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Anger Management: Cognitive Therapy Interventions7 CEUs Anger Management: Cognitive Therapy Interventions

Section 13
Association between Coping with Anger
and Feelings of Depression among Youths
Part One: Introduction and Methods

Question 13 | Answer Booklet | Table of Contents | Anger Management

Several recent studies have documented an association between adults' coping styles and risks of depression and depressive symptoms. Data suggest that emotion-focused coping is associated with increased odds of depression and that task-oriented coping behavior may be associated with a lower likelihood of depression.

The mechanism of action between coping styles and the risk of depression is not entirely dear, but several hypotheses have been put forward. It could be that specific modes of interpreting positive and negative events are differentially depressogenic and may therefore result in different lifestyles, which accommodate either the positive or the negative perspective. For instance, it may be that emotion-focused coping with regard to loss ultimately increases the likelihood of depressive feelings through social isolation because the individual is less emotionally equipped to reach out to old contacts or make new friends, and this often leads to social withdrawal, isolation, and depression.
It is also conceivable that there are neuroendocrine or neurobiological substrates associated with emotion-focused coping that increase the risk of depression through neurochemical changes or pathways. It is further possible that depression leads to the development of an emotion-oriented style of coping as a result of slowed thinking, leads to having a negative worldview, or leads to limits in cognitive or physical functioning associated with the depression itself.

Alternatively, it may be that a third outside variable, such as a personality factor, is associated with the co-occurrence of depression and specific coping behaviors. For instance, neuroticism may be associated with an increased likelihood of smoking cigarettes and depressive symptoms when distressed.

Data from clinical studies on adult inpatients and outpatients suggest that there are differences in coping behaviors between patients with and without depression. Also, Jorm et al. examined the relation between depression and a wide variety of coping behaviors, finding that there are significant differences in types of behavior depending on the level of severity of depression. Previous studies have also shown that coping behaviors are associated with physical outcomes among those with medical illnesses as well, yet these analyses have not specifically been extended to mental disorders.
There is a long-held belief that anger and depression are intricately linked and that anger that is excessive, unexpressed, or "turned inward" leads to depression. Thus, an individual's method of coping with anger may be related to the likelihood of that individual experiencing depression. If a person engages in behaviors that are linked to effectively managing and discharging angry feelings and increasing healthy behavior, that person's likelihood of developing depression may be different (lower) from that of someone who copes with depression by engaging in behaviors that are harmful to that person's health, self-destructive in terms of social relationships or economic well-being, or associated with an increased risk of depression.

Although previous investigations among adults in clinical and community samples suggest that coping styles may be related to depressive symptoms, several pertinent areas have remained relatively neglected. First, it is not known whether previous findings are generalizable to youths in the community. Second, previous data are from clinical samples; therefore, it is not possible to determine whether coping strategies are associated with depression among youths in the community or whether coping styles are associated with selection into treatment. Third, despite gender differences in coping behaviors and risks of depression, no study has examined the relation between gender, coping behavior when angry, and the likelihood of depression.

Against this background, the goal of the current study was to begin to fill this gap by examining the association between coping behavior when angry and the likelihood of depression among youths. First, I examined the relation between coping behavior when angry and depression. Second, I examined the association between coping behavior when angry and gender. Third, I determined the association between coping behavior when angry and feelings of depression by gender.

On the basis of previous findings, I hypothesized that activity-oriented coping behavior when angry would be associated with a significantly lower likelihood of feelings of depression among youths compared with that associated with emotion-oriented coping behavior when angry. I also predicted that activity-oriented coping would be more common among male youths than among female youths.

Study Population

The National Institute of Child Health and Human Development supported a nationally representative survey of US youths in grades 6 through 10 during spring 1998. The survey, titled the Health Behavior of School-Aged Children (HBSC), was part of a collaborative, cross-national research project involving 30 countries and coordinated by the World Health Organization. The US sampling universe consisted of all public, Catholic, and other private school students in grades 6 through 10, or their equivalent, excluding schools with enrollments of fewer than 14 students.

The sample was a stratified 2-stage cluster of classes. The sample selection was stratified by racial/ethnic status to provide an oversample of Black and Hispanic students. The sample was also stratified by geographic region and counties' metropolitan statistical area status (largest urban areas/not largest urban areas), with probability proportional to total enrollment in eligible grades of the primary sampling units. Sample size was calculated in order to provide adequate numbers for making comparisons and producing results for all US students in grades 6 through 10.

The sampling plan was designed to support 2 overlapping studies with different sampling requirements. The "base study," or HBSC study, employed methods that produced a self-weighting sample of students at each of 3 target age levels ( 11 , 13 ,and 15 years).

The base study sample was designed to be equivalent to ±3% at a 95% confidence level (CI), which was established by the international HBSC commission. The full US study was designed to meet the additional goal of estimating African American and Hispanic characteristics within 5% at a 90% CI. These results are based on the full US study.

Response Rates
Because of the lack of state and local infrastructure to support the HBSC in the United States, a relatively low school participation rate was anticipated. In order to achieve the requisite number of participants by subpopulation, a low, conservative participation rate was assumed. There were 664 schools selected to participate in the HBSC survey. Of those 664, 386 schools agreed to participate, yielding a school participation rate of 58%. Within the 386 participating schools, 20 533 students were eligible for participation, and 17 000 participated, yielding a student response rate of 83%. These participation rates were sufficient to achieve the targeted precision levels and confidence intervals for the subpopulations of interest.

The school-based sample design used 1 class period for completion of the questionnaire. Responding students in sampled classes were excluded if they were out of the target range for grade or if their age was outside the 99th percentile for grade (n=440 students), or if either grade or age were unknown (n= 39 students), yielding an analytic sample of 15 686 students.

Measures were obtained from a self-report questionnaire containing 102 questions about health behavior and relevant demographic variables. Items were based on both theoretical hypotheses related to the social context of adolescents and measurements that had been validated in other studies or previous World Health Organization-HBSC surveys. Measures were pretested.

Behavior When Angry
Respondents were asked a series of self-report questions regarding their behavior when angry. Respondents were asked, "What do you usually do when you get angry?" and then specific activities were queried, including, "Find someone to talk to, drink alcohol, take drugs, stuff myself with food, listen to music, get into a physical fight, get into a verbal argument, go ride a bike, think about hurting myself on purpose, smoke a cigarette, exercise, pray, go for a walk, and cry." Answers were yes or no. "Stuff myself with food," "think about hurting myself," and "cry" were omitted from the analyses in the current study because they may be symptoms of depression.

Feelings of Depression
Depression was assessed with a self-report item: "During the past 12 months, did you ever feel sad, blue, down, or depressed almost every day for two weeks or more in a row?" Answers were yes or no. Then we took those who responded affirmatively to this question, and also, to define the participants with feelings of depression, endorsed at least 4 of the following 10 depression symptoms: ( 1 ) irritable when depressed, ( 2 ) lost interest when depressed, ( 3 ) gained weight when depressed, ( 4 ) lost weight when depressed, ( 5 ) couldn't concentrate when depressed, ( 6 ) couldn't sleep when depressed, ( 7 ) slept a lot when depressed, (8 ) rotten person when depressed, (9 ) thought of hurting self when depressed, (10) thought of death when depressed. Participants who endorsed the depression self-report item, in addition to endorsing at least 4 out of 10 depression symptoms, were considered to have feelings of depression, for the purposes of this study.

Analytic Strategy
First, all 11 coping behaviors were entered into an exploratory factor analysis with the use of principal components analysis with Varimax rotation. Next, the association between each of these 4 factors and the likelihood of depression was examined with multivariate logistic regression analyses to produce odds ratios with 95% CIs.

Next, the same method was used to examine the relation between gender and specific coping behaviors. Third, independence-based F tests were used to determine the relation between gender, depressive feelings, and self-reported coping behaviors when angry.

Next, multivariate logistic regression analyses were used to determine the association between each coping factor and the likelihood of depression in the past year, after adjustment for differences in gender, race, parental education, and having a single parent. The sample was stratified by each grade assessed and among the whole sample, with adjustment for age.

The analyses were stratified in order to make apparent any changes in relation between coping behavior when angry, gender, and depressive symptoms between pre- and postpubertal youths. Additional gender-specific analyses were also run. SPSS for Windows (9.0) was used for all statistical analyses.
-Goodwin, Renee D., American Journal of Public Health, Apr2006, Vol. 96, Issue 4

Personal Reflection Exercise #4
The preceding section contained information about association between coping with anger and feelings of depression among youths. Write three case study examples regarding how you might use the content of this section in your practice.

What are two hypotheses concerning the mechanism of action between coping styles and the risk of depression? Record the letter of the correct answer the Answer Booklet.

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