Translating Cognitive Vulnerability Theory Into Improved Adolescent Depression Screening: A Receiver Operating Characteristic Approach

Abstract

Traditionally, screening research tests how well a given symptom inventory can identify a concurrent depressive episode. Although developmental psychopathology could inform screening protocols for a myriad of depression outcomes (e.g., prospective depressive episodes), approaches typically used in research make it difficult to translate these findings. Using a translational analytic approach and multiwave longitudinal study design, we examined how screening for cognitive vulnerabilities (rumination, dysfunctional attitudes, and attributional style) may improve our ability to identify concurrent depressive episodes, prospective depressive episodes, first lifetime episodes of depression, and recurrent major depressive episodes. There were 473 sixth-grade (early adolescents) and ninth-grade (middle adolescents; Age_M = 13.15, Age_SD = 1.62) students who completed baseline self-report cognitive vulnerability and depressive symptom measures. At baseline and every 6 months for 3 years, pediatric depression interviews were completed by the caregiver and youth. A receiver operating characteristic (ROC) approach was utilized to test our aims. Distinct algorithms best forecasted our depression outcomes. Rumination and attributional style emerged as unique and incrementally valid predictors for prospective episodes after controlling for baseline depressive symptoms. Rumination was the only unique predictor for first lifetime depressive episodes. For recurrent major depression, rumination in early adolescence and attributional style in middle adolescence served as incremental predictors beyond baseline depressive symptoms. Proposed cutoffs and diagnostic likelihood ratios are offered for algorithms for each depression outcome. Assessing cognitive vulnerability represents a feasible method to improve depression screening initiatives. Using an ROC-informed approach can help prevention initiatives better leverage the considerable gains made within developmental psychopathology research.

Notes

¹ We also used a more traditional hierarchical logistic regression approach to test our assumptions concerning incremental validity (Hunsley & Meyer, 2003). The pattern of findings across cognitive vulnerabilities was identical.

² For FLED, a degenerate pattern for rumination emerged, as moderate scores corresponded to a higher DLR (i.e., increased FLED risk) than elevated rumination scores. Smoothing techniques using the k-nearest neighbors algorithm were unable to fix the degenerate pattern of data. Inspection of quintiles revealed that using a lower score for our threshold (23 instead of 36) and subthreshold (19 instead of 20) led to a monotonic trend in our tertiles. In favor of parsimony, however, we decided to keep uniform cutoffs for our depression outcomes. Prevention programs specifically focused on FLED should consider using these lower cutoff scores within screening protocols.

³ The impact of degeneracy noted in Table 2 for rumination is partially mitigated in the combined model as moderate and high levels of rumination are treated the same within the context of elevated depression scores.

Additional information

Funding

This research was supported by the National Institute of Mental Health Grants 5R01MH077195 and 5R01MH077178 awarded to Benjamin Hankin and Jami Young.