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Temporal Associations Between Depressive Symptoms and Self-reported Sexually Transmitted Disease Among Adolescents
Lydia A. Shrier, MD, MPH;
Sion Kim Harris, PhD;
William R. Beardslee, MD
Arch Pediatr Adolesc Med. 2002;156:599-606.
ABSTRACT
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Objective To examine the longitudinal associations between depressive symptoms
and self-reported sexually transmitted disease (STD) diagnosis among adolescents.
Setting and Participants National Longitudinal Study of Adolescent Health data were analyzed
for 7th through 12th graders who reported having sexual intercourse between
baseline (Wave 1) and 1-year follow-up (Wave 2) in-home interviews (N = 4738
[2232 boys, 2506 girls]). The association between level of depressive symptoms
at Wave 1 and self-reported diagnosis of STD between Wave 1 and Wave 2 was
explored separately for boys and girls using logistic regression that controlled
for age, race/ethnicity, virginity, and history of STD at Wave 1. Alcohol
and marijuana use were assessed as potential mediators. The association between
interval STD diagnosis and subsequent very high levels of depressive symptoms
(predictive of major depression) was also examined separately by sex controlling
for demographic characteristics and baseline depressive symptoms.
Main Outcome Measures Self-reported STD diagnosis and depressive symptoms.
Results For boys and girls, higher frequency of depressive symptoms at baseline
predicted increased risk of being diagnosed as having an STD within 1 year.
After adjusting for history of STD, the association was no longer significant
for girls. Alcohol and marijuana use did not mediate this association for
either sex, although very frequent alcohol use was an independent predictor
of STD diagnosis for boys. For boys and girls, being diagnosed as having an
STD within 1 year was associated with very high levels of depressive symptoms
at the end of that year in both bivariate and multivariate models.
Conclusions Screening for depressive symptoms in sexually active adolescents, particularly
boys, may identify those at risk for STDs. In addition, adolescents who are
diagnosed as having STDs should be monitored for depression. These findings
suggest that adolescent preventive care needs to include regular, comprehensive
assessments of both mental health and STD.
INTRODUCTION
SEVERAL STUDIES in adolescents and adults have reported associations
between mental health problems and sexually transmitted diseases (STDs).1-9
Compared with nondepressed youth, depressed children and adolescents have
poor social relationships10 and may be more
emotionally reactive in peer relationships,11
factors that may contribute to increased STD risk behavior. Individuals with
severe mental illness may engage in high-risk sexual behaviors as a result
of poor impulse control, impaired judgment, and lack of knowledge or understanding
of the risks.12 In addition, affective disorders
are associated with substance use,13-14
which is related to increased sexual risk behavior and STDs.15-18
Depressed individuals may also use sexual risk behaviors as part of
a coping response to their depressive symptoms. Research has suggested that
men, in particular, tend to purposively turn their attention away from depressive
symptoms and onto neutral or pleasant activities,19-20
such as sexual intercourse. Less is known about the coping responses of adolescents
but some research suggests that by early to middle adolescence, boys exhibit
distractive coping styles that are similar to those of adult men.21-22
Most previous studies on mental health problems and STDs have focused
on specialized populations, such as psychiatric patients,2, 4
homeless and runaway youth,1, 23
and patients in STD clinics.8 In addition,
most research to date has been cross-sectional8-9,24
and therefore has not addressed the temporal nature of the relationship between
mental health problems and acquisition of STDs. There are psychological sequelae
of receiving an STD diagnosis,25-29
so the possibility that mental health problems follow rather than precede
an STD diagnosis must be considered. Previous research has demonstrated that
physical illness is a predictor of depression; in one prospective study of
adolescents, physical disease and functional impairment at baseline were identified
as risk factors for major depressive disorder 1 year later.30
These findings are consistent with the integrative theory of depression,31 which draws on empirical findings and contemporary
causal theories of depression in proposing that environmental and personal
mechanisms interact to produce an episode of depression. Specifically, the
theory postulates that eliciting events lead to a heightened state of self-focused
attention that, in turn, results in a variety of affective, behavioral, and
cognitive transformations that exacerbate dysphoria and induce and maintain
a depressive episode. The diagnosis of an STD may represent an antecedent
event that initiates the depression-producing process. Alternatively, an STD
may be the result of the behavior changes that follow the evoking event and
increased self-focused attention. It will be important to elucidate the relationship
between depression and STD to design effective prevention programs for both
of these pressing public health problems.
The objective of this study was to explore the reciprocal associations
between depressive symptoms and diagnosis of STD using data from the National
Longitudinal Study of Adolescent Health (Add Health),32
a longitudinal study of a national sample of adolescents. We hypothesized
that depressive symptoms would be associated with self-reported STD diagnosis
in the following year and that, among those without clinically significant
depressive symptoms at baseline, reporting an STD diagnosis would be associated
with clinically significant depressive symptoms at the end of the year. We
anticipated that sex differences would exist in these associations. In addition,
based on our previous analyses,9 we hypothesized
that substance use would mediate the association between depressive symptoms
and later STD diagnosis in boys but not girls.
PARTICIPANTS AND METHODS
SAMPLE SELECTION
Details of the design and collection of data in Add Health are described
elsewhere.32-33 Students in the
7th through 12th grades from a systematic, random sample of 80 high schools
and 52 associated feeder schools across the United States completed baseline
in-home interviews (Wave 1). A total of 20 745 students completed the
baseline 90-minute in-home interview between April and December 1995. Approximately
1 year later, 13 568 adolescents completed a second in-home interview
(Wave 2). For the analytic sample, the mean (SD) interval between Wave 1 and
Wave 2 interviews was 11.1 (1.7) months. Adolescents who were in the 12th
grade at baseline or who were part of the subsample with disabilities were
not interviewed in Wave 2. Each case was given a weight based on the sampling
design such that the sample would be representative of all US 7th through
12th grade students.34 The analyses herein
include data from adolescents who participated in both Wave 1 and Wave 2 interviews,
who reported consistently on separate questions that they had sexual intercourse
by Wave 2 and that they had sexual intercourse at least once during the interval
between the 2 interviews, and for whom sample weights were available35 (N = 4738). The study protocol was approved by the
University of North Carolina (Chapel Hill) institutional review board on research
involving human subjects.
VARIABLES
At baseline and follow-up, the frequency of depressive symptoms in the
past week was assessed using a modified version of the 20-item Center for
Epidemiologic Studies Depression Scale (CES-D).36
The CES-D has been used in several studies of adolescents37-38
and has demonstrated good reliability and validity in adolescent and adult
samples.39-41
Internal consistency reliability is generally greater than .8036, 39-41
and higher CES-D scores are correlated with diagnostic interview–validated
depression.36, 39-40
The depressive symptoms scale in this study (19 items; range of possible scores,
0-54) had high internal consistency reliability (Cronbach  coefficient42 = .87 at both baseline and follow-up). As previously
reported,9 factor analysis of these items demonstrated
the 4-factor structure that has been described for the CES-D.36, 41
Scores predictive of major depressive disorder in adolescents have been identified
(22 for males, 24 for females).39 These scores
were adapted proportionally to the modified scale (21 for males, 23 for females)
and used to identify a "very high" level of depressive symptoms. The remaining
scores were divided into equal groups with "low," "moderate," and "high" levels
of depressive symptoms to create a 4-category variable.9
If at least 80% of the scale items had been completed, missing data were filled
in using imputation with sample means.
At Wave 1 ("ever") and Wave 2 (for the interval between the 2 interviews),
adolescents were asked individual questions about whether they had been told
by a doctor or a nurse that they had each of the following STDs: chlamydia,
gonorrhea, syphilis, HIV (human immunodeficiency virus) or AIDS (acquired
immunodeficiency syndrome), genital herpes, genital warts, and trichomoniasis.
Because of the low numbers of boys and girls reporting each STD, it was not
possible to conduct analyses using the individual STD variables, so variables
were constructed for self-reported history of 1 or more STDs at Wave 1 and
for diagnosis of 1 or more STDs between Waves 1 and 2.
Alcohol use was measured at Wave 2 by the number of drinking days in
the previous year, categorized as none, minimal (1-2 days in the past year
to once per month or less), moderately frequent (2-3 days per month to 1-2
days per week), and very frequent (3-5 days per week to every day or almost
every day). Marijuana use was determined at Wave 2 by the response to a question
on whether the adolescent had tried or used marijuana since Wave 1.
Age in years at Wave 2 was determined from the month and year of birth
and the month and year of the study interview and was categorized to correspond
with the developmental stages of early, middle, and late adolescence (12-14,
15-17, and 18-21 years).43 Gender was evaluated
by the interviewer and confirmed by asking the adolescent if it was not apparent.
Self-reported race or ethnicity was categorized as non-Hispanic white, non-Hispanic
black, Hispanic, and other (included small numbers of adolescents reporting
American Indian or Native American, Asian or Pacific Islander, and other race).
To account for the effect of recent coital debut on acquiring an STD, adolescents
who had never had sexual intercourse at baseline but became sexually active
during the interval between Wave 1 and Wave 2 were distinguished from those
who reported having been sexually active at baseline.
DATA ANALYSIS
Data management and descriptive analyses were performed using SPSS for
Windows version 10.0 (SPSS Inc, Chicago, Ill). Appropriate bivariate tests
and multivariate logistic regression models using weighted data were analyzed
with SUDAAN version 7.5.4 (Research Triangle Institute, Research Triangle
Park, NC) to adjust for the design effects associated with the complex clustered
sampling design used in Add Health.44 The first
set of logistic regression models (models A1-A3) evaluated whether baseline
depressive symptoms independently predicted diagnosis of an STD within the
following year. To account for the effect of a previous diagnosis of STD on
the odds of future STDs, all models controlled for ever being diagnosed as
having an STD at baseline. In model A1, the variable measuring baseline depressive
symptoms was entered into the model. Model A2 adjusted for the demographic
variables (age, race/ethnicity) and baseline sexual activity. To determine
whether substance use mediated the association between depressive symptoms
and STD diagnosis, the substance use variables significantly associated with
both depressive symptoms and STD diagnosis on bivariate analysis were added
in model A3. A variable functions as a mediator to the degree to which it
accounts for the association between an independent variable (predictor) and
a dependent variable (outcome).45 According
to Kraemer et al,46 because the definition
of a mediator suggests that it explains how and why the independent variable
works to produce the outcome, a mediator should occur after the independent
variable. Additionally, a mediator should be significantly associated with
both the independent variable and the dependent variable and, when controlled
for, cause a previously significant association between the independent and
dependent variables to no longer be significant.45
The second set of analyses explored the possibility that the diagnosis
of STD precedes rather than follows the development of depression. To identify
the risk of the most clinically relevant level of depressive symptoms, we
used the "very high" category of depressive symptoms as the outcome. To determine
a change in depressive symptoms to the very high level, these analyses excluded
adolescents who reported very high levels of depressive symptoms at baseline
(n = 624, [212 boys and 412 girls]). Hierarchical models examined whether
ever being diagnosed as having an STD between Wave 1 and Wave 2 was associated
with a very high level of depressive symptoms at Wave 2, first controlling
for depressive symptoms at baseline alone (model B1) and then adding demographic
characteristics and virginity (model B2). Significance was defined at P<.05. Because of small cell sizes, we could not determine
interaction terms with reliable estimates. All analyses were conducted separately
for boys and girls.
RESULTS
SAMPLE CHARACTERISTICS
Characteristics of the sample are shown in Table 1. The sample was almost equally male (n = 2232) and female
(n = 2506) and predominantly non-Hispanic white and black. Mean (SD) age was
16.8 (1.4) years for males (range, 13-23 years) and 17.0 (1.4) years for females
(range, 13-21 years). Almost half of boys (45.5%) and girls (48.2%) were aged
between 15 and 17 years.
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Table 1. Characteristics of Boys and Girls Who Had Sexual Intercourse
Between Wave 1 and Wave 2 of Add Health*
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Most adolescents (71.4% of boys, 69.0% of girls) who had sexual intercourse
in the year between Wave 1 and Wave 2 reported having already initiated sexual
activity at baseline. Girls were almost twice as likely as boys to report
a history of STD at baseline (5.4% vs 2.8%, P<.001)
and to report being diagnosed as having an STD between Wave 1 and Wave 2 (6.1%
vs 3.2%, P<.001). Eighty percent of the interval
STDs were reported by adolescents who did not have a history of STD at baseline.
The median depressive symptoms score was slightly higher for girls than
for boys at both Wave 1 (13 vs 10; Mann-Whitney U
test, P<.001) and Wave 2 (12 vs 10; Mann-Whitney U test, P<.001). At both times,
approximately 1 of every 10 boys and almost 1 of every 6 girls reported very
high levels of depressive symptoms. More than 42% of adolescents with very
high levels of depressive symptoms at Wave 2 had reported very high levels
at Wave 1.
Baseline substance use was prevalent. Almost two thirds of boys and
girls reported alcohol use in the year before the Wave 2 interview; more boys
(8.7%) than girls (5.2%) reported very frequent alcohol use (P<.001). Almost half of both boys and girls had used marijuana at
least once between Wave 1 and Wave 2.
DEPRESSIVE SYMPTOMS AS A PREDICTOR OF STD DIAGNOSIS
For boys and girls, level of depressive symptoms at Wave 1 was associated
with diagnosis of STD between Wave 1 and Wave 2 in unadjusted analyses. Compared
with boys with low and moderate levels of depressive symptoms, boys with high
and very high levels of depressive symptoms were more likely to have been
diagnosed as having an STD between Waves 1 and 2 (1.3% low and 1.7% moderate
vs 5.4% high and 6.5% very high; P<.005). Similarly,
girls with high and very high levels of depressive symptoms were more likely
than those with low and moderate levels of depressive symptoms to report an
interval STD diagnosis (7.1% high and 9.4% very high vs 4.9% low and 4.6%
moderate; P<.05).
Among boys, after adjusting for a history of STD at baseline, both high
and very high levels of depressive symptoms remained independently associated
with being diagnosed as having an STD within the following year (Table 2, model A1). This association was
robust to the addition of the demographic and sexual debut variables (model
A2). Compared with boys with a low level of depressive symptoms, those with
high and very high levels at baseline had 3.92 times and 3.98 times, respectively,
the odds of being diagnosed as having an STD by the 1-year follow-up interview.
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Table 2. Logistic Regression Models for Baseline Depressive Symptoms
Predicting Diagnosis of a Sexually Transmitted Disease (STD) Within 1 Year*
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For boys, very frequent alcohol use was associated with baseline level
of depressive symptoms (P<.005) and diagnosis
of interval STD (P<.05) on bivariate analysis.
However, in the adjusted model (Table 2, model A3), the addition of the alcohol use variable did not substantially
change the parameter estimates for the level of depressive symptoms, which
remained significantly associated with STD diagnosis. Very frequent alcohol
use was independently associated with STD diagnosis (OR, 3.11; 95% CI, 1.02-9.52),
so the alcohol use variable was retained in model A3. Marijuana use was not
significantly associated with the dependent variable, STD diagnosis, so further
analyses assessing marijuana use as a mediator were not performed. For girls,
Wave 1 level of depressive symptoms did not predict STD diagnosis by Wave
2 in either of the adjusted models (Table
2, models A1 and A2).
DIAGNOSIS OF STD AS A PREDICTOR OF VERY HIGH LEVELS OF DEPRESSIVE SYMPTOMS
Among boys and girls without very high levels of depressive symptoms
at baseline, diagnosis of STD between Wave 1 and Wave 2 was associated with
an increase in depressive symptoms to very high levels at Wave 2. For boys,
31% of those reporting an interval diagnosis of STD had very high levels of
depressive symptoms at Wave 2, compared with only 9% of boys without a diagnosis
of STD between Waves 1 and 2 (P<.01). Compared
with those without an interval STD diagnosis, twice as many girls with STD
diagnoses reported very high levels of depressive symptoms at Wave 2 (28%
vs 14%, P<.05). These associations remained significant
in the adjusted logistic regression models for both boys and girls. Self-reported
diagnosis of interval STD was associated with 3.3 (boys) and 2.4 (girls) times
the odds of very high levels of depressive symptoms at Wave 2 (Table 3, model B2).
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Table 3. Logistic Regression Models for Diagnosis of a Sexually Transmitted
Disease (STD) in the Year Between Baseline and Follow-up Predicting Very High
Levels of Depressive Symptoms at Follow-up*
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COMMENT
Despite efforts to reduce the prevalence of STDs, adolescents and young
adults continue to demonstrate high rates of chlamydia, gonorrhea, and syphilis,47 and are experiencing greater increases in the seroprevalence
of herpes simplex virus 2 than adults.48 Approximately
1 in 4 new STD diagnoses is in a teenager.49
Dysthymia, major depressive disorder, and other psychiatric disorders also
affect young people at alarming rates.37, 50-53
In one community sample of older adolescents, nearly 30% reported at least
1 current symptom of a major depressive episode.54
This longitudinal study suggests that the temporal relationship between
depressive symptoms and STD is complex and gender specific. For boys, the
association is bidirectional; boys with depressive symptoms were at increased
risk for being diagnosed as having an STD by the 1-year follow-up and boys
diagnosed as having an STD by the 1-year follow-up were at increased risk
for reporting very high levels of depressive symptoms at the end of that year.
Among girls, recent STD diagnosis was a risk factor for future depression,
but depressive symptoms were not associated with being diagnosed as having
an STD once models controlled for baseline history of STD.
Sex differences in the expression of psychological distress exist among
adolescents.55-58
While girls with depressive disorders tend to exhibit classic symptoms of
social withdrawal, diminished interest in pleasurable activities, and low
libido,59 boys with psychiatric symptoms are
more prone to engage in acting-out behaviors,55
which may include sexual behaviors that increase the risk of acquiring an
STD. One explanation for this sex difference is that social sanctions against
men appearing depressed may encourage boys to demonstrate nondepressive behaviors.
Social pressures for boys and men not to display their emotions may also result
in differential societal responses to depressive symptoms in men vs women.20 In a study of roommates of college freshmen, roommates
were more likely to rate a depressed man negatively than a depressed women.60 In addition, several studies in adolescents21-22 and adults19-20
with depressive symptoms suggest that while females tend to use ruminative
coping, males are more likely to distract themselves by engaging in pleasurable
activities. Further research is needed to determine if sexual behavior is
part of a distractive coping response to depressive symptoms in boys.
Previous cross-sectional analyses9 suggest
that use of alcohol and marijuana may mediate the association between depressive
symptoms and STD diagnosis among boys. However, although alcohol use every
day or almost every day was an independent predictor of STD diagnosis in our
study, neither alcohol nor marijuana use functioned as a mediator between
baseline depressive symptoms and later STD diagnosis.
Cross-sectional studies have observed increased depressive symptoms
in young women who report a history of STD9, 24
and in adult women who are STD clinic patients.8
In our analyses of adolescent girls, while recent diagnosis of STD was a risk
factor for depression, depressive symptoms did not predict future STD diagnosis
once history of STD was entered into the models. To explore this finding further,
we examined the interaction between baseline depressive symptoms and history
of STD. The cell sizes were small and the interaction term did not achieve
significance. However, there was a suggestion of effect modification; girls
with a history of STD who had higher depressive symptoms at baseline were
at greater risk of contracting an STD between Wave 1 and Wave 2 than might
be expected from the individual independent effects of a history of STD and
increased depressive symptoms. It is possible that for girls with increased
depressive symptoms at Wave 1, the risk behaviors associated with STD preceded
the Wave 1 interview. Alternatively, similar to this study, previous reports
have noted high rates of both depressive symptoms3, 8
and STD diagnosis8 in women. As a result, it
may be difficult to detect increases in the prevalence of either condition
among girls. Finally, while high rates of depressive symptoms may co-occur
or follow the diagnosis of an STD, depression may not predict STD among girls
in a general, nonclinical population. Factors such as poverty or other life
stressors not included in these analyses may be important in determining whether
high depressive symptoms are an important predictor of STD in certain young
female subpopulations.
We found that among boys and girls who did not have very high levels
of depressive symptoms at baseline, diagnosis of an STD by the 1-year follow-up
was associated with very high levels of depressive symptoms at the end of
that year. Our analyses used a score cutoff that has been correlated with
a psychiatric diagnosis of depression on previous research using a similar
depressive symptoms scale.39 By restricting
these analyses to adolescents who did not report a very high level of depressive
symptoms at Wave 1 and controlling for level of depressive symptoms at Wave
1, we attempted to examine the association between STD diagnosis and very
high depressive symptoms occurring later. However, because the STD diagnosis
could have occurred at any time between Wave 1 and Wave 2, it is possible
that the diagnosis could have been made after the development of very high
depressive symptoms. Nonetheless, these findings support literature suggesting
that there are psychological sequelae to being diagnosed as having an STD.25-29
Diagnosis of an STD may be the antecedent event that initiates the process
leading to the depressive episode.31 In support
of this contention, one cross-sectional study comparing the psychological
morbidity among individuals infected vs those not infected with genital herpes
found that nearly 1 in 4 participants with herpes reported emotional trauma
attributable to the infection.29 In our study,
the small numbers of students reporting each STD precluded analysis by specific
STD or by bacterial vs viral STD. It is likely that psychological sequelae
related to the diagnosis of an incurable viral STD differ from those related
to a curable bacterial STD. Psychological sequelae may also differ between
the sexes depending on the physical consequences associated with a particular
STD. For example, because girls with genital chlamydial infection may be informed
of the possibility of subsequent infertility or ectopic pregnancy, they may
be more likely than boys to experience psychological morbidity associated
with being diagnosed as having this STD. However, in this study, we found
that boys and girls who reported being diagnosed as having an STD were at
increased risk of future depression. It is possible that the diagnosis of
STD may not alone cause later clinical depression but that the STD may be
an indicator of psychosocial problems that can lead to depression. It is important
to use the time of STD diagnosis and follow-up as an opportunity for screening
for depressive symptoms.
This study has several limitations. Although the depressive symptoms
scale used in Add Health was derived from the CES-D, which has been shown
to be valid and reliable in adolescent samples,39-41
the psychometric properties of the modified scale have not been established.
However, most Add Health scale items are identical to the items in the CES-D
and the results of our internal consistency reliability and factor analyses
suggest that the modified scale performs similarly to the CES-D. Depressive
symptoms were assessed for a 1-week period before each interview date; data
on chronic or recurrent depressive symptoms between Wave 1 and Wave 2 were
not available. We would expect to find only a stronger association between
depressive symptoms and STD diagnosis among students for whom symptoms occur
more frequently or last longer. Adolescents who are not in school, such as
those who are homeless or runaways or who have been expelled, are at increased
risk for both mental health problems and STDs.61-62
Because the data collected in Add Health are self-reported, adolescents may
underreport or overreport depressive symptoms and STD history.63
Studies have shown that the CES-D is well correlated with clinical depression
diagnosed by interview.39-41
Adolescents may be able to report diagnosis of STD fairly accurately,64 although a recent prospective study found that only
69% of adolescent girls with biologically confirmed STD accurately reported
their positive STD status.65 The prevalence
of very high depressive symptoms in this study (13.0% of boys and girls combined)
is comparable with the 12.1% of high school students identified as severely
depressed on the CES-D in a previous study.39
The proportion of sexually active adolescents reporting a history of STD diagnosis
was approximately one half the rates of infection with gonorrhea and chlamydia
noted in a study screening high school students.66
Most students with infection in that study were asymptomatic and had not received
STD screening in the previous year; among those with STD symptoms, not all
sought care. The questions on STD in Add Health referred to being told by
a doctor or nurse of the diagnosis, so the true prevalence of sexually transmitted
infections in this sample is likely to have been underestimated. This may
be especially true for boys, who are less likely than girls to receive preventive
health care, including screening for STDs.65, 67
Boys in this study were half as likely to report either a history of STD at
Wave 1 or diagnosis of STD between Wave 1 and Wave 2. While it is possible
that boys underreport having STDs compared with girls, a study of high school–based
screening has reported similar findings with actual, as opposed to self-reported
STD.66 If boys were less likely than girls
to report having STDs, our findings would be affected if the tendency to underreport
differed by level of depressive symptoms. Systematic underreporting of STDs
may result in misclassification bias and increased type II error.65 Despite this possibility, we still found significant
associations between depressive symptoms and self-reported STD. In addition,
at the time that the Add Health Wave 1 and Wave 2 data were collected, the
relatively insensitive methods used in STD testing (nonnucleic acid amplification)
and limited screening in adolescents would result in further underestimation
of STD in this study. The use of biological measures of STD incidence in future
studies will be important and may strengthen the findings in this study. Finally,
the date of the STD diagnosis was not elicited, so we were unable to determine
the interval of time between this diagnosis and the subsequent report of very
high levels of depressive symptoms.
To develop appropriate, effective STD prevention interventions, it will
be important to further elucidate the sex differences in the association between
depressive symptoms and future STD diagnosis and to identify the mechanisms
and mediational pathways of the reciprocal association. Prospective research
will also be important to develop risk indicators and to prevent the development
of clinically significant depressive symptoms in adolescents who have been
diagnosed as having STDs. Clinicians, including mental health professionals,
need to recognize the temporal associations between depressive symptoms and
STDs in adolescents. Although girls are more likely than boys to report depressive
symptoms after early adolescence,10 our findings
suggest that clinicians need to be particularly alert to boys with depressive
symptoms, who are at increased risk for being diagnosed as having an STD.
Clinical encounters for health maintenance, STD screening and treatment, contraception,
and mental health treatment all provide opportunities for screening for both
depressive symptoms and STDs.
| What This Study Adds
While previous cross-sectional research has linked STDs and mental health
problems, the temporal nature of the association between these 2 prevalent
conditions has not been fully explored. This longitudinal study suggests a
bidirectional association for boys; boys with depressive symptoms were at
increased risk for reporting an STD diagnosis at 1-year follow-up and boys
who self-reported a diagnosis of STD at 1-year follow-up were at increased
risk for reporting very high levels of depressive symptoms at the end of that
year. Among girls, self-report of a recent STD diagnosis was a risk factor
for very high levels of depressive symptoms, but depressive symptoms did not
predict reporting an STD diagnosis once models controlled for baseline history
of STD. Medical and mental health clinicians need to screen sexually active
adolescents for depressive symptoms and for STDs.
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AUTHOR INFORMATION
Accepted for publication February 28, 2002.
Dr Shrier was supported in part by the Charles A. Janeway Award in Child
Health Research (HD27805-08), Child Health Research Center, Children's Hospital,
Boston, and by grant 5K23MH01845 from the National Institute of Mental Health,
National Institutes of Health, Bethesda, Md.
This research is based on data from the Add Health project, a program
project designed by J. Richard Udry (principal incestigator) and Peter Bearman,
and funded by grant P01-HD31921 from the National Institute of Child Health
and Human Development to the Carolina Population Center, University of North
Carolina at Chapel Hill, with cooperative funding participation by the National
Cancer Institute; the National Institute of Alcohol Abuse and Alcoholism;
the National Institute on Deafness and Other Communication Disorders; the
National Institute on Drug Abuse; the National Institute of General Medical
Sciences; the National Institute of Mental Health; the National Institute
of Nursing Research; the Office of AIDS Research, NIH; the Office of Behavior
and Social Science Research, NIH; the Office of Director, NIH; the Office
of Research on Women's Health, NIH; the Office of Population Affairs, DHHS
(Department of Health and Human Services); the National Center for Health
Statistics; Centers for Disease Control and Prevention, DHHS; the Office of
Minority Health, Centers for Disease Control and Prevention, DHHS; the Office
of Minority Health, Office of Public Health and Science, DHHS; the Office
of the Assistant Secretary for Planning and Evaluation, DHHS; and the National
Science Foundation. Persons interested in obtaining data files from The National
Longitudinal Study of Adolescent Health should contact Add Health Project,
Carolina Population Center, 123 W Franklin St, Chapel Hill, NC 27516-3997
(e-mail: addhealth{at}unc.edu).
Corresponding author and reprints: Lydia A. Shrier, MD, MPH, Division
of Adolescent/Young Adult Medicine, Children's Hospital, 300 Longwood Ave,
Boston, MA 02115 (e-mail: lydia.shrier{at}tch.harvard.edu).
From the Division of Adolescent/Young Adult Medicine, Department of
Medicine (Dr Shrier); Clinical Research Core Programs Office (Dr Harris),
and Department of Psychiatry (Dr Beardslee), Children's Hospital, Harvard
Medical School, Boston, Mass.
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