Abstract
Based on former empirical studies and theoretical models the present study investigated, whether stress symptoms, stress coping and somatic complaints are different between depressed girls and healthy controls. 148 girls with a mean age of 15 years were studied twice with 6 months between the two assessments. 74 fulfilled DSM IV criteria for major depression at first assessment. Stress symptoms, stress coping and somatic complaints were measured with validated German questionnaires. Depressed girls showed more stress symptoms and a higher stress vulnerability. On the other hand in stress coping depressed girls preferred destructive strategies and had a lack of useful behaviors such as problem solving or search for social support. Somatic complaints had a significant influence on severity of depression six months later. The results were interpreted with respect to the cognitive model of Beck.
Keywords: Stress; Depression; Stress coping; Somatic complaints; Girls; Cognitive model
Depression in Children and Adolescents is Frequent
In a representative sample from Germany lifetime prevalence for depression in youth of 21% was found [1].
In Middle East countries 57% of youth have been observed to be depressed [2].
A unique and consistent model for etiology and maintenance of depression in adolescents is not available at present. Therefore, we review empirically supported factors, that have been proposed by [3] as a basis for explaining depression in adolescents.
Social Factors
The risk to develop a psychiatric disorder in general is heightened for children from families with a low socioeconomic status. This has been already shown in a large epidemiological study by [4]
Children from families with a low income had a threefold greater probability to develop a depressive disorder. This has been confirmed in a study by [5].
Factors Related to the Families of Depressed Children
The families are characterized by the lack of positive supporting interactions with parents. These may be extremely focusing on conflicts and therefore provoke anger and aggression in children. Such conditions are especially present, when a high degree of parental psychopathology could be identified [6].
The Significance of Stress for the Depressive Disorder
A controlled study of [7] showed that psychosocial stressors reinforce the depression and are also more frequent as a consequence of depression.
This has been supported in a study of [8] by a longitudinal analysis.
Inadequate stress coping
Destructive stress coping in adolescents diagnosed as depressed has been found in [9]
Neuroendocrine Findings
The severity of depressive symptoms is significantly correlated with cortisol levels during a laboratory stressor [10].
A long duration of depression leads to stress related hyperactivity of HPA axis [11].
A dysregulated feedback of cortisol secretion after stress is reported by [12]. Cortisol does not recover.
A lack of social support results in a hyperactivity of HPA axis. Not seeking social support then is responsible for the maintenance of depression as well as for hyperactivity of the HPA axis [13].
Somatic Complaints in Depressed Youth
In a twin study with 1300 families explained variance in depression by somatic complaints was 44% [14].
Complaints which were in particular related to sleep have been observed in 38% in a sample of [15].
The empirical literature shows, that depression in adolescents is characterized by a high stress load but on the other hand by inadequate stress coping. In addition somatic complaints are frequent. In a longitudinal design the present study investigated differences in stress load, stress coping, and somatic complaints between depressed girls and controls. Differences in activity of HPA axis are also taken into account.
Methods
All Patients were recruited from the Department of child and adolescent psychiatry in a general hospital in Trier and fulfilled DSM IV criteria for major depression which was proved by a structured clinical interview.
A control group was recruited by advertisements in the local newspaper.
The study was approved by the ethical committee of the University of Trier (17.2.2010).
All participants were paid for participation.
Patients and controls were assessed twice with a time interval of 6 months between the two measurement points.
There were no significant differences between patients and controls with respect to these characteristics.
Questionnaires
The severity of depression was assessed by the Depression Inventory for children and adolescents (DIKJ) [16].
Coping Strategies
Reactions to stressful situations were obtained by the coping questionnaire for children and adolescents (SVF-KJ) [17]. The questionnaire measures reactions to stress, when a stress situation is imaged. It comprises strategies which reduce stress as well as strategies that enhance stress. 9 subscales are provided.
Stress Load
Stress load was assessed by the questionnaire for stress and stress coping for children and adolescents (SSKJ). [18].
The subscales comprise 1.vulnerability to stress, 2. physical symptoms of stress such as headache, stomach ache or exhaustion. 3. psychological symptoms of stress such as depressed mood and anxiety.
All participants collected saliva samples after awakening to determine cortisol.
Somatic complaints were measured by the Giessen Complaint Questionnaire for children (GBB) [19]. It comprises the subscales exhaustion, stomach ache, pain in legs, circulatory problems, and complaints of a cold.
Results
The depressed girls had a mean value of 19.3 ± 7.5, the controls of 9.7 ± 6.4 on the Depression Scale.
As expected the mean for the depressed girls was significantly higher and indicates clinically significant depression according to norm-tables for this questionnaire.
Major Depression (n=74)
Controls (n=74)
Age (years)
15.7 ± 2.1
15.1 ± 2.4
High school (%)
66
81
Parents academic education %
4
10
Table 1: Description of the sample.
Scale of SSKJ
Controls
Major Depression
Stress vulnerability
15.5 ± 3.0
17.7 ± 2.8
Physical stress symptoms
10.1 ± 2.7
11.8 ± 3.0
Psychol. stress symptoms
21.9 ± 5.5
27.6 ± 5.1
Table 2: Mean values for stress load in patients and controls.
Scales of SVFKJ
Controls
Major Depression
Down playing
17.2 ± 5.4
14.9 ± 5.4
Distraction
11.2 ± 5.5
9.6 ± 5.0
Control of stress
23.2 ± 4.3
19.9 ± 5.9
Positive self instruction
22.5 ± 5.0
18.0 ± 6.7
Social suport
20.4 ± 4.9
18.1 ± 5.9
Passive avoidance
13.8 ± 6.3
19.0 ± 7.1
Rumination
17.9 ± 6.1
21.5 ± 7.0
Resignation
8.5 ± 5.8
13.7 ± 7.5
Aggression
11.7 ± 6.4
15.6 ± 6.9
Table 3: Mean values for stress coping strategies in patients and controls.
Time of cortisol sample
Controls
Major Depression
Awakening
7,2 ± 3,8
6,7 ± 3,5
+ 30 minutes
10,4 ± 3,9
10,8 ± 4,4
+ 45 minutes
9,9 ± 3,9
11,3 ± 4,2
+ 60 minutes
8,9 ± 4,0
10,7 ± 4,3
Table 4: Mean cortisol after awakening for the comparison groups (Mean ± SD) in nmol/ml.
GBB-KJ scale
Controls
Major Depression
Exhaustion
8.7 ± 4.9
14.2 ± 5.4
Stomachache
7.1 ± 3.4
9.4 ± 4.0
Pain in legs
5.4 ± 3.9
8.7 ± 5.3
4.1 ± 3.5
8.0 ± 4.5
Complaints of a cold
10.4 ± 4.3
11.7 ± 4.5
Table 5: Somatic complaints for girls with depression and controls (M ± SD).
Somatic complaints were obtained with the Giessen Complaint Questionnaire for children (GBB). It comprises the subscales exhaustion, stomach ache, pain in legs, Circulatory problems, and complaints of a cold. Internal consistency of the subscales is 80 [16].
The statistical analysis for comparison between depressed patients and controls with MANOVA for all three scales simultaneously was significant with F (3, 144) = 16.2, p<.001.
The depressed girls had significantly higher mean values on all three scales
They felt more stress load physically as well as psychologically and were more vulnerable to the perception of stress situations.
The comparison of the means with a MANOVA for all 9 scales simultaneously yields F (9, 138) = 4.4, p<.001.
The coping strategies of the girls with depression were significantly more inadequate than those of the controls.
They avoid stress situations passively. If a stress situation was present, they ruminate extensively over the situation. Resignation and aggression are also possible, whereas a lack of constructive reactions such as the search for social support can be observed.
Mean cortisol over time was analyzed by MANOVA for repeated measurement. A significant interaction effect between cortisol over time and comparison group was found. ), F (3,132) = 3.01, p < .04. Excluding awakening all means were higher for girls with major depression.
The comparison of the mean values with MANOVA for all scales simultaneously yielded F (5, 139) = 10.1, p<.001, depressed girls suffered significantly more by somatic complaints, in particular by exhaustion, pain in legs and circulatory problems.
Linear multiple regression analysis was used to identify effects of somatic complaints on severity of depression after six months.
Regression Analysis 1
Dependent variable was severity of depression according to DIKJ
As predictors served psychological stress load, physiological stress load, the coping strategy passive avoidance and mean cortisol 60 minutes after awakening.
The regression equation was significant with F (4,136) = 17, 4 p<.001 and an explained variance of 32%. Significant predictors were psychological stress load, the coping strategy, and mean cortisol.
Regression Analysis 2
Dependent variable was severity of depression according to DIKJ
As predictors served psychological stress load, physiological stress load, the coping strategy passive avoidance, mean cortisol 60 minutes after awakening and somatic complaints at first measurement. The regression equation was significant with F (9,135) =10, 5 p<.001 and an explained variance of 39%. Significant predictors were psychological stress load, circulatory problems, pain in legs, and mean cortisol after awakening.
Discussion
Female adolescents with depression reported a markedly higher stress load than non-depressed young girls. This was true for general vulnerability against stress, for psychological stress load and also for physiological signs of stress.
This is a confirmation of data which are known from former investigations.
In a study with standardized diaries in 15-year-old depressed children a heightened vulnerability to stressors such as family conflicts or school problems was a highly significant predictor for maintenance of depressive symptoms [22]. And may also be interpreted as a risk factor for developing depression. A correlation between stress load and depression has been seen in a case-control study.
Inadequate stress coping is also figured in [23]. A high degree of depression led to behavior such as denying stress, rumination, self blame, and resignation, but not to constructive tries to deal with stress such as problem-solving
The results which have been found for depressed adolescents can be integrated into a cognitive model of depression that has been proposed for adults by [20] A high stress load on a physiological as well as psychological level activates in the short term inadequate stress coping strategies and cognitions such as resignation, rumination or aggression which prevent an adequate coping in the long-term and therefore support maintenance of depressive symptoms. Empirical support for this interpretation comes from a longitudinal study of [21], who investigated cognitive factors in depressed adolescents and confirmed the postulates of Beck rather than the response style theory.
The results of the regression analyses seem to be a meaningful extension of previous data insofar as a significant influence of somatic complaints on maintenance of depressive symptoms can be concluded. A treatment recommendation may be to diagnose somatic complaints carefully and probably take into account medication or family assessment [22].
The present study cannot be interpreted without limitations. The sample size was relatively small and only girls have been investigated. A generalization to boys at the moment is not possible. Also the age range was restricted to younger adolescents. Further it has to be considered that all information was based on self ratings and future investigation should take into account external evaluation.
Ethics Approval and Consent to Participate
The study was approved by the ethical committee of University of Trier (0505 2011). All participants gave their written informed consent to participate.
Competing Interest
Competing interests the author declares that there are no competing interests.
Authors Contributions
R. L. planned this study, collected the data, did the statistical analysis, wrote and reviewed the manuscript.
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