Richard T. Liu

Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

Within the past 20 years, depression research has given increasing consideration to the possibility of complex and reciprocal relations between stress and depression. Not only does stress increase risk for depression (i.e., a stress exposure model of depression), but depression, or depressogenic vulnerabilities, in turn, also increases susceptibility to stressful events that are at least in part influenced by the individual (i.e., stress generation; Hammen, 1991). The present review provides a systematic examination of the stress generation literature to date, with specific focus given to depression and depressogenic risk factors (i.e., past stress, negative cognitive styles, and personality and interpersonal vulnerabilities) as predictors of the stress generation effect, as well as gender differences in stress generation, the sequelae of generated stress, and the relative specificity of this phenomenon to depression. The research thus far appears most consistent in supporting the role of depression in predicting generated stress, although more research is still required. In addition to highlighting these findings, methodological limitations and conceptual gaps in the literature are discussed with the view of informing future research in this area.

Suicidal Ideation and Self-Harm in Lesbian, Gay, Bisexual, and Transgender Youth

BACKGROUND Suicide is the third-leading cause of death among adolescents and nonsuicidal self-harm occurs in 13%-45% of individuals within this age group, making these phenomena major public health concerns. Lesbian, gay, bisexual, and transgender (LGBT) youth particularly are at risk for engaging in these behaviors. Nevertheless, relatively little is known about the specific risk factors associated with suicidal ideation and self-harm behaviors in the population. PURPOSE This study provides a longitudinal evaluation of the relative contributions of general and LGBT-specific risk factors as well as protective factors to the occurrence of suicidal ideation and self-harm in an ethnically diverse sample of LGBT youth. METHODS A community sample of 246 LGBT youth (aged 16-20 years) was followed prospectively over five time points at regular 6-month intervals. Participants completed a baseline structured interview assessing suicide attempt history and questionnaires measuring gender nonconformity, impulsivity, and sensation-seeking. At follow-up assessments, participants completed a structured interview assessing self-harm and questionnaires for suicidal ideation, hopelessness, social support, and LGBT victimization. Data were collected from 2007 to 2011, and HLM analyses were conducted in 2011. RESULTS A history of attempted suicide (p=0.05); impulsivity (p=0.01); and prospective LGBT victimization (p=0.03) and low social support (p=0.02) were associated with increased risk for suicidal ideation. Suicide attempt history (p<0.01); sensation-seeking (p=0.04); female gender (p<0.01); childhood gender nonconformity (p<0.01); and prospective hopelessness (p<0.01) and victimization (p<0.01) were associated with greater self-harm. CONCLUSIONS General and LGBT-specific risk factors both uniquely contribute to likelihood of suicidal ideation and self-harm in LGBT youth, which may, in part, account for the higher risk of these phenomena observed in this population.

Stressful Life Events and Depression Symptoms: The Effect of Childhood Emotional Abuse on Stress Reactivity

OBJECTIVE Stressful life events are associated with an increase in depressive symptoms and the onset of major depression. Importantly, research has shown that the role of stress changes over the course of depression. The present study extends the current literature by examining the effects of early life stress on emotional reactivity to current stressors. METHOD In a multiwave study (N = 281, mean age = 18.76; 68% female), we investigated the proximal changes that occur in depressive symptoms when individuals are faced with life stress and whether a history of childhood emotional abuse moderates this relationship. RESULTS Results support the stress sensitivity hypothesis for early emotional abuse history. Individuals with greater childhood emotional abuse severity experienced greater increases in depressive symptoms when confronted with current dependent stressors, controlling for childhood physical and sexual abuse. CONCLUSIONS This study highlights the importance of emotional abuse as an indicator for reactivity to stressful life events.

Life events and suicidal ideation and behavior: A systematic review

Despite the sustained theoretical and empirical interest over the past 40years in the association between life events and suicidal ideation and behavior, the literature in this area has yet to be systematically reviewed. The current article provides a comprehensive review of the empirical literature pertaining to life events in relation to at least one aspect of suicidal ideation and behavior (i.e., suicidal ideation, plans, attempts, degree of suicidal intent, medical severity of attempt, repeat versus first lifetime attempt status, and death by suicide). A total of 95 articles meeting inclusion criteria were identified by a literature search using Medline and PsycINFO. Evidence for an association between negative life events and suicidal ideation and behavior was generally consistent, with strongest support found for more severe than with less severe forms of suicidal ideation and behavior. Support for an inverse relation between positive events and suicidal ideation and behavior was generally lacking. Although there is general support for life stressors as a risk factor for suicidal ideation and behavior, interpretation of these findings is constrained by methodological limitations prevalent in much of the literature, particularly in the case of suicidal ideation and suicide plans. Recommendations for future research are provided.

Social support as a protective factor in suicide: Findings from two nationally representative samples

BACKGROUND Suicide is a problem of worldwide concern and research on possible protective factors is needed. We explored the role of social support as one such factor. Specifically, we hypothesized that increased social support would be associated with decreased likelihood of a lifetime suicide attempt in two nationally representative samples as well as a high-risk subsample. METHODS We analyzed the relationship between social support and lifetime history of a suicide attempt, controlling for a variety of related psychopathology and demographic variables, in the National Comorbidity Study Replication (NCS-R), a United States sample and the Adult Psychiatric Morbidity Study (APMS), an English sample. RESULTS Results indicate that social support is associated with decreased likelihood of a lifetime suicide attempt controlling for a variety of related predictors in both the full US sample (OR=0.68, p<.001) and the full English sample (OR=0.93, p<.01). LIMITATIONS The cross-sectional data do not allow true cause and effect analyses. CONCLUSIONS Our findings suggest social support is associated with decreased likelihood of a lifetime suicide attempt. Social support is a highly modifiable factor that can be used to improve existing suicide prevention programs worldwide.

Prospective prediction of suicide in a nationally representative sample: religious service attendance as a protective factor

BACKGROUND Previous research into religious service attendance as a protective factor against suicide has been conducted only retrospectively, with psychological autopsy studies using proxy informants of completed suicide, rather than prospectively, with completed suicide as a dependent variable. AIMS To determine whether individuals who frequently attended religious services were less likely to die by suicide than those who did not attend so frequently. METHOD We analysed data from a nationally representative sample (n = 20 014), collected in the USA between 1988 and 1994, and follow-up mortality data from baseline to the end of 2006. RESULTS Cox proportional hazard regression analysis indicated that those who frequently attended religious services were less likely to die by suicide than those who did not attend, after accounting for the effects of other relevant risk factors. CONCLUSIONS Frequent religious service attendance is a long-term protective factor against suicide.

Stressful Life Events and Depression Symptoms

OBJECTIVE Stressful life events are associated with an increase in depressive symptoms and the onset of major depression. Importantly, research has shown that the role of stress changes over the course of depression. The present study extends the current literature by examining the effects of early life stress on emotional reactivity to current stressors. METHOD In a multiwave study (N = 281, mean age = 18.76; 68% female), we investigated the proximal changes that occur in depressive symptoms when individuals are faced with life stress and whether a history of childhood emotional abuse moderates this relationship. RESULTS Results support the stress sensitivity hypothesis for early emotional abuse history. Individuals with greater childhood emotional abuse severity experienced greater increases in depressive symptoms when confronted with current dependent stressors, controlling for childhood physical and sexual abuse. CONCLUSIONS This study highlights the importance of emotional abuse as an indicator for reactivity to stressful life events.

An experiential avoidance conceptualization of depressive rumination: three tests of the model.

This study examined an experiential avoidance conceptualization of depressive rumination in 3 ways: 1) associations among questionnaire measures of rumination, experiential avoidance, and fear of emotions; 2) performance on a dichotic listening task that highlights preferences for non-depressive material; and 3) psychophysiological reactivity in an avoidance paradigm modeled after the one used by Borkovec, Lyonfields, Wiser, and Deihl (1993) in their examination of worry. One hundred and thirty-eight undergraduates completed questionnaire measures and participated in a clinical interview to diagnose current and past episodes of depression. Of those, 100 were randomly assigned to a rumination or relaxation induction condition and participated in a dichotic listening task, rumination/relaxation induction, and depression induction. Questionnaire measures confirmed a relationship between rumination status and avoidance; however, no significant effects were found in the dichotic listening task. Psychophysiological measures indicated no difference in physiological response to a depression induction among high ruminators (HR). However, low ruminators (LR) in the relaxation condition exhibited a larger IBI response than LR in the rumination condition. Overall, these results provide partial support for an avoidance conceptualization of depressive rumination. Implications of these findings are discussed.

Emotional maltreatment and depression: prospective prediction of depressive episodes

Background: Most research to date on the role of maltreatment experiences in depression has focused on physical and sexual maltreatment. However, several researchers have theorized that emotional maltreatment may be more strongly linked to depression. Furthermore, prospective studies in this area are lacking. This study addressed these issues by examining whether experiences of current emotional maltreatment predicted the development of new prospective episodes of major (MD) or minor depression (MiD), and the subtype of hopelessness depression (HD) in young adults. It also assessed whether current emotional maltreatment from peers and from authority figures separately predicted the occurrence of depressive episodes. Method: One hundred and sixty‐five participants from the Cognitive Vulnerability to Depression Project were followed prospectively for 2.5 years. Current emotional maltreatment and new depressive episodes were assessed with life event and diagnostic interviews administered every 6 weeks. Results: Greater overall emotional maltreatment predicted shorter time to onset of new MD, MiD, and HD episodes. Peer‐ and authority‐perpetrated emotional maltreatment separately predicted shorter time to development of new HD episodes. Conclusions: Greater emotional maltreatment in young adults prospectively predicts onset of depression, particularly HD. These findings highlight the importance of adult emotional maltreatment experiences in determining targets for prevention and treatment. Depression and Anxiety, 2009.

Stress generation: Future directions and clinical implications

Although the past two decades have seen increasing empirical interest in stress generation, the process whereby depressed or depression-prone individuals experience higher rates of life stress that are at least in part influenced by their own cognitive and behavioral characteristics, several important aspects of this phenomenon remain relatively unexamined, leaving open several promising opportunities for future advancement of the field. The current paper begins with a brief review of the extant literature on the influence of cognitive, behavioral and interpersonal, childhood maltreatment, and genetic factors on stress generation. An integrative theoretical model is then presented tying together these different lines of research in accounting for the stress generation effect and its potential depressogenic sequelae (i.e., depression recurrence and depression contagion). Drawing on this model, particular focus is given to the need to identify the behavioral processes through which cognitive factors confer risk for stress generation, as well as to the need for research assessing the full etiological chain posited by the stress generation hypothesis linking self-generated stress with subsequent depression. In addition, methodological issues of particular relevance to this area of research are discussed. The current review ends with a consideration of the clinical implications of the stress generation phenomenon.