SSCP Journal Club - Week 6: Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

This week's journal article is Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

It can be found here

Article Objective- 

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.

Relationship between stress and risk of depression has been documented in:

• Episodic/Acute Stressors (Kendler et al, 1998)
• Chronic Stress (Hammen, 2005 for review)
• Recent negative life events (Gibbs et al., 2003)
• Early negative life events (Harkness et al., 2006)
• Children (Cole and Turner, 1993)
• Adolescent (Tram and Cole, 2000)
• Young adult (Hankin et al., 2005)
• Geriatric samples (Fiske et al., 2003)

Early Theories: Stress Exposure Models of Depression - Stressful life events significantly increase individual susceptibility to the onset of depression. Next generation models that have received empirical support include:

• Biological diathesis-stress models (see Levinson, 2006 for a recent review)
• Bio-cognitive mediational models (Beevers et al., 2009; Hilt,et al., 2007)
• Cognitive diathesis-stress models (Abramson, et al. 1989; Beck, 1967,1987)
• Cognitive-developmental mediational conceptualizations (Cole, 1990, 1991)
• Interpersonal diathesis-stress theories (Joiner, et al., 1999; see Van Orden et al., 2005 for a review)

More Recent Theory: Stress Generation Model of Depression- while the traditional stress exposure model of depression very much remains an important focus of research, increasing consideration also has been given to a complimentary and similarly important process, whereby depression, or depressogenic vulnerability factors, plays an active role in generating the very stresses that place individuals at heightened risk for future depression.

Method:

·         Due to the otherwise broad nature of this research, the present review only considered articles that provided a specific test of the stress generation hypothesis.

·         Articles were included if:

o   they assessed multiple dependent life events by themselves, or distinguished them from independent ones, and

o   examined them in relation to relevant predictors, thus offering a fairly clean and direct test of the stress generation hypothesis.

·         Articles were identified individually through a PsycINFO search

·         Totaled 57 relevant articles

Predictors of stress generation. The authors then comprehensively reviewed the literature of the following 5 different predictors of stress generation. Citations for the most interesting/seminal work included:

·         Depression (Page 4)- those with reported symptoms of depression report higher rates of dependent episodic stressors than other conditions (Hammen, 1991; Harkness et al., 1999; Shih and Eberhart, 2008)
·         Stress (Page 6)- Depressive symptomatology alone does not seem adequately to account for the stress generation pattern, as heightened levels of negative dependent life stress also have been found to occur during periods of remission. Just as past depression consistently has been found to be a strong predictor of future depression, so may past stress predict future stress. (Hammen et al., 2009; Daley et al., 1997)
·         Negative cognitive style (Page 7)- Stress generation, in large part, is also the product of enduring maladaptive characteristics and behaviors of the individual, several cognitive and personality factors have been implicated in the generation of dependent stress. (Harkness and Stewart, 2007; Shih et al., 2009; Simons et al, 1993; for hopelessness research, see Joiner et al., 2005a & b)
·         Personality and interpersonal vulnerabilities (Page 8)- The authors also reviewed the studies investigating the generation of dependent or interpersonal stress in relation to a number of individual personality and interpersonal characteristics (i.e., Axis II patholoty).

o   PD clusters and depression: Daley et al., 2000, 2006, 1998

o   Neuroticism and Stress Generation: Kercher et al., 2009;

o   Maladaptive coping and problem solving strategies in stress generation: Holahan et al., 2005; Barker, 2007

o   Attachment  styles as risk factors of stress generation (Bottonari et al., 2007

o   Dependency and Reassurance-seeking and stress generation (Shahar and Priel, 2003; Shih et al., 2009)

o   Sociotropy and autonomy as predictors of stress generation (Beck 1983; for chronic stress see Nelson et al., 2001; for acute stress see Shih et al, 2006)

o   FUTURE RESEARCH NOTE FROM AUTHORS: Although these studies provide general support for interpersonal characteristics, in the form of attachment styles, coping strategies, dependency, sociotropy, autonomy, and reassuranceseeking, as contributors to stress generation, research on the unique effect of different interpersonal vulnerabilities is still relatively lacking (see Shahar et al., 2004, for an exception, albeit without distinguishing between dependent and independent stresses in the relevant mediational analyses). It would be important for future research to address this gap in the literature by evaluating multiple interpersonal vulnerabilities simultaneously in prospectively predicting dependent stress, as this approach would allow for a determination of their individual unique and cumulative or additive contribution to the stress generation effect.

·         Gender differences in stress generation (page 12)-  an emerging finding in the literature suggests that there may be a gender difference in the stress generation pattern. Specifically, it may be of greater relevance to women than men. (Rudolph and Hammen 1999, 2000; Barker, 2007; Stafford et al., 2007). The authors report there is some evidence that the female gender:

o   is associated with the generation of dependent stresses

o   Mediates of depression

o   moderates the stress generation effect of depression

o   is mediated in its relation with generated stress by interpersonal vulnerabilities

o   moderates the effect of cognitive and interpersonal predictors of dependent stress.

The authors conclude the review by examining:

·         The Sequelae of generated stress (Page 13)- the degree to which stress generation contributes directly to subsequent depressive symptomatology and diagnoses. Kendler et al (1999) suggests this may be true based on dependent stressors, particularly interpersonal ones, being more strongly associated with depression compared to independent stressors. (for additional evidence see Davila et al., 1995, 1997; Bos et al., 2007)
·         Specificity of stress generation to depression- Stress generation may also be involved in the onset of other disorders (Hammen et al., 2006; Harkness and Luther 2001)

o   Note: A great deal of the studies involving direct comparison between disorders generally spport the view of stress generation being specific to depression (e.g., Wingate and Joiner, 2004; Hammen, 1991)

Future Research ideas

·         There is now a substantial amount of support for the stress generation effect in depression, with many studies replicating the original finding (Hammen, 1991) that depression is associated with subsequent occurrence of dependent stress. The majority of these studies, however, have focused on episodic stress, and very little attention has been devoted to establishing the generation of chronic stress. A great deal of research is needed in the area of the onset of depression (and other disorders) following chronic stress.
·         The involvement of other cognitive vulnerabilities in stress generation are in need of more rigorous research, such as dysfunctional attitudes, rumination, and low self-perceived competence.
·         Although studies on personality and interpersonal vulnerabilities have provided more consistent support for their involvement in stress generation, these vulnerabilities have largely been considered in isolation, precluding any evaluation of their unique and potential additive or cumulative effects on stress generation. Future research should also examine the inter-relations between multiple cognitive and interpersonal vulnerabilities in increasing the occurrence of stressful life events.
·         Much more research is needed on gender differences and stress generation to better understand the etiology of these differences.
·         Thus far, it seems fairly well established that the stress generation effect is specific to dependent stress, particularly within interpersonal domains. Finer-level analyses of these dependent stresses may also be possible, however, by considering domain-specific stresses (e.g., work-, peer-, and family-related stress; Hammen, 2006).
·         Prior methodological issues that could be improved upon:

o   The reliance on self-report

o   The operationalization of stress in the literature

Discussion Questions:

1.    Given the strong interconnection between stress and depression, can these two constructs ever be truly disentangled? Are there measures outside of self report that could be used to better distinguish what is going on between the two?
2.    What other forms of psychopathology may stress generation be involved in? And to that effect, what other forms of psychopathology can depression lead to, and how can we distinguish between the two?
3.    I found a lot of the literature cited in the section about specificity of stress generation to be interesting, as I would expect stress to impact the episodic onset of many of the disorders they discussed, such as Bipolar. Could disorders such as bipolar be more affected by chronic stress given the nature of their consistently rocky interpersonal relationships?
4.    Do generated stressors match one’s underlying responsible vulnerabilities? That is, does one’s vulnerabilities uniquely predict their pattern of generated stress?