RESEARCH REPORT doi:10.1111/j.1360-0443.2006.01621.

Psychological symptoms and physical health and

health behaviours in adolescents: a prospective 2-year
study in East London

Charlotte Clark1, Mary M. Haines1, Jenny Head1, Emily Klineberg1, Muna Arephin1,
Russell Viner2, Stephanie J. C. Taylor3, Robert Booy4, Kam Bhui1 & Stephen A. Stansfeld1
Centre for Psychiatry,Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary’s School of Medicine and Dentistry, University of London, UK,1
Department of Paediatrics, Royal Free and University College London Medical School, University College London, UK,2 Centre for Health Science, Barts and the
London, Queen Mary’s School of Medicine and Dentistry, University of London, UK3 and Department of Child Health, Barts and the London, Queen Mary’s School
of Medicine and Dentistry, University of London, UK4

ABSTRACT

Aims To examine whether physical health and health-risk behaviours in young people are risk factors for psycho-
logical distress and depressive symptoms over a 2-year period. Design/setting A 2-year, prospective epidemiological
cohort study in East London. Participants A total of 1615 adolescents from the Research with East London Adoles-
cents: Community Health Survey (RELACHS)—a representative cohort of young people aged 11–12 and 13–14 years
at baseline, followed-up after 2 years. Measurements Psychological distress and depressive symptoms identified by the
self-report Strengths and Difficulties Questionnaire and the Short Moods and Feelings Questionnaire at baseline and
follow-up. Data on overweight/obesity, general health, long-standing illness, physical activity, smoking, alcohol use and
drug use were collected from questionnaires completed by the adolescents at baseline and follow-up. Findings At
follow-up, 10.1% of males and 12.9% of females reported psychological distress; 20% of males and 33.7% of females
reported depressive symptoms. Having tried drugs or engaged in two or more health-risk behaviours (smoking, alcohol
use or drug use) at baseline predicted psychological distress and depressive symptoms at follow-up. Smoking on its own,
long-standing illness, obesity/overweight and activity levels were not associated with later psychological health.
Risk of poor psychological health at follow-up was associated strongly with psychological health at baseline.
Conclusions Psychological health at baseline was the strongest predictor of psychological health at follow-up. Engag-
ing in two or more health-risk behaviours moderately increased the risk of poor psychological health, suggesting that
prevention strategies targeting co-occuring substance use may reduce burden of disease.

Keywords Adolescence, alcohol, drug use, psychological health, smoking.

Correspondence to: Charlotte Clark, Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary’s School of
Medicine and Dentistry, University of London, Old Anatomy Building, Charterhouse Square, London, EC1M 6BQ, UK. E-mail: c.clark@qmul.ac.uk
Submitted 7 December 2005; initial review completed 7 March 2006; final version accepted 23 June 2006

INTRODUCTION Increasing rates of psychological ill health could be

For many individuals mental disorders begin in early
life [1] and there is increasing evidence of continuity
between common mental disorders in adolescence and
early adulthood [2–5]. Rates of psychological ill-health
in adolescents are increasing [6] and identifying
modifiable risk factors for adolescent psychological
health becomes increasingly important, given the per-
sistence of adolescent psychological health into
adulthood.
linked to increasing rates of health-risk behaviours such
as smoking, alcohol and drug use [7]. Unlike innate risk
factors, such as gender, health-risk behaviours are poten-
tially modifiable through health promotion campaigns.
Prospective studies have investigated the role of smoking,
alcohol use and drug use in the aetiology of depression;
however, it has been difficult to establish the pathways
between substance use and psychological health, because
of the considerable overlap in predictors [8]. Some studies
have found that smoking leads to depression [9–12];

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
 Health behaviour predictors of psychological symptoms
however, there is stronger evidence that depression pre-
cedes smoking [9,12–19].
Conversely, cannabis and alcohol use may precede
depression [8,20,21]. However, a recent study found no
prospective association between alcohol use and depres-
sion after adjustment for background factors such as
socio-economic status and previous psychological health
[22]. It has also been suggested that the pathway for can-
nabis use may differ in adolescence and early adulthood,
with poor psychological health preceding cannabis use in
adolescence and cannabis use preceding poor psychologi-
cal health in early adulthood [20].
Despite the predominant focus upon individual
health-risk behaviours, we know that health-risk behav-
iours co-occur in adolescence [7,23,24]. This clustering
of health-risk behaviours has been explained by gateway
theories, where the use of one substance leads to experi-
mentation and use of other substances [12,25] or by
common risk factors relating to substance use [26,27].
Gateway effects are stronger in adolescence than in early
adulthood [28]. It is not known whether greater risk for
psychological health is related to individual health-risk
behaviours or the co-occurrence of health-risk
behaviours.
Adolescent physical health also contributes to the aeti-
ology of psychological health, yet fewer studies have inves-
tigated these relationships. While there is cross-sectional
support for associations between physical activity levels,
general health and psychological health [29–33], pro-
spective studies of these associations are lacking [34].
Furthermore, the pathways between obesity and psycho-
logical health remain to be clarified: overall there is stron-
ger evidence that depression leads to later obesity [35,36]
than obesity leading to later depression [37]. Understand-
ing the longitudinal associations between physical health
and psychological health will enable the further identifi-
cation of risk factors, which are potentially modifiable.
Using longitudinal data from a community sample of
UK adolescents, we examine the contribution of physical
health and health-risk behaviours to the development of
psychological distress and depressive symptoms. It was
hypothesized that engaging in health-risk behaviours
(smoking, alcohol use, drug use or the co-occurrence of
these behaviours), general health, being overweight or
obese, being physically inactive and long-standing illness
would increase the risk of later psychological distress and
depressive symptoms.
METHODS
The RELACHS study (Research with East London Adoles-
cents: Community Health Survey) is a longitudinal
school-based questionnaire study of a representative
sample of adolescents attending 28 schools in East
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
127
London. The schools were selected randomly and bal-
anced in terms of single-gender and mixed-gender
schools. Two classes from each year group were selected
from each school, which gives unequal probabilities of
selection. At baseline, 2790 adolescents from year 7 (11–
12 years) and year 9 (12–14 years) took part (84%
response rate, 73% from non-white UK ethnicities). The
participants were followed-up 2 years later when the ado-
lescents were in year 9 (13–14 years) and year 11 (15–
16 years), resampling 75% of the baseline participants.
Reasons for loss to follow-up included having left school
between phases (7.8%), being absent from school with no
reason (6.5%), parent opt-out (2.4%), being absent for
other school activities (1.5%) and pupil opt-out (1.1%).
Measures
The questionnaire contained the same questions relating
to psychological health, physical health and health-risk
behaviours at baseline and follow-up.
Psychological health
Two measures of psychological health were used. Psy-
chological distress was measured by the self-report
Strengths and Difficulties Questionnaire (SDQ) [38,39],
which is a psychometrically valid instrument for assess-
ing psychological morbidity in British adolescents. An
overall score on the SDQ is derived by summing four
subscales relating to conduct problems, emotional
difficulties, hyperactivity and peer relationship problems.
A dichotomous measure of psychological distress was
derived, with a score equal or greater than 18 on the total
difficulties scale indicating caseness [40]. Depressive
symptoms were measured using the Short Moods and
Feeling Questionnaire (SMFQ) [41]. A dichotomous
measure of depressive symptoms was derived, with a
score of 8 or more symptoms indicating a high score.
Physical health and health-risk behaviours
Physical health and health-risk behaviour outcomes in
the baseline questionnaire included general health status
(very good, good versus fair, bad, very bad), presence of a
long-standing illness (asthma, eczema, epilepsy, diabetes,
hearing problems, eyesight problems, hayfever, chronic
fatigue syndrome/ME or other chronic illness), physical
activity (active versus inactive, exercising more or less
than twice a week for an hour [42], smoking behaviour
(never smoked versus ever tried or regular smoker) [43],
alcohol use (never tried, tried alcohol, consumed alcohol
in the past week) [43] and drug use (never tried versus
tried drugs—cannabis, glue/solvents/gas, ecstasy, crack,
heroin, amphetamines, LSD, cocaine, khat) [43]. A com-
posite measure of health-risk behaviour was created from
Addiction, 102, 126–135
128 Charlotte Clark et al.
the smoking behaviour, alcohol use and drug use ques-
tions, which measured whether the participant had
engaged in none, one, or two or more of these behaviours,
as published previously [24]. The composite measure of
health-risk behaviour was substance-specific and did not
include any additional health-risk behaviours such as
sexual activity.
In addition, at baseline all participants had their
height (Leicester portable stadiometer, CMS Camden Ltd,
London) and weight (Tanita Body Fact 300 electronic
scales, Tanita UK, Yiewsley, Middlesex) measured by
trained researchers working to a strict protocol [44].
These data were used to derive obesity and overweight
outcomes for the sample, using the 1990 growth refer-
ence (UK 90) definitions [45]. Obesity was defined as a
body mass index (BMI) above the 95th percentile and
overweight (which included obesity) being above the
85th percentile.
Socio-economic status and ethnicity
Socio-economic status was measured using data on each
pupil’s eligibility for free schools meals, which was pro-
vided by schools and Local Education Authorities. Free
school meals are known to be a reliable indicator of
socio-economic status in UK studies of young people [46].
Ethnicity was assessed using an adaptation of the Census
2001 questions; eight groups were use in the analysis
(White UK, White Other, Bangladeshi, Pakistani, Asian,
Indian, Black, Mixed, Other).
Procedure
Parents were informed by letter about the study and
passive parental consent was sought (with active opt-
out). The participants were informed verbally about the
study and gave written consent to take part. The ques-
tionnaire was group administered and completed by the
participants in classrooms under the supervision of the
research team, who answered any questions and checked
questionnaires for missing data. The research team also
took physical measurements in the classroom during this
session. Ethical approval was obtained from the East
London and City Local Research Ethics Committee.
Statistical analysis
All analyses were weighted to take account of unequal
probabilities of selection and differential sample attrition.
Logistic regression analyses were conducted to compare
the risk for psychological distress or depressive symptoms
at follow-up by physical health and health behaviours at
baseline (model 1). This model was then additionally
adjusted for psychological distress or depressive symptoms
at baseline (model 2). Model 1 was additionally conducted
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
on a subsample with no psychological health problems at
baseline (model 3). All models were adjusted for age,
gender and their interaction, eligibility for free school
meals and ethnicity. In addition, two versions of each
model were conducted; the first adjusted for the individual
smoking, alcohol and drug health-risk behaviours at base-
line, the second adjusted for the composite measure of
these health-risk behaviours at baseline. Odds ratios and
corresponding 95% confidence intervals were calculated
using the logistic regression command in STATA (version
8), with the cluster option specified to take into account
the clustering of pupils within schools. This option allows
for dependence between pupils in the same school.
RESULTS
The analyses were conducted on data from participants
who had completed both the baseline and follow-up
survey and had complete data on psychological
and physical health, as well as health behaviours
(unweighted n = 1615 for psychological distress;
unweighted n = 1513 for depressive symptoms). Analy-
ses were not stratified by gender, as there were no signifi-
cant gender interactions between the predictors and
outcome measures. Loss to follow-up was greater for
respondents from the White UK, White Other and Mixed-
race ethnicities but did not differ by age group.
Rates of psychological distress and depressive symptoms
from baseline to follow-up
Table 1 shows the cross-sectional proportion of partici-
pants reporting psychological distress and depressive
symptoms by gender and age group, at baseline and
follow-up. There were no significant gender differences in
rates of psychological distress at baseline or follow up
(baseline: males 8.9%, females 9.3%; follow up: males
10.1%, females 12.9%). Female participants reported sig-
nificantly higher rates of depressive symptoms than male
participants at baseline and follow-up (baseline 26.4%
compared with 18.3%; follow-up 33.7% compared with
20.0%). There were no significant age differences in rates
of psychological distress or depressive symptoms at base-
line or follow-up. Females were significantly more likely to
report depressive symptoms at both baseline and follow-
up, compared with males. Rates of psychological distress
and depressive symptoms did not vary significantly by
socio-economic status (results not shown), which is con-
sistent with an earlier finding for the baseline data [40].
Table 2 shows the longitudinal association between
psychological distress and depressive symptoms at base-
line and follow-up. Few young people reported experienc-
ing psychological distress at both baseline and follow-up;
however, there was a stronger continuity between
Addiction, 102, 126–135
 Table 1 Cross-sectional relationship between the proportion of participants with psychological distress (SDQ) and depressive symptoms (MFQ) by gender and age group, at baseline and follow-up (n, %).

SDQ MFQ

Not a case Case at Not a case Case at Not a case Case at Not a case Case at
at baseline baseline n (%) at follow-up follow-up at baseline baseline at follow-up follow-up)
n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Gender
Males 714 (91.1) 70 (8.9) 705 (89.9) 79 (10.1) 586 (81.7) 131 (18.3) 574 (80.0) 143 (20.0)
Females 729 (90.7) 75 (9.3) 700 (87.1) 104 (12.9) 564 (73.6) 202 (26.4) 508 (66.3) 258 (33.7)
P-value for c2 between gender 0.782 0.074 < 0.001 < 0.001
Bases (weighted) 1588 1588 1483 1483

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Age group
Year 7/9 635 (90.2) 69 (9.8) 620 (87.9) 85 (12.1) 496 (78.0) 141 (22.0) 473 (74.4) 163 (25.6)
Year 9/11 807 (91.3) 77 (8.7) 786 (89.0) 97 (11.0) 652 (77.1) 194 (22.9) 608 (71.8) 239 (28.2)
P-value for c2 between age group 0.460 0.505 0.675 0.267
Bases (weighted) 1588 1588 1483 1483

Unweighted base = 1615 for SDQ: Strengths and Difficulties Questionnaire (800 for males, 815 for females); unweighted base = 1513 for MFQ: Moods and Feelings Questionnaire (737 for males, 776 for females).
Health behaviour predictors of psychological symptoms
129

Addiction, 102, 126–135

130 Charlotte Clark et al.

Table 2 Longitudinal relationship between the proportion of participants with psychological distress (SDQ) and depressive symptoms
(MFQ) at baseline and follow-up (n, %).

Overall Males Females

Not a case Case at Not a case Case at Not a case Case at

at follow-up follow-up at follow-up follow-up at follow-up follow-up
n (%) n (%) n (%) n (%) n (%) n (%)

SDQ
Not a case at baseline 1313 (82.7) 130 (8.2) 655 (83.5) 59 (7.5) 658 (81.8) 71 (8.8)
Case at baseline 93 (5.9) 52 (3.3) 50 (6.4) 20 (2.6) 43 (5.3) 32 (4.1)
P-value (McNemar test*) 0.016 0.444 0.011
Bases (weighted)† 1588 784 804
MFQ
Not a case at baseline 925 (62.4) 224 (15.1) 499 (69.7) 86 (12.0) 426 (55.6) 138 (18.0)
Case at baseline 156 (10.5) 178 (12.0) 74 (10.3) 57 (8.0) 82 (10.7) 120 (15.7)
P-value (McNemar test*) < 0.001 0.385 < 0.001
Bases (weighted)‡ 1483 716 766

*Compares baseline with follow-up; †unweighted base = 1615 for SDQ: Strengths and Difficulties Questionnaire (800 for males, 815 for females);
‡unweighted base = 1513 for MFQ: Moods and Feelings Questionnaire (737 for males, 776 for females).

depressive symptoms at baseline and follow-up: 12.0%
reported depressive symptoms at both phases, while only
3.3% reported psychological distress at both phases.
Psychological distress, depressive symptoms and
physical health and health-related behaviours
two or more health-risk behaviours at baseline predicted
depressive symptoms for those with and without depres-
sive symptoms at baseline. Having tried drugs at baseline
was associated with depressive symptoms at follow-up
but not for the subsample without depressive symptoms
at baseline.

Tables 3 and 4 compare the physical health and health

behaviours at baseline of young people with psychologi- DISCUSSION
cal distress and depressive symptoms at follow-up. Young
Having tried drugs or engaged in two or more health-risk
people with psychological distress and depressive symp-
behaviours (smoking, alcohol use or drug use) predicted
toms at follow-up were more likely to have had poor
psychological distress and depressive symptoms over a
general health, to have consumed alcohol in the past
2-year period in an ethnically diverse sample of young
week, to have tried drugs and to have engaged in two or
people. Psychological distress was predicted additionally
more health-risk behaviours at baseline.
by general health status and having tried or regularly
Odds ratios for psychological distress at follow-up were
consumed alcohol at baseline. These findings were robust
significantly higher for young people who also reported
after adjustment for baseline measures of psychological
psychological distress at baseline (Table 3). Having con-
symptoms with the exception of alcohol use, which was
sumed alcohol in the past week, having tried drugs and
borderline significant. Smoking on its own, long-standing
having poorer health at baseline predicted psychological
illness, obesity/overweight and activity levels were not
distress at follow-up. Engaging in two or more health-risk
associated with increased risk for psychological distress
behaviours at baseline was associated with increased risk
or depressive symptoms. The associations between
of psychological distress at follow-up. These findings were
physical health and health-risk behaviours at baseline
robust after adjustment for psychological distress at base-
and psychological health were moderate and stronger
line, with the exception of having consumed alcohol,
associations existed between psychological health at
which was borderline significant. Few associations were
baseline and follow-up.
observed for the subsample with no psychological distress
at baseline, and only having tried drugs or engaging in
What the results might mean
two or more health-risk behaviours increased the risk of
psychological distress at follow-up. Overall, health-risk behaviours showed moderate rela-
Odds ratios for depressive symptoms at follow-up were tionships with psychological health over a 2-year period,
significantly higher for young people who reported indicating that the targeting of health-risk behaviours
depressive symptoms at baseline (Table 4). Engaging in may reduce the burden of disease in terms of adolescent

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 102, 126–135
 Table 3 Multivariate odds ratios for psychological distress at follow-up predicted by baseline physical health and health related behaviours.

Proportions
with and without
psychological
distress at follow-up Model 1† Model 2† Model 3†‡
for each baseline factor n = 1615 n = 1615 n = 1461

Baseline risk factors n§ Not a case Case OR 95%CI OR 95%CI n OR 95%CI

Version A
Fair, poor or very poor health 421 24.2 36.8 1.69** 1.21, 2.36 1.46* 1.03, 2.09 352 1.34 0.84, 2.15
Long-standing illness 433 26.6 30.2 1.04 0.77, 1.39 0.97 0.69, 1.38 379 1.23 0.84, 1.82
Overweight 554 33.9 39.0 1.12 0.79, 1.58 1.15 0.82, 1.61 496 1.14 0.81, 1.60
Tried or regular smoker 571 35.5 41.0 0.99 0.72, 1.35 0.98 0.71, 1.36 508 0.98 0.67, 1.43
Not consumed alcohol in past week 333 21.1 31.3 1.43 0.76, 2.68 1.48 0.78, 2.80 300 1.38 0.73, 2.59
Consumed alcohol in past week 79 5.3 13.4 2.14* 1.01, 4.51 2.05 0.94, 4.48 67 1.51 0.69, 3.29

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Inactive 827 48.9 45.6 0.88 0.67, 1.16 0.91 0.69, 1.20 724 0.90 0.64, 1.24
Tried drugs 154 8.7 16.5 1.71* 1.10, 2.64 1.49 0.97, 2.31 127 *1.62 1.02, 2.59
SDQ case at baseline 154 6.3 3.3 – – 5.19*** 3.32, 8.11 – –
Version B
Obesity 317 19.2 23.1 1.10 0.71, 1.69 1.10 0.72, 1.80 218 0.94 0.61, 1.46
Version C
One health-risk behaviour 474 36.5 38.8 1.17 0.77, 1.76 1.11 0.75, 1.64 426 1.04 0.65, 1.66
Two or more health-risk behaviours 294 24.4 40.2 2.05** 1.30, 3.23 1.95** 1.18, 3.22 257 1.86* 1.05, 3.29

***P < 0.001, ** P < 0.01, *P < 0.05. †All models are adjusted for age, gender, gender ¥ age, ethnicity, eligibility for free school meals. Version A further adjusts for general health status, long-standing illness, overweight, smoking,
alcohol use, drug use. Version B as Version A but adjusts for obesity rather than overweight. Version C as Version A but adjusts for clustering of health-risk behaviours rather than the individual smoking, alcohol and drug use
variables. ‡Model run on subsample who did not have psychological distress at baseline. §Number of respondents reporting the behaviour at baseline out of the total n = 1615: SDQ Strengths and Difficulties Questionnaire.
Health behaviour predictors of psychological symptoms
131

Addiction, 102, 126–135

 132

Table 4 Multivariate odds ratios for depressive symptoms at follow-up predicted by baseline physical health and health related behaviours. †

Proportions
with and without
depressive
Charlotte Clark et al.

symptoms at follow-up Model 1† Model 2† Model 3†‡

for each baseline factor n = 1513 n = 1513 n = 1170

Baseline risk factors n§ Not a case Case OR 95%CI OR 95%CI n OR 95%CI

Version A
Fair, poor or very poor health 402 23.6 33.2 1.42*** 1.15, 1.76 1.22 0.96, 1.55 267 1.14 0.83, 1.56
Long-standing illness 401 26.2 27.9 1.03 0.84, 1.25 0.96 0.78, 1.18 286 0.95 0.74, 1.22
Overweight 521 33.1 38.9 1.20 0.95, 1.53 1.16 0.90, 1.50 385 1.20 0.91, 1.57
Tried or regular smoking 533 34.5 40.4 1.17 0.88, 1.56 1.07 0.80, 1.43 358 1.29 0.96, 1.72
Not consumed alcohol in past week 320 22.1 23.9 1.10 0.78, 1.55 1.03 0.70, 1.50 228 0.88 0.53, 1.47
Consumed alcohol in past week 76 5.5 8.0 1.38 0.84, 2.26 1.52 0.90, 2.56 59 1.39 0.81, 2.36
Inactive 772 50.2 44.5 0.93 0.69, 1.25 0.96 0.71, 1.29 585 1.01 0.71, 1.45

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Tried drugs 148 8.0 15.0 1.84*** 1.27, 2.66 1.79*** 1.25, 2.57 102 1.72 0.95, 3.10
MFQ case at baseline 343 10.6 12.1 – 4.34*** 3.32, 5.68 – –
Version B
Obesity 296 19.1 21.4 1.04 0.80, 1.36 0.99 0.75, 1.30 214 0.92 0.57, 1.48

Version C
One health-risk behaviour 449 35.8 40.5 1.42 0.96, 2.09 1.28 0.86, 1.90 335 1.49* 1.02, 2.18

Two or more health-risk behaviours 278 24.4 32.7 1.74*** 1.25, 2.41 1.53* 1.07, 2.19 195 1.67* 1.11, 2.51

***P < 0.001, *P < 0.05. †All models are adjusted for age, gender, gender ¥ age, ethnicity, eligibility for free school meals. Version A further adjusts for general health status, long-standing illness, overweight, smoking, alcohol use,
drug use. Version B as Version A but adjusts for obesity rather than overweight. Version C as Version A but adjusts for clustering of health-risk behaviours rather than the individual smoking, alcohol and drug use variables. ‡Model
run on subsample who did not have depressive symptoms at baseline. §Number of respondents reporting the behaviour at baseline out of the total n = 1513: MFQ Moods and Feelings Questionnaire.

Addiction, 102, 126–135

 Health behaviour predictors of psychological symptoms
psychological health and early adulthood psychological
health. Stronger associations existed between psychologi-
cal health at baseline and follow-up. Young people with
psychological ill-health at baseline were four to five times
more likely to experience psychological distress or depres-
sive symptoms at follow-up, suggesting that prevention
strategies may be more successful in reducing the burden
of disease by focusing on young people with a history
of psychological ill-health, as well as health-risk
behaviours.
In terms of individual health-risk behaviours, drug
use showed the strongest associations with later psycho-
logical health and our findings support the argument for
drug use preceding psychological distress [8,21]. Drug
use in this sample, particularly the younger age group
(aged 11–12) is indicative of non-normative behaviour,
so we should not be surprised that it relates to later psy-
chological health problems. The association between
having consumed alcohol at baseline and psychological
distress at follow-up was of borderline significance after
adjustment for psychological distress at baseline, support-
ing a previous study which found no prospective associa-
tion between alcohol use and depression after adjustment
for prior psychological health [22]. Together these studies
provide limited support for the argument that alcohol use
precedes depressive symptoms [20].
Surprisingly, no associations were demonstrated
between smoking and later psychological health, con-
trary to previous findings [9–12]. The lack of replication
may be because our sample are younger than in previous
studies; few respondents reported smoking regularly
(> 1 cigarette a week), and in our analyses regular
smokers were combined with respondents who reported
having tried smoking, which may have limited the power
of the analyses.
No gender differences were found in the associations
between health-risk behaviours and psychological
health, suggesting that risk does not differ for males and
females. While our findings are in contrast to those of
some recent studies [20,21,47], our sample is younger
and it is possible that gender differences in these associa-
tions develop in later adolescence.
Prevention strategies targeting young people engag-
ing in co-occurring substance use, rather than specific,
individual substance use behaviours, may reduce the
burden of disease. This study is unable to cast light upon
theories of the co-occurrence of health-risk behaviours.
Study of the development of the co-occurrence of
health-risk factors would require more frequent longitu-
dinal data collection than the 2-year time-frame of this
study. From our data it is unclear whether use of one
substance leads to experimentation with other sub-
stances or whether there are shared risk factors for sub-
stance use. Previous studies have found that the key
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
133
pathways for accessibility to substances are through
peers and siblings who are already users [48–52].
Our findings partially support previous findings relat-
ing to physical health behaviours and risk of psychologi-
cal ill-health. We found a significant association between
general health and psychological health, supporting pre-
vious cross-sectional findings [29,30]. Interestingly, no
association was found for long-standing illness, which we
might expect to show a similar relationship with psycho-
logical health. One reason for this is that perceived
general health may encompass a physical and psycho-
logical evaluation of health, whereas long-standing
illness reflects only physical health. It is likely that an
evaluation of health with a psychological component
would be associated with mental health bias. Our findings
suggest that young people with poor general health may
be a vulnerable group at risk of developing psychological
ill-health.
Measures of overweight and obesity showed little rela-
tionship with psychological health over a 2-year period.
Previous studies have also failed to demonstrate an asso-
ciation between obesity and later depression, but have
found an association between depression and later
obesity [33,35,36]. We found no association between
levels of physical activity at baseline and psychological
health at follow-up, unlike a recent cross-sectional study
that found an association in males [33]. The lack of asso-
ciations observed between physical health and psycho-
logical health could reflect the relatively short follow-up
period of the study. Pathways of risk between obesity and
physical activity, and psychological health may occur
later in adolescence or take longer to develop than the
2-year time frame of this study.
Strengths and limitations
Earlier studies have been limited in the range of physical
health and health-risk behaviours examined. This study
of a representative ethnically diverse sample of East
London adolescents has used validated questions to inves-
tigate the risk associated with a wide range of physical
health and health-risk behaviours for adolescent psycho-
logical health. This study has a high participation rate at
baseline and follow-up.
The follow-up period of the study was limited to 2
years, which may affect the strength of associations
observed for some predictors and limit the conclusions
that can be drawn about pathways of causality between
general health, health-risk behaviours and psychological
health. In addition, further risk factors such as peer and
sibling influences on substance availability and sexual
activity were not assessed at baseline. The analyses are
based on self-report and are also limited to participants
with complete data for all the outcomes. We may have
Addiction, 102, 126–135
134 Charlotte Clark et al.
lost psychologically distressed participants from the
sample, but this seems less likely over a 2-year period; in
addition, psychologically distressed participants may be
more likely to have been absent from school during data
collection. While we have controlled for previous psycho-
logical health at baseline, the life-course history of psy-
chological health for these participants is unknown.
CONCLUSIONS
Building on previous findings that indicate that indi-
vidual substance use increases the risk for young people’s
psychological health [20,21], the results of this study
suggest that prevention strategies that target young
people engaging in co-occurring substance use may also
be a beneficial strategy for reducing the level of psycho-
logical disorders in young people. In addition, this study
illustrates, with a community sample, that the most vul-
nerable young people are those with previous psychologi-
cal ill-health, indicating that prevention strategies should
not focus solely on health-risk behaviours.
Acknowledgements
We are grateful for the support of the schools, parents
and students involved in this study, as well as the Com-
munity Advisory Board. We also thank the field team,
including Wendy Isenwater, Giash Ahmed, Sarah
Brentnall, Sultana Choudry-Dormer, Franca Davenport,
Davina Woodley-Jones, Amanda Lawrence, Rachel
Cameron and Hannah Bennett. Charlotte Clark is sup-
ported by an Academic Fellowship from the EPSRC; Muna
Arephin is supported by an ESRC award ‘Development
and persistence of human capability and resilience in the
social and geographical context’, reference number
L326253061. Phase 1 of the RELACHS study was com-
missioned by the East London and the City Health
Authority and Phase 2 by the Teenage Pregnancy Unit at
the Department of Health: we thank them for their
support. We also thank Tower Hamlets, City and Hackney
and Newham Primary Care Trusts for additional funding.
The study has been carried out independently from the
funders.
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