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Published in final edited form as: Depress Anxiety. 2015 Aug 20;33(1):66–74. doi: 10.1002/da.22402

Perceptions of close and group relationships mediate the relationship between anxiety and depression over a decade later

Nicholas C Jacobson 1,*, Michelle G Newman 1
PMCID: PMC4959466  NIHMSID: NIHMS801411  PMID: 26290461

Abstract

Background

Previous research has demonstrated that anxiety reliably predicts later depression, but little has been uncovered about the mechanism underlying this connection. Interpersonal relationships appear to be a viable mechanism of the association as anxiety has been shown to predict later deficits in both close (e.g., “best friendships”) and group relationships (e.g., classroom peer groups), and deficits in both close and group relationships have been linked to later depressive symptoms. The current study examined close and group relationships as potential mediators between anxiety and depression 12–14 years later.

Methods

In a nationally representative sample of adolescents (N = 6,504), anxiety was measured at baseline, perceptions of close relationships (i.e., feeling loved) and perceptions of group relationships (i.e., feeling part of a group) were measured 6 months later, and depression levels and diagnosis were measured 12–14 years later.

Results

Using structural equation models, the results showed that adolescent perceptions of both close and group relationships significantly mediated the relationship between adolescent anxiety and adult levels of depression. Furthermore, perceptions of not being accepted/loved in close relationships significantly mediated the relationship between adolescent anxiety and clinical depression in adulthood.

Conclusions

These results suggest that a perception of not being accepted in group relationships may be a mechanism by which heightened anxiety in adolescents leads to heightened nonclinical depression in adulthood. On the other hand, adolescent perceptions of not feeling loved or accepted in close relationships may be a mechanism by which heightened anxiety in adolescence leads to clinical depression—in adulthood.

Keywords: generalized anxiety disorder, negative affect, interpersonal relationships, major depression, social environment

Anxiety and depressive disorders are highly prevalent, with 29% of the U. S. population meeting criteria for a lifetime anxiety disorder and 21% meeting criteria for a lifetime depressive disorder.[1] These disorders also co-occur at high rates and are highly correlated when measured concurrently.[2–6] Elevated anxiety and depression are also both independently associated with decreased quality of life;[7] worse medication adherence;[8] increased risk of cardiovascular, respiratory, endocrinemetabolic, and autoimmune disorders;[9, 10] and increased all-cause mortality rates.[11–13] Given their high co-occurrence and independent broad impacts, it is important to understand the relationship between these two constructs.

In addition to their common co-occurrence, hundreds of studies have found that anxious symptoms often precede and predict the development of later depressive symptoms (see[14] for a meta-analysis;[15–18]), with effect sizes ranging from r = .16 to .45. However, the demonstration of a causal chain, showing the temporal mechanism (i.e., mediator) of how one variable goes on to predict another,[19] would help to provide some initial support for why anxiety is a potential risk factor for depression.

One potential mechanism linking anxiety and depression may be interpersonal relationships. For example, Newman and Erickson[20] theorized that as generalized anxiety is associated with submissive positions,[21] and submissiveness is indicative of passive and unempowered states, anxiety may put one at greater risk of developing depression. These authors also suggested that generalized anxiety negatively impacts interpersonal relationships,[22] and such diminished relationship status may be related to the development of other comorbidities, such as major depression.

Prospective research has linked general anxiety symptoms and later close interpersonal relationships, and close relationships have been linked to later depression. Specifically, general anxiety has been shown to predict having fewer best friends,[23] greater stress from the close relationships they do have,[24] and greater discomfort in discussing personal information with friends.[25] In terms of anxiety-predicting depression, theories of close relationships suggest that feelings of acceptance and love are among the greatest benefits of close relationships.[26, 27] Consequently, acceptance and love may be the aspects of a close relationship that would determine whether such relationships impact subsequent depression. In fact, rejection in close relationships longitudinally predicted later depressive symptoms.[28] Moreover, a decreased sense of belonging was longitudinally associated with severity of depression in those with a history of depression.[29] Additionally, perceived marital dissatisfaction longitudinally predicted depression in women.[30] Given that anxiety impacted perceptions of close relationships and close relationship satisfaction predicted later depression, it is possible that perceptions of close interpersonal relationships are a potential mechanism by which anxiety leads to later depression.

Along with close interpersonal relationship satisfaction, deficits in group relationships have also been associated prospectively with anxiety and depression. For example, Hanish et al.[31] found that general anxiety negatively predicted later peer withdrawal. Change in anxiety symptoms over the course of treatment was also prospectively related to social functioning in groups.[32] Additional studies found that peer acceptance negatively predicted subsequent depression,[33, 34] whereas peer withdrawal, peer humiliation, and peer victimization positively predicted later depression.[35–37] Thus, deficits in group relationships may also mediate the relationship between anxiety and depression, such that anxiety negatively predicts perceived group interactions, and these perceived group interactions negatively predict later depression.

Given that anxiety predicts perceptions of close (e.g., feeling accepted/loved) and group relationships (e.g., feeling part of a group) and that perceptions of close and group relationships predict depression, it is important to determine whether perceptions of close versus group relationships represent distinct constructs. In a factor analysis that included items relating to perceived close and group relationships, items relating to perceived close relationships (i.e., items related to the quality of the friendship between two people) loaded onto a separate factor from items related to perceived group relationships (i.e., items relating to feeling left out of a group).[38] Moreover, these two constructs were not significantly correlated (r = .04), suggesting that close and group relationships are distinct constructs. Further, close relationships and group relationships have both been jointly used to predict depressive symptoms, and they have been shown to have independent impacts.[39] Hence, perceptions of close relationships appear to be relatively distinct from perceptions of group relationships.

To date, only four studies have examined prospective mediators between anxiety and depression.[40–43] Among these studies, negative life events, reassurance seeking, locus of control, and problem solving have been examined, but none of these mediational relationships were significant.[40, 41] The only successful mediators of the relationship between anxiety and later depression were avoidance,[42] sociability, and interpersonal oversensitivity.[43] Most closely related to the current study, Starr et al.[43] showed that sociability and interpersonal oversensitivity mediated the relationship between generalized anxiety disorder and major depressive disorder 8 years later.

Accordingly, the present study investigated two possible mechanisms of the relationship between anxiety and later depression: perceptions of close relationships and perceptions of group relationships. We used a large nationally representative sample of adolescents in which anxiety was assessed at age 16. Perceptions of close relationships and perceptions of group relationships were then assessed 6months later. Lastly, levels and diagnosis of depression was assessed 12–14 years later. Based on previous research, we hypothesized the following: (1) the relationship between anxiety and depression would be mediated by perceptions of close relationships, such that anxiety would negatively predict perceptions of close relationships and perceptions of close relationships would negatively predict depression, (2) the relationship between anxiety and depression would be mediated by perceptions of group relationships, such that anxiety would negatively predict perceptions of group relationships and that perceptions of group relationships would negatively predict depression, (3) anxiety would predict clinical depression 12–14 years later, (4) anxiety and clinical depression would be mediated by close relationships, such that anxiety would negatively predict perceptions of close relationships and perceptions of close relationships would negatively predict clinical depression, and (5) anxiety and clinical depression would be mediated by group relationships, such that anxiety would negatively predict perceptions of group relationships and perceptions of group relationships would negatively predict clinical depression.

METHOD

PARTICIPANTS

Participants were recruited through the National Longitudinal Study of Adolescent Health (Add Health), which is a public use dataset.[44] This study utilized three waves of data collection: the first occurred from 1994 to 1995; the second occurred from 1995 to 1996; and the third wave occurred from 2007 to 2008. Data were collected through interviews with participants. The first wave of participants (N = 6,504, 48% male, M age = 16.04, 66% Caucasian, 25% African American, 1%American Indian, 4%Asian/Pacific Islander,5%Other) continued with little dropout over the second wave (N = 4,834, 48% male, M age = 16.53, 67% Caucasian, 23% African American, 1% American Indian, 4% Asian/Pacific Islander, 5% Other) and third wave (N = 5,114, 46% male, M age = 28.89, 68% Caucasian, 24% African American, 1% American Indian, 3% Asian/Pacific Islander, 4% Other). The Add Health study was performed in compliance by Code of Ethics of the World Medical Association and the University of North Carolina School of Public Health Institutional Review Board.

MEASURES

Anxiety Scale

Six items that measured physiological symptoms of anxiety were assessed at wave one. These items included (1) “feeling hot all over suddenly, for no reason,” (2) “cold sweats,” (3) “chest pains,” (4) “fearfulness,” (5) “a stomach ache or an upset stomach,” and (6) “trouble relaxing.” Using a confirmatory factor analysis, Jacobson and Newman[42] validated the scale and found that the items held together on a single scale in the current sample (χ2 = 143.14, p < .01, RHO = .974, CFI = .986, RMSEA = .053). Additionally, the internal consistency of this scale was adequate (α = .62).

Perceptions of Close and Group Relationships Scales

Two items that measured perceptions of close relationships included (1) “You feel socially accepted” and (2) “You feel loved and wanted.” Each of the items well represents measures of close relationships.[45] Likewise, two items measured perceptions of group relationship, including (1) “Since school started this year, how often have you had trouble getting along with other students?” (reverse-coded) and (2) “You feel like you are part of your school.” These items are comparable to items included in other measures of group affiliation.[46, 47] To validate these scales, a confirmatory factor analysis of both scales was conducted in a single model with correlated factor structures (this was necessary because otherwise the model would not have been identifiable). The model resulted in excellent fit (χ2 = 2.98, p = .08, RHO = .998, CFI = .997, RMSEA = .020). The correlations between the perceptions of close relationships factor and the perceptions of group relationships factor were significantly positive with moderate strength (r = .40, p < .001). Both the excellent fit and the moderate correlation suggest that the factors are moderately related, but to distinct scales. Additionally, the internal consistency for the perceptions of close relationships scale was good (α = .76), and the internal consistency for the perceptions of group relationships was excellent (α = .87).

Center for Epidemiologic Studies Depression Scale (CES-D)

The CES-D is a self-report measure of depression. A portion of the CES-D was administered to participants at the third wave. This included the following items: (1) “You were happy” (reverse-coded), (2) “You could not shake the blues, even with help from your friends and family,” (3) “You enjoyed life” (reverse-coded), (4) “You felt depressed,” (5) “You felt that you were just as good as other people” (reverse-coded), (6) “You felt sad,” (7) “You were bothered by things that usually don’t bother you,” (8) “You had trouble keeping your mind on what you were doing,” (9) “You felt that you were too tired to do things.” (10) “You felt that people disliked you.” The full CES-D has good concurrent validity (r = .73–.89 compared to the Symptom Checklist depression scale)[48] and adequate retest reliability (r = .57 averaged from 2 to 8 weeks).[49] Using the same sample, Jacobson and Newman[42] found that a confirmatory analysis of the items in the CES-D yielded adequate fit (χ2 = 1,650.44, p < .01, RHO = .977, CFI = .980, RMSEA = .050). The internal consistency of the scale for the ten items in the current sample was excellent (α = .979).

Depression Diagnosis

In the third wave of data collection, participants reported whether they had been diagnosed with a depressive disorder by their doctor, nurse, or health-care provider. These items indicated that 16.2% had been diagnosed with major depression.

PLANNED ANALYSES

Data analysis employed structural equation modeling, using the Lavaan package in R.[50] Latent variables were formed for anxiety, perceptions of close relationships, perceptions of group relationships, and depression scales.1 A manifest variable was used to represent clinical depression. All variables in this model were ordinal (and not continuous) or binary (in the case of predicting clinical depression). As such, bootstrapping with 10,000 draws was used to estimate all coefficients. Mediation was determined using bootstrapping of the indirect effect (A × B) for the regression coefficient of anxiety predicting the mediator (A), and the mediator-predicting depression (B).[53] In addition to using bootstrapping to estimate the standard errors, the analyses were conducted using robust maximum likelihood (MLR). All regression coefficients were standardized.[50]

Before interpreting each model, the model’s identification status was first tested by comparing the model’s completely standardized solutions against typically acceptable loadings.[54, 55] Next, the goodness of fit for the model was examined by using the following practical indices of goodness of fit: Tucker Lewis Index or Non-normed Fit Index (RHO, also titled NNFI)[56, 57], Comparative Fit Index (CFI, also titled RNI),[58, 59] and Root Mean Square Error of Approximation (RMSEA).[60, 61] Practical indices of goodness of fit were used in place of the chi-square fit statistics as the chi-square values are highly affected by large sample sizes, as in the present dataset. Missing data (approximately 6.6% missingness for the full sample) was handled using full information maximum likelihood (FIML).

RESULTS

ANXIETY AND DEPRESSION MEDIATED BY PERCEPTIONS OF CLOSE RELATIONSHIPS AND PERCEPTIONS OF GROUP RELATIONSHIPS

The first and second hypotheses were tested by using anxiety to predict perceptions of close relationships, perceptions of group relationships, and depression; and perceptions of close and group relationships were used to predict depression. Note that both close and group relationships were included in the same model, and, as such, analyses of the effects of close relationships controlled for the impact of group relationships (and vice versa). The goodness of fit indices indicated that the model had a good fit (χ2 = 1,397.76, p < .01, RHO = .935, CFI = .944, RMSEA = .034). Supporting our first hypothesis, anxiety significantly (β = −.22, SE = .03, Z = −6.39, p < .01) negatively predicted perceptions of close relationships, and perceptions of close relationships significantly (β = −.16, SE = .03, Z = −6.16, p < .01) negatively predicted depression (see Fig. 1). The estimate of the indirect effect of perceptions of close relationships was also significant (β = .034, SE = .01, Z = 4.98, p < .01), suggesting that perceptions of close relationships partially mediated the relationship between anxiety and depression. Additionally, perceptions of close relationships uniquely explained 16% of the total variation of anxiety-predicting depression. Supporting our second hypothesis, anxiety significantly (β =−.19, SE = .02, Z = −7.63, p < .01) negatively predicted perceptions of group relationships, and perceptions of group relationships significantly (β =−.11, SE = .02, Z=−5.36, p < .01) negatively predicted depression. Likewise, the indirect effect of perceptions of group relationships was also significant (β = .02, SE = .00, Z = 4.54, p < .01), signifying that perceptions of group relationships also partially mediated the relationship between anxiety and depression. Perceptions of group relationships uniquely explained 10% of the total variation between anxiety and later depression.

Figure 1.

Figure 1

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N= 6,504. In this figure, anxiety at wave one is predicting depression at wave three. Solid lines represent significant connections (p < .05), whereas dotted lines represent insignificant (p > .05) connections.

ANXIETY PREDICTING CLINICAL DEPRESSION

The hypothesis that anxiety would significantly predict later clinical depression was tested next. The goodness of fit indices indicated that the model had an excellent fit (χ2 = 113.10, p < .01, RHO = .948, CFI = .965, RMSEA = .033). Supporting our third hypothesis, wave one anxiety significantly (β = .17, SE = .02, Z = 7.15, p < .01) positively predicted wave three clinical depression, see Fig. 2.

Figure 2.

Figure 2

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N = 6,504. In this figure, anxiety at wave one is predicting depressive disorder at wave three. Solid lines represent significant connections (p < .05), whereas dotted lines represent insignificant (p > .05) connections.

ANXIETY AND CLINICAL DEPRESSION MEDIATED BY PERCEPTIONS OF CLOSE AND GROUP RELATIONSHIPS

Lastly, we tested the hypotheses that the relationship between anxiety and clinical depression would be mediated by close and group relationships. The goodness of fit indices indicated that the model had a good fit (χ2 = 424.139, p < .01, RHO = .936, CFI = .954, RMSEA = .038). Supporting our fourth hypothesis, anxiety significantly (β = −.21, SE = .03, Z = −6.17, p < .01) negatively predicted perceptions of close relationships, and perceptions of close relationships significantly (β = −.09, SE = .02, Z=−4.08, p < .01) negatively predicted clinical depression. Likewise, the indirect effect of perceptions of close relationships was significant (β = .02, SE = .01, Z = 3.82, p < .01), suggesting that close relationships partially mediated the relationship between anxiety and clinical depression and explained 11% of the total variation of anxiety predicting clinical depression. In contrast to our fifth hypothesis, although anxiety significantly (β = −.18, SE = .02, Z = −7.45, p < .01) negatively predicted perceptions of group relationships, perceptions of group relationships did not significantly (β =−.03, SE = .02, Z=−1.61, p < .01) predict clinical depression. The indirect effect of perceptions of group relationships was also not significant (β = .01, SE = .00, Z = 1.57, p = .11), suggesting that group relationships did not mediate the relationship between anxiety and clinical depression, see Fig. 3.

Figure 3.

Figure 3

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N = 6,504. In this figure, anxiety at wave one is predicting major depressive disorder at wave three. Solid lines represent significant connections (p < .05), whereas dotted lines represent insignificant (p > .05) connections.

DISCUSSION

These results suggest that close relationships may be a mechanism by which heightened levels of adolescent anxiety lead to clinical adult depression 12–14 years later. Thus, high anxiety prospectively makes one more likely to feel less loved and accepted in adolescence, and not feeling loved or accepted in adolescence predicts clinical depression in adulthood (explaining 16% of the variation between anxiety and adult levels of depression measured continuously, and 11% of the variation between adolescent anxiety and adult clinical depression).

These findings are largely consistent with the longitudinal association between close relationships and later levels of depression. Specifically, prior studies have found rejection in close relationships,[28] sense of belonging (Choenarom et al.),[29] and perceived marital dissatisfaction;[30] each predicted later levels of depression. However, this is the first study to show that, in addition to the longitudinal association between anxiety and depression levels, close relationships also predicted clinical depression.

In addition to close relationships, perceptions of group relationships mediated the relationship between levels of anxiety in adolescence and levels of depression in adulthood, explaining 10% of the variation between anxiety and depression for the general population. Specifically, high anxiety in adolescence prospectively makes one more likely to have trouble relating to others and fitting into one’s school, and trouble relating to others and feeling like one cannot fit in predicts high levels of depression in adulthood. However, these group relationships did not significantly predict clinical depression in adulthood. Thus, although both close and group relationships in adolescence independently predicted levels of depression in adulthood, only close relationships significantly impacted the pathogenesis of clinical depression.

Although previous studies have established a concurrent relationship between anxiety and group relationships,[62, 63] this was the first study to find that heightened levels of general anxiety were prospectively associated with later perceptions of group relationships (the only other prospective study examined social anxiety as a predictor).[64] Such findings are consistent with previous data that perceptions of group relationships prospectively negatively predicted depression.[33, 34] This is also the first study to examine the effect of group relationships in predicting later heightened depression and later clinical depression.

In regard to interpersonal factors as mediators between anxiety and later depression, the current findings parallel previous findings, suggesting that sociability and interpersonal oversensitivity mediated the relationship between generalized anxiety disorder and major depressive disorder 8 years later.[43] In combination with the current study, it is possible that concerns about being loved and accepted among close relationships may be more impactful in developing later clinical depression than disappointing others and facing others’ criticism within the context of groups. Likewise, interpersonal avoidance and difficulty making close friendships may be more impactful than socializing within the context of a group in predicting clinical levels of depression in adulthood. Moreover, both of these findings suggest that perceptions of interpersonal relationships and behaviors impacting interpersonal relationships may be mechanisms by which earlier anxiety leads to later depression.

These results also may have some important treatment implications. For example, an intervention that facilitates close relationships (or perceptions of close relationships) in adolescents with high anxiety may be useful in preventing the development of symptoms of adult depression. Moreover, if such an intervention was broadened to address group relationships, it also might be useful in reducing later subthreshold symptoms of depression.

Although the current study contains many strengths, it is important to mention several potential limitations. One of these is that we cannot specify the mechanisms by which anxiety predicts later deficits in close and group relationships, and how these close and group relationships go on to predict depression. The relationships between (1) anxiety and close relationships and (2) anxiety and group relationships could be due to conflict avoidance, lack of assertion, or overdependence on relationships among those with high levels of anxiety.[65] Additionally, close and group relationship satisfaction have been suggested to influence depressed feelings via loneliness.[66, 67] As such, future studies should examine if these and other constructs are potential mediators between group relationships and depressive symptoms in clinically anxious and clinically depressed participants.

Additionally, due to multicollinearity, the current study could not control for baseline depression within the analyses conducted. Moreover, as the Add Health study did not measure levels of anxiety at wave three, we were unable to examine the bilateral impact of depression at wave one on later anxiety. Thus, future studies should examine these relationships while controlling for baseline depression and also should examine the impact of depression on later anxiety.

Examining whether anxiety unidirectionally predicts depression or whether the relationship is bidirectional is important. Specifically, if anxiety unidirectionally predicts depression, it may suggest that anxiety is an early manifestation (i.e., prodrome) of depression. However, previous literature is mixed on whether depression predicts later anxiety. Some studies have not found a relationship between depression predicting later anxiety,[68, 69] whereas others have found that depression predicts later anxiety.[70–72] Thus, previous evidence is currently inconclusive about whether anxiety is a unilateral or bilateral predictor of later depression. Future research should further examine whether depression also predicts anxiety.

The current study results are particularly noteworthy given that in prior studies only three constructs (avoidance, sociability, and interpersonal oversensitivity) significantly mediated the relationship between anxiety and later depression.[42, 43, 73] Broadly, these findings highlight the large influence of interpersonal relationships as a pathway from anxiety in adolescents to depression in adulthood.

Acknowledgments

The data used in this publication were made available by the Data Archive on Adolescent Pregnancy and Pregnancy Prevention, Sociometrics Corporation, 170 State Street, Suite 260, Los Altos, CA 94022-2812. The study entitled The National Longitudinal Study of Adolescent Health (Add Health), study waves from 2001 to 2002 was conducted by J. Richard Udry of the Carolina Population Center, University of North Carolina atChapel Hill. Funding for the data collection was provided by the National Institute of Child Health and Human Development (NICHD) under grant no. P01-HD31921. Funding for the work done by the Data Archive on Adolescent Pregnancy and Pregnancy Prevention to prepare the data for public use was provided by the National Institute for Child Health and Human Development (NICHD) under contract no. N01-HD-9-3306 to Sociometrics Corporation. The original investigators, funding agency, and DAAPPP are not responsible for the analyses or interpretations presented here.

Footnotes

1

Baseline depression was not included in the present analyses due to multicollinearity. Specifically, there was a high correlation between anxiety and depression, and unstable model coefficients. The estimate of anxiety predicting depression varied widely when baseline depression was added to the model. Without baseline depression, anxiety significantly (β = .32, SE = .02) positively predicted depression. Despite this strong predictive relationship, when baseline depression was controlled for, the relationship between anxiety-predicting depression became significantly negative (β = −.20, SE = .04). Unstable estimates, such as those noted in this study, are symptomatic of multicollinearity.[51, 52] As such, baseline depression was removed from all models.

Conflict of interest. The authors do not have any conflicts of interest or financial disclosures.

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