Background
Major depression (MD) is one of the most common and debilitating psychiatric disorders worldwide [
1]. The onset can often be traced back to adolescence with prevalence rates of about 8% [
2,
3]. Suffering from MD early in life often seriously affects later development, as evidenced by e.g., school dropout and lower life satisfaction [
4,
5].
Besides genetic and other (e.g., cognitive) factors, psychosocial stressors are known to play an important role in the etiology of the disorder [
6,
7]. Due to the pervasiveness, impairments and high prevalence of youth MD, it is important to identify specific psychosocial stressors related to the disorder during this developmental period. Insight into such factors might increase treatment and prevention efforts. To date, knowledge concerning the relationship between specific stressors and depression predominantly originates from studies in (young) adults with MD or from non-clinical youth samples with elevated depressive symptoms. However, it remains unclear to what extent these results can be generalized to youths with a diagnosis of MD.
Previous studies on psychosocial stressors implicated in MD mainly focused on stressful life events (SLEs), defined as “cluster of social events requiring change in ongoing life adjustment” [
8]. SLEs, such as the death of a loved one or a serious illness, are supposed to play a causal role in the onset of juvenile MD [
7,
9].
With regard to SLEs in the context of family life, there are conflicting results concerning the predictive value of parental separation, divorce or living in a one-parent family for MD and depressive symptoms during youth or young adulthood [
10‐
16]. Related to this, findings are also inconclusive with regard to the role of experiences of loss (primarily in respect to the death of a parent) in the development of depressive symptoms and MD in youths and adults [
14,
17‐
19].
Investigations on school-related SLEs as predictors for MD in youth are relatively scarce. Prior findings on the predictive value of specific school-related events (e.g., repeating a grade or having to change school) for MD in youth are mixed [
16,
18]. Previous studies indicate that distinct stressful events due to low academic achievement (e.g., repeating a grade) predict MD in young adulthood [
19]. In this context, it needs to be emphasized that the effects of low academic achievement on the risk of MD are mainly evident in girls and show a bidirectional relationship with depressive symptoms [
19‐
21].
With respect to experiences of violence, there is robust evidence showing that the exposure to sexual or physical abuse are predictors of MD and depressive symptoms in youth [
22‐
24]. The effects of violence on youth depression have been shown to be enduring. In line with this, evidence suggests that elevated depressive symptoms and episodes of MD may even persist up to two years after having experienced incidences of violence [
24,
25].
Besides SLEs, other psychosocial factors may also play a role in youth MD. These factors encompass delinquent behavior, familial psychopathology, and birth-related, as well as sociodemographic factors. Results concerning the role of delinquent behavior in depressive symptoms in youths are inconclusive. Studies have identified delinquent behavior as an antecedent of depressive symptoms in male youths and young adult males. However, this finding does not seem to apply for females [
13,
26]. Moreover, evidence suggests that the relationship between delinquent behavior and depressive symptoms is rather bidirectional, with depressive symptoms resulting in delinquent acts and vice versa [
26,
27].
Studies investigating psychosocial birth-related aspects have identified emotional distress of the mother during pregnancy as a risk factor for juvenile MD [
28‐
30]. However, this result has not always been confirmed [
31]. In addition, the occurrence of a maternal postpartum depression has also been identified as a highly relevant factor contributing to MD and internalizing problems in juvenile offspring [
32‐
34]. However, there is also evidence showing that the relationship between a maternal postpartum depression and MD in youth is substantially mediated by a later maternal MD [
32]. Related to this issue, there is a large body of literature showing that parental depression is a major risk factor for MD in youth offspring [
35‐
38]. Intergenerational transmission of depression might be due to multiple mechanisms, such as neurobiological, behavioral, cognitive, and genetic pathways [
37,
39].
Regarding sociodemographic stressors, a low parental socioeconomic status does not seem to be a factor contributing to depressive psychopathology in youth and MD in young adults [
19,
40]. However, specific factors constituting the socioeconomic status have in part been found to predict youth MD. In particular, low parental education has been reported to be a risk factor for depressive symptoms and MD in youth [
12,
41], but this has not always been found [
16]. Moreover, parental unemployment is implicated in depressive symptoms and youth MD [
12,
42]. Results concerning the predictive value of migrant status of the parents on depressive symptoms and MD in youth are mixed [
16,
42].
Discrepant findings in studies investigating psychosocial stressors associated with youth MD may be explained by different factors including, e.g., (1) differences in age (youth vs. adulthood), (2) differences in defining and assessing psychosocial stressors, as well as (3) the definition of depression (MD vs. depressive symptoms).
In addition to investigating psychosocial stressors, a number of prior studies examined factors that may protect youths from developing MD. Among other factors, research in this domain has focused on social support and family climate. A positive family climate and social support have been supposed to act as protective factors in relation to overall psychopathology, and in particular regarding depressive symptoms and MD in youth [
43‐
45]. In line with this notion, it is also generally assumed that social support may attenuate the effects of psychosocial stressors on depressive symptoms [
46]. However, most empirical studies failed to find a buffering effect of social support and a positive family climate [
47‐
49]. These findings indicate that psychosocial stressors and social support/a positive family climate seem to independently influence the risk of depressive symptoms and MD in youth (but see [
50] for contradicting findings). However, most prior studies were restricted to non-clinical youth samples with elevated depressive symptoms [
47‐
49]. Thus, it remains unanswered whether these findings can be transferred to youths with a clinical diagnosis of MD. The only prior study that investigated the buffering effect of social support in clinically depressed youths and that was based on a prospective design comprised a relatively small sample (
N = 24) [
47]. To date, it remains an open question whether the buffering effect can be found in a larger sample of clinically depressed youth.
As summarized above, most results on psychosocial stressors and their interplay with protective factors originate from adult MD samples or from samples of youth with elevated depressive symptoms. However, results from studies investigating youths with heightened depressive symptoms cannot be transferred to youths with MD [
51]. Similarly, psychosocial stressors implicated in MD during adulthood may not be congruent with psychosocial stressors for youth MD [
52]. In this context, it needs to be emphasized that youth is characterized by changes in biological systems (e.g., the maturation of stress systems), as well as an increase of psychosocial stressors [
53,
54]. Therefore, this phase is considered an especially sensitive developmental period conveying a heightened risk of psychiatric disorders, including MD. Thus, it seems important to gain a deeper insight into psychosocial stressors and protective factors implicated in youth MD based on a well-characterized clinical sample.
Accordingly, the first aim of this study was to investigate specific psychosocial stressors in youth with MD and to identify the most relevant stressors for this patient group. The second aim was to examine whether social support and a positive family climate act as protective factors in youth MD and to investigate whether these factors moderate the relationship between specific psychosocial stressors and MD.
Building on prior findings, we hypothesized that the proportion of youths who experienced psychosocial stressors would be higher in the MD compared with the TD group. Specifically, we expected that the portion of youths experiencing violence would be higher in the MD than in the TD group [
24]. Additionally, we hypothesized that affective psychopathology would be increased in families of youths with MD, as compared with TD youths [
28,
30,
36]. Finally, we hypothesized that sociodemographic stressors would be more prevalent in the MD group [
12,
41,
42]. We also expected that TD youths would experience more social protective factors than youths with MD [
44,
45]. We did not state a directed hypothesis regarding the buffering effect of these protective factors on the link between psychosocial stressors and MD due to the scarce and mixed previous findings [
47‐
50].
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