The mediating role of health behaviors in the association between depression, anxiety and cancer incidence: an individual participant data meta-analysis.

BACKGROUND: Although behavioral mechanisms in the association among depression, anxiety, and cancer are plausible, few studies have empirically studied mediation by health behaviors. We aimed to examine the mediating role of several health behaviors in the associations among depression, anxiety, and the incidence of various cancer types (overall, breast, prostate, lung, colorectal, smoking-related, and alcohol-related cancers). METHODS: Two-stage individual participant data meta-analyses were performed based on 18 cohorts within the Psychosocial Factors and Cancer Incidence consortium that had a measure of depression or anxiety (N = 319 613, cancer incidence = 25 803). Health behaviors included smoking, physical inactivity, alcohol use, body mass index (BMI), sedentary behavior, and sleep duration and quality. In stage one, path-specific regression estimates were obtained in each cohort. In stage two, cohort-specific estimates were pooled using random-effects multivariate meta-analysis, and natural indirect effects (i.e. mediating effects) were calculated as hazard ratios (HRs). RESULTS: Smoking (HRs range 1.04-1.10) and physical inactivity (HRs range 1.01-1.02) significantly mediated the associations among depression, anxiety, and lung cancer. Smoking was also a mediator for smoking-related cancers (HRs range 1.03-1.06). There was mediation by health behaviors, especially smoking, physical inactivity, alcohol use, and a higher BMI, in the associations among depression, anxiety, and overall cancer or other types of cancer, but effects were small (HRs generally below 1.01). CONCLUSIONS: Smoking constitutes a mediating pathway linking depression and anxiety to lung cancer and smoking-related cancers. Our findings underline the importance of smoking cessation interventions for persons with depression or anxiety.

The role of explicit and implicit self-esteem in the relationship between childhood trauma and adult depression and anxiety.

BACKGROUND: Self-esteem is an important psychological concept that can be measured explicitly (reflective processing) and implicitly (associative processing). The current study examined 1) the association between childhood trauma (CT) and both explicit and implicit self-esteem, and 2) whether self-esteem mediated the association between CT and depression/anxiety. METHODS: In 1479 adult participants of the Netherlands Study of Depression and Anxiety, CT was assessed with a semi-structured interview, depression/anxiety symptoms with self-report questionnaires and explicit and implicit self-esteem with the Rosenberg Self-Esteem Scale and Implicit Association Test, respectively. ANOVAs and regression analyses determined the association between CT (no/mild/severe CT), its subtypes (abuse/neglect) and self-esteem. Finally, we examined whether self-esteem mediated the relationship between CT and depression/anxiety. RESULTS: Participants with CT reported lower explicit (but not lower implicit) self-esteem compared to those without CT (p < .001, partial η2 = 0.06). All CT types were associated with lower explicit self-esteem (p = .05 for sexual abuse, p < .001 for other CT types), while only emotional neglect significantly associated with lower implicit self-esteem after adjusting for sociodemographic characteristics (p = .03). Explicit self-esteem mediated the relationship between CT and depression/anxiety symptoms (proportion mediated = 48-77 %). LIMITATIONS: The cross-sectional design precludes from drawing firm conclusions about the direction of the proposed relationships. CONCLUSIONS: Our results suggested that the relationship between CT and depression/anxiety symptoms can at least partly be explained by explicit self-esteem. This is of clinical relevance as it points to explicit self-esteem as a potential relevant treatment target for people with CT.

Psychosocial factors, health behaviors and risk of cancer incidence: Testing interaction and effect modification in an individual participant data meta-analysis.

Depression, anxiety and other psychosocial factors are hypothesized to be involved in cancer development. We examined whether psychosocial factors interact with or modify the effects of health behaviors, such as smoking and alcohol use, in relation to cancer incidence. Two-stage individual participant data meta-analyses were performed based on 22 cohorts of the PSYchosocial factors and CAncer (PSY-CA) study. We examined nine psychosocial factors (depression diagnosis, depression symptoms, anxiety diagnosis, anxiety symptoms, perceived social support, loss events, general distress, neuroticism, relationship status), seven health behaviors/behavior-related factors (smoking, alcohol use, physical activity, body mass index, sedentary behavior, sleep quality, sleep duration) and seven cancer outcomes (overall cancer, smoking-related, alcohol-related, breast, lung, prostate, colorectal). Effects of the psychosocial factor, health behavior and their product term on cancer incidence were estimated using Cox regression. We pooled cohort-specific estimates using multivariate random-effects meta-analyses. Additive and multiplicative interaction/effect modification was examined. This study involved 437,827 participants, 36,961 incident cancer diagnoses, and 4,749,481 person years of follow-up. Out of 744 combinations of psychosocial factors, health behaviors, and cancer outcomes, we found no evidence of interaction. Effect modification was found for some combinations, but there were no clear patterns for any particular factors or outcomes involved. In this first large study to systematically examine potential interaction and effect modification, we found no evidence for psychosocial factors to interact with or modify health behaviors in relation to cancer incidence. The behavioral risk profile for cancer incidence is similar in people with and without psychosocial stress.

Depression, anxiety, and the risk of cancer: An individual participant data meta-analysis.

BACKGROUND: Depression and anxiety have long been hypothesized to be related to an increased cancer risk. Despite the great amount of research that has been conducted, findings are inconclusive. To provide a stronger basis for addressing the associations between depression, anxiety, and the incidence of various cancer types (overall, breast, lung, prostate, colorectal, alcohol-related, and smoking-related cancers), individual participant data (IPD) meta-analyses were performed within the Psychosocial Factors and Cancer Incidence (PSY-CA) consortium. METHODS: The PSY-CA consortium includes data from 18 cohorts with measures of depression or anxiety (up to N = 319,613; cancer incidences, 25,803; person-years of follow-up, 3,254,714). Both symptoms and a diagnosis of depression and anxiety were examined as predictors of future cancer risk. Two-stage IPD meta-analyses were run, first by using Cox regression models in each cohort (stage 1), and then by aggregating the results in random-effects meta-analyses (stage 2). RESULTS: No associations were found between depression or anxiety and overall, breast, prostate, colorectal, and alcohol-related cancers. Depression and anxiety (symptoms and diagnoses) were associated with the incidence of lung cancer and smoking-related cancers (hazard ratios [HRs], 1.06-1.60). However, these associations were substantially attenuated when additionally adjusting for known risk factors including smoking, alcohol use, and body mass index (HRs, 1.04-1.23). CONCLUSIONS: Depression and anxiety are not related to increased risk for most cancer outcomes, except for lung and smoking-related cancers. This study shows that key covariates are likely to explain the relationship between depression, anxiety, and lung and smoking-related cancers. PREREGISTRATION NUMBER: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=157677.

Psychosocial factors and cancer incidence (PSY-CA): Protocol for individual participant data meta-analyses.

OBJECTIVES: Psychosocial factors have been hypothesized to increase the risk of cancer. This study aims (1) to test whether psychosocial factors (depression, anxiety, recent loss events, subjective social support, relationship status, general distress, and neuroticism) are associated with the incidence of any cancer (any, breast, lung, prostate, colorectal, smoking-related, and alcohol-related); (2) to test the interaction between psychosocial factors and factors related to cancer risk (smoking, alcohol use, weight, physical activity, sedentary behavior, sleep, age, sex, education, hormone replacement therapy, and menopausal status) with regard to the incidence of cancer; and (3) to test the mediating role of health behaviors (smoking, alcohol use, weight, physical activity, sedentary behavior, and sleep) in the relationship between psychosocial factors and the incidence of cancer. METHODS: The psychosocial factors and cancer incidence (PSY-CA) consortium was established involving experts in the field of (psycho-)oncology, methodology, and epidemiology. Using data collected in 18 cohorts (N = 617,355), a preplanned two-stage individual participant data (IPD) meta-analysis is proposed. Standardized analyses will be conducted on harmonized datasets for each cohort (stage 1), and meta-analyses will be performed on the risk estimates (stage 2). CONCLUSION: PSY-CA aims to elucidate the relationship between psychosocial factors and cancer risk by addressing several shortcomings of prior meta-analyses.

Predictive value of implicit and explicit self-esteem for the recurrence of depression and anxiety disorders: A 3-year follow-up study.

Anxiety and depressive disorders are characterized by high rates of recurrence, substantially contributing to the high burden associated with these disorders. It is therefore crucial to identify factors related to recurrence, as they may provide viable targets for preventative intervention. Previous studies have observed a link between low self-esteem and subsequent symptoms of depression and anxiety, and low levels of self-esteem in those recovered from a depression or an anxiety disorder. Research also suggests that it is crucial to differentiate more explicit self-esteem (ESE) from more implicit self-esteem (ISE). The current study is the first to test whether ISE and ESE predict recurrence of depression and recurrence of anxiety during a 3-year follow-up as determined with clinical interviews. The sample included those with a history of a depressive disorder (n = 559) and/or a history of an anxiety disorder (n = 458) who had been depression- and anxiety-free for at least six months at baseline. During the 3-year follow-up, 119 (21%) and 104 (23%) had a depression and anxiety recurrence, respectively. ISE predicted recurrence of both depression and anxiety, even when statistically controlling for residual symptoms and neuroticism at baseline. ESE also showed predictive value, although this was not over and above residual symptoms. Explorative analyses suggest that ESE and ISE improved little, or not at all, from currently having a depression or anxiety disorder to recovery. These results therefore suggest that ISE may be an important target for interventions to prevent the recurrence of both depression and anxiety disorders. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Attentional bias for negative, positive, and threat words in current and remitted depression.

BACKGROUND: The aim of this study was to improve our understanding of the underlying mechanisms in the maintenance of depression. We examined attentional bias (AB) for negative and positive adjectives and general threat words in strictly-defined clinical groups of participants with pure Major Depressive Disorder (MDD) without a history of anxiety disorders (AD), mixed MDD and AD, and remitted participants. METHOD: We investigated both stimulus specificity and time course of AB in these groups, adopting a cross-sectional design. Data were drawn from the large scale Netherlands Study of Depression and Anxiety (NESDA), from which we selected all participants with pure current MDD without a history of AD (n = 29), all participants with current MDD and co-morbid AD(s) (n = 86), all remitted MDD participants (n = 294), and a comparison group without (a history of) MDD or ADs (n = 474). AB was measured with an Exogenous Cueing Task covering short and long presentation times (500 and 1250 ms) and 4 stimulus types (negative, positive, threat, neutral). RESULTS: Both traditional and trial level (dynamic) AB scores failed to show an AB for negative adjectives in participants with MDD or mixed MDD/AD. Specifically for long duration trials (1250 ms), remitted participants showed a larger AB traditional score (albeit the actual score still being negative) than the comparison group. The mixed MDD/AD group showed a higher trial-level AB score away from positive adjectives (1250 ms) than the comparisons. In addition, the mixed MDD/AD group showed higher and more variable trial-level AB scores away from short and towards longer presented general threat words together with a non-significant tendency to show less negative traditional AB scores for threat trials (500 ms) than the comparison group. CONCLUSIONS: All in all, the findings do not corroborate the view that an AB towards negative or away from positive adjectives is critically involved in currently depressed individuals. Yet, the relatively high (less negative) AB score for negative adjectives in remitted individuals points to the possibility that an AB for negative information may be involved as a risk factor in the recurrence of MDD.

Depression recurrence after recovery: Prognostic value of implicit and explicit self-depressed associations.

Identifying predictors of depression recurrence may highlight targets for relapse prevention. This study tested the hypothesis that strength of implicit and explicit self-depressed associations (SDA) following recovery would lower the threshold for the recurrence of depression. Two main analyses were conducted to test: (i) predictive validity of SDA for recurrence in individuals with a history of depression (at least six months depression free; n = 616, six-year follow-up); (ii) predictive validity of both post-depression SDA and the extent of change in SDA following recovery for recurrence in individuals who recovered in the first two years of the study (n = 220, four-year follow-up). Further exploratory analysis tested the scar model of SDA in participants without a history of depression at baseline. Recurrence rate was 49% in both the first and second analysis. In the first analysis, implicit SDA and explicit SDA were related to recurrence in the unadjusted models, but not when controlling for baseline symptoms. In the second analysis, post-depression explicit SDA predicted recurrence over and above baseline residual depressive symptomatology. There was no support that implicit SDA following depression related to recurrence. However, there was support that stronger explicit SDA following a recent depression increased risk for recurrence.

Influence of sad mood induction on implicit self-esteem and its relationship with symptoms of depression and anxiety.

BACKGROUND AND OBJECTIVES: Implicit self-esteem (ISE) refers to the valence of triggered associations when the self is activated. Despite theories, previous studies often fail to observe low ISE in depression and anxiety. It is feasible that sad mood is required to activate dysfunctional self-associations. The present study tested the following hypotheses: i) ISE is lower following a sad mood induction (SMI); ii) the relationship between ISE and level of depression/anxiety symptoms is relatively strong when ISE is measured during sad mood; iii) individuals with higher levels of depression/anxiety symptoms will show a relatively large decrease in ISE following a SMI. METHODS: In this mixed-designed study, university students completed the self-esteem implicit association test (IAT) either at baseline (control condition; n = 46) or following a SMI (experimental condition; n = 49). To test the third hypothesis, a SMI and IAT were also given in the control condition. Both conditions completed self-report measures of explicit self-esteem (ESE), and symptoms of depression and anxiety. RESULTS: There was no support for the first two hypotheses, but some support that symptoms of anxiety correlated with larger decreases in ISE following a SMI which partly supported the third hypothesis. This disappeared when controlling for multiple testing. LIMITATIONS: Results are limited to non-clinical participants. CONCLUSIONS: While ISE was robust against increases in sad mood, there was some tentative support that symptoms of anxiety were related to larger decreases in ISE following a SMI.

Implicit and Explicit Self-Esteem in Current, Remitted, Recovered, and Comorbid Depression and Anxiety Disorders: The NESDA Study.

BACKGROUND: Dual processing models of psychopathology emphasize the relevance of differentiating between deliberative self-evaluative processes (explicit self-esteem; ESE) and automatically-elicited affective self-associations (implicit self-esteem; ISE). It has been proposed that both low ESE and ISE would be involved in major depressive disorder (MDD) and anxiety disorders (AD). Further, it has been hypothesized that MDD and AD may result in a low ISE "scar" that may contribute to recurrence after remission. However, the available evidence provides no straightforward support for the relevance of low ISE in MDD/AD, and studies testing the relevance of discrepant SE even showed that especially high ISE combined with low ESE is predictive of the development of internalizing symptoms. However, these earlier findings have been limited by small sample sizes, poorly defined groups in terms of comorbidity and phase of the disorders, and by using inadequate indices of discrepant SE. Therefore, this study tested further the proposed role of ISE and discrepant SE in a large-scale study allowing for stricter differentiation between groups and phase of disorder. METHOD: In the context of the Netherlands Study of Depression and Anxiety (NESDA), we selected participants with current MDD (n = 60), AD (n = 111), and comorbid MDD/AD (n = 71), remitted MDD (n = 41), AD (n = 29), and comorbid MDD/AD (n = 14), recovered MDD (n = 136) and AD (n = 98), and never MDD or AD controls (n = 382). The Implicit Association Test was used to index ISE and the Rosenberg Self-Esteem Scale indexed ESE. RESULTS: Controls reported higher ESE than all other groups, and current comorbid MDD/AD had lower ESE than all other clinical groups. ISE was only lower than controls in current comorbid AD/MDD. Discrepant self-esteem (difference between ISE and ESE) was not associated with disorder status once controlling for ESE. LIMITATIONS: Cross-sectional design limits causal inferences. CONCLUSION: Findings suggest a prominent role for ESE in MDD and AD, while in comorbid MDD/AD negative self-evaluations are also present at the implicit level. There was no evidence to support the view that AD and MDD would result in a low ISE "scar".

Implicit and explicit self-esteem and their reciprocal relationship with symptoms of depression and social anxiety: a longitudinal study in adolescents.

BACKGROUND AND OBJECTIVES: A negative self-view is a prominent factor in most cognitive vulnerability models of depression and anxiety. Recently, there has been increased attention to differentiate between the implicit (automatic) and the explicit (reflective) processing of self-related evaluations. This longitudinal study aimed to test the association between implicit and explicit self-esteem and symptoms of adolescent depression and social anxiety disorder. Two complementary models were tested: the vulnerability model and the scarring effect model. METHOD: Participants were 1641 first and second year pupils of secondary schools in the Netherlands. The Rosenberg Self-Esteem Scale, self-esteem Implicit Association Test and Revised Child Anxiety and Depression Scale were completed to measure explicit self-esteem, implicit self-esteem and symptoms of social anxiety disorder (SAD) and major depressive disorder (MDD), respectively, at baseline and two-year follow-up. RESULTS: Explicit self-esteem at baseline was associated with symptoms of MDD and SAD at follow-up. Symptomatology at baseline was not associated with explicit self-esteem at follow-up. Implicit self-esteem was not associated with symptoms of MDD or SAD in either direction. LIMITATIONS: We relied on self-report measures of MDD and SAD symptomatology. Also, findings are based on a non-clinical sample. CONCLUSIONS: Our findings support the vulnerability model, and not the scarring effect model. The implications of these findings suggest support of an explicit self-esteem intervention to prevent increases in MDD and SAD symptomatology in non-clinical adolescents.