Future Mental Health Problems Research Articles

Roles of positive psychological outcomes in future health perception and mental health problems: A report from the Childhood Cancer Survivor Study.

Positive psychological outcomes among adolescent and young adult survivors of childhood cancer may influence long-term health status. We examined posttraumatic growth (PTG) and Life satisfaction (LS) in adolescence, and their impact on future emotional and physical health status in young adulthood. Survivors (n=2802) from the Childhood Cancer Survivor Study were longitudinally analyzed across social, emotional, and physical factors during adolescence (12-17years old), and PTG (PTG-Inventory) and LS (Cantril-Ladder-of-Life) during young adulthood (19-24years old). The impact of PTG and LS on survivors' future long-term mental health, physical health, and social skills was also examined (23-28years old) using Structural Equation Modeling. Survivors reported high levels of LS (M=7.43, range 1 to 10) and a positive impact from their cancer experience (M=48.78, range 0 to 105). Adolescent predictors of higher PTG included older age at diagnosis (p=0.001), experiencing more severe chronic health conditions (p=0.01), cancer recurrence/relapse (p=0.01), and being diagnosed with a non-CNS cancer (p=0.001). Higher perceived general health (p=0.01), higher social skills (p=0.001), and diagnosis with a non-CNS cancer (p=0.02) were associated with higher LS. Higher PTG during young adulthood predicted poorer perceived health (p=0.04) and worse emotional health (p=0.001) in later adulthood. Higher LS predicted better emotional health (p=0.001) and better perceived health (p=0.001). While LS was found to help survivors have better perceived long-term emotional and physical health outcomes, survivors with higher PTG fond both positive and negative impacts from cancer. Future therapeutic trials to improve LS should be considered.

Leisure Time Physical Activity and Risk of Developing Depression among the Youth of Kangra District, Himachal Pradesh, India.

Background:Physical inactivity during adolescence and youth has been considered as potential risk factor for future mental health problems. The present study was conducted with the aim to examine whether an association exists between leisure-time physical activity (PA) and depression among the youth of Kangra district, studying in professional or degree colleges.Methodology:A cross-sectional study was conducted among the students of Medical College (MC), Central University (CU) and Industrial Training Institute (ITI) of Kangra district. 370 adolescents and youth of age <25 years, who consented to participate, were recruited. The sample size was divided into three parts among all the three institutes. Only one question regarding leisure time PA (LTPA) was asked, as to how many hours spent in the last week; and Center for Epidemiologic Studies Depression Scale for Children (CES-DC) was used.Results:There were 124 participants from ITI, 126 from CU and 120 from MC. The mean score of CES-DC was highest among CU students 22.7 (±11.0) and lowest among MC students; 13.6 (±9.2). Low LTPA (<4 h) was significantly associated with higher depressive symptoms among all students (odds ratio [95% confidence interval]; 3.34 [1.41–7.92]).Conclusion:LTPA was associated with lower rates of depression.

Perceived stress and source of stress among undergraduate medical students of Government Medical College, Mysore

Background: Stress is defined as a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize. Medical school is recognized as a stressful environment that may have a negative effect on students’ academic performance, physical health, and psychosocial well-being. This stress when it exceeds the limit of tolerability causes various physical and mental health problems. Identifying this root cause will help us to put a barrier to many future mental health problems in a student’s life.Methods: It was a cross-sectional study done in Mysore Medical College among undergraduate students. Perceived stress scale was used to assess the level of stress and Medical student’s Stressor questionnaire was used to assess the source of stress.Results: A total of 303 students were included in the final analysis. Among them 51.5% were male and 48.5% were females. The age group of the students ranged between 18 and 24 with a mean age of 20.48 and standard deviation (SD) of 0.4. The mean and SD of PSS score is 17.7 and 5.5. The prevalence of mild, moderate and severe stress was 20%, 74% and 6% respectively. Majority of the students (40.9%) considered academic related stressors to be the source of high stress.Conclusions: In our study though majority of the students were stressed (80%), only 6% were severely stressed. The coping strategies adopted by the students like resorting to sleep and music/dance appeared to be appropriate methods of handling stress.

A protocol for the HeadCoach trial: the development and evaluation of an online mental health training program for workplace managers

BackgroundWithin high income countries, mental health is now the leading cause of long term sickness absence in the workplace. Managers are in a position to make changes and decisions that have a positive effect on the wellbeing of staff, the recovery of employees with mental ill health, and potentially prevent future mental health problems. However, managers report addressing workplace mental health issues as challenging. The aim of the HeadCoach trial is to evaluate the effectiveness of a newly developed online training intervention to determine whether it is able to build managers’ confidence to better support individuals within their teams who are experiencing mental ill health, and the confidence to promote manager behaviour likely to result in a more mentally healthy workplace.Methods/DesignWe will conduct a cluster randomised control trial (RCT) to evaluate the effect of HeadCoach, an online training intervention for managers with a focus on the mental health of their employees, compared to a waitlist control. The target sample is 168 managers, and their direct employees. Managers and employees will be assessed at baseline and at 4-month follow up. Managers will have an additional, intermediate assessment 6-weeks post-baseline. The primary outcome is change from baseline in managers’ self-reported confidence when dealing with mental health issues within their team and promoting a mentally healthy workplace. The difference between the intervention and waitlist control groups will be assessed using linear mixed effects repeated measures (MMRM) analysis of variance (ANOVA). Secondary managerial outcomes include mental health literacy, attitudes towards mental health issues in the workplace and managerial behaviour in dealing with mental health matters with their staff. Employee outcomes will be perceived level of manager support, engagement, psychological distress, and rates of sickness absence and presenteeism.DiscussionTo our knowledge this will be the first RCT of a purely online training intervention developed specifically for managers that promotes confidence to both support staff experiencing mental ill health and create a mentally healthy work environment. If successful, this intervention has the potential to provide an effective and efficient method of training managers in workplace mental health and to enhance employee wellbeing.Trial RegistrationAustralian and New Zealand Clinical Trials Registry ACTRN12617000279325

Psychological distance of climate change and mental health risks assessment of smallholder farmers in Northern Ghana: Is habituation a threat to climate change?

Although strong evidence shows climate change has physical impacts on human health, the mental health impacts appear unclear. The study aims to understand and explain the dynamic correlates between climate change and farmers’ emotional regulation practices, given psychological distance. Using 180 smallholder farmers in Northern Ghana, structural equation linear regression analysis showed that given psychological distance (geographical, social), different climate change indicators significantly influenced different emotional regulation practices among farmers. Although, studies show an association between climate change and climate change adaptation practices, the study revealed that, given psychological distance, emotional regulations of farmers predicted their preferences for different climate change adaptation techniques. It is concluded that the influence of climate change on farmers’ emotional regulation practices seems to predispose them to future mental (emotional) health problems. Emotional regulation also appears to be a significant factor that climate change and mental health interventionists need to pay attention to.

Why do children and adolescents bully their peers? A critical review of key theoretical frameworks

Bullying is a significant public health problem for children and adolescents worldwide. Evidence suggests that both being bullied (bullying victimisation) and bullying others (bullying perpetration) are associated with concurrent and future mental health problems. The onset and course of bullying perpetration are influenced by individual as well as systemic factors. Identifying effective solutions to address bullying requires a fundamental understanding of why it occurs. Drawing from multi-disciplinary domains, this review provides a summary and synthesis of the key theoretical frameworks applied to understanding and intervening on the issue of bullying. A number of explanatory models have been used to elucidate the dynamics of bullying, and broadly these correspond with either system (e.g., social-ecological, family systems, peer-group socialisation) or individual-level (e.g., developmental psychopathology, genetic, resource control, social-cognitive) frameworks. Each theory adds a unique perspective; however, no single framework comprehensively explains why bullying occurs. This review demonstrates that the integration of theoretical perspectives achieves a more nuanced understanding of bullying which is necessary for strengthening evidence-based interventions. Future progress requires researchers to integrate both the systems and individual-level theoretical frameworks to further improve current interventions. More effective intervention across different systems as well as tailoring interventions to the specific needs of the individuals directly involved in bullying will reduce exposure to a key risk factor for mental health problems.

"I Think He Will Have It Throughout His Whole Life": Parent and Youth Perspectives About Childhood Mental Health Problems.

Children's mental health (CMH) problems can be long-lasting. Even among children and youth who receive specialized CMH treatment, recurrence of problems is common. It is unknown whether youth and their parents view the possibility of future mental health problems. This has important implications for how CMH services should be delivered. This grounded theory study gained perspectives from youth (aged 12-15 years) who received CMH treatment ( n = 10) and their parents ( n = 10) about the expected course of CMH problems. Three disorder trajectories emerged: (a) not chronic, (b) chronic and persistent, and (c) chronic and remitting, with the majority of youth falling in the third trajectory. A gap in available services between CMH and adult care was perceived by parents, leaving them either help hopeful or help hungry about their child's future care. Improving care for youth with ongoing mental health problems is needed to minimize costs to families and the system.

Association between baseline psychological attributes and mental health outcomes after soldiers returned from deployment

BackgroundPsychological health is vital for effective employees, especially in stressful occupations like military and public safety sectors. Yet, until recently little empirical work has made the link between requisite psychological resources and important mental health outcomes across time in those sectors. In this study we explore the association between 14 baseline psychological health attributes (such as adaptability, coping ability, optimism) and mental health outcomes following exposure to combat deployment.MethodsRetrospective analysis of all U.S. Army soldiers who enlisted between 2009 and 2012 and took the Global Assessment Tools (GAT) before their first deployment (n = 63,186). We analyze whether a soldier screened positive for depression and posttraumatic stress disorder (PTSD) after returning from deployment using logistic regressions. Our key independent variables are 14 psychological attributes based on GAT, and we control for relevant demographic and service characteristics. In addition, we generate a composite risk score for each soldier based on the predicted probabilities from the above multivariate model using just baseline psychological attributes and demographic information.ResultsComparing those who scored in the bottom 5 percentile of each attribute to those in the top 95 percentile, the odds ratio of post-deployment depression symptoms ranges from 1.21 (95% CI 1.06, 1.40) for organizational trust to 1.73 (CI 1.52, 1.97) for baseline depression. The odds ratio of positive screening of PTSD symptoms ranges from 1.22 for family support (CI 1.08, 1.38) to 1.51 for baseline depression (CI 1.32, 1.73). The risk profile analysis shows that 31% of those who screened positive for depression and 27% of those who screened positive for PTSD were concentrated among the top 5% high risk population.ConclusionA set of validated, self-reported questions administered early in a soldier’s career can predict future mental health problems, and can be used to improve workforce fit and provide significant financial benefits to organizations that do so.

Longitudinal association between physical activity engagement during adolescence and mental health outcomes in young adults: A 21-year birth cohort study

ObjectivePrevious studies provide mixed evidence that physical activity engagement (PAE) in adolescence is associated with later mental health outcomes. This study aimed to examine the association between PAE at age 14 and mental health outcomes at age 21 using a large birth cohort study. Material and methodsProspective data from the Mater-University of Queensland Study of Pregnancy, consisting of 3493 young adults, were analyzed. PAE at age 14 was estimated using self-report, and participants were categorized into; (1) frequent, (2) infrequent, or (3) no PAE group. Mental health outcomes at age 21 consisted of; (1) common mental disorders, (2) psychosis-related outcomes, and, (3) emotional and behavioral problems. The association between PAE in adolescence and later mental health outcomes in young adulthood was examined using logistic regression, adjusted for age, sex, body mass index, and adolescent psychopathology. ResultsNo PAE at age 14 was associated with the increased likelihood of lifetime diagnosis of any affective disorder, elevated delusional ideation, and endorsement of visual perceptual disturbance at age 21. Conversely, infrequent PAE at age 14 was associated with the decreased likelihood of subsequent lifetime diagnosis of any substance use disorder. ConclusionOur findings suggest that lack of PAE in adolescence influences some, but not all, later mental health outcomes. Interventions to increase PAE in adolescence may represent an opportunity to prevent future mental health problems.

The Co-Development of Relational Aggression and Disruptive Behavior Symptoms from Late Childhood through Adolescence.

Researchers have debated whether relational aggression is a developmentally-normative behavior or a sign of some underlying psychopathology. However, due to the dearth of longitudinal studies, we know little about how relational aggression and more severe forms of disruptive behavior co-develop. The present study examined bidirectional associations between relational aggression and two psychiatric disorders, Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), using data from a longitudinal study of 674 Mexican-origin youth followed from age 10 to 16. Results showed that individuals who engaged in relational aggression tended to increase over time in ODD and CD symptoms, and conversely, individuals exhibiting symptoms of ODD and CD tended to increase in relational aggression. These findings held for boys and girls, for youth born in Mexico and the U.S., and after controlling for physical aggression. Thus, relational aggression seems to be both a developmentally-normative behavior and a predictor of future mental health problems.

Mental health among young adults in prison: the importance of childhood-onset conduct disorder.

BackgroundThe psychiatric health burden of prisoners is substantial. However, there is a lack of high-quality studies of psychiatric disorders among young adults with a high risk of reoffending.AimsTo investigate the lifetime prevalence of psychiatric disorders and use of mental health services among young male violent offenders and the impact of childhood-onset conduct disorder (COCD).MethodA nationally representative cohort (n = 270, age 18–25) of male offenders was followed back in medical records and clinically assessed by gold standard methods. Lifetime prevalences are presented together with odds ratios (ORs) as risk estimates in relation to COCD.ResultsPrevious use of psychiatric services among the participants was high but their lifetime psychiatric morbidity was even higher, with 93% meeting criteria for at least one Axis I disorder. The COCD group was overrepresented in most clinical categories and carried five times higher odds (OR = 5.1, 95% CI 2.0–12.8) of a psychotic disorder, three times higher odds (OR = 3.2, 95% CI 1.2–8.5) of a substance use disorder and two times higher odds of a mood disorder (OR = 2.3, 95% CI 1.3–4.0) or anxiety disorder (OR = 2.0, 95% CI 1.1–3.5).ConclusionsThe mental health burden is substantial among young violent offenders, and COCD is an important indicator of future mental health problems which must be a priority for public health efforts.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

A Novel Heart‐Centered, Gratitude‐Meditation Intervention to Increase Well‐Being among Adolescents

Population studies paint a dismal picture of the mental health status of adolescents, in the US and worldwide. Positive psychology, which takes a preventative approach to keeping individuals in higher states of well‐being, is being implemented increasingly among youth, with the goal of avoiding future mental health and psychological problems. In this study, a novel intervention, which fused the practice of meditation with gratitude visualizations, was tested among adolescents. The purpose of this quasi‐experimental study was to determine the extent to which the intervention affected life satisfaction, school satisfaction, and measured gratitude, among a culturally diverse cohort of adolescents. Instrumentation consisted of three positive psychology measures—the Student Life Satisfaction Scale, the School Satisfaction Subscale, and the Gratitude Questionnaire-Six-Item Form. Participants were randomly assigned either to the delayed‐intervention, no‐treatment control group or to the experimental group. The four‐week intervention was manualized primarily from the heart‐centered gratitude visualizations outlined in a happiness and positive emotions handbook, The Jewels of Happiness: Inspiration and Wisdom to Guide Your Life-Journey. The intervention significantly affected life satisfaction, school satisfaction, and gratitude of the experimental group, when compared to the control group. Medium to large effect sizes were detected using the ANCOVA statistical test.

Quality of life in relation to future mental health problems and offending: Testing the good lives model among detained girls.

Detained girls bear high levels of criminal behavior and mental health problems that are likely to persist into young adulthood. Research with these girls began primarily from a risk management perspective, whereas a strength-based empowering perspective may increase knowledge that could improve rehabilitation. This study examines detained girls' quality of life (QoL) in relation to future mental health problems and offending, thereby testing the strength-based good lives model of offender rehabilitation (GLM). At baseline, 95 girls (Mage = 16.25) completed the World Health Organization QoL instrument to assess their QoL prior to detention in the domains of physical health, psychological health, social relationships, and environment. Six months after discharge, mental health problems and offending were assessed by self-report measures. Structural equation models were conducted to test GLM's proposed (in)direct pathways from QoL (via mental health problems) toward offending. Although we could not find support for GLM's direct negative pathway from QoL to offending, our findings did provide support for GLM's indirect negative pathway via mental health problems to future offending. In addition, we found a direct positive pathway from detained girls' satisfaction with their social relationships to offending after discharge. The current findings support the potential relevance of addressing detained girls' QoL, pursuing the development of new skills, and supporting them to build constructive social contacts. Our findings, however, also show that clinicians should not only focus on strengths but that detecting and modifying mental health problems in this vulnerable group is also warranted. (PsycINFO Database Record

Are natural disasters in early childhood associated with mental health and substance use disorders as an adult?

Understanding factors that influence risk for mental health and substance use disorders is critical to improve population health and reduce social costs imposed by these disorders. We examine the impact of experiencing a natural disaster—a serious fire, tornado, flood, earthquake, or hurricane—by age five on adult mental health and substance use disorders. The analysis uses data from the 2004 to 2005 National Epidemiologic Survey of Alcohol and Related Conditions. The analysis sample includes 27,129 individuals ages 21–64 years. We also exploit information on parenting strategies to study how parents respond to natural disasters encountered by their children. We find that experiencing one or more of these natural disasters by age five increases the risk of mental health disorders in adulthood, particularly anxiety disorders, but not substance use disorders. Parents alter some, but not all, of their parenting strategies following a natural disaster experienced by their children. It is important to provide support, for example through counseling services and financial assistance, to families and children exposed to natural disasters to mitigate future mental health and substance use problems attributable to such exposure.

Prevalence and incidence of mental health problems among Dutch medical students and the study-related and personal risk factors: a longitudinal study.

A high prevalence of mental health problems (i.e. depression and/or anxiety) has been found in medical students in comparison with the general population. Therefore, the objective was first to study the prevalence and 1-year incidence of symptoms of depression, anxiety and any mental health problems among Dutch medical students and, second, to study which study-related and personal factors present a risk of these mental health problems. A 1-year prospective longitudinal study was performed among medical students of two medical faculties in the Netherlands (n=951). Health problems and study-related and personal factors were measured with an online questionnaire. Mental health problems were assessed by depression and/or anxiety symptoms (BSI-DEP and BSI-ANG). Univariate and multivariate hierarchical logistic regression analyses were performed to examine which of the study-related and personal factors predict mental health problems. At follow-up, 36%, 28% and 48% of the medical students reported symptoms of depression, anxiety and mental health problems, respectively. The incidence between 2010 and 2011 for depression was 20%, 17% for anxiety and 25% for mental health problems. Students who are worried about their own health during medical education are at an increased risk of future mental health problems (OR 2.0 [1.3-2.9], p=0.00). Excessive drinking behavior is a protective factor in this study (OR 0.7 [0.5-0.9], p=0.02). This study shows that only two out of nine factors are significantly associated with mental health problems among Dutch medical students, one risk factor and one protective factor.

Single item measures of self-rated mental health: a scoping review.

BackgroundA single-item measure of self-rated mental health (SRMH) is being used increasingly in health research and population health surveys. The item asks respondents to rate their mental health on a five-point scale from excellent to poor. This scoping study presents the first known review of the SRMH literature.MethodsElectronic databases of Medline, CINAHL, PsycINFO, EMBASE and Cochrane Reviews were searched using keywords. The databases were also searched using the titles of surveys known to include the SRMH single item. The search was supplemented by manually searching the bibliographic sections of the included studies. Two independent reviewers coded articles for inclusion or exclusion based on whether articles included SRMH. Each study was coded by theme and data were extracted about study design, sample, variables, and results.ResultsFifty-seven studies included SRMH. SRMH correlated moderately with the following mental health scales: Kessler Psychological Distress Scale, Patient Health Questionnaire, mental health subscales of the Short-Form Health Status Survey, Behaviour and Symptom Identification Scale, and World Mental Health Clinical Diagnostic Interview Schedule. However, responses to this item may differ across racial and ethnic groups. Poor SRMH was associated with poor self-rated health, physical health problems, increased health service utilization and less likelihood of being satisfied with mental health services. Poor or fair SRMH was also associated with social determinants of health, such as low socioeconomic position, weak social connections and neighbourhood stressors. Synthesis of this literature provides important information about the relationships SRMH has with other variables.ConclusionsSRMH is associated with multi-item measures of mental health, self-rated health, health problems, service utilization, and service satisfaction. Given these relationships and its use in epidemiologic surveys, SRMH should continue to be assessed as a population health measure. More studies need to examine relationships between SRMH and clinical mental illnesses. Longitudinal analyses should look at whether SRMH is predictive of future mental health problems.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-398) contains supplementary material, which is available to authorized users.

Antenatal depression and children's developmental outcomes: potential mechanisms and treatment options.

During the last decade there has been increased recognition of the prevalence of antenatal depression as well as an expansion in research examining the impact of maternal mood during pregnancy on offspring development. The aim of this review was to summarise the theoretical underpinnings and empirical evidence regarding the impact of antenatal depression on children's developmental outcomes. Biological mechanisms hypothesised to account for an association between antenatal depression and adverse offspring outcomes are first identified including the functioning of the prenatal Hypothalamic Pituitary Adrenal (HPA) axis and epigenetic processes. A systematic literature search is then conducted of studies examining the impact of antenatal depression on child development. In general, studies examining associations between antenatal depression and offspring temperament, cognitive and emotional outcomes reveal either no effect of the prenatal environment or small effects that often attenuate following adjustment for other antenatal and postnatal risk factors. In contrast, an independent effect of antenatal depression on children's conduct problems and antisocial behaviour is a well-replicated finding. There is emerging evidence that exposure to depression during pregnancy impacts negatively on offspring biology, although the findings are complex and require replication. Psychological and pharmacological treatments of antenatal depression are then reviewed, considering whether antidepressant medication exerts harmful effects on the foetus. We close by proposing that antenatal depression is an early marker of a developmental cascade to future mental health problems for both mothers and offspring.

Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients

Individuals with cancer are disproportionately affected by sleep disturbance and insomnia relative to the general population. These problems can be a consequence of the psychological, behavioral, and physical effects of a cancer diagnosis and treatment. Insomnia often persists for years and, when combined with already high levels of cancer-related distress, may place cancer survivors at a higher risk of future physical and mental health problems and poorer quality of life. The recommended first-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBT-I), a non-pharmacological treatment that incorporates cognitive and behavior-change techniques and targets dysfunctional attitudes, beliefs, and habits involving sleep. This article presents a comprehensive review of the literature examining the efficacy of CBT-I on sleep and psychological outcomes in cancer patients and survivors. The search revealed 12 studies (four uncontrolled, eight controlled) that evaluated the effects of CBT-I in cancer patients or survivors. Results suggest that CBT-I is associated with statistically and clinically significant improvements in subjective sleep outcomes in patients with cancer. CBT-I may also improve mood, fatigue, and overall quality of life, and can be successfully delivered through a variety of treatment modalities, making it possible to reach a broader range of patients who may not have access to more traditional programs. Future research in this area should focus on the translation of evidence into clinical practice in order to increase awareness and access to effective insomnia treatment in cancer care.

The Impact of Sexual Abuse Committed by a Child on Mental Health in Adulthood

Numerous research studies document the negative mental health outcomes associated with the experience of childhood sexual abuse. In addition, factors such as one's relationship with the perpetrator and the severity of the abuse predict the likelihood of future mental health problems. Less attention, however, has focused on the age of the perpetrator, and recent years have seen an increased interest in children who display sexual behavior problems. College students completed measures of mental health functioning and retrospective reports of maltreatment histories. Participants were categorized as abused by an adult (n = 48), teenager (n = 39), or another child (n = 37), and non-abused (n = 219). Victims of abuse, regardless of perpetrator age, displayed higher levels of mental health problems than non-abused participants. There were no differences between the abused groups on any of the mental health outcomes; however, individuals who were abused by other children were less likely to label their experiences as abuse.

GETTING STUCK IN THE BLUES: PERSISTENCE OF MENTAL HEALTH PROBLEMS IN AUSTRALIA

Do episodes of mental health (MH) problems cause future MH problems, and if yes, how strong are these dynamics? We quantify the degree of persistence in MH problems using nationally representative, longitudinal data from Australia and system generalized method of moments (GMM), and correlated random effects approaches are applied to separate true from spurious state dependence. Our results suggest only a moderate degree of persistence in MH problems when assuming that persistence is constant across the MH distribution once individual-specific heterogeneity is accounted for. However, individuals who fell once below a threshold that indicates an episode of depression are up to five times more likely to experience such a low score again a year later, indicating a strong element of state dependence in depression. Low income is a strong risk factor in state dependence for both men and women, which has important policy implications.