Arch Womens Ment Health (2006) 9: 139150

DOI 10.1007/s00737-006-0121-4

Original contribution

Gender differences in associations between depressive symptoms

and patterns of substance use and risky sexual behavior among
a nationally representative sample of U.S. adolescents
M. W. Waller1, D. D. Hallfors1 , C. T. Halpern2 , B. J. Iritani1 , C. A. Ford3 , and G. Guo4
1
Pacific Institute for Research and Evaluation, Chapel Hill, NC, U.S.A.
2
Department of Maternal and Child Health, School of Public Health, University of North Carolina, Chapel Hill, NC, U.S.A.
3
Department of Pediatrics and Internal Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, U.S.A.
4
Department of Sociology, University of North Carolina, Chapel Hill, NC, U.S.A.

Received May 15, 2005; accepted February 4, 2006

Published online March 27, 2006 # Springer-Verlag 2006

Summary
Objective: This study uses a cluster analysis of adolescents, based
on their substance use and sexual risk behaviors, to 1) examine associa-
tions between risk behavior patterns and depressive symptoms, stratified
by gender, and 2) examine gender differences in risk for depression.
Methods: Data are from a nationally representative survey of over
20,000 U.S. adolescents. Logistic regression was used to examine the
associations between 16 risk behavior patterns and current depressive
symptoms by gender.
Results: Compared to abstention, involvement in common adolescent
risk behaviors (drinking, smoking, and sexual intercourse) was asso-
ciated with increased odds of depressive symptoms in both sexes. How-
ever, sex differences in depressive symptoms vary by risk behavior
pattern. There were no differences in odds for depressive symptoms
between abstaining male and female adolescents (OR 1.07, 95%
CI 0.701.62). There were also few sex differences in odds of depressive
symptoms within the highest-risk behavior profiles. Among adolescents
showing light and moderate risk behavior patterns, females experienced
significantly more depressive symptoms than males.
Conclusions: Adolescents who engage in risk behaviors are at
increased risk for depressive symptoms. Girls engaging in low and
moderate substance use and sexual activity experience more depressive
symptoms than boys with similar behavior. Screening for depression is
indicated for female adolescents engaging in even experimental risk
behaviors.
Keywords: Gender differences; risk behavior; depression; substance
use; sexual activity; cluster analysis.
Introduction
Depression and depressive disorders are common during
adolescence (Centers for Disease Control and Preven-
tion, 2002; Lewinsohn et al, 1998). Data from the 2003
Youth Risk Behavior Surveillance Survey (YRBSS)
indicate that 28.6% of students in the past year had felt
so sad or hopeless almost every day for two or more
weeks in a row that they stopped participating in their
usual activities (Centers for Disease Control and Preven-
tion, 2004). The burden of illness associated with de-
pression during adolescence is considerable. Poor school
attendance and performance, deterioration of relation-
ships with peers and family, other health and psychoso-
cial problems such as anxiety and oppositional-defiant
disorders, substance use, and sexual activity have all
been found to be associated with depressive disorders
in adolescence (Brooks et al, 2002; Feldman & Wilson,
1997; Fergusson & Lynskey, 1995; Lewinsohn et al,
1993, 1996).
Large sex differences in depressive symptoms and
disorders emerge after puberty. Girls are more likely
to be depressed than boys (Allison et al, 2001; Born
et al, 2002; Centers for Disease Control and Prevention,
2002; MacKay et al, 2000). The rate of depression
appears to increase in adolescent females as a function
of age while the rate of depression appears to decrease
over adolescence in males (U.S. Department of Health
and Human Services, 1996; Wade et al, 2002). This is
often attributed to the changes in hormones and societal
expectations and experiences that accompany the onset
140
of puberty and menarche in females (Born et al, 2002;
Ge et al, 2001).
Drawing on previous work by Angold and colleagues
(Angold et al, 2003) examining the link between adoles-
cent depression and puberty we suggest that the role of risk
behavior may affect this association in several ways.
Angold et al (2003), propose that because gender differ-
ences in the prevalence of depression emerge at puberty,
hormonal changes that occur in girls at puberty may
directly affect the CNS functions, in particular, the neuro-
chemical processes involved in depression. On the other
hand, it may also be that social contexts and interactions
change at puberty as a result of changing body morphol-
ogy, leading to changes in self-perception and reactions of
others to them, and ultimately leading to depression. We
suggest that in addition to the normal physical changes of
puberty, and the reactions of self and others to those
changes, risk behavior may play an important role. There
are significant changes in the brain during adolescence,
and there is growing interest in understanding how sub-
stance use, which targets dopaminergic systems, may
change brain structure and chemistry, and in turn, cog-
nition and emotionality (Berman et al, 2003; Chambers
et al, 2003; Esposito-Smythers & Spirito, 2004; Rao et al,
1999; Tarter, 2002; Townshend & Duka, 2005; Zeigler
et al, 2005). Furthermore, positive and negative experi-
ences, such as romantic and sexual interactions, can
change hormone production (e.g., cortisol, oxytocin),
which in turn could affect neural changes. In addition, both
substance use and sexual activity may alter a girls social
context, which could induce stress and=or change self-
perceptions, both of which could contribute to depression.
Adolescent depression has been linked to substance
use, including smoking and alcohol use (Brook et al,
1998; Brooks et al, 2002; Burge et al, 1995; Hallfors
et al, 2004) and sexual activity (Brooks et al, 2002; Burge
et al, 1995; Hallfors et al, 2004), all common behav-
iors during adolescence (Centers for Disease Control
and Prevention, 2002; Johnston et al, 2003). In 2001,
45.6% of all high school students reported having ever
been sexually active, 33.9% reported current cigarette or
other tobacco use, and nearly half (47.1%) had used
alcohol in the previous 30 days (Centers for Disease
Control and Prevention, 2002).
An important clinical consideration is whether certain
patterns of substance use and risky sexual behaviors are
differentially associated with depression and whether
these associations vary by gender. Previous research on
adolescent risk behaviors has shown that risk behaviors
tend to covary (Basen-Engquist et al, 1996; Brener &
M. W. Waller et al
Collins, 1998; Burge et al, 1995; Farrell et al, 1992;
Jessor, 1991; Lindberg et al, 2000; Neumark-Sztainer
et al, 1996; Shrier et al, 1997), although patterns of
covariation are differentially common among race, eth-
nic, and gender groups (Halpern et al, 2004).
Hallfors and colleagues (Hallfors et al, 2004) doc-
umented strong relationships between risk behavior
patterns and three mental health indicators: depressive
symptoms, suicidal ideation, and previous suicide at-
tempts. Compared to abstaining youth, who showed
little depressive symptomatology, youth with any involve-
ment in substance use and=or sexual activity were at
significantly increased odds of negative mental health
outcomes. Use of marijuana and other illegal drugs
was associated with especially high risk. They con-
cluded that experimental and normative levels of sub-
stance use and sexual risk behaviors were risk factors
for depression, suicidal ideation, and suicide attempt.
However, they did not compare the relative risk for
depression between males and females. Furthermore,
they did not examine if females who abstain from risk
behaviors are also at increased risk for depression com-
pared to males who abstain after controlling for other
risk factors.
Therefore, the intent of the present study is to exam-
ine cross-sectionally whether the relationship between
patterns of risk behavior and depressive symptoms dif-
fers by gender. Previous research examining gender dif-
ferences in depression and pubertal status in females
would indicate that, if puberty increases the risk for
depression among girls regardless of risk behavior in-
volvement, we should expect adolescent girls to exhibit
higher levels of depressive symptoms than adolescent
boys even among those abstaining from risk behavior
(Born et al, 2002; Wade et al, 2002). Therefore, abstain-
ing females would exhibit more depressive symptoma-
tology than abstaining males, and, similarly, females
who use marijuana would exhibit more depressive symp-
tomatology than males who use marijuana. Using data
from the National Longitudinal Study of Adolescent
Health (Add Health), this study answers the question:
To what extent are 16 adolescent risk behavior patterns
of substance use and risky sexual behaviors differen-
tially associated with depressive symptoms for males
and females, controlling for age, race, Hispanic ethnic-
ity, parental education, family structure, and pubertal
status for females? If risk behavior explains gender dif-
ferences beyond what pubertal status accounts for, then
gender differences in depression may be ameliorated
by the prevention of risk behavior involvement.
Gender differences in adolescent depression
Methods
Sample
Data used in these analyses are from the Wave I contractual data
set of Add Health, a nationally representative probability sample
of adolescents in grades 7 through 12 in the 19941995 school
year. More than 20,000 in-home interviews were completed
between April and December, 1995. (See Bearman et al (2003)
for additional details.) In-home questionnaires were adminis-
tered via laptop computers and utilized audio computer-assisted
self-interviewing (ACASI) technology to collect information on
sensitive topics such as sexual activity and substance use. A total
of 18,922 Wave I respondents had valid sample weights and
were used in these analyses.
Independent measures
Socio-demographic measures: Gender was reported by the
respondent. Chronological age was determined by subtracting
the date of birth from the date of the interview, rounded to the
year. Race was based on respondents self-report (Udry &
Hendrickson-Smith, 1999) and categorized for this study as
white, black, or other. Hispanic ethnicity was based on the
respondents self-report of whether they were of Hispanic origin
and was a dichotomous variable. We used two different mea-
sures as proxies for socioeconomic status (SES): highest paren-
tal education and family structure. Highest parental education
was based on the adolescents report of the highest education
level attained by the resident mother or father figure. Family
structure was based on household roster information (Harris,
1999) and grouped into the following categories: two resident
parents, single mother, and other (including single fathers).
Pubertal status for females was calculated as the number of
years since menarche. Menarche occurs relatively late in pu-
berty, so it does not necessarily capture between individual dif-
ferences in observable physical maturation. However, by using
years since menarche as our measure, we retain individual dif-
ferences in progression through the pubertal transition. We
expect that years since menarche will be positively associated
with depressive symptoms. Girls who have not yet experienced
menarche are coded as 0 years. An equivalent pubertal status
marker was not available for males, therefore, no pubertal status
measure was used in the male analyses.
Configurations of risk behavior patterns: Similar to factor
analysis, which groups variables together, cluster analysis
groups individuals, based on the assumption that risk behaviors
often occur together and interact with each other. By combining
individuals with similar behavior patterns, cluster analysis
allows for the possible interaction of all the variables (in the
present case, up to 11-way interactions), resulting in a more
parsimonious model and a more holistic way of considering
youth behavior (Bergman, 1998; Magnusson, 1998).
Four clusters were defined a priori based on the complete
absence of risk behavior (Abstainers), or engagement in highly
distinctive risk behaviors for HIV and other STDs [IV Drug
Users, Sex for Drugs or Money, and Males Who Have Sex with
Males (MSM)]. Since K-means analysis becomes unreliable
with extreme observations, these less common behaviors were
examined first. Next we used K-means cluster analysis to iden-
141
tify the modal risk patterns based on the following self-reported
risk behaviors: cigarette use, alcohol consumption, binge drink-
ing, marijuana use, other illicit drug use, sexual intercourse,
condom use, lifetime number of sexual partners, and engaging
in sex while under the influence of alcohol or drugs. We exam-
ined 4 to 16 cluster solutions, testing 1,000 starting seed values
for each solution, and stratified the sample by biological sex,
race, ethnicity, age, and grade. Each stratum revealed the same
cluster solutions. This stability was so strong as to warrant
combining the entire sample for the final clustering solution.
After the extensive exploration of the data, a 12-cluster solution
was chosen. Combined with the 4 a priori clusters, the final 16
clusters yielded an R-square of 0.76. (See Halpern et al (2004)
for further detail on the construction of clusters.)
Each respondent was assigned to only one risk profile. The
difference between Abstainers and Light Substance Users (Sub-
stance Experimenters) is especially important. Abstainers are
defined as never having engaged in any risk behavior. Substance
Experimenters, on the other hand, may not be currently engag-
ing in any risk behavior, but they reported having engaged in
light risk behavior (substance use only) at a prior point.
Dependent measure
Depressive symptoms were assessed using a modified version
of the Center for Epidemiologic Studies Depression Scale
(CES-D) (Radloff, 1977). Add Health used 18 of the original
20 CES-D items and 2 slightly modified items. Rather than treat
depressive symptomatology as a continuous variable, we chose a
cut point likely to represent clinically significant depression.
The CES-D recommends a cut-off of 16 for defining depression
in adults. However, based on previous work by Roberts et al
(1991) we chose to use a higher cut-off point of
22 for males
and
24 for females to maximize the sensitivity and specific-
ity for detecting depressive symptoms diagnostic of depression
in adolescents and to provide a conservative estimate of the
prevalence of depression in the sample. Respondents with
missing data on any of the 20 items were not included in anal-
yses (n 131).
Statistical analyses
We conducted logistic regressions testing the relationship be-
tween cluster membership and depressive symptoms separate-
ly for males and females to test within-gender relationships.
Dummy variables were entered for each risk profile category,
with the Abstainer profile serving as the reference category, and
race, Hispanic ethnicity, age, highest parental education, and
family structure included as control variables. Pubertal status
was also included for female analyses only, since no equivalent
measure existed for males. The Males who have Sex with Males
(MSM) profile was excluded as a predictor among females
because only males are eligible to be in this profile. Next, a
series of logistic regressions, conducted separately for each risk
behavior group, was run to test whether males and females
within each risk cluster differed in depressive symptomatology.
The same control variables were included. The logistic regres-
sions were conducted using Stata version 8.0. (StataCorp,
College Station, TX, 2003). Analyses incorporated sampling
142 M. W. Waller et al

weights to yield national population estimates. In addition, sur- Table 2 displays the 16 clusters with labels, descrip-
vey commands were used to adjust standard errors for survey tions, and numbers for males and females. For clarity,
design effects resulting from Add Healths complex sampling.
cluster names refer to the most modal behavior(s) with-
Missing data in the regressions were handled using listwise
deletion. in a cluster. For example, Smokers refers to indivi-
duals whose most common and frequent risk behavior
is smoking cigarettes. Sex Experimenters are char-
Results
acterized by having reported relatively few sex part-
Sample description ners compared to Multiple Partners, who report 14 or
more sex partners in their lifetimes. Almost 50% of the
Respondents were split almost evenly between males and
sample is in the Abstainer or Substance Experimenter
females (Table 1). Approximately 76% were white, 17%
profile, the two most common profiles, closely followed
black, and 7% other races. Approximately 12% were
by Sex Experimenters. As profiles become more ex-
Hispanic. Most of the sample (about 71%) was from a
treme in their defining behaviors, membership dimin-
two-parent-headed household, 20% were from a single-
ishes, indicating the increasing deviance of the profile.
mother-headed household, and 9% were from a single-
Table 3 displays the weighted percentages of male
father or other type of household. Approximately 13% of
and female respondents who report depressive symp-
respondents were from families whose highest parental
toms by risk behavior pattern. In general, the preva-
educational attainment was less than a high school edu-
lence of depressive symptoms increases as the risk
cation, 32% had parents with a high school education or
behavior pattern becomes more deviant. Furthermore,
the equivalent, 22% had parents with some college or
the prevalence of depressive symptoms is greater in all
professional school training, and 34% had parents with
patterns with any risk behavior compared with the
a college degree or higher. Just over 10% of the girls in the
Abstainer profile.
sample were premenarcheal. Approximately 10% of the
sample met our cutoff criteria on the CES-D for depres-
sion. Significant sex differences were found (analyses Association between risk profile and depression
not shown): 12% of females met our criteria for depres- within gender
sion based on CES-D scores compared to 8% of males Figure 1 provides the odds ratio for depressive symptom-
(p< 0.0001). atology from the logistic regression examining males
only and adjusting for sociodemographic characteristics.
Table 1. Sociodemographic and psychological characteristics of ana-
lytical sample (N 18,922)
Among male adolescents, most, but not all, risk profiles
were associated with greater likelihood of depression
Characteristic N Weighted % compared to Abstainers, after adjusting for sociodemo-
Sex graphic characteristics. Although patterns involving
Female 9640 49.11 greater substance use were associated with increased
Male 9282 50.89 odds of symptoms of depression, membership in the
Race Alcohol and Sex Experimenters subgroup was not asso-
White 12,429 76.13
Black 4247 16.66 ciated with increased odds of symptoms of depression.
Other 2248 7.21 Males in the Substance Experimenters and Multiple
Hispanic Ethnicity Partners profiles had marginally greater odds ratios of
Hispanic 3230 12.14 depressive symptoms. Odds of high depressive symptom-
Not Hispanic 15,635 87.86
atology are highest among male IV drug users, with
Parent Education
Less than high school 2344 12.63
such individuals being over 6 times as likely as male
High school graduate=GED 5274 32.18 Abstainers to score
22 on the CES-D.
Some college 3755 21.54 Figure 2 provides the odds ratios for depressive
College grad or higher 6402 33.65
symptomatology from the logistic regression examining
Family Structure
females only and adjusting for sociodemographic charac-
Two parents 13,130 70.51
Single mother 4061 20.40 teristics, including pubertal status. In contrast to males,
Other 1733 9.09 among females every risk behavior pattern is associated
Age (in years) median 16.3 with increased risk for depressive symptomatology com-
range 11.5621.38 pared to Abstainers. Light Substance Experimenters and
 Weighted percentages represent national population estimates of 7th- Drinkers have the lowest odds of symptoms of depres-
to 12th-grade youth. sion following Abstainers, yet are still about 2 times
Gender differences in adolescent depression 143

Table 2. Behavioral patterns defining clusters and weighted percents at wave I for those with valid sample weights (N 18,799)

Cluster name Patterns of sexual behavior Males Females

and substance use at wave I
N at wave I Weighted % N at wave I Weighted %

1) Abstainers never engaged in any ATODa use 1887 21.25 2405 25.63
 none have had sexual intercourse
2) Substance infrequent or no current ATOD use 2247 25.69 2312 24.70
experimenters  none have had sexual intercourse
 33% report drinking 12 days in past year
 5% report binge drinking 12 days in past year
3) Sex experimenters all have had sexual intercourse 1498 13.86 1654 14.72
 median number of partners 1
 90% do not smoke, 64% do not drink
 91% do not binge drink
 40% did not use a condom at last intercourse
4) Drinkers all report past-year alcohol use 639 7.08 764 7.88
 34% report drinking
23 days=month
 22% report
once=month binge drinking
 infrequent or no illegal drug use
 none report sexual intercourse
5) Binge drinkers all report binge drinking once a month 548 5.62 308 3.21
 17% are daily cigarette smokers
 89% drink
23 days a month
 60% binge
once a week
 45% have had sexual intercourse
 31% report marijuana use in past month
6) Smokers and sex all are daily cigarette smokers (>30 to 6001 498 5.85 611 7.34
cigarettes in past month)
 8% report drinking
23 days=month
 22% report marijuana use in past month
 94% report no other illegal drug use
 62% have had sexual intercourse
 22% did not use a condom at last intercourse
7) Alcohol and sex all report occasional alcohol use & all 475 4.73 593 5.90
have had sexual intercourse
 51% did not use condom at last intercourse
 52% drink
once=month; 38% binge

once=month
 26% used marijuana in past 30 days
 56% report >1 sex partner
8) Combination sex all have had sexual intercourse and all 303 3.37 299 3.39
and drug use report alcohol or illegal drug use at most
recent intercourse
 over 50% are moderate to heavy smokers
 62% drink
23 days a month
 51% binge drink
23 days a month
 44% have used marijuana in past 30 days
 48% did not use a condom at last intercourse
9) Heavy substance all report moderate to high levels of smoking, 280 3.50 261 3.03
use and sex drinking, and binge drinking
 99% are daily smokers
 81% drink
23 days a month
 7% binge drink
23 days a month
 45% use marijuana; few use other illegal drugs
 91% have had sexual intercourse
10) Marijuana users all use marijuana 14 times in past month; 208 2.10 106 1.23
few use other illegal drugs
 57% drink alcohol
23 days a month
 66% are daily smokers
 74% have had sexual intercourse
 32% did not use a condom at last intercourse

(continued)
144 M. W. Waller et al

Table 2 (continued)

Cluster name Patterns of sexual behavior Males Females

and substance use at wave I
N at wave I Weighted % N at wave I Weighted %

11) Multiple partners all report 14 or more sex partners 170 1.75 60 0.72
 31% are daily smokers
 41% drink
23 days a month; 28% binge

23 days a month
 35% report marijuana use in past month
 92% report no other illegal drug use
 10% report AODb use at last intercourse
 47% did not use a condom at last intercourse
12) Sex for drugs all report sex for drugs or money 131 1.57 64 0.63
or money  30% are daily smokers
 50% drink
23 days a month; 43%
binge
23 days a month
 37% have used marijuana in past month
 78% report no other illegal drug use
 64% report >1 sex partner
 38% report no condom use at last intercourse
 20% report AOD use at last intercourse
13) High marijuana all use marijuana 10 times in past month and 129 1.43 64 0.74
and sex all have had sexual intercourse
 79% are daily smokers
 78% drink
23 days a month; 63% binge

23 days a month
 92% report marijuana use
20 times in past month
 all report AOD use at last intercourse
 82% report >1 sex partner
14) MSM all are males who have had sex with other males 78 0.70 NA NA
 78% report >1 sex partner
 48% are daily smokers
 40% have used marijuana in last 30 days
 40% did not use a condom at last intercourse
 17% have had sex for drugs or money
15) Marijuana and most report heavy marijuana use and all report 64 0.72 43 0.53
other drug users other illegal drug use >5 times in past year
 81% used marijuana
20 times in past month
 71% have had sexual intercourse
 30% report drug use at last intercourse
 81% binge drink
23 days=month
16) IV Drug users all have injected drugs 64 0.76 36 0.36
 over 80% have had sexual intercourse
 48% report no condom use at last intercourse
 65% report >1 sex partner
 over 60% report regular marijuana and other
illegal drug use
 30% report having sex for drugs or money
Total 9219 100 9580 100
a
ATOD alcohol, tobacco, and other drugs.
b
AOD alcohol and other drugs.

as likely to experience symptoms as Abstainers. Sex
Experimenters are over 3 times as likely as Abstainers
to experience depressive symptoms. As with males, the
tendency is for risk of depressive symptoms generally to
increase as the behavioral risk profile becomes more
deviant, with some exceptions. We also examined the
possibility that years since menarche and chronological
age were confounds in our female model. As we ex-
pected, years since menarche was positively correlated
with chronological age in females (r 0.72), suggesting
collinearity between the two variables. To test this, we
ran the model for females first with age only, then
with years since menarche only, and finally with both
included, and the estimates did not change. Neither years
Gender differences in adolescent depression 145

Table 3. Weighted percents of depressive symptoms among males and females by risk behavior profile

Cluster name Males Females

Weighted % 95% CI Weighted % 95% CI

1) Abstainers 3.6 2.74.8 4.5 3.45.9

2) Substance 5.6 4.47.1 9.4 7.911.3
experimenters
3) Sex experimenters 8.8 6.911.2 15.1 12.617.9
4) Drinkers 8.8 6.212.4 9.8 7.313.0
5) Binge drinkers 10.4 7.514.2 19.9 14.726.3
6) Smokers and sex 10.1 7.313.9 20.2 16.524.2
7) Alcohol and sex 5.4 3.67.8 19.0 15.323.4
8) Combination sex 15.4 10.621.9 25.5 19.732.2
and drug use
9) Heavy substance 17.4 11.725.1 16.7 12.222.3
use and sex
10) Marijuana users 20.4 13.928.8 30.1 18.345.2
11) Multiple partners 12.3 6.621.9 22.0 11.138.9
12) Sex for drugs 15.3 9.723.1 38.1 23.355.5
or money
13) High marijuana 17.6 9.829.4 25.3 13.143.2
and sex
14) MSM 20.6 10.736.0
15) Marijuana and 15.9 6.633.7 40.0 22.260.9
other drug users
16) IV Drug users 22.8 11.739.8 42.6 24.463.2
Total 8.2 7.49.0 12.4 11.313.6

 CI confidence interval.

Fig. 1. Odds ratios of males reporting depressive symptoms by risk behavior profile compared to Abstainers. The model controls for the
following sociodemographics: age, race, Hispanic ethnicity, highest parental education, and family structure. significant .05; not
significant
146 M. W. Waller et al

Fig. 2. Odds ratios of females reporting depressive symptoms by risk behavior profile compared to Abstainers. The model controls for the following
sociodemographics: age, race, Hispanic ethnicity, highest parental education, family structure, and pubertal status. Significant .05; not
significant

Fig. 3. Odds ratios of reporting depressive symptoms among females compared to males within risk behavior patterns. The model controls for the
following sociodemographics: age, race, Hispanic ethnicity, highest parental education, and family structure. Significant .05; not significant
Gender differences in adolescent depression
since menarche nor chronological age was significantly
associated with depression in our female model.
Gender differences in depression within risk
behavior profiles
Figure 3 presents the odds ratios of reporting depressive
symptoms for females compared to males, stratified by
each risk behavior profile and controlling for all socio-
demographic variables previously mentioned, with the
exception of years since menarche. Of the 15 risk be-
havior profiles (MSM is not included), 9 show no sig-
nificant gender differences in depressive symptoms,
although for all clusters the odds ratios of reporting
depressive symptoms are higher among females. Abstai-
ners and Drinkers have the smallest gender differences,
with odds ratios close to 1.0. Most risk profile groups
showing significant gender differences in depressive
symptoms reflect primarily early experimental and mod-
erate risk behavior (e.g., Substance Experimenters, Sex
Experimenters, Smokers, Alcohol and Sex Experiment-
ers) rather than highly risky sexual activity or illegal
substance use.
Discussion
For both males and females, we found strong positive
associations between depressive symptoms and risk be-
havior patterns. For females, any risk activity, no matter
how common or how modest in degree, was associated
with increased risk of depressive symptomatology com-
pared to abstention. In contrast, for males some behavior
patterns that reflect primarily sexual activity and modest
alcohol use were not significantly associated with depres-
sive symptoms. Our analyses testing gender differences in
depressive symptoms among adolescents who show simi-
lar patterns of risk behavior (i.e., who are grouped within
the same risk behavior cluster) indicate that most deviant
risk behavior is similarly associated with symptoms of
depression for both males and females. However, more
common types of experimentation appear to have un-
favorable associations with mental health primarily for
females. Most importantly, abstention is associated with
similarly low risk for symptoms of depression in both
males and females, and male and female abstainers do
not differ in odds of depressive symptoms. Thus, in the
absence of other risk factors for depression (i.e., sex and
substance use), being female does not confer additional
independent risk, and at high levels of risk taking, being
female does not confer additional risk.
These findings suggest that for the majority of adoles-
cents, that is, those who experiment with substances and
147
sexual activity, risk taking contributes to the sex dispar-
ity in depressive symptoms. Therefore, risk behavior
involvement may be an alternative explanation for why
gender differences emerge at puberty. We can speculate
that girls at low levels of risk behavior are more vulner-
able to social influences and consequences than males,
or that girls are more sensitive to the effects of substance
use and therefore, there may be greater effect on=
damage to their CNS. Alternatively, at high levels of risk
behavior, the negative social consequences and self-
assessment may be similar for both girls and boys, and
the higher levels of drug use on the CNS is sufficient to
affect boys as well as girls. Clearly more research is
indicated.
Many professional organizations recommend that
adolescents be regularly screened for risk behaviors
(Elster, 1998; Stevens & Lyle, 1994). Our findings gen-
erally support this comprehensive screening strategy for
risk behaviors and highlight the importance of thor-
oughly screening for depressive symptomatology among
adolescents who match high-risk profiles. However, at
this time, the U.S. Preventative Services Task Force has
argued that there is insufficient evidence for screening
for depression among asymptomatic adolescents (U.S.
Preventive Services Task Force, 2002). We suggest that
the findings from this study indicate that substance use
and sexual activity should constitute symptoms for
depression and that those who screen positively for
involvement in experimental risk behavior should also
be screened for depression.
Limitations
Several limitations apply to our findings. First, our mea-
sure of pubertal status does not capture the timing and
pace of observable pubertal change in physical charac-
teristics. Thus we may underestimate the contribution of
this factor. Until recently, it was thought that puberty
was not associated with depression in males. However, a
recent study by Kaltiala-Heino and colleagues (Kaltiala-
Heino et al, 2003) found that very early and late de-
veloping males, categorized by date of first ejaculation,
or oigarche, are also at increased risk for depression.
Unfortunately, measures available in Add Health do
not allow us to examine pubertal timing effects on male
depression with the same type of objective marker of
timing.
Another potential limitation is our use of different
cutoff points for males and females on our measure of
depressive symptoms. The use of a higher cutoff point
for females (24 vs. 22) could be viewed as stacking the
deck in favor of not finding gender differences. We
148
deliberately chose the cutoff points based on the pre-
vious work by Roberts and colleagues (Roberts et al,
1991), which found that the different cutoff points were
best with respect to maximizing sensitivity and speci-
ficity for identifying DSM-III major depression and
dysthymia among 9th 12th grade adolescents. Among
adolescents, a score of 22 among females is not equal
to a score of 22 among males. Therefore, by using the
different cutoff points our intent was to equate males and
females on their likelihood of being diagnosed with
major depression or dysthymia.
In spite of the overall large sample in Add Health,
some of the specific risk profiles examined have sam-
ples that are quite modest. Therefore, some of the non-
significant results may be due to insufficient power or
small cell samples rather than an actual absence of a
difference in the population. These insufficient results
must be reexamined again when sufficient samples
become available. We would also caution against assum-
ing the non-significant results are not still meaningful
and informative.
Another limitation is that this is a cross-sectional
analysis, and therefore examines only association be-
tween risk behavior and depressive symptoms, without
considering their temporal order of onset which we
acknowledge is an important research question. Our
intent, in this paper, was to focus specifically on how
risk for depressive symptoms may differ for males and
females depending on their involvement in substance
use and sexual risk behaviors. Risk behavior involve-
ment at normative levels appears to have more delete-
rious effects on girls than on boys. However, other
studies examining Add Health data longitudinally have
found that risk behavior most often preceded depres-
sion among adolescents (Goodman & Capitman, 2000;
Hallfors et al, 2005). More research is still needed
examining temporal ordering of depression and risk
behaviors in adolescence.
Finally, we recognize that in this study we have not
controlled for all possible influences and associations
with depressive symptoms. Nor have we actually tested
the direct influence of pubertal hormones on depression in
girls. It is certainly possible that there is a third factor we
did not control for that could explain the strong links we
found between risk behavior and depressive symptoms
and the gender differences or lack thereof.
Conclusion
Our results reveal some of the complexities in the rela-
tionship between mental health, puberty, and patterns of
M. W. Waller et al
risk behavior among adolescents. While previous
research has demonstrated an association between sub-
stance use and depression, our inclusion of patterns of
drug and sexual risk behaviors creates a more complete
picture of those adolescents most at risk for depressive
symptoms, and provides further information for clini-
cians to consider as they screen, evaluate, and treat ado-
lescent patients. In addition, the close examination of
gender differences in risk for depressive symptom-
otology among similarly behaving adolescents reveals
the complexity of the relationship between gender and
depression. Adolescent girls appear particularly vul-
nerable at low levels of risk behavior involvement com-
pared to males, although both males and females are at
increased risk compared to abstainers. At high levels of
risk behavior involvement, girls and boys are at con-
siderable but potentially equal risk for depressive symp-
toms. The role of pubertal hormones in adolescent
female depression remains unclear. We did not conduct
a direct test of hormonal influences on depressive symp-
toms. However, at least among our abstainers, we did
not find that being female was associated with any
greater risk for depressive symptoms. Nor did we find
that years since menarche, controlling for chronological
age, was significantly associated with depressive symp-
toms among girls after including risk behavior involve-
ment. Therefore, future research needs to look not only
at biological explanations but also social and environ-
mental, and ideally, the interactions between biological,
social, and environmental factors. For example, puber-
tal hormones may play an important role in adoles-
cent depression by making girls more vulnerable to
deleterious effects of substance use, but in the absence
of substance use, this vulnerability is not manifested.
Finally, future research should also examine more close-
ly females in the low- and moderate-risk behavior
clusters, who are at greater risk for depressive symptoms
than males, and attempt to uncover the mechanisms that
might be affecting this difference.
Acknowledgments
This research was funded by the National Institute on Drug
Abuse through grant R01-DA14496 (Denise Hallfors, P.I.)
The research uses data from Add Health, a program project
designed by J. Richard Udry, Peter S. Bearman, and Kathleen
Mullan Harris, and funded by a grant P01-HD31921 from the
National Institute of Child Health and Human Development, with
cooperative funding from 17 other agencies. Special acknowl-
edgment is due Ronald R. Rindfuss and Barbara Entwisle for
assistance in the original design. Persons interested in obtaining
data files from Add Health should contact Add Health, Carolina
Gender differences in adolescent depression
Population Center, 123 W. Franklin Street, Chapel Hill, NC
27516-2524 (www.cpc.unc.edu=addhealth=contract.html).
We are grateful to Jan Hendrickson-Smith, MA, and J. Richard
Udry, PhD, for development of a comprehensive variable for
race, to Kathleen Mullan Harris, PhD, and Suzanne Ryan,
PhD, for development of a measure of family structure. We also
thank Abenah Vanderpuije for her work in producing tables and
checking references, Daniel Bauer for his statistical assistance
and feedback on the results and drafts of the article, and the Add
Health Users Group at the Carolina Population Center for their
feedback on the results.
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