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* Departments of Behavioral Sciences and Health Education
# Biostatistics, Emory University, Rollins School of Public Health, Atlanta, Georgia
Department of Pediatrics, Division of Infectious Diseases, Epidemiology, and Immunology, Emory University School of Medicine, Atlanta, Georgia
Emory Center for AIDS Research, Atlanta, Georgia
|| School of Public Health at the University of Kentucky, Lexington, Kentucky
¶ Department of Pediatrics, University of Alabama, School of Medicine, Birmingham, Alabama
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. Adolescents were recruited from high-risk neighborhoods in Birmingham, Alabama. The sample comprised 460 black female adolescents (aged 14–18 years) who completed assessments at baseline and at 6 and 12 months. Only adolescents who consistently scored above the threshold for depression at all 3 assessments (n = 76) or below the threshold at all 3 assessments (n = 174) were included (N = 250) in the data analysis. Within this sample, adolescents who were depressed were compared with those who were not depressed with respect to the following health consequences: low self-esteem, emotional abuse, physical abuse, verbal abuse, poor body image, and antisocial behavior.
Results. Using generalized estimating equations and controlling for covariates, depressed adolescents were 5.3 times more likely to report low self-esteem, 4.3 times more likely to report emotional abuse, 3.7 times more likely to report being physically abused, and almost 3 times as likely to report being verbally abused. Furthermore, depressed adolescents were more than twice as likely to report poor body image and nearly twice as likely to report engaging in antisocial behaviors.
Conclusions. The findings suggest that a broad range of adverse health consequences may accompany depression among black female adolescents. Physicians need to be alert to the co-occurrence of depression and low self-esteem; emotional, physical, and verbal abuse; poor body image; and antisocial behaviors among this population.
Key Words: adolescent depression • adolescent health • adolescent sexual behavior • adverse outcomes • black
Abbreviations: CES-D, Center for Epidemiological Studies Depression Scale • GEE, generalized estimating equations
One of the most consistent findings in the adolescent literature is the higher prevalence of depression among girls compared with boys.1–5 Moreover, this gender difference in prevalence rates continues into adulthood.6 Few studies, however, have examined the association between black female adolescents' depression and the co-occurrence of adverse health consequences.
Depression has been associated with diverse adverse health consequences, including greater use of alcohol,7 increased sexually transmitted disease/HIV-related behaviors,8,9 eating disorders,10 sexual and physical abuse, and poor school performance.11 The relationship between adolescent depression and adverse health consequences has been examined primarily in clinic-based samples. Although these studies consistently document a relationship between depression and adolescents’ adverse health consequences, the findings are limited by the clinical nature of these samples. Furthermore, most studies that have examined these relationships have used a cross-sectional research design with a single assessment point. Given the high prevalence of depressive symptoms among black female adolescents,12 investigations that include a broader community representation of adolescents and that incorporate repeated measures designs are needed. Accordingly, the purpose of this study was to identify prospectively adverse health consequences that may co-occur with depression among a diverse sample of black female adolescents.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Design
The present study was part of a larger, intervention study. The study was designed to test for co-occurrences over 3 waves of data collection. Co-occurrence suggests that adolescents experience depression and any of the assessed adverse health outcomes simultaneously. Rather than an academic pursuit of determining cause and effect, we were concerned with identifying adverse health consequences that may accompany depression among black female adolescents.
A total of 460 adolescents completed baseline plus 6- and 12-month follow-up assessments. For providing a robust basis for comparing depressed with nondepressed adolescents, adolescents with depression scores that were "mixed" (ie, depressed at one time point but not another) were not included in the analysis. Thus, the analytic sample was composed of adolescents who were characterized into 2 groups: (1) consistently depressed at baseline and 6- and 12-month assessments (n = 76) and (2) consistently not depressed at the baseline and 6- and 12-month assessments (n = 174). This design allowed for a comparison of adverse health outcomes (occurring 1, 2, or 3 times during the 12-month period of observation) between adolescents who were consistently depressed versus those who were consistently not depressed. Thus, depression may be viewed (in the context of this design) as a stable construct and the adverse health outcomes as constructs that were free to vary. This design enabled us to identify forms of psychosocial burden that may accompany depression among black female adolescents.
Measures
Depression
Depression was assessed by using the Center for Epidemiological Studies Depression Scale (CES-D).13–15 The CES-D is 1 of the most frequently used self-report scales developed specifically as a screening instrument for depression in the general population. The instrument is not a psychiatric diagnostic tool and, thus, does not measure the presence of clinical depression. However, individuals who are classified as being depressed by the CES-D and are not clinically depressed are nonetheless likely to experience substantial psychosocial dysfunction.16 Thus, in this study, depression is considered a form of psychosocial impairment (ie, depressed affect) rather than clinical depression.
The CES-D has been shown to have desirable psychometric properties, including good internal consistency, acceptable test-retest reliability, and a high correlation with clinical diagnosis of depression.14,17–20 Although originally designed as a dimensional assessment of depression in adults, the instrument has also been used to screen for depression in children and adolescents,21–23 in whom it has similar psychometric properties to those shown in adults.24 The CES-D has demonstrated the ability to discriminate children with depressive disorders from those without psychopathology,22,23 to be valid for black individuals, to discriminate depressive disorders from other forms of psychopathology,24,25 and to have substantial correlations with other self-report measures of depressive symptoms and clinical ratings of depression, supporting the scale's validity.
The present study used the brief version of the CES-D. This version has 8 items and is highly correlated (r = 0.93) with the full 20-item scale. Sample items included, "I felt that I could not shake off the blues even with help from my family and friends," and, "I thought my life had been a failure." Adolescents report the frequency with which they experienced 8 depressive symptoms during the 7 days before assessments on a 4-point Likert scale ranging from 0 (<1 day) to 3 (5–7 days). A composite score is calculated by summing item responses (range: 0–24). Adolescents were categorized according to the recommended criterion for depression, with adolescents who had composite scores of 
7 being defined as depressed and adolescents with scores <7 defined as not depressed.26 The internal consistency of the scale with the present sample of black female adolescents was 0.83 and 0.87, respectively, for the 6- and 12-month follow-up assessments.
Adverse Health Consequences
The survey assessed a range of psychosocial burdens, including reports of verbal, emotional, and physical abuse in the past 6 months (eg, "In the past 6 months, has a boyfriend verbally abused you?"); antisocial behavior; self-esteem; and body image. Antisocial behavior was defined as having ever hit a teacher, been arrested, or been in a gang (eg, "Have you ever been in a gang?"). Adolescents who reported any of these behaviors were categorized as engaging in antisocial behavior.
Self-esteem was assessed using the Rosenberg self-esteem scale.27 This scale has been used widely with diverse populations (including black female adolescents) and has demonstrated satisfactory internal consistency in the present study (
= .79). The distribution of self-esteem scores was markedly skewed; thus, adolescents were classified as having "high" or "low" self-esteem on the basis of a median split of the distribution of self-esteem scores.
Body image was assessed using a modified version of the Ben-Tovim Walker Body Attitudes Questionnaire.28 The body image scale had acceptable internal consistency ( = .71). The distribution of body image scores was also skewed; thus, adolescents were classified as having "good" or "poor" perceptions of their body image on the basis of a median split of the distribution of body image scores. The median split was computed for the sample of 250 adolescents.
Sociodemographic Characteristics
The survey also assessed sociodemographic characteristics such as age, education, and whether the adolescent's family received government assistance.
Data Analysis
The multivariate technique of generalized estimating equations (GEE)29–31 was used to examine the relationships between subsequent reported depression and reported adverse health outcomes while accounting for the longitudinal design of the study. Because adolescents were assessed at 2 points during the follow-up period, an autoregressive correlation structure was used to control for the correlation between assessments of reported depression and reported adverse health outcomes at any number of the 3 assessment periods. A separate GEE model was constructed for each adverse health outcome considered. Each analysis yielded a single odds ratio estimate for depressed adolescents who reported 1 or more occurrence of any given adverse health outcome compared with nondepressed adolescents. In addition, because the present study was part of a larger, intervention study, we controlled statistically for treatment condition in each GEE model. Analyses were performed using Stata statistical software package, version 7.32
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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GEE Analyses
Adolescents who were classified as being depressed, relative to those who were classified as not being depressed, were significantly more likely to report each of the adverse health consequences assessed during the 12-month observation period. Depression was most strongly associated with adolescents' reporting low self-esteem. Compared with adolescents who were not depressed, depressed adolescents were 
5.3 times more likely to report low self-esteem (P = .0001). Furthermore, adolescents who reported being depressed were 4.3 times more likely to report the experience of emotional abuse during the 12-month follow-up (P = .001), >3 times as likely to report the experience of physical abuse (P = .002), and almost 3 times as likely to report the experience of verbal abuse (P = .007). Depressed adolescents were more than twice as likely to report poor body image (P = .0001) and 1.8 times as likely to report engaging in antisocial behaviors (P = .025; Table 2).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Increasing evidence suggests that mental disorders are often present at or near the time when adolescents experience adverse health outcomes such as the forms of psychosocial burden identified in this study. Whether psychopathology is preexistent, co-occurs with adverse health outcomes, or is 1 of its consequences is a complex question that awaits additional, more detailed, study. Nonetheless, evidence suggests that most adverse health outcomes do not occur alone; rather, they often cluster with other adverse health outcomes and psychopathology.33,34 Thus, future research should investigate other forms of psychosocial burden and various forms of health risk behavior that may accompany depression among black female adolescents.
Pediatricians, adolescent medicine specialists, and family practitioners have an integral role to play in adolescent health promotion35,36 as they are primarily responsible for providing care to adolescents. Moreover, pediatricians can assess adverse health outcomes and provide adolescents with preventive education, risk-reduction counseling, and referral for a more detailed psychiatric evaluation and specialized counseling.37–42 Specifically, findings from this study suggest that screening for depression is a critically important practice because depression may serve as a marker of other mental health problems (eg, low self-esteem, poor body image), abuse (eg, emotional, verbal, or physical abuse from a boyfriend), or antisocial behaviors. To the extent that these forms of psychosocial burden may, in turn, lead adolescents to engage in health risk behaviors, depression may indeed spawn a cascade effect that culminates in negative health status. Because the CES-D is only an 8-item measure, it can be easily incorporated into clinical protocols, as either a self-administered instrument or an interview during the intake procedure or comprehensive medical history, thus allowing clinicians to screen adolescents efficiently in general medical settings.
Limitations
The present study is not without limitations. Several studies report a modest relationship between the CES-D and a diagnosis of depression from a structured clinical interview.15,43 Adolescents with scores above the CES-D criterion may not meet diagnostic criteria for a "clinical case"; however, there are likely important psychological differences between those who score above and below the cutoff. Second, the CES-D assessed frequency of depressive symptoms over a 7-day period before completing each of the 3 assessments. Therefore, the CES-D may not be a valid measure of depressive symptoms during the entire follow-up period when adverse health outcomes may have occurred. Recent evidence, however, suggests that depressive symptoms are relatively stable throughout adolescence.44 Finally, the findings may not be generalized to other racial/ethnic groups. Additional research is needed to corroborate these findings with diverse adolescent populations.
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CONCLUSIONS |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Ralph J. DiClemente, PhD, Rollins School of Public Health/BSHE, Emory University, 1518 Clifton Rd, NE, Suite 554, Atlanta, GA 30322. E-mail: rdiclem{at}sph.emory.edu
No conflict of interest declared.
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This article has been cited by other articles:
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  R. J. DiClemente, L. F. Salazar, and R. A. Crosby A Review of STD/HIV Preventive Interventions for Adolescents: Sustaining Effects Using an Ecological Approach J. Pediatr. Psychol., September 1, 2007; 32(8): 888 - 906. [Abstract] [Full Text] [PDF]
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 E. G. Flaherty, R. Thompson, A. J. Litrownik, A. Theodore, D. J. English, M. M. Black, T. Wike, L. Whimper, D. K. Runyan, and H. Dubowitz Effect of Early Childhood Adversity on Child Health Arch Pediatr Adolesc Med, December 1, 2006; 160(12): 1232 - 1238. [Abstract] [Full Text] [PDF]
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