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Psychosocial Risks for Major Depression in Late Adolescence: A Longitudinal Community Study
Psychosocial Risks for Major Depression in Late Adolescence: A Longitudinal Community Study HELEN Z. REINHERZ, Sc.D., ROSE M. GIACO NIA, PH.D., BILGE PAKlZ, ED.M., AMY B. SILVERMAN, B.A., ABBIE K. FROST, PH.D., AND EVA S. LEFKOWITZ, B.A.
Abstract. Objective: An ongoing 14-year longitudinal study examined psychosocia l antecedents of major depression in late adolescence in a communi ty population. Method : Subjects were 385 adolescents followed between the ages of 5 and 18 years. Early health, familial, behavior, academic, and environmental risks for major depression were identified using data collected at ages 5, 9, 15, and 18 years. At age 18, a lifetime diagnosis of major depres sion was assessed using the NIMH Diagnostic Interview Schedule (DIS-III-R ). Results: For males, neonatal health problems, dependence problems at age 5 years, perceived unpopularity and poorer perceptions of their role in the family at age 9 years, remarriage of a parent, early family discord , and anxiety at age 15 years significantly increased the risk of developing major depression. Females with major depression, compared with nondepressed females, had older parents and came from larger families, and at age 9 years had greater perceived unpopularity and anxiety, lower self-esteem, and poorer perceptions of their role in the family. Depressed females also reported ,more stressful life events, including death of parent and pregnanc y. Conclu sions: Underscoring the importance of early psychosocial factors in the later development of major depres sion and pointing to specific risks, our findings can aid in developing strategies for prevention and early intervention. J. Am. Acad. Child Adolesc. Psychiatry, 1993,32, 6:1155-1163. Key Words: depression, adolescents, DSM-IlI-R. Despite increa sing evidence that adolescence is a key period for the onset of major depression (Burke et a!., 1990; Sorenson et aI., 1991) and mounting concern about the individual and social costs of depressive disorders (Regier et aI., 1988), little is known about specific early psychosocial antecedents for major depression as it emerges in adolescence. The identification of specific psychosocial antecedents for major depres sion can play a significant role in targeted early intervention and prevention efforts designed to reduce the severity , duration, and long-term consequences of this disorder. Researchers emphasize that prospective longitudinal studies are essential for determining whether risks for depression actually are antecedents, rather than concomitants or consequences of the disorder (Block et al., 1991; Fleming and Offord, 1990; Robertson and Simons , 1989). However, to date, there are few long-term prospective studies of representative U.S. community populations that span developmental periods from early childhood to late adolescence (Block et al., 1991; Lerner et al., 1985; Velez et al., 1989). Most community studies of depressive disorders in children and adolescents have been cross- sectional and have examined current risks (such as family functioning and recent life events) or broad antecedent risks such as gender (Bird et aI., 1989; Costello, 1989; Kashani et aI., 1987, 1988). Accepted February 5, 1993. The authors are with Simmons College School of Social Work, Boston,' MA. This research was supported by Grant MH41569 from the National Institute of Mental Health. An earlier version of this paper was presented at the annual meeting of the American Public Health Association, November 1992. Reprint requests to Dr. Reinherz; Simmons College School ofSocial Work, 51 Commonwealth Avenue, Boston, MA 02116. 0890-8567/93/3206-1155$03.00/0©1993 by the American Academy of Child and Adolescent Psychi atry. J. Am, Acad. Child Adolesc. Psychiatry, 32:6, November J993
Furthermore, most studies have examined only a few psychosocial factors and have not included sizable single-aged cohorts. The current study was designed to provide much-needed information about early psychosocial antecedents for major depression in late adolescence. The study followed a singleage cohort from ages 5 to 18 years , examining risks from several domains for a DSM-III-R lifetime diagnosis of major depression at age 18. The age of onset of depression was assessed as an additional means of determining which risk factors actually preceded the onset of depression. Risks for Major Depression Recent studies of depressive disorders and symptomatology have identified salient psychosocial risk factors that were included in the current study. Two broad sociodemographic factors, gender and socioeconomic status (SES), have been widely studied as risks for depression in children and adolescents. Most recent studies have reported that at adolescence females are at significantly greater risk than males for depression or depressive symptomatology (Garrison et aI., 1989; Kandel and Davies , 1982; Kashani et al., 1987; Reinherz et aI., 1989). However, there is mixed evidence about the relationship between family SES and depression in children and adolescents (Fleming and Offord, 1990; Kaplan et aI., 1984). Several family factors have been explored as risks for depressive disorders and symptomatology. Studies of family compo sition, such as birth order and number of siblings (Birtchnell, 1972; Gates et al., 1986; Munro , 1966), as well as changes in family composition due to parental divorce or remarriage (Fendrich et aI., 1990; McLeod, 1991; Velez et al., 1989) have yielded conflicting findings. In contrast, poor family functioning, ranging from perceived lack of closeness to parents to extreme family conflict and violence, consistently has been identified as a correlate of depressive
[[55
REINHERZ ET AL.
disorders and symptomatology (Fleming and Offord, 1990; Kandel and Davies, 1982; Kashani et aI., 1988; Robertson and Simons, 1989). Other risk factors for depression cover several domains. Neonatal and early childhood health problems (Cohen et aI., 1989) as well as later health problems (Katon and Sullivan, 1990; Wells et aI., 1985) have been linked to depressive disorders and symptomatology. Undesirable life events, especially those representing significant losses such as early death of a parent have also been identified as significant risks for later depression (Finkelstein, 1988; Harris et aI., 1986; Lloyd, 1980). There is contradictory evidence about whether academic failure is associated with depressive symptoms or disorders in childhood and adolescence (fleming and Offord, 1990). The link between preschool personality characteristics and behavior and depression in adolescence has been demonstrated in recent longitudinal studies (Block et aI., 1991; Lerner et aI., 1985). Later concurrent behavioral and emotional characteristics also are significantly related to depression, particularly self-esteem (Dean and Ensel, 1983; Fleming and Offord, 1990; Kandel and Davies, 1982; Simons and Miller, 1987), anxiety (Clark, 1989; Kashani et aI., 1987; Lewinsohn et aI., 1988), and perceived unpopularity or lack of social skills (Anderson et aI., 1989; Jacobsen et aI., 1983; Lewinsohn et aI., 1988). Method
The primary purpose of the current investigation was to identify, separately for each gender, specific psychosocial risks that are antecedents of major depression in late adolescence in a community population. Hypothesized early risks for major depression included family SES and composition, poor family relations, health problems, academic failure, behavioral and emotional characteristics, and undesirable life events. Using multiple informants (subjects, parents, teachers) and a variety of measures, data were collected at four major timepoints: when subjects were age 5 years (1977), age 9 years (1981), age 15 years (1987) and age 18 years (1990). A diagnosis of major depression and age of onset were assessed at age 18 years; risk factors were evaluated at the three previous timepoints (ages 5, 9, and 15 years). Parents (usually mothers) completed questionnaires and/or interviews when the subjects were 5, 9, and 15 years old. Mothers furnished histories of their children's health from the prenatal period to age 5 years. The subjects completed standardized questionnaires at 9 years old and were interviewed at ages 15 and 18 years. Teacher comments and school records of grades and grade retentions covered the period from age 6 to age 15 years. SAMPLE
The 385 adolescents were participants in an ongoing 14year longitudinal panel study that began in 1977 when these youth entered kindergarten in a representative working-class community in the Northeastern United States (Reinherz et al., 1989, 1993). In 1990, when subjects were last interviewed, most were seniors in high school, with a mean age 1156
of 17.9 years. The sample included 195 males and 190 females. Almost all (99%) of the adolescents were white, and the SES of their households continued to be predominantly working or lower-middle class (Reinherz et aI., 1993). Between 1977 and 1990, attrition occurred primarily in the transition from kindergarten to first grade when students transferred from the public school system to parochial schools. Nonetheless, over 74% of subjects who contined in the public school system through third grade remained in the study at age 18 years. In 1990, 96% of the 404 subjects interviewed in 1987 participated. At each major data collection wave, analyses verified that youth who continued to participate did not differ from nonparticipants on key demographic, academic, behavioral, or emotional factors (see Reinherz et aI., 1993, for additional detail). MEASURES
Major Depression
The NIMH Diagnostic Interview Schedule, Version III-R (DIS-III-R) (Robins et aI., 1989) provided a lifetime diagnosis of major depression according to DSM-III-R criteria, as well as age of onset. The DIS-III-R, a highly structured interview that may be administered by trained lay interviewers, was designed for use in epidemiological studies of psychiatric disorders. Validity studies of the original version of the DIS showed significant agreement between DIS diagnoses and other measures, including interviews by psychiatrists (Leaf et aI., 1991). In the current study the impairment of adolescents meeting DSM-III-R criteria for major depression was assessed additionally by comparing them with their nondepressed counterparts on three selfreport measures of functioning at age 18 years. The Youth Self Report (YSR) (Achenbach and Edelbrock, 1987) provided an index of total emotional and behavior problems, self-esteem was measured by the standardized Rosenberg Self-Esteem Scale (Rosenberg, 1986), and interpersonal problems were assessed by a scale created by project staff with an a. reliability of 0.75 (Reinherz et aI., 1993). Age of onset of major depression, using the DIS-III-R, was the youngest age reported by subjects for any depressive episode. The test-retest reliability of self-reported age of onset of major depression has been found to be excellent, particularly for younger subjects (Farrer et al., 1989). Age of onset was used in the current study to verify whether risks preceded the onset of major depression. The DIS-III-R was administered to the adolescents in 1990 (at age 18 years) by 10 trained interviewers with research or clinical experience. The training and monitoring of the interviewers (Reinherz et aI., 1993) resulted in high fidelity to DIS-III-R interview procedures. Risks for Major Depression
The psychosocial risk factors examined were those identified in previous studies of depressive disorders or symptomatology. Most risk factors were measured prospectively and covered the time period from birth to age 15 years. Family SES. Family SES was determined at ages 5, 9, and 15 years using the Hollingshead two-factor index of J.Am. Acad. Child Ado/esc. Psychiatry, 32:6, November 1993
RISKS FOR DEPRESSION IN LATE ADOLESCENCE
social position (Hollingshead and Redlich, 1958). The five Hollingshead categories were collapsed to two: "higher SES" (highest three categories) and "lower SES" (lowest two categories). Family Structure/Composition. Six risk factors described family composition. (1) Birth order (3rd or later), (2) older mother (30 or older at birth of subject), (3) older father (35 or older at birth of subject), and (4) larger family size (four or more children) were taken from the mother interview (age 5 years). These definitions of older parents were based on the distribution of parents' ages in the sample and represent the highest quartile. (5) Separation or divorce of parents and (6) remarriage of parents were determined from mother and subject interviews at several timepoints. Family Relations/Functioning. Two indices of family relations covered the period from ages 9 to 15 years. (1) The subject's perception of role in the family was constructed from seven "family-related" items in the Piers-Harris Children's Self Concept Scale (Piers, 1984), completed by subjects at age 9 years. This index included items such as " I am a disappointment to my family," and had an a reliability of 0.54. (2) Family arguments and violence (between ages 10 and 15 years) was based on parent and subject interviews. Items asked about the occurrence of increased arguments and violence between parents and between the subject and parents. This risk factor was coded as present if there was evidence of both family arguments and violence. Health Problems. Four indicators of health problems across birth to age 15 years were constructed. (1) Neonatal health problems was based on mothers' reports at the age 5 interview of any of six conditions immediately after birth: jaundice, turning blue, breathing difficulties, infections, birth injuries, or birth defects. (2) Illnesses and hospitalizations (birth to age 5), also from the age 5 years mother interview, was coded as positive if the child experienced one or more serious illnesses or two or more hospitalizations before age 6. (3) Onset of health problems (ages 6 to 9 years) and (4) onset of health problems (ages 10 to 15 years) were based on subject's report of any health problems that interfered "much" or "all of the time." Health problems included disorders such as heart disease, diabetes, asthma, as well as illnesses such as mononucleosis or venereal disease, and physical injuries. Behavior and Emotional Characteristics. Nine indicators, covering ages 5 to 15 years, were taken from mother reports on the Simmons Behavior Checklist (SBCL) (Reinherz and Gracey, 1983), and self-reports on the Piers-Harris Children's Self Concept Scale (Piers, 1984). The SBCL provided mother reports at ages 5, 9, and 15 years ofbehavior problems in areas such as dependence, shyness, and anxiety. SBCL scales have demonstrated acceptable internal consistency and test-retest reliability, as well as construct validity (Reinherz and Gracey, 1983; Reinherz et aI., 1989). The Piers-Harris, a standardized 80-item self-report measure for youth aged 8 to 18 years, provided subjects' selfperceptions of anxiety, popularity, and overall self-concept. The reliability and validity of the Piers-Harris are welldocumented (Piers, 1984). J. Am.Acad. Child Adolesc. Psy chiatry, 32:6, November 1993
(1) Dependence, (2) shyness, and (3) fear of new things were scales of SBCL completed by mothers during the age 5 interview. (4) Self-rated anxiety at age 9 and (5) self-rated anxiety at age 15 were the anxiety cluster scores of PiersHarris, with higher scores indicating higher levels of anxiety. (6) Perceived unpopularity at age 9 years was the popularity cluster score of the Piers-Harris; higher scores indicated more perceived unpopularity. (7) Overall self-concept at age 9 was the total score on the Piers-Harris. (8) Mother-rated anxiety at age 9, and (9) mother-rated anxiety at age 15 were taken from the SBCL. Academic Failure. Teacher ratings and school records provided four indices of academic failure. (1) Poor academic performance at age 9 was based on teacher ratings of overall academic achievement in grade 3. (2) Ds and Fs in English and math in grades 5 to 9 were taken from school records. This risk factor was considered to be present if 25% or more of course grades were Ds or Fs. (3) Grade retentions (ages 6 to 9) and (4) grade retentions (ages 10 to 15) were determined from school records. Stressful Life Events. Two stressful life events occurring by age 15 (1) death of parent and (2) pregnancy (for females) were identified from parent and subject interviews at several timepoints. ANALYSES
Analyses focused on the relationship between individual risk factors from several developmental periods and depression in late adolescence. For most analyses, risk factors were grouped into three broad time frames: (1) birth to age 5 years, (2) age 6 to age 9, and (3) age 10 to age 15. Analyses were conducted separately for males and females because there is substantial evidence of gender differences in risk factors for depressive disorders and symptomatology (Block et aI., 1991; Gjerde et aI., 1988; McLeod, 1991). For each gender, the relationship of individual risk factors to major depression was assessed through chi-square tests of independence (for dichotomous risk factors) or t tests for independent samples (for continuous risk measures). Odds ratios were calculated to summarize the relative risk of subsequently developing major depression if each risk factor was present. For risks originally measured as continuous variables, these odds ratios reflected the risk associated with extreme scores (highest quartile). Results
Thirty-six (9.4%) of the 385 adolescents met DSM-IlI-R lifetime criteria for major depression at age 18 years. These 36 adolescents, compared with their nondepressed counterparts, also demonstrated impaired functioning on overall emotional and behavioral problems (YSR total score, t = 5.67, df = 383, P < 0.001), interpersonal problems (t = 5.42 , df = 383, P < 0.001), and self-esteem (Rosenberg scale, t = -5.02, df = 383, p < 0.001). Furthermore, more than 58% of the depressed adolescents reported suicidal ideation, and 22% indicated they had attempted suicide. There were significant gender differences in both the lifetime prevalence and age of onset of major depression (Table 1). Females were three times as likely as males to meet 1157
REINHERZ ET AL.
lifetime criteria for major depression by age 18 (X2 = 8.3, df = 1, p < 0.01). Females also experienced significantly earlier onset than did their male counterparts (t = 2.1, df = 34, p < 0.05); 40% of depressed females versus only 10% of depressed males reported onset before age 15 years. These ages of onset also indicated that risks up to age 15 seemed to antedate the onset of depression for almost all depressed males. In contrast, for females, all risk factors occurring before age 10 years could be considered to precede the onset of depression. More detailed analyses were conducted to ascertain whether significant risk factors between ages 10 and 15 were antecedents for depression for those females with onset of depression before age 15. These analyses are reported in the text.
their role in the family (t = 3.0, df = 172, p < 0.01). Between ages 10 and 15 years, depressed males were nine times as likely as nondepressed males to have experienced both increased family arguments and family violence (X2 = 14.8, df = 1, p < 0.001). Finally, remarriage of a parent before the child reached age 15 was a significant risk for later depression (X2 = 4.3, df = 1, p < 0.05). Males with major depression also demonstrated significantly poorer perceptions of their popularity at age 9 (t = 2.0, df = 172, p < 0.05). Although anxiety at age 9 did not differ significantly between depressed and nondepressed males, by age 15 both self-rated anxiety (t = 2.1, df = 178, p < 0.05) and mother-rated anxiety (t = 2.0, df = 189, p < 0.05) emerged as significant risks for major depression at age 18 years.
RISKS FOR MAJOR DEPRESSION
For both males and females, risk factors from as early as birth covering most of the psychosocial domains studied were significantly related to major depression at age 18 (Tables 2 and 3). However, there was little overlap in specific risks for males and females, and there were noteworthy differences in the ages at which groups of factors emerged as significant risks. Risks f or Males
For males, several risks occurring before age 6 years predicted a lifetime diagnosis of major depression at age 18. Depressed males were 10 times as likely as nondepressed males to have experienced neonatal health problems (X2 = 16.2, df = 1, p < 0.001), and were seven times more likely to have had serious illness and hospitalizations before age 6 (X2 = 10.3, df = 1, p < 0.001). At age 5, depressed males were rated by their mothers as having significantly more problems with dependence than were nondepressed males (r = 2.1, df = 181, p < 0.05). A pattern of troubled family relations across developmental periods also characterized males with major depression. At age 9, compared with their nondepressed counterparts, depressed males had poorer perceptions of T ABL E
I. Gender Differences in Lifetime Prevalence and Age of Onset of Major Depression
Males
Females
Major Depression
n
%
n
%
Lifetime prevalence** Age of onset* 9-10 11-1 2 13-14 15-16 17-1 8
10
5.1
26
13.7
0 0 1 6 3
0.0 0.0 10.0 60.0 30.0
1 4 5 13 3
3.8 15.4 19.2 50.0 1l .5
Note: Percentages for lifetime prevalence based on total sample sizes: males = 195; females = 190. Percentages for age of onset categories based on only those with major depression: males = 10; females = 26. * p < 0.05 for t test of differences in average of onset, ** p < 0.01 for chi-square test of independence.
1158
Risks for Females
As was true for males, for females risks from as early as birth were significantly related to developing major depression in late adolescence. Four factors characterizing family structure at birth were related to major depression: being third or later in the birth order (X2 = 9.6, df = 1, p < 0.01), having a mother 30 years old or older (X2 = 6.0, df = 1, p < 0.01), a father 35 or older (X2 = 7.7, df = 1, p < 0.01), and three or more siblings (X2 = 5.3, df = 1, p < 0.05). These four risk factors were significantly intercorrelated (between 0.56 and 0.85) and embody a particular family constellation rather than distinct risks. In addition to family composition, poorer perceptions of role in the family at age 9 years was significantly related to major depression at age 18 (t = 2.1, df = 173, p < 0.05). Several early emotional and behavioral characteristics that preceded the onset of depression differed between depressed and nondepressed females. At 9 years old, girls who subsequently developed major depression held poorer perceptions of their popularity (t = 1.9, df = 173, p < 0.05), and had lower overall self-esteem (t = 2.2, df = 173, P < 0.05). Self-rated anxiety at age 9 was also significantly related to major depression at age 18 (t = 1.8, df = 173, p < 0.05). Anxiety at age 15 as a risk was examined only for those females whose depression occurred after age 15. Considering just those depressed females with onset of depression at age 16 or later (n = 9), both self-rated anxiety at age 15 (t = 3.82, df = 167, p < 0.001) and mother-rated anxiety at age 15 (t = 2.39, df = 169, p < 0.02) were significant antecedent risks when compared with nondepressed females. Although early health problems (up to age 9) did not differ between depressed and nondepressed girls, the onset of health problems between ages 10 and 15 was a significant antecedent risk for later depression. Females with onset of depression after age 15 were more than five times more likely than were nondepressed females to report the onset of health problems that interfered most or all of the time with their daily functioning (X2 = 7.8, df = 1, p < 0.005). These health problems included respiratory disorders, mononucleosis, arthritis, and headaches. Two undesirable life events were significantly related to major depression for females. Depressed females were seven J. Am. Acad. Child Adolesc. Psychiatry, 32:6, Nov emb er 1993
RISKS FOR DEPRESSION IN LATE ADOLESCENCE TABLE
2. Risk Factors for Major Depression at Age 18 Years for Males Major Depression (n = l O)"
Risk Factor Lower family socioeconomic status Age 5 years Age 9 years Age 15 years Family structure/composition Birth order (3rd or later) Older mother (30+ at birth of subject) Older father (35+ at birth of subject) Larger family size (4+ children) Parents separated or divorced (ages 0-15 years) Parent remarried (ages 0-15 years) Family relations/functioning Poorer perception of family role (age 9 years) Family arguments + violence (ages 10-15 years) Health problems Neonatal health problems Illness or hospitalization (ages 0-5 years) Onset serious health problem (ages 6-9 years) Onset serious health problem (ages 10-15 years) Academic failure Poor academic performance (teacher rated) (age 9 years) Retained in grade (ages 6-9 years) Ds and Fs (course grades) (ages 11-15 years) Retained in grade (ages 10-15 years) Life events before age 15 years Parent died
Ratio"
95% Confidence Interval
3.8 4.1 3.8
1.55 0.35 0.65
0.4-5.7 0.1-1.7 0.2-2.4
38.3 33.0 21.7 26.6 29.3 15.1
3.6 3.5 3.1 3.3 3.4 2.6*
0.69 0.51 0.40 0.69 1.60 3.74
0.2-2.8 0.1-2.5 0.1-3.3 0.1-3.4 0.4-5.9 1.0-14.1
16.3 16.7
22.0 9.7
3.2** 2.2***
5.33' 9.28
1.4-19.9 2.4-35.1
60.0 55.6 0.0 0.0
16.3 17.6
12.7 14.7 3.2 11.9
2.6*** 2.7*** 1.3 2.4
10.29 7.26
2.7-39.5 1.8-28.8
37.5 0.0 20.0 0.0
18.3
22.1 10.6 25.1 5.0
3.3 2.3 3.4 1.6
2.12
0.5-9.3
0.74
0.2-3.6
5.9
1.7
Odds Ratio'
95% Confidence Interval
5.10 1.88 1.92 1.84 2.09 3.00 0.83 4.23 5.12
1.2-21.2 0.5-7.6 0.5-7.1 0.5-7.5 0.6-7.6 0.9-10.9 0.2-4.1 1.1-16.5 1.4-19.0
%
Standard Error
%
60.0 20.0 40.0
16.3 13.3 16.3
49.2 41.8 50.6
30.0 20.0 10.0 20.0 40.0 40.0
15.3 13.3 10.0 13.3 16.3 16.3
60.0 50.0
13.3
0.0 Major Depression (n = l O)"
Behavioral/emotional characteristics Dependence (mother rated) (age 5 years) Shyness (mother rated) (age 5 years) Fear of new things (mother rated) (age 5 years) Anxiety (self-rated) (age 9 years) Anxiety (mother rated) (age 9 years) Unpopularity (self-rated) (age 9 years) Overall self-concept (self-rated) (age 9 years) Anxiety (self-rated) (age 15 years) Anxiety (mother rated) (age 15 years)
No Depression (n = 185)a Standard Error
Odds
No Depression (n = 185)a
Mean
Standard Deviation
Mean
Standard Deviation
7.89 5.60 4.10 4.00 11.50 5.60 54.50 4.22 8.60
1.90 1.90 1.45 2.49 2.92 2.46 12.17 2.95 3.47
6.76 5.00 3.95 3.18 10.42 4.02 58.99 2.28 7.02
1.59* 1.67 1.32 2.66 3.02 2.45* 11.36 2.68* 2.35*
Note: a ns vary slightly for risks due to missing data; b depressed vs. nondepressed odds ratio for presence of risk factor; 'depressed vs. nondepressed odds ratio for scoring in highest quartile on measure (lowest quartile for self-concept). * p < 0.05; ** P < 0.01; *** P < 0.001, one-tailed.
times as likely as nondepressed females to have experienced the death of a parent before age 15 (X2 = 6.9, df = 1, p < 0.01). In all cases, parent death occurred either earlier or at the same age as the reported onset of depression. Depressed females were also 13 times more likely to have become pregnant by age 15 (X2 = 7.2, df = 1, p < 0.01). None of these early pregnancies were carried to term, and the pregnancy preceded the reported age of onset of depression for all adolescents. Gender Similarities and Differences in Risks There were a few noteworthy similarities between males and females in risks. For both genders, a poorer perception J. Am. Acad. Child Adolesc. Psychiatry, 32:6, November 1993
of their role in the family at age 9 and greater perceived unpopularity at age 9 were associated with major depression in late adolescence. There were many differences in specific risks; a particularly striking one was death of a parent. Males were twice as likely as females in the total sample to have experienced the death of a parent before age 15 (5.9% versus 3.2%). However, none of the males whose parent died developed major depression by age 18, whereas half the females experiencing this loss did. Also striking were differences between males and females in the ages at which factors emerged as significant risks. 1159
REINHERZ ET AL. TABLE
3. Risk Factors for Major Depression at Age 18 Years for Females Major Depression (n = 26)a
Risk Factor Lower family socioeconomic status Age 5 years Age 9 years Age 15 years Family structure/composition Birth order (3rd or later) Older mother (30+ at birth of subject) Older father (35+ at birth of subject) Larger family size (4+ children) Parents separated or divorced (ages 0-15) Parent remarried (ages 0-15) Family relations/functioning Poorer perception of family role (age 9 years) Family arguments + violence (ages 10-15 years) Health problems Neonatal health problems Illness or hospitalization (ages 0-5 years) Onset serious health problem (ages 6-9 years) Onset serious health problem (ages 10-15 years)" Academic failure Poor academic performance (teacher rated) (age 9 years) Retained in grade (ages 6-9 years) Ds and Fs (course grades) (ages 11-15 years) Retained in grade (ages 10-15 years) Life events before age 15 years Parent died Subject became pregnant
Behavioral/emotional characteristics Dependence (mother rated) (age 5 years) Shyness (mother rated) (age 5 years) Fear of new things (mother rated) (age 5 years) Anxiety (self-rated) (age 9 years) Anxiety (mother rated) (age 9 years) Unpopularity (self-rated) (age 9 years) Overall self-concept (self-rated) (age 9 years) Anxiety (self-rated) (age 15 years)" Anxiety (mother rated) (age 15 years)"
No Depression (n = l64)a
95% Confidence Interval
%
Standard Error
%
57.7 34.8 53.8
9.9 10.2 10.0
51.0 50.4 50.0
4.0 4.4 4.0
1.31 0.53 1.17
0.6-3.0 0.2-1.3 0.5-2.7
61.5 50.0 48.0 46.2 19.2 15.4
9.7 10.0 10.2 10.0 7.9 7.2
30.4 26.4 21.9 24.4 29.3 11.0
3.7** 3.5** 3.3** 3.4* 3.6 2.4
3.67 2.79 3.29 2.66 0.58 1.47
1.6-8.7 1.2-6.5 1.4-7.6 1.1-6.2 0.2--4.8 0.5--4.8
30.8 11.5
9.2 6.4
15.4 9.8
3.0* 2.3
2.43' 1.21
0.9-6.3 0.3--4.5
8.7 15.4 7.7 60.0
6.0 7.2 5.3 16.3
13.8 21.8 6.1 21.3
2.9 3.3 1.9 3.2**
0.60 0.65 1.28 5.53
0.1-2.7 0.2-2.0 0.3-6.2 1.5-20.7
13.6 7.7 16.7 0.0
7.5 5.3 7.8
14.3 5.5 16.0 3.7
2.8 1.8 3.0 1.5
0.95 1.43 1.05
0.3-3.5 0.3-7.0 0.3-3.3
11.5 7.7
6.4 5.3 Major Depression (n = 26)a
Standard Error
1.8 1.0** 0.6 0.6** No Depression (n = l64)a
Mean
Standard Deviation
Mean
Standard Deviation
6.76 5.00 3.80 4.69 10.57 4.27 57.54 8.44 10.22
1.79 1.55 1.16 2.91 3.12 3.01 14.21 4.13 4.12
6.64 5.01 3.88 3.58 9.84 3.30 62.94 4.13 7.77
1.71 1.74 1.36 2.84* 3.12 2.37* 10.77* 3.25*** 2.94*
Odds Ratio"
7.00 13.58
1.3-36.8 1.2-155.0
Odds Ratio'
95% Confidence Interval
1.30 1.21 0.80 1.24 2.94 2.76 3.13 7.45 4.54
0.5-3.4 0.4-3.6 0.3-2.1 0.5-3.4 1.1-7.9 1.1-6.9 1.3-7.4 1.9-29.8 1.2-17.8
Note: a ns vary slightly for risks due to missing data; b depressed vs. nondepressed odds ratio for presence of risk factor; 'depressed vs. nondepressed odds ratio for scoring in highest quartile on measure (lowest quartile for self-concept); d only females with onset of depression after age 15 years (n = 10) were included in these analyses. * p < 0.05; ** p < 0.01; *** p < 0.001, one-tailed.
For females, the family constellation present at birth was significantly related to depression in late adolescence. In contrast, for males, later shifts in family structure, particularly the remarriage of a parent, were linked to depression. Also, whereas health problems immediately after birth were related to depression in adolescence for males, health did not become a significant risk for females until ages 10 to 15. Finally, although anxiety symptoms as early as age 9 were significantly associated with later depression for females, anxiety symptoms did not emerge as a significant risk for males until age 15. 1160
Discussion The current study, using a broad array of self-report and. parent-report measures and school records from a 14-year prospective study, identified risks from infancy and early childhood that are antecedents for major depression at age 18. The study also revealed differences in the patterns of psychosocial risks for males and females. Gender Differences in Prevalence and Onset Females in the current sample were three times as likely as males to have developed major depression by age 18, f. Am. Acad. Child Adolesc. Psychiatry, 32:6, November 1993
RISKS FOR DEPRESSION IN LATE ADOLESCENCE
and also reported a significantly earlier onset than males. Both these findings are consistent with previous research (Burke et al., 1990; Kashani et al., 1987; Sorenson et al., 1991). Health Problems
A striking finding in the current study was the significant association between neonatal health problems and major depression at age 18 for males. Cohen et al. (1989) also found that mother reports of postnatal and early childhood illness and injury were significantly related to major depression in late childhood and adolescence. In explaining the long-term effects of neonatal and childhood illness, researchers have speculated that parent-child interactions may be compromised by these illnesses (Cohen et al., 1989; Gizynski and Shapiro, 1990). Evidence from the current study suggests that neonatal health problems may have fostered a greater dependence of boys on their mothers. At age 5, males who had experienced neonatal health problems were rated by their mothers as being significantly more dependent than males without neonatal health problems (t = 2.7, df = 163, p < 0.01). Dependence at age 5 was in tum significantly related to major depression at age 18. For females, the later onset of health problems (between ages 10-15) was significantly related to major depression. There is support from other studies about the association between health problems and depressive symptoms or disorderin late childhood and adolescence (Jacobsen et al., 1983; Katon and Sullivan, 1990; Wells et al., 1985). Family Factors
Family factors played a significant role as risks for major depression for both genders. For females, the family configuration present at birth (birth order, parents' ages, and number of siblings) was a significant risk for major depression in late adolescence. Previous research findings on the link between these family factors and depressive disorders or symptoms are mixed (Birtchnell, 1972; Gates et al., 1986; Munro, 1966). Recent research may explain why early family structure is related to later depression in terms of its impact on parent-child relationships. Adolescents with a larger number of siblings or who are later in the birth order have reported significantly less closeness to their parents and tend to perceive their parents as less reasonable, less supportive, and more punitive (Bell and Avery, 1985; Kidwell, 1981). Consistent with this explanation, females in the current study who subsequently developed major depression also had significantly poorer perceptions of their role in the family at age 9 than did their nondepressed counterparts. Depressed males also had poorer perceptions of their role in the family at age 9 than did nondepressed males. However, unlike females, depressed males were significantly more likely than nondepressed males to have experienced both serious family arguments and violence between ages 10 and 15 years. Other researchers have documented an association between family conflict or aggressive means of handling family conflict and depression (Kashani et al., 1988; Robertson and Simons, 1989). J. Am. Acad. Child Adolesc. Psychiatry, 32:6, November 1993
Parental separation or divorce was not a significant risk for major depression for either gender, but the remarriage of a parent was significantly related to major depression for males. Although the link between parental divorce and children's later behavior and emotional problems has been widely studied (Fendrich et al., 1990; Hetherington et al., 1985; McLeod, 1991), considerably less attention has been directed toward the effects of remarriage of parents. Consistent with the current study, Velez et al. (1989) found that the presence of a stepfather in the home was marginally related to major depression. Unpopularity and Low Self-Esteem
Perceived unpopularity or poor social skills consistently have been identified as risks for depressive disorders and symptomatology (Battle, 1987; Jacobsen et al., 1983; Lewinsohn et al., 1988). Similarly, low self-esteem is a wellknown correlate of depressive symptoms or disorders (Allgood-Merten et al., 1990; Dean and Ensel, 1983; Fleming and Offord, 1990; Reinherz et al., 1989; Simons and Miller, 1987). As hypothesized, and in agreement with this previous research, the current study found a significant relationship between perceptions of unpopularity and major depression for both genders. Overall self-concept was also significantly lower for depressed than for nondepressed females. However, whereas previous studies linked current unpopularity or low self-esteem to current depressive symptoms, the present study revealed that these risk factors preceded the onset of major depression. By as early as age 9, many youth who would subsequently develop major depression in late adolescence were already manifesting feelings of low self-worth or unpopularity. Anxiety Symptoms
The significant co-occurrence of anxiety symptoms or disorders with depressive symptoms or disorders is well established (Clark, 1989; Kashani et al., 1987; Lewinsohn et al., 1988). Beyond confirming this consistent finding, the current study demonstrated that anxiety symptoms precede the onset of major depression. Findings also indicated there are gender differences in when anxiety emerges as a risk for later depression. Females in the current study, compared with males, experienced both an earlier onset of major depression and a corresponding earlier onset of anxiety symptoms. Stressful Life Events
Death of a parent and becoming pregnant were antecedent risks for later major depression for females. Other researchers also found a significant relationship between early loss of a parent and later depression (Finkelstein, 1988; Harris et al., 1986; Lloyd, 1980). Similarly, pregnancy in adolescence has been identified as a significant stressor (Coddington, 1984). SES and Academic Failure
Contrary to expectations, neither family SES nor academic failure at any developmental period was significantly related to major depression. Other studies of children and 1161
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adolescents have yielded mixed findings about the relationship between SES and depression (Bird et al., 1989; Kaplan et al., 1984; Velez et al., 1989) and the link between academic failure and depressive symptoms or disorders (Bird et al., 1989; Costello, 1989; Fleming et al., 1989; Garrison et al., 1989; Kandel and Davies, 1982; Velez et al., 1989).
identified risks requiring attention on the part of mental health professionals. Such early awareness and appropriate intervention may forestall the emergence of a depressive disorder that not only interferes with current functioning but also compromises future well-being. RESEARCH IMPLICATIONS
Limitations
Although the current study provided compelling evidence that risk factors from early childhood are associated with major depression in late adolescence, some limitations should be noted. First, the adolescents were from a predominately white working-class community in the northeast; thus, results may not be generalizable to adolescents in other geographic regions or of other ethnic and racial groups. Second, the small number of male adolescents with major depression provided statistical power to detect only "large" effects (Cohen, 1969) between depressed and nondepressed males. Conversely, a large number of significance tests were conducted in examining the association between individual risk factors and depression, elevating the possible risk of Type I errors. Finally, although most risk factors were measured prospectively, age of onset of depression was based on retrospective reports at age 18 years and may be subject to errors in recall. However, younger subjects, such as those in the current study, may be less prone to errors in recalling the age of onset than older subjects. Farrer et al. (1989) found the reliability of self-reported onset age for depression was better for 18 and 19 year olds than for older adults. CLINICAL IMPLICATIONS
The patterns of psychosocial risk for major depression identified by this study suggest specific points for preventive intervention. The finding of the associated risks of serious illness in infancy and dependence in the preschool years for boys suggests the need for effective counseling, education, and support for parents of seriously ill infants. Hospital personnel can be alerted to the serious mental health risk that major illness poses for the future well-being of children. Parental anxiety dealing with this stressor can result in strain in vital early parent-child relationships. Early intervention can be critical to prevent the development of unhealthy anxious attachment. Health complaints in prepubescent girls also can serve as identifiers of those girls who may be vulnerable to depression. Health professionals, counselors, and teachers should be alerted to these symptoms, particularly as they surface in early adolescence. These youngsters may be candidates for counseling along with appropriate medical treatment. In school settings educators may be in strategic positions to be sensitive to the inner perceptions of potentially depressed children and adolescents. Poor perceptions of selfworth, particularly as a family member, constituted a risk factor for both genders at age 9 years. School-based counseling groups are a possible source of support for these youngsters. Finally, some specific environmental stressors, such as death of a parent and pregnancy for girls, and remarriage of a parent and family conflict for boys, present clearly 1162
The areas of psychosocial risk identified in this study warrant future investigation. Issues linked to the time of onset of depressive disorder are particularly critical for understanding the etiological influence of specific psychosocial variables. It will be important to examine the variation in type of psychosocial risk characteristic of those developing depressive disorder in early adolescence compared with those developing depression in late adolescence. For example, do negative self-perceptions of family role and lower self-concept appear to be characteristics leading to earlier onset than environmental stressors such as parental remarriage? Ultimately, identification of the specific factors relating to earlier and later onset could result in more timely programs of intervention. Although onset of depression is generally earlier for girls than boys, the study of boys with earlier onset and girls with later onset who present deviant patterns should be informative. Examination of this group of youth with larger samples would cast additional light on gender differences. With replication using a larger sample such investigations would add to knowledge of the interplay of psychosocial variables. The present study highlighted the importance of the biological variable of gender as related to prevalence, time of onset, and determination of patterns on psychosocial risk. Future studies also should focus on other biological and genetic factors as well as their interaction with psychosocial factors. Planned research with the study cohort includes a closer examination of family histories of the subjects to attempt to cast additional light on the complex development of major depression. References Achenbach, T. M. & Edelbrock, C. (1987), Manual for the Youth Self-Report and Profile. Burlington, VT: University of Vermont , Department of Psychiatry . Allgood-Merten, B., Lewinsohn , P. M. & Hops, H. (1990), Sex differences and adolescent depression. J. Abnorm. Psychol., 99:55-63 . Anderson, J., Williams, S., McGee , R. & Silva, P. (1989), Cognitive and social correlates of DSM-III disorders in preadolescent children. J. Am. Acad. Child Adolesc. Psychiatry, 28:842-846. Battle, J. (1987), Relationship between self-esteem and depression among children . Psycho/. Rep., 60:1187-1190. Bell, N. J. & Avery, A. W. (1985), Family structure and parentadolescent relationships: does family structure really make a difference? Journal of Marriage and the Family, 11:503-508. Bird, H. R., Gould, M. S., Yager, T., Staghezza, B. & Canino , G. (1989), Risk factors for maladjustment in Puerto Rican children . J. Am. Acad. Child Adolesc. Psychiatry, 28:847-850. Birtchnell, J. (1972), Birth order and mental illness-A control study . Social Psychiatry, 7:167-179 . Block, J. H., Gjerde, P. F. & Block, J. H. (1991), Personality antecedents of depressive tendenc ies in 18-year-olds: a prospective study. J. Pers. Soc. Psycho/., 60:726-738. Burke, K. C., Burke, J. D., Regier, D. A. & Rae, D. S. (1990), Age at onset of selected mental disorders in five community populations. Arch. Gen. Psychiatry, 47:511-518.
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Clark, L. A. (1989), The anxiety and depressive disorders: descriptive psychopathology and differential diagnosis. In: Anxiety and Depression: Distinctive and Overlapping Features, eds: P. C. Kendall & D. Watson. San Diego: Academic Press, pp. 83-129. Coddington, R. D. (1984), Measuring the stressfulness of a child's environment. In: Stress in Childhood, ed: J. H. Humphrey. New York: AMS, pp. 91-127. Cohen, J. (1969), Statistical Power Analysis for the Behavioral Sciences. New York: Academic Press. Cohen, P., Velez, C. N., Brook, J. S. & Smith, J. (1989), Mechanisms of the relation between perinatal problems, early childhood illness,' and psychopathology in late childhood and adolescence. Child Dev., 60:701-709. Costello, E. J. (1989), Child psychiatric disorders and their correlates: a primary care pediatric sample. J. Am. Acad. Child Adolesc. Psychiatry, 28:851-855. Dean, A. & Ensel, W. M. (1983), The epidemiology of depression in young adults: the centrality of social support. Journal ofPsychiatric Treatment and Evaluation, 5:195-207. Farrer, L. A., Florio, L. P., Bruce, M. L., Leaf, P. J. & Weissman, M. M. (1989), Reliability of self-reported age at onset of major depression. J. Psychiatr. Res., 23:35-47. Fendrich, M., Warner, V. & Weissman, M. M. (1990), Family risk factors, parental depression, and psychopathology in offspring. Developmental Psychology, 26:40-50. Finkelstein, H. (1988), The long-term effects of early parent death: a review. J. Clin. Psychol., 44:3-9. Fleming, 1. E. & Offord, D. R. (1990), Epidemiology of childhood depressive disorders: a critical review. J. Am. Acad. ChildAdolesc. Psychiatry, 29:571-580. Fleming, J. E., Offord, D. R. & Boyle, M. H. (1989), Prevalence of childhood and adolescent depression in the Community Ontario Child Health Study. Br. J. Psychiatry, 155:647-654. Garrison, C. Z., Schluchter, M. D., Schoenbach, V. J. & Kaplan, B. K. (1989), Epidemiology of depressive symptoms in young adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 28:343-351. Gates, L., Lineberger, M. R., Crockett, J. & Hubbard, J. (1986), Birth order and its relationship to depression, anxiety, and self-concept test scores in children. J. Genet. Psychol., 149:29-34. Gizynski, M. & Shapiro, V. B. (1990), Depression and childhood illness. Child and Adolescent Social Work, 7:179-197. Gjerde, P. F., Block, J. & Block, J. H. (1988), Depressive symptoms and personality during late adolescence: gender differences in the externalization-internalization of symptom expression. J. Abnorm. Psychol., 97:475-486. Harris, T., Brown, G. W. & Bifulco, A. (1986), Loss of parent in childhood and adult psychiatric disorder: the role of lack of adequate parental care. Psychol. Med., 16:641-659. Hetherington, E. M., Cox, M. & Cox, R. (1985), Long-term effects of divorce and remarriage on the adjustment of children. J. Am. Acad. Child Psychiatry, 24:518-530. Hollingshead, A. G. & Redlich, F. C. (1958), Social Class and Mental Illness. New York: Wiley. Jacobsen, R. H., Lahey, B. B. & Strauss, C. C. (1983), Correlates of depressed mood in normal children. J. Abnorm. Child Psychol., 11:29-40. Kandel, D. B. & Davies, M. (1982), Epidemiology of depressive mood in adolescents. Arch. Gen. Psychiatry, 39:1205-1212. Kaplan, S. L., Hong, G. K. & Weinhold, C. (1984), Epidemiology of depressive symptomatology in adolescents. J. Am. Acad. Child Psychiatry, 23:91-98.
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Kashani,1. H., Beck, N. C., Hoeper, E. W. et al. (1987), Psychiatric disorders in a community sample of adolescents. Am. J. Psychiatry, 144:584-589. Kashani, J. H., Burbach, D. J. & Rosenberg, T. K. (1988), Perception of family conflict resolution and depressive symptomatology in adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 27:42-48. Katon, W. & Sullivan, M. D. (1990), Depression and chronic medical illness. J. Clin. Psychiatry, 51:3-11. Kidwell, J. S. (1981), Number of siblings, sibling spacing, sex, and birth order: their effects on perceived parent-adolescent relationships. Journal of Marriage and the Family, 43:315-332. Leaf, P. J., Myers, J. K. & McEvoy, L. T. (1991), Procedures used in the Epidemiologic Catchment Area study. In: Psychiatric Disorders in America, eds: L. N. Robins & D. A. Regier. New York: The Free Press, pp. 11-32. Lerner, J. A., Inui, T. S., Trupin, E. W. & Douglas, E. (1985), Preschool behavior can predict future psychiatric disorders. J. Am. Acad. Child Psychiatry, 24:42-48. Lewinsohn, P. M., Hops, H., Roberts, R. & Seeley, J. R. (1988), Adolescent Depression: Prevalence and Psychosocial Aspects. Paper presented at the annual meeting of the American Public Health Association, Boston, MA, November. Lloyd, C. (1980), Life events and depressive disorder reviewed. Arch. Gen. Psychiatry, 37:529-535. McLeod,1. D. (1991), Childhood parental loss and adult depression. J. Health Soc. Behav., 32:205-220. Munro, A. (1966), Some familial and social factors in depressive illness. Br. J. Psychiatry, 112:429-441. Piers, E. V. (1984), The Piers-Harris Children's Self-Concept Scale, Revised Manual. Los Angeles: Western Psychological Services. Regier, D. A., Hirschfeld, R., Goodwin, F. K., Burke, J. D., Lazar, J. B. & Judd, L. L. (1988), The NIMH depression awareness, recognition, and treatment program: structure, aims, and scientific basis. Am. J. Psychiatry, 145:1351-1357. Reinherz, H. Z., Giaconia, R. M., Lefkowitz, E. S., Pakiz, B. & Frost, A. K. (1993). Prevalence of psychiatric disorders in a community population of older adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 32:369-377 Reinherz, H. Z. & Gracey, C. A. (1983), The Simmons Behavior Checklist: Technical information. Boston, MA: Simmons College of Social Work. Reinherz, H. Z., Stewart-Berghauer, G., Pakiz, B., Frost, A., Moeykens, B. A. & Holmes, W. M. (1989), The relationship of early risk and current mediators to depressive symptomatology in adolescence. J. Am. Acad. Child Adolesc. Psychiatry, 28:942-947. Robertson, J. F. & Simons, R. L. (1989), Family factors, self-esteem, and adolescent depression. Journal of Marriage and the Family, 51:125-138. Robins, L., Helzer, J., Cottler, L. & Goldring, E. (1989), NIMH Diagnostic Interview Schedule Version III Revised. St. Louis, MO: Washington University, Department of Psychiatry. Rosenberg, M. (1986), Conceiving the Self. Malabar, FL: Basic Books, Inc. Simons, R. L. & Miller, M. G. (1987), Adolescent depression: assessing the impact of negative cognitions and socioenvironmental problems. Soc. Work, 32:326-330. Sorenson, S. B., Rutter, C. M. & Aneshensel, C. S. (1991), Depression in the community: an investigation into age of onset. J. Consult. Clin. Psychol., 59:541-546. Velez, C. N., Johnson, J. & Cohen, P. (1989), A longitudinal analysis of selected risk factors for childhood psychopathology. J. Am. Acad. Child Adolesc. Psychiatry, 28:861-864. Wells, V. E., Deykin, E. Y. & Klerman, G. L. (1985), Risk factors for depression in adolescence. Psychiatr. Dev., 3:83-108.
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Abstract. Objective: An ongoing 14-year longitudinal study examined psychosocia l antecedents of major depression in late adolescence in a communi ty population. Method : Subjects were 385 adolescents followed between the ages of 5 and 18 years. Early health, familial, behavior, academic, and environmental risks for major depression were identified using data collected at ages 5, 9, 15, and 18 years. At age 18, a lifetime diagnosis of major depres sion was assessed using the NIMH Diagnostic Interview Schedule (DIS-III-R ). Results: For males, neonatal health problems, dependence problems at age 5 years, perceived unpopularity and poorer perceptions of their role in the family at age 9 years, remarriage of a parent, early family discord , and anxiety at age 15 years significantly increased the risk of developing major depression. Females with major depression, compared with nondepressed females, had older parents and came from larger families, and at age 9 years had greater perceived unpopularity and anxiety, lower self-esteem, and poorer perceptions of their role in the family. Depressed females also reported ,more stressful life events, including death of parent and pregnanc y. Conclu sions: Underscoring the importance of early psychosocial factors in the later development of major depres sion and pointing to specific risks, our findings can aid in developing strategies for prevention and early intervention. J. Am. Acad. Child Adolesc. Psychiatry, 1993,32, 6:1155-1163. Key Words: depression, adolescents, DSM-IlI-R. Despite increa sing evidence that adolescence is a key period for the onset of major depression (Burke et a!., 1990; Sorenson et aI., 1991) and mounting concern about the individual and social costs of depressive disorders (Regier et aI., 1988), little is known about specific early psychosocial antecedents for major depression as it emerges in adolescence. The identification of specific psychosocial antecedents for major depres sion can play a significant role in targeted early intervention and prevention efforts designed to reduce the severity , duration, and long-term consequences of this disorder. Researchers emphasize that prospective longitudinal studies are essential for determining whether risks for depression actually are antecedents, rather than concomitants or consequences of the disorder (Block et al., 1991; Fleming and Offord, 1990; Robertson and Simons , 1989). However, to date, there are few long-term prospective studies of representative U.S. community populations that span developmental periods from early childhood to late adolescence (Block et al., 1991; Lerner et al., 1985; Velez et al., 1989). Most community studies of depressive disorders in children and adolescents have been cross- sectional and have examined current risks (such as family functioning and recent life events) or broad antecedent risks such as gender (Bird et aI., 1989; Costello, 1989; Kashani et aI., 1987, 1988). Accepted February 5, 1993. The authors are with Simmons College School of Social Work, Boston,' MA. This research was supported by Grant MH41569 from the National Institute of Mental Health. An earlier version of this paper was presented at the annual meeting of the American Public Health Association, November 1992. Reprint requests to Dr. Reinherz; Simmons College School ofSocial Work, 51 Commonwealth Avenue, Boston, MA 02116. 0890-8567/93/3206-1155$03.00/0©1993 by the American Academy of Child and Adolescent Psychi atry. J. Am, Acad. Child Adolesc. Psychiatry, 32:6, November J993
Furthermore, most studies have examined only a few psychosocial factors and have not included sizable single-aged cohorts. The current study was designed to provide much-needed information about early psychosocial antecedents for major depression in late adolescence. The study followed a singleage cohort from ages 5 to 18 years , examining risks from several domains for a DSM-III-R lifetime diagnosis of major depression at age 18. The age of onset of depression was assessed as an additional means of determining which risk factors actually preceded the onset of depression. Risks for Major Depression Recent studies of depressive disorders and symptomatology have identified salient psychosocial risk factors that were included in the current study. Two broad sociodemographic factors, gender and socioeconomic status (SES), have been widely studied as risks for depression in children and adolescents. Most recent studies have reported that at adolescence females are at significantly greater risk than males for depression or depressive symptomatology (Garrison et aI., 1989; Kandel and Davies , 1982; Kashani et al., 1987; Reinherz et aI., 1989). However, there is mixed evidence about the relationship between family SES and depression in children and adolescents (Fleming and Offord, 1990; Kaplan et aI., 1984). Several family factors have been explored as risks for depressive disorders and symptomatology. Studies of family compo sition, such as birth order and number of siblings (Birtchnell, 1972; Gates et al., 1986; Munro , 1966), as well as changes in family composition due to parental divorce or remarriage (Fendrich et aI., 1990; McLeod, 1991; Velez et al., 1989) have yielded conflicting findings. In contrast, poor family functioning, ranging from perceived lack of closeness to parents to extreme family conflict and violence, consistently has been identified as a correlate of depressive
[[55
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disorders and symptomatology (Fleming and Offord, 1990; Kandel and Davies, 1982; Kashani et aI., 1988; Robertson and Simons, 1989). Other risk factors for depression cover several domains. Neonatal and early childhood health problems (Cohen et aI., 1989) as well as later health problems (Katon and Sullivan, 1990; Wells et aI., 1985) have been linked to depressive disorders and symptomatology. Undesirable life events, especially those representing significant losses such as early death of a parent have also been identified as significant risks for later depression (Finkelstein, 1988; Harris et aI., 1986; Lloyd, 1980). There is contradictory evidence about whether academic failure is associated with depressive symptoms or disorders in childhood and adolescence (fleming and Offord, 1990). The link between preschool personality characteristics and behavior and depression in adolescence has been demonstrated in recent longitudinal studies (Block et aI., 1991; Lerner et aI., 1985). Later concurrent behavioral and emotional characteristics also are significantly related to depression, particularly self-esteem (Dean and Ensel, 1983; Fleming and Offord, 1990; Kandel and Davies, 1982; Simons and Miller, 1987), anxiety (Clark, 1989; Kashani et aI., 1987; Lewinsohn et aI., 1988), and perceived unpopularity or lack of social skills (Anderson et aI., 1989; Jacobsen et aI., 1983; Lewinsohn et aI., 1988). Method
The primary purpose of the current investigation was to identify, separately for each gender, specific psychosocial risks that are antecedents of major depression in late adolescence in a community population. Hypothesized early risks for major depression included family SES and composition, poor family relations, health problems, academic failure, behavioral and emotional characteristics, and undesirable life events. Using multiple informants (subjects, parents, teachers) and a variety of measures, data were collected at four major timepoints: when subjects were age 5 years (1977), age 9 years (1981), age 15 years (1987) and age 18 years (1990). A diagnosis of major depression and age of onset were assessed at age 18 years; risk factors were evaluated at the three previous timepoints (ages 5, 9, and 15 years). Parents (usually mothers) completed questionnaires and/or interviews when the subjects were 5, 9, and 15 years old. Mothers furnished histories of their children's health from the prenatal period to age 5 years. The subjects completed standardized questionnaires at 9 years old and were interviewed at ages 15 and 18 years. Teacher comments and school records of grades and grade retentions covered the period from age 6 to age 15 years. SAMPLE
The 385 adolescents were participants in an ongoing 14year longitudinal panel study that began in 1977 when these youth entered kindergarten in a representative working-class community in the Northeastern United States (Reinherz et al., 1989, 1993). In 1990, when subjects were last interviewed, most were seniors in high school, with a mean age 1156
of 17.9 years. The sample included 195 males and 190 females. Almost all (99%) of the adolescents were white, and the SES of their households continued to be predominantly working or lower-middle class (Reinherz et aI., 1993). Between 1977 and 1990, attrition occurred primarily in the transition from kindergarten to first grade when students transferred from the public school system to parochial schools. Nonetheless, over 74% of subjects who contined in the public school system through third grade remained in the study at age 18 years. In 1990, 96% of the 404 subjects interviewed in 1987 participated. At each major data collection wave, analyses verified that youth who continued to participate did not differ from nonparticipants on key demographic, academic, behavioral, or emotional factors (see Reinherz et aI., 1993, for additional detail). MEASURES
Major Depression
The NIMH Diagnostic Interview Schedule, Version III-R (DIS-III-R) (Robins et aI., 1989) provided a lifetime diagnosis of major depression according to DSM-III-R criteria, as well as age of onset. The DIS-III-R, a highly structured interview that may be administered by trained lay interviewers, was designed for use in epidemiological studies of psychiatric disorders. Validity studies of the original version of the DIS showed significant agreement between DIS diagnoses and other measures, including interviews by psychiatrists (Leaf et aI., 1991). In the current study the impairment of adolescents meeting DSM-III-R criteria for major depression was assessed additionally by comparing them with their nondepressed counterparts on three selfreport measures of functioning at age 18 years. The Youth Self Report (YSR) (Achenbach and Edelbrock, 1987) provided an index of total emotional and behavior problems, self-esteem was measured by the standardized Rosenberg Self-Esteem Scale (Rosenberg, 1986), and interpersonal problems were assessed by a scale created by project staff with an a. reliability of 0.75 (Reinherz et aI., 1993). Age of onset of major depression, using the DIS-III-R, was the youngest age reported by subjects for any depressive episode. The test-retest reliability of self-reported age of onset of major depression has been found to be excellent, particularly for younger subjects (Farrer et al., 1989). Age of onset was used in the current study to verify whether risks preceded the onset of major depression. The DIS-III-R was administered to the adolescents in 1990 (at age 18 years) by 10 trained interviewers with research or clinical experience. The training and monitoring of the interviewers (Reinherz et aI., 1993) resulted in high fidelity to DIS-III-R interview procedures. Risks for Major Depression
The psychosocial risk factors examined were those identified in previous studies of depressive disorders or symptomatology. Most risk factors were measured prospectively and covered the time period from birth to age 15 years. Family SES. Family SES was determined at ages 5, 9, and 15 years using the Hollingshead two-factor index of J.Am. Acad. Child Ado/esc. Psychiatry, 32:6, November 1993
RISKS FOR DEPRESSION IN LATE ADOLESCENCE
social position (Hollingshead and Redlich, 1958). The five Hollingshead categories were collapsed to two: "higher SES" (highest three categories) and "lower SES" (lowest two categories). Family Structure/Composition. Six risk factors described family composition. (1) Birth order (3rd or later), (2) older mother (30 or older at birth of subject), (3) older father (35 or older at birth of subject), and (4) larger family size (four or more children) were taken from the mother interview (age 5 years). These definitions of older parents were based on the distribution of parents' ages in the sample and represent the highest quartile. (5) Separation or divorce of parents and (6) remarriage of parents were determined from mother and subject interviews at several timepoints. Family Relations/Functioning. Two indices of family relations covered the period from ages 9 to 15 years. (1) The subject's perception of role in the family was constructed from seven "family-related" items in the Piers-Harris Children's Self Concept Scale (Piers, 1984), completed by subjects at age 9 years. This index included items such as " I am a disappointment to my family," and had an a reliability of 0.54. (2) Family arguments and violence (between ages 10 and 15 years) was based on parent and subject interviews. Items asked about the occurrence of increased arguments and violence between parents and between the subject and parents. This risk factor was coded as present if there was evidence of both family arguments and violence. Health Problems. Four indicators of health problems across birth to age 15 years were constructed. (1) Neonatal health problems was based on mothers' reports at the age 5 interview of any of six conditions immediately after birth: jaundice, turning blue, breathing difficulties, infections, birth injuries, or birth defects. (2) Illnesses and hospitalizations (birth to age 5), also from the age 5 years mother interview, was coded as positive if the child experienced one or more serious illnesses or two or more hospitalizations before age 6. (3) Onset of health problems (ages 6 to 9 years) and (4) onset of health problems (ages 10 to 15 years) were based on subject's report of any health problems that interfered "much" or "all of the time." Health problems included disorders such as heart disease, diabetes, asthma, as well as illnesses such as mononucleosis or venereal disease, and physical injuries. Behavior and Emotional Characteristics. Nine indicators, covering ages 5 to 15 years, were taken from mother reports on the Simmons Behavior Checklist (SBCL) (Reinherz and Gracey, 1983), and self-reports on the Piers-Harris Children's Self Concept Scale (Piers, 1984). The SBCL provided mother reports at ages 5, 9, and 15 years ofbehavior problems in areas such as dependence, shyness, and anxiety. SBCL scales have demonstrated acceptable internal consistency and test-retest reliability, as well as construct validity (Reinherz and Gracey, 1983; Reinherz et aI., 1989). The Piers-Harris, a standardized 80-item self-report measure for youth aged 8 to 18 years, provided subjects' selfperceptions of anxiety, popularity, and overall self-concept. The reliability and validity of the Piers-Harris are welldocumented (Piers, 1984). J. Am.Acad. Child Adolesc. Psy chiatry, 32:6, November 1993
(1) Dependence, (2) shyness, and (3) fear of new things were scales of SBCL completed by mothers during the age 5 interview. (4) Self-rated anxiety at age 9 and (5) self-rated anxiety at age 15 were the anxiety cluster scores of PiersHarris, with higher scores indicating higher levels of anxiety. (6) Perceived unpopularity at age 9 years was the popularity cluster score of the Piers-Harris; higher scores indicated more perceived unpopularity. (7) Overall self-concept at age 9 was the total score on the Piers-Harris. (8) Mother-rated anxiety at age 9, and (9) mother-rated anxiety at age 15 were taken from the SBCL. Academic Failure. Teacher ratings and school records provided four indices of academic failure. (1) Poor academic performance at age 9 was based on teacher ratings of overall academic achievement in grade 3. (2) Ds and Fs in English and math in grades 5 to 9 were taken from school records. This risk factor was considered to be present if 25% or more of course grades were Ds or Fs. (3) Grade retentions (ages 6 to 9) and (4) grade retentions (ages 10 to 15) were determined from school records. Stressful Life Events. Two stressful life events occurring by age 15 (1) death of parent and (2) pregnancy (for females) were identified from parent and subject interviews at several timepoints. ANALYSES
Analyses focused on the relationship between individual risk factors from several developmental periods and depression in late adolescence. For most analyses, risk factors were grouped into three broad time frames: (1) birth to age 5 years, (2) age 6 to age 9, and (3) age 10 to age 15. Analyses were conducted separately for males and females because there is substantial evidence of gender differences in risk factors for depressive disorders and symptomatology (Block et aI., 1991; Gjerde et aI., 1988; McLeod, 1991). For each gender, the relationship of individual risk factors to major depression was assessed through chi-square tests of independence (for dichotomous risk factors) or t tests for independent samples (for continuous risk measures). Odds ratios were calculated to summarize the relative risk of subsequently developing major depression if each risk factor was present. For risks originally measured as continuous variables, these odds ratios reflected the risk associated with extreme scores (highest quartile). Results
Thirty-six (9.4%) of the 385 adolescents met DSM-IlI-R lifetime criteria for major depression at age 18 years. These 36 adolescents, compared with their nondepressed counterparts, also demonstrated impaired functioning on overall emotional and behavioral problems (YSR total score, t = 5.67, df = 383, P < 0.001), interpersonal problems (t = 5.42 , df = 383, P < 0.001), and self-esteem (Rosenberg scale, t = -5.02, df = 383, p < 0.001). Furthermore, more than 58% of the depressed adolescents reported suicidal ideation, and 22% indicated they had attempted suicide. There were significant gender differences in both the lifetime prevalence and age of onset of major depression (Table 1). Females were three times as likely as males to meet 1157
REINHERZ ET AL.
lifetime criteria for major depression by age 18 (X2 = 8.3, df = 1, p < 0.01). Females also experienced significantly earlier onset than did their male counterparts (t = 2.1, df = 34, p < 0.05); 40% of depressed females versus only 10% of depressed males reported onset before age 15 years. These ages of onset also indicated that risks up to age 15 seemed to antedate the onset of depression for almost all depressed males. In contrast, for females, all risk factors occurring before age 10 years could be considered to precede the onset of depression. More detailed analyses were conducted to ascertain whether significant risk factors between ages 10 and 15 were antecedents for depression for those females with onset of depression before age 15. These analyses are reported in the text.
their role in the family (t = 3.0, df = 172, p < 0.01). Between ages 10 and 15 years, depressed males were nine times as likely as nondepressed males to have experienced both increased family arguments and family violence (X2 = 14.8, df = 1, p < 0.001). Finally, remarriage of a parent before the child reached age 15 was a significant risk for later depression (X2 = 4.3, df = 1, p < 0.05). Males with major depression also demonstrated significantly poorer perceptions of their popularity at age 9 (t = 2.0, df = 172, p < 0.05). Although anxiety at age 9 did not differ significantly between depressed and nondepressed males, by age 15 both self-rated anxiety (t = 2.1, df = 178, p < 0.05) and mother-rated anxiety (t = 2.0, df = 189, p < 0.05) emerged as significant risks for major depression at age 18 years.
RISKS FOR MAJOR DEPRESSION
For both males and females, risk factors from as early as birth covering most of the psychosocial domains studied were significantly related to major depression at age 18 (Tables 2 and 3). However, there was little overlap in specific risks for males and females, and there were noteworthy differences in the ages at which groups of factors emerged as significant risks. Risks f or Males
For males, several risks occurring before age 6 years predicted a lifetime diagnosis of major depression at age 18. Depressed males were 10 times as likely as nondepressed males to have experienced neonatal health problems (X2 = 16.2, df = 1, p < 0.001), and were seven times more likely to have had serious illness and hospitalizations before age 6 (X2 = 10.3, df = 1, p < 0.001). At age 5, depressed males were rated by their mothers as having significantly more problems with dependence than were nondepressed males (r = 2.1, df = 181, p < 0.05). A pattern of troubled family relations across developmental periods also characterized males with major depression. At age 9, compared with their nondepressed counterparts, depressed males had poorer perceptions of T ABL E
I. Gender Differences in Lifetime Prevalence and Age of Onset of Major Depression
Males
Females
Major Depression
n
%
n
%
Lifetime prevalence** Age of onset* 9-10 11-1 2 13-14 15-16 17-1 8
10
5.1
26
13.7
0 0 1 6 3
0.0 0.0 10.0 60.0 30.0
1 4 5 13 3
3.8 15.4 19.2 50.0 1l .5
Note: Percentages for lifetime prevalence based on total sample sizes: males = 195; females = 190. Percentages for age of onset categories based on only those with major depression: males = 10; females = 26. * p < 0.05 for t test of differences in average of onset, ** p < 0.01 for chi-square test of independence.
1158
Risks for Females
As was true for males, for females risks from as early as birth were significantly related to developing major depression in late adolescence. Four factors characterizing family structure at birth were related to major depression: being third or later in the birth order (X2 = 9.6, df = 1, p < 0.01), having a mother 30 years old or older (X2 = 6.0, df = 1, p < 0.01), a father 35 or older (X2 = 7.7, df = 1, p < 0.01), and three or more siblings (X2 = 5.3, df = 1, p < 0.05). These four risk factors were significantly intercorrelated (between 0.56 and 0.85) and embody a particular family constellation rather than distinct risks. In addition to family composition, poorer perceptions of role in the family at age 9 years was significantly related to major depression at age 18 (t = 2.1, df = 173, p < 0.05). Several early emotional and behavioral characteristics that preceded the onset of depression differed between depressed and nondepressed females. At 9 years old, girls who subsequently developed major depression held poorer perceptions of their popularity (t = 1.9, df = 173, p < 0.05), and had lower overall self-esteem (t = 2.2, df = 173, P < 0.05). Self-rated anxiety at age 9 was also significantly related to major depression at age 18 (t = 1.8, df = 173, p < 0.05). Anxiety at age 15 as a risk was examined only for those females whose depression occurred after age 15. Considering just those depressed females with onset of depression at age 16 or later (n = 9), both self-rated anxiety at age 15 (t = 3.82, df = 167, p < 0.001) and mother-rated anxiety at age 15 (t = 2.39, df = 169, p < 0.02) were significant antecedent risks when compared with nondepressed females. Although early health problems (up to age 9) did not differ between depressed and nondepressed girls, the onset of health problems between ages 10 and 15 was a significant antecedent risk for later depression. Females with onset of depression after age 15 were more than five times more likely than were nondepressed females to report the onset of health problems that interfered most or all of the time with their daily functioning (X2 = 7.8, df = 1, p < 0.005). These health problems included respiratory disorders, mononucleosis, arthritis, and headaches. Two undesirable life events were significantly related to major depression for females. Depressed females were seven J. Am. Acad. Child Adolesc. Psychiatry, 32:6, Nov emb er 1993
RISKS FOR DEPRESSION IN LATE ADOLESCENCE TABLE
2. Risk Factors for Major Depression at Age 18 Years for Males Major Depression (n = l O)"
Risk Factor Lower family socioeconomic status Age 5 years Age 9 years Age 15 years Family structure/composition Birth order (3rd or later) Older mother (30+ at birth of subject) Older father (35+ at birth of subject) Larger family size (4+ children) Parents separated or divorced (ages 0-15 years) Parent remarried (ages 0-15 years) Family relations/functioning Poorer perception of family role (age 9 years) Family arguments + violence (ages 10-15 years) Health problems Neonatal health problems Illness or hospitalization (ages 0-5 years) Onset serious health problem (ages 6-9 years) Onset serious health problem (ages 10-15 years) Academic failure Poor academic performance (teacher rated) (age 9 years) Retained in grade (ages 6-9 years) Ds and Fs (course grades) (ages 11-15 years) Retained in grade (ages 10-15 years) Life events before age 15 years Parent died
Ratio"
95% Confidence Interval
3.8 4.1 3.8
1.55 0.35 0.65
0.4-5.7 0.1-1.7 0.2-2.4
38.3 33.0 21.7 26.6 29.3 15.1
3.6 3.5 3.1 3.3 3.4 2.6*
0.69 0.51 0.40 0.69 1.60 3.74
0.2-2.8 0.1-2.5 0.1-3.3 0.1-3.4 0.4-5.9 1.0-14.1
16.3 16.7
22.0 9.7
3.2** 2.2***
5.33' 9.28
1.4-19.9 2.4-35.1
60.0 55.6 0.0 0.0
16.3 17.6
12.7 14.7 3.2 11.9
2.6*** 2.7*** 1.3 2.4
10.29 7.26
2.7-39.5 1.8-28.8
37.5 0.0 20.0 0.0
18.3
22.1 10.6 25.1 5.0
3.3 2.3 3.4 1.6
2.12
0.5-9.3
0.74
0.2-3.6
5.9
1.7
Odds Ratio'
95% Confidence Interval
5.10 1.88 1.92 1.84 2.09 3.00 0.83 4.23 5.12
1.2-21.2 0.5-7.6 0.5-7.1 0.5-7.5 0.6-7.6 0.9-10.9 0.2-4.1 1.1-16.5 1.4-19.0
%
Standard Error
%
60.0 20.0 40.0
16.3 13.3 16.3
49.2 41.8 50.6
30.0 20.0 10.0 20.0 40.0 40.0
15.3 13.3 10.0 13.3 16.3 16.3
60.0 50.0
13.3
0.0 Major Depression (n = l O)"
Behavioral/emotional characteristics Dependence (mother rated) (age 5 years) Shyness (mother rated) (age 5 years) Fear of new things (mother rated) (age 5 years) Anxiety (self-rated) (age 9 years) Anxiety (mother rated) (age 9 years) Unpopularity (self-rated) (age 9 years) Overall self-concept (self-rated) (age 9 years) Anxiety (self-rated) (age 15 years) Anxiety (mother rated) (age 15 years)
No Depression (n = 185)a Standard Error
Odds
No Depression (n = 185)a
Mean
Standard Deviation
Mean
Standard Deviation
7.89 5.60 4.10 4.00 11.50 5.60 54.50 4.22 8.60
1.90 1.90 1.45 2.49 2.92 2.46 12.17 2.95 3.47
6.76 5.00 3.95 3.18 10.42 4.02 58.99 2.28 7.02
1.59* 1.67 1.32 2.66 3.02 2.45* 11.36 2.68* 2.35*
Note: a ns vary slightly for risks due to missing data; b depressed vs. nondepressed odds ratio for presence of risk factor; 'depressed vs. nondepressed odds ratio for scoring in highest quartile on measure (lowest quartile for self-concept). * p < 0.05; ** P < 0.01; *** P < 0.001, one-tailed.
times as likely as nondepressed females to have experienced the death of a parent before age 15 (X2 = 6.9, df = 1, p < 0.01). In all cases, parent death occurred either earlier or at the same age as the reported onset of depression. Depressed females were also 13 times more likely to have become pregnant by age 15 (X2 = 7.2, df = 1, p < 0.01). None of these early pregnancies were carried to term, and the pregnancy preceded the reported age of onset of depression for all adolescents. Gender Similarities and Differences in Risks There were a few noteworthy similarities between males and females in risks. For both genders, a poorer perception J. Am. Acad. Child Adolesc. Psychiatry, 32:6, November 1993
of their role in the family at age 9 and greater perceived unpopularity at age 9 were associated with major depression in late adolescence. There were many differences in specific risks; a particularly striking one was death of a parent. Males were twice as likely as females in the total sample to have experienced the death of a parent before age 15 (5.9% versus 3.2%). However, none of the males whose parent died developed major depression by age 18, whereas half the females experiencing this loss did. Also striking were differences between males and females in the ages at which factors emerged as significant risks. 1159
REINHERZ ET AL. TABLE
3. Risk Factors for Major Depression at Age 18 Years for Females Major Depression (n = 26)a
Risk Factor Lower family socioeconomic status Age 5 years Age 9 years Age 15 years Family structure/composition Birth order (3rd or later) Older mother (30+ at birth of subject) Older father (35+ at birth of subject) Larger family size (4+ children) Parents separated or divorced (ages 0-15) Parent remarried (ages 0-15) Family relations/functioning Poorer perception of family role (age 9 years) Family arguments + violence (ages 10-15 years) Health problems Neonatal health problems Illness or hospitalization (ages 0-5 years) Onset serious health problem (ages 6-9 years) Onset serious health problem (ages 10-15 years)" Academic failure Poor academic performance (teacher rated) (age 9 years) Retained in grade (ages 6-9 years) Ds and Fs (course grades) (ages 11-15 years) Retained in grade (ages 10-15 years) Life events before age 15 years Parent died Subject became pregnant
Behavioral/emotional characteristics Dependence (mother rated) (age 5 years) Shyness (mother rated) (age 5 years) Fear of new things (mother rated) (age 5 years) Anxiety (self-rated) (age 9 years) Anxiety (mother rated) (age 9 years) Unpopularity (self-rated) (age 9 years) Overall self-concept (self-rated) (age 9 years) Anxiety (self-rated) (age 15 years)" Anxiety (mother rated) (age 15 years)"
No Depression (n = l64)a
95% Confidence Interval
%
Standard Error
%
57.7 34.8 53.8
9.9 10.2 10.0
51.0 50.4 50.0
4.0 4.4 4.0
1.31 0.53 1.17
0.6-3.0 0.2-1.3 0.5-2.7
61.5 50.0 48.0 46.2 19.2 15.4
9.7 10.0 10.2 10.0 7.9 7.2
30.4 26.4 21.9 24.4 29.3 11.0
3.7** 3.5** 3.3** 3.4* 3.6 2.4
3.67 2.79 3.29 2.66 0.58 1.47
1.6-8.7 1.2-6.5 1.4-7.6 1.1-6.2 0.2--4.8 0.5--4.8
30.8 11.5
9.2 6.4
15.4 9.8
3.0* 2.3
2.43' 1.21
0.9-6.3 0.3--4.5
8.7 15.4 7.7 60.0
6.0 7.2 5.3 16.3
13.8 21.8 6.1 21.3
2.9 3.3 1.9 3.2**
0.60 0.65 1.28 5.53
0.1-2.7 0.2-2.0 0.3-6.2 1.5-20.7
13.6 7.7 16.7 0.0
7.5 5.3 7.8
14.3 5.5 16.0 3.7
2.8 1.8 3.0 1.5
0.95 1.43 1.05
0.3-3.5 0.3-7.0 0.3-3.3
11.5 7.7
6.4 5.3 Major Depression (n = 26)a
Standard Error
1.8 1.0** 0.6 0.6** No Depression (n = l64)a
Mean
Standard Deviation
Mean
Standard Deviation
6.76 5.00 3.80 4.69 10.57 4.27 57.54 8.44 10.22
1.79 1.55 1.16 2.91 3.12 3.01 14.21 4.13 4.12
6.64 5.01 3.88 3.58 9.84 3.30 62.94 4.13 7.77
1.71 1.74 1.36 2.84* 3.12 2.37* 10.77* 3.25*** 2.94*
Odds Ratio"
7.00 13.58
1.3-36.8 1.2-155.0
Odds Ratio'
95% Confidence Interval
1.30 1.21 0.80 1.24 2.94 2.76 3.13 7.45 4.54
0.5-3.4 0.4-3.6 0.3-2.1 0.5-3.4 1.1-7.9 1.1-6.9 1.3-7.4 1.9-29.8 1.2-17.8
Note: a ns vary slightly for risks due to missing data; b depressed vs. nondepressed odds ratio for presence of risk factor; 'depressed vs. nondepressed odds ratio for scoring in highest quartile on measure (lowest quartile for self-concept); d only females with onset of depression after age 15 years (n = 10) were included in these analyses. * p < 0.05; ** p < 0.01; *** p < 0.001, one-tailed.
For females, the family constellation present at birth was significantly related to depression in late adolescence. In contrast, for males, later shifts in family structure, particularly the remarriage of a parent, were linked to depression. Also, whereas health problems immediately after birth were related to depression in adolescence for males, health did not become a significant risk for females until ages 10 to 15. Finally, although anxiety symptoms as early as age 9 were significantly associated with later depression for females, anxiety symptoms did not emerge as a significant risk for males until age 15. 1160
Discussion The current study, using a broad array of self-report and. parent-report measures and school records from a 14-year prospective study, identified risks from infancy and early childhood that are antecedents for major depression at age 18. The study also revealed differences in the patterns of psychosocial risks for males and females. Gender Differences in Prevalence and Onset Females in the current sample were three times as likely as males to have developed major depression by age 18, f. Am. Acad. Child Adolesc. Psychiatry, 32:6, November 1993
RISKS FOR DEPRESSION IN LATE ADOLESCENCE
and also reported a significantly earlier onset than males. Both these findings are consistent with previous research (Burke et al., 1990; Kashani et al., 1987; Sorenson et al., 1991). Health Problems
A striking finding in the current study was the significant association between neonatal health problems and major depression at age 18 for males. Cohen et al. (1989) also found that mother reports of postnatal and early childhood illness and injury were significantly related to major depression in late childhood and adolescence. In explaining the long-term effects of neonatal and childhood illness, researchers have speculated that parent-child interactions may be compromised by these illnesses (Cohen et al., 1989; Gizynski and Shapiro, 1990). Evidence from the current study suggests that neonatal health problems may have fostered a greater dependence of boys on their mothers. At age 5, males who had experienced neonatal health problems were rated by their mothers as being significantly more dependent than males without neonatal health problems (t = 2.7, df = 163, p < 0.01). Dependence at age 5 was in tum significantly related to major depression at age 18. For females, the later onset of health problems (between ages 10-15) was significantly related to major depression. There is support from other studies about the association between health problems and depressive symptoms or disorderin late childhood and adolescence (Jacobsen et al., 1983; Katon and Sullivan, 1990; Wells et al., 1985). Family Factors
Family factors played a significant role as risks for major depression for both genders. For females, the family configuration present at birth (birth order, parents' ages, and number of siblings) was a significant risk for major depression in late adolescence. Previous research findings on the link between these family factors and depressive disorders or symptoms are mixed (Birtchnell, 1972; Gates et al., 1986; Munro, 1966). Recent research may explain why early family structure is related to later depression in terms of its impact on parent-child relationships. Adolescents with a larger number of siblings or who are later in the birth order have reported significantly less closeness to their parents and tend to perceive their parents as less reasonable, less supportive, and more punitive (Bell and Avery, 1985; Kidwell, 1981). Consistent with this explanation, females in the current study who subsequently developed major depression also had significantly poorer perceptions of their role in the family at age 9 than did their nondepressed counterparts. Depressed males also had poorer perceptions of their role in the family at age 9 than did nondepressed males. However, unlike females, depressed males were significantly more likely than nondepressed males to have experienced both serious family arguments and violence between ages 10 and 15 years. Other researchers have documented an association between family conflict or aggressive means of handling family conflict and depression (Kashani et al., 1988; Robertson and Simons, 1989). J. Am. Acad. Child Adolesc. Psychiatry, 32:6, November 1993
Parental separation or divorce was not a significant risk for major depression for either gender, but the remarriage of a parent was significantly related to major depression for males. Although the link between parental divorce and children's later behavior and emotional problems has been widely studied (Fendrich et al., 1990; Hetherington et al., 1985; McLeod, 1991), considerably less attention has been directed toward the effects of remarriage of parents. Consistent with the current study, Velez et al. (1989) found that the presence of a stepfather in the home was marginally related to major depression. Unpopularity and Low Self-Esteem
Perceived unpopularity or poor social skills consistently have been identified as risks for depressive disorders and symptomatology (Battle, 1987; Jacobsen et al., 1983; Lewinsohn et al., 1988). Similarly, low self-esteem is a wellknown correlate of depressive symptoms or disorders (Allgood-Merten et al., 1990; Dean and Ensel, 1983; Fleming and Offord, 1990; Reinherz et al., 1989; Simons and Miller, 1987). As hypothesized, and in agreement with this previous research, the current study found a significant relationship between perceptions of unpopularity and major depression for both genders. Overall self-concept was also significantly lower for depressed than for nondepressed females. However, whereas previous studies linked current unpopularity or low self-esteem to current depressive symptoms, the present study revealed that these risk factors preceded the onset of major depression. By as early as age 9, many youth who would subsequently develop major depression in late adolescence were already manifesting feelings of low self-worth or unpopularity. Anxiety Symptoms
The significant co-occurrence of anxiety symptoms or disorders with depressive symptoms or disorders is well established (Clark, 1989; Kashani et al., 1987; Lewinsohn et al., 1988). Beyond confirming this consistent finding, the current study demonstrated that anxiety symptoms precede the onset of major depression. Findings also indicated there are gender differences in when anxiety emerges as a risk for later depression. Females in the current study, compared with males, experienced both an earlier onset of major depression and a corresponding earlier onset of anxiety symptoms. Stressful Life Events
Death of a parent and becoming pregnant were antecedent risks for later major depression for females. Other researchers also found a significant relationship between early loss of a parent and later depression (Finkelstein, 1988; Harris et al., 1986; Lloyd, 1980). Similarly, pregnancy in adolescence has been identified as a significant stressor (Coddington, 1984). SES and Academic Failure
Contrary to expectations, neither family SES nor academic failure at any developmental period was significantly related to major depression. Other studies of children and 1161
REINHERZ ET AL.
adolescents have yielded mixed findings about the relationship between SES and depression (Bird et al., 1989; Kaplan et al., 1984; Velez et al., 1989) and the link between academic failure and depressive symptoms or disorders (Bird et al., 1989; Costello, 1989; Fleming et al., 1989; Garrison et al., 1989; Kandel and Davies, 1982; Velez et al., 1989).
identified risks requiring attention on the part of mental health professionals. Such early awareness and appropriate intervention may forestall the emergence of a depressive disorder that not only interferes with current functioning but also compromises future well-being. RESEARCH IMPLICATIONS
Limitations
Although the current study provided compelling evidence that risk factors from early childhood are associated with major depression in late adolescence, some limitations should be noted. First, the adolescents were from a predominately white working-class community in the northeast; thus, results may not be generalizable to adolescents in other geographic regions or of other ethnic and racial groups. Second, the small number of male adolescents with major depression provided statistical power to detect only "large" effects (Cohen, 1969) between depressed and nondepressed males. Conversely, a large number of significance tests were conducted in examining the association between individual risk factors and depression, elevating the possible risk of Type I errors. Finally, although most risk factors were measured prospectively, age of onset of depression was based on retrospective reports at age 18 years and may be subject to errors in recall. However, younger subjects, such as those in the current study, may be less prone to errors in recalling the age of onset than older subjects. Farrer et al. (1989) found the reliability of self-reported onset age for depression was better for 18 and 19 year olds than for older adults. CLINICAL IMPLICATIONS
The patterns of psychosocial risk for major depression identified by this study suggest specific points for preventive intervention. The finding of the associated risks of serious illness in infancy and dependence in the preschool years for boys suggests the need for effective counseling, education, and support for parents of seriously ill infants. Hospital personnel can be alerted to the serious mental health risk that major illness poses for the future well-being of children. Parental anxiety dealing with this stressor can result in strain in vital early parent-child relationships. Early intervention can be critical to prevent the development of unhealthy anxious attachment. Health complaints in prepubescent girls also can serve as identifiers of those girls who may be vulnerable to depression. Health professionals, counselors, and teachers should be alerted to these symptoms, particularly as they surface in early adolescence. These youngsters may be candidates for counseling along with appropriate medical treatment. In school settings educators may be in strategic positions to be sensitive to the inner perceptions of potentially depressed children and adolescents. Poor perceptions of selfworth, particularly as a family member, constituted a risk factor for both genders at age 9 years. School-based counseling groups are a possible source of support for these youngsters. Finally, some specific environmental stressors, such as death of a parent and pregnancy for girls, and remarriage of a parent and family conflict for boys, present clearly 1162
The areas of psychosocial risk identified in this study warrant future investigation. Issues linked to the time of onset of depressive disorder are particularly critical for understanding the etiological influence of specific psychosocial variables. It will be important to examine the variation in type of psychosocial risk characteristic of those developing depressive disorder in early adolescence compared with those developing depression in late adolescence. For example, do negative self-perceptions of family role and lower self-concept appear to be characteristics leading to earlier onset than environmental stressors such as parental remarriage? Ultimately, identification of the specific factors relating to earlier and later onset could result in more timely programs of intervention. Although onset of depression is generally earlier for girls than boys, the study of boys with earlier onset and girls with later onset who present deviant patterns should be informative. Examination of this group of youth with larger samples would cast additional light on gender differences. With replication using a larger sample such investigations would add to knowledge of the interplay of psychosocial variables. The present study highlighted the importance of the biological variable of gender as related to prevalence, time of onset, and determination of patterns on psychosocial risk. Future studies also should focus on other biological and genetic factors as well as their interaction with psychosocial factors. Planned research with the study cohort includes a closer examination of family histories of the subjects to attempt to cast additional light on the complex development of major depression. References Achenbach, T. M. & Edelbrock, C. (1987), Manual for the Youth Self-Report and Profile. Burlington, VT: University of Vermont , Department of Psychiatry . Allgood-Merten, B., Lewinsohn , P. M. & Hops, H. (1990), Sex differences and adolescent depression. J. Abnorm. Psychol., 99:55-63 . Anderson, J., Williams, S., McGee , R. & Silva, P. (1989), Cognitive and social correlates of DSM-III disorders in preadolescent children. J. Am. Acad. Child Adolesc. Psychiatry, 28:842-846. Battle, J. (1987), Relationship between self-esteem and depression among children . Psycho/. Rep., 60:1187-1190. Bell, N. J. & Avery, A. W. (1985), Family structure and parentadolescent relationships: does family structure really make a difference? Journal of Marriage and the Family, 11:503-508. Bird, H. R., Gould, M. S., Yager, T., Staghezza, B. & Canino , G. (1989), Risk factors for maladjustment in Puerto Rican children . J. Am. Acad. Child Adolesc. Psychiatry, 28:847-850. Birtchnell, J. (1972), Birth order and mental illness-A control study . Social Psychiatry, 7:167-179 . Block, J. H., Gjerde, P. F. & Block, J. H. (1991), Personality antecedents of depressive tendenc ies in 18-year-olds: a prospective study. J. Pers. Soc. Psycho/., 60:726-738. Burke, K. C., Burke, J. D., Regier, D. A. & Rae, D. S. (1990), Age at onset of selected mental disorders in five community populations. Arch. Gen. Psychiatry, 47:511-518.
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RISKS FOR DEPRESSION IN LATE ADOLESCENCE
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