Battling with Depressive Feelings and Suicidal Ideation: Role of Friendships and Effective Coping in Young Individuals From Hunza Valley, Pakistan

Received 28 Aug, 2020

Accepted 11 Mar, 2021

Published 30 Jun, 2021

The present study aimed at examining the association between psychological distress, coping strategies, friendship (satisfaction and affection), and suicidal ideation among young individuals of Hunza Valley, Pakistan. The sample of the present study consisted of 117 boys and 278 girls (N = 395). The purposive sampling technique was used to select study participants from different schools and colleges of Hunza valley, Pakistan. The measures of the study included Depression, Anxiety, and Stress Scale (Lovibond & Lovibond, 1995), Brief Cope (Carver, 1997), McGill Friendship Questionnaire-Respondent's Affection (Mendelson & Aboud, 2012), and Suicide Ideation Scale (Rudd, 1989). Analysis was carried out using, t-test analysis, regression analysis, and correlation techniques. The findings of the study indicated significant positive relationships between psychological distress (indicated by the presence of depressive symptoms and suicidal ideation), avoidant coping, humor, and suicide ideation. The findings further indicated that female adolescents scored higher on psychological distress and friendship satisfaction whereas males scored higher on friendship affection. Multiple regression analysis showed predictive nature of age, avoidance coping, friendship satisfaction, and suicidal ideation in depressive symptoms among adolescents.

Mental health is a state of well-being which enables a person to identify his capabilities, cope with daily life stressors and work productively (World Health Organization, 2003). These capabilities are solidified during the period of adolescence; stable emotional and behavioural health at this age is a precursor for a healthy and productive life (Fergusson, Boden, & Horwood, 2007; Fergusson, Horwood, & Ridder, 2005). Importantly, if mental health problems left untreated, leads to influence person’s quality of life and cause severe distress (Andrade, 2017). Key indicators of mental health include depression, anxiety and stress (Al-Naggar & Al-Naggar, 2012). Depression is considered as the most common disorder (Kessler et al., 2003) related with other kinds of psycho-pathologies such as anxiety, stress and negative affect (Al-Nima, Rosenberg, Archer, & Garcia, 2013). In recent years the mental health of university students has given key attention and findings reported higher risks of psychological distress including anxiety and depression in university students as compared to others (Bayram & Bilgel, 2008; Bewick, Koutsopoulou, Miles, Slaa, & Barkham, 2010; Wintre & Yaffe, 2000; Vaez, Kristenson, & Laflamme, 2004). However, it is believed that the ability to cope with anxiety, depression and other negative events results in higher self-esteem, self-confidence, well-being, psychological and physical health (Greden, 2002).

Coping is a combination of cognitive, behavioral and emotional ability oriented towards accomplishment of stressful events (Stanisławski, 2019). Coping strategies include approach and avoidant coping strategies (Appelhans & Schmeck, 2002). Approach coping is an ability to attain information regarding stressful situations, its consequences and removal whereas avoidance strategy targets denying and dodging stressful situations (Endler & Parker, 1990). In adolescents the feeling of being supported by others not only generates good coping strategies but also leads to positive attitudes towards their future (de Wilde, Kienhorst, Diekstra, & Wolters, 1993). Ghazanfari and Kadampoor (2012) reported significant relationships between coping abilities and mental health. Moreover, mastery in confronting adversity and major stressors is associated with lower anxiety, depression (Mirowsky & Ross 2003; Taylor, Shelley & Stanton, 2007; van Berkel, 2009) and behavioral response to stressors (Taylor et al., 2007; Taylor, Lerner, Sherman, Sage, & McDowell, 2003). Furthermore, maladaptive coping strategies have been significantly associated with suicidal behavior (Becker-Weidman, Jacobs, Reinecke, Silva, & March, 2010; Orbach, Bar-Joseph, & Dror, 1990).

Adolescents’ well-being is highly influenced by their interaction in multiple contexts (Finkenauer, Willems, Weise, & Bartels, 2019; Resnick et al., 1997). The contexts in which the interactions of adolescents are highly embedded includes family, school, friendships, and passionate contacts such as peers and social groups (Bearman & Moody, 2004). The quality of relationships in these contexts is a vital marker of future psychological health of adolescents (Chen, Brody, & Miller, 2017; Rubin, Bukowski, &Parker, 1998). This may be due to the fact good relationships enhance perceived social support and general sense of wellbeing; this in turn enables the individual to have good coping strategies and having a healthier life and relationships (Taylor et al., 2000). Previous research reported that children and adolescents with channelled compassionate contexts experience higher levels of motivation, social skills, self-worth; lower behavioral troubles and satisfactory academic performance (Hansen, Giacoletti, & Nangie, 1995; Savin-Williams & Bemdt, 1990). Moreover, adolescents who lack social support tend to experience lower self-worth, low self-confidence (Tani, Chavez, & Deffenbacher, 2001; Qualter& Munn, 2002), low self-esteem, symptoms of depression and suicide attempts (Bearman, 1991; Berkman, Glass, Brissette, & Seeman, 2000; Deng, Li, Liu, & Chui, 2021; Tam, Lee, Har, &Pook, 2011).Similarly, adolescents who tend to be engaged at schools may have greater wellbeing and sense of belonging. A rationale of the research was to explore the role that protective factors that may play in alleviating the symptoms of depression and associated features of suicidal ideation. Previously, research has reported that the prevalence of mental distress in adolescents is associated with other risk factors and mental disorders (Nordentoft, Mortensen, & Pedersen, 2011) and the diagnosis of such comorbidities has been reported with at least 90% estimation (Arsenault-Lapierre, Kim, & Turecki, 2004; Bertolote & Fleischmann, 2002). Risk factors include cognitive difficulties, loneliness, family psychiatric history and gender, especially being a male (Hawton, Comabella, Haw, & Saunders, 2013). A number of studies also hinted at the presence of and strong associations between suicide ideation and depression in adolescents (Gensichen, Teising, Konig, Gerlach, &Petersen, 2010; Kachur, Potter, Powell, & Rosenberg, 1995; Morales-Vives, & Dueñas, 2018; Naseem & Munaf, 2017). Thus the culmination of contextual and relationship problems can predispose adolescents to experience depression and suicidal ideation.

A high prevalence rate of anxiety and depression has been reported in previous multiple studies for the adolescent population of Pakistan. For example Luni, Ansari, Jawad, Dawson, and Baig (2009) screened sample of Sindhi adolescent’s and found a rate of 43.1% of anxiety and depression (Luni et al., 2009). What is more, in rural Punjab, 66% of women and 25% of men undergo anxiety and depression problems (Mumford, Saeed, Ahmad, Latif, & Mubbashar, 1997). 60% of women in Northern areas of Pakistan (Gilgit) reported anxiety and depression (Dodani & Zuberi, 2000). Moreover, higher prevalence of emotional issues and psychiatric morbidity was reported in Chitral valley (Ahmed, Nisa, Yousufzai, Khoja, & Chaudhry, 2016; Mumford, Nazir, Jilani, & Baig, 1996). Additionally, in Federally Administered Tribal Areas of Pakistan, 60% of women and 45% of men reported emotional problems (Husain, Chaudhry, Afridi, Tomenson, & Creed, 2007). A study conducted by Murshid (2017) on adolescents of South Asia illustrated depressive tendencies in 53%, 25%, 11.9%, 10.37% for Pakistan, India, Myanmar and Sri Lanka, respectively. Findings of Murshid (2017) reported that 14.5% of adolescents met the criteria of depression screening and 50% of respondents had three or more friends. Thus, having really close friends didn’t guard against having feelings of depression. As such, results indicated that individuals with close friends were less prone to depressive symptoms. In every society, individuals have gender roles (Blackstone, 2003; Gilligan, 1982). Both males and females are expected to cope with the stressors caused by these roles differently (Al-Bahrani, Aldhafri, Alkharusi, Kazem, & Alzubiadi, 2013; Frydenberg, 1997).

In Pakistan, very negligible work has been done on adolescents regarding the effects of stressful life events (Saeed, 2010). Mental health issues are also only discussed in prevalence studies and rates of reporting in OPDs across the country hospitals; however, it is evident from such research that the inability to cope with stressful problems may have extreme consequences; these may range from minor adjustment issues to more extreme problems like suicidal ideation among other negative experience (Portzky, Audenaert, & van-Heeringen, 2005).Until presented at clinics or tertiary mental health facilities, most families tend to deal with and put up with the mental health issues themselves. Actual stats and picture of such problems remain invisible and understudied. Hence, a purpose of the study was to explore factors that are associated with depressive symptoms and possible existence of suicidal ideations. The present study focussed on friendship styles and effective coping as factors that may play a limiting role for psychological distress and suicide ideation among adolescents of Hunza valley, Pakistan. Furthermore, the demographics were selected using previous research which indicates that factors as small as the number of siblings adds to the stressors in terms of parental attention and resource utilization; but can be a blessing in terms of friends for life and companionship (Bobbitt-Zeher & Downey, 2013). Therefore, in present study role of age and number of siblings has been specially investigated in relation to study variables. The specific population was chosen as there have been incidences of teenage depression in the last few years. This provides an opportunity for the research to explore if these two factors can play a role in mitigating the negative effects. The data was analysed in multitude of ways to ensure that the experience of such negative experiences could be understood comprehensively. Thus, the research compares individuals with different genders, less and more depressive symptoms and suicide ideation to obtain knowledge about their anxiety and depression levels, coping strategies and friendship aspects. The hypotheses of the study are:

1.	There will be significant positive relationship between anxiety, stress, and depressive symptoms in adolescents.
2.	There will be significant negative associations between approach coping and depressive symptoms.
3.	Avoidant coping will be positively associated with depressive symptoms among adolescents.
4.	There will be significant negative relationships between friendship affection, satisfaction, with depressive symptoms.
5.	There will be significant positive relationships between suicide ideation and depressive symptoms.
6.	Anxiety, stress, coping styles, friendship affection, satisfaction, and suicide ideation will predict depressive symptoms in adolescents.

METHOD

Sample
A sample of 395 adolescents (males = 117, females = 278) was recruited from multiple schools and colleges of Hunza valley. Ages ranged from 13-20 years (M_age = 16.56, SD = 1.67). A purposive sampling technique was used to approach the participants. The number of siblings of participants was categorized into 3 groups: having 1-4 siblings (41.3%; n = 163); 5 siblings (25%; n = 101); 6-10 (33.2%; n = 131). Individuals belonging to a joint family system were 92 (23.3%) whereas 303 (76.6%) belong to nuclear family system. 308 fathers of respondents were working (78.0%), 54 (13.7) were non-working and 33 (8.4%) were deceased. Moreover, 113 mothers of individuals were working (28.6), 264 (66.8%) non-working and 18 (4.6%) were deceased. Family income of 178 PKR (45.1%) individuals was less than 25,000 PKR, 157 (39.7%) had 25,000-65,000 PKR; 50 (12.7%) had 65,000-250,000 PKR and 10 (2.5%) had more than 250,000 PKR.

Instruments
Depression, Anxiety, and Stress Scale (DASS-21). To measure emotional states such as depression, anxiety, and stress, Lovibond and Lovibond (1995) designed self-report inventory DASS-21. Each subscale was composed of 7 items and responses are given on a 4-point Likert scale (0 = Did not apply to me at all – 3 = Most of the time). The alpha reliability for DASS-21 was .94; however alpha reliabilities of subscales were .85, .85 and .87 for Depression, Anxiety, and Stress, respectively in a non-clinical population (Asghari, Saed, & Dibajnia, 2008).

Brief Cope. Carver (1997) developed a 28-item self-report inventory to identify coping responses in individuals. The scale comprised of 14 theoretically identified coping responses including self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. Each construct consisted of two items to examine coping mechanisms adopted by an individual when exposed to stressful situations. Items are scored on a 4-point Likert scale ranging from 1 = I haven't been doing this at all - 4 = I've been doing this a lot. In the present study, two coping styles such as approach coping (active coping, positive reframing, planning, acceptance, seeking emotional support, and seeking informational support), avoidant coping (denial, substance use, venting, behavioral disengagement, self-distraction and self-blame). According to Nunnally and Bernstein (1994) and Kline (1999) all 14 coping dimensions demonstrated good reliability.

McGill Friendship Questionnaire-Respondent's Affection (MFQ-RA). The 16-item MFQ-RA is developed to examine feelings and satisfaction of friendship (Mendelson & Aboud, 2012). It consisted of two subscales; friendship affection and friendship satisfaction. Response options ranges on a 9-point Likert scale ranging from “Very much disagree" to "Very much agree”. The Cronbach’s alpha values of .96 and .92 were reported for affection and satisfaction, respectively (Mendelson & Aboud, 2012).

Suicidal Ideation Scale (SIS). Rudd (1989) designed suicidal ideation scale to measure presence and absence of suicidal ideas, its frequency and prior attempts. Ten items are scored on a 5-point Likert scale (1 = Never to 5 = Always). Rudd (1989) reported higher Cronbach’s alpha value, .86 for SIS.

Procedure
For the purpose of data collection a meeting was conducted with authorities of different educational institutions in Hunza valley. To approach target sample, the nature and purpose of study was discussed. After getting permission from higher authorities’ researcher was given one class slot for data collection. The purpose and nature of study was disclosed with the study participants and informed consent was shared. After taking consent the questionnaire booklet was distributed among all the participants. Thus, data administration was done in group. The queries of participants were addressed and also informed about their right to quit at any moment. After data collection study participants were given debriefing and appreciated for their time and participation were addressed. After debriefing, their participation was encouraged by the researcher.

RESULTS

The result section follows descriptive statistics, correlation, and regression analysis to examine the study variables. Additionally, analyses including t-test statistics on gender and two-step clustering were applied for accessing information regarding individuals with less and higher depression and suicide ideation among individuals.

Table 1:	Alpha Reliabilities and Descriptive Statistics for Study Variables (N = 395)

Results in Table 1 explain descriptive statistics of depression, anxiety, stress, psychological distress, coping styles, friendship (affection and satisfaction) and suicide ideation. Findings reveal acceptable alpha reliabilities for scales and their subscales. However, the subscale of coping scale such as religion has not been included in further analysis due to poor Cronbach’s alpha value in the present study. To study the relationship between the study variables, Pearson correlations were calculated. Two demographic variables, age and number of siblings were included.

Table 2:	Correlation between Age, Number of Siblings, Depression, Anxiety Stress, Psychological Distress, Coping Styles, Friendship (Affection and Satisfaction) and Suicide Ideation (N = 395)
Note. Siblings = Number of Siblings, PsyD = Psychological Distress, ApCoping = Approach Coping AvCoping = Avoidant Coping, SI = Suicide Ideation *p < .05, **p < .01, ***p < .001

Results in Table 2 indicate significant positive relationship between psychological distress, avoidant coping, humor, and suicide ideation. However, age, number of siblings, and friendship (affection and satisfaction) show non-significant relationships with suicide ideation. To study the relationship between the genders and the study variables, t-test analysis was used. The results are presented below.

Table 3:	Comparison of Gender on Depression, Anxiety, Stress Psychological distress, Coping Strategies, Friendship Satisfaction and Affection, and Suicide Ideation among Adolescents (N = 395)
Note. * p < .05; **p < .01

Table 3 illustrates gender differences in regards to study variables. Findings indicate significant gender differences on anxiety, stress, psychological distress, friendship affection and satisfaction. Mean values indicate that higher scores for female on anxiety, stress, psychological distress and friendship satisfaction in comparison to males. However, males show higher score on friendship affection than females.

Table 4:	Two-Step Clustering for Individuals with Less Suicide Ideation and Depressive Symptoms, and Higher Suicide Ideation and Depressive Symptoms with Study Variables (N = 395)
Note. ApCoping = Approach Coping; AvCoping = Avoidant Coping; F.Affection = Friendship Affection F. Satisfaction = Friendship Satisfaction.

Results in Table 4 indicate the data set of two groups such as individuals with less suicide ideation and depressive symptoms, and individuals with higher suicide ideation and depressive symptoms with study variables. Findings reveal that these two groups significantly differ on anxiety, stress, avoidant coping and friendship satisfaction. Findings reveal that individuals with suicide ideation and depressive symptoms do not show anxiety, stress, friendship satisfaction and avoidant coping than individuals with less suicide ideation and depressive symptoms.

Table 5:	Multiple Linear Regression Analysis for the Effect Age, Number of Siblings, Anxiety, Stress, Coping Styles and Suicide Ideation on Depressive Symptoms (N = 395)
*p< .05; **p < .01; ***p < .001

Table 5 signifies the predictive role of study variables on depressive symptoms in adolescents. In Model 1 findings indicate that age is significant predictor and explains 12% of variance in depressive symptoms. Moreover, in Model 2 anxiety is significant negative and avoiding coping, friendship satisfaction and suicide ideation are significant positive predictors of depressive symptoms. Model 2 explained 83% of the variance in depressive symptoms among adolescents.

DISCUSSION

The current study suggests significant relationship between anxiety, stress, avoidant coping, humor, suicide ideation and depressive symptoms. Numerous studies displayed significant positive associations between anxiety and depressive symptoms (Hammen, Brennan, & Shih, 2004; Eisenbarth, Champeau, & Donatelle, 2013; Ghorbani, Krauss, Watson, & Le-Breton, 2008; Al-Nima, Rosenberg, Archer, & Garcia, 2013). Additionally, Roohafza (2014) reported that avoidance coping is a key risk factor for depression and anxiety. Furthermore, multiple studies reported significant relationships between humor (Freiheit, Overholser, & Lehnert, 1998), suicide ideation (Luo, Wang, Wang, & Cai, 2016; Britton et al., 2008; Gensichen, Teising, Konig, Gerlach, & Petersen, 2010) and depressive symptoms. In addition, current study also revealed non-significant associations between age, number of siblings and depressive symptoms. However, Sen (2004) suggested that the likelihood of depression increases with age and having siblings and interaction helps in social-cognitive progress (Dunn, 2007; Howe, Rinaldi, Jennings, & Petrakos, 2002).

In line with previous studies current study revealed significant gender differences of gender psychological distress. According to findings females report higher psychological distress in comparison to males (Pezirkianidis, Karakasidou, Lakioti, Stalikas, & Galanakis, 2018). Moreover, females reported higher friendship satisfaction in comparison to males. However, evidence regarding gender differences on friendship are inconsistent. For instance, Rose and Rudolph (2006) suggested equal friendship satisfaction among both boys and girls however, non-significant differences among boys and girls has been also reported (Weeks, 2013; Zarbatany, Conley, & Pepper, 2004). The reason could be that girls in the community are forced to follow a lifestyle where their voices are invisible. Not only do they tend to be more sensitive and may be more prone to feel the pressures of life, their coping strategies may not be effective against the damaging effects of the stress and anxiety.

The present study examined the sample on the basis of intensity of suicide ideation and depressive symptoms. Results revealed that individuals with lower symptoms of suicide ideation and depression scored higher on anxiety, stress, approach coping, and friendship satisfaction in comparison to individuals with higher symptoms of suicide ideation depressive symptoms. However, evidence suggests anxiety and stress as a significant risk factor for suicide ideation among adolescents (Boden, Fergusson, & Horwood, 2007; Haider Ghazanfar et al., 2015; Mamun, Rayhan, Akter, & Griffiths, 2020). Moreover, use of appropriate coping strategies might mitigate and assist individual in confronting stressful circumstances which might significantly influence mental health problems (ECNP, 2017). According to results individuals with higher depressive symptoms and suicide ideation scored less on friendship affection and satisfaction. Likewise, a study conducted by reported higher suicide ideation among individuals with less support from friends (Endo et al., 2014) as relationship with friend’s play substantial role in the development and emotional and social development during adolescence (Fredrick & Demaray, 2018).

It is also found that age significantly predicts depressive symptoms in adolescents (Brooks, Harris, Thrall, & Woods, 2002; Chen et al., 2013). Moreover, anxiety, avoiding coping, friendship satisfaction and suicide ideation significantly predicted depressive symptoms. The predictive nature of study variables in depressive symptoms is supported by past literature. According to Bufferd et al. (2014) poor peer functioning, and prior anxiety predicts later depression issues. Additionally, interpersonal stressors such as increased number of friends increase depressed mood whereas problems with classmates’ influence individual’s security and sense of adequacy insecurity (Fiorilli, Capitello, Barni, Buonomo, & Gentile, 2019). Furthermore, findings provide the predictive role of suicide ideation in adolescents, which means that individuals with suicide ideation are susceptible to experience depression. However, literature suggests the predictive role of depression in suicide (Cong & Ling, 2020; Yen, 2005).

LIMITATIONS AND IMPLICATIONS

The sample was recruited from rural areas (Hunza, Gilgit Baltistan) of Pakistan. However, future researchers should also consider urban areas of Pakistan for a comparative study. Additionally, adolescents not attending educational institutions should also be considered in future studies. The findings of the research are significant for this very reason; the information and responses are from the undiagnosed population. The level of distress and feelings of despair are apparent from the data; the findings can help government and policy makers to take appropriate steps in helping these youngsters out. Findings of the present study provide knowledge regarding mental health of adolescents that might be affected by personal and social issues. It will also assist professionals related to academics and health setups to consider importance of other emotional issues, coping strategies, friendship and suicide ideation that influences mental health of an individual.

CONCLUSION

The present research investigated the relationship between anxiety, stress, psychological distress, avoidant coping, humor, suicide ideation, and depression in the sampled young individuals. The findings have significance in terms of their implications. Correlation analysis revealed a significant positive relationship with avoidant coping, humor, and suicide ideation among adolescents. In addition, the study also revealed less anxiety, stress, friendship satisfaction, and avoidant coping among adolescents with higher suicide ideation and depressive symptoms in comparison to adolescents with less suicide ideation and depressive symptoms which needs to be probed by further other studies in the context of Pakistan. Improving social interactions during the adolescence phase might play a substantial role in mitigating psychological distress among adolescents in the community.

REFERENCES

1. Ahmed, Z., Nisa, Q., Yousufzai, A. W., Khoja, S., & Chaudhry, J. (2016). Trends and patterns of suicide in people of Chitral, Khyber Pakhtunkhwa, Pakistan.Khyber Medical University Journal,8(2).
2. Al-Bahrani, M., Aldhafri, S., Alkharusi, H., Kazem, A., & Alzubiadi, A. (2013). Age and gender differences in coping style across various problems: Omani adolescents' perspective.Journal of Adolescence,36(2), 303-309.
3. Al Nima, A., Rosenberg, P., Archer, T., & Garcia, D. (2013). Anxiety, affect, self-esteem, and stress: Mediation and moderation effects on depression.PloS one,8(9), e73265.
4. Al-Naggar, R. A., & Al-Naggar, D. H. (2012). Prevalence and associated factors of emotional disorder among Malaysian university students.Int J Collab Res Intern Med Public Health,4, 1401-11.
5. Andrade, S. (2017). Cultural Influences on Mental Health.
6. Appelhans, B. M., & Schmeck, R. R. (2002). Learning styles and approach versus avoidant coping during academic exam preparation.College Student Journal,36(1), 157-161.
7. Arsenault-Lapierre, G., Kim, C., & Turecki, G. (2004). Psychiatric diagnoses in 3275 suicides: A meta-analysis.BMC Psychiatry,4(1), 3
8. Asghari, A., Saed, F., & Dibajnia, P. (2008). Psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a non-clinical Iranian sample.Int J Psychol,2(2), 82-102.
9. Bayram, N., & Bilgel, N. (2008). The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students.Social psychiatry and Psychiatric Epidemiology,43(8), 667-672.
10. Bearman, P. S. (1991, September). The social structure of suicide. InSociological Forum, 6(3), 501-524.
11. Bearman, P. S., & Moody, J. (2004). Suicide and friendships among American adolescents.American Journal of Public Health,94(1), 89-95.
12. Bearman, P. S. (1991, September). The social structure of suicide. Sociological Forum, 6(3), 501-524.
13. Bertolote, J. M., & Fleischmann, A. (2002). Suicide and psychiatric diagnosis: A worldwide perspective.World Psychiatry,1(3), 181.
14. Bewick, B., Koutsopoulou, G., Miles, J., Slaa, E., & Barkham, M. (2010). Changes in undergraduate students’ psychological well‐being as they progress through university.Studies in Higher Education,35(6), 633-645.
15. Blackstone, A. M. (2003). Gender roles and society.
16. Bobbitt-Zeher, D., & Downey, D. B. (2013). Number of siblings and friendship nominations among adolescents.Journal of Family Issues,34(9), 1175-1193.
17. Boden, J. M., Fergusson, D. M., & Horwood, L. J. (2007). Anxiety disorders and suicidal behaviours in adolescence and young adulthood: Findings from a longitudinal study.Psychological Medicine,37(3), 431.
18. Bostanci, M., Ozdel, O., Oguzhanoglu, N. K., Ozdel, L., Ergin, A., Ergin, N., ... & Karadag, F. (2005). Depressive symptomatology among university students in Denizli, Turkey: Prevalence and sociodemographic correlates.Croat med J,46(1), 96-100.
19. Britton, P. C., Duberstein, P. R., Conner, K. R., Heisel, M. J., Hirsch, J. K., & Conwell, Y. (2008). Reasons for living, hopelessness, and suicide ideation among depressed adults 50 years or older.The American Journal of Geriatric Psychiatry,16(9), 736-741.
20. Brooks, T. L., Harris, S. K., Thrall, J. S., & Woods, E. R. (2002). Association of adolescent risk behaviors with mental health symptoms in high school students.Journal of Adolescent Health,31(3), 240-246.
21. Bufferd, S. J., Dougherty, L. R., Olino, T. M., Dyson, M. W., Laptook, R. S., Carlson, G. A., & Klein, D. N. (2014). Predictors of the onset of depression in young children: A multi‐method, multi‐informant longitudinal study from ages 3 to 6.Journal of Child Psychology and Psychiatry,55(11), 1279-1287.
22. Carver, C. S. (1997). You want to measure coping but your protocol’too long: Consider the brief cope.International Journal of Behavioral Medicine,4(1), 92.
23. Chen, E., Brody, G. H., & Miller, G. E. (2017). Childhood close family relationships and health.American Psychologist,72(6), 555.
24. Chen, L., Wang, L., Qiu, X. H., Yang, X. X., Qiao, Z. X., Yang, Y. J., & Liang, Y. (2013). Depression among Chinese university students: prevalence and socio-demographic correlates.PloS One,8(3), e58379.
25. Cong, C. W., & Ling, W. S. (2020). The predicting effects of depression and selfesteem on suicidal ideation among adolescents in Kuala Lumpur, Malaysia.Journal of Health and Translational Medicine,23(1), 60-66.
26. Deng, Y., Li, X., Liu, L., & Chui, W. H. (2021). Suicide attempts and perceived social support among Chinese drug users: The mediating role of self-esteem and depression.International Journal of Environmental Research and Public Health,18(1), 208.
27. de Wilde, E. J., Kienhorst, I. C., Diekstra, R. F., & Wolters, W. H. (1993). The specificity of psychological characteristics of adolescent suicide attempters.Journal of the American Academy of Child & Adolescent Psychiatry,32(1), 51-59.
28. Dodani, S., & Zuberi, R. W. (2000). Center-based prevalence of anxiety and depression in women of the northern areas of Pakistan.Journal of Pakistan Medical Association,50(5), 138.
29. Dunn, J. (2007). Siblings and Socialization. In J. E. Grusec & P. D. Hastings (Eds.),Handbook of Socialization: Theory and Research(pp. 309-327). New York, NY, US: Guilford Press.
30. Eisenbarth, C.A., Champeau, D.A. & Donatelle, R.J. (2013). Relationship of Appraised Stress, Coping Strategies, and Negative Affect among College Students. International Journal of Psychology and Behavioral Sciences, 3, 131-138.
31. Eller, T., Aluoja, A., Vasar, V., &Veldi, M. (2006). Symptoms of anxiety and depression in Estonian medical students with sleep problems.Depression and Anxiety,23(4), 250-256.
32. Endler, N. S., & Parker, J. D. (1990). State and trait anxiety, depression and coping styles.Australian Journal of Psychology,42(2), 207-220.
33. Endo, G., Tachikawa, H., Fukuoka, Y., Aiba, M., Nemoto, K., Shiratori, Y., ... & Asada, T. (2014). How perceived social support relates to suicidal ideation: A Japanese social resident survey.International Journal of Social Psychiatry,60(3), 290-298.
34. European College of Neuro Psychopharmacology (ECNP, 2017). Coping skills affect women's anxiety levels, study shows. Science Daily.
35. Faramarzi, M., Pasha, H., Esmaelzadeh, S., Jorsarai, G., Mir, M. R. A., & Abedi, S. (2013). Is coping strategies predictor of anxiety and depression in couple infertile? Health, 5(3), 1-7.
36. Fergusson, D. M., Boden, J. M., & Horwood, L. J. (2007). Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes.The British Journal of Psychiatry,191(4), 335-342.
37. Fergusson, D. M., Horwood, L. J., & Ridder, E. M. (2005). Show me the child at seven: The consequences of conduct problems in childhood for psychosocial functioning in adulthood.Journal of child psychology and psychiatry,46(8), 837-849.
38. Finkenauer, C., Willems, Y. E., Weise, M., & Bartels, M. (2019). The social context of adolescent relationships.
39. Fiorilli, C., Capitello, T. G., Barni, D., Buonomo, I., & Gentile, S. (2019). Predicting adolescent depression: The interrelated roles of self-esteem and interpersonal stressors.Frontiers in Psychology,10, 565.
40. Fredrick, S. S., &Demaray, M. K. (2018). Peer victimization and suicidal ideation: The role of gender and depression in a school-based sample. Journal of School Psychology,67, 1-15.
41. Freiheit, S. R., Overholser, J. C., & Lehnert, K. L. (1998). The association between humor and depression in adolescent psychiatric inpatients and high school students.Journal of Adolescent Research,13(1), 32-48.
42. Frydenberg, E. (1997). Adolescent coping: Theoretical and research perspectives. Routledge. London.
43. Gensichen, J., Teising, A., König, J., Gerlach, F. M., & Petersen, J. J. (2010). Predictors of suicidal ideation in depressive primary care patients.Journal of Affective Disorders,125(1-3), 124-127.
44. Gensichen, J., Teising, A., König, J., Gerlach, F. M., & Petersen, J. J. (2010). Predictors of suicidal ideation in depressive primary care patients.Journal of Affective Disorders,125(1-3), 124-127.
45. Ghazanfari, F. & Kadampoor, A. (2012) Considering the Coping Strategy and Mental Health in Residents of Khorramabad City. The Quarterly Journal of Fundamentals of Mental Health, 9, 37.
46. Ghorbani, N., Krauss, S. W., Watson, P. J., & LeBreton, D. (2008). Relationship of perceived stress with depression: Complete mediation by perceived control and anxiety in Iran and the United States.International Journal of Psychology,43(6), 958-968.
47. Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press.
48. Greden, J. F. (2002). Unmet need: What justifies the search for a new antidepressant?.The Journal of Clinical Psychiatry, 63(2), 3-7.
49. Haider Ghazanfar, S. H., Ghazanfar, A., Bhatti, J. R. A., ul Haq, I., Saeed, R., Shafi, M. S., ... & Naseem, S. (2015). Suicidal ideation among Pakistani medical students.Rawal Medical Journal,40(4), 458-462.
50. Hammen, C., Brennan, P.A., & Shih, J. H. (2004). Family discord and stress predictors of depression and other disorders in adolescent children of depressed and nondepressed women. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 994-1002.
51. Hansen, D. J., Giacoletti, A. M., & Nangle, D. W. (1995). Social interactions and adjustment. In V. B. Van Hasselt & M. Hersen (Eds.), Handbook of adolescent psychopathology: A guide to diagnosis and treatment (pp. 102-129). New York: MacMillan.
52. Hawton, K., Comabella, C. C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression: A systematic review.Journal of Affective Disorders,147(1-3), 17-28.
53. Howe, N., Rinaldi, C. M., Jennings, M., & Petrakos, H. (2002). No! The lambs can stay out because they got cozies: Constructive and destructive sibling conflict, pretend play, and social understanding.Child Development,73(5), 1460-1473.
54. Husain, N., Chaudhry, I. B., Afridi, M. A., Tomenson, B., & Creed, F. (2007). Life stress and depression in a tribal area of Pakistan.The British Journal of Psychiatry,190(1), 36-41.
55. Inskip, H., Harris, C., & Barraclough, B. (1998). Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia.The British Journal of Psychiatry,172(1), 35-37.6.
56. Jones, D. C. (1991). Friendship satisfaction and gender: An examination of sex differences in contributors to friendship satisfaction [Abstract].Journal of Social and Personal Relationships,8(2), 167-185.
57. Kachur, S. P., Potter, L. B., Powell, K. E., & Rosenberg, M. L. (1995). Suicide: epidemiology, prevention, and treatment.Adolescent Medicine, 6(2), 171-182.
58. Kessler, R. C., & Walters, E. E. (1998). Epidemiology of DSM‐III‐R major depression and minor depression among adolescents and young adults in the national comorbidity survey.Depression and Anxiety,7(1), 3-14.
59. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., ... & Wang, P. S. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R).Jama,289(23), 3095-3105.
60. Kline, P. (1999). The handbook of psychological testing. London, United Kingdom: Routledge.
61. Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories.Behaviour Research and Therapy,33(3), 335-343.
62. Luni, F. K., Ansari, B., Jawad, A., Dawson, A., & Baig, S. M. (2009). Prevalence of depression and anxiety in a village in Sindh.Journal of Ayub Medical College Abbottabad,21(2), 68-72.
63. Luo, X., Wang, Q., Wang, X., & Cai, T. (2016). Reasons for living and hope as the protective factors against suicidality in Chinese patients with depression: a cross sectional study.BMC Psychiatry,16(1), 252.
64. Mamun, M. A., Rayhan, I., Akter, K., & Griffiths, M. D. (2020). Prevalence and predisposing factors of suicidal ideation among the university students in Bangladesh: A single-site survey.International Journal of Mental Health and Addiction, 1-14.
65. Mendelson, M. J., & Aboud, F. (2012). McGill Friendship Questionnaire-Respondent’s affection (MFQ-RA).Measurement Instrument Database for the Social Science.
66. Mikolajczyk, R. T., Maxwell, A. E., El Ansari, W., Naydenova, V., Stock, C., Ilieva, S., ... & Nagyova, I. (2008). Prevalence of depressive symptoms in university students from Germany, Denmark, Poland and Bulgaria.Social Psychiatry and Psychiatric Epidemiology,43(2), 105-112.
67. Morales-Vives, F., & Dueñas, J. M. (2018). Predicting suicidal ideation in adolescent boys and girls: The role of psychological maturity, personality traits, depression and life satisfaction.The Spanish Journal of Psychology,21,e10.
68. Mumford, D. B., Nazir, M., & Baig, I. Y. (1996). Stress and psychiatric disorder in the Hindu Kush: A community survey of mountain villages in Chitral, Pakistan.The British Journal of Psychiatry,168(3), 299-307.
69. Mumford, D. B., Saeed, K., Ahmad, I., Latif, S., & Mubbashar, M. H. (1997). Stress and psychiatric disorder in rural Punjab: A community survey.The British Journal of Psychiatry,170(5), 473-478.
70. Murshid, N. S. (2017). Parents, friends, and depression: A multi-country study of adolescents in South Asia.Children and Youth Services Review,79, 160-165.
71. Naseem, S., & Munaf, S. (2017). Suicidal ideation, depression, anxiety, stress, and life satisfaction of medical, engineering, and social sciences students.Journal of Ayub Medical College Abbottabad,29(3), 422-427.
72. Nordentoft, M., Mortensen, P. B., & Pedersen, C. B. (2011). Absolute risk of suicide after first hospital contact in mental disorder.Archives of General Psychiatry,68(10), 1058-1064.
73. NovoPsych, (n.d.). Brief-COPE – novopsych Psychometrics.
74. Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York, NY: McGraw-Hill.
75. Orbach, I., Bar‐Joseph, H., & Dror, N. (1990). Styles of problem solving in suicidal individuals.Suicide and Life‐Threatening Behavior,20(1), 56-64.
76. Patterson, B. R., & Bettini, L. A. (1993). Age, depression, and friendship: Development of a general friendship inventory.Communication Research Reports,10(2), 161-170.
77. Pezirkianidis, C., Karakasidou, E., Lakioti, A., Stalikas, A., & Galanakis, M. (2018). Psychometric properties of the Depression, Anxiety, Stress Scales-21 (DASS-21) in a Greek Sample.Psychology,9(15), 2933-2950.
78. Portzky, G., Audenaert, K., & van Heeringen, K. (2005). Suicide among adolescents.Social Psychiatry and Psychiatric Epidemiology,40(11), 922-930.
79. Qualter, P., & Munn, P. (2002). The separateness of social and emotional loneliness in childhood.Journal of Child Psychology and Psychiatry,43(2), 233-244.
80. Resnick, M. D., Bearman, P. S., Blum, R. W., Bauman, K. E., Harris, K. M., Jones, J., ... & Udry, J. R. (1997). Protecting adolescents from harm: Findings from the National longitudinal study on adolescent health.Jama,278(10), 823-832.
81. Robins, E., Murphy, G. E., Wilkinson Jr., R. H., Gassner, S., & Kayes, J. (1959). Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides.American Journal of Public Health and the Nations Health,49(7), 888-899.
82. Roohafza, H. R., Afshar, H., Keshteli, A. H., Mohammadi, N., Feizi, A., Taslimi, M., & Adibi, P. (2014). What's the role of perceived social support and coping styles in depression and anxiety?.Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences,19(10), 944.
83. Rose, A. J., & Rudolph, K. D. (2006). A review of sex differences in peer relationship processes: Potential trade-offs for the emotional and behavioral development of girls and boys. Psychological Bulletin, 132, 98-131.
84. Rudd, M. D. (1989). The prevalence of suicidal ideation among college students.Suicide and Life‐Threatening Behavior,19(2), 173-183.
85. Saeed, I. (2010).Daily stressors, coping strategies and adjustment of adolescents(Doctoral Dissertation), Quaid-i-Azam University, Islamabad, Pakistan.
86. Savin-Williams, R. C., & Berndt, T. J. (1990). Friendship and peer relations.
87. Sen, B. (2004). Adolescent propensity for depressed mood and help seeking: Race and gender differences.Journal of Mental Health Policy and Economics,7(3), 133-145.
88. Shaikh, B. T., Kahloon, A., Kazmi, M., Khalid, H., Nawaz, K., Khan, N., & Khan, S. (2004). Students, stress and coping strategies: A case of Pakistani medical school.Education for Health-Abingdon-Carfax Publishing Limited-,17, 346-353.
89. Stanisławski, K. (2019). The coping circumplex model: an integrative model of the structure of coping with stress.Frontiers in Psychology,10, 694.
90. Stewart-Brown, S., Evans, J., Patterson, J., Petersen, S., Doll, H., Balding, J., & Regis, D. (2000). The health of students in institutes of higher education: an important and neglected public health problem?.Journal of Public Health,22(4), 492-499.
91. Tam, C. L., Lee, T. H., Har, W. M., & Pook, W. L. (2011). Perceived social support and self-esteem towards gender roles: Contributing factors in adolescents.Asian Social Science,7(8), 49.
92. Tani, C. R., Chavez, E. L., & Deffenbacher, J. L. (2001). Peer isolation and drug use among white non-Hispanic and Mexican American adolescents.Adolescence,36(141), 127.
93. Taylor, S. E., & Stanton, A. L. (2007). Coping resources, coping processes, and mental health.Annu. Rev. Clin. Psychol.,3, 377-401.
94. Taylor, S. E., Klein, L. C., Lewis, B. P., Gruenewald, T. L., Gurung, R. A., & Updegraff, J. A. (2000). Biobehavioral responses to stress in females: Tend-and-befriend, not fight-or-flight.Psychological Review,107(3), 411.
95. Taylor, S. E., Lerner, J. S., Sherman, D. K., Sage, R. M., & McDowell, N. K. (2003). Are self-enhancing cognitions associated with healthy or unhealthy biological profiles?Journal of Personality and Social Psychology,85(4), 605.
96. Teh, C. K., Ngo, C. W., bintiZulkifli, R. A., Vellasamy, R., & Suresh, K. (2015). Depression, anxiety and stress among undergraduate students: A cross sectional study.Open Journal of Epidemiology,5(04), 260.
97. Vaez, M., Kristenson, M., & Laflamme, L. (2004). Perceived quality of life and self-rated health among first-year university students.Social Indicators Research, 68(2), 221-234.
98. Voelker, R. (2003). Mounting student depression taxing campus mental health services. Jama, 289(16), 2055-2056.
99. van Berkel, H. K. (2009). The relationship between personality, coping styles and stress, anxiety and depression (Master’s Thesis). University of Canterbury, New Zealand.
100. Weeks, M. S. (2013). Gender, loneliness, and friendship satisfaction in early adulthood: The role of friendship features and friendship expectations (doctoral dissertation). Department of Psychology & Neuroscience in the Graduate School of Duke University. Durham, U.K.
101. Wintre, M. G., & Yaffe, M. (2000). First-year students’ adjustment to university life as a function of relationships with parents.Journal of Adolescent Research,15(1), 9-37.
102. Wong, J. G., Cheung, E. P., Chan, K. K., Ma, K. K., & Wa Tang, S. (2006). Web-based survey of depression, anxiety and stress in first-year tertiary education students in Hong Kong.Australian & New Zealand Journal of Psychiatry,40(9), 777-782.
103. World Health Organization (2003). Investing in mental health.
104. Yen, Y. C., Yang, M. J., Yang, M. S., Lung, F. W., Shih, C. H., Hahn, C. Y., & Lo, H. Y. (2005). Suicidal ideation and associated factors among community‐dwelling elders in Taiwan. Psychiatry and Clinical Neurosciences, 59(4), 365-371.
105. Zarbatany, L., Conley, R., & Pepper, S. (2004). Personality and gender differences in friendship needs and experiences in preadolescence and young adulthood. International Journal of Behavioral Development, 28(4), 299-310.