Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter August 10, 2016

Depressive symptoms, hostility, and hopelessness in inner-city adolescent health clinic patients: factor structure and demographic correlates

Kathleen A. Pajer EMAIL logo , Michael C. Edwards , Andrea E. Lourie , Sherecce Fields and Savannah Kalman



Depression, hostility, and hopelessness are risk factors for adult cardiovascular disease (CVD). People living in inner-city environments are particularly vulnerable. These associations may begin in adolescence, but research in this area is hampered by inadequate knowledge about how these negative psychological factors are related in teens and how they are affected by demographic characteristics. We hypothesized that depression, hostility, and hopelessness are one construct, and that this construct would be associated with race and gender in attendees at an inner-city adolescent health clinic.


Two hundred and forty-six 15–18-year-old patients filled out instruments measuring depressive symptoms, hostility, and hopelessness. Confirmatory factor analysis was used to determine whether the negative psychological factors comprised a single construct or three separate ones. General linear modeling (GLM) was used to test the associations between demographic characteristics and the results of the factor analysis.


Depressive symptoms, hostility, and hopelessness were best characterized as three separate constructs, not one (root mean square error of approximation (RMSEA)=0.041, 90% confidence interval (CI)=(0.035, 0.047), comparative fit index (CFI)=0.98). There were no significant relationships between demographic variables and depressive symptoms or hostility. Six percent of the variance in hopelessness scores was accounted for by gender, race, and the interaction between the two (F=3.76; p=0.006), with White males, reporting the highest levels of hopelessness.


In an urban adolescent health clinic population, depressive symptoms, hostility, and hopelessness were best understood as three separate constructs. Hopelessness was significantly higher in White males. Implications for future clinical research on negative psychological factors in teens are discussed.

Award Identifier / Grant number: 1R01MH066003-01A1

Funding statement: The authors thank Cynthia Holland-Hall, M.D. the staff of the Nationwide Children’s Hospital’s (NCH) Adolescent Medicine Clinic, and Elaine Damo from the NCH Research Data Center. We also thank the study participants for their time and effort. The study was supported by the National Institutes of Health: 1R01MH066003-01A1 (Pajer-PI) and the Research Institute for Nationwide Children’s Hospital, Internal Funds (Pajer-PI).

Acknowledgments and Funding

The authors thank Cynthia Holland-Hall, M.D. the staff of the Nationwide Children’s Hospital’s (NCH) Adolescent Medicine Clinic, and Elaine Damo from the NCH Research Data Center. We also thank the study participants for their time and effort. The study was supported by the National Institutes of Health: 1R01MH066003-01A1 (Pajer-PI) and the Research Institute for Nationwide Children’s Hospital, Internal Funds (Pajer-PI).


1. Suls J, Bunde J. Anger, anxiety, and depression as risk factors for cardiovascular disease: the problems and implications of overlapping affective dispositions. Psychol Bull 2005;131:260–300.10.1037/0033-2909.131.2.260Search in Google Scholar PubMed

2. Kubzansky LD, Davidson KW, Rozanski A. The clinical impact of negative psychological states: expanding the spectrum of risk for coronary artery disease. Psychosom Med 2005;67(Suppl 1):S10–4.10.1097/01.psy.0000164012.88829.41Search in Google Scholar PubMed

3. Everson SA, Kaplan GA, Goldberg DE, Salonen R, Salonen JT, et al. Hopelessness and 4-year progression of carotid atherosclerosis. The Kuopio Ischemic Heart Disease Risk Factor Study. Arterioscl Throm Vas 1997;17:1490–5.10.1161/01.ATV.17.8.1490Search in Google Scholar

4. Possel P, Mitchell AM, Ronkainen K, Kaplan GA, Kauhanen J, et al. Do depressive symptoms predict the incidence of myocardial infarction independent of hopelessness? J Health Psychol 2015;20:60–8.10.1177/1359105313498109Search in Google Scholar PubMed

5. Appleton KM, Woodside JV, Arveiler D, Haas B, Amouyel P, et al. A role for behavior in the relationships between depression and hostility and cardiovascular disease incidence, mortality, and all-cause mortality: the prime study. Ann Behav Med 2016;50:582–91.10.1007/s12160-016-9784-xSearch in Google Scholar PubMed

6. Lundgren O, Garvin P, Jonasson L, Andersson G, Kristenson M. Psychological resources are associated with reduced incidence of coronary heart disease. An 8-year follow-up of a community-based Swedish sample. Int J Behav Med 2015;22:77–84.10.1007/s12529-014-9387-5Search in Google Scholar PubMed

7. Nayyar D, Hwang SW. Cardiovascular health issues in inner city populations. Can J Cardiol 2015;31:1130–8.10.1016/j.cjca.2015.04.011Search in Google Scholar PubMed

8. Bolland JM. Hopelessness and risk behaviour among adolescents living in high-poverty inner-city neighbourhoods. J Adolesc 2003;26:145–58.10.1016/S0140-1971(02)00136-7Search in Google Scholar PubMed

9. Stiffman AR, Earls F, Robins LN, Jung KG. Problems and help seeking in high-risk adolescent patients of health clinics. J Adolesc Health Care 1988;9:305–9.10.1016/0197-0070(88)90255-0Search in Google Scholar PubMed

10. Lieberman A, Adalist-Estrin A, Erinle O, Sloan N. On-site mental health care: a route to improving access to mental health services in an inner-city, adolescent medicine clinic. Child Care Health Dev 2006;32:407–13.10.1111/j.1365-2214.2006.00620.xSearch in Google Scholar PubMed

11. Bartlett JA, Schleifer SJ, Johnson RL, Keller SE. Depression in inner city adolescents attending an adolescent medicine clinic. J Adolesc Health 1991;12:316–8.10.1016/0197-0070(91)90006-8Search in Google Scholar PubMed

12. Raikkonen K, Matthews KA, Salomon K. Hostility predicts metabolic syndrome risk factors in children and adolescents. Health Psychol 2003;22:279–86.10.1037/0278-6133.22.3.279Search in Google Scholar PubMed

13. Pajer K, Hoffman R, Gardner W, Chang CN, Boley D, et al. Endothelial dysfunction and negative emotions in adolescent girls. Int J Adolesc Med Health 2016;28:141–8.10.1515/ijamh-2014-0080Search in Google Scholar PubMed

14. Goldstein BI, Carnethon MR, Matthews KA, McIntyre RS, Miller GE, et al. Major depressive disorder and bipolar disorder predispose youth to accelerated atherosclerosis and early cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2015;132:965–86.10.1161/CIR.0000000000000229Search in Google Scholar PubMed

15. Sirois BC, Sears SF, Jr., Bertolet B. Biomedical and psychosocial predictors of anginal frequency in patients following angioplasty with and without coronary stenting. J Behav Med 2003;26:535–51.10.1023/A:1026201818892Search in Google Scholar PubMed

16. Cunningham S, Gunn T, Alladin A, Cawthorpe D. Anxiety, depression and hopelessness in adolescents: a structural equation model. J Can Acad Child Adolesc Psychiatry 2008;17:137–44.Search in Google Scholar PubMed

17. Knox S, Barnes A, Kiefe C, Lewis CE, Iribarren C, et al. History of depression, race, and cardiovascular risk in CARDIA. Int J Behav Med 2006;13:44–50.10.1207/s15327558ijbm1301_6Search in Google Scholar PubMed

18. Everson-Rose SA, Lewis TT, Karavolos K, Matthews KA, Sutton-Tyrrell K, et al. Cynical hostility and carotid atherosclerosis in African American and white women: the Study of Women’s Health Across the Nation (SWAN) Heart Study. Am Heart J 2006;152:982.e7–13.10.1016/j.ahj.2006.08.010Search in Google Scholar PubMed

19. Krantz DS, Olson MB, Francis JL, Phankao C, Bairey Merz CN, et al. Anger, hostility, and cardiac symptoms in women with suspected coronary artery disease: the Women’s Ischemia Syndrome Evaluation (WISE) Study. J Womens Health (Larchmt) 2006;15:1214–23.10.1089/jwh.2006.15.1214Search in Google Scholar PubMed

20. Murray ET, Diez Roux AV, Carnethon M, Lutsey PL, Ni H, et al. Trajectories of neighborhood poverty and associations with subclinical atherosclerosis and associated risk factors: the multi-ethnic study of atherosclerosis. Am J Epidemiol 2010;171:1099–108.10.1093/aje/kwq044Search in Google Scholar PubMed PubMed Central

21. Klabbers G, Bosma H, Van Lenthe FJ, Kempen GI, Van Eijk JT, et al. The relative contributions of hostility and depressive symptoms to the income gradient in hospital-based incidence of ischaemic heart disease: 12-Year follow-up findings from the GLOBE study. Soc Sci Med 2009;69:1272–80.10.1016/j.socscimed.2009.07.031Search in Google Scholar PubMed

22. Beck AT, Steer RA, Brown GK. Manual for the beck depression inventory-II, 2nd ed. San Antonio, TX: Psychological Corporation, 1996.10.1037/t00742-000Search in Google Scholar

23. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–71.10.1001/archpsyc.1961.01710120031004Search in Google Scholar PubMed

24. Ambrosini PJ, Metz C, Bianchi MD, Rabinovich H, Undie A. Concurrent validity and psychometric properties of the Beck Depression Inventory in outpatient adolescents. J Am Acad Child Adolesc Psychiatry 1991;30:51–7.10.1097/00004583-199101000-00008Search in Google Scholar PubMed

25. Osman A, Kopper BA, Barrios F, Gutierrez PM, Bagge CL. Reliability and validity of the Beck depression inventory–II with adolescent psychiatric inpatients. Psychol Assess 2004;16:120–32.10.1037/1040-3590.16.2.120Search in Google Scholar PubMed

26. Beck A, Steer R, Ball R, Ranieri W. Comparison of beck depression inventories -IA and -II in psychiatric outpatients. J Pers Assess 1996;67:588–97.10.1207/s15327752jpa6703_13Search in Google Scholar PubMed

27. Strik JJ, Honig A, Lousberg R, Denollet J. Sensitivity and specificity of observer and self-report questionnaires in major and minor depression following myocardial infarction. Psychosomatics 2001;42:423–8.10.1176/appi.psy.42.5.423Search in Google Scholar PubMed

28. Woodall KL, Matthews KA. Changes in and stability of hostile characteristics: results from a 4-year longitudinal study of children. J Pers Soc Psychol 1993;64:491–9.10.1037/0022-3514.64.3.491Search in Google Scholar PubMed

29. Liehr P, Meininger JC, Mueller WH, Chan W, Frazier L, et al. Psychometric testing of the adolescent version of the Cook-Medley hostility scale. Issues Compr Pediatr Nurs 2000;23:103–16.10.1080/01460860050121420Search in Google Scholar PubMed

30. Bunde J, Suls J. A quantitative analysis of the relationship between the Cook-Medley Hostility Scale and traditional coronary artery disease risk factors. Health Psychol 2006;25:493–500.10.1037/0278-6133.25.4.493Search in Google Scholar PubMed

31. Barefoot JC, Dahlstrom WG, Williams RB, Jr. Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians. Psychosom Med 1983;45:59–63.10.1097/00006842-198303000-00008Search in Google Scholar PubMed

32. Barefoot JC, Dodge KA, Peterson BL, Dahlstrom WG, Williams RB, Jr. The Cook-Medley hostility scale: item content and ability to predict survival. Psychosom Med 1989;51:46–57.10.1097/00006842-198901000-00005Search in Google Scholar PubMed

33. Miller TQ, Smith TW, Turner CW, Guijarro ML, Hallet AJ. A meta-analytic review of research on hostility and physical health. Psychol Bull 1996;119:322–48.10.1037/0033-2909.119.2.322Search in Google Scholar PubMed

34. Siegler IC, Peterson BL, Barefoot JC, Williams RB. Hostility during late adolescence predicts coronary risk factors at mid-life. Am J Epidemiol 1992;136:146–54.10.1093/oxfordjournals.aje.a116481Search in Google Scholar PubMed

35. Beck A, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 1974;42:861–5.10.1037/h0037562Search in Google Scholar PubMed

36. Beck A, Steer R. Manual for the beck hopelessness scale. San Antonio, Tex: Psychological Corporation, 1988.Search in Google Scholar

37. Steer R, Kumar G, Beck A. Hopelessness in adolescent psychiatric inpatients. Psychol Rep 1993;72:559–64.10.2466/pr0.1993.72.2.559Search in Google Scholar PubMed

38. Lester D. Hopelessness in adolescents. J Affect Disord 2015;173:221–5.10.1016/j.jad.2014.10.048Search in Google Scholar PubMed

39. Wirth RJ, Edwards MC. Item factor analysis: current approaches and future directions. Psychol Methods 2007;12:58–79.10.1037/1082-989X.12.1.58Search in Google Scholar PubMed PubMed Central

40. Browne MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, editors. Testing structural equation models. New York, NY: Sage, 1993:136–62.Search in Google Scholar

41. Bentler PM. Comparative fit indexes in structural models. Psychol Bull 1990;107:238–46.10.1037/0033-2909.107.2.238Search in Google Scholar PubMed

42. Olejnik S, Algina J. Generalized eta and omega squared statistics: measures of effect size for some common research designs. Psychol Methods 2003;8:434–47.10.1037/1082-989X.8.4.434Search in Google Scholar PubMed

43. Bleil ME, Gianaros PJ, Jennings JR, Flory JD, Manuck SB, et al. Trait negative affect: toward an integrated model of understanding psychological risk for impairment in cardiac autonomic function. Psychosom Med 2008;70:328–37.10.1097/PSY.0b013e31816baefaSearch in Google Scholar PubMed

44. Landis D, Gaylord-Harden NK, Malinowski SL, Grant KE, Carleton RA, et al. Urban adolescent stress and hopelessness. J Adolesc 2007;30:1051–70.10.1016/j.adolescence.2007.02.001Search in Google Scholar PubMed

45. Grunbaum JA, Vernon SW, Clasen CM. The association between anger and hostility and risk factors for coronary heart disease in children and adolescents: a review. Ann Behav Med 1997;19:179–89.10.1007/BF02883335Search in Google Scholar PubMed

46. Rottenberg J, Yaroslavsky I, Carney RM, Freedland KE, George CJ, et al. The association between major depressive disorder in childhood and risk factors for cardiovascular disease in adolescence. Psychosom Med 2014;76:122–7.10.1097/PSY.0000000000000028Search in Google Scholar PubMed

47. Waloszek JM, Byrne ML, Woods MJ, Nicholas CL, Bei B, et al. Early physiological markers of cardiovascular risk in community based adolescents with a depressive disorder. J Affect Disord 2015;175:403–10.10.1016/j.jad.2015.01.008Search in Google Scholar PubMed

48. Alt RL. Where the boys are not: a brief overview of male preventive health. WMJ: official publication of the State Medical Society of Wisconsin 2002;101:22–7.Search in Google Scholar

49. Juszczak L, Cooper K. Improving the health and well-being of adolescent boys. Nurs Clin North Am 2002;37:433–42.10.1016/S0029-6465(02)00004-XSearch in Google Scholar PubMed

50. Gibbons RD, Weiss DJ, Kupfer DJ, Frank E, Fagiolini A, et al. Using computerized adaptive testing to reduce the burden of mental health assessment. Psychiatr Serv 2008;59:361–8.10.1176/ps.2008.59.4.361Search in Google Scholar PubMed PubMed Central

51. Gibbons RD, Weiss DJ, Pilkonis PA, Frank E, Moore T, et al. Development of a computerized adaptive test for depression. Arch Gen Psychiatry 2012;69:1104–12.10.1001/archgenpsychiatry.2012.14Search in Google Scholar PubMed PubMed Central

52. Gardner W, Kelleher KJ, Pajer K. Multidimensional adaptive testing for mental health problems in primary care. Med Care 2002;40:812–23.10.1097/00005650-200209000-00010Search in Google Scholar PubMed

Received: 2016-1-24
Accepted: 2016-6-29
Published Online: 2016-8-10

©2018 Walter de Gruyter GmbH, Berlin/Boston

Downloaded on 5.12.2022 from
Scroll Up Arrow