Background
Adolescent mood and anxiety disorders affect a significant portion of the global adolescent population, accounting for 45% of the global disease burden on youths aged 15–19 [
1]. Even below a clinical threshold, depression and anxiety are associated with many negative physical, social, behavioral, and health outcomes, which can last a lifetime [
2,
3], such as increased risks in health, behavior, and education [
4]. Nearly half of all behavioral and emotional disorders have an initial onset during adolescence [
5], increasing the risk of these disorders in adulthood by 2-to-3 times [
6]. Therefore, this transitional phase of adolescence is a critical time to prevent and treat emotional disorders like depression and anxiety.
One approach to combat youth mental health disorders might lie in the promotion of positive aspects of psychological functioning, such as psychological wellbeing, which may play a preventative and therapeutic role in the development of emotional disorders [
7,
8]. Broadly defined, psychological wellbeing refers to an individual’s condition of experiencing their lives positively [
9]. It can include the positive feelings of satisfaction, accomplishment, and fulfillment in diverse life domains as well as the lack of negative aspects like mental illness and loneliness [
10]. Given its multiplicity, psychological wellbeing is measured by many models, including PERMA (Positive Emotion, Engagement, Relationships, Meaning and Accomplishment; [
11]), subjective wellbeing (SWB; [
12]), and community quality of life (QoL; [
13]). Gratitude, social support, self-perception, and happiness have also been used to measure psychological wellbeing [
14,
15].
The extent to which psychological wellbeing plays a preventative or therapeutic role in adolescent psychopathology depends partly on the nature of the overlap between the two [
7]. Many studies have shown that psychological wellbeing and psychopathology are strongly and negatively associated [
16,
17]. Indeed, the strength of this association—generally, correlations of
r = − 0.40 to
r = − 0.55—suggests that these two constructs may be two distinct but overlapping dimensions of functioning [
7]. Observers have described this relationship through a binary continuum model, as well as through a dual-factor model. In the binary continuum model, psychological wellbeing and psychopathology are on the extreme opposite ends of a wellbeing band [
18]. In the dual-factor model, the two constructs are distinct but related [
8,
19]. One study assessed Australian adolescents (
N = 345) for psychological wellbeing (measured by happiness, life satisfaction, and positive affect scales) and psychopathology (measured by depression, anxiety, and negative affect scales), which revealed two factors for psychological wellbeing and youth psychopathology, respectively [
20]. Another study used the dual-factor model along with self-report scores to classify Canadian youths (
N = 407) into four categories: (1) high psychological wellbeing and low psychopathy, (2) low psychological wellbeing and high psychopathy, (3) low psychological wellbeing and low psychopathy, and (4) high psychological wellbeing and high psychopathy [
8]. Another study with American adolescents (
N = 349) found that by using the cutoff norms for the Child Behavior Checklist and corresponding psychological wellbeing scores, adolescents could also be classified into one of the four groups mentioned above, providing further evidence that psychological wellbeing and adolescent psychopathology may be distinct but interrelated [
19].
Beyond the evidence from many cross-sectional studies, one recent Dutch study investigated the extent to which the association between psychological wellbeing and psychopathology is a function of correlated genetic and/or correlated environmental factors [
7]. In the study, psychological wellbeing was assessed (measured by subjective happiness, quality of life, and satisfaction with life) for a large population-based cohort of adolescent twins and their non-twin siblings (
N = 9136 and 1474, respectively). Psychopathology was also assessed (measured by all syndrome and broad band based scales of the Achenbach System of Empirically Based Assessments (ASEBA) Youth Self Report Scale). The study found significant negative associations between psychological wellbeing and psychopathology, which were primarily explained by genetic correlations [
7]. This finding––that a genetic liability to lower levels of psychological wellbeing may be suggestive of genetic liability to higher levels of psychopathology––supports the use of psychological wellbeing measures to screen for adolescent psychopathology before the presence of clear signs of psychopathology [
7].
The use of psychological wellbeing indices to combat adolescent psychopathology may be of particular importance for adolescent populations in Sub Saharan Africa (SSA). Not only are there high prevalence rates of adolescent depression and anxiety symptoms in SSA countries [
21], there is currently a dearth of research with this population, limiting the knowledge of rates, comorbidity, correlates, predictors, protective factors, and treatment options in this region [
22]. In SSA, treatment options for psychopathology are limited [
2,
21], government spending on mental healthcare is minimal [
21], and societal stigma against mental illnesses dissuades many from seeking help [
23]. Indeed, research that espouses the association between psychological wellbeing and adolescent psychopathology with SSA populations may be of public policy utility in this region. For example, the societal stigma around mental health limits help-seeking amongst Kenyan adolescents, many of whom do not want to be diagnosed with mental disorders, much less seek treatment for it [
23]. If we could use psychological wellbeing indices (like gratitude and happiness) to inform the public health efforts on the screening, prevention, and treatments for youth mental disorders, then these efforts could be done in a potentially non-stigmatizing manner.
One way of expanding our knowledge of the relationship between psychological wellbeing and adolescent psychopathology might lie in the use of network analysis—a novel conceptual model in which a psychological construct is conceptualized as the interplay of traits or symptoms that influence each other [
24]. In a network structure, a psychological construct (e.g., a symptom or a trait) is represented by a node, and the relationship between each pair of constructs is depicted by an edge between the corresponding nodes. Networks allow for the identification of the central symptoms or traits of a psychological construct, which are likely to activate the entire network and might be sites for direct targeting in prevention and treatment [
25]. The network framework has been used to circumvent some of the theoretical and psychometric limitations of traditional models [
26], such as the classification of the symptoms into discrete mental disorders by the DSM [
27]. Classification models are problematic since mental disorders share a broad spectrum of overlapping symptoms [
24] and since specific disorders may have a wide range of symptoms with different treatments [
28]. As network analysis conceptualizes psychiatric disorders as systems the emerge from symptoms interactions and not an underlying disease entity, they embrace and account for the comorbidity and heterogeneity of emotional disorders [
29].
In addition to identifying and targeting the central symptoms of an emotional disorder for reduction and the central traits of psychological wellbeing for enhancement, network analysis can help shed light on the connectivity between psychological wellbeing and adolescent psychopathology. Specifically, we can identify an individual psychological wellbeing trait that is highly connected to a particular emotional disorder symptom and quantify the nature of that connectivity. Overall, network analysis can allow us to study the structure of psychopathology and psychological wellbeing, jointly.
In the present study, we used network analysis to analyze the structure of psychological wellbeing indicators and symptoms of depression and anxiety in a large community sample of adolescents in Kenya. Happiness, gratitude, optimism, perceived control, and social support measures were used to assess psychological wellbeing, while depression and anxiety symptoms were used to assess adolescent psychopathology. The aims of our study were to investigate: (1) the structures and clusters that the indicators of psychological wellbeing and the symptoms of depression and anxiety form in a network––i.e., whether psychological wellbeing items form a distinct cluster or overlap with the symptoms of psychopathology, (2) the central nodes (i.e., symptoms or traits) in a network of psychological wellbeing and youth psychopathology, and (3) the important “bridge” nodes that connect the community cluster of psychological wellbeing and the community cluster of adolescent psychopathology. The present study is, to the best of our knowledge, the first of its kind to investigate psychological wellbeing and youth depression and anxiety symptoms in a community sample of SSA adolescents.
Discussion
We conducted a network analysis to analyze the structure of psychological wellbeing indicators and symptoms of depression and anxiety in a greatly understudied population in Sub Saharan Africa––a large community sample of Kenyan adolescents. Our results, which were robust to statistical and accuracy tests, revealed how indicators of psychological wellbeing (like happiness and gratitude) and psychopathology measures of depression and anxiety clustered in a network. We also identified the central features of adolescent psychopathology and wellbeing, as well as the interconnectedness of the various items within these domains.
This study is, to the best of our knowledge, the first attempt of its kind to combine wellbeing elements and psychopathology in a network approach with SSA youths. The recent network research of child and adolescent psychopathology has been conducted almost exclusively with Western adolescent populations [
52,
57‐
60] with only a few studies in the Global South [
61‐
63]. More research focused on SSA youths is necessary since there are scientific benefits of cross-cultural research and culture affects psychopathology and psychological wellbeing. Additionally, there is the potential utility of such research in SSA where prevalence rates for mental disorders are high [
2,
21], stigma inhibits help-seeking [
23], mental healthcare infrastructure is poor [
2], and a large percentage of the population is youthful (the mean age in Kenya is 19.4 years [
64].) Thus, our results expand our understanding of psychological wellbeing in relation to adolescent psychopathology in a hitherto understudied and at-risk population.
In our psychological well-being, depression, and anxiety network, two distinct clusters emerged. The constructs of psychological wellbeing (gratitude, happiness, optimism, social support, and perceived control) clustered together, while the constructs of adolescent psychopathology (depression and anxiety) formed a separate community in the network. Thus, our findings offer support for the dual factor model of psychopathology and psychological wellbeing, in which the two concepts are distinct but related constructs [
8,
19]. We found that the elements of psychopathology and those of psychological wellbeing formed two distinct clusters that were strongly and negatively associated with each other. Within the positive psychological wellbeing cluster, we found each of the constructs of psychological wellbeing to form distinct but closely connected clusters. This suggests that happiness, optimism, gratitude, and perceived control are separate but closely related constructs of psychological wellbeing. Happiness and optimism were highly connected, perhaps due to their overlapping notions or perhaps since they were subscales of the same index. Similarly, within the psychopathology cluster, anxiety and depression did not overlap but formed separate yet closely related clusters.
The wellbeing items––
family provides emotional help and support, I feel happy, I love life, I am a joyful person, and
I have a lot to be thankful for––as well as the psychopathology items–
–self-blame, depressed mood, uncontrollable worry, nervousness, and
I cannot do well at tests no matter how hard I try––were the most central nodes in our network of psychological wellbeing and adolescent psychopathological, according to
strength. This suggests that these items, which represent a diversity of items from different measures, may be especially important because they are strongly connected to other symptoms. Specifically, the two most central nodes in the network were
family provides emotional help and support and
self-blame. Emotional help and support from family and loved ones during this development period appear to be key to tackle negative psychopathological symptoms. As shown in Fig.
2, three of the four happiness items were in the top seven most central nodes, suggesting the potential utility of using happiness traits to uncover and prevent mental health symptoms.
Additionally, we defined two communities for the psychological wellbeing and adolescent psychopathology measures. The social support items––family helps me, I can talk to family about problems, and family willing to help me make decisions––were the most important bridge nodes that connected the two community clusters. In addition, nervousness was the most important psychopathology bridge node between the two clusters.
It is particularly striking that four of the top five strongest bridge nodes were social support items. The association between social support and mental health problems, as well as the interpretation of social support as an important protective factor against depression and anxiety, has been documented extensively elsewhere [
65,
66]. In the context of Kenyan youths, it is critical to view social support in light of the nature of the Kenyan educational system. Indeed, some observers have pointed out that rather than social support, many Kenyan youths experience increased psychosocial pressure from their families, friends, and loved ones to do well in the end-of-secondary school examinations [
67]. As these examinations are important in determining future prospects, the external pressure to succeed from friends and families has been linked with increased depressive and anxiety symptoms amongst Kenyan youths [
32]. Future studies should replicate these findings, as the association between academics, social support, and adolescent psychopathology could potentially have important public policy implications.
It is worth highlighting that little interest/pleasure emerged as the most negative bridge node. While further investigations are required to explore the means through which this symptom affects the relationship between positive wellbeing and psychopathology, one can imagine that having little interest/pleasure in everyday things may lead adolescents to live withdrawn lives that are absent of social support needed to improve positive wellbeing.
While these findings are insufficient to draw claims about interventions, they may suggest why positive psychological interventions that target psychological wellbeing elements rather than psychopathology—such as the
Shamiri (“thrive”) intervention [
30]—have been successful in treating depression and anxiety symptoms with Kenyan youths. For example, research on trait gratitude suggests that having a lot of things to be grateful for is associated with exhibiting positive states and outcomes that may buffer against depression and anxiety [
68]. Perhaps interventions that make salient elements of psychological wellbeing like gratitude may be effective in reducing youth depression and anxiety symptoms [
31,
36,
37] because they target central elements in the network of wellbeing and psychopathology (e.g.,
I have a lot to be grateful for). Further studies are required to investigate this proposition, which may be particularly promising for SSA regions where social stigma around psychopathology might inhibit help-seeking.
An important strength of our study is the large sample size; however, the network connectivity that we report might not be generalized across different samples in SSA. In addition, our use of LASSO regularization to reduce false positives—which is the current “norm of practice” in many similar studies (see [
52,
53], for example)—limits our ability to interpret our findings as independent of the sample. While we use this regularization technique to offer opportunities for comparison of our findings with those in the literature, it may be valuable for future research that uses network analysis to adopt regularization techniques that lend themselves to generalizability. That said, this weakness should be considered within the broader context of there being very few attempts to describe adolescent psychopathology and psychological wellbeing with a sample from SSA.
Another limitation is that we use measures that have minimal previous use with Kenyan youths. Though the psychometric properties of these studies have been studied and validated elsewhere, it is important that future studies use more culturally apt and psychometrically robust measures to replicate our findings. Finally, another limitation is that our study does not address the complicated clustering of our data or the role of sociodemographic variables in the network between adolescent psychopathology and wellbeing. We investigated the network differences and similarities between urban and rural subgroups (see Additional file
1: Appendix A in the Supplementary Materials.) Future studies are required to investigate this.
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