Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

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Abstract

Within the past 20 years, depression research has given increasing consideration to the possibility of complex and reciprocal relations between stress and depression. Not only does stress increase risk for depression (i.e., a stress exposure model of depression), but depression, or depressogenic vulnerabilities, in turn, also increases susceptibility to stressful events that are at least in part influenced by the individual (i.e., stress generation; Hammen, 1991). The present review provides a systematic examination of the stress generation literature to date, with specific focus given to depression and depressogenic risk factors (i.e., past stress, negative cognitive styles, and personality and interpersonal vulnerabilities) as predictors of the stress generation effect, as well as gender differences in stress generation, the sequelae of generated stress, and the relative specificity of this phenomenon to depression. The research thus far appears most consistent in supporting the role of depression in predicting generated stress, although more research is still required. In addition to highlighting these findings, methodological limitations and conceptual gaps in the literature are discussed with the view of informing future research in this area.

Introduction

Depression is one of the most prevalent forms of psychopathology, afflicting approximately 20 to 25% of women and 10 to 17% of men within their lifetime (Kessler et al., 1994, Levinson, 2006). It is also recurrent, with each episode increasing risk of subsequent ones (Kessler, 2002). Current estimates of the recurrence of depression suggest that 50 to 60% of individuals who experience one depressive episode go on to experience a second one, with 70 to 80% of these eventually experiencing a third episode, and 90% of individuals with three past episodes going on to experience a fourth (American Psychiatric Association, 2000, Burcusa & Iacono, 2007, Lewinsohn et al., 1989, Monroe & Harkness, 2005, Solomon et al., 2000). Fully elucidating relations between stress and depression is critical to advancing our understanding of the processes involved in the etiology and often chronic course (i.e., duration, relapse, and recurrence) of this common and debilitating disorder.

In the present article, we begin with a brief discussion of the early history of research on stress and depression, with its emphasis on the stress exposure model. From this context, we then focus on emergence of the stress generation hypothesis and present a review of the evidence to date concerning this perspective. As stress generation has been hypothesized to be a product not only of individuals' depressive symptoms, but also of their characteristics and behavioral tendencies (e.g., cognitions, values, and traits; Hammen, 1991, Hammen, 2006), this review will include a discussion of the literature on depression, past stress, negative cognitive styles, and personality or interpersonal styles in relation to the stress generation process. Several notable reviews of research on stress generation have been published in recent years (i.e., Hammen, 1999, Hammen, 2006). We attempted to add to these past reviews in several ways. First, based on our inclusion/exclusion criteria detailed below, the rate at which articles in this area are published seems to be steadily increasing each year, doubtless a reflection of the still-growing interest in stress generation. Consequently, since the most recent of these reviews (Hammen, 2006), 21 new articles have been published, representing 37% of extant reports on stress generation based on the present literature search. Thus, the current article provides an update in the form of a comprehensive review of the research on this topic. In addition, we attempted to offer several recommendations for future research, while also elaborating on issues raised by Hammen (2006) that as yet remain unaddressed in the empirical literature.

That stressful life events are associated with risk for depression is a well-established finding in the research literature (Hammen, 2005, Kessler, 1997, Mazure, 1998, Paykel, 2003). The relation between stress and risk for depression has been documented for episodic, or acute, stresses (Kendler, Karkowski & Prescott, 1998) and chronic stresses (Hammen, Kim, Eberhart & Brennan, 2009; see Hammen, 2005 for a review), and both recent and early negative life events (Gibb et al., 2003, Harkness et al., 2006). It has been documented in child (Cole & Turner, 1993), adolescent (Tram & Cole, 2000), young adult (Hankin, Kassel & Abela, 2005), and geriatric samples (Fiske et al., 2003, Moos et al., 2005). Moreover, life stress has been implicated in the first onset of depression (Kendler et al., 1999, Lewinsohn et al., 1999), depressive relapse (Swindle, Cronkite & Moos, 1989), recurrence of depression (Monroe, Roberts, Kupfer & Frank, 1996; see Burcusa & Iacono 2007, for a recent review; but also see Paykel, 2003, Stroud et al., 2008, for some evidence to indicate that major life stressors are more strongly associated with the first one or two depressive episodes than with later ones), and the exacerbation of depressive symptoms (Lewinsohn, Hoberman & Rosenbaum, 1988).

Guiding much of early research on stress and depression was a tacit assumption that the relation between the two is unidirectional. Specifically, in what has been termed a stress exposure model of depression, it is implied that stressful life events significantly increase individual susceptibility to this disorder. Initial conceptualizations of this model also held that individuals are largely passive recipients of environmental stressors, having little, if any, significant role in the shaping of events within their lives relevant to the development of depression. Thus, early research gave primacy to independent relative to dependent events. Independent, or fateful, life events are those whose occurrence is outside the individual's control (e.g., death of a friend or relative), whereas dependent life events are those whose occurrence is influenced by characteristics of the individual (e.g., getting into an argument). Several mediational and moderational models elaborating on this basic relation between stress and depression have received empirical support, including biological diathesis-stress models (see Levinson, 2006 for a recent review), bio-cognitive mediational models (e.g., Beevers et al., 2009, Hilt et al., 2007), cognitive diathesis-stress models (e.g., Abramson et al., 1989, Beck, 1967, Beck, 1987), cognitive-developmental mediational conceptualizations (e.g., Cole, 1990, Cole, 1991), as well as interpersonal diathesis-stress theories (e.g., Joiner, Metalsky, Katz & Beach, 1999; also see Van Orden, Wingate, Gordon & Joiner, 2005 for a review).

Although several researchers have speculated that depression may be associated with an increased likelihood of subsequent stress (e.g., Compas et al., 1989, Dohrenwend & Dohrenwend, 1981, Depue & Monroe, 1986), early studies largely treated this issue as a methodological confound, with the principal objective being to investigate the predominant stress exposure perspective (Cui & Vaillant, 1997, Hammen, 1991, Hammen, 1992). In accurately documenting the causal relation from stress to depression, it was necessary to control, statistically or otherwise address, any stresses that may be the product of prior symptoms of depression or characteristics of the individual (i.e., dependent life stresses). Together with the early view of individuals as passive recipients of life stresses, this may in part account for the greater initial attention given by researchers to the role of independent or fateful life events, relative to dependent life events, in predicting depression, which is nevertheless of important theoretical and empirical interest in its own right (see Daley et al., 1997). Although crucial to establishing the link between exposure to stressful life events and development of depression, the approach taken by these early studies also left outside of consideration the possibility of additional, but equally important, relations between stress and depression (Hammen, 1991).

Within the last 20 years, however, the focus of depression research has shifted towards a greater awareness of the complex and reciprocal relation between stress and depression. That is, while the traditional stress exposure model of depression very much remains an important focus of research, increasing consideration also has been given to a complimentary and similarly important process, whereby depression, or depressogenic vulnerability factors, plays an active role in generating the very stresses that place individuals at heightened risk for future depression.

Although, as previously mentioned, several researchers have commented on the possibility of a relation between depression and subsequent stressors, Hammen (1991) was the first clearly to formulate and test the stress generation model of depression. According to the stress generation perspective, depression-prone individuals are not simply passive respondents to stressful events in their lives, but active agents in the creation of depressogenic life stressors. That is, individuals vulnerable to depression, when compared to those without such vulnerability, are likely to experience a higher rate of dependent events, particularly within interpersonal domains, but not independent or fateful events. Moreover, these dependent events are, in some measure, influenced by maladaptive characteristics (e.g., cognitive styles, traits, attachment styles, values and expectations) and behaviors of the individual (Hammen, 1991, Hammen, 2006). Considering that interpersonal and dependent events, compared to independent ones, seem to be more predictive of depression (Kendler et al., 1999), the generation of dependent life stresses, in turn, may potentially have a role in the maintenance of current depression or increase in the likelihood of subsequent depression onset and recurrence (Hammen, 1991, Joiner, Wingate & Otamendi, 2005). Thus, stress generation to some degree may account for the often chronic course of depression (Belsher & Costello, 1988, Monroe & Harkness, 2005, Solomon et al., 2000).

Before proceeding with a review of the stress generation literature, it should be noted that recognition of the important role of stress generation in depression pathogenesis has also led to revisions of earlier theoretical models and development of new ones integrating both stress exposure and stress generation perspectives within fully transactional models of depression (e.g., Hankin & Abramson, 2001, Joiner, Wingate & Otamendi, 2005). In these transactional or reciprocal models, individual depressogenic characteristics or depressive symptoms are hypothesized to interact with stress in a bidirectional manner, with depressogenic characteristics or symptoms generating later stress, and prior stress influencing the development of these same characteristics or symptoms.

Section snippets

Method

In reviewing the extant literature on stress generation, it is worth noting that the amount of research that may be interpreted as generally in line with the stress generation perspective is quite broad, and could essentially encompass any study that includes putative risk factors (e.g., perfectionism or physical illness) as predictors, and some form of stress (e.g., general distress, quality of peer or romantic relationships) as an outcome of interest. For this reason, in the present review,

Predictors of stress generation: depression

Preliminary support for the stress generation model came from Hammen (1991) original finding that, relative to treatment-seeking women with chronic physical health conditions, bipolar disorder, and healthy controls, those with a history of recurrent unipolar depression reported higher rates of dependent episodic stressors, especially in the form of conflicts within interpersonal domains. The groups, however, did not differ in rates of independent stressful life events over a one-year

Conclusions and future directions

In summary, there is now a substantial amount of support for the stress generation effect in depression, with many studies replicating the original finding (Hammen, 1991) that depression is associated with subsequent occurrence of dependent stress. The majority of these studies, however, have focused on episodic stress, and very little attention has been devoted to establishing the generation of chronic stress. Stress generation research has expanded beyond the effects of depressive

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