Research reportEnhancing depression screening to identify college students at risk for persistent depressive symptoms
Introduction
The point prevalence rate of Major Depressive Disorder (MDD) among college students has been estimated at 5.2% (Eisenberg et al., 2007). Further, 43.2% of college students in the United States reported feeling so depressed that it was difficult to function at least once in the previous 12 months (American College Health Association, 2008). In addition to causing personal distress, depressive symptoms in college students are associated with considerable academic impairment (Deroma et al., 2009, Heiligenstein et al., 1996).
Given the high rate of depressive symptoms and associated impairment among college students, colleges and universities have developed and implemented depression screening programs to identify students in need of mental health services and provide appropriate follow-up evaluations or prevention and treatment resources (Garlow et al., 2008, Voelker, 2003). These depression screening programs have resulted in an increased demand for evaluation and treatment on already overburdened university mental health centers (Voelker, 2003). Identification of possible “cases” in depression screening programs has exacerbated the imbalance between the demand for mental health services and the ability of campus mental health centers to provide those services.
One strategy to reduce the imbalance would be to expand the number of mental health service providers at campus mental health centers, which would require greater investments of resources by universities. An alternative strategy would be to refine screening strategies so as to identify a smaller number of cases in need of further evaluation and possible treatment. As will be elaborated below, many college students who screen positive for depressive symptoms will experience transient periods of distress that are likely to dissipate without mental health services (Goncalves et al., 2012). A smaller number of college students who screen positive for depressive symptoms will experience persistent and impairing levels of depression. Students in the latter group represent ideal candidates for referral to campus mental health services.
The purpose of the present study was to identify variables that predicted which college students who screen positive for elevated depressive symptoms would experience a persistent course of depressive symptoms over a one-year period. With these variables in hand, depression screening programs can be tailored to identify a subset of cases who are most in need of mental health services, reducing the burden on campus mental health centers while also making treatment available to those who are most in need.
Past research among college students indicates heterogeneity in the course of depressive symptoms. For example, in a study of depressive symptom maintenance in 117 college students who screened positive for depressive symptoms, only 32 (27.3%) continued to screen positive for depressive symptoms two years later (Zivin et al., 2009). Similarly, a study of 262 college students assessed 12 weeks apart showed some students reported increases in depressive symptoms while other students reported decreases over this period (Goncalves et al., 2012). These findings among college students mirror findings on the heterogeneous courses of depressive symptoms among adolescents, emerging adults, and young adults (Pettit et al., 2010, Stoolmiller et al., 2005, Yaroslavsky et al., 2013).
Existing depression screening programs identify individuals with currently elevated symptoms, and thus likely identify individuals who will go on to experience both persistent and non-persistent courses of depressive symptoms. Theories of depressive symptom maintenance can inform the selection of variables that are likely to distinguish between persistent and non-persistent courses. The interpersonal theory of chronic depression (Pettit and Joiner, 2006) posits that excessive reassurance-seeking and negative feedback-seeking have a deleterious impact on interpersonal relationships and social functioning, which contributes to the persistence of depressive symptoms. Excessive reassurance-seeking is a tendency to persistently seek confirmation from others that one is loved and worthy, even when such assurance has already been provided (Joiner et al., 1999). Negative feedback-seeking is a tendency to request or value negative social evaluations of oneself because they are congruent with one׳s own negative self-views (Pettit and Joiner, 2001). The interpersonal theory also posits that low social support (i.e., poor interpersonal belongingness) contributes to depressive symptom persistence. A large body of empirical work provides support for concurrent and prospective associations between depressive symptoms and excessive reassurance-seeking, negative feedback-seeking, and social support (Evraire and Dozois, 2011, Pettit et al., 2011, Starr and Davila, 2008). In addition to the interpersonal theory, response styles theory proposes that a tendency toward rumination, or repetitively focusing on one׳s dysphoric mood and the causes of that mood, contributes to the persistence of depressive symptoms (Nolen-Hoeksema, 1991). Research has demonstrated an association between rumination and depressive symptoms course (Hilt et al., 2010, Nolen-Hoeksema, 1991).
The purposes of the present study were to identify distinct courses of depressive symptoms over a 12-month period among college students who screened positive on a depression symptom measure and to examine predictors of those courses. A two-phase screening process was used, intended to mimic a general depression screening approach (Mackenzie et al., 2011) followed by a more in-depth assessment prior to service utilization. Students first completed a brief depressive symptoms screen and those who reported elevated symptoms were invited to participate in a more in-depth assessment. Students who reported elevated symptoms at the in-depth assessment were re-assessed at three subsequent evaluations over a one year period.
Consistent with previous research (Zivin et al., 2009) it was expected that a subgroup of students would demonstrate a persistently elevated symptom course and that a second subgroup would demonstrate a course of decreasing symptom severity. Based on the interpersonal theory and response styles theory, it was expected that levels of excessive reassurance-seeking, negative feedback-seeking, social support, and rumination would significantly distinguish students in the persistently elevated subgroup from students in the decreasing severity subgroup. Significant predictors of subgroup membership were then examined to derive the optimal cut points for identifying members of the persistently elevated subgroup.
Section snippets
Participants and procedures
Prior to conducting this study, all procedures were approved by the appropriate Institutional Review Board. Participants (n=1079) were recruited from an undergraduate psychology pool. All participants provided written informed consent after the nature of the study was explained. Participants first completed a screening phase in which they were administered the Center for Epidemiological Studies-Depression scale (CES-D; Radloff, 1977); those who reported moderate to severe depressive symptom
Identification of depressive symptom courses
Based on preliminary analyses of single-group trajectories, a quadratic growth model was used to estimate LCGAs with 1–5 classes; relative fit indices for all models are presented in Table 1 and unconditional LCGA results are presented in Table 2. Inspection of relative fit indices for the models provided mixed findings with regard to the preferred number of classes (see Table 1). While adj. BIC indicated diminishing gains beyond a 4-class model, significant LMR values indicated preference for
Discussion
Among 150 college students who screened positive for depressive symptoms, we found evidence of two courses of depressive symptoms over a one-year follow-up: a decreasing severity course and a persisting course. Social disconnection and negative feedback-seeking both significantly predicted class membership with greater scores on measures of social disconnection and negative feedback-seeking at baseline indicative of a higher odds of being in the persistently elevated symptom class.
Consistent
Conclusions
The present study identified courses of depressive symptoms over a 12-month period among college students who screened positive on a depression symptom measure and examined predictors of those trajectories. Results indicated that the presence of two symptom courses, one of persistently elevated depressive symptoms and a second with decreasing symptom severity. Social disconnection and negative feedback-seeking at a baseline assessment both significantly predicted depressive symptom course.
Role of funding source
This work was funded in part by a Florida International University Presidential Fellowship Award to Ryan M. Hill. The funding source has no role in the conduct or analysis of the research.
Conflict of interest
The authors have no conflicts of interest to report.
Acknowledgments
The authors are grateful to Florida International University, which helped fund the research via a Presidential Fellowship award to Ryan M. Hill. The authors are also grateful to all of the college students who participated in the study.
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