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    Rirst Onset Lewinsohn

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    Fabi k
    study

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    © All Rights Reserved
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    vat itn First Onset Versus Recurrence of Depression: Differential Processes of Psychosocial Risk Peter M. Lewinsoha, Nicholas B. Allen, and John R. Seeley Oregon Research Insite Differenta isk factors forthe onset of depression were prospectively examined in 2 comma 708), some af whom had a history of major depressive disorder (MDD: 423). From the theories of J. Teasdale (1983, Post (1992) concerning the etiology of intial versus recurrent episodes of depression, hypothesized that (a) dysphoric mood and dysfunctional thinking styles would be correlated i sample af adolescents 11 = 286) and Some of whom did not (= among those wi mood or syaypta piso Tan H. Gotlib Stanford University based 988) and R. he authors ighly ‘previous history of MDD than among those without a history of MDD; (b) dysphoric and dysfunctional thinking would be a stronger predictor of ons (0n = 43) than of first onsets (11 = 70); and (e) major life strexs would be a stronger predictor ‘of fit onsets of MDD than of recurrent episndes. The results prove support forthe 3 hypotheses and suggest istnet pre Over the past 2 decades, considerable research has been con- ducted examining psychosocial correlates of depression, ‘The re- sults of these studies are important for our understanding of the ‘phenomenology of depression and have contributed to the devel- ‘opment of theories concerning the cognitive and social functioning of depressed individuals. Fewer investigations have attempted to identify and elucidate risk factors for depression, ‘The identificn- tion of risk factors for depression is critical both for the develop ment and evaluation of theories of the etiology of depression and {or identifying individuals who are at clevated risk for developing this disorder OF interest is that recent theories of depression highlight the importance of examining risk factors for depression and further- ‘more suggest that different risk factors or processes may be im- plicated in first versus subsequent onsets of this disorder. Given that depression isa highly recurrent disorder (Belsher & Costello, 1988; Lewinsohn, Zeiss, & Duncan, 1989; Mueller et al., 1996), the identification of specific processes and factors associated with risk for first onsets versus recurrent episodes will have important ‘implications not only for understanding the etiology of these states ‘and how depression evolves over the course of recurrent episodes but also for prevention efforts simed at relapse and recurrence of depression among individuals with a history of this disorder. ‘Teasdale’s (1983, 1988) differential activation hypothesis, for example, proposes that vulnerability to severe depressive states is influenced by pattems of information processing thet occur during Peter M, Lewinsohn, Nicholas B. Allen, and John R. Seley, Oregon Research Intute, Bugene, Oregon; lan H, Gotlib, Department of Psychol- ogy, Stanford University ‘This esearch was partially supported by National Institute of Mental Health Grats MH40501 and MHSOS22. Correspondence concerning this article should be addressed to Peter M. Lewinsohn, Oregon Research Insitute 1715 Franklin Boulevard, Eugene, Oregon 97403-1983, Electronic mail may be sent to pete@ori.or. 483 25 ae involved in the onset of first and recurrent episodes of MDD, mild states of dysphoria, Dysphorie mood states are hypothesized (o activate negatively biased interpretations of experience, as ex- cemplified by Beck's dysfunctional attitudes (Beck, Rush, Shaw, & Emery, 1979) and other negative biases in information processing (eg. Gotlib & MacLeod, 1997; Williams, Watts, MacLeod, é Mathews, 1988). These dysfunetional cognitive processes, in tum, are hypothesized to maintain and exacerbate the dysphoric mood state, often leading to clinical states of depression, Consistent with these hypotheses and with Bower's (1981) formulation of the effects of mood on memory, a number of empirical investigations have demonstrated that depression is associated with a strong bias for the retrieval of negative material from memory (e.g., Gilboa & Gotlib, 1997; Teasdale & Bamard, 1993), Williams et al, (1988) have similarly postulated that negative self-referential material is extensively rehearsed and elaborated during depressive episodes, strengthening the likelihood that this material might contribute to f recurrence of depression, even though it may not have been implicated in the onset of the intial depressive episode, Teasdale (1983, 1988) has underscored the importance of dif {erentiating between first onsets and relapse episodes of depression and has proposed that the links between depressogenic information-processing siyles and dysphoric affect wil be stronger among individuals who have previously experienced a depressive episode than among previously nondepressed persons. Empirical results consistent with this formulation have been reported by Teasdale and Dent (1987) and by Miranda and her colleagues using the Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978; .g., Miranda & Persons, 1988; Miranda, Persons, & Byers, 1990; but see also Rosenbaum, Lewinsohn, & Gotlib, 1996). To ate, however, no study has prospectively compared the roles of depressive mood/symptoms and dysfunctional thinking in first ‘onsets and recurrences of depression. Consistent with Teasdale's hypothesis and with Bower's (1981) model, we predicted that the association between depressive symptoms and dysfunctional thinking would be stronger for adolescents with a previous history 484 LEWINSOHN, ALLEN, si of major depressive disorder (MDD) than history of MDD. Another aecount of the differential processes involved in risk for first versus subsequent depressive episodes is that formulated by Post and his colleagues (eg., Post, 1992; Post etal, 1996). These investigators have proposed that with repeated episodes of depres sion, both sensitization to stressors and episode sensitization take place. Post suggests thatthe “kindling” model of seizure activity ‘and stimulint-induced behavioral sensitization might provide a useful framework for understanding the neurobiological changes {hat oceur with recurrent depressions. In the context of psychoso- cial risk factors for depression, this perspective predicts that eater “autonomy” of episodes will occur with repeated depres- sive experiences. That is, episodes will become more spontaneous and less stongly linked to psychosocial contingencies (Post etal. 1996). Speciticully, Post’s model suggests that psychosocial stres- sors will more strongly predict the precipitation of initial episodes (of depression than they will of subsequent episodes. Post (1992) reviewed the empirical evidence from 12 previous studies that Compared the role of psychosocial stess in the onset of initial and subsequent episodes of depression, Consistent with his formula ‘ion, Post found remarkable consistency with which psychosocial stress was associated more strongly with onset of initial episodes ‘of depression than with onset of subsequent episodes, As Post has pointed oul, however, the majority of these studies were retraspec- tive in design. It is clear that further investigation of this issue using prospective designs is warranted. In the present study, we tested the prediction that stress would be a stronger predictor of first episodes of MDD than of recurrences (ie. that stress would interact with the presence of a history of MDD in predicting the onset of a depressive episode) In this study we used the data set derived from the Oregon ‘Adolescent Depression Project (OADP; eg, Lewinsohn et al. 1993, 1994) to examine differential risk factors for frst onsets versus recurrent episodes of depression. The OADP is a ity-based, longitudinal investigation of the epidemiology of psychiatric disorders ina cohort of 1,507 high schoo! students ‘who participated in extensive diagnostic and psychosocial assess- ments at entry into the study and approximately 1 year late. The ADP study has a number of distinct advantages for examining hypotheses regarding risk factors for depression, Fist, its design allows for a prospective analysis of risk factors. Second, because of the age of the participants involved in the OADP, the proportion Of those participants who are experiencing their first depressive episode during the follow up period is greater than the number that Would be expected in an older sample, where it ean be difficult to find adequate numbers of participants who are experiencing their first depressive episode (Lewinsohn, Hoberman, & Rosenbaum, 1988). Furthermore, in an adolescent sample, usually the vast ‘majority oF those who have experienced previous depression have experienced only one episode, This inexperience allows us to examine processes involved early in the evolution of recurrent depressions, processes that may be more difficult to examine in adult samples in which those with a positive history have often experienced multiple previous episodes. Finally, adults who are experiencing their first depressive episode later in their lives may represent a different sample from those who experienced first episodes during childhood and adolescence, adolescents with no ELEY, AND GOTLIB In a previous report based on the same data set, we have shown thatthe total life events and a composite measure of Depressotypic Cognitions: Pessimism, which included items from the DAS, pre- dicted future MDD episodes (Lewinsohn et al.. 1994). tn another article, we reported that a specific life event, a recent romantic ‘breakup, predicted a first onset of MDD but did not predict MDD recurrence (Monroe, Rohde, Seeley, & Lewinsohn, in press). In this article, we examined a seties of specific hypotheses regarding risk for first and later episodes of depression, With respect (0 cross-sectional analyses, Teasdale's (1983, 1988) differential ac- tivation hypothesis. predicts that dysfunctional thinking, as 12- flected by scores on the DAS, will be more strongly associated with dysphoric mood among those participants with previous, depression than among those without previous depressive epi- sodes. The “prospective” extrapolation of this hypothesis is that dysphoric mood or symptoms in combination with dysfunctional thinking will be a stronger predictor of relapse or recurrence than of first onset of depression, Finally, Post's (1992) kindling model predicts that psychosocial stress will be a stronger predictor of the onset of frst episodes than it will of recurrent episodes, which are ‘more autonomous of exogenous stress, In this context, we explored the relation between levels of life stress and risk for onset in adolescents with and without a history of depression to examine ‘more specifically the nature of the association between levels of life stress and risk for depressive episodes (i.e. is it a “dose~ response” relation, or is there a critical threshold at which life stress becomes depressogenic?) Method Participants and Procedure Partieipans were selected in thre cohoms fom aine senior high schools (approximstly 10.200 students) representative of urban and rr dite in westem Oregon, Sampling factions of 10S, 195, and 20% were used foreach coho: sampling within each school was proportional f size of the schoo, size ofthe grade within the Schoo, and the proportion of boys and gies within the grade. A total of 1,709 adolescents completed the inal CTD) asessments interview and questionnaires) between 1987 and 1989, with an overall paicipation ate of 61%, AL the second assesment (72), 1307 participants (88%) returned for « readainisation of the imerview and questionnaires (mean TIWT2 interval = 13:8 months, SD = 23). ‘We made several checks onthe represcatativenss of the sample. Firs, we compared the demographic characteristics ofthe sanple withthe 1980, census and found no differences on gender, etinic statis, or parental sucation level, It was not surprising that our sale hid significantly ‘more chilren under 18 yeas of age in the home and sigh higher roporton of two-parent families. Second, we compared our patcpants with those adolescents who declined to palpate on several demographic ‘vaiables, These «wo groups didnot differ with respect to gender of head of household, family size, and mumber of parents in the household, Al- though the declines’ mean socioeconomic satus (SES) was signtianly lower than that of the participants, F(1,2023) = 97.9, p< 001, both st0ups were well within the range ofthe middle clas. Significant dr ences were alo found for grade and gender 12th graders (67%) were more likely to participate inthe study than were Sth graders (59%), 203, N= 2511) = 105, p < .O5; female students (68%) were mote likely 1 paripate than were male students (60%), (1, = 2575) = 173, p < ol Finally, a8 an additonal check on the representativeness of the serple, We asiessed 100 paricipans wo had iilly refused to puricipate but FIRST ONSET VERSU responded! positively $1) inducement, Ths sumple dd not fer fm the min sample en type oF number of current and lifetime lintel iggnoses, numero exten of line symp, race, tent employ= ent Slats, o reponses to the yustioniite variables. Hewevee, ea pared with 100 randomly selected participants, detiners were ls likly to be from eworparent Faiies (66% vs. 74: (LN = 200) = 6.6, p 5; hd patents with less edeation, FUU,TTS) = 65, y < S; and reported a lower geade point average 29 v3. 3.1) FU,T89) = 4.6, p< 5, All of these analyses suggested 1 inde exceptions, the stulens in our sample were representative of high schoo students in western Oregon. “To evaluate t tron T1072, we enmpared hase who i at p pants (n = 1507) on eit small but statiiealy significant differences betwen these 180 groups oF panicpanes. The 72 parieipants were slighty higher on parental SES, FULA1431) = 1.6,p-< 0 umber in household 1.1683) = 40, p< (05: proportion of female tents S88 vs. ADM: 41, A= 1709) = 132, 1p-© 01} ad parental eeational level, FU,1S44) ~ IL, p <0 The two groups di not difer on measures of psyehorathology (eg ‘umber of suicide atempis and number of episodes of current and pas isorders,inluding depression, self-report depression metsues, ee, oF ara level. Siniicanty higher atti rates were ved or adolescents ‘wno ha history of esruive behavior dvorders (179 vs. 11S: x Ne 1108) = 3 history of substanee use dsonders had signitieanty (260k vs, Hit: 2, = 819) = 77, p< ON, The demuogeaphic characteris of the final TIHT2 sample were as follows: meat age vas 16.6 yeu (SD = 1.2}; 525 were emule; 9% were ‘uys-White: 71% were living with two parents: 53% were living with both biological paroos; 15% were in th grade, 27% were in 1h rode, 26% woe in [1th grad, 329 were in 12h grade and [2% had rpoated a rade Parens* oecupational status consist of 34% unskilled, 8% semiskiled, 214 skied, 58% winor professional, and 10% professional egree to which the sample might have become bissed pate at T2 (n = 202) variables, There were 7p < 001). Finally, within male studens, those with a ation rate Diagnostic Interview Adolescents were interviewed with a version of the Schedule for Arfee- tive Disorders and Schizophrenia for School-Age Children (K-SADS) that combined features of the Bpidemiologic version (K-SADS-B; Orvaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982) and the Present Epi- sode version (K-SADS-P) and included additional items generated in consultation with the late Dr. Puig-Antich to derive diagnoses os per revised third edition of the Diagnostic and Statistical Manual of Mental Disonlers (DSM-ll-R; American Psychiatic Association, 1987) disor ders, AUT, participants were interviewed using the Longitudinl Interval Follow-Up Evaluation (LIFE; Keller eta, 1987), which provides detailed information about the course of psychiatric symptoms und disorders since the intial K-SADS interview, with rigorous criteria for recovery from a diagnosed disorder (ic, symptom free for 8 or more weeks). Therefore, diagnostic information was availble regarding the occurrence, onset age, and duration ofall disorders before and during the course ofthe sudy. Dignosti interviewers were carefully selected, trained, and supervised, and all interviews were audio- or videotaped, For reliability purposes, second interviewer reviewed the recordings of approximately 129% ofthe imerviews and made diagnoses. Interater reliability was evaluated by the kappa staustc (Cohen, 1960); the kappas for eurent and lifetime MDD diagnoses at T! were .5 and 86, respectively. The interrater reliability of the LIFE interviews was als high and comparable to that reported by the orginal authors (Keller ea, 1987). Measures Stress: Major life evens, There are two major approaches to the assessment of life suess: the selEreport approach, which usually uses RECURRENCE OF DEPRESSION 485 checklists of siessfl life events, and the investigator-cuted approach, ‘which uses semistructured interviews and independent rating af stesso (Brown & Haris, 197K; Kessler, 1997; Montae & McQuaid, 1994). Although the self-report appruact i Lfetress assessment bas been eit tized for luck of consistent def ibility Brown, 1974; MeQuaid etal, 1992), confining dhe use of sllsteport stress assessment to events that are very likely to be severe and salient does Permit economical assessment of life events in large samples while sil ability. In this study we use self-report methodology fo examine the occurrence of 10 negative life events that have been experienced by the adolescent during dhe past year, all of which are fkely to be severe and salient (ep, illness or accident requiring hospitalization, ested, lll home or moved away), These events were veleeted fom Schedule of event Experiences (Holmes & Rhe, 1967) and Lite Evens ander & Block, 1979), Current depression. The 21-item Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) was used 10 assess current depressive symptonssolegy, The coefficient alpha ofthis seale was AR; I-year test-retest r= 67 Depressorypie cognitions. Nine items from the Dysfunctional At tudes Seate (DAS: Weissman & Beck, 1978) wer pilex work (Andrews, Lewiasoln, Hops, & Roberts, 1993), The eoreation between che 8-tem abbreviated seale and the 20-item seake was 93. This seule measures the lendeney of adolescents to endorse dysfunctional at ies postulated by Beck (1976) to be associated with depression, and the 9-tem version used in this study included items rom the two major factors ‘of the full seale (Cane, Olinger, Gotlib, & Kuiper, 1986% Performance Evaluation (eg.. "My life is wasted unless Tam a sueeess”) and Approval by Others (eg. should be able to please everybody"). The coefficient alpha of this seale was 16; -yeue test-retest = 59, tions of events and po retaining adequate n Schedule selectel on the bass of Results, Dysphorie Mood, D Hisiory ysfitnctional Thinking, and Depression On the basis of Teasdale's (1988) differentia activation hypoth- esis and results reported by Miranda and her colleagues, we predicted that dysphoric mood would be more strongly associated ‘with dysfunctional thinking among adolescents with a previous history of MDD than among adolescents with no history of MDD, To examine this prediction, we computed the correlation between dysphoric mood and depressotypic cognitions (DAS scores) at TI separately for adolescents with a history of MDD prior to TI (n= 286) and for adolescents without a history of MDD prior to TI (n= 1,423), Both of these groups included adolescents who met teria for MDD at TI (ns = 29 and 13, respectively). Before computing the correlation between the BDI and DAS within the two MDD history groups, however, we examined differences ‘between these two groups of participants with respect to the means ‘and variances of the scores on the BDI and DAS. With respect BDI scores, the MDD-history group had significantly higher means and SDs than did the no-MDD-history group, Mf = 10.9 (SD = 8.5) versus M = 6.3 (SD = 7.0), (1707) = 981, p <.001, Levene’s test for equality of variances = 22.34, p < 001, With respect to DAS scores, adolescents with a history of MDD did not differ significantly from adolescents without a history of MDD, M = 143 (SD = 63) versus M = 13.7 (SD = 64), (1707) = 1.38, p > .05, Levene's test for equality of variances

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