Disentangling between-person and within-person associations of physical symptoms of depression with self-perceived health and life satisfaction: A longitudinal study in Chilean adults

Abstract

Depression is a major health problem in Chile. Evidence suggests that physical symptoms of depression (PSD) negatively impact self-perceived health and life satisfaction. The aim of this study was to determine the between-person and within-person associations of PSD with self-perceived health and life satisfaction in Chilean adults. The sample consisted of 1424 participants (64.54% female; M_age = 46.77, SD = 14.88) with data in five waves of the Social Longitudinal Study of Chile. Variables were measured through self-report questionnaires. Hypotheses were tested using multilevel analysis. At the within-person level, physical slowing, fatigue, and sleep problems were associated with poorer self-perceived health and lower life satisfaction. At the between-person level, physical slowing and fatigue were associated with poorer perceived health and lower life satisfaction. PSD are associated with self-perceived health and life satisfaction in Chilean adults longitudinally. The study highlights the importance of monitoring PSD changes in Chilean adults.

Keywords

depression life satisfaction physical symptoms of depression self-perceived health

Introduction

Depression is a major contributor to the global disease burden (Vos et al., 2020), responsible for 49.4 million disability-adjusted life years (Santomauro et al., 2021). During the COVID-19 pandemic, depression prevalence increased by 25% (World Health Organization, 2022). In Chile, depression is a serious public health problem that disproportionately affects women and people of low socioeconomic status (Markkula et al., 2017). As of 2016, 15.8% of the Chilean population had suspected depression, yet only 18.7% of those diagnosed received treatment (Ministerio de Salud, 2018). Moreover, 19.3% of Chilean adults have moderate or severe depressive symptoms, and 14.2% report suicidal ideation (Jiménez-Molina et al., 2021). Chile’s suicide rate of eight per 100,000 inhabitants ranks 10th out of 33 countries in the Americas (Organizacion Panamericana de la Salud, 2023). During the COVID-19 pandemic in 2020, 241,000 new cases of depression were diagnosed in Chile equivalent to an increase of 40.6% compared to 2019 (Celis-Morales and Nazar, 2022). This is concerning, because depression is associated with negative health outcomes, such as cardiovascular risk (Bucciarelli et al., 2020), poor quality of life (Ribeiro et al., 2020), and lower subjective well-being (Hou et al., 2020).

Physical symptoms like fatigue, appetite changes, sleep disturbances, and physical slowing are involved in depressive symptomatology (Iob et al., 2020). Like the symptoms of other pathologies, the physical symptoms of depression (PSD) are conceptualized as situational stimuli that inform deviations from normal functioning, which can activate cognitive representations of illness (Hagger and Orbell, 2022). These symptoms may vary in intensity, duration, and discomfort, and can occur individually, simultaneously, or sequentially (Savelieva et al., 2021). Previous studies suggest that PSD negatively affect self-perceived health (Hirsch et al., 2022; Ohtsuki et al., 2021) and life satisfaction (Abiddine et al., 2022; Fan and Smith, 2018). This is important because self-perceived health predicts morbidity (Wang et al., 2020) and mortality (Dramé et al., 2023), while life satisfaction is an indicator of psychological well-being related to positive outcomes such as happiness (Lara et al., 2020), self-esteem (Szcześniak et al., 2021), and adaptive coping strategies (Gori et al., 2020). Although there have been reports of high levels of PSD in Chilean adults (Durán-Agüero et al., 2019; Herrera et al., 2021), evidence of its association with self-perceived health and life satisfaction in this population is limited.

The potential effects of PSD on self-perceived health and life satisfaction can be understood through the perspective of the Theory of Unpleasant Symptoms (Lenz et al., 1995). According to this model, experiencing unpleasant symptoms reduces the individual’s performance in terms of functional activity related to activities of daily living, interaction with others or domains such as work, and also cognitive activity involved in problem solving or concentration (Lee et al., 2017). This is consistent with the literature on the consequences of PSD (Fan et al., 2023; Hamilton et al., 2023; Zuraikat et al., 2020). In this way, the experience of functional performance impairment can change an individual’s psychological state. With regard to this view, evidence shows that reductions in functional and cognitive performance are systematically associated with lower self-perceived health (Caramenti and Castiglioni, 2022) and life satisfaction (Hastaoglu and Mollaoglu, 2022; Kim et al., 2020; Smith and Konik, 2022).

Most of the research on the link of PSD to self-perceived health and life satisfaction often relies on cross-sectional data and between-person relationships (Abiddine et al., 2022; Ahorsu et al., 2020; Aslani et al., 2019; Fan and Smith, 2018). That is the extent to which people who report high levels of PSD, compared to others with low levels, have lower self-perceived health and life satisfaction scores at a particular time point. However, PSD may fluctuate significantly over time (Powell et al., 2017; van Eeden et al., 2019). Thus, when individuals experience more PSD than usual, they may tend to report worse self-perceived health and less life satisfaction. This reflects a within-person relationship between these variables, consistent with the dynamic nature of PSD and the Theory of Unpleasant Symptoms (Lee et al., 2017). In support of this hypothesis, prior research has found within-person relationships of depressive symptoms with cognitive performance (Laukka et al., 2018; Zainal and Newman, 2021) and different health outcomes (Marrie et al., 2021; Paolillo et al., 2020), which are relevant to explain life satisfaction and self-perceived health.

Few studies have examined the within-person relationships of PSD with self-perceived health and life satisfaction. A reason for this gap may be the fact that self-perceived health and life satisfaction are considered relatively stable constructs (Doornenbal and Bakx, 2021; van de Weijer et al., 2022). However, there is evidence that these variables can change. Approximately 40% of self-perceived health scores in adults change within a month (Zajacova and Dowd, 2011). Likewise, in a study with older adults, it was observed that 34% of the variability in self-perceived health across 5 years corresponded to within-person changes (Arnberg et al., 2016). Moreover, Lysberg et al. (2021) found that 70% of Norwegian adults showed fluctuations in life satisfaction over time. Thus, it is important to consider self-perceived health and life satisfaction as constructs that can vary both between individuals and within individuals. The distinction between the two types of variability is also relevant, as it allows the design of personalized interventions to promote subjective well-being and may be necessary to assess their effectiveness.

From a methodological perspective, it is important to differentiate between-person and within-person associations that PSD may have with self-perceived health and life satisfaction, because the meaning of both relationships is different (Howard, 2015). Also, between-person and within-person associations can be statistically independent, that is, they may differ in magnitude and direction (Rohrer and Murayama, 2023). Failure to differentiate both types of associations, as occurs in cross-sectional data, can bias results and lead to inappropriate conclusions (Hoffman, 2014).

Therefore, the aim of this study was to determine the between-person and within-person associations of PSD with self-perceived health and life satisfaction in Chilean adults. It is hypothesized that (H1) at the within-person level, higher than usual levels of PSD will be related to poor self-perceived health and lower life satisfaction on that occasion; and (H2) at the between-person level, individuals with higher levels of PSD will show poor self-perceived health and lower life satisfaction.

Methods

Sample

Secondary data from the Longitudinal Social Study of Chile (Estudio Longitudinal Social de Chile, ELSOC) conducted by the Center for the Study of Conflict and Social Cohesion (Centro de Estudios de Conflicto y Cohesión Social, 2022) were analyzed. ELSOC is an annual panel survey representative of the Chilean adult population residing in urban areas oriented to the temporal analysis of conflict and social cohesion. It measures domains like well-being, socioeconomic indicators, social networks, attitudes, and political behaviors. The sampling design is probabilistic, stratified, clustered and multistage. To date, the survey has five waves covering 2016, 2017, 2018, 2019, and 2021. Two thousand, nine hundred twenty-seven participants (n = 2927) were enrolled in the first wave, and 1513 (n = 1513) were measured in all waves. Cases with invalid responses (“Don’t know” or “No response”) on the variables of interest were removed from the database (n = 237), yielding an analytical sample of 1424 cases (n = 1424) with complete data on the variables analyzed.

Measures

Self-perceived health

It was measured through a single item (“You would say your health is. . .”) with a five-point response scale ranging from 0 (“Poor”) to 4 (“Excellent”). Higher scores on this item reflect higher levels of self-perceived health.

Life satisfaction

It was measured with a single question (“How satisfied or dissatisfied are you with your life at the moment?”) with a five-point response scale ranging from 0 (“Completely dissatisfied”) to 4 (“Completely satisfied”). Higher scores on this item indicate higher levels of life satisfaction.

Physical symptoms of depression (PSD)

Four self-report items were used from an adapted version of the Patient Health Questionnaire 9 (PHQ-9; Kroenke et al., 2001) that measured the frequency of sleep problems (“Difficulty falling asleep, sleeping through the night, or oversleeping”), fatigue (“Tiredness or feeling a lack of energy”), appetite changes (“Decreased or increased appetite”), and physical slowing (“Your movements and body language have been so slowed that they have been noticed by others”) in the past 2 weeks. The items had a five-point response format (0 = “Never”, 4 = “Every day”). The PHQ-9 has shown evidence of validity and reliability in adult Chilean population (Baader et al., 2012). The PSD items presented acceptable internal consistency (standardized Cronbach’s α) at each time point: 0.761, 0.799, 0.796, 0.803 and 0.703, respectively.

Covariates

Time in the study, sex (0 = “Male”, 1 = “Female”), age in years, educational level (0 = “No education”, 9 = “Graduate studies”), and current depression treatment (0 = “Yes”, 1 = “No”) were considered. Demographic and depression treatment covariates were baseline variables.

Ethical statement

All procedures were approved by the ethics committee of the sponsoring university, which is ascribed to the Declaration of Helsinki.

Procedures

The procedures involved in the implementation of ELSOC are described below. Participants were invited to participate through home visits. During the first four waves (2016–2019) the survey was administered through interviews assisted with electronic devices. Trained research assistants conducted the interviews. However, in the fifth wave (2021) the application was conducted remotely via telephone. Participants signed an informed consent form emphasizing the confidentiality of the information provided. The average duration of each interview was 55 minutes in 2016. Participants were rewarded with gift cards in each wave that had a value of 6000 CLP (≈9.30 USD) between 2016 and 2019, and 9000 CLP (≈11.85 USD) in 2021. Additional details can be found in the study’s methodological manual (Centro de Estudios de Conflicto y Cohesión Social, 2021).

To access the survey data, the open access link available on the website of the Center for the Study of Conflict and Social Cohesion (https://dataverse.harvard.edu/dataverse/elsoc) was used.

Statistical analysis

In participants enrolled from the first wave, the non-significant result of Little’s MCAR test [χ² (2.082) = 2.169, p = 0.089] indicated that the missing data in PSD, life satisfaction, and self-perceived health throughout the study was completely at random.

Given that the outcome measures and predictors of interest are nested within individuals, the hypotheses were tested using multilevel analyses. Time-varying and time-invariant versions of each PSD were created to separate their between-person and within-person effects (Curran and Bauer, 2011). Time-varying predictors (level 1) were defined as PSD scores centered on the person’s average, indicating person-specific deviations on one occasion from their own average. Time-invariant predictors (level 2) were the individual PSD averages centered on the grand mean of the sample. This allows for capturing variability in the usual PSD levels.

In the first step, intra-class correlation coefficients (ICC) were calculated with random intercept-only models to assess the relevance of decomposing the variance of the outcomes and PSD into between-person and within-person variability. In the second step, to evaluate the hypotheses, we ran base models constructed as:

\begin{array}{l} {H e a l t h}_{t i} \lor {S a t i s f a c t i o n}_{t i} = β_{0 i} + \\ β_{1 i} ({S l o w i n g}_{t i} - {S l o w i n g}_{i}) + \\ β_{2 i} ({F a t i g u e}_{t i} - {F a t i g u e}_{i}) + \\ β_{3 i} ({S l e e p}_{t i} - {S l e e p}_{i}) + \\ β_{4 i} ({A p p e t i t e}_{t i} - {A p p e t i t e}_{i}) + \\ β_{5 i} ({T i m e}_{t i}) + e_{t i} \end{array}

(1)

At level 1, self-perceived health and life satisfaction scores for person i at time t (Health_ti and Satisfaction_ti) are function of an individual-specific intercept (β_0i), slope parameters for the individual-specific coupling of PSD with self-perceived health and life satisfaction (β_1i–β_4i), and a residual error term (e_ti). In addition, the linear slope of time (β_5i) was included.

\begin{matrix} β_{0 i} = γ_{00} + γ_{01} ({S l o w i n g}_{i} - 0.45) \\ + γ_{02} (F a t i g u e_{i} - 1.14) + γ_{03} (S l e e p_{i} - 1.01) \\ + γ_{04} (A p p e t i t e_{i} - 0.87) + γ_{05} (S e x_{i}) \\ + γ_{06} (A g e_{i}) + γ_{07} (E d u c a t i o n_{i}) \\ + γ_{08} (T r e a t m e n t_{i}) + U_{0 i} \\ β_{1 i} = γ_{10} \\ β_{2 i} = γ_{20} \\ β_{3 i} = γ_{30} \\ β_{4 i} = γ_{40} \\ β_{5 i} = γ_{50} \end{matrix}

(2)

At level 2, person-specific intercepts are expressed as a function of a fixed intercept (γ₀₀), between-person effects of PSD (γ₀₁–γ₀₄), sex (γ₀₅), age (γ₀₆), education (γ₀₇), and depression treatment (γ₀₈), and person-specific residual deviations from the fixed intercept (U_0i). In the base models, within-person effects were treated as fixed effects at level 2. The numerical values in this equation correspond to the grand means used to center the between-person PSD.

In the third step, random effects were tested to examine whether the within-person effects of PSD differed across individuals. Significant random effects were retained based on likelihood ratio tests (LRT; Hoffman, 2014). An unstructured covariance matrix was used for random effects.

All analyses were run with R v.4.3.0 (R Core Team, 2023). For the multilevel models, the lmer function of the lme4 v.1.1-33 package was used, complemented with the lmerTest library, which delivers p-values obtained with the Satterthwaite approach (Hox et al., 2017). For the final models, pseudo-standardized regression coefficients were calculated using the effectsize package, which standardizes the outcomes and predictors at their respective levels of analysis. Model parameters were estimated using the maximum likelihood method. An alpha of 0.05 was used in all analyses.

Results

Table 1 displays the baseline characteristics of the analytical sample (n = 1424). The majority were women (64.54%) and employed (58.16%). Figure 1 indicates no significant systematic patterns of change in self-perceived health, life satisfaction, and PSD over time.

Table 1.

Descriptive statistics of the sample characteristics.

Variable	M (SD)
Sex, female (N; %)	919 (64.54)
Age	46.77 (14.88)
Education, completed high school (N; %)	430 (30.20)
Principal activity, paid work (N; %)	827 (58.16)
Marital status, married (N; %)	539 (37.93)
Monthly income (CLP)	469,602 (688,360)
Depression treatment, Yes (N; %)	299 (21.00)
Sleep problems	0.91 (1.12)
Fatigue	1.09 (1.08)
Appetite changes	0.82 (1.08)
Physical slowing	0.44 (0.86)
Self-perceived health	1.69 (0.86)
Life satisfaction	2.74 (0.85)

Source: Own elaboration.

M:Mean; SD: Standard deviation; N: Frequency; %: Percent; CLP: Chilean Pesos.

Figure 1.

Sample means of self-perceived health, life satisfaction, and physical symptoms of depression over time.

The ICCs for life satisfaction and PSD ranged from 0.219 to 0.307, suggesting that at least 69.3% of the total variance was due to variation around person averages, that is, within-person variability. Furthermore, 52.7% of the variance in self-perceived health was due to within-person variability (ICC = 0.473). This highlights the importance of analyzing the variance of the PSD to predict life satisfaction and self-perceived health.

The random effects of within-person sleep problems on self-perceived health [χ² (2) = 9.261, p = 0.010] and within-person fatigue on life satisfaction [χ² (2) =30.904, p < 0.001] were statistically significant, indicating that exists individual differences in these associations. These random effects were retained in the final model (Table 2).

Table 2.

Multilevel model results for the relationships of physical symptoms of depression with self-perceived health and life satisfaction.

Fixed effects	Self-perceived health				Life satisfaction
Fixed effects	B	β	SE	p	B	β	SE	p
Between-person
Intercept (γ₀₀)	1.949	0.00	0.076	<0.001	2.413	0.00	0.070	<0.001
Physical slowing (γ₀₁)	−0.123	−.10	0.036	<0.001	−0.156	−.19	0.033	<0.001
Fatigue (γ₀₂)	−0.275	−.32	0.032	<0.001	−0.174	−.29	0.030	<0.001
Sleep problems (γ₀₃)	−0.034	−.04	0.027	0.209	−0.053	−.10	0.025	0.032
Appetite changes (γ₀₄)	−0.100	−.11	0.030	<0.001	−0.022	−.04	0.027	0.421
Sex (γ₀₅)	−0.105	−.08	0.030	<0.001	0.064	0.07	0.028	0.021
Age (γ₀₆)	−0.011	−.27	0.001	<0.001	0.002	0.08	0.001	0.010
Education (γ₀₇)	0.059	0.21	0.007	<0.001	0.032	0.17	0.006	<0.001
Depression treatment (γ₀₈)	0.063	0.04	0.035	0.077	0.054	0.05	0.033	0.100
Within-person
Physical slowing (γ₁₀)	−0.055	−.06	0.013	<0.001	−0.039	−.03	0.015	0.009
Fatigue (γ₂₀)	−0.061	−.08	0.011	<0.001	−0.057	−.06	0.014	<0.001
Sleep problems (γ₃₀)	−0.028	−.04	0.011	0.009	−0.028	−.03	0.012	0.020
Appetite changes (γ₄₀)	−0.032	−.04	0.010	0.001	−0.017	−.02	0.012	0.140
Time (γ₅₀)	−0.009	−.02	0.005	0.093	0.042	0.08	0.006	<0.001
Random effects
Random intercept residual variance (τ²₀)	0.191				0.123
Random slope variance of fatigue (τ²₂)					0.025
Random slope variance of sleep problems (τ²₃)	0.009
Level-1 residual variance (σ_e²)	0.382				0.511

Source: Own elaboration.

B: Unstandardized regression coefficient; β: Pseudo-standardized regression coefficient; SE: Standard error.

Within-person associations of PSD with self-perceived health and Life Satisfaction

Significant within-person associations were found between all PSD and self-perceived health. Self-perceived health is worse on occasions where individuals report higher than usual levels of physical slowing (γ₁₀ = −0.055, β = −0.06, SE = 0.013, p < 0.001), fatigue (γ₂₀ = −0.061, β = −0.08, SE = 0.011, p < 0.001), sleep problems (γ₃₀ = −0.028, β = −0.04, SE = 0.011, p = 0.009), and appetite changes (γ₄₀ = −0.032, β = −0.04, SE = 0.010, p = 0.001). Except for appetite changes (γ₄₀ = −0.017, β = −0.02, SE = 0.012, p = 0.140), the other PSD also showed significant within-person associations with life satisfaction. Individuals report less life satisfaction on occasions where they exhibit higher than usual levels of physical slowing (γ₁₀ = −0.039, β = −0.03, SE = 0.015, p = 0.009), fatigue (γ₂₀ = −0.057, β = −0.06, SE = 0.014, p < 0.001), and sleep problems (γ₃₀ = −0.028, β = −0.03, SE = 0.012, p = 0.020). Additionally, the effect of time was not significant for self-perceived health (γ₅₀ = −0.009, β = −0.02, SE = 0.005, p = 0.093) but it was significant for life satisfaction (γ₅₀ = 0.042, β = 0.08, SE = 0.006, p < 0.001).

Between-person associations of PSD with self-perceived health and Life Satisfaction

Adjusting for sex, age, education, and depression treatment, negative and significant between-person associations of physical slowing (γ₀₁ = −0.123, β = −0.10, SE = 0.036, p = < 0.001), fatigue (γ₀₂ = −0.275, β = −0.32, SE = 0.032, p < 0.001), and appetite changes (γ₀₄ = −0.100, β = −0.11, SE = 0.030, p < 0.001) with self-perceived health were found. Individuals who experienced higher levels on average of physical slowing, fatigue, and appetite changes tended to report worse self-perceived health. However, sleep problems were not associated with self-perceived health at the between-person level (γ₀₃ = −0.034, β = −0.04, SE = 0.027, p = 0.209). On the other hand, after adjusting for covariates, the between-person relationships of physical slowing (γ₀₁ = −0.156, β = −0.19, SE = 0.033, p < 0.001), fatigue (γ₀₂ = −0.174, β = −0.29, SE = 0.030, p < 0.001), and sleep problems (γ₀₃ = −0.053, β = −0.10, SE = 0.025, p = 0.032) with life satisfaction were negative and significant. Life satisfaction was lower in individuals with higher levels of physical slowing, fatigue, and sleep problems. Individual means of appetite changes were not associated with life satisfaction (γ₀₄ = −0.022, β = −0.04, SE = 0.027, p = 0.421).

The models explained 49.9% and 28.6% of variance in self-perceived health (Conditional R² = 0.499) and life satisfaction (Conditional R² = 0.286), respectively.

Discussion

The aim of the present study was to determine the between-person and within-person associations of PSD with self-perceived health and life satisfaction in Chilean adults. The findings partially supported the hypotheses. Self-perceived health showed negative within-person associations with the four PSD examined, while life satisfaction had negative within-person associations specifically with three PSD: physical slowing, fatigue, and sleep problems. These results suggest that, on occasions when individuals experience higher than usual levels of physical slowing, fatigue, and sleep problems, they perceive worse health and lower life satisfaction, but more appetite changes than usual were only associated with worse self-perceived health. The results of the between-person associations indicated that individuals with high levels of physical slowing, fatigue, and appetite changes perceive worse health and that life satisfaction is lower in individuals with high levels of physical slowing, fatigue, and sleep problems. At the between-person level, sleep problems were not related to self-perceived health, and appetite changes were not associated with life satisfaction.

The results of this study are in line with previous research. PSD has been negatively related to self-perceived health and life satisfaction in cross-sectional studies (Abiddine et al., 2022; Ahorsu et al., 2020; Aslani et al., 2019; Fan and Smith, 2018). Longitudinal relationships between specific PSD and health-related outcomes have also been found. Stadtbaeumer et al. (2020) reported a within-person association between cancer-related fatigue and functional health in cancer survivors. Similarly, Lynch-Milder et al. (2023) found a bidirectional relationship over time between insomnia and pain in young people with chronic pain. Additionally, Bejarano and Cushing (2018) found a within-person association between appetite changes and starchy food consumption in adolescents.

Additionally, the findings illustrate the interaction between symptoms and psychological factors proposed by the Theory of Unpleasant Symptoms (Lenz et al., 1995). According to the evidence, multiple PSD may be reducing performance relative to functional and/or cognitive activity, so that the perception of this impairment could have a negative impact on life satisfaction (Hastaoglu and Mollaoglu, 2022; Kim et al., 2020; Smith and Konik, 2022) and self-perceived health (Caramenti and Castiglioni, 2022). However, the results further suggest that this process requires taking into account inter-individual and intra-individual variations to separate the stable and dynamic components of PSD. This is also important for understanding self-perceived health and life satisfaction, but challenges the idea of its stability (Doornenbal and Bakx, 2021; van de Weijer et al., 2022) and points to the need to predict its fluctuation over time, similar to other constructs in social science (Knowles and Olatunji, 2020). In line with this notion, the present research shows that experiencing sustained or transient PSD is differentially associated with well-being as measured by self-perceived health and life satisfaction. Therefore, it is advisable to review and expand the Theory of Unpleasant Symptoms by including both sources of variability.

An unexpected finding was the lack of between-person association of self-perceived health with sleep problems. Meta-analytic evidence supports that sleep disorders are associated with negative physical health outcomes (Wu et al., 2023). One explanation for this finding could be that people may have adapted to sleep problems subjectively (Banks and Dinges, 2007), which may not be linked to their overall perception of health. Likewise, one study found that objective measures of sleep duration were related to hypertension risk, while subjective ones were not (Bathgate et al., 2016). It is also possible that this result could be the product of particularities of the Chilean population that introduce unanticipated moderating variables. For example, it has been observed that a significant proportion of Chilean adults use anxiolytics (Oyarzun-Gonzalez et al., 2020) or sleep medications (Saldías et al., 2020), which could contribute to the management of sleep disturbances by mitigating their influence on self-perceived health. Similarly, appetite changes were not related to life satisfaction. This could respond to the fact that, unlike fatigue, sleep problems, or physical slowing, appetite changes by themselves might not significantly impact domains related to life satisfaction, such as meaning in life, daily functioning, performance, social involvement, or goal attainment.

Our findings have practical implications. The evaluation of PSD in Chilean adults should be systematic. Those with fatigue, appetite changes, physical slowing, and sleep problems may be at risk for chronic conditions (Wang et al., 2020), and less happiness (Lara et al., 2020). It is important to monitor PSD in this population and implement strategies to reduce it. Interventions should be used to address fluctuations in PSD in Chilean adults and provide real-time relief from symptoms. Ecological momentary interventions are a promising strategy for managing depressive symptomatology that contributes to this goal (Yim et al., 2020).

To our knowledge, this is the first study that distinguishes between-person and within-person relationships of PSD with self-perceived health and life satisfaction in Chilean adults, a population whose epidemiological profile is marked by high rates of depression. Similarly, the findings contribute to the understanding of a specific subgroup of depressive symptoms that may have unique effects on well-being using a longitudinal design. In contrast to previous literature, the results also show the dynamic nature of self-perceived health and life satisfaction. However, there are limitations that should be addressed. First, self-perceived health is a subjective indicator of physical health that does not inform which specific facet of health is impacted by PSD. Second, despite the use of longitudinal data, within-person associations are not sufficient to draw conclusions about the causal effects of PSD on self-perceived health and life satisfaction. Therefore, the results should not be interpreted as the direct influence of PSD on the outcomes examined. Third, the sleep problems item did not allow for a comprehensive assessment of sleep disorders. Fourth, objective indicators of physical health, such as body mass index or inflammatory markers, were not controlled for, which is problematic because of their potential influence on self-perceived health. Fifth, the Theory of Unpleasant Symptoms implicitly proposes a mediation hypothesis where symptoms may affect psychological variables through performance. This hypothesis was not tested in this study. Despite these limitations, the results of this study are valuable because they demonstrate that, regardless of sex, age, or education, there are between-person and within-person associations of PSD with self-perceived health and life satisfaction.

Future studies should consider objective biomarkers of physical health as outcomes or covariates and more comprehensive scales for the assessment of sleep disorders, to determine the specific effects of sleep disturbances on health and life satisfaction. At the same time, it is desirable to have experimental designs to examine whether the reduction of PSD through interventions can contribute to an improvement in self-perceived health and life satisfaction. In light of the Theory of Unpleasant Symptoms, it is advisable to test how functional and cognitive performance might mediate the within-person association of PSD with self-perceived health and life satisfaction. Finally, considering that experiencing PSD is a serious problem in the clinical population with a diagnosis of depressive disorder, a future line of research may be to establish its within-person and between-person associations with subjective well-being in this group.

The present study analyzed the within-person and between-person relationships of PSD with life satisfaction and self-perceived health in a sample of Chilean adults. Using multilevel analysis over a longitudinal panel design and controlling for demographic covariates, it was found that experiencing high or higher than usual levels of PSD differentially predicted these outcomes. These findings are relevant to understanding well-being at local and global scale, and have theoretical and practical implications for the management of PSD.

Footnotes

Data sharing statement

The data files from the current study are also available in the Harvard Dataverse repository at .

Declaration of conflicting interests

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

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Programa de Formación de Capital Humano Avanzado of the Agencia Nacional de Investigación y Desarrollo (ANID) through agreement 21200887 for National Doctorate in 2020, awarded to Dr. (c) Luis Mario Castellanos; agreement 21211377 for National Doctorate in 2021, awarded to Dr. (c) Mauro P. Olivera; and agreement 21210761 for National Doctorate in 2021, awarded to Dr. (c) Jorge Schleef. These funding sources or the Center for Studies of Conflict and Social Cohesion had no role in the conceptualization, results, and conclusions of this study.

Ethics approval

All procedures were approved by the Institutional Review Board of the sponsoring university, which is ascribed to the Declaration of Helsinki.

Informed consent

All participants gave informed consent prior to participation in this study.

ORCID iDs

Mauro P. Olivera

Manuel S. Ortiz

References

Abiddine

FZE

Aljaberi

Gadelrab

, et al. (2022) Mediated effects of insomnia in the association between problematic social media use and subjective well-being among university students during COVID-19 pandemic. Sleep Epidemiology 2: 100030.

Ahorsu

Lin

C-Y

Pakpour

(2020) The association between health status and insomnia, mental health, and preventive behaviors: The mediating role of fear of COVID-19. Gerontology and Geriatric Medicine 6: 1–9.

Arnberg

Lekander

Morey

, et al. (2016) Self-rated health and interleukin-6: Longitudinal relationships in older adults. Brain, Behavior, and Immunity 54: 226–232.

Aslani

Kattamis

Lyrakos

, et al. (2019) The effect of fatigue on self-perceived health in patients with hemoglobinopathies in a greek representative sample. Health Research Journal 5(1): 10.

Baader

M T

Molina

F JL

Venezian

B S

, et al. (2012) Validación y utilidad de la encuesta PHQ-9 (Patient Health Questionnaire) en el diagnóstico de depresión en pacientes usuarios de atención primaria en Chile. Revista Chilena de Neuro-Psiquiatria 50(1): 10–22.

Banks

Dinges

(2007) Behavioral and physiological consequences of sleep restriction. Journal of Clinical Sleep Medicine 3(5): 519–528.

Bathgate

Edinger

Wyatt

, et al. (2016) Objective but not subjective short sleep duration associated with increased risk for hypertension in individuals with insomnia. Sleep 39(5): 1037–1045.

Bejarano

Cushing

(2018) Dietary motivation and hedonic hunger predict palatable food consumption: An intensive longitudinal study of adolescents. Annals of Behavioral Medicine 52(9): 773–786.

Bucciarelli

Caterino

Bianco

, et al. (2020) Depression and cardiovascular disease: The deep blue sea of women’s heart. Trends in Cardiovascular Medicine 30(3): 170–176.

10.

Caramenti

Castiglioni

(2022) Determinants of Self-Perceived Health: The Importance of Physical Well-Being but Also of Mental Health and Cognitive Functioning. Behavioral Sciences (Basel, Switzerland) 12(12): 498.

11.

Celis-Morales

Nazar

(2022) Cambios en la prevalencia de depresión en Chile y el mundo debido a la pandemia por COVID-19. Revista Médica de Chile 150(5): 691–692.

12.

Centro de Estudios de Conflicto y Cohesión Social (2021) Manual de Usuario de Estudio Longitudinal Social de Chile. Santiago, Chile: Centro de Estudios de Conflicto y Cohesión Social (COES).

13.

Centro de Estudios de Conflicto y Cohesión Social (2022) Estudio Longitudinal Social de Chile, Versión Panel Combinada 2016-2019 (ELSOC_Wide_2016_2019_v1.00). [Archivo de datos]. Santiago, Chile: Centro de Estudios de Conflicto y Cohesión Social (COES).

14.

Curran

Bauer

(2011) The disaggregation of within-person and between-person effects in longitudinal models of change. Annual Review of Psychology 62(1): 583–619.

15.

Doornenbal

Bakx

(2021) Self-rated health trajectories: A dynamic time warp analysis. Preventive Medicine Reports 24: 101510. DOI: 10.1016/j.pmedr.2021.101510

16.

Dramé

Cantegrit

Godaert

(2023) Self-rated health as a predictor of mortality in older adults: A systematic review. International Journal of Environmental Research and Public Health 20(5): 3813. DOI: 10.3390/ijerph20053813

17.

Durán-Agüero

Sepulveda

Guerrero-Wyss

(2019) Sleep disorders and anthropometric measures in Chilean university students. Revista Española de Nutrición Humana y Dietética 23(3): 153–161.

18.

Fan

Lin

, et al. (2023) Effects of mindfulness and fatigue on emotional processing: An event-related potentials study. Frontiers in Behavioral Neuroscience 17: 1175067. DOI: 10.3389/fnbeh.2023.1175067

19.

Fan

Smith

(2018) The mediating effect of fatigue on work-life balance and positive well-being in railway staff. Open Journal of Social Sciences 6(6): 1–10.

20.

Gori

Topino

Di Fabio

(2020) The protective role of life satisfaction, coping strategies and defense mechanisms on perceived stress due to COVID-19 emergency: A chained mediation model. PLoS One 15(11): e0242402.

21.

Hagger

Orbell

(2022) The common sense model of illness self-regulation: A conceptual review and proposed extended model. Health Psychology Review 16(3): 347–377.

22.

Hamilton

Tsypes

Zelazny

, et al. (2023) Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults. Journal of Child Psychology and Psychiatry 64(1): 27–38.

23.

Hastaoglu

Mollaoglu

(2022) The effects of activities of daily living education on the independence and life satisfaction of elders. Perspectives in Psychiatric Care 58(4): 2978–2985.

24.

Herrera

Elgueta

Fernández

, et al. (2021) A longitudinal study monitoring the quality of life in a national cohort of older adults in Chile before and during the COVID-19 outbreak. BMC Geriatrics 21(1): 1–12. DOI: 10.1186/s12877-021-02110-3

25.

Hirsch

Stephens

Crane

(2022) Fatigue, depression, cardiovascular risk, and self-rated health: Comparing a community sample of adults to those with a history of myocardial infarction. Clinical Nursing Research 31(2): 174–182.

26.

Hoffman

(ed.) (2014) Longitudinal Analysis Modeling Within-Person Fluctuation and Change, 1st edn. New York: Routledge.

27.

Hou

Chen

, et al. (2020) Role of rs454214 in personality mediated depression and subjective well-being. Scientific Reports 10(1), 5702. DOI: 10.1038/s41598-020-62486-x

28.

Howard

(2015) Leveraging time-varying covariates to test within- and between-person effects and interactions in the multilevel linear model. Emerging Adulthood 3(6): 400–412.

29.

Hox

Moerbeek

van de Schoot

(eds) (2017) Multilevel Analysis: Techniques and Applications, 3rd edn. New York: Routledge.

30.

Iob

Kirschbaum

Steptoe

(2020) Persistent depressive symptoms, HPA-axis hyperactivity, and inflammation: The role of cognitive-affective and somatic symptoms. Molecular Psychiatry 25(5): 1130–1140.

31.

Jiménez-Molina Reyes

Rojas

(2021) Determinantes socioeconómicos y brechas de género de la sintomatología depresiva en Chile Socioeconomic determinants and gender gaps in depressive symptoms in Chile. Rev Med Chile. Available at: https://coes.cl/encuesta-panel/

32.

Kim

Choe

Lee

(2020) Depression, loneliness, social support, activities of daily living, and life satisfaction in older adults at high-risk of dementia. International Journal of Environmental Research and Public Health 17(24): 9448.

33.

Knowles

Olatunji

(2020) Specificity of trait anxiety in anxiety and depression: Meta-analysis of the state-Trait Anxiety Inventory. Clinical Psychology Review 82: 101928.

34.

Kroenke

Spitzer

Williams

(2001) The PHQ-9 validity of a brief depression severity measure. Journal of General Internal Medicine 16(9): 606–613.

35.

Lara

Vázquez

Ogallar

, et al. (2020) Psychosocial resources for hedonic balance, life satisfaction and happiness in the elderly: A path analysis. International Journal of Environmental Research and Public Health 17(16), 5684. DOI: 10.3390/ijerph17165684

36.

Laukka

Dykiert

Allerhand

, et al. (2018) Effects of between-person differences and within-person changes in symptoms of anxiety and depression on older age cognitive performance. Psychological Medicine 48(8): 1350–1358.

37.

Lee

Vincent

Finnegan

(2017) An analysis and evaluation of the theory of unpleasant symptoms. ANS. Advances in Nursing Science 40(1): E16–E39.

38.

Lenz

Suppe

Gift

, et al. (1995) Collaborative development of middle-range nursing theories: toward a theory of unpleasant symptoms. ANS. Advances in Nursing Science 17(3): 1–13.

39.

Lynch-Milder

McQuillan

Honaker

, et al. (2023) Concurrent and longitudinal associations among insomnia symptoms, internalizing problems, and chronic pain in youth. Health Psychology 42(1): 15–23.

40.

Lysberg

Bjerregaard Bertelsen

Lysberg

, et al. (2021) Change and stability: Within-person life satisfaction over a 20-year period using data from the HUNT survey. Scandinavian Journal of Public Health 49(8): 851–856.

41.

Markkula

Zitko

Peña

, et al. (2017) Prevalence, trends, correlates and treatment of depression in Chile in 2003 to 2010. Social Psychiatry and Psychiatric Epidemiology 52(4): 399–409.

42.

Marrie

R A

Graff

Fisk

, et al. (2021). The relationship between symptoms of depression and anxiety and disease activity in IBD over time. Inflammatory Bowel Diseases, 27(8), 1285–1293.

43.

Ministerio de Salud (2018) Primeros y segundos resultados de la Encuesta Nacional de Salud 2016-2017. Ministerio de salud de Chile. http://epi.minsal.cl/resultados-encuestas/

44.

Ohtsuki

Wakasugi

Narukawa

, et al. (2021) Are lifestyle factors significantly associated with self-rated health among Japanese female healthcare students? BMC Public Health 21(1): 505. DOI: 10.1186/s12889-021-10435-2

45.

Organización Panamericana de la Salud. (2023). Una nueva agenda para la salud mental en las Américas. Informe de la Comisión de Alto Nivel sobre Salud Mental y COVID-19 de la Organización Panamericana de la Salud. Washington, D.C.: OPS.

46.

Oyarzún-González

Ferreccio

Abner

, et al. (2020). Polypharmacy in a semirural community in Chile: Results from Maule Cohort. Pharmacoepidemiology and Drug Safety 29(3): 306–315.

47.

Paolillo

Pasipanodya

Moore

, et al. (2020) Cumulative burden of depression and neurocognitive decline among persons with HIV: A longitudinal study. Journal of Acquired Immune Deficiency Syndromes 84(3): 304–312.

48.

Powell

DJH

Liossi

Schlotz

, et al. (2017) Tracking daily fatigue fluctuations in multiple sclerosis: Ecological momentary assessment provides unique insights. Journal of Behavioral Medicine 40(5): 772–783.

49.

R Core Team (2023) R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.

50.

Ribeiro

Teixeira

Araújo

, et al. (2020) Anxiety, depression and quality of life in older adults: Trajectories of influence across age. International Journal of Environmental Research and Public Health 17(23), 9039. DOI: 10.3390/ijerph17239039

51.

Rohrer

Murayama

(2023) These are not the effects you are looking for: Causality and the within-/between-persons distinction in longitudinal data analysis. Advances in Methods and Practices in Psychological Science 6(1), 25152459221140842.

52.

Saldías

Brockmann

Santín

, et al. (2020) Estudio de prevalencia de síndrome de apneas obstructivas del sueño en la población adulta chilena. Subestudio de la Encuesta Nacional de Salud, 2016/17. Revista Médica de Chile 148(7): 895–905.

53.

Santomauro

Mantilla Herrera

Shadid

, et al. (2021) Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet 398(10312): 1700–1712.

54.

Savelieva

Komulainen

Elovainio

, et al. (2021). Longitudinal associations between specific symptoms of depression: Network analysis in a prospective cohort study. Journal of Affective Disorders, 278, 99–106.

55.

Smith

Konik

(2022) Who is satisfied with life? Personality, cognitive flexibility, and life satisfaction. Current Psychology 41: 9019–9026.

56.

Stadtbaeumer

Müller

Goergen

, et al. (2020) The interplay between cancer-related fatigue and functional health in Hodgkin lymphoma survivors. Health Psychology 39(10): 905–911.

57.

Szcześniak

Mazur

Rodzeń

, et al. (2021) Influence of life satisfaction on self-esteem among young adults: The mediating role of self-presentation. Psychology Research and Behavior Management 14: 1473–1482.

58.

van de Weijer

de Vries

Pelt

DHM

, et al. (2022) Self-rated health when population health is challenged by the COVID-19 pandemic; a longitudinal study. Social Science & Medicine 306, 115156.

59.

van Eeden

van Hemert

Carlier

IVE

, et al. (2019) Severity, course trajectory, and within-person variability of individual symptoms in patients with major depressive disorder. Acta Psychiatrica Scandinavica 139(2): 194–205.

60.

Vos

Lim

Abbafati

, et al. (2020) Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 396(10258): 1204–1222.

61.

Wang

Zhang

Wang

, et al. (2020) [Correlation between hypertension label and self-rated health in adult residents in China]. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi 41(3): 379–384.

62.

World Health Organization (2022, March 2) COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide. World Health Organization. https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide

63.

Zou

, et al. (2023) Insomnia and multiple health outcomes: Umbrella review of meta-analyses of prospective cohort studies. Public Health 215: 66–74.

64.

Yim

Lui

LMW

Lee

, et al. (2020) The utility of smartphone-based, ecological momentary assessment for depressive symptoms. Journal of Affective Disorders 274: 602–609.

65.

Zainal

Newman

(2021). Depression and executive functioning bidirectionally impair one another across 9 years: Evidence from within-person latent change and cross-lagged models. European Psychiatry: The Journal of the Association of European Psychiatrists, 64(1), e43.

66.

Zajacova

Dowd

(2011) Reliability of self-rated health in US Adults. American Journal of Epidemiology 174(8): 977–983.

67.

Zuraikat

Makarem

Liao

, et al. (2020) Measures of poor sleep quality are associated with higher energy intake and poor diet quality in a diverse sample of women from the Go red for women strategically focused research network. Journal of the American Heart Association 9(4), e014587.