Open Journal of Depression
2013. Vol.2, No.1, 1-6
Published Online February 2013 in SciRes (http://www.scirp.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2013.21001
The Mediating Effects of Social Support and Coping on the
Stress-Depression Relationship in Rural and Urban Adolescents
Einar B. Thorsteinsson1, Stephanie Mariee Ryan1, Sigrun Sveinbjornsdottir2
1University of New England, Armidale, Australia
2University of Akureyri, Akureyri, Iceland
Received November 7th, 2012; revised December 10th, 2012; accepted December 18th, 2012
This study examined the relationship between potential risk and protective factors for depression among
167 girls and 343 boys in urban and rural areas of NSW, Australia. The risk and protective factors in-
cluded social support, coping style, and perceived stress. The results indicated no significant differences
in depression and risk and protective factors for rural and urban adolescents. Maladaptive coping (rumi-
nation and acting out) and social support (satisfaction and number of supporters) were partial mediators of
the relationship between perceived stress and depression with the overall model explaining 66% of the
variance in depression. Thus changes to coping and to social support network need to be addressed in any
intervention aimed at reducing the impact of perceived stress on depression in adolescents.
Keywords: Social Support; Depression; Coping; Perceived Stress; Adolescent
Introduction
It is well recognized that adolescence is a major transitional
period in a person’s life (Dumont & Provost, 1999) including
unusually large cognitive, emotional, social, and physical
changes (Seiffge-Krenke, Weidemann, Fentner, Aegenheister,
& Poeblau, 2001). Recent neurobiological research indicates
that adolescents, around puberty in particular, may be overly
sensitive to stress as compared with children and adults (Romeo,
2010). Adolescence has been described as a sensitive period
due to brain development, a phase in the life-span where vul-
nerability towards development of depression is heightened
(Andersen & Teicher, 2008). In general, adolescents experience
stressful situations such as those concerning family relations,
school performance, interpersonal relationships (friends and
romantic partners), and financial restraints (Byrne, Davenport,
& Mazanov, 2007; Moksnes, Byrne, Mazanov, & Espnes,
2010). If the demands of these situations exceed the individu-
als’ capacity to cope there will be an increased risk of depres-
sion, anxiety, and/or drug and alcohol abuse.
Depression in adolescence has been linked with negative
health effects and found to be a predictor of depression in adul-
thood (Reinherz et al., 1989), especially if it is diagnosed in
combination with oppositional defiant disorder, anxiety and
substance use (Copeland, Shanahan, Costello, & Angold, 2009).
As many as a quarter of those with major depressive disorder
during adulthood have reported onset during childhood or ado-
lescence (Sorenson, Rutter, & Aneshensel, 1991). For the pur-
pose of prevention, it is important to identify possible protec-
tive and risk factors for depression during adolescence.
Findings suggest that protective factors for depression might
include adaptive coping (e.g., seeking social support), and high
social support (satisfaction with support and network size).
Thus, social support has been found to protect against the ef-
fects of stress in adults (Cohen & Wills, 1985) and adolescents
(Burke & Weir, 1978; Levitt, Guacci Franco, & Levitt, 1993),
and to attenuate the effects of stress on psychological problems
(Schmeelk-Cone & Zimmerman, 2003). Several studies have
already shown the importance of social support in reducing the
impact of stressful situations on cardiovascular reactivity
(Thorsteinsson & James, 1999; Thorsteinsson, James, Douglas,
& Omodei, 2011), suggesting that support plays a causal role in
protecting the individual’s cardiovascular health. A growing
interest for neurobiological aspects of resilience to stress is
noted, not least to explore the complex interaction between
social support, developmental stage and diverse social factors
(Ozbay, Fitterling, Charney, & Southwick, 2008).
In relation to coping, research shows that well-adapted ado-
lescents use more mature coping strategies than poorly adapted
adolescents (Jorgensen & Dusek, 1990) and they are more ac-
tive in dealing with stress (Tolor & Fehon, 1987). Consequently,
adolescents who approach their challenges are better adjusted
than those who avoid them (Ebata & Moos, 1991); they have
fewer behavioral problems and a higher level of ego develop-
ment (Recklitis & Noam, 1999). Avoidant or maladaptive cop-
ing, such as rumination and acting out, is repeatedly reported as
a risk factor for depression. Thus, rumination is suggested as a
vulnerability factor for both adolescent depression and sub-
stance use (Skitch & Abela, 2008). A longitudinal study in-
cluding early versus late adolescence revealed that when active
coping was present in early adolescence it predicted less per-
ceived stress later on towards the same stressors regardless of
situations (Seiffge-Krenke, Aunola, & Nurmi, 2009). However,
if internal coping (e.g., withdrawal, rumination) was commonly
used in early adolescence then the outcome was reversed with
the stress perception being high in late adolescence.
Maladaptive coping such as aggressive or disruptive beha-
vior (acting out, anger) is repeatedly reported as a risk factor for
depression and thus it is correlated with greater depression
relative to those who use adaptive coping (i.e., problem solving
and seeking social support; Galaif, Sussman, Chou, & Wills,
2003; Jose et al., 1998; Kosterman et al., 2010; Murberg & Bru,

E. B. THORSTEINSSON ET AL.
2005). Likewise, Murberg and Bru (2005) found that aggressive
coping was related to depression and that anger coping sus-
tained depression, perceived stress, and the use of illicit drugs.
Seiffge-Krenke and Klessinger (2000) reported that avoidant
coping was consistently associated with higher levels of de-
pressive symptoms while approach oriented coping was not.
The use of maladaptive coping (e.g., rumination) may thus
influence the way adolescents respond to depression and con-
sequently the duration of depressive episodes.
Adolescents in rural areas may be faced with higher levels of
depression and stress than adolescents in urban areas. Day,
Kane, and Roberts (2000) examined the prevalence rates of
stress and depression in rural Western Australia and reported
that rural dwellers experience high situational stress on a
day-to-day basis including isolation and income factors. Day et
al. propose in their review that stress and depression in rural
populations might be higher than in urban populations. How-
ever, previous research using an adult sample contradicts this
suggestion proposing instead that rural populations have lower
levels of depression (Crowell, George, Blazer, & Landerman,
1986). Social geography research into areas such as rural geog-
raphy, mental health geography, and the social geographies of
caring challenges the “idyllic nature of rural life” (Boyd & Parr,
2008), and suggests that there may be differences between rural
and urban populations. Social geography suggests that rural
populations have to deal with difficult mental health issues just
like urban populations. They also may have to cope with li-
mited resources or access to mental health services (Aisbett,
Boyd, Francis, Newnham, & Newnham, 2007), and individuals
with mental illness in rural areas may also feel more isolated
from their community (Boyd & Parr). Quine et al. (2003), in a
rural versus urban sample, found higher levels of depression,
youth suicide, and teenage pregnancy. They believed this could
be explained by a structural imbalance between urban and rural
adolescents in Australia because rural adolescents report fewer
educational, occupational, and recreational opportunities. In
rural adolescent populations, depression has been found to cor-
relate negatively with peer- and family social support, self-
esteem, and optimism in rural adolescents (Weber, Puskar, &
Ren, 2010).
Based on the findings reported above, it was hypothesized
that 1) rural adolescents would have higher levels of perceived
stress and depression than their urban counterparts; 2) low so-
cial support would be associated with high depression; 3) high
maladaptive coping would be associated with high depression
and low social support; 4) social support would mediate (reduce)
the effects of perceived stress on depression; 5) adaptive coping
would mediate (reduce) the effects of perceived stress on de-
pression; and 6) that maladaptive coping would mediate (aug-
ment) the effects of perceived stress on depression.
Method
Participants
There were 510 participants with complete data, 343 boys
and 167 girls. Participants were between the ages of 14 and 18
(M = 15.50, SD = .89). Participants were from rural (n = 123,
schools outside large cities in New South Wales, Australia) and
urban (n = 387, schools in Sydney, NSW, Australia) areas. All
were private schools but with diverse student populations in
terms of family socioeconomic background given the schools’
online profile, location, and religious denomination. The schools
were all non-government and included three independent and
three low-fee paying Catholic schools.
Of 697 questionnaires 187 were excluded as they were empty
or with very limited information. Thus there was a participation
rate of 73%. No comparison of excluded versus included par-
ticipants was possible due to the extent of missing data in the
excluded group.
According to the norms of the depression scale, about 14%
of the sample had “extremely severe” depression, 7% “severe”,
15% “moderate”, 10% “mild”, and 53% had “normal” levels.
Measures
Depression was measured by the depression subscale on the
Depression, Anxiety, and Stress Scales (DASS-21; Lovibond &
Lovibond, 1995). The DASS-21 has good internal consistency
with alphas ranging from .87 to .94 for each of its 7-item
sub-scales, and adequate validity in a variety of populations
(Antony, Bieling, Cox, Enns, & Swinson, 1998). The scale is a
4 point Likert scale ranging from 0 (Did not apply to me) to 3
(Applied to me very much, or most of the time) to answer ques-
tions such as “I felt that life was meaningless”. In the present
study, the internal reliability for the depression sub-scale
was .90. Total scores were averaged rather than summed across
items to keep the link between the total score and the anchors
on the 4-point scale.
Perceived stress was measured using the Perceived Stress
Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983). This is a
10-item measure of how often respondents have viewed their
life situations as stressful over the past month (Cohen et al.,
1983), such as “In the last month how often have you felt that
you were unable to control the important things in your life”.
The scale is a 5-point Likert scale, ranging from 0 (Never) to 4
(Very often). Items 4, 5, 7, and 8 are reverse-scored. The PSS is
the most widely used psychological instrument for measuring
the perception of stress (Cohen, 1988), and is correlated with a
variety of health symptoms and help-seeking behaviors (Cohen
et al., 1983). In the present study, internal reliability for the PSS
was .85.
The Measure of Adolescent Coping Strategies (MACS;
Sveinbjornsdottir, 2005; Sveinbjornsdottir & Thorsteinsson,
2012) is a 34-item scale, including five primary factors: (a)
distraction/stoicism, (b) acting out, (c) rumination, (d) seeking
social support, and (e) self-care. These five factors comprise
two dimensions, one adaptive (a, d, and e) and the other mal-
adaptive (b and c). It has cross-cultural validation and good
test-retest reliability and adequate internal reliability compared
with other adolescent coping scales (for a review of other
measures see Sveinbjornsdottir & Thorsteinsson, 2008). The
MACS was standardized through exploratory factor analysis
and the participation of 3034 Australian adolescents and 6908
Icelandic adolescents. The factor structure has been tested using
confirmatory factor analysis and found to be good, CFI = .94,
TLI = .92, GFI = .95, RMSEA = .054 [90% CI .045, .064], and
SRMR = .063 (Sveinbjornsdottir & Thorsteinsson, 2012). Par-
ticipants were asked to think of a stressful situation they had
experienced during the recent past (i.e., something that hap-
pened at school, in their family, relations with other people, or
their health). They were then asked to circle a number for each
item on a 4-point Likert scale ranging from 0 (I did not use) to
3 (I used almost all the time). In the present study, the MACS
had an adequate internal reliability for distraction/stoicism
2

E. B. THORSTEINSSON ET AL.
of .72, acting out .77, rumination .73, seeking social support .70,
and self-care .71.
Social support was measured using the Social Support Ques-
tionnaire Short Form (SSQ6; Sarason, Sarason, Shearin, &
Pierce, 1987), a psychometrically sound and conveniently ad-
ministered instrument. It has good internal reliability and cor-
relates highly with the full-scale SSQ (Sarason et al., 1987).
The items have two parts. The first part of each item assesses
the number of available others (SSQN) the participant has who
he/she can rely on in times of need. An example of the type of
question is “Who do you know whom you can trust with infor-
mation that could get you into trouble”. In the second part of
the item, the participant is asked to indicate on a 6-point Likert
scale how satisfied (SSQS) he/she is with the overall support
from the number of people indicated in the first part ranging
from 1 (Very dissatisfied) to 6 (Very satisfied). In the present
study, internal reliability for the SSQS was .86 and for the
SSQN .93.
Procedure
Ethics approval was granted by the university’s human ethics
committee and participating schools. Participants were re-
cruited from schools in urban areas (Sydney, NSW, Australia)
and in rural areas of NSW (i.e., schools outside large cities).
Teachers approached students in their classes about participat-
ing in the study and consent forms were sent home to the par-
ents or guardians of the students. A day was organized for the
participating school to complete the questionnaires.
One participant had missing values for social support satis-
faction and number. These values were estimated using the
expectation-maximization (EM) algorithm within SPSS missing
values analysis. The following variables were used to predict
the missing values: age, sex, social support satisfaction and
number, DASS21 (depression, anxiety, and stress), MACS (dis-
traction/stoicism, acting out, rumination, seeking social support,
and self-care), and perceived stress.
SPSS (version 20) was used for routine statistical analyses in
raw and processed data with statistical significance set at .05
and expected mean differences to be above 0.30 standard de-
viation units (d). AMOS (version 20) was used for structural
equation modeling (SEM): modeling mediators of the perceived
stress-depression relationship. Recommendations by Kline
(2005) were used to select fit indices. The Comparative Fit
Index (CFI) ranges from 0 to 1, with those above .90 suggest-
ing good fit, for the Root Mean Square Error of Approximation
(RMSEA) and Squared Root Mean Residual (SRMR) a value of
0 represents perfect fit. RMSEA values below .08 and SRMR
values. 10 are generally interpreted as favorable. All parameters
for the model were estimated using AMOS’ maximum likeli-
hood algorithm.
Further testing of potential mediators was conducted using
the bootstrap method by Preacher and Hayes (2004) replacing
the Sobel test. This method compares coefficients for the total
effect, path c (effects of independent variable on the dependent
variable without any mediators) with the coefficient for the
direct effect c’ (effects of independent variable on the depend-
ent variable with any mediators included). There is significant
mediation if the c-c’ difference is larger than zero based on a
95% bootstrap generated confidence interval. Unstandardized b
coefficient with 95% confidence interval is reported, in square
brackets, to show if the proposed mediator mediates the pro-
posed relationship or not.
Results
There was no statistically significant difference between ur-
ban and rural populations for perceived stress or depression all
effect sizes being small (see Table 1), thus the samples were
analyzed as one. Social support satisfaction and number were
both significantly associated with depression (see Table 2).
High maladaptive coping, acting out and rumination were asso-
ciated with high depression. High acting out was associated
with low social support while high rumination was associated
with low support satisfaction but not low support number (see
Table 2). Examination of the mediation effects of social sup-
port and coping found that adaptive coping including distrac-
tion/stoicism b = .01 [−.01, .04], seeking social support b = .00
[−.01, .01], and self-care b = .00 [−.01, .01] did not mediate the
effects of perceived stress on depression. Acting out, b = .09
[.05, .13], and rumination, b = .09 [.04, .14] were partial me-
diators of the relationship between perceived stress and depres-
sion. Social support satisfaction, b = .04 [.01, .07] and number,
b = .04 [.02, .06] were partial mediators of the effects of per-
ceived stress on depression.
SEM was used to model these mediation effects showing that
perceived stress, maladaptive coping, and social support ex-
plained about 66% of the variance in depression (see Figure 1).
Discussion
The first hypothesis was not supported with little difference
in perceived stress and depression levels between rural and
urban adolescents contradicting suggestions by Day et al.
(2000), Crowell et al. (1986), and Quine et al. (2010). The se-
cond hypothesis was supported with high depression and low
social support (satisfaction and number of supporters) levels
being associated, thus supporting previous research and theory
(Burke & Weir, 1978; Cohen & Wills, 1985; Dumont & Pro-
vost, 1999; Levitt et al., 1993). High maladaptive coping was
associated with high depression and low social support thus
supporting the third hypothesis. The fourth hypothesis was
supported with social support mediating the effects of perceived
stress on depression expanding on the findings by Day et al.
(2000) and Weber et al. (2010). The fifth hypothesis was not
supported in that adaptive coping did not attenuate the effects
of perceived stress on depression. The final hypothesis was
supported, finding that maladaptive coping augmented the ef-
fects of perceived stress on depression.
The resulting model, as shown in Figure 1, supported the
hypotheses further showing that it is important to target both
maladaptive coping and social support to reduce the impact of
perceived stress on depression. The results showed that high
rumination (e.g., hoping that the problem will disappear or
Table 1.
Perceived stress and depression means (SD) for all, urban, and rural
participants with a comparison of urban and rural participants.
Measure All
(N = 510)
Urban
(n = 387)
Rural
(n = 123) d (CI95%)
Perceived
Stress 1.79 (.75)1.78 (.74) 1.85 (.76) .09 [−.11, .30]
Depression .84 (.81) .83 (.80) .88 (.84) .06 [−.14, .26]

E. B. THORSTEINSSON ET AL.
4
Table 2.
Correlation matrix for key variables (N = 510).
Variable 1 2 3 4 5 6 7 8
1. Perceived stress -
2. Support satisfaction −.28** -
3. Support number −.19** .47** -
4. Distraction/stoicism −.25** .18** .28** -
5. Acting out .37** −.22** −.19** −.12** -
6. Rumination .51** −.11* −.02 −.03 .40** -
7. Seeking support −.04 .23** .33** .43** .01 .20** -
8. Self-care −.11* .18** .26** .47** .03 .08 .50** -
9. Depression .66** −.30** −.30** −.22** .47** .51** −.11* −.12**
*p < .05 (two-tailed), **p < .01 (two-tailed).
Perceived
stress
Depression
Maladaptive
coping
.71
*
.17
*
[
.66
*
]
Rumination
.57
*
.70
*
.58
*
[.50
*
]
Acting out
Social
support
Social support
satisfaction
Support numbers
.68
*
.68
*
[.12
*
]
-.35
*
-.24
*
Figure 1.
The mediation of acting out and rumination of the perceived stress–depression relationship. Percentage of
variance explained given in square brackets. 2(18) = 68.29, p < .001, CFI = .970, TLI = .926, RMSEA
= .052 (.040, .066), SRMR = .044. *p < .05 (one-tailed).
hoping for a miracle) and high acting out (e.g., aggressive be-
havior) were important predictors of high depression levels
along with low social support (satisfaction and number). The
model in Figure 1 thus supports and expands on previous find-
ings presenting a testable model. The model supports previous
findings suggesting that engaging in maladaptive coping strate-
gies has negative repercussions for the adolescent (DeLongis &
Holtzman, 2005) and that social support attenuates the impact
of stress (e.g., Burke & Weir, 1978; Cohen & Wills, 1985; Day
et al., 2000; Dumont & Provost, 1999; Levitt et al., 1993).
Although the correlation between adaptive coping and de-
pression was in the expected direction, adaptive coping was not
a significant mediator of the perceived stress to depression
relationship. According to Delongis and Holtzman (2005), the
inconsistent findings in relation to adaptive coping may be due
to the nature of the situation evoking perceived stress levels, the
social context in which the coping occurs, and the personality
of the individual. The present findings might be interpreted to
mean that adaptive coping is ‘overshadowed’ by social support,
a construct related to seeking social support (Sveinbjornsdottir
& Thorsteinsson, 2012).
The small differences between the urban and rural adolescent
samples may have been due to a lack of any real differences
between these populations. However, there may be differences
in the type of stressful situations experienced by these groups
and not in the level of perceived stress, at least for adolescents.
Findings from social geography research (Boyd & Parr, 2008)
have not really been integrated into a mental health model cap-
turing the differences between urban and rural adolescents, thus
future studies might operationalise urban and rural based on
social geography research to help clarify any potential differ-
ences between urban and rural adolescents.
Cross-sectional studies do not address causal directions.
Therefore, more work is required to model the effects of coping
and social support on the stress to depression relationship. Lon-
gitudinal and experimental studies are needed to try and address
causal pathways. Despite a good participation rate, larger sam-
ples are needed to examine sex and location differences. The

E. B. THORSTEINSSON ET AL.
social support pathway may be more “important” for rural ado-
lescents than urban adolescents (Baume & Clinton, 1997) sug-
gesting that remote rural areas may be more at risk than rural
towns that are not so remote; in the present study remote rural
towns were not significantly represented.
Conclusion
These findings suggest that improving social support satis-
faction and networks may benefit adolescents through reduced
impact of perceived stress on depression levels. Similarly, re-
ducing maladaptive coping behavior may also lessen the impact
of perceived stress on depression. Consequently, in order to
replace maladaptive coping with adaptive coping and to im-
prove social networks, adolescents need to become aware of
and understand the impact their ways of coping and social net-
works may have on their well-being. For that purpose, educa-
tion in general and cognitive behavior therapy in clinical cases
might prove useful.
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