Co-occurrence Of Depressive Symptoms Research Articles

The co-occurrence of depressive symptoms and cognitive impairment and its relationship with diabetes self-care behaviors

The co-occurrence of depressive symptoms and cognitive impairment and its relationship with diabetes self-care behaviors

Effects of Functional Disability and Depressive Symptoms on Mortality in Older Mexican-American Adults with Diabetes Mellitus.

To examine the effect of co-occurring depressive symptoms and functional disability on mortality in older Mexican-American adults with diabetes mellitus. Longitudinal cohort study. Hispanic Established Populations for the Epidemiological Study of the Elderly (HEPESE) survey conducted in the southwestern United States (Texas, Colorado, Arizona, New Mexico, California). Community-dwelling Mexican Americans with self-reported diabetes mellitus participating in the HEPESE survey (N = 624). Functional disability was assessed using a modified version of the Katz activity of daily living scale. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale. Mortality was determined by examining death certificates and reports from relatives. Cox proportional hazards regression analyses were used to examine the hazard of mortality as a function of co-occurring depressive symptoms and functional disability. Over a 9.2-year follow-up, 391 participants died. Co-occurring high depressive symptoms and functional disability increased the risk of mortality (hazard ratio (HR) = 3.02, 95% confidence interval (CI) = 2.11-4.34). Risk was greater in men (HR = 8.11, 95% CI = 4.34-16.31) than women (HR = 2.21, 95% CI = 1.42-3.43). Co-occurring depressive symptoms and functional disability in older Mexican-American adults with diabetes mellitus increases mortality risk, especially in men. These findings have important implications for research, practice, and public health interventions.

Posttraumatic Stress Disorder and Depression in Men and Women Who Perpetrate Intimate Partner Violence.

Poor mental health is a risk factor for intimate partner violence (IPV) perpetration. Literature suggests that gender differences play a role in this association. The aims of this study were to examine the: 1) prevalence of IPV perpetrated by men and women; and 2) association between symptoms of depression or posttraumatic stress disorder (PTSD) and IPV perpetration among men and women. A convenience sample of 210 people living in three peri-urban areas in South Africa completed self-report questionnaires that assessed symptoms of common mental health disorders and IPV. Gender differences were not found with regard to perpetrating physical assault and psychological aggression, although men were more likely than women to report perpetration of sexual coercion (42.9% vs. 23.8%). Men who reported higher symptoms of PTSD were 3 times (OR = 2.63, p = .023) more likely to report perpetrating sexual coercion, when controlling for demographic characteristics and symptoms of depression, than men who reported lower levels of PTSD. Women who reported moderate to severe symptoms of depression were 4 times (OR = 3.9, p = .01) more likely to report perpetrating physical assault, when controlling for demographic characteristics and symptoms of PTSD, than women who reported minimal to mild symptoms of depression. Findings add further support for differences in rates of IPV perpetration, and poor mental health as a risk for IPV perpetration. Interventions aimed at reducing IPV perpetration in the South African setting will only be marginally effective if gender-specific interventions are not developed that consider co-occurring symptoms of PTSD and depression.

Risk of Diabetes in Older Adults with Co-Occurring Depressive Symptoms and Cardiometabolic Abnormalities: Prospective Analysis from the English Longitudinal Study of Ageing.

High depressive symptoms and cardiometabolic abnormalities are independently associated with an increased risk of diabetes. The purpose of this study was to assess the association of co-occurring depressive symptoms and cardiometabolic abnormalities on risk of diabetes in a representative sample of the English population aged 50 years and older. Data were from the English Longitudinal Study of Ageing. The sample comprised of 4454 participants without diabetes at baseline. High depressive symptoms were based on a score of 4 or more on the 8-item binary Centre for Epidemiologic Studies–Depression scale. Cardiometabolic abnormalities were defined as 3 or more cardiometabolic risk factors (hypertension, impaired glycemic control, systemic inflammation, low high-density lipoprotein cholesterol, high triglycerides, and central obesity). Cox proportional hazards regressions assessed the association between co-occurring depressive symptoms and cardiometabolic abnormalities with incidence of diabetes. Multiple imputation by chained equations was performed to account for missing data. Covariates included age, sex, education, income, smoking status, physical activity, alcohol consumption, and cardiovascular comorbidity. The follow-up period consisted of 106 months, during which 193 participants reported a diagnosis of diabetes. Diabetes incidence rates were compared across the following four groups: 1) no or low depressive symptoms and no cardiometabolic abnormalities (reference group, n = 2717); 2) high depressive symptoms only (n = 338); 3) cardiometabolic abnormalities only (n = 1180); and 4) high depressive symptoms and cardiometabolic abnormalities (n = 219). Compared to the reference group, the hazard ratio for diabetes was 1.29 (95% CI 0.63, 2.64) for those with high depressive symptoms only, 3.88 (95% CI 2.77, 5.44) for those with cardiometabolic abnormalities only, and 5.56 (95% CI 3.45, 8.94) for those with both high depressive symptoms and cardiometabolic abnormalities, after adjusting for socio-demographic, lifestyle and clinical variables. These findings suggest that those with high depressive symptoms and cardiometabolic abnormalities are at a particularly increased risk of type 2 diabetes.

An Online Intervention for Co-Occurring Depression and Problematic Alcohol Use in Young People: Primary Outcomes From a Randomized Controlled Trial.

BackgroundDepression and problematic alcohol use represent two of the major causes of disease burden in young adults. These conditions frequently co-occur and this is associated with increased harm and poorer outcomes than either disorder in isolation. Integrated treatments have been shown to be effective; however, there remains a significant gap between those in need of treatment and those receiving it. The increased availability of eHealth programs presents a unique opportunity to treat these conditions.ObjectiveThis study aimed to evaluate the feasibility and preliminary efficacy of an automated Web-based self-help intervention (DEAL Project) in treating co-occurring depressive symptoms and problematic alcohol use in young people.MethodsYoung people (aged 18 to 25 years) with moderate depression symptoms and drinking at hazardous levels (recruited largely via social media) were randomly allocated to the DEAL Project (n=60) or a Web-based attention-control condition (HealthWatch; n=44). The trial consisted of a 4-week intervention phase with follow-up assessment at posttreatment and at 3 and 6 months postbaseline. The primary outcomes were change in depression severity according to the Patient Health Questionnaire-9 as well as quantity and frequency of alcohol use (TOT-AL).ResultsThe DEAL Project was associated with statistically significant improvement in depression symptom severity (d=0.71) and reductions in alcohol use quantity (d=0.99) and frequency (d=0.76) in the short term compared to the control group. At 6-month follow-up, the improvements in the intervention group were maintained; however, the differences between the intervention and control groups were no longer statistically significant, such that between-group effects were in the small to moderate range at 6 months (depression symptoms: d=0.39; alcohol quantity: d=–0.09; alcohol frequency: d=0.24).ConclusionsOverall, the DEAL Project was associated with more rapid improvement in both depression symptoms and alcohol use outcomes in young people with these co-occurring conditions relative to an attention-control condition. However, long-term outcomes are less clear.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000033741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363461 (Archived by WebCite at http://www.webcitation.org/6fpsLEGOy)

Assessment of the relationship between self-reported cognitive distortions and adult ADHD, anxiety, depression, and hopelessness

The current chart review study examined the relationship between self-reported cognitive distortions, attention-deficit/hyperactivity disorder (ADHD) symptoms, and co-occurring symptoms of depression and anxiety in a clinical sample of adults diagnosed with ADHD. Thirty subjects completed inventories measuring cognitive distortions, ADHD, anxiety, depression, and hopelessness as part of the standard diagnostic evaluation protocol used in a university-based outpatient clinic specializing in adult ADHD. A series of correlational analyses were conducted to assess the relationship between self-reported cognitive distortions, ADHD, anxiety, depression, and hopelessness. Results indicated a significant, positive correlation between self-reported cognitive distortions and ADHD. Responses to individual items on the measure of cognitive distortions were tabulated to identify the prevalence of specific cognitive distortion categories, with Perfectionism emerging as the most frequently endorsed. Further clinical implications of these findings are discussed.

Investigation of anxiety and depression symptom co-morbidity in a community sample with type 2 diabetes: Associations with indicators of self-care.

Ascertain the association of elevated co-occurring anxiety and depression symptoms, elevated anxiety symptoms alone or elevated depression symptoms alone with indicators of self-care behaviours in people with type 2 diabetes. Data from a community sample of 1,990 people diagnosed with type 2 diabetes for less than 10 years were assessed. All participants took part in a telephone interview. Questionnaires examined depression, anxiety, health, and indicators of self-care (physical activity, blood glucose monitoring, diet and smoking). Data were assessed with cross tabulations, ANOVA and logistic regression. Groups who met criteria for elevated co-occurring anxiety and depression symptoms, elevated anxiety symptoms and elevated depression symptoms were more likely to report poor eating habits. Meeting criteria for either elevated depression symptoms (with and without anxiety) was also associated with an increased likelihood of not meeting physical activity recommendations. Those people with elevated depression and anxiety scores were more likely to be a current smoker. Those people who meet criteria for elevated anxiety and/or depression symptoms are less likely to report adhering to self-care recommendations. These associations are particularly marked in those people with elevated depression symptoms with or without co-occurring anxiety symptoms. There is a lot of evidence emphasising the importance of monitoring depressive symptoms in people with diabetes. Our results add to this, indicating that adherence to self-care recommendations should be carefully monitored in people with depression and anxiety symptoms.

Combined Effect of Slow Gait Speed and Depressive Symptoms on Incident Disability in Older Adults

ObjectivesTo elucidate whether a combination of slow gait speed and depressive symptoms result in higher risk of incident disability in older adults than either symptom individually. DesignProspective cohort study. SettingObu City, Aichi Prefecture, Japan. ParticipantsParticipants were 4038 older adults (48.7% male, mean age = 71 years) who met the study inclusion criteria. MeasurementsLongitudinal data on incident disability were collected up to 33 months [median 31 months (interquartile range 29–32 months)] after baseline. We monitored monthly incident disability, defined as Japanese long-term care insurance certification for personal support or care. Baseline measurements included covariates for incident disability, gait speed, and the Geriatric Depression Scale for assessing depressive symptoms. The associations between slow gait, depressive symptoms, or their co-occurrence, and incident disability were examined. ResultsControl participants were the reference in an adjusted Cox proportional hazard regression model. Participants with co-occurring slow gait and depressive symptoms showed a greater risk of incident disability [hazard ratio (HR) 3.08, confidence interval (CI) 95% 2.00–4.75]. Greater risk was also found for participants with slow gait speed alone (HR 2.44, CI 95% 1.71–3.47) and depressive symptoms alone (HR 1.60, CI 95% 1.01–2.53). ConclusionsOlder adults with both risk factors may require early detection and physical and psychological intervention.

Meta-Analysis of Trauma-Focused Cognitive Behavioral Therapy for Treating PTSD and Co-occurring Depression Among Children and Adolescents

We evaluated the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) for treating posttraumatic stress disorder and co-occurring depression symptoms across 21 between-group studies representing the data of 1,860 children and adolescents (1,106 girls and 754 boys). Separate meta-analytic procedures were conducted for studies that implemented wait-list/no treatment and alternative treatment comparisons to estimate aggregated treatment effect of TF-CBT and moderators of effect size magnitude. Limitations of our findings and implications for counselors are discussed.

Cognitive impairment in depressed students of Cairo University Hospital

Introduction Major depression may affect the ability to think, concentrate, make decisions, formulate ideas, reason, and remember. Patients with major depression also often show neurocognitive deficits consistent with frontal lobe dysfunction. The co-occurrence of depressive symptoms and cognitive impairment plays a role in determining disability in individuals. Aim of the study To assess the presence of cognitive deficits in depressed undergraduate university students and then to assess the correlation between severity of depression and cognitive impairment in these students. Patients and methods After obtaining consent from the ethical committee in Kasr El Aini Hospital, 50 patients with the diagnosis of Major Depressive Disorder according to the DSM-IV criteria were recruited from the psychiatric outpatient clinic of Cairo University Student Hospital, with no sex preference. Fifty control participants of similar age, sex, and educational backgrounds were recruited as volunteers. Psychometric procedures: Beck Depression Inventory for severity of depression, selected subtests of Wechsler Adult Intelligence Scale (WAIS), and Wechsler Memory Scale-Revised (WMS-R). Results Medical and paramedical students recruited from six faculties constituted 40% of the entire sample. Forty percent of the cases were diagnosed with moderate depression, whereas 60% of them were diagnosed with severe depression. All the scores of the subtests of WAIS and WMS-R used were higher in the control group. The scores of the Beck Depression Inventory were correlated positively with the digit symbol and digit span subtests of WAIS and to figural memory and visual memory span subtests of WMS-R. Conclusion Depressed undergraduate university students had more cognitive deficits than nondepressed students. The severity of depression was correlated positively with some of these cognitive deficits.

Mechanisms of Alcohol Use Disorder Severity in Adolescents with Co-occurring Depressive Symptoms: Findings from a School-Based Substance Use Intervention

Individuals with co-occurring alcohol abuse and depressive symptoms were hypothesized to present to treatment with unique etiological pathways, contexts of drinking, topography and consequences of drinking. Two hundred and seventy-three (273) adolescents participated in a motivational enhancement therapy-based intervention specifically developed for adolescent substance users in schools. Data for the present study were collected at intake. The proposed serial mediation multivariate path model included depressive symptoms, drinking to cope and typical blood alcohol concentration (tBAC) as predictors of consequences resultant in symptoms congruent with a DSM-5 alcohol use disorder (AUD). This path model exhibited a good fit to the data when including covariates of alcohol consumption and affective dysregulation, χ (5,) 2 = 3.45, p = 0.63; CFI = 1.00; NFI = 0.98; RFI = 0.93; RMSEA = 0.00 (0.07–0.87). The final model accounted for 44 % of the variance in the prediction of AUD symptoms. The indirect effect of depressive symptoms to AUD symptoms indicated that drinking to cope and tBAC fully mediated the model. Co-occurring depressive symptoms create a unique pathway to increased AUD severity in adolescents. This pathway provides a potential mechanism for understanding the increased risk of comorbidity and highlights that the increased risk imparted by depressive symptoms is underscored by affective dysregulation and caused by an increased intensity of alcohol use in specific contexts. This mechanism suggests that a specificity of treatment is needed, such that adolescents with higher levels of AUD symptoms and elevated depressive symptoms who drink to cope should receive appropriately tailored services.

Effectiveness of Cognitive Processing Therapy for Treating Posttraumatic Stress Disorder

Analyzing 11 studies, we evaluated the effectiveness of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD) and co-occurring depression symptoms in individuals diagnosed with PTSD. Separate meta-analytic procedures for between-group studies using waitlist or alternative treatment comparisons yielded large to very large effect sizes for CPT versus waitlist, and medium to large effect sizes when CPT was compared to alternative treatments. Implications for evidence-supported practice and study limitations are discussed.

PTSD and reasons for living: Associations with depressive symptoms and alcohol use

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and behavior, and is found to frequently co-occur with other conditions that exacerbate the risk for suicidal behavior. Despite these findings, few individuals with PTSD engage in suicidal acts, and there has been little research to examine those factors that protect against such behaviors. The current study used path analysis to examine the association among PTSD, depression, hazardous alcohol consumption, and beliefs about suicide (i.e., reasons for living) in a community sample with motor vehicle accident related-PTSD (N=50). Reasons for living were inversely associated with PTSD, depression, and alcohol use. Further, depression symptom severity accounted for the association between PTSD symptom severity and reasons for living. In contrast, hazardous alcohol consumption only demonstrated a trend for accounting for the association between PTSD and reasons for living. Our findings highlight the importance of clinicians assessing co-occurring depression symptoms and suggest the potential use of interventions that promote adaptive cognitions about suicide among people with PTSD.

The Risk of Unintended Pregnancy Among Young Women with Mental Health Symptoms

Depression and stress have been linked with poor contraceptive behavior but whether existing mental health symptoms influence womens subsequent risk of unintended pregnancy is unclear. We prospectively examined the effect of depression and stress symptoms on young womens pregnancy risk over one year. We used panel data from a longitudinal study of 992 U.S. women ages 18-20 years who reported a strong desire to avoid pregnancy. Weekly journal surveys measured relationship contraceptive use and pregnancy outcomes. We examined 27572 journal surveys from 940 women over the first study year. Our outcome was self-reported pregnancy. At baseline we assessed moderate/severe depression (CESD-5) and stress (PSS-4) symptoms. We estimated the effect of baseline mental health symptoms on pregnancy risk with discrete-time mixed-effects proportional hazard models using logistic regression. At baseline 24% and 23% of women reported moderate/severe depression and stress symptoms respectively. Ten percent of young women not intending pregnancy became pregnant during the study. Rates of pregnancy were higher among women with baseline depression (14% versus 9% p = 0.04) and stress (15% versus 9% p = 0.03) compared to women without symptoms. In multivariable models the risk of pregnancy was 1.6 times higher among women with stress symptoms compared to those without stress (aRR 1.6 CI 1.12.7). Women with co-occurring stress and depression symptoms had over twice the risk of pregnancy (aRR 2.1 CI 1.13.8) compared to those without symptoms. Among women without a prior pregnancy having co-occurring stress and depression symptoms was the strongest predictor of subsequent pregnancy (aRR 2.3 CI 1.24.3) while stress alone was the strongest predictor among women with a prior pregnancy (aRR 3.0 CI 1.18.8). Depression symptoms were not independently associated with young womens pregnancy risk. In conclusion stress and especially co-occurring stress and depression symptoms consistently and adversely influenced these young womens risk of unintended pregnancy over one year. Copyright (c) 2013 Elsevier Ltd. All rights reserved.

Predictors of eating disorders outcomes in Polish teenage patients

Aim of the studyThe aim of this study was to assess factors associated with outcome of eating disorders in Polish teenage patients.Subject or material and methodsAnalyses covered the data of 47 patients diagnosed with any of the eating disorders according to DSM IV consulted for the first time in the outpatients clinic of the Child and Adolescent Psychiatry Unit between 2002/2004 in Krakow (DGN1), Poland and then followed-up between 2009/2011 (DGN2). The influence of the number of variables collected at DGN1 on outcomes were analysed.ResultsThe outcomes of anorexia nervosa and bulimia nervosa are influenced by some aspects of clinical picture, patients’ objective family situation, their self-image and the perception they have of their family relations. The co-occurrence of depressive symptoms and younger age of parents proved to be the most clinically important negative outcome predictors in whole group of eating disorders.DiscussionSmall size of group in the follow-up study is the most important limitating factor.ConclusionsConclusion: Outcomes in eating disorders are affected by several psycho-bio-social factors common for all patients and specific for diagnosis type they initially present.

Effectiveness of Dialectical Behavior Therapy for Treating Eating Disorders

This study evaluated the effectiveness of dialectical behavior therapy (DBT) for treating eating disorder episodes and co‐occurring depression symptoms among individuals diagnosed with eating disorders. Separate meta‐analytic procedures for between‐groups and single‐group studies were conducted and yielded large effect sizes, indicating that DBT may be efficacious for decreasing disordered episodes among women diagnosed with eating disorders; medium to large effect sizes were noted for treating depression symptoms. Implications for evidence‐supported practice and study limitations are discussed.

The risk of unintended pregnancy among young women with mental health symptoms

Depression and stress have been linked with poor contraceptive behavior, but whether existing mental health symptoms influence women's subsequent risk of unintended pregnancy is unclear. We prospectively examined the effect of depression and stress symptoms on young women's pregnancy risk over one year. We used panel data from a longitudinal study of 992 U.S. women ages 18–20 years who reported a strong desire to avoid pregnancy. Weekly journal surveys measured relationship, contraceptive use and pregnancy outcomes. We examined 27,572 journal surveys from 940 women over the first study year. Our outcome was self-reported pregnancy. At baseline, we assessed moderate/severe depression (CESD-5) and stress (PSS-4) symptoms. We estimated the effect of baseline mental health symptoms on pregnancy risk with discrete-time, mixed-effects, proportional hazard models using logistic regression. At baseline, 24% and 23% of women reported moderate/severe depression and stress symptoms, respectively. Ten percent of young women not intending pregnancy became pregnant during the study. Rates of pregnancy were higher among women with baseline depression (14% versus 9%, p = 0.04) and stress (15% versus 9%, p = 0.03) compared to women without symptoms. In multivariable models, the risk of pregnancy was 1.6 times higher among women with stress symptoms compared to those without stress (aRR 1.6, CI 1.1,2.7). Women with co-occurring stress and depression symptoms had over twice the risk of pregnancy (aRR 2.1, CI 1.1,3.8) compared to those without symptoms. Among women without a prior pregnancy, having co-occurring stress and depression symptoms was the strongest predictor of subsequent pregnancy (aRR 2.3, CI 1.2,4.3), while stress alone was the strongest predictor among women with a prior pregnancy (aRR 3.0, CI 1.1,8.8). Depression symptoms were not independently associated with young women's pregnancy risk. In conclusion, stress, and especially co-occurring stress and depression symptoms, consistently and adversely influenced these young women's risk of unintended pregnancy over one year.

Co-occurring Aggressive and Depressive Symptoms as Related to Overestimations of Competence in Children with Attention-Deficit/Hyperactivity Disorder

Research indicates that on average, children with attention-deficit/hyperactivity disorder (ADHD) overestimate their competence in various domains. ADHD also frequently co-occurs with disorders involving aggressive and depressive symptoms, which themselves seem to influence estimations of self-competence in social, academic, and behavioral domains. In particular, high levels of aggressive behavior are generally associated with overestimations of competence, and high levels of depressive symptoms are related to underestimations of competence. This paper reviews studies of overestimations of competence among children with ADHD and examines the extent to which comorbid aggressive or depressive symptoms may be influencing these estimates. Although significant challenges arise due to limited information regarding comorbidities and problematic methods used to assess overestimations of competence, existing evidence suggests that ADHD may be associated with overestimations of competence over and above co-occurring aggression. As well, studies suggest that comorbid depression may reduce the appearance of overestimations of competence in children with ADHD. Underlying mechanisms (e.g., neuropsychological deficits or self-protection) of overestimations in children with ADHD are discussed, each with particular clinical implications for the assessment and treatment of ADHD. Future research would do well to carefully consider and explicitly describe the comorbid aggressive and depressive characteristics among individuals with ADHD when overestimations of competence are examined.

The Relation of Co-occurring Musculoskeletal Pain and Depressive Symptoms With Work Ability

To examine the relationship of musculoskeletal pain and depressive symptoms, occurring alone or both together, with self-rated current work ability and thoughts of early retirement. In a nationally representative sample drawn in 2000-2001, we studied actively working subjects aged 30 to 64 years (n = 4009). Musculoskeletal pain was associated with moderate/poor physical work ability (adjusted odds ratio [OR] = 2.9; 95% confidence interval [CI], 2.0 to 4.2) and mental work ability (OR = 1.6; 95% CI, 1.2 to 2.2). Depressive symptoms were associated with moderate/poor mental work ability only (adjusted OR = 4.2; 95% CI, 2.3 to 7.9). Moreover, only musculoskeletal pain was associated with thoughts of early retirement (OR = 1.4; 95% CI, 1.1 to 1.8). There was an interaction between musculoskeletal pain and depressive symptoms regarding physical work ability and thoughts of early retirement. Co-occurrence of musculoskeletal pain and depressive symptoms is strongly related to poor self-rated physical work ability.

Transcription Factor Activating Protein-2β (TFAP-2β) genotype and symptoms of attention deficit hyperactivity disorder in relation to symptoms of depression in two independent samples

The Transcription Factor Activating Protein-2β (TFAP-2β) gene has been shown to influence monoaminergic neurotransmission, and several genes important for monoaminergic function have binding sites for TFAP-2β. Familial studies of attention deficit hyperactivity disorder (ADHD) suggest a hereditary-determined subtype of ADHD with comorbid depression. We examined a functional variation of the TFAP-2β gene in the context of co-occurring symptoms of ADHD and depression in two independent population-based samples of adolescents (Group A, n = 175 and Group B, n = 1,506) from Sweden. Results indicated 6.1 to 7.8% of adolescents screened positively for ADHD and depression symptoms. Symptoms of depression were more common among girls who screened positively for ADHD and did not carry the nine-repeat allele of the TFAP-2β intron 1 Variable Number Tandem Repeat (VNTR) polymorphism. The presence of the nine-repeat variant of the TFAP-2β intron 1 VNTR appears to protect girls with ADHD symptoms from the co-expression of symptoms of depression.