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Cited by 63Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMental Health Research TopicsChild and Adolescent Psychosocial and Emotional Development

Experiential avoidance predicts persistence of major depressive disorder and generalized anxiety disorder in late adolescence

Open access
Mellick, William H., Mills, James A., Kroska, Emily B., Calarge, Chadi A., Sharp, Carla, Dindo, Lilian N.·2019·The Journal of Clinical Psychiatry
DOI 10.4088/jcp.18m12265PMC PMC6854672
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Abstract

Objective: Experiential avoidance (EA) is a transdiagnostic construct that may underlie the high comorbidity between major depressive disorder (MDD) and generalized anxiety disorder (GAD). This analysis used data from a longitudinal study (conducted September 2010-April 2016) to examine whether adolescent EA varies by MDD and GAD symptomatology trajectory and predicts said trajectories. Longitudinal associations between EA, anxiety, and depression symptoms were also examined. Methods: Adolescents aged 15 to 20 years (N = 183) were followed for 2 years using a comprehensive assessment battery. Symptom trajectory modeling, using weekly symptom ratings, identified 4 MDD and 4 GAD trajectories that were collapsed to form combined MDD/GAD trajectory groups: Persistent (n = 81), High-Decreasing (n = 44), Normal-Increasing (n = 37), and Minimal (n = 21). Group-based trajectory modeling, analyses of covariance, structural equation modeling, and linear regression analyses were performed. DSM-IV-TR criteria were used for MDD and GAD diagnoses. Results: The Persistent adolescents had higher EA than other groups (P values ≤.001), with greater EA stability versus High-Decreasing adolescents (P=.008). EA predicted anxiety and depressive symptoms alike (P values ≤.005), which in turn did not predict EA (P values ≥.188). EA, at both time points, predicted combined MDD/GAD trajectories after adjustment for depressive and anxiety symptoms and other confounders (P values <.001). Conclusions: EA appears to be an important predictor of MDD and GAD symptomatology in older adolescents, potentially serving as a treatment target. Findings suggest a possible trait-like nature for EA, perhaps increasing risk for the emergence and persistence of MDD and/or GAD. © 2019 Physicians Postgraduate Press, Inc.

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Crossref · 10.4088/jcp.18m12265

Cites

51 of 51 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 16 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Groups significantly differed in EA change between V1 and V2 (F(3,175)=4.23, p=0.006, η2=0.068), after adjusting for age, sex, cumulative SSRI exposure, and V1 EA.

    “Groups significantly differed in EA change between V1 and V2 (F (3, 175) = 4.23, p = 0.006, η2 = 0.068), after adjusting for age (p > 0.90), sex (p > 0.50), cumulative SSRI exposure (p > 0.40), and V1 EA (β = −0.469, p < 0.001, 95% confidence interval [CI] = −0.602 to −0.335).”
    Quote in the paperSubstantial claim
  • Findingown data

    A four-group trajectory model provided the best fit for both MDD and GAD across linear, quadratic, and cubic modeling.

    “A 4-group trajectory model offered the best fit for both MDD and GAD regardless of whether linear, quadratic, or cubic modeling was used (see supplementary figures A and B).”
    Quote in the paperSubstantial claim
  • Findingown data

    EA at both time points predicted combined MDD/GAD trajectories after adjusting for depressive and anxiety symptoms and other confounders (p < 0.001).

    “EA, at both time points, predicted combined MDD/GAD trajectories after adjusting for depressive and anxiety symptoms and other confounders (p-values < 0.001).”
    Quote in the paperSubstantial claim
  • Findingown data

    Anxiety and depressive symptoms did not predict EA (p ≥ 0.188).

    “EA predicted anxiety and depressive symptoms alike (p-values ≤ 0.005), which in turn did not predict EA (p-values ≥ 0.188).”
    Quote in the paperSubstantial claim
  • Findingown data

    The difference in EA change was driven by a significant difference between the High-Decreasing and Persistent groups (mean difference in Δ EA = 4.38, 95% CI = 0.815 to 7.950, p = 0.008).

    “Post-hoc analyses showed that the effect was driven by a significant difference in EA change between the High-Decreasing and the Persistent groups (Mean difference in Δ EA = 4.38, 95% CI = 0.815 to 7.950, p = 0.008).”
    Quote in the paperSubstantial claim
  • May combine two claims. 17
  • Classified as probably not a substantial claim. 22

  • May combine two claims.

    Findingown data

    EA, depression, and anxiety symptoms were significantly correlated at each of the two visits and across visits.

    “EA, depression, and anxiety symptoms were significantly correlated at each of the 2 visits when the EA was assessed, as well as across visits (Table 3).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    V2 analyses yielded similar results, with EA as the only significant symptom-level predictor of combined MDD/GAD trajectories.

    “V2 analyses yielded similar results with EA the only significant symptom-level predictor of combined MDD/GAD trajectories.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Participants were assigned to four combined MDD/GAD trajectory groups: Persistent (n=81), High-Decreasing (n=44), Normal-Increasing (n=37), and Minimal (n=21).

    “Symptom trajectory modeling, using weekly symptom ratings, identified 4 MDD and 4 GAD trajectories which were collapsed to form combined MDD/GAD trajectory groups: Persistent (n = 81), High-Decreasing (n = 44), Normal-Increasing (n = 37), and Minimal (n = 21).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In hierarchical regression, V1 EA, anxiety, and depressive symptoms predicted an additional 15% of outcome variance, with V1 EA as the only significant symptom-level predictor.

    “V1 EA, anxiety, and depressive symptoms were entered at step 2, predicting an additional 15% of outcome variance with V1 EA as the only significant symptom-level predictor.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    EA at V1 predicted V2 anxiety and depressive symptoms, and V1 EA was the only significant predictor of V2 EA.

    “EA at V1 predicted V2 anxiety and depressive symptoms, with V1 EA being the sole significant predictor of V2 EA.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Persistent adolescents reported significantly higher EA at both V1 and V2 than adolescents in other trajectory groups, who did not differ from one another (p ≥ 0.05).

    “With respect to EA, Persistent adolescents reported significantly greater symptoms at both V1 and V2 than adolescents in other trajectory groups, who did not differ from one another (p-values ≥ 0.05).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The AAQ-II has demonstrated good psychometrics in late-adolescent and young-adult samples.

    “The AAQ-II has demonstrated good psychometrics in late-adolescent and young-adult samples.22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Some adult studies failed to support the role of EA in the onset and course of distress disorders.

    “While these findings highlight the role EA might play in the onset and course of distress disorders, other adult studies failed to support it.1516”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1516]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Study design and conductown data

    The 183 participants with complete EA data did not significantly differ from those with partial EA data on age, sex, ethnicity, EA, anxiety symptoms, or depressive symptoms, but they differed on race.

    “This left 183 participants with complete data, who did not significantly differ from those with partial EA data on age (p = 0.131), sex (p = 0.507), ethnicity (p = 0.523), EA (p = 0.747), anxiety symptoms (p = 0.484), or depressive symptoms (p = 0.871) though they differed on race (p ≤ 0.001).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Generalizability of the findings could have been limited by the low ethnic/racial diversity of the participants.

    “Finally, generalizability of the findings could have been hampered by the limited ethnic/racial diversity of the participants.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    V1 and V2 results were little changed when using abbreviated AAQ-II scores.

    “Moreover, V1 and V2 results were little changed when performing analyses with abbreviated AAQ-II scores.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The findings suggest that EA may have a trait-like nature and may increase risk for the emergence and persistence of MDD and/or GAD.

    “Findings suggest a possible trait-like nature for EA, perhaps increasing risk for the emergence and persistence of MDD and/or GAD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    EA appears to be an important predictor of MDD/GAD symptomology in older adolescents and may serve as a treatment target.

    “EA appears to be an important predictor of MDD/GAD symptomology in older adolescents, potentially serving as a treatment target.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Avoidance of distressing experiences reduces immediate contact and provides short-term relief, but in the long term it leads to greater dysfunction and increased distress.

    “Avoidance of distressing experiences reduces immediate contact with the distressing experiences, delivering short-term relief. Long-term, however, it leads to greater dysfunction and increased distress.56”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [56]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    EA positively predicted daily levels of social anxiety and emotional distress over 3 weeks in college undergraduates.

    “Finally, EA positively predicted daily levels of social anxiety and emotional distress over 3 weeks in a sample of college undergraduates.14”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    After imputing missing data to N=239, V2 analyses yielded the same pattern of results.

    “After imputing for missing data, increasing the sample to N = 239, V2 analyses yielded the same pattern of results (data available upon request).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Dysfunctional distress, regardless of excessive worrying, appears to have significant cross-sectional and longitudinal associations with depressive and anxiety symptomology.

    “Therefore, Dysfunctional distress, regardless of excessive worrying, appears to have significant cross-sectional and longitudinal associations with depressive and anxiety symptomology.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    ACT is an empirically supported treatment for MDD and anxiety disorders, as well as other chronic health problems.

    “ACT has been identified as an empirically supported treatment for MDD and anxiety disorders, as well as other chronic health problems.47”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [47]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In adults, EA was mostly stable within individuals but did increase and decrease with distress disorder occurrence and remittance.

    “While EA was mostly stable within individuals, it did increase and decrease with distress disorder occurrence and remittance.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    EA predicted changes in diagnostic status in adults.

    “EA also predicted changes in diagnostic status.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Internal consistency of the BDI-II was 0.93 at V1 and 0.94 at V2.

    “Internal consistencies were 0.93 and 0.94 for V1 and V2, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Whether the findings apply to early adolescents remains to be determined.

    “Moreover, whether the findings apply to early adolescents is to be determined.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Internal consistency of the BAI was 0.91 at both V1 and V2.

    “Internal consistencies were 0.91 at both V1 and V2.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A significant portion of participants were taking SSRIs, which effectively treat MDD and GAD.

    “Additionally, a significant portion of participants were taking SSRIs, which treat MDD and GAD effectively.4546”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4546]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Internal consistency of the AAQ-II was 0.92 at V1 and 0.93 at V2.

    “Internal consistencies, as measured by Cronbach’s alpha (α), were 0.92 and 0.93 for V1 and V2, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Assessing baseline EA would have been preferable, but the AAQ-II was added post hoc to the study battery.

    “Assessing baseline EA would have been preferable; however, the AAQ-II was a post-hoc addition to the study battery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A reduction in EA was significantly associated with a reduction in depressive symptoms over a 1-year treatment study of borderline personality disorder.

    “A separate study found reduction in EA was significantly associated with reduction in depressive symptoms over the course of a 1-year treatment study of borderline personality disorder.13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Age, sex, and cumulative SSRI exposure were included as covariates because of potential confounding effects.

    “Covariates included age, sex, and cumulative SSRI exposure (defined as cumulative time [in days] taking an SSRI) given potential confounding effects.3334”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3334]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    EA is posited to relate to psychopathology through implicit and explicit pathways.

    “EA is posited to relate to various forms of psychopathology through both implicit (i.e., classically-conditioned) and explicit pathways (i.e., deliberate avoidance).78”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    VIF and Tolerance indices showed no threat of multicollinearity in either model.

    “Variance Inflation Factor (VIF, Mdn ≤ 1.154) and Tolerance (Mdn ≤ 0.867) indices revealed no threat of multicollinearity in either model.32”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    It is not fully clear how SSRI use may have moderated the results, although it was accounted for in analyses.

    “Although accounted for in the analyses, it is not fully clear how SSRI use may have moderated the results.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Supplemental SEM and regression analyses used an abbreviated 5-item AAQ-II to reduce potential predictor-outcome overlap.

    “Supplemental SEM and regression analyses were performed with an abbreviated, 5-item AAQ-II score to examine whether results would replicate when the items strongly resembling anxiety symptoms (“I worry about not being able to control my worries and feelings” and “Worries get in the way of my successes”) were excluded. This approach was taken to reduce potential predictor-outcome overlap.35”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

32 of 32

  • The paper relies on this without support.

    No prior longitudinal study has examined adolescent EA in relation to distress disorders (MDD and GAD).

    “To the best of our knowledge, there has yet to be a longitudinal study of adolescent EA in relation to distress disorders (i.e., MDD and GAD).”

  • The paper relies on this without support.

    No prior study has jointly examined longitudinal relations between EA, depression, and anxiety symptom severity.

    “Moreover, no study has jointly examined longitudinal relations between EA, depression, and anxiety symptom severity.”
2 of 2

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  • ConsistentF(3, 175) = 4.23reported p = .006 · recomputed p = .006

    “F (3, 175) = 4.23, p = .006”

  • Consistentχ²(5) = 8.16reported p > .1 · recomputed p = .148

    “χ2 (5) = 8.16, p > .10”

2 of 2

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Authors
Mellick, W. H., Mills, J. A., Kroska, E. B., Calarge, C. A., Sharp, C., & Dindo, L. N.
Affiliations
  • Medical University of South Carolina (US)
  • University of Iowa (US)
  • Baylor College of Medicine (US)
  • University of Houston (US)
  • Michael E. DeBakey VA Medical Center (US)
Corresponding author
Dindo, Lilian N.
ORCID
Venue
The Journal of Clinical Psychiatry
Publisher
Physicians Postgraduate Press, Inc
Published
2019-10-22
Volume
80
Issue
6
ISSN
  • 0160-6689 (ISSN-L)
  • 1555-2101
DOI
10.4088/jcp.18m12265
PMC
PMC6854672
OpenAlex
W2980625082
Semantic Scholar
0675c59126e3c96629f30c88367196af9c96bbed
Cited by
63
References
53
Citations by year
2026: 9 · 2025: 8 · 2024: 20 · 2023: 9 · 2022: 11 · 2021: 3 · 2020: 3
FWCI
5.00
Type
journal article
Language
en
Open access
Locations
  • The Journal of Clinical Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (UL1TR000442)
  • National Institute on Alcohol Abuse and Alcoholism (F32AA027136)
  • National Institute of Mental Health (R01MH090072, K23MH085005)
  • National Center for Research Resources
  • National Center for Advancing Translational Sciences
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
experiential avoidance, major depressive disorder, generalized anxiety disorder, late adolescence, symptom trajectories, comorbidities, transdiagnostic constructs, dysthymia, anxiety symptoms, treatment goals
MeSH terms
Correlation of Data, Adolescent, Anxiety Disorders, Avoidance Learning, Chronic Disease, Major Depressive Disorder, Female, Humans, Longitudinal Studies, Male, Surveys and Questionnaires, Risk Factors, Comorbidity, Selective Serotonin Reuptake Inhibitors, Problem-Based Learning, Young Adult, Acceptance and Commitment Therapy

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