Latent trajectory classes of depressive and anxiety disorders from adolescence to adulthood: descriptions of classes and associations with risk factors
Introduction
Depressive and anxiety disorders frequently co-occur in both children and adults [1], [2]. For example, in the National Comorbidity Study-Replication, of individuals with a depressive disorder, 59% had a lifetime diagnosis of an anxiety disorder [3]. In her review, Clark [4] found that 56% of individuals with a depressive disorder had a lifetime anxiety disorder; rates of depressive disorders in individuals with anxiety disorders varied from 20% to 63%, depending on the type of anxiety disorder.
Many studies have examined the relationship between depressive and anxiety disorders over time. One methodology relied on cross-sectional and retrospective designs and generally found that the onset of anxiety disorders typically occurs before the onset of depressive disorders in adults [3], [4], [5], [6], [7] and youth [8], although dysthymia was found to precede anxiety disorders in a few studies [7], [9]. It is unclear how recall biases influence these results, and these cross-sectional studies have not focused on bidirectional relationships between these disorders.
A second approach has involved examining temporal associations between depressive and anxiety disorders using prospective longitudinal designs with clinical, community, and high-risk samples of children, adolescents, and adults. These methods provide the opportunity to examine bidirectional associations between disorders and developmental effects that may partially account for comorbidity. Studies of high-risk samples, as indexed by a family history of depressive disorders [10], [11], [12], and community samples of youth who are assessed through childhood and/or adolescence [13], [14], [15] find that anxiety often precedes depressive disorders throughout childhood and adolescence. Studies of clinical populations with longitudinal assessments of psychopathology find bidirectional relationships between depressive and anxiety disorders [16], [17] in samples of youth. Existing longitudinal research, however, has largely relied on follow-up periods within the same broad developmental period (ie, childhood and adolescence) or between adjacent developmental periods (eg, childhood and early adolescence).
A third approach has been to examine the structure of internalizing psychopathology over time [18], [19], [20]. These methods conceptualize depressive and anxiety disorders as resulting from shared underlying vulnerability factors. For example, 2 recent longitudinal epidemiological studies examined the relation between depressive and anxiety disorders over multiple developmental periods and found that both shared and unique factors influence depression and anxiety [18], [20].
Another potential approach to studying the longitudinal relation between depressive and anxiety disorders involves examining within-person trajectories of depressive and anxiety disorders over time using latent growth curve modeling or hierarchical linear modeling procedures. A number of studies have used these techniques to examine changes in depressive symptoms across adolescence [21] and from adolescence through early young adulthood [22], [23], [24]. Others have examined the course of depressive disorders in conjunction with the development of other disorders during adolescents [25], [26], [27]; however, we are not aware of any study examining the simultaneous trajectory of depressive and anxiety disorders across multiple developmental periods.
Studies examining the relation between depressive and anxiety disorders using variable-centered data analytic approaches assume that associations between variables are largely the same across all individuals in a population. However, it is possible that distinct subtypes of individuals demonstrate different relations between depressive and anxiety disorders over time. Person-centered approaches, like growth curve analysis, allow for heterogeneity of developmental trajectories but do not identify subgroups of individuals who exhibit similar trajectories. To detect such unobserved subgroups, it is necessary to use newer person-centered data analytic approaches designed to identify distinct trajectory classes [28], such as latent class growth analysis (LCGA) [29]. Latent class growth analysis is a longitudinal extension of latent class analysis that examines the possibility that relatively homogenous subgroups of individuals can be extracted from longitudinal data based on the growth trajectory of individuals. In addition, in this analytic approach, the trajectories of depressive and anxiety disorders can be estimated simultaneously. No studies, to our knowledge, have examined the conjoint trajectories of depressive and anxiety disorders simultaneously using this approach.
The present study examines the conjoint trajectories of depressive and anxiety disorders from adolescence through late young adulthood in the Oregon Adolescent Depression Project (OADP) [30] using LCGA [29]. Based on findings that anxiety disorders typically precede depressive disorders, we expected to identify a class of individuals who have an initially high probability of anxiety disorder that precedes an increasing probability of depressive disorder. In addition, based on theory and empirical evidence that depressive and anxiety disorders have both overlapping and distinct vulnerabilities [31], [32], we expected to find a class of individuals with high probabilities of having both depressive and anxiety disorders, depressive disorders only, anxiety disorders only, and neither depressive nor anxiety disorders. As anxiety disorders tend to be relatively persistent, we anticipated finding a class of individuals with a consistently high probability of anxiety disorder over time. Finally, as depressive disorders can be chronic or episodic, we anticipated that several trajectory classes of depressive disorders that differ with respect to persistence over time would be identified.
To assess the meaning and validity of the trajectory classes, we explored whether the identified classes were associated with different patterns of internal and external correlates. These patterns might allow for the identification of common and specific risk factors for various forms of internalizing psychopathology. For example, shared risk factors associated with both trajectories of depressive and anxiety disorders could form the basis for general preventative efforts. Conversely, unique risk factors might highlight a group with specific temporal patterns of risk, which would suggest timing for prevention strategies. We examined four sets of factors that may be associated with depressive and anxiety disorders. First, we tested whether trajectories differed as a function of the specific depressive and anxiety disorder(s) present. In addition, as both depressive and anxiety disorders frequently co-occur with substance use disorders (SUDs [33]), we examined the associations between trajectory classes and lifetime SUD. Some suggest that comorbidity between SUD and depressive disorders represents a distinct subtype of disorder, which may partially explain the observed heterogeneity of the course of disorder [34], [35].
Second, we examined associations between family history of psychopathology and class membership. Parental depression is one of the best established risk factors for developing a depressive disorder [36]. Similarly, parental anxiety disorders are associated with increased rates of anxiety disorders [37], [38]. We expected that trajectory classes characterized by a preponderance of depression would be associated with parental history of depressive disorders and trajectory classes that were characterized by anxiety would be associated with parental history of anxiety disorders. In addition, there is conflicting evidence concerning the independent or co-transmission of internalizing disorders and SUDs. Some work finds that offspring of parents with SUD develop later depressive and anxiety disorders [39], [40], whereas others [41] do not. Thus, we examine the associations between class membership and parental SUD.
Female sex is a robust correlate of both depressive and anxiety disorders [42]. Hence, we also examined the association between sex and class membership.
Fourth, we explored associations between retrospective measures of childhood physical and sexual abuse and trajectory class membership, as early adversity has been found to be associated with onset of both mood and anxiety disorders [43], as well as with persistence of mood disorders [44].
Section snippets
Participants
The OADP [30] is a longitudinal study of a large cohort of high school students who were assessed twice during adolescence, a third time at an average age of 24 years, and a fourth time at an average age of 30 years. Participants were randomly selected from nine high schools in western Oregon. A total of 1709 adolescents (age, 14-18 years; mean [SD] age, 16.6 [1.2] years) completed the initial (T1) assessments between 1987 and 1989, with a 61% participation rate. Approximately 1 year later,
Results
Period prevalence rates of depressive and anxiety disorders at each of the time intervals are displayed in Table 1.
Discussion
The goal of this study was to use a person-centered data analytic approach to examine the joint course of depressive and anxiety disorders. The first aim was to examine the conjoint trajectory of depressive and anxiety disorders and explore class membership as a function of specific diagnoses. The second aim was to explore the meaning and validity of the trajectory classes by examining their associations with selected internal and external correlates.
Acknowledgment
This work was partially supported by National Institute of Mental Health grants RO1 MH66023 (Dr Klein), RO1 MH40501, RO1 MH50522, and RO1 MH52858 (Dr Lewinsohn). Portions of these data were presented at the Twentieth Annual Meeting of the Society for Research in Psychopathology, San Diego, CA, October 2006.
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