Abstract
Anxiety and depression are common among adolescents in China, and evidence shows that subthreshold depression has a strong relationship with depression. This study uses network analysis to investigate comorbid anxiety and depression and their associations with response styles among Chinese adolescents with subthreshold depression. 371 Participants completed measures of assessing the anxious and depressvie symptoms, and the response styles. Bridge symptoms were calculated to identify, respectively, anxiety and depression networks’ main symptoms. A flow network of response styles was used as we investigated specific relationships among anxiety, depression, and response style. Network analysis revealed physiological and affective symptoms, where affect may be positive or depressed, were central. The most noticeable bridge symptoms were physical and somatic. Depressed affect and physical symptoms were positively correlated with rumination, while harm avoidance had a weak positive correlation with distraction. Timely interventions targeting both sets of symptoms are needed for the alleviation and prevention of depressive symptoms and anxiety. Depressed affect and harm avoidance have links to rumination and distraction, which increases comprehension of how response styles are related to depression as well as anxiety.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
Bai, W., Cai, H., Liu, S., Chen, X., Sha, S., Cheung, T., Lin, J. J., Cui, X., Ng, C. H., & Xiang, Y. T. (2021). Anxiety and depressive symptoms in college students during the late stage of the COVID-19 outbreak: A network approach. Translational Psychiatry, 11(1), 638. https://doi.org/10.1038/s41398-021-01738-4
Balázs, J., Miklósi, M., Keresztény, Á., Hoven, C. W., Carli, V., Wasserman, C., Apter, A., Bobes, J., Brunner, R., Cosman, D., Cotter, P., Haring, C., Iosue, M., Kaess, M., Kahn, J., Keeley, H. S., Marušič, D., Poštuvan, V., Resch, F., … Wasserman, D. (2013). Adolescent subthreshold-depression and anxiety: Psychopathology, functional impairment and increased suicide risk. Journal of Child Psychology and Psychiatry and Allied Disciplines, 54(6), 670–677. https://doi.org/10.1111/jcpp.12016
Bani Mohammad, E., & Ahmad, M. (2019). Virtual reality as a distraction technique for pain and anxiety among patients with breast cancer: A randomized control trial. Palliative and Supportive Care, 17(1), 29–34. https://doi.org/10.1017/S1478951518000639
Beard, C., Millner, A. J., Forgeard, M. J., Fried, E. I., Hsu, K. J., Treadway, M. T., Leonard, C. V., Kertz, S. J., & Björgvinsson, T. (2016). Network analysis of depression and anxiety symptom relationships in a psychiatric sample. Psychological Medicine, 46(16), 3359–3369. https://doi.org/10.1017/S0033291716002300
Bekhuis, E., Schoevers, R. A., Borkulo, C. D., Rosmalen, J. G., & Boschloo, L. (2016). The network structure of depressive, anxiety and somatic symptoms. Journal of Psychosomatic Research, 85, 55–55. https://doi.org/10.1016/j.jpsychores.2016.03.134
Bertha, E. A., & Balázs, J. (2013). Subthreshold depression in adolescence: A systematic review. European Child & Adolescent Psychiatry, 22(10), 589–603. https://doi.org/10.1007/s00787-013-0411-0
Borsboom, D., & Cramer, A. O. (2013). Network analysis: An integrative approach to the structure of psychopathology. Annual Review of Clinical Psychology, 9, 91–121. https://doi.org/10.1146/annurev-clinpsy-050212-185608
Cai, H., Bai, W., Liu, H., Chen, X., Qi, H., Liu, R., Cheung, T., Su, Z., Lin, J., Tang, Y. L., Jackson, T., Zhang, Q., & Xiang, Y. T. (2022). Network analysis of depressive and anxiety symptoms in adolescents during the later stage of the COVID-19 pandemic. Translational Psychiatry, 12(1), 98. https://doi.org/10.1038/s41398-022-01838-9
Clayborne, Z. M., Varin, M., & Colman, I. (2019). Systematic review and Meta-analysis: Adolescent depression and long-term psychosocial outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 58(1), 72–79. https://doi.org/10.1016/j.jaac.2018.07.896
Constantin, K., English, M. M., & Mazmanian, D. (2018). Anxiety, depression, and procrastination among students: Rumination plays a larger mediating role than worry. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 36, 15–27. https://doi.org/10.1007/s10942-017-0271-5
Cramer, A. O., Waldorp, L. J., van der Maas, H. L., & Borsboom, D. (2010). Comorbidity: A network perspective. Behavioral and Brain Sciences, 33(2–3), 137–193. https://doi.org/10.1017/S0140525X09991567
Cramer, A. O., Waldorp, L. J., van der Maas H. L., & Borsboom, D. (2010). Complex realities require complex theories: Refining and extending the network approach to mental disorders. Behavioral and Brain Sciences, 33, 178–193. https://doi.org/10.1017/S0140525X10000920
Epskamp, S., Borsboom, D., & Fried, E. I. (2018). Estimating psychological networks and their accuracy: A tutorial paper. Behavior Research Methods, 50(1), 195–212. https://doi.org/10.1017/S0140525X10000920
Epskamp, S., Cramer, A. O., Waldorp, L. J., Schmittmann, V. D., & Borsboom, D. (2012). Qgraph: Network visualizations of relationships in psychometric data. Journal of Statistical Software, 48, 1–18. https://doi.org/10.18637/jss.v048.i04
Everaert, J., Koster, E. H., & Derakshan, N. (2012). The combined cognitive bias hypothesis in depression. Clinical Psychology Review, 32(5), 413–424. https://doi.org/10.1016/j.cpr.2012.04.003
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the global burden of disease study 2017. Lancet, 392(10159), 1789–1858. https://doi.org/10.1016/S0140-6736(18)32279-7
Garabiles, M. R., Lao, C. K., Xiong, Y., & Hall, B. J. (2019). Exploring comorbidity between anxiety and depression among migrant Filipino domestic workers: A network approach. Journal of Affective Disorders, 250, 85–93. https://doi.org/10.1016/j.jad.2019.02.062
Georgiades, K., Lewinsohn, P. M., Monroe, S. M., & Seeley, J. R. (2006). Major depressive disorder in adolescence: The role of subthreshold symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 45(8), 936–944. https://doi.org/10.1097/01.chi.0000223313.25536.47
González-Tejera, G., Canino, G., Ramírez, R., Chávez, L., Shrout, P., Bird, H., Bravo, M., Martínez-Taboas, A., Ribera, J., & Bauermeister, J. (2005). Examining minor and major depression in adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines, 46(8), 888–899. https://doi.org/10.1111/j.1469-7610.2005.00370.x
Hsu, K. J., Beard, C., Rifkin, L., Dillon, D. G., Pizzagalli, D. A., & Björgvinsson, T. (2015). Transdiagnostic mechanisms in depression and anxiety: The role of rumination and attentional control. Journal of Affective Disorders, 188, 22–27. https://doi.org/10.1016/j.jad.2015.08.008
Huang, H., Gundapuneedi, T., & Rao, U. (2012). White matter disruptions in adolescents exposed to childhood maltreatment and vulnerability to psychopathology. Neuropsychopharmacology, 37(12), 2693–2701.
Jin, Y., Sha, S., Tian, T., Wang, Q., Liang, S., Wang, Z., Liu, Y., Cheung, T., Su, Z., Ng, C. H., & Xiang, Y. T. (2022). Network analysis of comorbid depression and anxiety and their associations with quality of life among clinicians in public hospitals during the late stage of the COVID-19 pandemic in China. Journal of Affective Disorders, 314, 193–200. https://doi.org/10.1016/j.jad.2022.06.051
Johnson, D., Dupuis, G., Piche, J., Clayborne, Z., & Colman, I. (2018). Adult mental health outcomes of adolescent depression: A systematic review. Depression and Anxiety, 35(8), 700–716. https://doi.org/10.1002/da.22777
Jones, P. J., Ma, R., & McNally, R. J. (2019). Bridge centrality: A network approach to understanding comorbidity. Multivariate Behavioral Research, 56, 353–367. https://doi.org/10.1080/00273171.2019.1614898
Jones, P. J., Ma, R., & McNally, R. J. (2021). Bridge centrality: A network approach to understanding comorbidity. Multivariate Behavioral Research, 56(2), 353–367. https://doi.org/10.1080/00273171.2019.1614898
Just, N., & Alloy, L. B. (1997). The response styles theory of depression: Tests and an extension of the theory. Journal of Abnormal Psychology, 106(2), 221–229. https://doi.org/10.1037//0021-843x.106.2.221
Kaiser, T., Herzog, P., Voderholzer, U., & Brakemeier, E. L. (2021). Unraveling the comorbidity of depression and anxiety in a large inpatient sample: Network analysis to examine bridge symptoms. Depression and Anxiety, 38(3), 307–317. https://doi.org/10.1002/da.23136
Kobayashi, R., Miyatani, M., & Nakao, T. (2021). High working memory capacity facilitates distraction as an emotion regulation strategy. Current Psychology, 40, 1159–1167. https://doi.org/10.1007/s12144-018-0041-2
Koster, E. H., Fox, E., & MacLeod, C. (2009). Introduction to the special section on cognitive bias modification in emotional disorders. Journal of Abnormal Psychology, 118(1), 1–4. https://doi.org/10.1037/a0014379
LeMoult, J., Yoon, K. L., & Joormann, J. (2016). Rumination and cognitive distraction in major depressive disorder: An examination of respiratory sinus arrhythmia. Journal of Psychopathology and Behavioral Assessment, 38, 20–29. https://doi.org/10.1007/s10862-015-9510-1
Liu, R., Chen, X., Qi, H., Feng, Y., Su, Z., Cheung, T., Jackson, T., Lei, H., Zhang, L., & Xiang, Y. T. (2022). Network analysis of depressive and anxiety symptoms in adolescents during and after the COVID-19 outbreak peak. Journal of Affective Disorders, 301, 463–471. https://doi.org/10.1016/j.jad.2021.12.137
Lo, B. C. Y., Zhao, Y., Ho, Y. C., & Au, T. K. (2017). Psychometric properties of the children’s response styles questionnaire in a Hong Kong Chinese community sample. Health and Quality of Life Outcomes, 15(1), 198. https://doi.org/10.1186/s12955-017-0774-x
Lyubomirsky, S., Layous, K., Chancellor, J., & Nelson, S. K. (2015). Thinking about rumination: The scholarly contributions and intellectual legacy of Susan Nolen-Hoeksema. Annual Review of Clinical Psychology, 11, 1–22. https://doi.org/10.1146/annurev-clinpsy-032814-112733
Lyubomirsky, S., & Nolen-Hoeksema, S. (1993). Self-perpetuating properties of dysphoric rumination. Journal of Personality and Social Psychology, 65(2), 339–349. https://doi.org/10.1037//0022-3514.65.2.339
Ma, S., Yang, J., Cheng, H., Wang, W., Chen, G., Bai, H., Yao, L., & Liu, Z. (2022). The central symptoms of depression, anxiety, and somatization: A network analysis. All Life, 15(1), 933–941. https://doi.org/10.1080/26895293.2022.2120091
Makhubela, M. (2021). Comorbid anxiety and depression psychopathology in university students: A network approach. South African Journal of Psychology, 51(1), 35–53. https://doi.org/10.1177/0081246320973839
March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 554–565. https://doi.org/10.1097/00004583-199704000-00019
McLaughlin, K. A., & Nolen-Hoeksema, S. (2012). Interpersonal stress generation as a mechanism linking rumination to internalizing symptoms in early adolescents. Journal of Clinical Child and Adolescent Psychology, 41(5), 584–597. https://doi.org/10.1080/15374416.2012.704840
Mullarkey, M. C., Marchetti, I., & Beevers, C. G. (2019). Using Network Analysis to identify central symptoms of adolescent depression. Journal of Clinical Child and Adolescent Psychology, 48(4), 656–668. https://doi.org/10.1080/15374416.2018.1437735
Nolen-Hoeksema, S. (1987). Sex differences in unipolar depression: Evidence and theory. Psychological Bulletin, 101(2), 259–282. https://doi.org/10.1037/0033-2909.101.2.259
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100(4), 569–582. https://doi.org/10.1037//0021-843x.100.4.569
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109(3), 504–511. https://doi.org/10.1037/0021-843X.109.3.504
Nolen-Hoeksema, S., & Davis, C. G. (1999). Thanks for sharing that”: Ruminators and their social support networks. Journal of Personality and Social Psychology, 77(4), 801–814. https://doi.org/10.1037/0022-3514.77.4.801
Nolen-Hoeksema, S., & Morrow, J. (1993). Effects of rumination and distraction on naturally occurring depressed mood. Cognition and Emotion, 7, 561–570. https://doi.org/10.1080/02699939308409206
Nolen-Hoeksema, S., Parker, L. E., & Larson, J. (1994). Ruminative coping with depressed mood following loss. Journal of Personality and Social Psychology, 67(1), 92–104. https://doi.org/10.1037//0022-3514.67.1.92
Osborn, T. L., Campbell, S., Ndetei, D. M., & Weisz. (2020). Network analysis reveals central symptoms of adolescent depression and anxiety in Sub-Saharan Africa. In: PsyArXiv. https://doi.org/10.31234/osf.io/dv6c9
Parmentier, F. B. R., García-Toro, M., García-Campayo, J., Yañez, A. M., Andrés, P., & Gili, M. (2019). Mindfulness and symptoms of depression and anxiety in the general population: The mediating roles of worry, rumination, reappraisal and suppression. Frontiers in Psychology, 10, 506. https://doi.org/10.3389/fpsyg.2019.00506
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. https://doi.org/10.1177/014662167700100306
Robinaugh, D. J., Hoekstra, R. H. A., Toner, E. R., & Borsboom, D. (2020). The network approach to psychopathology: A review of the literature 2008–2018 and an agenda for future research. Psychological Medicine, 50(3), 353–366. https://doi.org/10.1017/S0033291719003404
Ryder, A. G., Yang, J., & Heine, S. J. (2002). Somatization vs. psychologization of emotional distress: A paradigmatic example for cultural psychopathology. In W. J. Lonner, D. L. Dinnel, S. A. Hayes, & D. N. Sattler (Eds.), Online readings in psychology and culture. Center for Cross-Cultural Research, Western Washington University. Unit 9, Chap. 3.
Shankman, S. A., Lewinsohn, P. M., Klein, D. N., Small, J. W., Seeley, J. R., & Altman, S. E. (2009). Subthreshold conditions as precursors for full syndrome disorders: A 15-year longitudinal study of multiple diagnostic classes. Journal of Child Psychology and Psychiatry and Allied Disciplines, 50(12), 1485–1494. https://doi.org/10.1111/j.1469-7610.2009.02117.x
Steinberg, L. (2005). Cognitive and affective development in adolescence. Trends in Cognitive Sciences, 9(2), 69–74.
Sun, X. Y., Li, Y. X., Yu, C. Q., & Li, L. M. (2017). Reliability and validity of depression scales of chinese version: A systematic review (in Chinese). Chinese Journal of Epidemiology, 38, 110–116. https://doi.org/10.3760/cma.j.issn.0254-6450.2017.01.021
Suslow, T., Hußlack, A., Kersting, A., & Bodenschatz, C. M. (2020). Attentional biases to emotional information in clinical depression: A systematic and meta-analytic review of eye tracking findings. Journal of Affective Disorders, 274, 632–642. https://doi.org/10.1016/j.jad.2020.05.140
Tan, X., Zhang, J., & Yang, Q. L. (2013). TCM psychological intervention for subthreshold depression and its mechanism. Chinese General Practice, 16(8), 2649–2651.
Tuithof, M., Ten Have, M., van Dorsselaer, S., Kleinjan, M., Beekman, A., & de Graaf, R. (2018). Course of subthreshold depression into a depressive disorder and its risk factors. Journal of Affective Disorders, 241, 206–215. https://doi.org/10.1016/j.jad.2018.08.010
van Borkulo, C. D., van Bork, R., Boschloo, L., Kossakowski, J. J., Tio, P., Schoevers, R. A., Borsboom, D., & Waldorp, L. J. (2022). Comparing network structures on three aspects: A permutation test. Psychological Methods. https://doi.org/10.1037/met0000476. Advance online publication.
Volkaert, B., Wante, L., Van Beveren, M. L., Vervoort, L., & Braet, C. (2020). Training adaptive emotion regulation skills in early adolescents: The effects of distraction, acceptance, cognitive reappraisal, and problem solving. Cognitive Therapy and Research, 44(3), 678–696. https://doi.org/10.1007/s10608-019-10073-4
Wang, Y., Hu, Z., Feng, Y., Wilson, A., & Chen, R. (2020). Changes in network centrality of psychopathology symptoms between the COVID-19 outbreak and after peak. Molecular Psychiatry, 25(12), 3140–3149. https://doi.org/10.1038/s41380-020-00881-6
Wasil, A. R., Venturo-Conerly, K. E., Shinde, S., Patel, V., & Jones, P. J. (2020). Applying network analysis to understand depression and substance use in indian adolescents. Journal of Affective Disorders, 265, 278–286. https://doi.org/10.1016/j.jad.2020.01.025
Waugh, C. E., Shing, E. Z., & Furr, R. M. (2020). Not all disengagement coping strategies are created equal: Positive distraction, but not avoidance, can be an adaptive coping strategy for chronic life stressors. Anxiety Stress and Coping, 33(5), 511–529. https://doi.org/10.1080/10615806.2020.1755820
Wesselhoeft, R., Sørensen, M. J., Heiervang, E. R., & Bilenberg, N. (2013). Subthreshold depression in children and adolescents - a systematic review. Journal of Affective Disorders, 151(1), 7–22. https://doi.org/10.1016/j.jad.2013.06.010
Whisman, M. A., du Pont, A., & Butterworth, P. (2020). Longitudinal associations between rumination and depressive symptoms in a probability sample of adults. Journal of Affective Disorders, 260, 680–686. https://doi.org/10.1016/j.jad.2019.09.035
Wong, M., & Power, T. G. (2018). Links between coping strategies and depressive symptoms among girls and boys during the transition to primary school. Early Education and Development, 30, 178–195. https://doi.org/10.1080/10409289.2018.1544811
World Health Organization. (2018). Adolescent mental health: Fact sheet. WHO.
Yao, S., Zou, T., Zhu, X., Abela, J. R., Auerbach, R. P., & Tong, X. (2007). Reliability and validity of the chinese version of the multidimensional anxiety scale for children among chinese secondary school students. Child Psychiatry and Human Development, 38(1), 1–16. https://doi.org/10.1007/s10578-006-0039-0
Zhang, J., Qin, S., Zhou, Y., Meng, L., Su, H., & Zhao, S. (2018). A randomized controlled trial of mindfulness-based Tai Chi Chuan for subthreshold depression adolescents. Neuropsychiatric Disease and Treatment, 14, 2313–2321. https://doi.org/10.2147/NDT.S173255
Funding
The research was supported by the National Natural Science Foundation of China [Grant No. 32200911], the Philosophy and Social Science Research in Colleges and Universities of Jiangsu Province [Project No. 2022SJYB0179], and the Startup Foundation for Introducing Talent of NUIST [Project No. 2022r047].
Author information
Authors and Affiliations
Contributions
Peng Fan: Methodology, Data curation, Formal analysis, Writing – original draft.
Tingting Wang: Methodology, Investigation, Resources, Writing – review & editing.
Jiawen Wang: Methodology, Writing - Review & Editing.
Junyi Wang: Conceptualization, Data curation, Methodology, Writing - Review & Editing, Supervision, Funding acquisition, Project administration.
Corresponding author
Ethics declarations
Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the ethics review board of the corresponding institution.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Conflict of interest
The authors declare no conflict of interest.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
Below is the link to the electronic supplementary material.
ESM 1
(DOCX 330 KB)
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Fan, P., Wang, T., Wang, J. et al. Network analysis of comorbid depression and anxiety and their associations with response style among adolescents with subthreshold depression. Curr Psychol 43, 8665–8674 (2024). https://doi.org/10.1007/s12144-023-04992-5
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12144-023-04992-5