Depression: Latinx Adolescent Girls’ Perceived Triggers

Abstract

Research on depression among Latinx populations is increasing; however, a focus on what triggers depression among this community is lacking. This study aims to identify perceived triggers for depression through a secondary analysis of 28 adolescent girls who self-identified as Latinx (mean age = 17.07 years, SD = 0.77). Sixty-one percent of the girls reported being first generation (born in Mexico), having lived in Mexico an average of 8.95 years and the primary language at home being Spanish (63%). Of these, the associated triggers of 20 major depression episodes (MDE) and eight minor depressive episodes (i.e., two to four MDE criteria endorsed) were examined. Seventy-five triggers were identified with a majority reflecting family/parent relationships, romance/friendship issues, and self and others’ expectations/pressures. These findings suggest that certain life events and stressors precede depressive symptoms among Latinx adolescent girls.

Keywords

depression Latina adolescents triggers risk factors

Major depression is a disorder that is common (Centers for Disease Control and Prevention, 2010). In the United States, about 16.2% of individuals are affected by Major Depressive Disorder (MDD; Kessler et al., 2003) with the prevalence steadily increasing (Maes et al., 2012). Estimates show that about 27% of the Latinx¹ population is affected by MDD (Albert Einstein College of Medicine, 2014), with the average length of the disorder at 7 to 9 months and a recurrence rate of 70% by the fifth year of remission (Maes et al., 2012).

Depression Among Adolescents

Adolescence is a critical time period for developing depression and has been found to have a lifetime prevalence ranging from 15% to 20% (Maes et al., 2012). The development of depression during adolescence is associated with greater risks including impairment in school functioning (Nolen-Hoeksema, Girgus, & Seligman, 1992), relationships with others (Twenge & Nolen-Hoeksema, 2002), and substance abuse (Galambos, Leadbeater, & Barker, 2004; Glied & Pine, 2002; Maes et al., 2012). In addition, depression among adolescents is also associated with other lifelong repercussions (Glied & Pine, 2002), such as difficulty forming healthy and stable relationships in adulthood (Haarasilta, Marttunen, Kaprio, & Aro, 2004) and difficulties in completing developmental tasks leading to deficits in physical and psychological well-being (Galambos et al., 2004). Although it would be ideal if adolescents were diagnosed and treated for depressive symptoms as early as possible, previous literature finds that depression among this group is often undiagnosed and untreated, and, instead, attributed to adolescent daily stressors (Galambos et al., 2004).

Depression Among Latinx Adolescents

Adolescents of Latinx origin are two thirds more likely to develop depression (Twenge & Nolen-Hoeksema, 2002) and report higher rates of depression (36.2%) when compared with Black non-Hispanic (28.4%) and White non-Hispanic (25.8%) youth (Knopf, Park, & Mulye, 2008; Twenge & Nolen-Hoeksema, 2002). Furthermore, Latinx youth are among the highest ranked group who experience depressive symptoms and internalize problems when compared with other ethnic backgrounds (Roberts, Roberts, & Chen, 1997) making them a vulnerable population with greater risk of developing depressive symptoms.

During the adolescent years, girls’ symptoms of depression increase at a higher rate than their male counterparts (Twenge & Nolen-Hoeksema, 2002) with an increased likelihood of lifetime MDD (15.6%) compared with adolescent males (12.2%; Knopf et al., 2008). Latinx adolescent girls often report high rates of depression (Potochnick & Perreira, 2010) and high prevalence of severe suicidal ideation (Zayas, Lester, Cabassa, & Fortuna, 2005), including suicide attempts (Fortuna, Perez, Canino, Sribney, & Alegria, 2007). In fact, one in three Latinx adolescent females has seriously considered suicide (Substance Abuse and Mental Health Services Administration, 2001). Given the association between depressive symptoms and suicidal behavior among Latinx female adolescents, it is important to identify not only the factors that increase the development of depression but also the direct causes of depression.

Triggers

The onset of psychological disorders is often associated with an event or stressor (Gupta & Gupta, 2012; Jones & Craddock, 2001). The known situations that lead to psychological distress are referred to as triggers, which are often very personal to the individual (Gupta & Gupta, 2012). Currently, the literature on triggers for depression is scarce, even more so among adolescent populations. It is important to identify triggers for disorders in order to tailor resources toward reducing risk. Research on posttraumatic stress disorder, for example, has shown that the identification of triggers has been helpful in treating individuals by creating healthy coping skills (Ehlers et al., 2010; Sharkansky, Brief, Peirce, Meehan, & Mannix, 1999; Toffolo, Smeets, & van den Hout, 2012).

Triggers for Depression

Given the high prevalence and limited research on the topic of depression among Latinx adolescent girls, a closer look at what triggers depression may reveal important factors to consider for prevention and treatment intervention development. One approach to increasing knowledge among Latinx girls is assessing for triggers that contribute to the onset of depression. The dearth of information on triggers for depression among the general population and the Latinx population is a major gap that this study aims to fill. The small number of studies assessing for triggers for depression all suggest that life stressors are directly related to the onset of depression (Maes et al., 2012; Monroe, Rohde, Seeley, & Lewinsohn, 1999; Twenge & Nolen-Hoeksema, 2002). Stressful life events, such as the end of romantic relationships (Monroe et al., 1999), exposure to suicide, and loss of loved ones (Maes et al., 2012), often trigger depression among older adolescent and young adult populations (Hammen, 2009; Proudfoot et al., 2012). Furthermore, social changes, including school transitions, may be a trigger for depression among girls (Twenge & Nolen-Hoeksema, 2002).

The primary aim of this study is to explore and report on the triggers that Latinx adolescent girls experience prior to the onset of depressive symptoms. The findings will be based on the girls’ perceptions and subjective experiences of what triggered their symptoms. In addition, this study intends to examine whether a specific type of trigger is more common with a greater number of depressive symptoms. This study is a secondary analysis from a larger study and, therefore, the findings are preliminary in nature.

Method

Overview

The data for the current study was gathered from a larger study examining cultural and psychological risk factors for major depression among Latinx adolescent girls (Barrera, 2005). The larger study included 43 adolescent high school girls of which 28 were included in this secondary analysis given that they endorsed major depressive episode diagnostic symptoms and associated triggers.

Participants were recruited from a high school during the 2003-2004 academic year through a one-page flyer that was added to mailed school registration packets. All 11th and 12th grade girls who self-identified as Latinx were eligible to participate in the study. Interviews with participants were conducted at two time points, at the beginning of the academic school year and again at the end of the academic year. Interviews at both time points were used to gather information regarding current and past social, cultural, and mental health factors that were related to an onset and/or recurrence of depressive episodes. Based on the previous academic year’s enrollment, a total of 194 eleventh and twelfth grade girls were eligible to participate. Of those, 89 indicated an interest in participating and 43 were included in the larger study given that they provided parental consent, child assent, and completed both the baseline and follow-up assessments.

The 28 participants included in this report were girls who when assessed for a MDE endorsed Criteria A and/or B and, therefore, were assessed for the remaining symptoms of the diagnosis. Of these, 25 endorsed criteria for a depressive episode at baseline (regardless of whether it met criteria for a MDE or a minor depressive episode) and three additional participants who met criteria at follow-up only (Figure 1).

Figure 1.

Flowchart showing the selection of the study sample from the parent study.

Participants

Participants included 28 eleventh and twelfth grade high school students who self-identified as Latinx. On average, they were 17.01 years (SD = 0.77) and 71% (n = 20) were in the 12th grade. All participants resided in an urban Western city of the United States and had lived in the United States for at least 8.95 years (SD = 5.28) with 61% reporting that they were first generation born in Mexico. Participants born in the United States were more acculturated than their Mexican-born peers (t(26) = 3.75, p = .01). Fifty-seven percent of the participants chose to complete all study materials in English.

Materials

Demographic questionnaire

A 10-item questionnaire was administered to the participants including those above the age of 18 years and their parents, which inquired about ethnicity, place of birth, years in the United States, and preferred language. The questionnaire also inquired about the parents’ marital status, level of education, and income.

Structured Clinical Interview for DSM-IV, research version (SCID)

The SCID (First, Spitzer, Gibbon, & Williams, 1997) is a semi-structured diagnostic instrument that is widely used to aid in the diagnosis of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) disorders. This instrument assesses for current and lifetime disorders based on DSM-IV diagnostic criteria (First et al., 1997). A qualitative description of the associated triggers is assessed for each coded depressive episode. The SCID has an interrater reliability of 0.89 among a diverse sample of late Latinx adolescent females (Daley, Hammen, Damila, & Burge, 1998).

Acculturation Rating Scale for Mexican Americans-II (ARSMA-II)

The ARSMA-II is used to assess acculturation among the Mexican American community (Cuéllar, Arnold, & Maldonado, 1995). Scale 1 of the ARSMA-II is composed of 13 Anglo-Oriented scale (AOS) items and 17 Mexican-Oriented scale (MOS) items. All items are scored on a 5-point Likert-type scale (i.e., 1 = not at all to 5 = extremely often or almost always) based on respondents’ frequency of engaging in certain behaviors. An acculturation score is achieved by subtracting the MOS from the AOS. Good internal consistencies for the MOS (0.88) and AOS (0.86) were found in a sample of Latinx college freshmen (Cuéllar & Roberts, 1997).

Procedure

Data analysis

Qualitative coding was used to categorize the reports of what triggered depressive symptoms. As described by Saldaña (2012), three qualitative coding methods include descriptive, magnitude, and in vivo coding. Descriptive coding is the process in which qualitative information is coded into a broad category, while magnitude coding provides additional information regarding the descriptive code, including the frequency and intensity of a broad category. In vivo coding is the use of the direct report/qualitative information of the participant and, in this study, in vivo coding is used to provide examples of each descriptive code included. Two bilingual individuals independently coded the participants’ reported triggers and achieved a consensus of a preliminary list of codes. After the list of preliminary codes were created, the two individuals assessed for reliability and consistency of coding prior to coming to a consensus over the final list of codes.

Quantitative analyses were conducted to assess whether differences in trigger frequency and type were present between U.S.- and Mexican-born girls. T tests were conducted to examine differences in acculturation (ARSMA-II) and the number of depressive symptoms (SCID) reported between U.S.- and Mexican-born girls.

Results

The 28 Latinx adolescents reported 75 total qualitative triggers, which were coded into nine different categories. The triggers reported are based on the Latinx adolescent girls’ perceptions of what they believed contributed to their depressive symptoms as measured by the SCID and, therefore, describe their subjective experiences. On average, between one and nine triggers were reported per depressive episode (major and minor) among the 28 girls. No significant differences were found in the number of depressive symptoms based on country of birth, t(26) = 0.45, p > .05.

Triggers

Family/parents

The most common code category was family/parents with a total of 15 (20%) separate triggers reported. Qualitative data in this category included difficulties between teens and their parents (e.g., “Problems with parents,” “Problems with mother”), parent, adolescent, or family member moving (e.g., “Uncle left to the marines,” “Parents moved,” “Left my home and family because of problems and now I live with my cousin”), or an illness inflicting a family member (e.g., “Grandparents are sick,” “Brother started to change because he is using drugs and I can’t help him”).

Romantic/friends

This category included a total of 14 (19%) separate qualitative triggers. The triggers were descriptive of social interactions such as their romantic relationships (e.g., “My first love and boyfriend for several years and we broke up several times,” “Separated from my daughter’s father”) and friendships (e.g., “Problems with friends”).

Expectations/pressures

Expectations/pressures included 13 (17%) of the total 75 triggers. Within this category, four subcodes were identified: expectations/pressures of the self, expectations/pressures of religion, expectations/pressures from parents, and expectations/pressures from school.

Expectations/pressures of the self

Expectations/pressures of the self were the most endorsed subcode with nine of the 13 codes. This subcode included adolescents’ disappointment with themselves (e.g., “Not doing what I was supposed to do. Disappointed in self and had to stay extra year,” “Feeling guilty and messed up because had a child at a young age”) and hopelessness or being unsure about the future (e.g., “Hopelessness about the future,” “Unsure about future”).

Expectations/pressures from parents

Two of the total 13 codes were reported by one adolescent and were related to themes of disappointing her parents (e.g., “Not good enough for parents,” “Parents say [I] am messed up”).

Expectations/pressures of religion and Expectations/pressures from school

One adolescent reported a trigger of expectations/pressures of religion (e.g., “Pressure from church; there is too much expectation”) and from school (e.g., “School, the pressure for college and scholarships”).

Death

Nine (12%) of the 75 triggers were related to a theme of death of a friend (e.g., “Close friend died”), family (e.g., cousin, sibling, and grandparents), or during pregnancy (e.g., “Pregnant and lost baby”).

General triggers

Adolescents also reported a number of different triggers, including school/academic, health, general external events, and employment. School/academic triggers were reported 4 times (5%; for example, “College applications,” Got kicked out of school for ditching and not understanding,” “Study,” “Stressed [because of] GPA”) as did triggers associated with their health (5%; for example, “Car accident that caused a lot of pain and being inside,” “Physical body break,” “No sleep,” “Hit by a car and in a coma”). Adolescents also reported external events triggering their depression, including transitions (e.g., “Went to Mexico for the summer and didn’t want to come back to the United States,” “When arrived from Mexico”), school (e.g., “Car accident caused me to get kicked out of school because I was unable to catch up”), and threats (e.g., “Almost raped and stayed in room”). One adolescent reported lack of employment as a trigger for depression (e.g., “No job”).

Nonspecific

A total of 13 (17%) of the 75 triggers were categorized as nonspecific given adolescents’ responses including “I don’t know,” “Nothing,” and not being able to verbalize the specific trigger to their depressive symptoms (e.g., “Problems with everything in life,” “A lot of things happened”).

Trigger Amount and Type Based on Country of Birth

Trigger amount

An examination of the number of triggers reported per major or minor depression episode assessed between U.S.-born and Mexican-born adolescents revealed that a majority of the Mexican-born participants endorsed only one trigger per episode (29% vs. 4% U.S.-born). In contrast, a majority of the U.S.-born participants identified three or more triggers per episode (21% vs. 14% Mexican-born; see Table 1).

Table 1.

Trigger Amount Endorsed Between U.S.-Born and Mexican-Born Participants.

Trigger(s) per episode	U.S.-born (n = 11)	Mexican-born (n = 17)
One trigger	4% (n = 1)	29% (n = 8)
Two triggers	14% (n = 4)	18% (n = 5)
Three or more triggers	21% (n = 6)	14% (n = 4)

Trigger type

No statistical differences were found based on country of birth in the types of triggers that were endorsed (Table 2).

Table 2.

Trigger Type Endorsed Between U.S.-Born and Mexican-Born Participants.

Trigger types	U.S.-born (n = 11)	Mexican born (n = 17)
Family/parents	25% (n = 7)	21% (n = 6)
Romantic/friends	11% (n = 3)	25% (n = 7)
Expectations/pressures	11% (n = 3)	14% (n = 4)
Death	7% (n = 2)	14% (n = 4)
General triggers	14% (n = 4)	21% (n = 6)
Nonspecific	18% (n = 5)	7% (n = 2)

Discussion

Among the Latinx adolescent girls in this study, a number of different triggers were reported, including issues involving their relationships (familial and romantic), loss of a loved one (i.e., death of family member or close friend), expectations and pressures from themselves and others, life stressors (i.e., employment, school, health, and external events), and nonspecific triggers. Maes and colleagues (2012) reported that stressful life events, including the end of romantic relationships and loss of loved ones, were triggers for depression among adolescents and young adults. However, their report that exposure to suicide was a trigger for depression was not present in these findings as no adolescent girl from this sample reported suicide of others or themselves. In addition, our finding that transitions precede depressive symptoms is congruent with Twenge and Nolen-Hoeksema’s (2002) report. In general, findings from this study strengthen and match previous reports of what triggers depression; however, other triggers such as expectations/pressures were also found.

Although many factors may play a role in major and minor depression, this study aimed to look at what adolescent Latinx girls perceived their triggers to be, which is their subjective experiences rather than external reasons based on the perception of others or the relationship between their depression and other factors (e.g., stress) as measured previously in the literature. As an example, one participant reported, “Separated from my daughter’s father” as the trigger of her depression. It is possible that being pregnant while in high school and, subsequently, becoming a teen mother are significant causes and stressors for developing depression (Lanzi, Bert, Jacobs, & Center for the Prevention of Child Neglect, 2009), both situations are directly related to her relationship with the father of her child. As such, we can only infer that being separated from her baby’s father is the cause of her distress as opposed to being pregnant as an adolescent or becoming a teen mother, life events may not have been negative for this adolescent. Therefore, the current findings can be used as preliminary information for future studies that aim to more closely examine and decipher the specific triggers for Latinx adolescents’ symptoms of depression.

Despite the fact that very little is known about what triggers depression among the Latinx community, based on the results of this study, it is recommended that further inquiry be focused on the parent/family-child relationship. Given the Latinx value of familismo, the strong bond that exists between family members (Ayón, Marsiglia, & Bermudez-Parsai, 2010), it would be beneficial to assess whether this cultural value influences or mediates what triggers depression among this community. Our findings show that the most common trigger was issues related to the family and parents. Some of these triggers indicate family dysfunction, whether it was past (“Left family and home because of problems . . .”) or present (“Feels no support from parents”). Given that familismo and seeking support from family members is most often useful when the family is functional, it would be beneficial to focus on the impact of familial ties on depression in Latinx adolescents. Previous research has found that familismo is associated with lower conflict in the parent-child relationship (Smokowski & Bacallao, 2006), which then may also be related to fewer triggers that lead to the onset of depressive episodes. Examining whether familismo influences depressive symptoms among Latinx adolescents may help improve parent/family-child interventions by focusing on parenting when tailoring depression interventions among this population.

Of the girls in this study, those who reported a higher number of triggers often reported a greater number of depressive symptoms (not always meeting MDE criteria). This finding suggests that there is a possible relationship between the number of triggers an individual reports and the number of symptoms experienced, which can then lead to a more serious case of depression (i.e., MDE diagnosis). In addition, it does not appear that a specific category of triggers was more common among those that reported a greater number of MDEs. Given the small sample size of this study, we were unable to conduct these analyses. Thus, future studies should examine the positive relationship between the number of triggers reported and the number of MDEs and whether a certain trigger type is more highly correlated with an MDE or whether there is a tipping point for increasing the risk of the incidence or recurrence of MDE.

Further analyses were conducted to examine whether differences between the adolescent girls born in the United States and those born in Mexico were present. Our analyses showed that those born in the United States reported higher acculturation levels, which is not surprising. However, no differences were found in the number of depressive symptoms reported within the episodes assessed, which is inconsistent with previous research suggesting that higher acculturation is associated with more severe mental health concerns (Escobar, Nervi, & Gara, 2000).

An examination of the amount of triggers reported based on country of birth indicated that those born in the United States tended to report a higher number of total triggers per depression episode assessed. On the contrary, among the girls that were born in Mexico, those that reported one trigger and those that reported two or more triggers was almost equal. This finding raises the question regarding how place of birth impacts the number of triggers that precede the onset of depressive symptoms. In addition, differences between the types of triggers reported by the U.S.-born and the Mexican-born girls were unremarkable. Continuing to examine differences between youth born in the United States and those born in other Latin American countries, extending farther than Mexico, is therefore needed.

Several limitations need to be considered in light of the findings of this study. Given that this study is based on secondary analysis of data collected in 2003-2004 from a small sample of girls, the findings may not be reflective of current triggers for Latinx adolescent girls. Furthermore, the parent study did not directly press participants for triggers, therefore, it is possible that the girls simply did not want to state a specific event that preceded their depressive symptoms. Future studies should aim to include a greater and more diverse sample of Latinx youth, including a wider age range and adolescents from other Latinx origins given that a majority of the girls in this study were of Mexican origin and all were either in the 11th or 12th grade of high school.

The current study is one of the few studies examining triggers for major depression among the Latinx community. In identifying triggers for depression among this at-risk population, clinicians may be better informed of the risk factors for depression and better prepared to identify a cause for an individual’s depressive symptoms, which would inform treatment. Examining triggers adds to the limited literature on the subjective causes of depression among Latinx youth with the long-term goal of informing the focus of prevention and treatment interventions tailored for this population. Considering that adolescents are a vulnerable population for the first onset of depression (Clarke et al., 2001), it is exceedingly beneficial to have this knowledge available to inform their care.

Footnotes

Acknowledgements

This study would not have been possible without the guidance and mentorship of W. Edward Craighead, PhD, and the late Elisa Facio, PhD. Dr. Barrera is appreciative of the support provided by school administrators and the girls who shared their lived experiences.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Reyna Rodriguez received a BA in psychology and Spanish Studies from the University of California, Santa Cruz, in 2015. Her research interests include reducing mental health disparities among the Latinx community, while also improving resources for depression among Latinx youth and their families. She aspires to become a culturally humble clinician that can provide services in both English and Spanish to the Latinx community.

Izbieta Rocha received a BS in psychology and social action from Palo Alto University. Her research interest is focused on mental health in the Latinx community. She is part of the Palo Alto University Diversity and Community Mental Health area of emphasis and she aspires to work closely with the community to provide and develop mental health services.

Alinne Z. Barrera completed her undergraduate degree at the University of California, Berkeley, and her PhD degree at the University of Colorado, Boulder. She is a bilingual/bicultural California licensed clinical psychologist, and an associate professor and Associate Director of Clinical Training. Her clinical and research areas of interest are broadly focused on expanding mental health services to Latinx and Spanish-speaking women.

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