Published online July 3, 2006
PEDIATRICS Vol. 118 No. 1 July 2006, pp. 189-200 (doi:10.1542/peds.2005-1320)
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Right arrow Adolescent Medicine

Depressive Symptoms as a Longitudinal Predictor of Sexual Risk Behaviors Among US Middle and High School Students

Jocelyn A. Lehrer, ScDa, Lydia A. Shrier, MD, MPHb, Steven Gortmaker, PhDc and Stephen Buka, ScDc

a Bixby Center for Reproductive Health Research and Policy, University of California, San Francisco, California
b Division of Adolescent Medicine, Harvard Medical School, Children’s Hospital Boston, Boston, Massachusetts
c Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The purpose of this study was to examine whether depressive symptoms are predictive of subsequent sexual risk behavior in a national probability sample of US middle and high school students.

METHODS. Sexually active, unmarried, middle and high school students (n = 4152) participated in home interviews in waves I and II of the National Longitudinal Study of Adolescent Health, at an ~1-year interval. Associations between baseline depressive symptoms and sexual risk behaviors over the course of the following year were examined separately for boys and girls, adjusting for demographic variables, religiosity, same-sex attraction/behavior, sexual intercourse before age 10, and baseline sexual risk behavior.

RESULTS. In adjusted models, boys and girls with high depressive symptom levels at baseline were significantly more likely than those with low symptom levels to report ≥1 of the examined sexual risk behaviors over the course of the 1-year follow-up period. For boys, high depressive symptom levels were specifically predictive of condom nonuse at last sex, birth control nonuse at last sex, and substance use at last sex; these results were similar to those of parallel analyses with a continuous depression measure. For girls, moderate depressive symptoms were associated with substance use at last sex, and no significant associations were found between high depressive symptom levels and individual sexual risk behaviors. Parallel analyses with the continuous depression measure found significant associations for condom nonuse at last sex, birth control nonuse at last sex, ≥3 sexual partners, and any sexual risk behavior.

CONCLUSION. In this study, depressive symptoms predicted sexual risk behavior in a national sample of male and female middle and high school students over a 1-year period.

Key Words: adolescents • depressive symptoms • depression • sexual behavior • unsafe sex • HIV

Abbreviations: SRB—sexual risk behavior(s) • STI—sexually transmitted infection(s) • CES-D—Center for Epidemiologic Studies-Depression Scale • CI—confidence interval • A-CASI—audio-computer-assisted self-interview

Although depressive symptoms and sexually transmitted infections (STI), including HIV, are salient public health problems faced by US adolescents, few studies have examined the extent to which depressive symptoms among adolescents may contribute to HIV/STI risk over time. Insofar as sexual risk behaviors (SRB) such as condom nonuse and multiple partners contribute to HIV/STI risk,1 improved understanding of the contribution of depressive symptoms to SRB is needed to more effectively identify youths at elevated risk of HIV/STI and to design maximally effective prevention programs for youths.

In 2003, 45% of female and 48% of male high school students in the national Youth Risk Behavior Survey sample reported ever having had sexual intercourse, and 11% of girls and 18% of boys reported having ≥4 lifetime sexual partners. Among sexually active adolescents, 43% of girls and 31% of boys did not report condom use at last sex, and 21% of girls and 30% of boys reported use of alcohol or other drugs at last sex.2 Although trends since 1991 for some youth SRB have been encouraging,3,4 the prevalence of SRB among youths remains high. In turn, recent estimates suggest that almost 50% of the 19 million new cases of STI in the United States each year occur among youths 15 to 24 years of age.5 At least 50% of new HIV infections have been estimated to occur among youths <25 years of age,6 and most recent infections among young people have been transmitted sexually.7,8

Brown et al9 noted that, although adolescents as a population have high rates of SRB and STI, adolescents do not represent a homogeneous group; certain subpopulations, including youths with psychiatric difficulties, may be at elevated risk of adverse behaviors and outcomes. Major depression is among the most common mental health problems faced by youths, with estimates of lifetime prevalence over the course of adolescence ranging from 15% to 20%.10 High rates of subthreshold depressive symptoms among youths have also been reported. For example, 11% of subjects 15 to 18 years of age in the National Comorbidity Survey reported a lifetime history of Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised-defined minor depression,11 and 29% of Youth Risk Behavior Survey respondents reported having felt so sad or hopeless over the course of 2 consecutive weeks in the past year that they ceased some usual activities.12 Subthreshold depressive symptoms have been associated with substantial psychosocial impairment and subsequent onset of major depression and substance use disorders.13–15 At the same time, <50% of children and adolescents with mental disorders receive mental health services from the health or human services sectors,16,17 and it is likely that a larger proportion of youths with subthreshold symptom levels of untreated.

Research in recent years has begun to suggest links between depressive symptoms and SRB/STI among adolescents. However, most studies have been cross-sectional, such that the temporal relationship between mental health factors and SRB/STI outcomes cannot be ascertained, and most have been conducted with clinical or other specialized samples. In cross-sectional studies, depressive symptoms have been associated with outcomes including condom nonuse and self-reported STI.18 Symptoms of depression or stress have been associated with birth control nonuse,19 as well as a scale of SRB including sexual activity, multiple or high-risk partners, and consistency of condom use.20 Affective disorders, including major depression and dysthymia, have been associated cross-sectionally with biologically identified STI and infrequent condom use21 and associated retrospectively among girls with teenage childbearing, sexual activity, and multiple sexual partners.22 Overall, most cross-sectional studies support an association between depressive symptoms or disorders and SRB among adolescents and young adults,23–27 although a number have had null findings.28–32

Among longitudinal studies, a national study of middle and high school students found that boys with highest levels of baseline depressive symptoms had 4 times the odds of self-report of STI within the following year, compared with boys with low baseline symptom levels.33 A 6-month study of black adolescent girls recruited in schools and clinics found associations between psychological distress and subsequent pregnancy, high-risk attitudes regarding condom use, and SRB including unprotected vaginal intercourse, nonmonogamous sex partners, and contraception nonuse.34 A 2-year study of rural adolescents attending a primary care clinic found associations between depressive symptoms and SRB for boys and girls in bivariate but not multivariate analyses.35 Depressive symptoms were found to be associated with earlier onset and more-persistent patterns of sexual intercourse in a 2-year study of suburban high school students.36 In summary, although findings have been mixed, most cross-sectional and longitudinal investigations suggest a link between depressive symptoms and SRB among youths.

The present study examined associations between depressive symptoms and SRB in a longitudinal manner with a national probability sample of US middle and high school students, with data from the National Longitudinal Study of Adolescent Health (Add Health). Effects of both moderate (subthreshold) depressive symptom levels and high symptom levels, which may correspond to a clinical diagnosis of a mood disorder,37 were considered. Because there is research identifying gender differences in the expression of depressive symptoms among adults and adolescents,38–41 analyses were conducted separately according to gender.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Data
Details of the design of and data collection in the Add Health study have been presented elsewhere.42 In brief, a stratified random sample of 80 US high schools was drawn from a list of eligible US high schools, with the probability of selection proportional to school size. One feeder school for each high school was selected randomly, with the probability proportional to its contribution to the high school population; schools that included grades 7 to 12 served as their own feeder school. A total of 132 schools participated in the core study. Wave I home interview data were collected from youths in grades 7 to 12 in 1995; wave II home interview data were collected in 1996 from all wave I participants except a disabled subsample and youths who were in grade 12 at wave I. Grand sample weights were assigned by the Add Health study to home interview subjects to take into account attrition from wave I to wave II, as well as subgroup oversampling. The numbers of participants with sampling weights in waves I and II were 18924 and 13570, respectively. In addition, 82% of wave I home interview subjects with sampling weights had a parent or guardian who participated in a parent home interview. Data for all SRB baseline and outcome variables for this study were collected with audio-computer-assisted self-interview (A-CASI), a method that has been found to increase the validity of reporting for sensitive questions.43,44 Written informed consent was provided by the adolescent participants and a parent or guardian.

Sample
The sample for this study was restricted to the 4152 subjects in the contractual use data set45 with grand sample weights who participated in home interviews in both waves I and II, were unmarried at wave II (99.2% of the unweighted base sample of 13570), reported having had sexual intercourse between waves I and II (35% of the base sample), had nonmissing data for the 4 primary SRB outcomes (31.5% of the base sample), and were missing ≤3 items on the wave I depressive symptoms scale (99.7% of the base sample). Twenty-seven subjects in the final sample had missing wave II data regarding the date of last sexual intercourse but were included in analyses because they had nonmissing data for SRB items that were asked only of subjects who were determined in Add Health to have had intercourse between waves I and II.

Depressive Symptoms
Past-week depressive symptoms were assessed in wave I with a 19-item, modified Center for Epidemiologic Studies-Depression Scale (CES-D).46 The original 20-item scale has been widely used as a measure of depressive symptoms in epidemiologic research and as a first-stage screening tool for clinical depression in community samples. In the modified scale available in Add Health, 2 original CES-D items were dropped, namely, "My sleep was restless," and "I had crying spells." One item was added: "I felt that life was not worth living." Two additional items were rephrased. Item scores on the modified scale correspond to symptom frequency and range from 0 (never or rarely) to 3 (most or all of the time); overall scale scores thus range from 0 to 56. Internal consistency reliability (Cronbach's {alpha}) for the 19-item scale was .85 for boys and .89 for girls in the present sample; these values are consistent with those found for the CES-D with adolescents in other studies.37,47,48

CES-D cutoff scores of 22 and 24 have been found to maximize sensitivity (0.84) and specificity (0.75) for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised-defined major depressive disorder or dysthymia for adolescent boys and girls, respectively.37 Proportionally adapted to the 19-item scale, the cutoff scores used in this study for above-threshold or "high" depressive symptom levels were 21 for boys and 23 for girls.33,49 The subjects falling below the high cutoff score were divided into 2 equal-sized (weighted) groups, which corresponded to "moderate" and "low" score categories. The approach to defining moderate and low score categories was determined for the purpose of analysis and is consistent with the approach taken in other Add Health studies.33 For boys, the moderate score category ranged from 9.5 to <21 and low scores were <9.5. For girls, the moderate score category ranged from 11 to <23 and low scores were <11. Secondary parallel analyses were also conducted with the continuous depressive symptoms scale, for greater statistical power.

Primary Outcome Variables
Any SRB
This was a dichotomous variable indicating the occurrence between waves I and II of ≥1 of the SRB listed below.

Condom Nonuse at Last Sex
All subjects who reported having had sexual intercourse between waves I and II were asked whether condom use occurred at last sex. Sexual intercourse is defined in the Add Health survey as male/female vaginal intercourse.

Nonuse of Any Birth Control at Last Sex
All subjects who reported having had sexual intercourse between waves I and II were asked about use of birth control at last sex.

Alcohol and/or Other Drug Use at Last Sex
This dichotomous composite variable incorporates yes/no responses to 2 separate survey items asking whether alcohol use or drug use occurred at last sexual intercourse. The items were asked of subjects who reported having had sexual intercourse between waves I and II. Substance use among adolescents has been found to increase the likelihood of both sexual intercourse and condom nonuse at the event level.50,51

Three or More Sexual Partners Between Waves I and II
At wave II, subjects were permitted to identify up to 3 romantic partners and up to 3 nonromantic partners they had had since wave I. The outcome variable was created in 2 steps. First, the number of romantic partners with whom the subject reported having vaginal or anal intercourse between waves I and II was counted. Among subjects who reported only romantic relationships, the number of sexual partners between waves I and II was represented by this sum. Among subjects who reported nonromantic relationships in addition to romantic relationships (or only nonromantic relationships), the total number of sexual partners between waves I and II was identified with a single comprehensive item, "Since the month of last interview, with how many people, in total, have you ever had a sexual relationship?" With this count variable, a final dichotomous variable indicating ≥3 sexual partners between waves I and II was created.

Control Variables
Age
All control variables were measured at wave I, except for number of years between waves I and II. Corresponding to developmental stages of early, middle, and late adolescence, 3 wave I age categories were used: 12 to 14 years, 15 to 17 years, and ≥18 years.52

Race/Ethnicity
Four categories were used: non-Hispanic white, non-Hispanic black, Hispanic, and other. Youths who reported >1 race/ethnicity were assigned to the category with which they indicated they most identified.

Poverty Status
This variable indicates family income below the 1994 federal poverty threshold, adjusted for the number of household members. Twenty-three percent of subjects were missing data for this item; a missing indicator variable was included for those subjects.

Family Structure
The categories used were 2 biological or adoptive parents, stepfamily, and other.

Wave I (Baseline) SRB
Each wave II SRB outcome variable had a corresponding dichotomous wave I SRB variable. These variables represented condom nonuse at last sex, nonuse of any birth control at last sex, use of alcohol/other drugs at last sex, and ≥3 sexual partners in past year (constructed with the wave I item, "Since January 1, 1994, with how many people in total have you had a sexual relationship?").

Time Between Waves I and II
This variable reflected the length of time (in years) between wave I and wave II interviews for each subject.

Covariates
Same-Sex Romantic Attraction and/or Same-Sex Partners at Both Wave I and Wave II
Given independent associations of same-sex attraction/behavior or orientation with depression and suicidality,53,54 and substance use and SRB,54–56 as well as the fact that some SRB considered in this study may not apply to subjects with only same-sex partners, the present study controlled for same-sex attraction and behavior. Data were collected with A-CASI.

Sexual Intercourse at ≤10 Years of Age
Insofar as sexual intercourse at ≤10 years of age has a diminished likelihood of having been consensual, this variable aims to reflect, to the extent possible, experiences of forced intercourse at a young age. Given independent associations of childhood sexual abuse with SRB27,57,58 and with psychiatric conditions that may produce elevated depressive symptom scores, including depressive and anxiety disorders and substance abuse,59,60 this variable may act as a confounder and therefore was included in analyses. Data were collected with A-CASI.

High Religiosity
This was a dichotomous variable, measured as weekly or more-frequent attendance at religious services versus less-than-weekly attendance. Religiosity has been found to be a protective factor against substance use among adolescents61–63 and has been associated with a later age at sexual debut.61 Aspects of religiosity have also been found to be protective against various SRB among youths,64,65 although negative associations have been found between aspects of religiosity and condom use.66

Statistical Analyses
All analyses were performed with SAS version 8 software (SAS Institute, Cary, NC) and were conducted separately for boys and girls. Bivariate regression models were used instead of {chi}2 tests to take into account the capabilities of SAS version 8 software with clustered data. Multivariate models were built sequentially; categorical depressive symptom variables were added first, followed by sociodemographic variables of age, race/ethnicity, poverty status, and family structure. Time between waves I and II was also included in models predicting multiple partners or the summary variable of any SRB, because the number of partners increased, as expected, with the amount of time between interviews. Covariates of same-sex attraction/behavior, intercourse at ≤10 years of age, and religiosity were then added, followed by the wave I SRB corresponding to the independent variable. All models had low depressive symptom levels as the reference category; fully adjusted models were also reanalyzed with moderate symptoms as the reference category, to identify significant differences between high and moderate symptom levels in their associations with the outcome variables. For increased power, secondary logistic regression analyses examining multivariate associations between continuous depressive symptom scores and each SRB outcome variable were also conducted separately for boys and girls. For the 12 subjects who were missing ≤3 depressive symptom items, scores for the missing items were imputed as the mean score of the other items.

The SAS Proc GENMOD function was used for all regression analyses, with specification of an independent working correlation structure.67 The use of generalized estimating equations permitted correct and robust estimation of SEs, given the clustered nature of the data (youths within schools). Adjusted grand sample weights were used in analyses to yield estimates generalizable to the population of US youths addressed in the study. P values were 2-tailed, with significance defined as P < .05.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Sample Characteristics
Descriptive statistics for the study sample are presented in Table 1. The sample was 54% female. Most subjects were non-Hispanic white and 15 to 17 years of age. More than 15% of boys and girls lived in households below the poverty line. More than 9% of boys and 15.7% of girls had high depressive symptom levels at wave I (P < .01); there was no significant difference between the genders in prevalence of moderate symptom levels. Mean depressive symptom scores for boys and girls were 11.0 and 13.9, respectively (P < .01). Sixty-three percent of boys and 55% of girls reported engaging in ≥1 of the measured SRB between wave I and wave II interviews. Boys were significantly more likely than girls to report the use of alcohol or other drugs at last sex (P < .01), ≥3 sexual partners (P < .01), and any SRB (P < .01); girls were more likely than boys to report condom nonuse at last sex (P < .01). The amount of time between wave I and wave II interviews ranged from 0.46 to 2.38 years for boys and from 0.43 to 1.28 years for girls (Table 1); for the genders combined, the median amount of time between wave I and wave II interviews was 0.93 years.


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  		TABLE 1 Descriptive Statistics for Study Sample (Weighted %)

 
Boys
In unadjusted analyses for boys, high depressive symptom levels were associated significantly with the summary variable assessing any SRB, as well as condom nonuse at last sex, birth control nonuse at last sex, and alcohol/other drug use at last sex (Table 2). Moderate depressive symptom scores were associated with any SRB. Forty percent of boys who reported alcohol/drug use at last sex also reported condom nonuse at last sex (P = .08), and 35% of boys who reported alcohol/drug use at last sex also reported birth control nonuse at last sex (P = .01); these findings provide some evidence for an association between substance use and other SRB at the event level for boys. Forty-four percent of boys who reported alcohol/drug use at last sex also reported having ≥3 sexual partners since the wave I interview (P < .01) (data not shown).


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  		TABLE 2 Bivariate Associations Between Wave I Depressive Symptoms and Wave II SRB

 
In adjusted models that controlled for sociodemographic features, covariates, and corresponding baseline SRB, boys with high depressive symptom levels, compared with low depressive symptom levels, were found to have 1.71 times the odds of any SRB (95% confidence interval [CI]: 1.01–2.90), 1.57 times the odds of condom nonuse at last sex (95% CI: 1.01–2.44), 1.76 times the odds of birth control nonuse at last sex (95% CI: 1.15–2.69), and 2.45 times the odds of alcohol/drug use at last sex (95% CI: 1.50–4.02); there was not a significant relationship with having ≥3 partners (Table 3). In contrast, associations between moderate symptom levels and each individual SRB outcome were insignificant, although a marginally significant association (P = .10) was discerned with the overall SRB scale. In adjusted models that substituted moderate depressive symptoms as the reference group, high depressive symptom levels were found to have significantly stronger associations than moderate symptom levels with condom nonuse (P = .03), birth control nonuse (P = .04), and alcohol/drug use (P = .01). These findings suggest a threshold effect of high depressive symptom levels on the likelihood of some SRB for boys.


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  		TABLE 3 Multivariate Associations Between Wave I Depressive Symptoms and Wave II SRB Among Boys (Unweighted n = 1921)

 
Parallel secondary analyses with the continuous CES-D measure produced results consistent with those of analyses with the categorical depression variable; associations were found between depressive symptoms and the summary SRB variable, condom nonuse, birth control nonuse, and alcohol/other drug use (Table 4). Because a high percentage of boys reported having had ≥3 sexual partners between waves I and II, additional adjusted analyses assessing associations between continuous depressive symptoms and dichotomous variables representing greater numbers of past-year sexual partners (≥4 partners, ≥5 partners, and ≥6 partners) were conducted; no association was found.


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  		TABLE 4 Multivariate Associations Between Wave I Depressive Symptoms (Continuous Measure) and Wave II SRB, According to Gender

 
Girls
In unadjusted analyses for girls, both moderate and high depressive symptom levels were associated significantly with the summary SRB outcome variable, condom nonuse at last sex, birth control nonuse at last sex, and ≥3 sexual partners in the past year (Table 2). Moderate depressive symptom levels were associated with alcohol/drug use at last sex, whereas the effect of high depressive symptom levels did not attain significance. Fifty-three percent of girls who reported alcohol/drug use at last sex also reported condom nonuse at last sex (P = .02), and 38% of girls who reported alcohol/drug use at last sex also reported birth control nonuse at last sex (P = .01); these findings provide evidence for an association between substance use and other SRB at the event level for girls. Thirty-five percent of girls who reported alcohol/drug use at last sex also reported ≥3 sexual partners (P < .01) (data not shown).

In fully adjusted models with the categorical depressive symptoms variable, high depressive symptom levels at baseline were associated with 1.50 times the odds of any SRB (95% CI: 1.04–2.16) and moderate symptom levels had a marginally significant association with any SRB (odds ratio: 1.28; 95% CI: 1.00–1.63; P = .05) (Table 5). Girls with moderate depressive symptom levels, compared with low depressive symptom levels, were also found to have 1.41 times the odds of alcohol/drug use at last sex (95% CI: 1.00–2.00; P = .049). Although associations did not achieve statistical significance for condom nonuse, birth control nonuse, or multiple partners once baseline SRB was added to the model, the pattern of associations between high and moderate symptom levels was suggestive of a dose-response relationship between depressive symptoms and SRB likelihood; that is, the effect size for moderate depressive symptom levels was consistently midway between those for high and low symptom levels, and the 95% CIs extended to higher values for high symptom levels, compared with moderate symptom levels. Also, in models with moderate symptoms as the reference group, no significant differences were found between high and moderate symptom levels in their association with any SRB outcome.


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  		TABLE 5 Multivariate Associations Between Wave I Depressive Symptoms and Wave II SRB Among Girls (Unweighted n = 2231)

 
The lack of significance seen for some outcomes with the categorical depression variables might have been related to insufficient power. Secondary analyses with the continuous depressive symptom measure, which allowed for greater power, found depressive symptoms among girls to be associated significantly with any SRB, condom nonuse, birth control nonuse, and multiple sexual partners; the odds of any SRB increased by 17.6% with a 1-SD increase in depressive symptom score. Associations were not significant for alcohol/drug use at last sex (Table 4). Taken together, multivariate analyses for girls provided evidence of a dose-response relationship between depressive symptoms and most SRB outcomes, and associations between depressive symptoms and the summary any-SRB variable were robust to specification of the depressive symptoms variable. Significant associations were also found in additional adjusted analyses between continuous depressive symptoms and dichotomous variables representing greater numbers of past-year sexual partners (≥4 partners, ≥5 partners, and ≥6 partners); the magnitude of association was comparable to that for ≥3 partners (data not shown). Regarding other factors, weekly or greater attendance at religious services was marginally significant as an independent risk factor for birth control nonuse among girls (adjusted odds ratio: 1.30; 95% CI: 1.00–1.68; P = .05).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Findings from this national study provide evidence that depressive symptoms are predictive of subsequent SRB among male and female middle and high school students. Boys and girls with high depressive symptom levels at baseline were significantly more likely than those with low symptom levels to report any of the examined SRB in the 1-year follow-up period. For boys, high depressive symptom levels were specifically predictive of condom nonuse at last sex, birth control nonuse at last sex, and substance use at last sex; these results were similar to those of parallel analyses with a continuous depression measure. For girls, no significant associations were found between high depressive symptom levels and individual SRB; moderate depressive symptom levels were associated with substance use at last sex. Parallel analyses with the continuous depression measure found additional significant associations for condom nonuse at last sex, birth control nonuse at last sex, ≥3 sexual partners, and any SRB.

Previous research has suggested various interrelated mechanisms through which adolescent depressive symptoms and disorders might act to increase the likelihood of SRB. First, depressed youths often have impaired social relationships and diminished social support from family members and peers.68,69 Youths who are both emotionally distressed and socially isolated may be more apt to seek or to be pressured successfully into sexual activity, for some form of shared intimacy or maintenance of valued relationships. These factors may account in part for the associations observed among girls in this study between depressive symptoms and multiple sexual partners, as well as condom and birth control nonuse. Consistent with this possibility, a study of motivations for sexual intercourse among college students found that having sex to "please or appease" one's partner was associated with less consistent contraception and with unplanned pregnancy.70

Second, depressive symptoms may be associated with diminished self-efficacy (ie, confidence in one's ability to undertake a specific action in a given context71) regarding factors such as resistance to sexual pressure, safer sex negotiation, mechanics of condom or other birth control use, and refusal of alcohol/other drugs, leading to an increased likelihood of SRB. Condom-related self-efficacy has been found to be an important predictor of youth condom use,72–74 and various studies have found self-efficacies relevant to SRB to be diminished among depressed youths, including social self-efficacy75,76 and self-efficacy to refuse heavy drinking.77 Depression is also associated with diminished self-esteem among adolescents,78–80 and some studies have found low self-esteem to be associated with SRB among girls.63,81

Along these lines, depressive symptoms may augment youth susceptibility to peer influence and observational learning effects related to SRB, thereby increasing the likelihood of imitation of peer risk behavior. [Social cognitive theory defines observational learning as the twofold process through which subjects learn which behaviors are appropriate or desirable, ie (1) observing behaviors performed by role models or similar others and (2) observing the reinforcements received.71] One study of youths found evidence supporting this hypothesis with respect to physical fighting and suicidal behavior among adolescents; high levels of subject depressive symptoms in conjunction with high levels of peer risk behavior were associated with the highest rates of subject risk behavior.82 Although peer influence is an important predictor of SRB among nontroubled youths, youths with emotional difficulties may be particularly vulnerable to perceived and actual social norms and pressures, because of a heightened desire to avoid peer rejection and to gain or preserve relationships.32,83

Risk behaviors often occur in clusters,84 and SRB have been found to co-occur with substance use, delinquency, and other risk behaviors.85 Youths with psychiatric disorders are more likely to associate with peers who engage in SRB, substance use, delinquency, and other risk behaviors and who are at elevated risk of HIV/STI.9,86 Youths specifically with major depression have also reported elevated rates of deviant peer involvement.87 Perceived and actual norms regarding SRB may thus differ for youths with versus without depressive symptoms and may contribute to an increased likelihood of SRB among emotionally distressed youths. It is also relevant to note that the same amount of SRB confers greater HIV/STI risk for youths in social networks with elevated STI prevalence.88

Next, depressive symptoms are aversive and may lead to coping efforts in the form of behaviors that have anticipated and valued outcomes of temporary distraction or relief from the affective experience.89 The likelihood of SRB may increase when sexual experiences are pursued from a motivation toward expedited symptom relief, with short-term gratification being valued over potential longer-term consequences; this may contribute to the associations observed in this study between depressive symptoms and both condom and birth control nonuse among boys and girls.

Numerous studies have also found a link between depressive symptoms/disorders and substance use and abuse among youths35,90–92 and suggest that substance use may serve in part as self-medication for emotional distress. Substance use and abuse, in turn, have demonstrated prospective and cross-sectional associations with SRB among youths, as well as event-level associations.50,51,93,94 The motivation to alleviate aversive depressive symptoms may thus increase the likelihood of SRB directly, through increased motivation for sexual activity, or it may be mediated through the disinhibiting or other social effects of substance use (ie, substance use may contribute to the association of emotionally distressed youths with risky peer groups that engage in substance use as well as SRB and other risk behaviors). In this study, alcohol/drug use at last sex was associated with other SRB at last sex for boys and girls.

Finally, depressive symptoms are associated with suicidal and other self-harming behaviors among adolescents,95–98 and SRB may represent another form of self-destructive behavior.9,99 Sexual risk-taking may also more generally reflect a diminished value placed on personal health and self-protection that is associated with depressive symptoms.100 In sum, various interrelated aspects of the intrapersonal and external environment experienced by youths with depressive symptoms may act and interact to increase the likelihood of SRB and resultant HIV/STI.

Various limitations of the present study should be noted. First, although use of the adapted CES-D cutoff values for adolescents recommended by Roberts et al37 maximizes sensitivity and specificity for major depressive disorder and dysthymia, the modified CES-D scale used in this study is not a diagnostic tool; therefore, we can only comment with respect to the associations between SRB and depressive symptoms shared by a variety of affective and other disorders, subclinical states, and transient mood states. The single wave I measurement of past-week depressive symptoms may also not fully reflect the severity or chronicity of symptoms over the period between waves I and II, both of which may be relevant to SRB likelihood in this period. However, some studies have noted the stability of depressed mood among adolescents.35,101–103

Second, SRB at waves I and II might have been either over- or under-reported because of social desirability bias (eg, it may be socially desirable for boys to have more sexual partners). If it was associated in a systematic manner with the level of depressive symptoms, then SRB misreporting might have led to bias in the estimation of associations between depressive symptoms and SRB. Depressive symptoms also might have been underreported (A-CASI was not used for these survey items); however, this would lead to underestimation of associations between depressive symptoms and SRB.

Third, residual confounding might have contributed to overestimation of associations between depressive symptoms and subsequent SRB. Dating violence has been associated with both depression104 and SRB among adolescents,105 and additional research should aim to include this variable in analyses. Mania is also associated with hypersexuality among adolescents.106 It is possible that unmeasured mania, associated with experiences of depressive symptoms, might account to an extent for the association observed among girls between depressive symptoms and multiple sexual partners. However, the lifetime prevalence of mania by the end of adolescence has been reported to be ≤2%,13 and it is thus unlikely that experiences of mania would account for a large proportion of the association observed.

Fourth, Add Health defined sexual intercourse as male-female vaginal intercourse and asked about condom use, birth control use, and substance use at last sex only if subjects reported having had sexual intercourse. This might reduce the estimation of SRB among youths who reported exclusively same-sex partners between waves I and II; however, these youths represented 0.61% of the weighted sample. Finally, the study focused on school-based youths, and results are not generalizable beyond this population.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
This study is among the first to examine longitudinal associations between depressive symptoms and SRB in a national probability sample of US youths. Baseline depressive symptoms were found to be predictive of subsequent SRB among boys and girls. Additional longitudinal research should examine gender-specific mediators and moderators for associations between depressive symptoms and SRB among adolescents, as well as whether diagnosed affective disorders predict subsequent SRB and diagnosed STI.

The association between depressive symptoms and SRB found in this study suggests a need for (1) primary care providers to screen for depressive symptoms and to provide sexual health counseling for youths at risk,107 (2) mental health practitioners to provide basic counseling on SRB to youths with depressive symptoms/disorders, and (3) sexual health providers, such as at STI clinics, to identify depressive symptoms among clients and refer them for mental health care if needed (research has begun to identify reciprocal relationships between STI and depressive symptoms33). The finding of a prospective relationship between depressive symptoms and SRB in this school-based sample also suggests a potential need to incorporate discussion of mental health/mood factors into population-based HIV/STI prevention programs for youths; increased understanding of gender-specific mechanisms for the association between depressive symptoms and SRB would be helpful for intervention design. Finally, an association between depressive symptoms and SRB risk among youths provides an additional reason for expansion of programs for mental health promotion, prevention of depressive symptoms/disorders, early identification and treatment, and prevention of recurrence/relapse. Schools would be a natural setting for expanded, population-based efforts in mental health promotion, prevention, and care for adolescents.


   ACKNOWLEDGMENTS
 
This research used data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris and funded by grant P01-HD31921 from the National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies.

Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 W Franklin St, Chapel Hill, NC 27516-2524 (www.cpc.unc.edu/addhealth/contract.html).


   FOOTNOTES
 
Accepted Jan 3, 2006.

Address correspondence to Jocelyn A. Lehrer, ScD, 4601 25th St #7, San Francisco, CA 94114. E-mail: jlehrer1{at}gmail.com

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
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