Abstract
Background:
Perceptions of personal attributes as less malleable are associated with more severe depression symptoms and less active coping in youth. Perceptions of depression itself as relatively fixed have been linked to more severe depression symptoms; however, it is not known how beliefs about depression relate to active and avoidant coping behaviors in particular.
Methods:
We gathered information about beliefs about depression and activation and avoidance behaviors among 104 adolescents with high depression symptoms. The primary depression belief examined was prognostic pessimism, or the belief that depression is relatively permanent. We calculated correlations between this belief and activation and avoidance/rumination behaviors.
Results:
Prognostic pessimism was negatively correlated with behavioral activation scores (r = −.31; p = .001), and was positively correlated with behavioral avoidance/rumination scores (r = .30; p = .002).
Limitations:
This data was cross-sectional, and relied on self-report measures of depression beliefs and behaviors.
Conclusions:
Adolescents who believe that depression is relatively permanent might feel less motivated to engage in effortful activation behaviors, instead favoring avoidance. These results may help elucidate the ways in which malleability beliefs relate to mental health outcomes among adolescents, and highlight prognostic pessimism as a potential treatment target for reducing depressogenic behaviors.
Keywords: depression, adolescent, prognostic pessimism, behavioral activation
Research has shown that an important factor for the course and outcome of adolescent depression is treatment-relevant beliefs (Curry et al., 2006). One type of belief that is associated with depression severity is prognostic pessimism—the belief that depression is relatively permanent and unlikely to remit (Lebowitz & Ahn, 2015). Beliefs about the permanence of personal traits—referred to as “mindsets” (Dweck, 2009)—are associated with depression in youth: those who believe personal traits are more permanent report higher depression (Schleider, Abel, & Weisz, 2015). Moreover, research has shown that prognostic pessimism for depression specifically is associated with more severe depression symptoms (Schroder et al., 2016). However, research has yet to explain why.
One way in which prognostic pessimism may be linked to depression symptoms is as a possible influence on coping behaviors that impact depression levels. Mindsets impact responses to difficulty and distress: those who believe exerting effort towards a problem is likely to result in success are more likely to exert effort or approach behaviors towards the problem rather than passive or avoidant responses (Dweck, 2009). Fixed mindsets about emotions and personality traits are consistently associated with more passive coping styles, which are in turn associated with more severe depression symptoms (Burnette et al., 2020; Horwitz, Hill, & King, 2011; Kneeland & Dovidio, 2020). Similarly, it is possible that prognostic pessimism for depression may influence coping behaviors in a way that then increases depression symptoms. A cross-sectional correlation between prognostic pessimism and coping behaviors would be consistent with this theoretical model.
Present Study
This study explored the relationship between prognostic pessimism for depression and depression-related coping behaviors (activation and avoidance/rumination behaviors) in a sample of depressed adolescents. We hypothesized that prognostic pessimism for depression would be negatively correlated with activation behaviors and positively correlated with avoidance/rumination behaviors.
Method
Participants
Data were drawn from the baseline survey battery of an NIH-funded longitudinal study [NIH-grant number: 1DP5OD028123-01]. Participants were 106 adolescents in New York State whose caregivers were recruited using Facebook advertisements. Adolescents were eligible for the study if they were within the age range of 11–16, had access to their own smartphone device, were fluent in English, and had a Children’s Depression Inventory-2 (CDI-2; Kovacs, 2014) T-score greater than or equal to 60 for their sex and age (i.e., 80th percentile or higher for depressive symptoms) or endorsed seeking treatment for depression within the past two years. This data was collected between February 2020 and February 2021.
Ethical Considerations
Before participation, adolescents provided informed assent to participate and caregivers provided informed consent. All procedures were approved by Stony Brook University’s Institutional Review Board prior to enrollment of the first participant.
Assessments and Measures
Prognostic pessimism for depression was reported by adolescents via a one-item measure consistent with prior research (Lebowitz & Ahn, 2015). Participants were instructed to imagine that they were going through depression in the future, and asked, “How permanent do you think the depression would be?” Responses were on a 5-point Likert-type scale ranging from (1) Not permanent at all to (5) Completely permanent.
Behavioral activation and avoidance/rumination were adolescent-reported and were measured using the Behavioral Activation for Depression Scale (BADS; Kanter et al., 2006). The BADS is a list of 25 statements describing behavior in the past week that respondents endorse on a Likert-type scale from (0) Not at all to (6) Completely. The BADS includes subscales for activation (seven items, measuring focused goal-directed activation and completion of scheduled activities) and avoidance/rumination (eight items, measuring avoidance of negative aversive states and engaging in rumination rather than active problem solving) behaviors that are believed to impact depression symptoms. The BADS had good internal consistency in this sample both overall (ɑ = .86) and for the activation (ɑ = .80) and avoidance/rumination (ɑ = .87) subscales. This measure has been used to measure depression-related behaviors with adolescents (McCauley et al., 2016).
Depression symptom severity was measured using the Children’s Depression Inventory-2 (CDI-2; Kovacs, 2014). The measure’s internal consistency in this sample was ɑ = .92.
Data Analytic Plan
All data processing and analytic methods were specified prior to analyses in a preregistration available at https://osf.io/54k2y/. Analytic code is also available at that location. Rank-order (Spearman) correlation coefficients and corresponding p-values were calculated between scores on the prognostic pessimism item and both the activation and avoidance/rumination BADS subscale scores. In order to replicate relationships from previous research, we also calculated correlations between depression symptom severity and the three other variables (prognostic pessimism, activation, avoidance/rumination). Missing data was removed pairwise.
Results
Two participants did not respond to the prognostic pessimism and were dropped from analyses, leaving an analytic sample of 104. Of these, one had a missing BADS activation score and one had a missing depression score. Characteristics of the analytic sample are reported in Table 1. The mean BADS activation score was 14.76 (SD = 8.28), and the mean BADS avoidance/rumination score was 20.88 (SD = 12.28). The mean score for prognostic pessimism for depression was 2.95 (SD = 1.12).
Table 1.
Sample Characteristics
| Characteristic | n | % |
|---|---|---|
| Race/Ethnicity | ||
| Asian-American/Pacific Islander non-Hispanic | 2 | 1.92 |
| Black non-Hispanic | 12 | 11.54 |
| Hispanic | 14 | 13.46 |
| Other/Multiple non-Hispanic | 14 | 13.46 |
| White non-Hispanic | 62 | 59.62 |
| Gender | ||
| Cisgender man | 36 | 34.62 |
| Cisgender woman | 63 | 60.58 |
| Other/non-binary gender identity | 5 | 4.81 |
| Age | ||
| 11 | 3 | 2.88 |
| 12 | 12 | 11.54 |
| 13 | 23 | 22.12 |
| 14 | 20 | 19.23 |
| 15 | 27 | 25.96 |
| 16 | 19 | 18.27 |
| Annual family income | ||
| $0-$19,000 | 9 | 8.65 |
| $20,000-$39,000 | 13 | 12.50 |
| $40,000–$59,000 | 8 | 7.69 |
| $60,000–$79,000 | 16 | 15.38 |
| $80,000–$99,000 | 17 | 16.35 |
| $100,000–$119,000 | 5 | 4.81 |
| $120,000–$140,000 | 8 | 7.69 |
| $140,000+ | 27 | 26.92 |
Mean scores on each BADS subscale by level of prognostic pessimism are displayed in Figure 1. As hypothesized, prognostic pessimism was moderately negatively correlated with BADS activation scores, such that those who believed depression was more permanent reported fewer activation behaviors (r = −.31; p = .001). Additionally, prognostic pessimism was moderately positively correlated with BADS avoidance/rumination scores, such that adolescents who believed depression was more permanent reported more avoidance/rumination behaviors (r = .30; p = .002). Depression symptom severity was positively associated with prognostic pessimism, r = 0.47; negatively associated with activation, r = −0.49; and positively associated with avoidance/rumination, r = 0.75.
Figure 1:
Mean behavioral activation and avoidance/rumination scores by prognostic pessimism level. BADS = Behavioral Activation for Depression Scale.
Discussion
As hypothesized, prognostic pessimism for depression was negatively correlated with activation behaviors, such that adolescents who believed depression to be more permanent were less likely to engage in a variety of activities and pursue long-term goals despite difficulty. Frequency of such activation behaviors is negatively correlated with depression severity (a finding replicated in this sample; Kanter et al., 2006). Additionally, prognostic pessimism for depression was positively correlated with avoidance/rumination behaviors, such that those who believed depression to be more permanent reported engaging more frequently in activities to avoid experiencing negative feelings and also thinking about their problems. Frequency of these behaviors is positively correlated with depression severity (a finding replicated in this sample; Kanter et al., 2006).
These results are consistent with multiple causal models of the relationship between prognostic pessimism and coping. One possible explanation is that prognostic pessimism influences adolescents’ choice of coping efforts. Coping decisions when faced with difficulties are influenced by individuals’ expectations about the outcome of specific coping efforts (Catanzaro et al., 2000). Adolescents who believe that depression is relatively changeable may be more optimistic that changing their behavior can influence their depression symptoms; in turn, this may foster the use of more behavioral activation coping strategies and fewer avoidance strategies. Conversely, those who believe depression is relatively permanent might hold more pessimistic expectations for the results of active efforts to improve their depression symptoms. Such adolescents might then feel less motivated to engage in effortful activation behaviors, instead favoring avoidance or rumination in the face of their depression. In this way, present results are consistent with a model where prognostic pessimism informs how adolescents deal with depression symptoms.
Importantly, there are alternative interpretations of the observed correlations between prognostic pessimism for depression and the behaviors measured here. For example, it is possible that prognostic pessimism is a consequence of, rather than a contributor to, more severe depression and depressogenic behaviors. In other words, prognostic pessimism may not itself drive unhelpful coping behaviors but be just a consequence of more severe depression, which also is associated with avoidance and withdrawal. This would also produce the pattern of results observed here. Thus, further study will be necessary to clarify the directionality of these associations, which may be either unidirectional or bidirectional in nature.
Prognostic pessimism is a negative belief about the future, and is likely closely related to—or perhaps best conceived as a facet of—hopelessness. Hopelessness figures heavily in models of depression such as the hopelessness theory of depression (Abramson et al., 1989) and Beck’s cognitive model of depression (Beck et al., 1979), both of which identify negative expectations for the future as an important driver of depressive processes. However, specific outcome beliefs (e.g., self-efficacy in a particular area) predict human behavior better than more general ones. For this reason, we believe that prognostic pessimism is of interest as a potential contributor to depression-related behaviors, above and beyond linking maladaptive coping to general hopelessness. Further, we believe that identifying specific hopelessness-related beliefs that may predict depressogenic behaviors can lead to a more detailed understanding of why hopelessness is so central to depression.
This study has several limitations. First, the cross-sectional nature of the data does not allow insight into how the connection between depression permanence beliefs and activation/avoidance behaviors unfolds over time. Second, the study relied on self-report-measures, including of the recent frequency of activation and avoidance behaviors; such retrospective reports of behavior may be biased and not match actual daily behaviors. Associations between variables may also have been inflated by shared method variance. Additionally, the wording of the prognostic pessimism question used here asked participants about an imagined future period of depression rather than their current one. While this is consistent with language used in previous research (Lebowitz & Ahn, 2015), this language could have impacted responses if adolescents had different beliefs about future periods of depression than their current one.
Future research should continue to explore the connections between adolescents’ beliefs about the nature of depression and their own depression-related behaviors. For example, longitudinal studies could investigate whether coping behaviors mediate the relationship between prognostic pessimism and depression symptom severity. Moreover, intervention research may investigate the effects of targeting prognostic pessimism in depressed adolescents on their coping behaviors and clinical outcomes
Highlights:
Pessimistic beliefs about depression have been linked to worse depression symptoms
Teens who are pessimistic about their depression use less active coping behaviors
Teens with pessimistic depression beliefs also use more avoidant coping behavior
Funding:
This study was supported by the National Institutes of Health, Office of the Director, grant number DP5OD028123 (PI: JLS).
Footnotes
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Declaration of Interest: JLS serves on the Scientific Advisory Board for Walden Wise; is Co-Founder and Co-Director of Single Session Support Solutions. Inc.; and receives book royalties from New Harbinger, Oxford University Press, and Little Brown Book Group. JBP, ILA, and SC declare no conflicts of interest.
Data Availability
Data and analytic code for this study are available at https://osf.io/54k2y/.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data and analytic code for this study are available at https://osf.io/54k2y/.