Depression-Related Psychosocial Variables - American Psychological ...

Copyright 1997 by the American Psychological Association, Inc. 0021-843X/97/$3.00

Journal of Abnormal Psychology 1997, Vol. 106, No. 3, 365-375

Depression-Related Psychosocial Variables: Are They Specific to Depression in Adolescents? Ian H. Gotlib

Peter M. Lewinsohn Oregon Research Institute

Stanford University

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

John R. Seeley Oregon Research Institute Although the psychosocial difficulties associated with adolescent depression are relatively well known, the extent to which these problems are specific to depression has received little attention. The authors examined the specificity to depression of a wide range of psychosocial variables in the following 3 groups of adolescents: depressed cases (n = 48), nonaffective disorder cases (n = 92), and never mentally ill participants (n = 1,079). The authors found 3 of the 44 variables assessed in this study to be strongly specific to depression, and only the depressed participants exhibited more problematic functioning than did the never mentally ill controls. Three variables are as follows: selfconsciousness, self-esteem, and a reduction in activities because of physical illness or injury. Eight variables were more strongly associated with depression than with nonaffective disorder, and 8 variables characterized both depressed and nonaffective disorder adolescents. Implications of these findings for psychosocial theories of depression are discussed.

A growing literature has documented the pervasive difficulties in psychosocial functioning exhibited by depressed persons (cf. Gotlib & Hammen, 1992). These problems occur in multiple spheres, including cognitions, self-perceptions, interpersonal behaviors, stressors, coping skills, and physical health. For example, compared with their nondepressed counterparts, depressed persons have been found to report more dysfunctional cognitions and attributions (e.g., Alloy, Peterson, Abramson, & Seligman, 1984; Barnett & Gotlib, 1990), lower self-esteem (e.g., Roberts, Gotlib, & Kassel, 1996), and less socially skillful interpersonal behavior and problem-solving ability (e.g., Gotlib & Asarnow, 1979; "toungren & Lewinsohn, 1980). Depressed persons have also been found to report receiving less social support, having fewer close relationships, and experiencing three to six times as many stressful life events as do nondepressed individuals (e.g., Brown & Harris, 1978; Monroe, Imhoff, Wise, & Harris, 1983). Indeed, given these elevated levels of stress, it is noteworthy that depressed individuals emit fewer and less effective coping behaviors and strategies than do nondepressed persons (e.g., Gotlib & Whiffen, 1989; Rohde, Lewinsohn, Tilson, & Seeley, 1990). Finally, compared with nondepressed persons, depressed individuals have been found to report a greater number of physical health symptoms and problems (cf. Cohen-Cole & Kaufman, 1993).

Although we have made considerable gains over the past decade with respect to our understanding the nature of psychosocial deficits in depressed individuals, a number of important issues remain unresolved. Two of these issues were the focus of the present study. The first issue concerns the specificity to depression of these deficits in psychosocial functioning. It is now apparent that, in addition to symptoms of depression, depressed persons also exhibit symptoms that are characteristic of a wide range of other psychiatric disorders (cf. Gotlib & Cane, 1989; Maser & Cloninger, 1990; Rohde, Lewinsohn, & Seeley, 1991). For example, estimates from the Epidemiologic Catchment Area study (Regier, Burke, & Burke, 1990) for 6month prevalence rates showed that 33% of those individuals with an affective disorder also had an anxiety disorder and that 21% of those with an anxiety disorder also had a concurrent affective disorder. Despite these high rates of comorbidity, deficits in psychosocial functioning that are exhibited by depressed individuals are often attributed specifically to the depression. A number of investigators, however, have found that nondepressed psychiatric persons exhibit patterns of problematic functioning similar to those demonstrated by depressed persons, including lower levels of self-esteem (e.g., Kendler & Hays, 1982), deficits in social support and interpersonal skills (e.g., Bellack, Morrison, Mueser, & Wade, 1989; Pattison, de Francisco, Wood, Frazier, & Crowder, 1975), elevated levels of stress (e.g., Caton, Koh, Fleiss, Barrow, & Goldstein, 1985), and less effective coping behaviors (e.g., Vitaliano, Maiuro, Russo, & Becker, 1987). Moreover, in several investigations in which depressed individuals were compared explicitly with nondepressed psychiatric controls, researchers have failed to demonstrate specificity of psychosocial dysfunction to depression (e.g., Harder, Strauss, Kokes, Ritzier, & Gift, 1989; Hollon, Kendall, & Lumry, 1986). Thus, the extent to which psychosocial deficits are specific to

Peter M. Lewinsohn and John R. Seeley, Oregon Research Institute; Ian H. Gotlib, Department of Psychology, Stanford University. This research was supported in part by National Institute of Mental Health Grants MH40501 and MH50522. Correspondence concerning this article should be addressed to Peter M. Lewinsohn, Oregon Research Institute, 1715 Franklin Boulevard, Eugene, Oregon 97403-1983. Electronic mail may be sent via Internet to [email protected].

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depression or are more broadly characteristic of psychopathology in general is unclear. This issue can be addressed in at least two ways. The first way is by including a group of nondepressed psychiatric control participants in addition to groups of depressed cases and normal controls (i.e., never mentally ill). This approach permits an explicit comparison of cases of depression and cases of nonaffective forms of psychopathology. The second method involves including both pure cases of depression and cases in which depression is comorbid with other psychiatric disorders. This approach allows an examination of whether the psychosocial characteristic under investigation is manifested only by comorbid depressives, compared with those participants with pure depression. Both of these approaches were used in the present study. Specificity to depression would be demonstrated most strongly if the depressed adolescents are found to differ significantly from both the nondepressed psychiatric and normal controls, who in turn do not differ significantly from each other. Specificity would also be demonstrated, albeit less strongly, if the depressed adolescents are found to exhibit the most problematic functioning, followed by the nondepressed psychiatric controls, who in turn exhibit more problematic functioning than do the normal controls. Nonspecificity would be demonstrated if the variable in question is significantly elevated in both depressed and in nonaffective disorder adolescents. The second issue examined in this study concerns the fact that the overwhelming majority of research examining psychosocial aspects of depression has been conducted with adults. It is not clear, therefore, whether similar psychosocial deficits would also characterize the functioning of depressed children and adolescents. It is interesting to note that recent studies with younger populations have reported results comparable with those found in studies of depressed adults. It is becoming increasingly apparent that, like depression in adults, depression in children and adolescents disrupts their cognitive, interpersonal, and other role functioning (e.g., Asarnow & Bates, 1988; Kaslow, Tanenbaum, Abramson, Peterson, & Seligman, 1983; Kovacs, 1985; Lewinsohn et al., 1994). Again, however, it is important to note that, with few exceptions, these studies involve comparisons between depressed adolescents and normal controls. Consequently, results of these investigations have not addressed the specificity of these deficits to depression. The degree to which deficits in psychosocial functioning are specific to depression has important implications for psychosocial theories of depression. To the extent that variables are specific to depression, their potential etiologic importance is increased. Although nonspecificity of functioning would not necessarily imply that the psychosocial constructs under study do not play a role in depression (cf. Berkman & Breslow, 1983; Garber & Hollon, 1991), it is likely that different mechanisms would be postulated for the roles of specific and nonspecific (i.e., general) factors in the etiology and maintenance of depression. Moreover, given that most depressed samples in the literature have included a substantial proportion of persons with comorbid disorders, it is unclear to what extent psychosocial deficits that have been found to be associated with depression are attributable to depression per se, or are because of the presence of the comorbid condition. Clearly, the identification of those psychosocial characteristics that are specific to depression is

important both for more precise theoretical development and for clinical intervention and prevention. The Oregon Adolescent Depression Project (OADP; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993) provides us with a unique opportunity to examine these issues. The OADP consisted of a large, randomly selected cohort of high school students (age 14-18 years) who were assessed on a wide array of psychosocial and diagnostic measures. On the basis of the diagnostic information obtained from the adolescents, it was possible to divide the sample into the following three distinct groups: (a) adolescents who met criteria for a current diagnosis of major depressive disorder (MDD) or dysthymia; (b) adolescents who did not meet criteria for a current diagnosis of depression but who did meet criteria for a current diagnosis of anxiety disorder, substance use disorder, or disruptive behavior disorder (nonaffective disorder control group); and (c) a never mentally ill control group. In previous publications that describe results from the OADP, we reported findings concerning the prevalence and incidence of the third edition, revised Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) disorders (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993); epidemiologic parameters of MDD, such as age at onset, episode duration, and time to recurrence (Lewinsohn, Clarke, Seeley, & Rohde, 1994); psychosocial risk factors for depression (Lewinsohn et al., 1994); and the extent and the effects of the comorbidity of depression with other DSM-IIIR disorders (Lewinsohn, Rohde, & Seeley, 1995; Lewinsohn, Rohde, Seeley, & Hops, 1991; Rohde et al., 1991) on selected clinical outcome measures. Most recently, we examined the specificity of the psychosocial variables assessed in this project in the onset of depression (Lewinsohn, Gotlib, & Seeley, 1995). In that article, we examined the differential ability of the psychosocial variables to predict the onset (i.e., their role as antecedents) of two distinct psychiatric disorders (MDD and psychoactive substance use disorder; SUD). We found that stress (minor and major events), negative cognitions, emotional reliance, physical symptoms and disease, history of suicide attempt, and a past episode of depression or anxiety disorder functioned as specific risk factors for the onset of MDD. In contrast, depressive symptoms, internalizing and externalizing behavior problems, poor coping skills, interpersonal conflict with parents, and dissatisfaction with grades were found to predict the onset of both MDD and SUD. Our goal in the present article is to further examine the specificity of deficits in psychosocial functioning in depressed adolescents. We first examined the extent to which deficits in particular psychosocial variables are specific to depression or also characterize persons with other disorders. We then assessed the related issue of comorbidity of psychiatric disorder with depression. To examine this issue requires the assessment both of participants whose depression is comorbid with another psychiatric disorder and of participants who have pure depression.

Method Participants and Procedure Participants were selected in three cohorts from nine senior high schools (approximately 10,200 students) representative of urban and


ADOLESCENT PSYCHOPATHOLOGY rural districts in western Oregon. Sampling fractions of 10%, 19%, and 20% were used for each cohort; sampling within each school was proportional to size of the school, grade within the school, and gender within the grade. A total of 1,709 adolescents completed the initial (Tl) assessments between 1987 and 1989, with an overall participation rate of 61%. At the second assessment (T2), 1,507 participants (88%) returned for a readministration of the interview and questionnaire (mean T1-T2 interval = 13.8 months, SO = 2.3). The representativeness of the sample was evaluated with several procedures. Demographic characteristics of the sample were compared with 1980 census data provided by the school districts. No differences were found on gender, ethnicity, or parental education level, although participants had a slightly higher proportion of two-parent families. Second, participants were compared with those who declined. The two groups were similar on gender of head of household, family size, number of parents in the household, and ethnicity. Students who declined had a slightly lower socioeconomic level (although both groups represented the middle class), 12th-grade students (67%) were more likely to participate than 9th-grade students (59%), and female students (68%) were more likely to participate than male students (60%). Overall, participants in the sample at Tl were representative of high school students in western Oregon. Additional details regarding the sample are provided in Lewinsohn et al. (1993). The demographic characteristics of the Tl sample were as follows: Their mean age was 16.6 years (SD = 1.2); 52% were girls, 9% were non-White; 71% were living with two parents, 53% were living with both biological parents; 15% were in 9th grade, 27% were in 10th grade, 26% were in llth grade, and 32% were in 12th grade; and, overall, 12% had repeated a grade. Parent's occupational status consisted of 3% unskilled, 8% semiskilled, 21% skilled, 58% minor professional, and 10% professional.

Diagnostic Interview Adolescents were interviewed at Tl with a version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (KSADS) that combined features of the epidemiologic version (Orvaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982) and the Present Episode version, and it included additional items to derive diagnoses of most disorders as per DSM-UI-R criteria (American Psychiatric Association, 1987). Diagnostic interviewers were carefully trained and supervised. For reliability purposes, all interviews were either audio- or videotaped, and a second interviewer reviewed the recordings of 12% of the interviews. Interrater reliability was evaluated by the kappa statistic (Cohen 1960). Kappas at Tl were equal to or greater than .80 with the exception of the following diagnoses: current anxiety disorder (K = .60), lifetime anxiety disorder (K = .53), lifetime dysthymia (K = .58), lifetime bipolar disorder (K = .49), and lifetime eating disorder (« = .66).

Diagnostic Groups The following three diagnostic groups were formed for the purposes of this study: a depression (D) group consisting of participants who met DSM-1II-R criteria for major depression or dysthymia at Tl (n = 48); a nonaffective disorder (NAD) group consisting of participants who met criteria, in about equal proportion, for anxiety disorders, disruptive behavior disorders, or substance use disorders at Tl (n = 92); and a never mentally ill (NMI) control group consisting of participants who did not meet criteria for any current or past DSM-III-R disorder at Tl (n = 1,079). Moreover, the depression group was composed of the following two subgroups: adolescents with pure depression (i.e., who at Tl met DSM-III-R criteria only for major depression or dysthymia; n = 27) and adolescents with comorbid depression, who at Tl met DSM-III-R criteria for both major depression or dysthymia and for at least one other nonaffective psychiatric disorder (n = 21).

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Measures Psychosocial constructs. An extensive questionnaire battery of measures was administered, with the intent of assessing all psychosocial variables known or hypothesized to be related to depression (materials available on request). On the basis of extensive pilot studies (Andrews, Lewinsohn, Hops, & Roberts, 1993), most of the measures were shortened (unless noted, the instrument has been abbreviated). Because a large number of variables were administered, measures were reduced to a smaller number of composite scores. Variables were rationally categorized into general clusters, which were submitted to principal components analysis with varimax rotation. Measures in each component with loadings greater than .40 were standardized and summed by using unit weighting to create composite scores. Any two composite scores that were found to be strongly correlated (r > .50) were combined into a single construct (see Lewinsohn et al., 1993, for more details). With these procedures, most of the psychosocial measures were categorized into 21 constructs (the remaining 23 variables were retained as miscellaneous individual measures and are described below). A brief description of each construct is given below, including the number of items, Cronbach's coefficient alpha (on the basis of scale scores where they were available rather than individual items), and test-retest (TlT2) reliability. All variables were scored such that higher values indicated more problematic functioning. The stress: daily hassles construct (a = .79, r = .55) consisted of 20 items from the Unpleasant Events Schedule (Lewinsohn, Mermelstein, Alexander, & MacPhillamy, 1985). The stress: major life events construct (a = .78, r = .52) consisted of 14 events from the Schedule of Recent Experience (Holmes & Rahe, 1967) and the Life Events Schedule (Sandier & Block, 1979), rated for occurrence to self or significant others in the past year. The current depression construct (M interscale r = .54, a = .82, r = .40) consisted of the 20-item Center for Epidemiologic Studies— Depression Scale (CES-D; Radloff, 1977), the 21-item Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a single (5-point) item assessing depression level during the past week, and the interviewer-rated 14-item Hamilton Depression Rating Scale (Hamilton, 1960). The other psychopathology: internalizing behavior problems construct (M interscale r = .25, a = .72, r = .55) assessed the tendency to worry (5 items; Maudsley Obsessional Compulsive Inventory; Hodgson & Rachman, 1977), hypomanic behavior (12 items; General Behavior Inventory; Depue et al., 1981), state anxiety (10 items; State-Trait Anxiety Inventory; Spielberger, Gorsuch, & Lushene, 1970), quantity and nature of sleep (8 items), and hypochondriasis (8 items; Pilowsky, 1967). The other psychopathology: externalizing behavior problems construct (M interscale r - .32, a = .71, r = .42) consisted of the number of current K-SADS symptoms for attention-deficit hyperactivity (15 items), conduct (17 items), and oppositional disorders (11 items), and an unpublished scale assessing conduct problems (6 items). The depressotypic negative cognitions construct (M interscale r = .29, a = .61, r = .61) consisted of the Frequency of Self-Reinforcement Attitude Questionnaire (10 items; Heiby, 1982), the Subjective Probability Questionnaire (5 items; Mufioz & Lewinsohn, 1976), the Dysfunctional Attitude Scale (9 items; Weissman & Beck, 1978), and items assessing perceived control over one's life (3 items; Pearlin & Schooler, 1978). The depressotypic attributional style construct (a = .63, r = .55) consisted of the Kastan Attributional Style Questionnaire for Children (48 items; Kaslow, Tanenbaum, & Seligman, 1978). Two scores were derived, standardized, and summed. Positive events attributed to unstable, external, and specific causes, and negative events attributed to stable, internal, and global causes. The self-consciousness construct (a = .74, r = .54) consisted of the Self-Consciousness Scale (9 items; Fenigstein, Scheier, & Buss, 1975). The self-esteem construct (M interscale r — .33, a = .59, r = .62)


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consisted of the Body Parts Satisfaction Scale (3 items; Berscheid, Walster, & Bohrnstedt, 1973), the Physical Appearance Evaluation subscale (3 items; Winstead & Cash, 1984), and the Rosenberg Self-Esteem Scale (3 items; Rosenberg, 1965). The self-rated social competence construct (M interscale r = .60, a = .75, r = .64) consisted of the Social Subscale of the Perceived Competence Scale for Children (5 items; Harter, 1982) and of adjectives that assess perceived social competence (7 items; Lewinsohn, Mischel, Chaplin, & Barton, 1980). The emotional reliance construct (a = .83, r = .54) consisted of the Emotional Reliance Scale (10 items; Hirschfeld, Klerman, Chodoff, Korchin, & Barrett, 1976), assessing the extent to which individuals desire more support and approval from others and are interpersonally sensitive. The future goals: academic construct (Af interscale r = .39, a = .72, r = .74) contained single-item measures of estimated future education, self-perceived adequacy of school performance, perceived ability to complete college, and the Importance Placed on Life Goals Scale (5 items; Bachman, Johnston, & O'Malley, 1985), assessing the importance of future academic goals. The future goals: family construct (a = .61, r = .58) assessed the importance of future goals related to marriage and family (5 items; adapted from Bachman et al., 1985). The future goals: occupational construct (a = .63, r — .48) assessed the importance of future income level and steady employment (3 items; adapted from Bachman et al., 1985). The coping skills construct (a = .76, r = .55) consisted of a 17item scale originally selected from the Self-Control Scale (Rosenbaum, 1980), the Antidepressive Activity Questionnaire (Rippere, 1977), and the Ways of Coping Questionnaire (Fblkman & Lazarus, 1980). The social support: family construct (M interscale r = .30, a = .77, r = .64) consisted of items from the Conflict Behavior Questionnaire (11 items; Prinz, Foster, Kent, & O'Leary, 1979), the Parent Attitude Research Instrument (6 items; Schaefer, 1965), the Cohesion subscale of the Family Environment Scale (3 items; Moos, 1974), the Competence scale of the \buth Self-Report (2 items; Achenbach & Edelbrock, 1987), and a paper-and-pencil adaptation of the Arizona Social Support Interview Schedule (ASSIS; Barrera, 1986). The social support: friends construct (M interscale r = .28, a = .72, r = .60) consisted of the Social Competence Scale (2 items; Harter, 1982), the University of California, Los Angeles, Loneliness Scale (8 items; Russell, Peplau, & Cutrona, 1980), the Competence scales of the 'ifouth Self-Report (3 items), and the number for friends listed as providing social support from the ASSIS. The interpersonal: conflict with parents construct (a = .81, r = .51) consisted of the Issues Checklist (45 items; Robin & Weiss, 1980). The occurrence of events during the past 2 weeks and average intensity were standardized and summed. The interpersonal: attractiveness construct (a = .94, r = .22) consisted of the interviewer-rated Interpersonal Attraction Measure (17 items; McCroskey & McCain, 1974). The physical illness construct (M interscale r = .25, a = .51, r = .46) consisted of number of visits to a physician, days spent in bed as a result of illness, and the occurrence of 88 physical symptoms during the past 12 months. The maturational level construct (8 items, a = .64, r = .58, for girls; 11 items, a = .74, r = .74 for boys) contained items adapted from Petersen, Crockett, Richards, and Boxer (1988) that assess current pubertal status. Items assessed the amount of hair on various body parts and changes in body shape (women only) and changes in voice (men only). Miscellaneous measures. Additional variables were assessed but were not included in the constructs because either they did not rationally fit into a general cluster or they did not load significantly on a component (i.e., < .40). The measures included death of a parent before age 13, a tendency to present oneself in a socially desirable manner (6 items,

a = .53, r = .54; Marlowe-Crowne Social Desirability Scale; Crowne & Marlowe, 1960), hypomanic personality style (15 items, a = .68, r = .55; Hypomanic Personality Scale; Eckblad & Chapman, 1986), and vocabulary level (10 items, a = .72, r = .72; Vocabulary subtest of the Shipley Institute of Living Scale; Shipley, 1940). Additional singleitem measures of academic performance included GPA, satisfaction with grade average, perceived parental satisfaction with grade average, number of missed school days in the past 6 weeks, number of times late for school in the past 6 weeks, frequency of failure to complete homework, and repeated a grade in school. Additional single-item measures assessing health included self-rated health, estimated body fat percentage (Quetelet obesity index; weight and height), frequency of exercise, use of medications (prescription or over the counter), overnight stays in a hospital, and whether an injury or illness in the past year had caused difficulties with feeding or dressing, climbing stairs or getting outdoors, with work or participation in school, or a reduction in activity level. The lifetime occurrence of 88 physical symptoms was also assessed by self-report. Finally, adolescents reported whether they had ever used tobacco (yes or no) and their current rate of tobacco use (6-point scale). Results

Analytic Strategy Our analyses focused on the goal of determining the extent to which each psychosocial variable is strongly specific to depression (i.e., only the D group, and not the NAD group, is significantly elevated over the NMI group). We also allowed for a weaker degree of specificity in which D > NAD > NMI. Variables were considered to be nonspecific if both the D and the NAD groups differed significantly from the NMI group but did not differ significantly from each other. In addition, variables that were elevated in the NAD group, but not in the D group, were also identified. Finally, for both variables that were found to be specific to depression and variables that were found to be nonspecific, we compared the pure and the comorbid depressed adolescents to examine the potential role of comorbidity in contributing to these group differences. Diagnostic group differences on the dependent variables were tested with one-way analyses of covariance, adjusting for age and gender. Contingency table analyses and logistic regression analyses were conducted to examine group differences on dichotomous variables. If significant overall group differences were obtained, subsequent pairwise contrasts were conducted. Although each of the psychosocial variables was selected because of its hypothesized association with depression, we did conduct a relatively large number of analyses. Consequently, we set alpha sip < .01, two-tailed.

Demographic Characteristics Demographic characteristics of participants in the three groups are presented in Table 1. As can be seen, the D group contained a nonsignificantly larger proportion of female participants than did the other two groups, X 2 (2, N = 1,219) = 8.28, p > .01. Both the D and the NAD groups had a significantly larger proportion of adolescents not living with both biological parents than did the NMI group, * 2 (2, N = 1,219) = 15.31, p < .01. No significant differences were obtained among the three groups with respect to age, ethnicity, or highest parental education within the household.

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Table 1 Demographic Characteristics of the Three Diagnostic Groups Diagnostic group


Variable Girls (%) Age M (SD) White (%) Living with NMI, NAD > NMI, D = NAD; o = NAD > NMI, D = NMI; s = weakly specific to depression; N = nonspecific to depression; GPA = grade point average. " F values are reported for continuous-type variables. b Redesignation based on subsequent analysis of comorbidity; see text for explanation. *p < .01. **p < .001. t Dichotomous variable.

it is possible that comorbidity affected the above-mentioned findings. For example, for variables that were found to be N to depression (i.e., elevated in both the D and NAD groups), and even for those that were specific (S, s) to depression, the eleva-

tion of the D group could have been due to the functioning of the comorbid participants, that is, the pure depressed participants may not have been elevated on these variables and the comorbidity or the comorbid disorder, rather than the depression


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per se, would have been responsible for the elevation in the D group. To evaluate the impact of comorbidity on the variables that were found to be specific to depression, planned contrasts were conducted comparing the pure (n = 27) and the comorbid depressed participants (n = 21). Because of the number of additional comparisons, the alpha for these and the subsequent analyses was set atp < .005, two-tailed. Of the three S variables and the eight s variables, no significant differences were obtained for the comparisons between the two groups. Therefore, the specificity of these variables to depression is not attributable to comorbid depression. We also evaluated the impact of comorbidity on the variables that were found to be n to depression by comparing the pure and the comorbid depressed participants on these variables, both with each other and with the NAD and the NMI controls. The pure and the comorbid depressed adolescents differed significantly from each other only with respect to externalizing problem behaviors (p < .005 ), with the comorbid depressed adolescents demonstrating higher scores. It is important to note, however, that the pure depressives also differed from the NMIs on this variable (p < .005), indicating that although comorbidity played a role in elevating the depressed group relative to the NMI participants, depression per se also contributed to this elevation. Four of the 12 N variables were significantly elevated in the comorbid depressed group (p < .005), but not in the pure depressed group, compared with the NMIs: major life events, low future goals, academic, conflict with parents, and low interpersonal attractiveness. These variables, therefore, were redesignated in Table 2 as being related only to NADs (o). For the remaining eight variables, the pure D group was significantly elevated over the NMI group.

Discussion Although a large number of psychosocial variables were found in the present study to be correlated with depression, only the following three were found to be S specific to this disorder: self-consciousness, self-esteem, and change or decrease in activities because of physical illness or injury. Thus, compared with adolescents with other forms of psychopathology and to NMI controls, depressed adolescents were more self-conscious, had lower self-esteem, and changed or decreased their activities because of physical illness or injury. Clearly these are the kinds of variables that should be emphasized in psychosocial theories of the phenomenology of depression. Because they are uniquely associated with depression, these variables also deserve special attention in the design of interventions for this disorder. The identification in the present study of self-consciousness and self-esteem as variables that are strongly specific to depression provides empirical support for theories of this disorder that focus on the importance of these constructs. For example, Lewinsohn, Hoberman, Teri, and Hautzinger (1985) proposed an integrative, multifactorial model of the etiology and maintenance of depression, and a critical component of this model is self-consciousness, or self-focus, which is postulated to make salient the individual's sense of failure to meet internal standards and to lead to increased dysphoria and to several of the other cognitive, behavioral, and emotional symptoms of depression. Self-focus is also a central concept in another theory of depres-

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sion that was formulated by Pyszczynski and Greenberg (1987). Pyszczynski and Greenberg emphasized the role of self-focused attention in the onset and maintenance of depression. Briefly, they postulated a sequence of events that begins with the loss of a central source of self-esteem, such as the break up of an important interpersonal relationship or the loss of a job, which leads to an increase in self-focus (see Ingram, 1990, for an elaborated, but similar, self-absorption model of psychopathology). Other theorists and investigators have focused on self-esteem as an important variable in the onset and maintenance of depression. For example, Flippo and Lewinsohn (1971) found that low self-esteem was associated with higher levels of depressive symptoms. In an interesting extension of this finding, Kernis, Grannemann, and Mathis (1991) found that the relation between low self-esteem and depression was stronger in individuals with chronic low self-esteem than it was in persons whose levels of self-esteem fluctuated. More recently, Roberts, Gotlib, and Kassel (1996) found that level of self-esteem prospectively predicted change in depressive symptoms. These findings, considered together with the results of the present study, suggest that self-esteem is a critical aspect of depression that not only is a specific component of this disorder, but further, that may predict onset of depression. The third variable that was found in the present study to be strongly specific to the phenomenology of adolescent depression was change or decrease in activities because of physical illness or injury. As was the case with self-consciousness, a reduction in activities is also consistent with Lewinsohn, Hoberman, et al.'s (1985) theory of depression. Lewinsohn, Mermelstein, et al. postulated that events that disrupt important areas of functioning, particularly when they lead to a decrease in activities, will elevate an individual's risk for depression. Thus, according to this model, physical illness is expected to be related to depressive onset to the extent that it disrupts important activities of living, or impedes the ability to engage in valued activities. Indeed, in a previous report examining the same sample of participants, Lewinsohn, Seeley, Hibbard, Rohde, and Sack (1996) found that functional impairment because of physical illness or injury was significantly related to both concurrent and prospective episodes of MDD. Relatively little attention has been paid to poor physical health and its associated problems as risk factors for depression in adolescents, likely because adolescents are typically assumed to be a group that is generally in good health. However, the consistency of our findings lead us to recommend that investigators attend more explicitly to issues involving reduction in activities and functional impairment because of physical illness or injury in this population. It is important to note that the variables assessing cognitive functioning (i.e., negative cognitions and depressotypic attributional style) were found in the present study to be weakly specific to depression. That is, although these variables were elevated in the depressed adolescents, they were also elevated, albeit less strongly, in the psychiatric control participants. This pattern of results provides qualified support for cognitive theories of depression that implicate attributional style (e.g., Abramson, Seligman, & Teasdale, 1978) and negative cognitive functioning (e.g., Beck, Rush, Shaw, & Emery, 1979) in depression and suggests that a portion of the association between negative


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cognitive functioning and depression is because of the comorbidity of depression with other NADs. In addition, several other variables were more strongly associated with depression than they were with NADs, although even the nonaffective control group differed from the NMI controls. The more strongly associated variables with depression are as follows: current depression, internalizing behavior problems, negative cognitions, depressotypic attributional style, low selfrated social competence, emotional reliance, poor coping skills, and low social support from friends. These, too, are variables of which theoretical and clinical importance has been recognized in the depression literature. It is important to note that the present findings indicate that although these variables are not uniquely associated with depression, they do play a substantial role in the phenomenology of adolescent depression. It will be important in future research to assess explicitly the nature of the association of these psychosocial variables with depression and other forms of psychopathology. In this study, we also identified a third class of variables—the nonspecific variables. For these variables, the NAD adolescents exhibited a level of dysfunction equivalent to that demonstrated by the depressed adolescents. Given the fact that these variables were found to be related equally strongly to depression and to NAD, it is important that investigators begin to assess the mechanisms or pathways by which these variables are related to psychopathology. In this context, it is noteworthy that many of these variables involve different aspects of a nonsupportive or stressful interaction of the adolescent with the environment. Therefore, although these variables were found in the present study to be nonspecific to depression, it is possible that they interact with other variables, most likely personality variables, to produce different psychopathological outcomes (cf. Garber & Hollon, 1991). This is particularly likely given the heterogenous composition of the NAD group. Clearly, an important task for future research will be to examine these variables in well-defined groups that are characterized by a variety of psychopathological disorders. We should also comment on the influence of comorbidity on the association of life events with depression. As we noted earlier, a number of investigators have found previously that depressed individuals report up to six times as many stressful life events as do nondepressed persons (e.g., Brown & Harris, 1978; Costello, 1982). In the present study, an elevated level of major life events was found to be a nonspecific characteristic of depressed adolescents. That is, although depressed adolescents reported more life events than did NMI controls, they did not differ on this variable from adolescents with other psychiatric disorders. More important, however, when we compared comorbid and pure depressed adolescents on this variable, it was clear that the elevated level of life events among the depressed participants was because of the comorbidity of depression with other psychiatric disorders; the pure depressed adolescents did not differ from the NMI control participants with respect to the number of negative life events they reported experiencing. Thus, the present findings suggest that increased levels of negative life events found among depressed participants in previous studies may have been due to the comorbidity of other disorders with depression, or indeed, to the other disorders themselves, rather than to depression per se. Given the centrality of the concept of stressful life events to both biological and psychosocial theories

of depression, it is important that this finding be replicated in other studies, and the association between the occurrence of stressful life events and the onset of various types of psychopathology be examined more explicitly. It is important to note that several variables that have been found in previous studies to be related to depression were found to be unrelated to this disorder in the current investigation. For example, in a previous report, Klein, Lewinsohn, and Seeley (1996) found significant associations between hypomanic personality style and lifetime diagnoses of MOD, disruptive behavior disorders, SUDs but not lifetime diagnosis of anxiety disorder. In the present study, hypomanic personality style was not found to be related to current depression but was significantly associated with current NAD. There are at least two explanations for the discrepancy between these two studies. First, the currently depressed group in the present study was much smaller than was the lifetime depression group in the Klein et al. investigation, and the resultant lower power in the present study could have been responsible for the statistically nonsignificant association of hypomanic personality study and depression. Second, and more likely, it is possible that there was a greater degree of comorbidity with NADs in the lifetime comparisons than was the case in the present study, and it is the lifetime comorbidity, rather than the concurrent comorbidity, that was contributing to the association of hypomanic personality style with lifetime depression. We did not find significant associations of school difficulties and social desirability with depression in the present study. The discrepancy between these negative findings and positive associations in previous studies is likely a function of the difference between defining groups on the basis of self-reports of symptoms of distress (such as scores on the CES-D), as has been done in previous studies, and categorizing adolescents on the basis of psychiatric diagnoses derived from structured clinical interviews, as was done in the current investigation. For example, Blechman, McEnroe, Carella, and Audette (1986); Cole (1990); and Forehand, Brody, Long, and Fauber (1988) all found school difficulties to be associated with self-reports of depressive symptoms. In the present study, school difficulties were not related to a clinical diagnosis of depression, although in analyses not reported here, we did find significant correlations between school difficulties and CES-D scores across the entire sample. Similarly, although in previous research there have been significant correlations between the Marlowe-Crowne Social Desirability Scale and depressive symptoms in adults (e.g., Cole, 1988), in the present study this measure was unrelated to a clinical diagnosis of depression in adolescents. Again, in analyses not reported here, we also found a significant correlation between the Social Desirability Scale and the CES-D. These discrepancies clearly underscore the significance of differences between self-reported and clinician-rated depression in examining psychosocial concomitants of depression, and it is critical that this difference be reconciled in future investigations of this disorder. Finally, in closing, it is important to note some limitations of the present study. First, our primary focus in this study was on the specificity or generality of psychosocial risk factors associated with depression. To this end, we examined the psychosocial functioning of adolescents diagnosed with unipolar depression. Consequently, our findings may not be generalizable to bipolar


ADOLESCENT PSYCHOPATHOLOGY disorders. A notable strength of our study, however, is that we included data from a group of adolescents with psychiatric diagnoses other than affective disorder. This group consisted of adolescents who were diagnosed with SUDs, anxiety disorders, and disruptive behavior disorders. Despite the broad range of psychopathology represented in this study, however, it is important to note that there are other disorders that were not examined here, such as schizophrenia and eating and somatoform disorders. Thus, it is possible that the variables found in this study to be specific to depression are specific only when compared with the other disorders that were examined here. A related point involves the distinction between syndrome and symptoms of psychopathology. Although adolescents in different groups did not share primary psychiatric diagnoses, we should note that adolescents with different disorders may nevertheless have shared symptoms. In particular, anxiety and depression have significant comorbidity not only at the syndrome level (e.g., Clark, 1989) but also with respect to symptoms (e.g., Gotlib & Cane, 1989; Maser & Cloninger, 1990). Thus, it is possible that variables emerged as nonspecific in this study because of this overlap in symptoms, rather than because the variables are important in several forms of psychopathology above and beyond their association with particular shared symptoms. Additional research is required to elucidate further the specificity of deficits in psychosocial functioning to depression, as well as the generality of these deficits to other psychiatric disorders. Nevertheless, by using precisely defined psychiatric diagnostic criteria, the present study clearly identified a particular set of variables as specific to depression in a large sample of adolescents.

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