Depressive symptoms and their associations with anger and aggression in Russian adolescents

doi:10.21203/rs.3.rs-3085432/v1

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Depressive symptoms and their associations with anger and aggression in Russian adolescents

https://doi.org/10.21203/rs.3.rs-3085432/v1

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published 16 Nov, 2023

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This study investigated the prevalence of clinically significant (current major depressive episode) and subthreshold depressive symptoms and explored their association with aggression and anger, while controlling for comorbid mental health problems in a general population sample of adolescents from Northern Russia. The sample consisted of 2600 participants, aged 13–17 years (59.3% female; 95.7% ethnic Russian). Symptoms of a major depressive episode, types of anger and aggression (anger rumination, trait anger, physical, verbal and social aggression) and comorbid problems (posttraumatic stress, alcohol use, anxiety, and hyperactivity/impulsivity) were assessed by means of self-reports. The prevalence of a clinically significant depressive episode in the past month was 3.5%, while for subthreshold depression it was 21.6%. All anger and aggression variables, as well as comorbid problems increased together with increasing levels of depression. When adjusting for comorbidity, depression was only significantly associated with social aggression and anger rumination. Among adolescents with depression, boys reported higher levels of social and verbal aggression and of anger rumination than girls. Overt aggressive behavior associated with depression was primarily explained by comorbid mental health problems, whereas anger rumination and social aggression had more direct associations with depression, independent of comorbidity and were gender-specific. The results of this study suggest that interventions aiming to reduce aggressive behavior in adolescents should consider depression and its comorbid conditions.

Major depression

subthreshold depressive symtoms

comorbidity

aggression

anger

adolescents

gender

Individuals suffering from psychiatric disorders have a well-documented risk of engaging in aggressive behavior [1, 2, 3]. Among the disorders that are likely to increase the risk for aggressive behavior previous research has indicated schizophrenia [4], alcohol and drug use [5], posttraumatic stress disorder [6], attention-deficit/hyperactivity disorder (ADHD) [7], and autism spectrum disorder [8]. Despite seeming less intuitive, an association has also been consistently reported between depression and aggressive behavior both in adults [e.g. 9], and in children and adolescents [10, 11], in clinical and general population samples.

Depression is one of the most common psychiatric disorders, with its prevalence rates rising substantially throughout adolescence. Thus, Costello et al. [12] reported that the overall prevalence of any depressive disorder was 2.8% in children under 13 years of age and 5.6% in adolescents aged 13 to 18. Other studies have reported higher numbers, including 10.5% for any depressive disorder and 29.2% for subthreshold depression in a large European study of adolescents [13], with a 25% lifetime prevalence of major depressive disorder by the end of adolescence [14]. While overall depression rates are generally similar by gender in childhood [e.g. 12], females have been consistently found to have an increased risk of depression during adolescence [15].

Against this backdrop this study aimed to examine the association between depression and anger and aggression in a general population sample of adolescents. According to the General Strain Theory [16], aggressive behavior in relation to depression may emanate from feelings of strain, leading to negative emotions that need to be released. More generally, as depressive symptoms may lead to impaired neurocognitive performance [17], problems with emotional regulation and poor impulse control [18], and increased irritability and anger [19], it seems reasonable to expect that different symptoms of depression may impact different aspects of aggression, given that aggression is a very heterogeneous behavior in its own right. It has been further suggested that it may not be depressed mood itself, but rather specific depressive symptoms, such as agitation [20] or psychotic features [21] that increase the risk for aggression. Hence, when exploring the association between depression and aggression, it is important to clearly define which symptoms constellate a depressive episode.

Historically, the relation between depression and aggression was thought to reflect a broader association between internalizing and externalizing forms of psychopathology [22] and hence, could be explained by comorbid conditions rather than the depression itself [23]. Indeed, considerable research has shown an association between aggression and anxiety, ADHD, substance abuse and posttraumatic stress [24, 25], which are all also highly comorbid with depression. However, a recent study of adults from the general population that controlled for potential confounders, such as comorbid alcohol and drug use, familial confounding, a previous history of violence and socio-demographic factors, was still able to demonstrate a two- to three-fold increase in the risk of committing a violent crime by depressed individuals [9]. Similarly, a study of juvenile offenders showed an independent effect of depression on aggressive behavior [11]. Considering the potential complexity of the association between depression, its comorbid conditions and different types of aggression, when examining the depression-aggression association it is important to also control for a broad range of comorbid psychopathology, which by itself can potentially impact aggressive behavior.

Regarding anger and aggression, it is plausible that some forms of these constructs may be more influenced by depression than others. Anger rumination is a cognitive-emotional process referring to the tendency to dwell on frustrating experiences and recall past anger experiences [26], and while both anger rumination and sadness rumination are related to deficits in cognitive inhibition and the ability to eliminate extraneous negative information from working memory [27], they represent two distinct concepts and are differently related to aggression [28]. Having said this, as sadness and anger are interwoven and often co-occur [29], it has also been suggested that sadness rumination (i.e. the internal attribution of negative events), which is indicative of depression, is closely associated with and can transform into anger rumination (i.e. the external attribution of negative events), which in turn is a precursor to aggression [30]. Trait anger represents a disposition to perceive situations as annoying or frustrating, and the tendency to react in such situations with more frequent elevations in state anger [31] and it may be associated with depression through emotion regulation and anger rumination [32]. In contrast, aggression refers to the behavioral expression of anger that can take the form of physical or verbal acts [33], or more subtle forms, such as social aggression, which refers to behaviors that intentionally damage interpersonal relationships and/or social status through non-confrontational and concealed methods [34], but all forms of aggression can be linked to cognitive-emotional aspects of depression [27].

It is also important to examine whether there are gender differences in the observed associations. Previous research has shown that boys consistently report more overt aggression compared to girls [35, 36], while in a large international study of children [37] boys reported being more physically aggressive than girls across all countries, but no consistent gender differences were observed in social aggression, particularly in studies from non-Western countries. Other studies have suggested however, that gender differences in social aggression may become more apparent in adolescence, especially in girls [38]. Despite these observed gender differences in nearly all forms of aggression, until now, findings regarding the strength of the association between depression and aggression in boys versus girls have been inconsistent, suggesting no gender differences [10], or a stronger association in males [39, 40] or females [41], thus highlighting the need for more research.

Most studies on depression, anger and aggression have been conducted in high income Western countries, while fewer studies have investigated this research question among low- and middle-income countries. Further, to our knowledge, no previous study has explored the associations between depression and different types of aggression in adolescents from the general population, while controlling for comorbid problems and other potential confounders. The aim of the current study was therefore to 1) assess the prevalence of depressive symptoms corresponding to a major depressive episode and subthreshold depression in a general population sample of 13–17 year old adolescents from Northern Russia; 2) investigate the associations between a major depressive episode, subthreshold depression, different types of anger and aggression (anger rumination, trait anger, and verbal, physical and social aggression), and comorbid problems (posttraumatic stress, alcohol use, anxiety, hyperactivity/impulsivity); while 3) also exploring the role of gender differences in these associations.

Study population

This study was conducted in Arkhangelsk, the largest city in the Northern European part of Russia. According to census data [42], the population of Arkhangelsk is slightly over 349,000 and approximately 30,000 adolescents are in the 13–17-year-old age range. The SES of the population is generally in the low to average range for Russia. Permission to conduct this study in selected schools was obtained from the Arkhangelsk city administration and the study was conducted in collaboration with the local schools’ administration. The study involved all the main districts of the city and the number of potential participants from each district was calculated in proportion to the total number of adolescents of the relevant age residing in the district. A randomized selection procedure was used to obtain a representative sample with school buildings and classes designated as the units of randomization. In stage one, 14 schools were randomly selected from 71 eligible schools, all of which agreed to participate and were included in the study, yielding a total of 210 classes in grades 6 to 11. In stage 2, data were collected from students in 70 randomly selected classes (out of 210), resulting in a sample of 2838 students. Students with incomplete reports were excluded. Adolescents from the excluded group (n = 238) were more likely to be male (59.1% vs. 40.9%, χ2(1) = 30.66, p < .001), and reported higher levels of verbal (M(SD) = 5.00(4.32) vs 4.26(3.52); t = 2.87; p < .001, physical (M(SD) = 4.14(4.02) vs 2.97(3.39); t = 4.77; p < .001) and social aggression (M(SD) = 16.06(6.77) vs 15.03(4.65); t = 2.96; p < .001). The excluded adolescents did not differ from those in the study on any other variables.

The final sample consisted of 2600 participants, who ranged in age from 13 to 17 years old (M(SD) = 14.90(1.13)). The composition of the sample was 59.5% female (n = 1547) and predominantly of Russian origin (95.8%), followed by a small proportion of other (predominantly Slavic) nationalities, an accurate reflection of the local public school population. Most of the participants (75.6%) came from two-parent families, whereas 24.4% had divorced, separated or widowed parents. According to student reports, 93.0% of their fathers and 94.4% of mothers had completed the equivalent of a high school education or beyond.

Procedure

Parents were informed of the survey prior to the study and were offered the opportunity to decline participation. Before the survey’s administration, students were read a detailed assent form describing their participation and confidentiality, and were asked to sign it to indicate assent. Students also had the option to decline at the time of administration (parent and student refusals were less than 1%). Students completed the survey in one class period during a normal school day. Surveys were administered in Russian. This study was approved by the institutional ethics committee of the Institute of Psychiatry, Northern State Medical University (Arkhangelsk, Russia) and permission to conduct the study was obtained from the Arkhangelsk city administration.

Measures

Depressive symptoms

Depression was measured with an adapted version of the Center for Epidemiologic Studies-Depression Scale (CES-D) [43], which has excellent psychometric properties with adolescents [44], and has been used with Russian adolescents previously [45]. Respondents were asked to indicate the presence of ten depressive symptoms during the past 30 days on a three-point scale: “Not true” (0); “Somewhat true” (1); or “Certainly true” (2). The scale had a good internal consistency of .84.

A proxy for a current MDE was created following DSM-5 criteria [46], according to which, five or more symptoms of depression should be present, and at least one of the symptoms should include either depressed mood, or loss of interest. Depressed mood in the past 30 days was determined based on a positive response (Certainly true) to one or more of the following four items: “I felt really down”; “I felt like crying”; “I felt that I could not shake off my sad feelings even with help from my family or friends”; and “I felt bothered by people and things” (irritable mood). Diminished interest was assessed with the item: “I have lost my interest in other people or things”. In addition, several other depressive symptoms were assessed, namely, decreased appetite (“I did not feel like eating; my appetite was poor”); problems with sleep (“I didn’t sleep well”); loss of energy (“I was tired”); feelings of excessive guilt (“I felt that many bad things were my fault”); and diminished ability to think or concentrate (“I found it difficult to concentrate”). A combined score for clinically significant depression (CSD, 1/0), as a proxy for a current depressive episode was calculated, with five or more symptoms of depression present, where at least one of the symptoms included either depressed mood, or loss of interest. In addition, in order to assess SDS, an additional score (not overlapping with CSD) was calculated based on the same criteria, but the scoring for these items could also include Somewhat true answers. All other students whose symptoms did not fulfill criteria for either CDS or SDS were considered as having a low depression score (LDS).

Anger and Aggression

The Anger Rumination Scale (ARS) [47] measures the tendency to focus attention on angry moods, recall past anger experiences, and think about the causes and consequences of anger episodes. The Russian version of the ARS is comprised of 17 items (e.g. “When someone makes me angry I can’t stop thinking about how to get back at them”, “After an argument is over, I keep fighting with this person in my imagination”, and “I think about the reasons people treat me badly”), rated on a 4-point scale from “Almost never” (1) to “Almost always" (4). The total score can range from 17 to 68 with higher scores indicating more anger rumination. The ARS has demonstrated adequate internal consistency and test–retest reliability as well as convergent and discriminant validity [47]. Cronbach’s α for the scale in this study was .95.

The Trait Anger Scale of the State Trait Anger Expression Inventory (STAXI) [31] represents one of the most commonly used measures of anger and consists of 10 items that assess a general tendency to experience anger, either in the absence of a direct provocation or as a result of specific triggers, such as criticism or unfair treatment by others (e.g. “I feel infuriated when I do a good job and get a poor evaluation” and “I get angry when I’m slowed down by others’ mistakes”). Items are rated on a 4-point scale (from “Almost never” (1) to “Almost always” (4)). The total score can range from 10 to 40 with higher scores indicating more trait anger. The scale has been validated in Russia previously [48]. Cronbach’s α for the scale was .92.

Physical and verbal aggressive behaviors [49] were assessed with 5 items each, describing common forms of aggressive behaviors in children and adolescents (e.g. “Pushed or shoved somebody”, and “Punched someone in a fight” for physical aggression and “Teased others” and “Called others names” for verbal aggression). The students rated the frequency of their aggressive behavior in the past 30 days on a 4-point scale (from “Never” (0) to “5 or more times” (3)). The possible total score could range from 0 to 30 with higher scores indicating more aggression. These scales have demonstrated good psychometric properties with Russian adolescents previously [50]. Cronbach’s alphas for the scales were respectively .80 and .82.

Social aggression [49] was assessed with 9 items describing non-confrontational behaviors aiming at intentionally damaging social relationships, status and reputation directed towards a peer. Specifically, the scale asked the respondents to think about a peer they “did not like very much” and answer if they have even engaged in behavior such as “Spread rumors/gossip about this person”, “Told others not to be friends with this person”, and “Told others bad things about this person”). The students rated each item using a 4-point scale with response options ranging from “Almost never” (1) to “Almost always” (4). The possible total score ranges from 9 to 36; higher scores indicate more social aggression. The construct of social aggression is distinct from the measures of physical and verbal aggression and the scale has also previously shown good psychometric properties with Russian adolescents [50]. Cronbach’s α for the scale in this study was .83.

Comorbid conditions

Posttraumatic stress was assessed with the Child Post-Traumatic Stress - Reaction Index (CPTS-RI) [51], a 20-item scale assessing the frequency of posttraumatic symptoms (e.g., “Do you get scared or afraid because you think about bad things that have happened to you?,” “Do thoughts or pictures of bad things that have happened to you come back to you, even when you don’t want them to?,” “If someone comes up behind you all of a sudden, or if you hear a loud noise, do you jump?”) on a 5-point scale, ranging from “Never” (0) to ”Most of the time” (4). The degree of reaction is categorized as doubtful (score < 12), mild (score = 12–24), moderate (score = 25–39), severe (score = 40–59), or very severe (score ≥ 60). Total scores can range from 0 to 80, with higher scores corresponding closely with a clinical diagnosis of posttraumatic stress disorder (PTSD) [52], including in Russian adolescents [53]. Cronbach’s α = .87.

Alcohol use was assessed with three items derived from the Monitoring the Future Scale [54]. Students responded if they had had a drink of a beer, wine or strong alcohol (separate items for each type of drink) in the past 30 days on a four-point scale, ranging from “Never” (0) to “More than a few times” (3). The possible scale score ranges from 0 to 9, with higher scores indicating greater alcohol use.

The hyperactivity/inattention scale of the Strengths and Difficulties Questionnaire (SDQ) [55] was used to assess these symptoms. The SDQ represents one of the most widely internationally used screening instruments of mental health problems in children and adolescents [see e.g. 56], and has been previously validated with Russian adolescents [57]. It consists of five items (e.g., ”I am restless. I cannot stay still for a long”, “I am constantly fidgeting or squirming” and “I am easily distracted”). Respondents are asked to rate their behavior and feelings for the past 6 months on a three-point scale (from “Not True” (0) to “Certainly True” (2)). The total score could range from 0 to 10 with higher scores indicating more hyperactivity/inattention symptoms. Cronbach’s α = .65.

Anxiety symptoms were measured with 12-items [49], inquiring about worrisome thoughts and feelings (e.g. “I feel nervous when I get called on in class”, “I stay away from things that make me nervous”), that are rated on a three-point scale (from “Not True” (0) to” Certainly True” (2)). This measure has been extensively used with Russian adolescents previously [e.g. 58]. The total score ranged from 0 to 24, with higher scores reflecting increasing anxiety symptoms. Cronbach’s α = .83.

A proxy for Socioeconomic Status (SES) was created using students’ reports on a single family status (1/0), a lower level of parental education (incomplete college education or lower, 1/0), and parental employment status (full time (0), part time (1) and unemployed (2)). The possible total score could range from 0 to 7 with higher scores indicate lower SES.

Statistical analyses

Data were analyzed using SPSS version 26.0. Chi-square and independent sample t-tests were used for univariate comparisons of demographic characteristics and of dependent variables across gender. General linear models (GLM) multivariate analysis of covariance (MANCOVA) was used to determine main and interaction effects across the three fixed factors of depression (LDS = 0, SDS = 1, CSD = 2) and gender (boys = 1, girls = 0), while adjusting for the covariates of age and SES. In the first set of analyses, the dependent variables included anger rumination, trait anger, physical, verbal and social aggression, together with the comorbid problems of posttraumatic stress, anxiety, hyperactivity/inattention and alcohol use, in order to investigate the associations between depression and comorbidity and to explore if such associations would be found in the study population. Hence, we used a 3 (depression) X 2 (gender) design for each cluster of variables.

The MANCOVA was subsequently repeated, adjusting for the comorbid symptoms of posttraumatic stress, alcohol use, anxiety and hyperactivity/impulsivity (instead of using them as dependent variables), in addition to the covariates of age and SES. The unique contributions of each of the two fixed factors, of one interaction term, and of the covariates were assessed through follow-up between-subject tests and unstandardized parameter estimates derived from the MANCOVA. Results are presented as means (M) and standard deviations (SD), and for individual outcomes, as partial eta squared (η2), a common metric of effect size that represents the unique amount of variance explained by each predictor variable. In the analyses, two-tailed tests with a p-value of < 0.05 were considered statistically significant.

Prevalence of individual depressive symptoms, subthreshold depression and a major depressive episode by gender

The prevalence of depressive symptoms, constituting a major depressive episode, is presented in Table 1 (“Certainly true” scores only), listed according to the DSM-5 criteria for a current major depressive episode.

Table 1

Prevalence of depressive symptoms (Certainly true scores only) constituting a current major depressive episode in boys and girls
Symptoms	Boys	Girls	Chi-square, p
Depressed mood (one of the following):	252 (24.7%)	545 (35.9%)	35.55; <.001
I felt really down	89 (8.4%)	214 (13.8%)	18.30; <.001
I felt like crying	58 (5.5%)	267 (17.3%)	80.90; <.001
I felt that I could not shake off my sad feelings even with help from my family or friends	69 (6.5%)	154 (9.9%)	9.78; <.01
I felt bothered by people and things	132 (12.4%)	247 (16.0%)	6.83; <.01
Diminished interest:
I have lost my interest in other people or things	98 (9.4%)	139 (9.1%)	.01; ns
Other depressive symptoms (≥ 4 symptoms present):	47 (4.5%)	72 (4.7%)	.06; ns
I did not feel like eating; my appetite was poor	72 (6.8%)	119 (7.7%)	.77; ns
I didn’t sleep well	136 (12.7%)	149 (9.6%)	6.23; <.05
I was tired	258 (24.2%)	424 (27.4%)	3.36; ns
I felt that many bad things were my fault	86 (8.1%)	164 (10.6%)	4.85; <.05
I found it difficult to concentrate.	178 (16.7%)	266 (17.2%)	.12; ns

Table 1 about here

The prevalence of depressed mood during the past 30 days was significantly higher in girls for all corresponding symptoms, whereas no gender differences were found with regard to diminished interest. In addition, several other depressive symptoms were evaluated, including decreased appetite, problems with sleep, loss of energy, feelings of inappropriate guilt, and diminished ability to concentrate. Four or more of these symptoms (all with “Certainly true” scores), in addition to either depressed mood or diminished interest, had to be present to indicate a current major depressive episode, and no gender differences were found in the combined prevalence of 4 or more symptoms. A total of 92 (3.5%) adolescents were identified as having clinically significant depression symptoms (corresponding to a current major depressive episode with the symptoms present in the past 30 days, denoted as a CSD from this point forward. In addition, 561 (21.6%) adolescents reported the presence of the same depressive symptoms, corresponding to a current major depressive episode (DSM-5), but where the “Sometimes true” scores were included, who were thus considered as having a subthreshold depression score (SDS), as opposed to all other adolescents (n = 1947; 74.9%), who were considered as having a low depression score (LDS). No gender differences were observed, when comparing CSD (35 (3.3%) in boys vs 57 (3.7%) in girls, χ2 = .24; Cramer’s V = .010; ns), but when the SDS adolescents were compared, the prevalence of depression became significantly more prevalent in girls (184 /17.5%) in boys vs 377 (24.4%) in girls, χ2 = 18.44; Cramer’s V = .084; p < .001).

Generalized Linear Modeling

Tables 2 and 3 present the results of comparisons of the aggression scores by gender and depression.

Table 2

Types of anger and aggression and comorbid problems (M (SD)) in relation to depression scores in boys (B) and girls (G)
		LDS	SDS	MDE	Total group
Physical aggression	B	4.17 (3.82)	4.81 (3.77)	6.17 (5.19)	4.34 (3.88)
	G	1.87 (2.52)	2.41 (2.88)	2.84 (2.74)	2.03 (2.63)
Verbal aggression	B	4.61 (4.00)	5.86 (3.61)	6.69 (4.90)	4.90 (4.00)
	G	3.60 (3.00)	4.40 (3.21)	4.65 (2.93)	3.83 (3.07)
Social aggression	B	14.61 (4.40)	15.86 (5.50)	20.31 (10.26)	15.02 (5.02)
	G	14.89 (4.32)	15.22 (4.22)	16.77 (6.07)	15.04 (4.39)
Anger rumination	B	28.89 (10.09)	33.41 (10.07)	42.40 (15.53)	30.13 (10.68)
	G	31.06 (9.17)	35.23 (9.64)	38.61 (9.97)	32.35 (9.81)
Trait anger	B	19.33 (6.60)	22.01 (6.44)	25.46 (8.89)	20.00 (6.81)
	G	20.89 (6.56)	23.67 (6.94)	26.84 (7.54)	21.79 (6.87)
Alcohol use	B	4.37 (3.10)	4.79 (3.03)	4.09 (3.71)	4.43 (3.11)
	G	4.22 (2.98)	4.81 (2.95)	5.40 (2.82)	4.41 (2.98)
Posttraumatic stress	B	16.03 (10.02)	23.64 (12.22)	30.71 (16.07)	17.84 (11.30)
	G	19.11 (10.03)	26.08 (11.60)	35.86 (14.05)	21.43 (11.36)
Hyperactivity/	B	3.75 (1.95)	4.76 (2.00)	6.07 (1.68)	4.08 (2.04)
impulsivity	G	3.39 (1.97)	4.66 (1.82)	5.31 (2.13)	3.67 (2.03)
Anxiety	B	11.77 (5.64)	14.36 (5.79)	13.91 (6.87)	12.30 (5.80)
	G	13.62 (5.53)	14.92 (5.24)	16.98 (4.86)	14.06 (5.49)
Note: LDS – low depression score, SDS – subthreshold depression score, CDS – clinical depression score (corresponding to DSM-V criteria for a current major depressive episode

Table 3

Effect sizes for each dependent variable (aggression scores and comorbidity) (η², p)
	Age	SES	Gender	Depression	Depression x Gender
Physical aggression	.003, < .01	.001, ns	.040, < .001	.011, < .001	.001, ns
Verbal aggression	.000, ns	.000, ns	.012, < .001	.018, < .001	.001, ns
Social aggression	.002, < .05	.001, ns	.000, ns	.023, < .001	.006, < .001
Anger rumination	.002, < .05	.000, ns	.005, < .001	.055, < .001	.003, < .01
Trait anger	.001, ns	.000, ns	.003, < .01	.044, < .001	.000, ns
Alcohol use	.096, < .001	.000, ns	.000, ns	.000, ns	.002, < .05
Posttraumatic stress	.000, ns	.006, < .001	.007, < .001	112, < .001	.001, ns
Hyperactivity	.002, < .05	.002, < .05	.003, < .01	.074, < .001	.001, ns
Anxiety	.002, < .05	.002, < .05	.007, < .001	.024, < .001	.003, < .05
Note: SES - proxy for socio-economic status. The analyses were adjusted for age and SES.
η² - Eta-squared, p – significance level

Tables 2 and 3 about here

The results suggest that the proposed model was significant and could explain 16% of the variance in the outcome variables (Wilks’ lambda = .836; F (9, 2584) = 56.21, p < .001, η2 = .164). The main effect for Depression was significant (Wilks’ lambda = .832; F (18, 5168) = 27.62, p < .001, η2 = .088), suggesting differences in the levels of aggression and comorbid problems by depression. The follow-up tests (Table 3) indicated that all aggression variables, as well as posttraumatic stress, anxiety and hyperactivity/impulsivity levels increased together with increasing levels of depression from LDS to SDS to MDE. The main effect for Gender was also significant (Wilks’ lambda = .926; F (9, 2584) = 23.10, p < .001, η2 = .074), and the follow-up tests demonstrated significant gender differences in all dependent variables, except for social aggression and alcohol use, with boys having higher ratings on physical and verbal aggression and hyperactivity/impulsivity, but lower levels of anger rumination, trait anger, posttraumatic stress and anxiety. The main effect for Age was significant (Wilks’ lambda = .885; F (9, 2584) = 37.24, p < .001, η2 = .115), with the follow-up tests demonstrating an increase in anger rumination, physical and social aggression, alcohol use, hyperactivity/impulsivity and anxiety with increasing age. The main effect for SES was significant (Wilks’ lambda = .990; F (9, 2584) = 3.02, < .001, η2 = .010), and yet the follow-up tests suggested that none of the aggression variables were related to SES and the differences were explained by posttraumatic stress, hyperactivity/impulsivity and anxiety. Finally, the interaction effect for Depression x Gender was significant (Wilks’ lambda = .978; F (18, 5168) = 3.19, p < .001, η2 = .011), indicating gender-specific differences in the dependent variables in relation to depression, and more specifically in social aggression and anger rumination (higher in boys with depression), as well as in anxiety and alcohol use (higher in girls with depression) (Table 3).

Table 4 presents the individual effects for each dependent variable, using the same model as above, but now also adjusting for comorbid problems (posttraumatic stress, alcohol use, anxiety and hyperactivity/impulsivity), in addition to the previously used covariates of age and SES.

Table 4

Effect sizes for each dependent variable (types of aggression, anger rumination, trait anger) (η², p) after adjusting for comorbidity
	Age	SES	PTS	Alcohol use	Hyperactivity/ impulsivity	Anxiety	Gender	Depression	Depression x Gender
Physical aggression	.018, < .001	.000, ns	.023, < .001	.034, < .001	.028, < .001	.011, < .001	.051, < .001	.000, ns	.002, ns
Verbal aggression	.006, < .001	.000, ns	.018, < .001	.060, < .001	.045, < .001	.002, < .05	.020, < .001	.001, ns	.003, < .05
Social aggression	.001, ns	.000, ns	.045, < .001	.029, < .001	.029, < .001	.001, ns	.012, < .001	.006, < .001	.010, < .001
Anger rumination	.001, ns	.000, ns	.119, < .001	.009, < .001	.010, < .001	.074, < .001	.004, < .01	.004, < .01	.007, < .001
Trait anger	.001, ns	.000, ns	.032, < .001	.034, < .001	.094, < .001	.025, < .001	.000, ns	.002, ns	.001, ns
Note: SES - proxy for socio-economic status; PTS- posttraumatic stress. The analyses were adjusted for age, SES and comorbidity, η² - Eta-squared, p – significance level.

Table 4 about here

The results suggest that the proposed model was significant and explained 6.5% of the variance in the outcome variables (Wilks’ lambda = .935; F (5, 2584) = 36.17, p < .001, η2 = .065). The main effect for Depression was significant (Wilks’ lambda = .986; F (10, 5168) = 3.55, p < .001, η2 = .007), suggesting remaining differences in aggression in relation to depression. The follow-up tests (Table 4) indicated that depressed adolescents now differed from others only with regard to social aggression and anger rumination. The main effect for Gender was also significant (Wilks’ lambda = .938; F (5, 2584) = 34.20, p < .001, η2 = .062), and the follow-up tests showed significant differences between boys and girls in all aggression variables, with higher levels in boys, except for trait anger. The main effect for Age was significant (Wilks’ lambda = .980; F (5, 2584) = 10.52, p < .001, η2 = .020), with the follow-up tests demonstrating an increase in verbal and physical aggression with increasing age. The main effect for SES was not significant (Wilks’ lambda = .997; F (5, 2584) = 1.42, ns, η2 = .003). Finally, the main effects for posttraumatic stress (Wilks’ lambda = .856; F (5, 2584) = 86.69; p < .001, η2 = .144), alcohol use (Wilks’ lambda = .919; F (5, 2584) = 45.31; p < .001, η2 = .081), hyperactivity/impulsivity (Wilks’ lambda = .887; F (5, 2584) = 66.14, p < .001, η2 = .113) and anxiety (Wilks’ lambda = .899; F (5, 2584) = 58.17, p < .001, η2 = .101) were all significant, with increasing levels of comorbid problems being related to all of the aggressive variables, except for anxiety, which was not related to social aggression. The interaction effect for Depression x Gender was also significant (Wilks’ lambda = .984; F (10, 5168) = 4.22, p < .001, η2 = .008), indicating gender-specific differences in aggression in relation to depression (Table 4), with higher levels of social and verbal aggression and of anger rumination in depressed boys, as compared to depressed girls.

This study assessed the prevalence of depressive symptoms in Russian adolescents aged 13–17 years old in the general population and found that the prevalence of a current clinically significant depression for the past month (3.5%) corresponding to a current major depressive episode for the past month was similar to that observed in adolescents in other countries. Levels of all the aggression variables, as well as posttraumatic stress, and anxiety and hyperactivity/impulsivity increased together with increasing levels of depressive symptoms, while all of the comorbid conditions were also associated with aggression. When adjusting for comorbidity, only the attenuated association between depressive symptoms and social aggression and anger rumination remained statistically significant. Depressed boys, as compared to depressed girls, reported higher levels of social and verbal aggression and of anger rumination.

To our knowledge, this is the first study to report on the prevalence of major depression in Russian adolescents. A recent report from the World Health Organization [59] found that the prevalence of depression in the Russian general population was 5.5%, although without reference to any specific age groups. While the prevalence of individual depressive symptoms in the present study was rather high, and the level of SDS was substantial (more than one-fifth of the adolescents), the prevalence of clinically significant depression (CSD) was much lower (3.5%) and similar to that reported in other studies on adolescents from primarily North America and Europe [12, 60]. This finding suggests that the combination of the specific symptoms rather than the number of symptoms needs to be taken into account when assessing the prevalence of major depression in the general population. While the prevalence of most of the individual depressive symptoms was higher in girls than in boys, the prevalence of CSD did not differ significantly by gender, which seems to contradict previous reports of an increased risk of depression in females during adolescence [15], and which might be potentially explained by a greater proportion of younger adolescents in the present study. At the same time, when the SDS group was included, the prevalence of depressive symptoms became significantly more prevalent in girls, which is in line with previous research.

Similar to previous reports with both adults and adolescents [see 27 for a review], the present study demonstrated that depressed adolescents from the general population report higher levels of aggression than their non-depressed peers and that these differences involved both cognitive-emotional aspects of aggression (anger rumination and trait anger), but also behavioral aspects, such as physical, verbal and social aggression. In addition, depressed adolescents also had higher scores on almost all of the comorbid conditions, all of which were also linked to different types of anger and aggression. In connection with this it has been suggested that both PTSD and depression may be independently associated with physical aggression toward others [61], or that depressive symptoms may mediate the link between PTSD and aggressive behaviors [6, 62]. Similarly, it has also been hypothesized that emotional dysregulation, commonly observed in depressed individuals, may represent a common denominator underlying the comorbidity between ADHD and aggression [63].

Considering the potential complexity of the association between depression, its comorbid conditions and different types of aggression, it was important to assess how much difference in aggression would remain in relation to depression, after controlling for comorbidity. The substantial decrease in the significance of this association suggests that a major role is played by comorbidity in this relationship, especially with regard to the behavioral aspects of aggression. However, the fact that the association remained significant for social aggression and anger rumination (albeit substantially attenuated) even after controlling for comorbidity, suggests there may be a more direct link between depression and anger and aggression that is unrelated to comorbid symptoms.

With regard to the gender-specific differences in aggression observed in the present study, boys had higher ratings than girls for physical and verbal aggression, but did not differ in social aggression and had lower scores on anger rumination. The initial similarities in social aggression observed between boys and girls disappeared after controlling for comorbidity, and the gender differences became more pronounced, with higher levels of social aggression in girls. An interaction effect was found of depression by gender on social and verbal aggression and anger rumination, with higher scores in depressed boys. Previous research on the association between depression and different aspects of aggression by gender has been rather limited and produced inconsistent results. Similar to this study, a number of studies have reported the association being stronger in depressed adult males, as compared to females, with greater hostility [64], impulsivity, irritability and more frequent anger attacks [40], and rumination, being more strongly associated with both depression and physical-verbal aggression in adolescent boys rather than girls [65]. At the same time, other studies have reported that the association between depression and physical aggression may be stronger in both adolescent [10] and adult females [41]. Some studies have also noted that greater irritability and anger following depressive episodes in males may be associated with higher rates of comorbid externalizing problems, such as substance abuse and hyperactive behaviors [40], which was partially supported by the present study. Given the heterogeneity of these results, more research is needed in order to clarify the role of depression in aggression in boys and girls.

The present study had several important strengths, including the use of a large community-based sample of adolescents from a non-Western country, use of a clear definition of depressive episode and being able to assess different types of aggression and anger. However, it also had a number of limitations. Assessment was based solely on self-reports, which may have been subject to reporting bias. In addition, studies relying on symptom scales rather than DSM/ICD criteria to identify people with major depression are likely to overestimate prevalence rates [66], and the same limitations can be equally applied even to the measures used for assessing comorbidity, making the findings more difficult to replicate, and hence a more clinically sound evaluation with other measures, such as a structured diagnostic interview should be included in future studies. Other types of events or symptoms that may have occurred (and could have impacted on anger and aggression) were not assessed in this study. As this study was cross-sectional causality could not be established for the observed associations. The effect size for the interaction terms, especially for verbal aggression, was relatively small, suggesting that the specific impact of the interaction between these factors may be limited. Finally, the exclusion of subjects due to inconsistent reporting could have resulted in selection bias that may have also affected the results.

To conclude, the prevalence of clinically significant depression (corresponding to the current major depressive episode) in Russian adolescents was similar to that reported for other countries. Most of the overtly aggressive behavior in adolescents associated with depression may be related to its comorbid problems, but depressive symptoms also have an independent association with the cognitive-emotional and covert aspects of aggression, which may also be gender-specific. This study has clinical implications, suggesting that the adequate identification and treatment of depression and its comorbid conditions may have an impact on aggressive behavior in adolescents.

Availability of data and materials: Access to the data is restricted to the research group members in accordance with the initial decision of the ethics committee.

Conflict of interests: All the authors declare that there are no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: No funding for the study was received.

Acknowledgements: Not applicable

Authors’ contribution: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by VR and RK. The first draft of the manuscript was written by VR and all authors commented on the manuscript. All authors read and approved the final manuscript.

Data: The data used in the study cannot be shared due to the limitations specified in the decision of the Ethical committee. All other materials/instruments used in the study can be shared upon request. Please address your requests to the corresponding author (VR).

Funding: The authors did not receive support from any organization for the submitted work.

Competing interests: The authors have no competing interests to declare that are relevant to the content of this article.

Ethics approval: The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. It was approved by the institutional ethics committee of the Institute of Psychiatry, Northern State Medical University, Arkhangelsk, Russia.

Consent to participate: Informed consent was obtained from all individual participants included in the study

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Depressive symptoms and their associations with anger and aggression in Russian adolescents

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Abstract

Introduction

Methods

Study population

Procedure

Measures

Depressive symptoms

Anger and Aggression

Comorbid conditions

Statistical analyses

Results

Prevalence of individual depressive symptoms, subthreshold depression and a major depressive episode by gender

Generalized Linear Modeling

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1