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RESEARCH REPORT doi:10.1111/j.1360-0443.2006.01621.

Psychological symptoms and physical health and


health behaviours in adolescents: a prospective 2-year
study in East London

Charlotte Clark1, Mary M. Haines1, Jenny Head1, Emily Klineberg1, Muna Arephin1,
Russell Viner2, Stephanie J. C. Taylor3, Robert Booy4, Kam Bhui1 & Stephen A. Stansfeld1
Centre for Psychiatry,Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary’s School of Medicine and Dentistry, University of London, UK,1
Department of Paediatrics, Royal Free and University College London Medical School, University College London, UK,2 Centre for Health Science, Barts and the
London, Queen Mary’s School of Medicine and Dentistry, University of London, UK3 and Department of Child Health, Barts and the London, Queen Mary’s School
of Medicine and Dentistry, University of London, UK4

ABSTRACT

Aims To examine whether physical health and health-risk behaviours in young people are risk factors for psycho-
logical distress and depressive symptoms over a 2-year period. Design/setting A 2-year, prospective epidemiological
cohort study in East London. Participants A total of 1615 adolescents from the Research with East London Adoles-
cents: Community Health Survey (RELACHS)—a representative cohort of young people aged 11–12 and 13–14 years
at baseline, followed-up after 2 years. Measurements Psychological distress and depressive symptoms identified by the
self-report Strengths and Difficulties Questionnaire and the Short Moods and Feelings Questionnaire at baseline and
follow-up. Data on overweight/obesity, general health, long-standing illness, physical activity, smoking, alcohol use and
drug use were collected from questionnaires completed by the adolescents at baseline and follow-up. Findings At
follow-up, 10.1% of males and 12.9% of females reported psychological distress; 20% of males and 33.7% of females
reported depressive symptoms. Having tried drugs or engaged in two or more health-risk behaviours (smoking, alcohol
use or drug use) at baseline predicted psychological distress and depressive symptoms at follow-up. Smoking on its own,
long-standing illness, obesity/overweight and activity levels were not associated with later psychological health.
Risk of poor psychological health at follow-up was associated strongly with psychological health at baseline.
Conclusions Psychological health at baseline was the strongest predictor of psychological health at follow-up. Engag-
ing in two or more health-risk behaviours moderately increased the risk of poor psychological health, suggesting that
prevention strategies targeting co-occuring substance use may reduce burden of disease.

Keywords Adolescence, alcohol, drug use, psychological health, smoking.

Correspondence to: Charlotte Clark, Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary’s School of
Medicine and Dentistry, University of London, Old Anatomy Building, Charterhouse Square, London, EC1M 6BQ, UK. E-mail: c.clark@qmul.ac.uk
Submitted 7 December 2005; initial review completed 7 March 2006; final version accepted 23 June 2006

INTRODUCTION Increasing rates of psychological ill health could be


linked to increasing rates of health-risk behaviours such
For many individuals mental disorders begin in early as smoking, alcohol and drug use [7]. Unlike innate risk
life [1] and there is increasing evidence of continuity factors, such as gender, health-risk behaviours are poten-
between common mental disorders in adolescence and tially modifiable through health promotion campaigns.
early adulthood [2–5]. Rates of psychological ill-health Prospective studies have investigated the role of smoking,
in adolescents are increasing [6] and identifying alcohol use and drug use in the aetiology of depression;
modifiable risk factors for adolescent psychological however, it has been difficult to establish the pathways
health becomes increasingly important, given the per- between substance use and psychological health, because
sistence of adolescent psychological health into of the considerable overlap in predictors [8]. Some studies
adulthood. have found that smoking leads to depression [9–12];

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
Health behaviour predictors of psychological symptoms 127

however, there is stronger evidence that depression pre- London. The schools were selected randomly and bal-
cedes smoking [9,12–19]. anced in terms of single-gender and mixed-gender
Conversely, cannabis and alcohol use may precede schools. Two classes from each year group were selected
depression [8,20,21]. However, a recent study found no from each school, which gives unequal probabilities of
prospective association between alcohol use and depres- selection. At baseline, 2790 adolescents from year 7 (11–
sion after adjustment for background factors such as 12 years) and year 9 (12–14 years) took part (84%
socio-economic status and previous psychological health response rate, 73% from non-white UK ethnicities). The
[22]. It has also been suggested that the pathway for can- participants were followed-up 2 years later when the ado-
nabis use may differ in adolescence and early adulthood, lescents were in year 9 (13–14 years) and year 11 (15–
with poor psychological health preceding cannabis use in 16 years), resampling 75% of the baseline participants.
adolescence and cannabis use preceding poor psychologi- Reasons for loss to follow-up included having left school
cal health in early adulthood [20]. between phases (7.8%), being absent from school with no
Despite the predominant focus upon individual reason (6.5%), parent opt-out (2.4%), being absent for
health-risk behaviours, we know that health-risk behav- other school activities (1.5%) and pupil opt-out (1.1%).
iours co-occur in adolescence [7,23,24]. This clustering
of health-risk behaviours has been explained by gateway Measures
theories, where the use of one substance leads to experi-
mentation and use of other substances [12,25] or by The questionnaire contained the same questions relating
common risk factors relating to substance use [26,27]. to psychological health, physical health and health-risk
Gateway effects are stronger in adolescence than in early behaviours at baseline and follow-up.
adulthood [28]. It is not known whether greater risk for
psychological health is related to individual health-risk Psychological health
behaviours or the co-occurrence of health-risk Two measures of psychological health were used. Psy-
behaviours. chological distress was measured by the self-report
Adolescent physical health also contributes to the aeti- Strengths and Difficulties Questionnaire (SDQ) [38,39],
ology of psychological health, yet fewer studies have inves- which is a psychometrically valid instrument for assess-
tigated these relationships. While there is cross-sectional ing psychological morbidity in British adolescents. An
support for associations between physical activity levels, overall score on the SDQ is derived by summing four
general health and psychological health [29–33], pro- subscales relating to conduct problems, emotional
spective studies of these associations are lacking [34]. difficulties, hyperactivity and peer relationship problems.
Furthermore, the pathways between obesity and psycho- A dichotomous measure of psychological distress was
logical health remain to be clarified: overall there is stron- derived, with a score equal or greater than 18 on the total
ger evidence that depression leads to later obesity [35,36] difficulties scale indicating caseness [40]. Depressive
than obesity leading to later depression [37]. Understand- symptoms were measured using the Short Moods and
ing the longitudinal associations between physical health Feeling Questionnaire (SMFQ) [41]. A dichotomous
and psychological health will enable the further identifi- measure of depressive symptoms was derived, with a
cation of risk factors, which are potentially modifiable. score of 8 or more symptoms indicating a high score.
Using longitudinal data from a community sample of
UK adolescents, we examine the contribution of physical
Physical health and health-risk behaviours
health and health-risk behaviours to the development of
psychological distress and depressive symptoms. It was Physical health and health-risk behaviour outcomes in
hypothesized that engaging in health-risk behaviours the baseline questionnaire included general health status
(smoking, alcohol use, drug use or the co-occurrence of (very good, good versus fair, bad, very bad), presence of a
these behaviours), general health, being overweight or long-standing illness (asthma, eczema, epilepsy, diabetes,
obese, being physically inactive and long-standing illness hearing problems, eyesight problems, hayfever, chronic
would increase the risk of later psychological distress and fatigue syndrome/ME or other chronic illness), physical
depressive symptoms. activity (active versus inactive, exercising more or less
than twice a week for an hour [42], smoking behaviour
(never smoked versus ever tried or regular smoker) [43],
METHODS
alcohol use (never tried, tried alcohol, consumed alcohol
The RELACHS study (Research with East London Adoles- in the past week) [43] and drug use (never tried versus
cents: Community Health Survey) is a longitudinal tried drugs—cannabis, glue/solvents/gas, ecstasy, crack,
school-based questionnaire study of a representative heroin, amphetamines, LSD, cocaine, khat) [43]. A com-
sample of adolescents attending 28 schools in East posite measure of health-risk behaviour was created from

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
128 Charlotte Clark et al.

the smoking behaviour, alcohol use and drug use ques- on a subsample with no psychological health problems at
tions, which measured whether the participant had baseline (model 3). All models were adjusted for age,
engaged in none, one, or two or more of these behaviours, gender and their interaction, eligibility for free school
as published previously [24]. The composite measure of meals and ethnicity. In addition, two versions of each
health-risk behaviour was substance-specific and did not model were conducted; the first adjusted for the individual
include any additional health-risk behaviours such as smoking, alcohol and drug health-risk behaviours at base-
sexual activity. line, the second adjusted for the composite measure of
In addition, at baseline all participants had their these health-risk behaviours at baseline. Odds ratios and
height (Leicester portable stadiometer, CMS Camden Ltd, corresponding 95% confidence intervals were calculated
London) and weight (Tanita Body Fact 300 electronic using the logistic regression command in STATA (version
scales, Tanita UK, Yiewsley, Middlesex) measured by 8), with the cluster option specified to take into account
trained researchers working to a strict protocol [44]. the clustering of pupils within schools. This option allows
These data were used to derive obesity and overweight for dependence between pupils in the same school.
outcomes for the sample, using the 1990 growth refer-
ence (UK 90) definitions [45]. Obesity was defined as a
body mass index (BMI) above the 95th percentile and RESULTS
overweight (which included obesity) being above the
The analyses were conducted on data from participants
85th percentile.
who had completed both the baseline and follow-up
survey and had complete data on psychological
Socio-economic status and ethnicity and physical health, as well as health behaviours
Socio-economic status was measured using data on each (unweighted n = 1615 for psychological distress;
pupil’s eligibility for free schools meals, which was pro- unweighted n = 1513 for depressive symptoms). Analy-
vided by schools and Local Education Authorities. Free ses were not stratified by gender, as there were no signifi-
school meals are known to be a reliable indicator of cant gender interactions between the predictors and
socio-economic status in UK studies of young people [46]. outcome measures. Loss to follow-up was greater for
Ethnicity was assessed using an adaptation of the Census respondents from the White UK, White Other and Mixed-
2001 questions; eight groups were use in the analysis race ethnicities but did not differ by age group.
(White UK, White Other, Bangladeshi, Pakistani, Asian,
Indian, Black, Mixed, Other). Rates of psychological distress and depressive symptoms
from baseline to follow-up
Procedure Table 1 shows the cross-sectional proportion of partici-
Parents were informed by letter about the study and pants reporting psychological distress and depressive
passive parental consent was sought (with active opt- symptoms by gender and age group, at baseline and
out). The participants were informed verbally about the follow-up. There were no significant gender differences in
study and gave written consent to take part. The ques- rates of psychological distress at baseline or follow up
tionnaire was group administered and completed by the (baseline: males 8.9%, females 9.3%; follow up: males
participants in classrooms under the supervision of the 10.1%, females 12.9%). Female participants reported sig-
research team, who answered any questions and checked nificantly higher rates of depressive symptoms than male
questionnaires for missing data. The research team also participants at baseline and follow-up (baseline 26.4%
took physical measurements in the classroom during this compared with 18.3%; follow-up 33.7% compared with
session. Ethical approval was obtained from the East 20.0%). There were no significant age differences in rates
London and City Local Research Ethics Committee. of psychological distress or depressive symptoms at base-
line or follow-up. Females were significantly more likely to
report depressive symptoms at both baseline and follow-
Statistical analysis
up, compared with males. Rates of psychological distress
All analyses were weighted to take account of unequal and depressive symptoms did not vary significantly by
probabilities of selection and differential sample attrition. socio-economic status (results not shown), which is con-
Logistic regression analyses were conducted to compare sistent with an earlier finding for the baseline data [40].
the risk for psychological distress or depressive symptoms Table 2 shows the longitudinal association between
at follow-up by physical health and health behaviours at psychological distress and depressive symptoms at base-
baseline (model 1). This model was then additionally line and follow-up. Few young people reported experienc-
adjusted for psychological distress or depressive symptoms ing psychological distress at both baseline and follow-up;
at baseline (model 2). Model 1 was additionally conducted however, there was a stronger continuity between

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
Table 1 Cross-sectional relationship between the proportion of participants with psychological distress (SDQ) and depressive symptoms (MFQ) by gender and age group, at baseline and follow-up (n, %).

SDQ MFQ

Not a case Case at Not a case Case at Not a case Case at Not a case Case at
at baseline baseline n (%) at follow-up follow-up at baseline baseline at follow-up follow-up)
n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Gender
Males 714 (91.1) 70 (8.9) 705 (89.9) 79 (10.1) 586 (81.7) 131 (18.3) 574 (80.0) 143 (20.0)
Females 729 (90.7) 75 (9.3) 700 (87.1) 104 (12.9) 564 (73.6) 202 (26.4) 508 (66.3) 258 (33.7)
P-value for c2 between gender 0.782 0.074 < 0.001 < 0.001
Bases (weighted) 1588 1588 1483 1483

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Age group
Year 7/9 635 (90.2) 69 (9.8) 620 (87.9) 85 (12.1) 496 (78.0) 141 (22.0) 473 (74.4) 163 (25.6)
Year 9/11 807 (91.3) 77 (8.7) 786 (89.0) 97 (11.0) 652 (77.1) 194 (22.9) 608 (71.8) 239 (28.2)
P-value for c2 between age group 0.460 0.505 0.675 0.267
Bases (weighted) 1588 1588 1483 1483

Unweighted base = 1615 for SDQ: Strengths and Difficulties Questionnaire (800 for males, 815 for females); unweighted base = 1513 for MFQ: Moods and Feelings Questionnaire (737 for males, 776 for females).
Health behaviour predictors of psychological symptoms
129

Addiction, 102, 126–135


130 Charlotte Clark et al.

Table 2 Longitudinal relationship between the proportion of participants with psychological distress (SDQ) and depressive symptoms
(MFQ) at baseline and follow-up (n, %).

Overall Males Females

Not a case Case at Not a case Case at Not a case Case at


at follow-up follow-up at follow-up follow-up at follow-up follow-up
n (%) n (%) n (%) n (%) n (%) n (%)

SDQ
Not a case at baseline 1313 (82.7) 130 (8.2) 655 (83.5) 59 (7.5) 658 (81.8) 71 (8.8)
Case at baseline 93 (5.9) 52 (3.3) 50 (6.4) 20 (2.6) 43 (5.3) 32 (4.1)
P-value (McNemar test*) 0.016 0.444 0.011
Bases (weighted)† 1588 784 804
MFQ
Not a case at baseline 925 (62.4) 224 (15.1) 499 (69.7) 86 (12.0) 426 (55.6) 138 (18.0)
Case at baseline 156 (10.5) 178 (12.0) 74 (10.3) 57 (8.0) 82 (10.7) 120 (15.7)
P-value (McNemar test*) < 0.001 0.385 < 0.001
Bases (weighted)‡ 1483 716 766

*Compares baseline with follow-up; †unweighted base = 1615 for SDQ: Strengths and Difficulties Questionnaire (800 for males, 815 for females);
‡unweighted base = 1513 for MFQ: Moods and Feelings Questionnaire (737 for males, 776 for females).

depressive symptoms at baseline and follow-up: 12.0% two or more health-risk behaviours at baseline predicted
reported depressive symptoms at both phases, while only depressive symptoms for those with and without depres-
3.3% reported psychological distress at both phases. sive symptoms at baseline. Having tried drugs at baseline
was associated with depressive symptoms at follow-up
Psychological distress, depressive symptoms and but not for the subsample without depressive symptoms
physical health and health-related behaviours at baseline.

Tables 3 and 4 compare the physical health and health


behaviours at baseline of young people with psychologi- DISCUSSION
cal distress and depressive symptoms at follow-up. Young
Having tried drugs or engaged in two or more health-risk
people with psychological distress and depressive symp-
behaviours (smoking, alcohol use or drug use) predicted
toms at follow-up were more likely to have had poor
psychological distress and depressive symptoms over a
general health, to have consumed alcohol in the past
2-year period in an ethnically diverse sample of young
week, to have tried drugs and to have engaged in two or
people. Psychological distress was predicted additionally
more health-risk behaviours at baseline.
by general health status and having tried or regularly
Odds ratios for psychological distress at follow-up were
consumed alcohol at baseline. These findings were robust
significantly higher for young people who also reported
after adjustment for baseline measures of psychological
psychological distress at baseline (Table 3). Having con-
symptoms with the exception of alcohol use, which was
sumed alcohol in the past week, having tried drugs and
borderline significant. Smoking on its own, long-standing
having poorer health at baseline predicted psychological
illness, obesity/overweight and activity levels were not
distress at follow-up. Engaging in two or more health-risk
associated with increased risk for psychological distress
behaviours at baseline was associated with increased risk
or depressive symptoms. The associations between
of psychological distress at follow-up. These findings were
physical health and health-risk behaviours at baseline
robust after adjustment for psychological distress at base-
and psychological health were moderate and stronger
line, with the exception of having consumed alcohol,
associations existed between psychological health at
which was borderline significant. Few associations were
baseline and follow-up.
observed for the subsample with no psychological distress
at baseline, and only having tried drugs or engaging in
What the results might mean
two or more health-risk behaviours increased the risk of
psychological distress at follow-up. Overall, health-risk behaviours showed moderate rela-
Odds ratios for depressive symptoms at follow-up were tionships with psychological health over a 2-year period,
significantly higher for young people who reported indicating that the targeting of health-risk behaviours
depressive symptoms at baseline (Table 4). Engaging in may reduce the burden of disease in terms of adolescent

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
Table 3 Multivariate odds ratios for psychological distress at follow-up predicted by baseline physical health and health related behaviours.

Proportions
with and without
psychological
distress at follow-up Model 1† Model 2† Model 3†‡
for each baseline factor n = 1615 n = 1615 n = 1461

Baseline risk factors n§ Not a case Case OR 95%CI OR 95%CI n OR 95%CI

Version A
Fair, poor or very poor health 421 24.2 36.8 1.69** 1.21, 2.36 1.46* 1.03, 2.09 352 1.34 0.84, 2.15
Long-standing illness 433 26.6 30.2 1.04 0.77, 1.39 0.97 0.69, 1.38 379 1.23 0.84, 1.82
Overweight 554 33.9 39.0 1.12 0.79, 1.58 1.15 0.82, 1.61 496 1.14 0.81, 1.60
Tried or regular smoker 571 35.5 41.0 0.99 0.72, 1.35 0.98 0.71, 1.36 508 0.98 0.67, 1.43
Not consumed alcohol in past week 333 21.1 31.3 1.43 0.76, 2.68 1.48 0.78, 2.80 300 1.38 0.73, 2.59
Consumed alcohol in past week 79 5.3 13.4 2.14* 1.01, 4.51 2.05 0.94, 4.48 67 1.51 0.69, 3.29

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Inactive 827 48.9 45.6 0.88 0.67, 1.16 0.91 0.69, 1.20 724 0.90 0.64, 1.24
Tried drugs 154 8.7 16.5 1.71* 1.10, 2.64 1.49 0.97, 2.31 127 *1.62 1.02, 2.59
SDQ case at baseline 154 6.3 3.3 – – 5.19*** 3.32, 8.11 – –
Version B
Obesity 317 19.2 23.1 1.10 0.71, 1.69 1.10 0.72, 1.80 218 0.94 0.61, 1.46
Version C
One health-risk behaviour 474 36.5 38.8 1.17 0.77, 1.76 1.11 0.75, 1.64 426 1.04 0.65, 1.66
Two or more health-risk behaviours 294 24.4 40.2 2.05** 1.30, 3.23 1.95** 1.18, 3.22 257 1.86* 1.05, 3.29

***P < 0.001, ** P < 0.01, *P < 0.05. †All models are adjusted for age, gender, gender ¥ age, ethnicity, eligibility for free school meals. Version A further adjusts for general health status, long-standing illness, overweight, smoking,
alcohol use, drug use. Version B as Version A but adjusts for obesity rather than overweight. Version C as Version A but adjusts for clustering of health-risk behaviours rather than the individual smoking, alcohol and drug use
variables. ‡Model run on subsample who did not have psychological distress at baseline. §Number of respondents reporting the behaviour at baseline out of the total n = 1615: SDQ Strengths and Difficulties Questionnaire.
Health behaviour predictors of psychological symptoms
131

Addiction, 102, 126–135


132

Table 4 Multivariate odds ratios for depressive symptoms at follow-up predicted by baseline physical health and health related behaviours. †

Proportions
with and without
depressive
Charlotte Clark et al.

symptoms at follow-up Model 1† Model 2† Model 3†‡


for each baseline factor n = 1513 n = 1513 n = 1170

Baseline risk factors n§ Not a case Case OR 95%CI OR 95%CI n OR 95%CI

Version A
Fair, poor or very poor health 402 23.6 33.2 1.42*** 1.15, 1.76 1.22 0.96, 1.55 267 1.14 0.83, 1.56
Long-standing illness 401 26.2 27.9 1.03 0.84, 1.25 0.96 0.78, 1.18 286 0.95 0.74, 1.22
Overweight 521 33.1 38.9 1.20 0.95, 1.53 1.16 0.90, 1.50 385 1.20 0.91, 1.57
Tried or regular smoking 533 34.5 40.4 1.17 0.88, 1.56 1.07 0.80, 1.43 358 1.29 0.96, 1.72
Not consumed alcohol in past week 320 22.1 23.9 1.10 0.78, 1.55 1.03 0.70, 1.50 228 0.88 0.53, 1.47
Consumed alcohol in past week 76 5.5 8.0 1.38 0.84, 2.26 1.52 0.90, 2.56 59 1.39 0.81, 2.36
Inactive 772 50.2 44.5 0.93 0.69, 1.25 0.96 0.71, 1.29 585 1.01 0.71, 1.45

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Tried drugs 148 8.0 15.0 1.84*** 1.27, 2.66 1.79*** 1.25, 2.57 102 1.72 0.95, 3.10
MFQ case at baseline 343 10.6 12.1 – 4.34*** 3.32, 5.68 – –
Version B
Obesity 296 19.1 21.4 1.04 0.80, 1.36 0.99 0.75, 1.30 214 0.92 0.57, 1.48

Version C
One health-risk behaviour 449 35.8 40.5 1.42 0.96, 2.09 1.28 0.86, 1.90 335 1.49* 1.02, 2.18

Two or more health-risk behaviours 278 24.4 32.7 1.74*** 1.25, 2.41 1.53* 1.07, 2.19 195 1.67* 1.11, 2.51

***P < 0.001, *P < 0.05. †All models are adjusted for age, gender, gender ¥ age, ethnicity, eligibility for free school meals. Version A further adjusts for general health status, long-standing illness, overweight, smoking, alcohol use,
drug use. Version B as Version A but adjusts for obesity rather than overweight. Version C as Version A but adjusts for clustering of health-risk behaviours rather than the individual smoking, alcohol and drug use variables. ‡Model
run on subsample who did not have depressive symptoms at baseline. §Number of respondents reporting the behaviour at baseline out of the total n = 1513: MFQ Moods and Feelings Questionnaire.

Addiction, 102, 126–135


Health behaviour predictors of psychological symptoms 133

psychological health and early adulthood psychological pathways for accessibility to substances are through
health. Stronger associations existed between psychologi- peers and siblings who are already users [48–52].
cal health at baseline and follow-up. Young people with Our findings partially support previous findings relat-
psychological ill-health at baseline were four to five times ing to physical health behaviours and risk of psychologi-
more likely to experience psychological distress or depres- cal ill-health. We found a significant association between
sive symptoms at follow-up, suggesting that prevention general health and psychological health, supporting pre-
strategies may be more successful in reducing the burden vious cross-sectional findings [29,30]. Interestingly, no
of disease by focusing on young people with a history association was found for long-standing illness, which we
of psychological ill-health, as well as health-risk might expect to show a similar relationship with psycho-
behaviours. logical health. One reason for this is that perceived
In terms of individual health-risk behaviours, drug general health may encompass a physical and psycho-
use showed the strongest associations with later psycho- logical evaluation of health, whereas long-standing
logical health and our findings support the argument for illness reflects only physical health. It is likely that an
drug use preceding psychological distress [8,21]. Drug evaluation of health with a psychological component
use in this sample, particularly the younger age group would be associated with mental health bias. Our findings
(aged 11–12) is indicative of non-normative behaviour, suggest that young people with poor general health may
so we should not be surprised that it relates to later psy- be a vulnerable group at risk of developing psychological
chological health problems. The association between ill-health.
having consumed alcohol at baseline and psychological Measures of overweight and obesity showed little rela-
distress at follow-up was of borderline significance after tionship with psychological health over a 2-year period.
adjustment for psychological distress at baseline, support- Previous studies have also failed to demonstrate an asso-
ing a previous study which found no prospective associa- ciation between obesity and later depression, but have
tion between alcohol use and depression after adjustment found an association between depression and later
for prior psychological health [22]. Together these studies obesity [33,35,36]. We found no association between
provide limited support for the argument that alcohol use levels of physical activity at baseline and psychological
precedes depressive symptoms [20]. health at follow-up, unlike a recent cross-sectional study
Surprisingly, no associations were demonstrated that found an association in males [33]. The lack of asso-
between smoking and later psychological health, con- ciations observed between physical health and psycho-
trary to previous findings [9–12]. The lack of replication logical health could reflect the relatively short follow-up
may be because our sample are younger than in previous period of the study. Pathways of risk between obesity and
studies; few respondents reported smoking regularly physical activity, and psychological health may occur
(> 1 cigarette a week), and in our analyses regular later in adolescence or take longer to develop than the
smokers were combined with respondents who reported 2-year time frame of this study.
having tried smoking, which may have limited the power
of the analyses.
Strengths and limitations
No gender differences were found in the associations
between health-risk behaviours and psychological Earlier studies have been limited in the range of physical
health, suggesting that risk does not differ for males and health and health-risk behaviours examined. This study
females. While our findings are in contrast to those of of a representative ethnically diverse sample of East
some recent studies [20,21,47], our sample is younger London adolescents has used validated questions to inves-
and it is possible that gender differences in these associa- tigate the risk associated with a wide range of physical
tions develop in later adolescence. health and health-risk behaviours for adolescent psycho-
Prevention strategies targeting young people engag- logical health. This study has a high participation rate at
ing in co-occurring substance use, rather than specific, baseline and follow-up.
individual substance use behaviours, may reduce the The follow-up period of the study was limited to 2
burden of disease. This study is unable to cast light upon years, which may affect the strength of associations
theories of the co-occurrence of health-risk behaviours. observed for some predictors and limit the conclusions
Study of the development of the co-occurrence of that can be drawn about pathways of causality between
health-risk factors would require more frequent longitu- general health, health-risk behaviours and psychological
dinal data collection than the 2-year time-frame of this health. In addition, further risk factors such as peer and
study. From our data it is unclear whether use of one sibling influences on substance availability and sexual
substance leads to experimentation with other sub- activity were not assessed at baseline. The analyses are
stances or whether there are shared risk factors for sub- based on self-report and are also limited to participants
stance use. Previous studies have found that the key with complete data for all the outcomes. We may have

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
134 Charlotte Clark et al.

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