: Intercept represents DSR score at Week 0 (i.e., week before follow-up period) when all covariates are equal to zero. Correlates and predictors of recurrent depression 31 Table 4. Secondary control coping significantly (p<.05) predicted DSR scores over the followup, controlling for covariates [sex, age, SES, week, prior MDEs, total stress levels (lagged 7 weeks), DSR scores (lagged 7 weeks)]. Predictors B (SE) Intercept .67 (.62) Sex .10 (.12) Age .10 (.02) SES -.01 (.01) Week .10 (.01)*** Prior MDEs .03 (.01)~ Prior Stress .11 (.02)*** Prior Depression -.14 (.03)** Secondary Control 2.05 (1.37) Week X Secondary Control -.20 (.03)*** Prior Stress X Secondary Control -.41 (.09)*** ~p < .10; *p < .05; ** p < .01; ***p< .001 Note: Intercept represents DSR score at Week 0 (i.e., week before follow-up period) when all covariates are equal to zero. Correlates and predictors of recurrent depression 32 Table 5: Involuntary engagement coping significantly (p<.05) predicted DSR scores over the follow-up, controlling for covariates [sex, age, SES, week, prior MDEs, total stress levels (lagged 7 weeks), DSR scores (lagged 7 weeks)]. Predictors B (SE) Intercept 1.22 (.63)~ Sex .09 (.12) Age .004 (.02) SES -.01 (.01) Week -.02 (.009)* Prior MDEs .03 (.01)* Prior Stress .003(.03) Prior Depression -.10 (.03)*** Involuntary Engagement .002 (1.56) Week X Involuntary Engagement .14 (.04)*** Stress X Involuntary Engagement .07 (.09) ~p < .10; *p < .05; ** p < .01; ***p< .001 Note: Intercept represents DSR score at Week 0 (i.e., week before follow-up period) when all covariates are equal to zero. Correlates and predictors of recurrent depression 33 Table 6. Involuntary disengagement significantly (p<.05) predicted DSR scores over the followup, controlling for covariates [sex, age, SES, week, prior MDEs, total stress levels (lagged 7 weeks), DSR scores (lagged 7 weeks)]. Predictors B (SE) Intercept 1.23 (.61)* Sex .11 (.13) Age .001 (.02) SES -.005 (.01) Week -.02 (.01)* Prior MDEs .03 (.01)~ Prior Stress -.11 (.02)*** Prior Depression -.14 (.03)*** Involuntary Disengagement -.40 (2.22) Week X Involuntary Disengagement .21 (.05)*** Prior Stress X Involuntary Disengagement .77 (.14)*** ~p < .10; *p < .05; ** p < .01; ***p< .001 Note: Intercept represents DSR score at Week 0 (i.e., week before follow-up period) when all covariates are equal to zero. Correlates and predictors of recurrent depression 34 Table 7. Emotional Abuse X Prior Stress significantly (p<.001) predicted DSR scores over the follow-up, controlling for covariates [sex, age, SES, week, prior MDEs, total stress levels (lagged 7 weeks), DSR scores (lagged 7 weeks)]. Predictors B (SE) Intercept 1.06 (.57)~ Sex .11 (.13) Age .01 (.02) SES -.01 (.01) Week .01 (.00)~ Prior MDEs .03 (.01)* Prior Stress -.06 (.01)*** Prior Depression -.14 (.03)*** Emotional Abuse -.01 (.03) Week X Emotional Abuse .00 (.00) Prior Stress X Emotional Abuse .01 (.00)*** ~p < .10; *p < .05; ** p < .01; ***p< .001. Correlates and predictors of recurrent depression 35 Lagged Effects of Stress on Depression Relation of Stress to Depression(B) 0.04 0.035 0.03 0.025 0.02 0.015 0.01 0.005 0 1 3 5 7 9 11 13 15 Weeks (lagged) Figure 1. The strongest predictive association between total stress level and depressive symptoms was seven weeks. At this interval, the effect of stress levels on depressive symptoms was estimated as 0.03 (p < .001). Stress remained a significant predictor of increases in DSR scores up to a lag of 14 weeks Correlates and predictors of recurrent depression 36 Figure 2 Depression Symptom Ratings (DSR) 3 2 .5 2 High Emotional Abuse 1 .5 *** 1 0 .5 0 Low High Stress Level Low Emotional Abuse Correlates and predictors of recurrent depression 37 Figure 3. Emotional Abuse X Prior Stress X Week interaction High Emotional Abuse Depression Symptom Ratings (DSR) 3 *** 2.5 2 High Stress 1.5 Low Stress 1 0.5 0 Weeks Low Emotional Abuse Depression Symptom Ratings (DSR) 3 2.5 *** High Stress 2 Low Stress 1.5 1 0.5 0 Weeks Correlates and predictors of recurrent depression 38 Figure 4. Emotional Neglect X Prior Stress x Week interaction: High Emotional Neglect Depression Symptom Ratings (DSR) 3 2.5 High Stress ** 2 Low Stress *** 1.5 1 0.5 0 Weeks Low Emotional Neglect Depression Symptom Ratings (DSR) 3 2.5 *** 2 High Stress Low Stress 1.5 1 0.5 0 Weeks Correlates and predictors of recurrent depression 39 Figure 5. Sexual Abuse X Prior Stress x Week interaction: High Sexual Abuse Depression Symptom Ratings (DSR) 3 2.5 2 *** High Stress ** Low Stress 1.5 1 0.5 0 Weeks Low Sexual Abuse Depression Symptom Ratings (DSR) 3 2.5 High Stress 2 Low Stress 1.5 1 0.5 0 Weeks