Salivary markers of stress in upper secondary school

U fiziološkom odgovoru na stres i kontroli stresnog odgovora uglavnom sudjeluju dvije komponente neuroendokrinog sustava, simpatičko-medularna (SAM) os, koja regulira prvi odgovor na stres i os hipotalamus-adenohipofiza-kora nadbubrežne žlijezde (HPAC), čija se aktivacija uočava 15 do 20 minuta nakon stresnog podražaja. Cilj ovog istraživanja bilo je ispitati bazalnu, fiziološku aktivnost SAM i HPAC osi te njihovu povezanost s nizom kovarijabli (spol, tip škole, turnus pohađanja nastave, ritam spavanja i budnosti te demografska, akademska i društvena obilježja) u zdravih učenika koji pohađaju završne razrede srednjih škola. Specifični ciljevi uključivali su ispitivanje koncentracije kortizola i aktivnosti alfa-amilaze kao salivarnih biljega odgovora na stres te istraživanje njihove povezanosti sa subjektivnim procjenama razine stresa i sa strategijama suočavanja sa stresom, kao i s polimorfizmima jednog nukleotida (SNP) gena za mineralokortikoidni i glukokortikoidni receptor (rs5522, rs6189, rs6190) te za vezni protein 5 za FK506 (rs1360780). U istraživanje su bila uključena 903 maturanta gimnazija i strukovnih škola iz četiri najveća grada u Hrvatskoj (Zagreb, Split, Rijeka i Osijek). Uzorci sline prikupljeni kod kuće, tijekom jednog radnog dana u tri vremenske točke (po buđenju, 30 do 45 minuta nakon buđenja i neposredno prije lijeganja), uzeti su za analizu koncentracija kortizola dok se aktivnost alfa-amilaze mjerila samo u jednom uzorku, neposredno po buđenju. Kako bi se ispitao cirkadijalni ritam lučenja kortizola analizirani su i indeksi lučenja kortizola (CAR, DCD, AUCG). Učenice su imale statistički značajno veće koncentracije kortizola u jutarnjim satima, dok se koncentracije kortizola neposredno prije lijeganja nisu razlikovale među spolovima. Učenice imaju različite obrasce priprema za izazove koji ih očekuju tijekom nadolazećeg dana u odnosu na učenike, imaju značajno viši CAR, izraženiji DCD, veći AUCG u odnosu na učenike koji su imali statistički značajno veću aktivnost alfa-amilaze. Turnus pohađanja nastave, koji svakako posljedično utječe na ritam spavanja i trajanje budnosti, pokazao se kao prediktor lučenja kortizola. Statistički značajne razlike većine varijabli kortizola potvrđene su između učenika koji pohađaju različite turnuse nastave (SCC30-45, CAR, DCD i AUCG). Učenici koji su se budili ranije i imali duže trajanje budnosti imali su veći CAR, niži DCD i veći AUCG. Nisu potvrđene statistički značajne razlike niti jedne ispitivane varijable u učenika koji pohađaju različite tipove škola (gimnazije vs. strukovne škole). Također, statistički značajne razlike između učenika i učenica bile su uočene i u subjektivnoj procjeni stresa, suočavanju te njihovoj povezanosti s koncentracijama i indeksima kortizola. Zabrinutost za budućnost su oba spola procijenila kao najstresniju domenu života, dok su učenice imale statistički značajno veću razinu ukupnog stresa u odnosu na učenike te su više koristile aktivno suočavanje sa stresom. U ovom su istraživanju pronađene statistički značajne razlike povezanosti alela G polimorfizma rs 5522 s višom koncentracijom kortizola po buđenju (P=0,036), nižim CAR-om (P=0,021), dok je povezanost s DCD-om bila granična (P=0,050). Može se pretpostaviti kako učenici s dokazanim alelom G imaju niži CAR te zbog toga pokazuju lošiju pripremljenost za stresne izazove u nadolazećem danu, unatoč nešto izraženijim vrijednostima DCD-a. Ovo istraživanje ukazuje na potrebu definiranja protokola prikupljanja uzoraka sline u nekliničkim uvjetima i metodoloških smjernica za populacijska istraživanja, ponajprije zbog postojanja niza kovarijabli koje utječu na mjerenje koncentracije kortizola i aktivnosti alfa-amilaze. Dobiveni rezultati doprinose saznanjima o spolnim razlikama u funkciji HPAC osi, koje bi se trebale primijeniti i tijekom provedbe preventivnih mjera u adolescenata te ranijeg otkrivanja skupina koje su posebno osjetljive na stresne poticaje.Physiological response to stress and the control of the stress response is mediated by two major components of the neuroendocrinological systems, sympathetic nervous (SAM) system and hypothalamic-pituitary-adrenal (HPA) axis. In the stress response, the SAM axis is first activated. About fifteen to twenty minutes following the SAM activation, the HPA axis is activated. The aim of the study was to examine basal, physiologically activity of the SAM and HPAC axis activity and to determine associations of various covariates (gender, school type, school shift, sleep-wake rhythm, demographic, academic and life style characteristics) with altered daily salivary cortisol profiles in healthy students attending finishing grades of secondary schools. Specific aims of the study were to analyse concentration of cortisol and activity of alpha- amylase, as salivary markers of stress reaction, to determine association of salivary markers of stress with stress perception and coping, and to determine associations of salivary markers of stress with single nucleotide polymorphisms (SNP) in the genes for the mineralocorticoid and glucocorticoid receptors (rs5522, rs6189, rs6190) and FK506 binding protein 5 (rs1360780). The study included 903 secondary school students enrolled in the finishing classes of gymnasiums and vocational schools from the four largest cities in Croatia (Zagreb, Split, Rijeka and Osijek). The saliva samples were collected at students’ homes, over the course of one weekday. Salivary cortisol was sampled at three time points: at awakening, 30 to 45 after wakening and at bedtime. Salivary alpha-amylase was sampled at awakening. In order to analyse the circadian rhythm of salivary cortisol secretion, three indexes were analysed (CAR, DCD and AUCG).Females had higher morning concentrations of salivary cortisol than males, whereas bedtime cortisol concentrations were not different in females and males. Females had different salivary cortisol profile and different mechanisms for preparing for the anticipated stress of the upcoming day, higher CAR, steeper DCD and larger AUCG than males. On the other side, males had higher activity of salivary alpha-amylase. School shift, and therefore the sleep-wake up rhythm, was an important predictor of the secretion of salivary cortisol. There were statistically significant differences in two school shifts with respect to the majority of salivary cortisol measures (SCC30-45, CAR, DCD and AUCG). Students who woke-up earlier and were longer awake had larger CAR, flatter DCD and larger AUCG. Students from two types of schools (gymnasiums vs. vocational schools) did not differ in any of the measured salivary variables. Furthermore, female and male students differed significantly in stress perception, coping and associations between stress perception, coping and salivary cortisol concentrations and indexes. Future was rated as the most stressful problem domain in both sexes. The perception of total stress was higher in females than males, and females used more active coping than males. Finally, we found statistically significant differences in associations between G allele of rs 5522 polymorphism and higher cortisol concentration at awakening (P=0.036), lower CAR (P=0.021) and higher DCD (P=0.050), but at borderline. It can be hypothesized that the G allele is associated with the lower CAR and therefore, decreased ability of preparing for the anticipated stress (despite borderline association with the steeper DCD). This study points to the need for defining the protocol for salivary sampling in non-clinical conditions and developing methodological guidelines for population-based research, primarily due to the number of co-variables that affect the concentration of salivary cortisol and the activity of salivary alpha-amylase. Obtained results contribute to better understanding of sex differences in the functioning of the HPA axis, which should be considered in the prevention of various psychopathological conditions in adolescence and used for earlier identification of vulnerable groups at high risk of stress-related health problems

Reference intervals for six salivary cortisol measures based on the Croatian Late Adolescence Stress Study (CLASS)

IN ENGLISH: INTRODUCTION: The aim of this nested study is to provide the reference intervals for already published measurements of salivary cortisol from the Croatian Adolescence Stress Study (CLASS). MATERIAL AND METHODS: A total of 969 individuals (372 males and 597 females) were included in the reference sample (age range: 18-21 years). Salivary cortisol concentrations were determined by the enzyme immunoassay (LUCIO-Medical ELISA Salivary Cortisol Kit, Nal von Minden, Germany) in the Department of Medical Laboratory Diagnostics, University Hospital Split. Nonparametric statistics were used for calculating the reference intervals (RIs) and 90% confidence intervals (90% CIs). RESULTS: The lower limits of RIs determined by the direct method were higher in females (> 10%) than in males for the cortisol concentrations at awakening (SCC0), 30 to 45 after awakening (SCC30-45) and at bedtime (SCCbedtime). The upper limits of RIs for the SCCbedtime were higher (> 10%) in males than in females. Females also had higher upper limits of RIs for the cortisol awakening response (CAR) and the diurnal cortisol slope (DCS) and higher lower limits of RIs for the CAR and the area under the curve with respect to ground (AUCG). The lower limits of RIs for the DCS were higher in males than in females. CONCLUSIONS: Obtained reference values open the arena for introducing salivary bioscience in Croatian clinical laboratory practice and provide important data for better understanding of gender differences in adaptation to stress during late adolescence. --------------- IN CROATIAN: UVOD: Cilj ove studije bio je definirati referentne intervale za objavljene mjere salivarnog kortizola iz Hrvatskog istraživanja stresa u kasnoj adolescenciji (CLASS). MATERIJALI I METODE: Ukupno 969 ispitanika (372 djevojaka i 597 mladića) uključeno je u referentni uzorak (18-21 godine starosti). Koncentracije salivarnog kortizola izmjerene su imunokemijskom ELISA metodom (LUCIO-Medical ELISA Salivary Cortisol Kit, Nal von Minden, Germany) u Zavodu za medicinsko laboratorijsku dijagnostiku Kliničkog bolničkog centra Split. Referentni intervali (RI) i 90%-tni intervali pouzdanosti (90% CI) izračunati su neparametrijskim metodama. REZULTATI: Donja granica referentnog intervala određena izravnom metodom veća je kod djevojaka (>10%) nego mladića za koncentracije kortizola u sve tri vremenske točke (po buđenju, 30-45 minuta nakon buđenja i neposredno prije lijeganja). Gornja granica referentnog intervala za koncentracije salivarnog kortizola neposredno prije lijeganja veća je kod mladića (>10%) u odnosu na djevojke. Također, djevojke imaju veću gornju granicu referentnog intervala za odgovor kortizola na buđenje (engl. cortisol awakening response, CAR) i cirkadijano smanjenje kortizola (engl. diurnal cortisol slope, DCS) te veću donju granicu referentnog intervala za CAR i površinu ispod krivulje u odnosu na nultu razinu (engl. area under the curve with respect to ground, AUCG). Indeks cirkadijanog smanjenja kortizola, DCS je u donjoj granici referentnog intervala veći kod mladića u odnosu na djevojke. ZAKLJUČCI: Objavljeni referentni intervali mjera salivarnog kortizola važni su zbog uvođenje salivarnih analiza u rutinsku kliničku praksu u RH i pridonose detaljnijim spoznajama o spolnim razlikama u adaptacijskim mehanizmima na stresne poticaje tijekom kasne adolescencije

Lažno pozitivni nalaz metadona u mokraći bolesnika liječenog kvetiapinom

We present a case of T.M. admitted to University Department of Psychiatry, Split University Hospital Center, in Croatia, because of the acute psychotic reaction (F23.9). The patient’s urine tested positive for methadone without a history of methadone ingestion. Urine drug screen was performed with the COBAS Integra Methadone II test kit (kinetic interaction of microparticles in solution /KIMS/ methodology) by Roche. Drugs that have been shown to cross-react with methadone feature a tricyclic structure with a sulfur and nitrogen atom in the middle ring, which is common for both quetiapine and methadone. Therefore, it is plausible that this structural similarity between quetiapine and methadone could underlie the cross-reactivity on methadone drug screen. Besides quetiapine, a number of routinely prescribed medications have been associated with triggering false-positive urine drug screen results. Verification of the test results with a different screening test or additional analytical tests should be performed to avoid adverse consequences for the patients.Testovi probira mokraće široko su prihvaćena metoda brzog otkrivanja moguće zloporabe psihoaktivnih supstanca. Najčešće korišteni testovi analize mokraće na droge su imunokemijske metode, unatoč činjenici da su prijavljeni brojni slučajevi lažno-pozitivnih rezultata za mnoge od testova za brzo otkrivanje. Potvrda mogućih pozitivnih probira mokraće na lijekove, koja je neophodna kako bi se smanjio broj prijava lažno pozitivnih rezultata, može biti skupa i zahtijevati veći utrošak vremena za analizu. Prikazuje se slučaj bolesnika T.M. zaprimljenog u Kliniku za psihijatriju Kliničkog bolničkog centra Split poradi akutne psihotične reakcije (F23). U mokraći bolesnika testiranog na metadon isti je otkriven, ali bez potvrde konzumacije istog. Analiza mokraće provedena je testom COBAS Integra Methadone II (kinetička interakcija mikročestica u otopini, metoda KIMS) tvrtke Roche. Lijekovi koji su pokazali križnu reaktivnost s metadonom sadrže tricikličnu strukturu s atomima sumpora i dušika u srednjem prstenu, što je zajedničko i kvetiapinu i metadonu. Stoga je za pretpostaviti da je strukturna sličnost kvetiapina i metadona uzrokom križne reaktivnosti u testu probira na metadon. Uz kvetiapin, velik broj rutinski propisivanih lijekova pokazao je povezanost s pojavom lažno-pozitivnih rezultata u testovima mokraće. Kako bi se izbjegle neželjene posljedice za bolesnike potrebna je verifikacija rezultata dodatnim metodama potvrde

Analysis of leptin, adiponectin and adiponectin gene polymorphism and leptin receptor in obese children and adolescents

Background: The aim of this study was to determine serum levels of leptin and adiponectin of obese children to identify the influence of leptin receptor gene polymorphisms on leptin resistance and leptin levels, as well as the association between the polymorphisms of adiponectin gene and adiponectin levels.Materials and methods: A case-control study comparing a study group of 74 obese children (age 13.34±2.60 years) to a normal weight-age matched (age 13.39±2.64 years) control group of 69 children. In both groups, body mass index (BMI) and waist/hip circumference, systolic and diastolic blood pressure were measured. Also, the leptin and adiponectin levels, as well as glucose and lipid metabolism parameters, and highly sensitive C-reactive protein (hs-CRP) were measured. Insulin sensitivity was evaluated using fasting insulinemia and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). All subjects were tested for gene-tic polymorphisms in LEPRQ223R (rs1137101), ADIPOQ G276T (rs1501299) and ADIPOT45G (rs2241766).Results: The phenotypes of the obese children study group were significantly higher than in the control group in weight, BMI, waist/hip circumferences and systolic blood pressure (SBP) (P<0.001). We confirmed that in obese children the levels of leptin in the blood are increased and levels of adiponectin are decreased (P<0.001). The differences of the genotype distributions of leptin receptor (LEPRQ223R) and adiponectin (ADIPOG276T and ADIPOT45G) gene polymorphisms in the study group of obese chil-dren and a control group was not observed.Conclusion: In this study, we demonstrated increased leptin level and significantly decreased level of adiponectin in the obese children group compared with the control group. The results of the analysis of glucose metabolism and lipidogram between the two groups showed that insulin, HOMA-IR, and triglycerides, as well as hsCRP were increased and significantly different in the group of obese children compared to the control group, as expected. However, by including a significantly larger number of tested and control samples of both sexes and age-specific groups, with a larger number of tested SNPs, the genes investigated in this study would probably give better insight into a multicomplex disease such as obesity

Laboratory policies and practices for thyroid function tests in Croatia: survey on behalf of Working Group for Laboratory Endocrinology of the Croatian Society of Medical Biochemistry and Laboratory Medicine

IntroductionLaboratory plays important part in screening, diagnosis, and management of thyroid disorders. The aim of this study was to estimate current laboratory preanalytical, analytical and postanalytical practices and policies in Croatia. Materials and methodsWorking Group for Laboratory Endocrinology of the Croatian Society of Medical Biochemistry and Laboratory Medicine designed a questionnaire with 27 questions and statements regarding practices and protocols in measuring thyroid function tests. The survey was sent to 111 medical biochemistry laboratories participating in external quality assurance scheme for thyroid hormones organized by Croatian Centre for Quality Assessment in Laboratory Medicine. Data is presented as absolute numbers and proportions. ResultsFifty-three participants returned the questionnaire. Response rate varied depending on question, yielding a total survey response rate of 46-48%. All respondents perform thyroid stimulating hormone (TSH). From all other thyroid tests, most performed is free thyroxine (37/53) and least TSH-stimulating immunoglobulin (1/53). Laboratories are using nine different immunoassay methods. One tenth of laboratories is verifying manufacturer’s declared limit of quantification for TSH and one third is verifying implemented reference intervals for all performed tests. Most of laboratories (91%) adopt the manufacturer’s reference interval for adult population. Reference intervals for TSH are reported with different percentiles (90, 95 or 99 percentiles). ConclusionThis survey showed current practices and policies in Croatian laboratories regarding thyroid testing. The results identified some critical spots and will serve as a foundation in creating national guidelines in order to harmonize laboratory procedures in thyroid testing in Croatia

Diagnostic Utility of Serum Leucine-Rich α-2-Glycoprotein 1 for Acute Appendicitis in Children

Purpose: The aim of this study is to assess the diagnostic utility of serum leucine-rich α-2-glycoprotein 1 (LRG1) in pediatric patients with acute abdominal pain, admitted to the emergency surgical unit, in order to make a prompt and accurate diagnosis of acute appendicitis. Patients and methods: Pediatric patients older than 5 years of age who presented to the emergency department from 15 October 2021 to 30 June 2022 with acute abdominal pain and suspected acute appendicitis were prospectively recruited in the study. Demographic and clinical data, as well as operative and postoperative data, were recorded. A total of 92 patients were equally distributed into two groups: children with acute appendicitis who underwent laparoscopic appendectomy and non-appendicitis patients, presenting with non-specific abdominal pain. LRG1 levels were determined using a commercially available LRG1 enzyme-linked immunosorbent assay (ELISA) kit. Serum LRG1 levels, as well as other inflammatory markers (white blood cell count (WBC), C-reactive protein (CRP) and absolute neutrophil count) were compared between groups. Results: The median level of LRG1 in serum was significantly higher in the group of children with pathohistologically confirmed acute appendicitis than in the control group, at 350.3 µg/mL (interquartile range (IQR) 165.2–560.3) and 25.7 µg/mL (IQR 14.7–36.8) (p p 69.1 µg/mL was found to perfectly separate acute appendicitis cases from controls. Additionally, as expected, each of the examined laboratory inflammatory markers provided a significantly higher values in the acute appendicitis group compared to the control group: WBC 14.6 × 109/L (IQR 12.7, 18.7) vs. 7.0 × 109/L (IQR 5.4, 9.0) (p p p < 0.001). Conclusions: LRG1 in the serum was found to be a promising novel biomarker, with excellent differentiation of acute appendicitis from non-appendicitis cases in children presenting with non-specific abdominal pain

Weather conditions: a neglected factor in human salivary cortisol research?

IN ENGLISH: There is ample evidence that environmental stressors such as extreme weather conditions affect animal behavior and that this process is in part mediated through the elevated activity of the hypothalamic pituitary adrenal axis which results in an increase in cortisol secretion. This relationship has not been extensively researched in humans, and weather conditions have not been analyzed as a potential confounder in human studies of stress. Consequently, the goal of this paper was to assess the relationship between salivary cortisol and weather conditions in the course of everyday life and to test a possible moderating effect of two weather-related variables, the climate region and timing of exposure to outdoors conditions. The sample consisted of 903 secondary school students aged 18 to 21 years from Mediterranean and Continental regions. Cortisol from saliva was sampled in naturalistic settings at three time points over the course of a single day. We found that weather conditions are related to salivary cortisol concentration and that this relationship may be moderated by both the specific climate and the anticipation of immediate exposure to outdoors conditions. Unpleasant weather conditions are predictive for the level of salivary cortisol, but only among individuals who anticipate being exposed to it in the immediate future (e.g., in students attending school in the morning shift). We also demonstrated that isolated weather conditions or their patterns may be relevant in one climate area (e.g., Continental) while less relevant in the other (e.g., Mediterranean). Results of this study draw attention to the importance of controlling weather conditions in human salivary cortisol research. --------------- IN CROATIAN: Mnoštvo je dokaza da okolišni stresori poput ekstremnih vremenskih uvjeta utječu na ponašanje životinja te da je ovaj proces djelomice posredovan kroz povišenu aktivnost hipotalamičko-pituitarno-adrenalno-kortikalne osi, što rezultira povećanim lučenjem kortizola. Ovaj odnos nije opsežno istraživan kod ljudi, a vremenski uvjeti nisu analizirani kao potencijalni zamagljujući čimbenik u istraživanjima ljudskog stresa. Slijedom toga, cilj ovoga rada bio je procijeniti povezanost salivarnog kortizola i vremenskih uvjeta tijekom svakodnevnih životnih aktivnosti i provjeriti mogući moderacijski učinak dviju varijabli vezanih uz vremenske uvjete, a to su klimatska regija i vrijeme izlaganja vanjskim uvjetima. Uzorak se sastojao od 903 učenika srednjih škola u dobi od 18 do 21 godine iz sredozemne i kontinentalne regije. Kortizol iz sline uzorkovan je u prirodnim uvjetima u tri vremenske točke tijekom jednoga dana. Utvrdili smo da su vremenski uvjeti povezani s koncentracijom salivarnog kortizola te da je ova povezanost možda posredovana specifičnom klimom, i očekivanjem neposredne izloženosti uvjetima na otvorenom. Neugodni vremenski uvjeti prediktivni su za razinu salivarnog kortizola, ali samo kod ispitanika koji predviđaju da će im biti izloženi u bliskoj budućnosti (npr. kod učenika koji pohađaju školu u jutarnjoj smjeni). Također smo pokazali da izolirani vremenski uvjeti ili njihovi obrasci mogu biti relevantni u jednom klimatskom području (npr. kontinentalnom), a manje relevantni u drugom (npr. sredozemnom). Rezultati istraživanja ukazuju na važnost kontroliranja varijable vremenskih uvjeta u istraživanjima humanog salivarnog kortizola

Daily salivary cortisol profile: Insights from the Croatian Late Adolescence Stress Study (CLASS)

Introduction: The aim of the study was to examine basal hypothalamic-pituitary-adrenal (HPA) axis activity and to determine associations of various covariates (gender, sleep-wake rhythm, demographic, academic, life style and health-related characteristics) with altered daily salivary cortisol profiles in late adolescence. Materials and methods: The total analytic sample consisted of 903 Croatian secondary school students aged 18 - 21 years (median 19 years). Salivary cortisol was sampled at home at three time points over the course of one week and its concentrations were measured by using the enzyme immunoassay. Results: In comparison to males, female students had a higher cortisol awakening response (CAR) (median 4.69, IQR 10.46 and median 3.03, IQR 8.94, respectively; P < 0.001), a steeper (“healthier”) diurnal cortisol slope (DCS) (median 0.51, IQR 0.55 and median 0.44, IQR 0.51, respectively; P = 0.001), and a greater area under curve with respect to ground (AUCG) (median 206.79, IQR 111.78 and median 191.46, IQR 104.18, respectively; P < 0.001). Those students who woke-up earlier and were awake longer, had a higher CAR (P < 0.001), a flatter (“less healthy”) DCS (P < 0.001), and a greater AUCG (P < 0.001), than students who woke-up later and were awake shorter. Less consistent but still significant predictors of salivary cortisol indexes were age, school behaviour, friendship, diet healthiness and drug abuse. Conclusion: Gender and sleep-wake up rhythm were major determinants of the altered daily salivary cortisol profiles in late adolescence. The predictive power of other covariates, although less clear, has a potential for identifying vulnerable subgroups such as male drug users and females without a best friend

The impact of stress and coping strategies on life satisfaction in a national sample of adolescents: a structural equation modelling approach

Although stress strongly predicts life satisfaction, the psychosocial mechanisms underlying this association remain unclear. To investigate the possible mediating role of coping, we conducted a cross‐sectional study that assessed youths' life stress levels, propensity to engage in three different coping styles (i.e., active coping, internal coping, & withdrawal), and life satisfaction in a probabilistic, twostage stratifed cluster sample of 1830 high school seniors (986 females ; age range 17–22 years old) from 26 schools in or around the four largest cities in Croatia. We used correlational analyses and structural equation modelling to test the hypothesis that coping mediates the relation between stress and life satisfaction. The tested model was marginally acceptable χ2 = 1613.85, df = 177, p < 0.001, goodness‐of‐ft‐index = 0.92, Comparative Fit Index = 0.91, Tucker‐ Lewis Index = 0.89, root mean square error of approximation = 0.067 (90% CI = 0.064 to 0.070), standardized root mean squared residual = 0.056. As hypothesized, stress was related to life satisfaction directly (βc’ = −0.22, p < 0.01) but also indirectly (βab = −0.05, p < 0.01) by affecting youths' likelihood of engaging in withdrawal behaviours, such as avoiding problems, distracting, or using anger, alcohol, or drugs. The proportion of the total effect mediated by withdrawal was 19.4%. In contrast, neither active nor internal coping were signifcant mediators. Based on these results, we conclude that preventive and educational programs for enhancing youth mental health may beneft from reducing adolescents' stress levels and stress‐related withdrawal behaviour, and by encouraging youth to use active coping strategies instead