Major depressive episode and health care use among adolescents and young adults

Objective: The aim was to analyze how major depressive episode (MDE), chronic illness and their co-existence are associated with health care use in young people. Method: As part of the Finnish Health Care Survey 1996, a random sample of 942 15 to 24-year-olds was interviewed. DS M-III-R MDE over the previous 12 months was assessed using the University of Michigan Composite Diagnostic Interview Short Form (UM-CIDI SF). Results: Of the study population, 43.7% (n=439) reported recent use of services for physical illness, the highest proportion being among respondents with both MDE and chronic illness (73.9 %). In multivariable logistic regression analysis, disabling chronic illness (OR 2.59; 95% CI 1.51, 4.45) was related to treatment use for physical causes while MDE alone (OR 1.56; 95% CI 0.95, 2.58) or accompanied with chronic illness (OR 2.47; 95% CI 0.99, 6.14) showed borderline associations. In all, 1.5% (n=14) of the respondents reported recent health care use for any mental health problems. Of the 68 subjects with MDE, 51.5% (n=35) were estimated to be in need of treatment while 20.6% (n=14) had actually sought care for depression during the preceding year. Psychosocial impairment showed borderline association with treatment use (OR 3.77; 95% CI 0.97, 14.7). Only two subjects (14 %) reported recent use of antidepressant medication. Conclusions: MDE in adolescents and young adults is undertreated. An tidepressant medication was seldom used in Finland in 1996. Young people suffering from both MDE and chronic illness are likely to use services other than psychiatric services, and systematic screening for depressive symptoms in these treatment settings is recommended. Accepted: 21 January 2003 Correspondence to Dr. Linnea Haarasilta     

The role of stress in the onset of depressive disorders

Background: We conducted the present study to evaluate the impact of stressful events on the onset of depressive disorders in a Spanish clinical sample, compared to a control group matched for age, sex, civil status and social class. We compared our results with those of other studies carried out with samples that were both clinically and culturally similar to ours. Method: Fifty depressed patients that were diagnosed with a depressive episode in the 6 months prior to the interview and 50 healthy controls were included in the study. Both groups were compared on the “Life Events and Difficulties Schedule” (LEDS). Results: Of the depressive patients, 68 % compared to only 18 % of the control individuals experienced at least one provoking agent in the 12 months prior to the onset of the symptoms. The risk of developing a depressive disorder was 9.7 % greater in subjects exposed to such provoking agents. Chronic difficulties are equally important to the genesis of depressive disorders as severe life events. No significant differences were seen between the two diagnostic subgroups of depressed patients in the accumulation of severe events, major difficulties or provoking agents. Conclusion: The results support the view that stress is a major factor in the aetiology of depressive disorders. The amount of stress suffered by the patients, however, was less than that found in our healthy sample. Important issues about the model of interaction between stress and depression are discussed. Accepted: 29 July 2002 Correspondence to L. Rojo     

Subscales scores of the Lithuanian version of CBCL--preliminary data on the emotional and behavioural problems in childhood and adolescence

This study set out to investigate some psychometric properties of the Lithuanian version of CBCL for providing the preliminary data on the emotional and behavioural problems in Lithuanian children taking factors such as gender, age, SES and family composition into account. The CBCL was completed by parents of 7- to 11- and 12- to 14-year-old school children (N = 1296) drawn from the urban and suburban population. Younger boys scored higher than girls on externalizing problems and total problems scores, and older girls scored higher on internalizing problems. Younger children scored higher than the older children on total problems and externalizing problems scores. The comparisons with the US sample indicated that the levels of problem behaviour in 7- to 14-year-old children are similar to those found in the US. Lithuanian children had higher total problem scores; however, the effect sizes for other scales, except the attention problems scale and the somatic complaints scale, were very small. Similar to other studies, we found significant SES effects on total problem scores. Problem scores were highest for the lowest SES children. In general, this study supports previous findings concerning CBCL: similarities in emotional and behavioural problems outweigh differences in cross-cultural studies based on CBCL. Accepted: 14 January 2003 Correspondence to R. Zukauskiene     

First-time hospitalisation for depressive and/or anxiety disorders and severe life events

Background: It has been suggested that the impact of antecedent life events differs between first and subsequent episodes of depressive or anxiety disorders. Method: We used the Bedford College methodology to determine the presence of severe events and/or major difficulties in two different groups of patients hospitalised for neurotic disorders, and in a control group of healthy subjects from the general population. Results: The experience of severe events and/or major difficulties was significantly higher in patients being hospitalised for the first time than in patients who had been hospitalised several times, or in the control group. This difference was observed for female patients only. Conclusions: Two hypotheses are put forward as an explanation of these results. Accepted: 23 April 2002 Correspondence to F. Amiel-Lebigre     

Relation between anxiety and depressive disorders in childhood and adolescence.

Current research indicates that there is a strong relationship between pediatric anxiety disorders and depression. Assessment measures show high rates of correlation between depression and anxiety and much of the overlap may be related to a common domain of negative affectivity. Anxious youth and depressed youth share a cognitive style marked by a negative bias in information processing. Anxiety disorders and depression are frequently comorbid in children and adolescents. About 25-50% of depressed youth have comorbid anxiety disorders and about 10-15% of anxious youth have depression. Twin and family studies have demonstrated that pediatric anxiety disorders and depression likely share some common genetic factors or influences. Selective serotonin reuptake inhibitors and cognitive-behavioral therapy have been shown in randomized controlled trials to be efficacious for both pediatric depression and anxiety disorders. Integrating the treatment literature with studies of phenomenology, biology and genetics indicates that pediatric anxiety disorders and depression may share a genetically determined neurobiological component that could involve neural circuits that include or are modulated by serotonergic neurons. This component could contribute to the negative affective temperament that appears to be common in both pediatric depression and anxiety disorders.     

Treatment-resistant depression in adolescents: review and updates on clinical management

Treatment-resistant depression (TRD) in adolescents is prevalent and impairing. We here review the definition, prevalence, clinical significance, risk factors, and management of TRD in adolescents. Risk factors associated with TRD include characteristics of depression (severity, level of hopelessness, and suicidal ideation), psychiatric and medical comorbidities, environmental factors (family conflict, maternal depression, and history of abuse), and pharmacokinetics and other biomarkers. Management options include review of the adequacy of the initial treatment, re-assessment for the above-noted factors that might predispose to treatment resistance, switching antidepressants, and augmentation with medication or psychotherapy. Other modalities, such as electroconvulsive therapy, vagal nerve stimulation, and repetitive transcranial magnetic stimulation, are also reviewed.     

Family functioning in adolescents at high and low risk for major depressive disorder

Families of two subgroups of adolescents in the community, at high and low risk for major depressive disorder, were compared on the McMaster Family Assessment Device (FAD) and the General Health Questionnaire (GHQ). Families of high-risk adolescents who became depressed by follow-up at one year were comared with other families of high-risk subjects. The only significant difference on FAD ratings for high- and low-risk groups was on the sub-scale Roles as reported by mothers. FAD ratings showed that, compared with mothers, fathers of high-risk adolescents held significantly worse views of their families' functioning on the sub-scales Problem Solving. Affective Responsiveness and Behaviour Control. There were no such differences between low-risk parents. Both mothers and fathers of high-risk adolescents reported their own mental health as significantly poorer than mothers and fathers of low-risks. The mental health of mothers in the high-risk group only was significantly associated with their FAD ratings. Adolescents rated their families as significantly worse on the FAD than their parents and the lower their mood and self-esteem, the worse they rated their families on the FAD. Subsequent MDD in adolescents by follow-up at one year was not associated with the FAD scores of any family member, nor with either parent's mental health. Accepted: 26 January 2001     

Electrodermal activity in antidepressant medicated and unmedicated depressive patients and in matched healthy subjects

A group of 59 depressive in- and outpatients displayed statistically significantly subnormal electrodermal activity (EDA) according to the skin conductance level, the skin conductance response magnitude, the skin conductance response rate, and the index of nonresponding during neutral tone stimulation, compared to 59 mentally and somatically healthy subjects, individually matched for age and sex. Comparisons between 20 antidepressant medicated and 20 unmedicated patients, matched for age, and comparisons between 21 drug-free patients and 10 patients medicated exclusively with antidepressants yielded no statistically significant difference in any EDA variable. However, all the electrodermal central values were somewhat lower in the medicated patients, possibly an effect of greater severity of symptoms. The present and previous findings offer strong support to the hypothesis of a subnormal function of the electrodermal activity in groups of depressive patients.     

The use of multiple informants in identifying the risk factors of depressive and disruptive disorders

Objective: The aim of this study was to asses whether children and their parents identify the same risk factors for disruptive and depressive disorders and to analyze whether combining informant data with a rule that classifies the diagnosis as present if confirmed by at least one informant (OR rule) masks distinctive patterns identified in informant-specific analyses. Method: Bivariate logistic regression equations were estimated using the diagnostic classification, based on DISC 2.1, as the outcome variable and informant (parent or child), characteristics of the youth (gender and age), indicators of the context of the interview (site), and family characteristics (income, parental monitoring, and adverse family environment) as predictors. The same predictors were also analyzed with the combined informant (OR rule) as outcome variable. Results: Prevalence of all diagnoses varied with informant. Depressive disorders were more prevalent when the informant was the youth and disruptive disorders when the informant was the parent. The effect of age varied with informant. Odds of being classified as having a DISC disorder increased with age when the informant was the youth but the same effect was not observed when the parent was the informant. When information from parents and youth are combined (with an OR rule) the age effect for disruptive disorders vanishes, and its effect for depressive disorders weakens. Conclusions: Informants are not interchangeable. Parent- and youth-based estimates of the prevalence of disruptive and depressive disorders were different and showed distinctive age relationships. Combining information from different sources (parents and youths) obscures the apparent effect of age noted in the two informant groups. Received: 5 September 2001 / Accepted: 8 August 2002 Dr. Garrett Fitzmaurice was funded in part by NIMH grant RO1-MH54693. Correspondence to Prof. Maritza Rubio-Stipec, Ph.D.     

Personality disorders in former child psychiatric patients

The present case-control study was undertaken in order to investigate the long-term outcome with respect to personality disorder (PD) symptomatology in former child psychiatric in-patients as compared to matched controls from the general population. Altogether 359 former patients and 359 controls were invited to participate in the study. Of these, 164 (46 %) former patients and 193 (54 %) controls approved participation. From these, 137 age and sex-matched pairs with a mean age of 30.7 (SD = 6.8) years were constructed. Adult PD symptomatology was assessed by means of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). There were 52 former patients (38 %) and 15 controls (10.9 %) who fulfilled criteria for at least one DSM-IV self-reported PD. There was a significantly higher prevalence for all specific self-reported PDs in former patients compared to controls. The mean number of disorders was 1.7 (SD = 2.6) in former patients and 0.3 (SD = 0.8) in controls. Moreover, former patients fulfilled more PD criteria than controls (23 vs. 11; median numbers). The former patients had significantly lower global functioning and more psychosocial problems than the controls. These problems were related to personality pathology. The results of this study indicate that child psychiatric morbidity seems to increase the risk for adult PD symptomatology. However, the results may be biased by the low participation rate. Accepted: 11 September 2002 Correspondence to Lisa Ekselius, MD, PhD     

Obsessive compulsive behaviour and depressive symptoms in young people with Tourette syndrome. A controlled study

Tourette syndrome (TS) is characterised by multiple motor and one or more vocal tics. There have been no controlled studies using standardised instruments of depressive symptoms and obsessive compulsive symptomatology (OCS) in young people with TS. We completed a study of phenomenology and psychopathology in children with TS, including a controlled evaluation of the association between depressive symptoms, OCS, and TS. 57 people aged 15 or under with TS were recruited. Phenomenology and psychopathology were assessed using standardised instruments. The association between TS, depressive symptoms and obsessionality was investigated using 75 age- and gender-matched controls. There were high levels of depressive symptomatology and OCS in the TS group. Twenty-three (40 %) had carried out self-injurious behaviours and 34 (60 %) met criteria for Attention Deficit Hyperactivity Disorder (ADHD). Depressive symptoms and obsessionality were higher in the TS cohort compared with the control group; this excess persisted after adjustment for the effects of age, gender and comorbidity between depression and obsessionality. This study demonstrates high levels of psychopathology in children with TS, including ADHD, OCS and depressive symptoms. The findings illustrate the potentially complex, challenging combination of difficulties encountered by children with TS and those who care for them. Accepted: 2 October 2002 Correspondence to Mary M. Robertson, MD, MRCPCH, FRCPsych     

Electroconvulsive therapy in adolescence

The aim of this work is to discuss the ethical issues regarding the use of electroconvulsive therapy (ECT) in adolescents. Ethical implications of ECT in adolescents are analyzed in the light of general medical ethics, which include five prominent principles with respect to autonomy, nonmaleficence, beneficence, justice, and cautiousness. As adults, adolescents with acute psychotic impairment raise an inherent conflict between the respect for the patient's autonomy, on the one side, and the principle of beneficence on the other. However, this age group presents particular dilemmas: (i) As any adolescent suffering from a psychiatric illness is a highly vulnerable subject, society asks for particular attention. The consequence of potential overprotection is that the adolescent may remain untreated because of unrealistic fears regarding ECT. (ii) Some of these fears are linked to the cognitive secondary effects of ECT. Although preliminary data are reassuring, more empirical research on this population should be encouraged. (iii) Cautiousness recommends the use of ECT in limited indications catatonia, mood disorders, and intractable acute psychotic disorders. We conclude that there is no ethical reason to ban the use of ECT in adolescents. Ethical options in clinical practice must be evaluated empirically with respect to the consequences for the patient. Dogmatic views should be set aside. Accepted: 7 July 1999     

Cross-cultural assessment of childhood temperament. A confirmatory factor analysis of the French Emotionality Activity and Sociability (EAS) questionnaire

The Emotionality Activity Sociability (EAS) questionnaire focuses on heritable individual differences in reactivity and behavior which are often referred to in developmental temperament research. Psychometric properties of the French version of EAS were examined in a sample of 197 school-children aged six to 12 years. Parents, teachers and children aged nine years and more completed parallel forms of the EAS questionnaire. Confirmatory factor analysis was used to examine the fit between the original factors and the data. Internal consistency of each subscale, inter-rater and external validity were also examined. Children-rated EAS showed the best indices of fit between the four hypothesized factors and the data, but internal consistency was generally lower than in adult-rated questionnaires. Shyness and sociability showed significant overlap in both parent and teacher-rated EAS. The low concordance between child- and adult-ratings indicates that temperament evaluation and interpretation of items may be influenced by subjective and/or developmental factors. Results are discussed in the perspective of validity versus cross-cultural comparability of temperament measurement. The theoretical four-factor structure was not completely replicable in our sample. Accepted: 21 August 2001     

Psycho-social determinants for psychiatric hospitalisation for neurotic disorders in women

Background: Much has been written about the determinants of psychiatric hospitalisation, chiefly for psychotic patients in an emergency. This paper reports the results of a comparative study between in-patients and pathological subjects from the general population. The aim of this work is to evidence the psycho-social determinants of hospitalisation in a psychiatric department for neurotic disorders. Methods: This study was conducted on a socially fairly privileged population which was, therefore, also fairly homogeneous. The subjects from the two groups were assessed clinically using standardised instruments both for diagnosis (SCAN) and for psycho-social variables (Stressful Life Events: LEDS; Social Support and Self-esteem: Pearlin checklist; care itinerary). Results: Following the analysis of frequency and a multivariate logistic regression analysis, four risk factors for hospitalisation for neurotic disorders were evidenced, including: severity of neurotic disorders, taking a long time to consult a specialist after first onset of anxiety disorders, poor social support, and having experienced one or more provoking agents (Brown and Harris methodology) in the year previous to hospitalisation. Conclusion: The severity of the mental pathology is largely responsible for hospitalisation in neurotic patients as it is in psychotic patients, but it is not the only determinant for hospitalisation. Accepted: 1 December 2002     

A core curriculum for child and adolescent psychiatry

 This paper suggests that it will be increasingly necessary to have a core curriculum for training in child and adolescent psychiatry. The reasons include the growth of knowledge, need for selection of information, the influence of evidence-based practice and accountability, and recognition of training across the European community. The principles for organising a curriculum are coherence, accessibility, and the context of professional development. Implementation of these principles is illustrated by the St Mary’s training programme in London. Important components are the reading seminars in developmental psychopathology and the psychological treatments course. Implementing a core curriculum nationally and internationally would have difficulties, which could be overcome by a compromise of central control and local interests and initiatives.     

Autism spectrum and attention-deficit disorders in girls. Some neuropsychological aspects

This study compared the neuropsychological test profiles of non-mentally retarded girls and boys consecutively referred to a neuropsychiatric clinic and those of contrast cases of girls from mainstream classrooms of one G?teborg school district. To avoid overreliance on the male prototype with regard to diagnostic criteria the clinical group comprised a mixed sample of girls and boys without diagnostic subgrouping. Clinic girls had a lower IQ than comparison girls. Girls were more impaired than the boys with respect to executive functions and scored less well on theory of mind tasks. Previous studies have shown girls with autism and mental retardation to be more severely affected than boys both with regard to level of intellectual functioning and overall measures of brain dysfunction. The present study indicates that clinic girls with a variety of neuropsychiatric disorders at higher levels of intellectual functioning (some of which met diagnostic criteria for autism spectrum disorder) may also be more severely affected than boys with corresponding types of "surface" problems.     

Comparing the German versions of the Strengths and Difficulties Questionnaire (SDQ-Deu) and the Child Behavior Checklist

 The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioural screening questionnaire that can be completed in about 5 minutes by the parents and teachers of 4–16 year olds. The scores of the English version correlate well with those of the considerably longer Child Behavior Checklist (CBCL). The present study compares the German versions of the questionnaires. Both SDQ and CBCL were completed by the parents of 273 children drawn from psychiatric clinics (N = 163) and from a community sample (N = 110). The children from the community sample also filled in the SDQ self-report and the Youth Self Report (YSR). The children from the clinic sample received an ICD-10 diagnosis if applicable. Scores from the parent and self-rated SDQ and CBCL/YSR were highly correlated and equally able to distinguish between the community and clinic samples, with the SDQ showing significantly better results regarding the total scores. They were also equally able to distinguish between disorders within the clinic sample, the only significant difference being that the SDQ was better able to differentiate between children with and without hyperactivity-inattention. The study shows that like the English originals, the SDQ-Deu and the German CBCL are equally valid for most clinical and research purposes. Accepted: 22 February 2000     

Self-reported strengths and difficulties in a community sample of Finnish adolescents

The psychometric properties of the self-report version of the Strengths and Difficulties Questionnaire (SDQ) among Finnish 13- to 17-year-old adolescents (n = 1,458) were studied. The results show that the psychometric properties of the Finnish SDQ self-report were adequate. The results of the correlation analysis confirmed the postulated structure of the SDQ self-report. The correlations of the items to their respective subscales ranged from moderate to high (r = 0.47–0.73). The internal consistency was acceptable on three and somewhat lower on two of the five subscales (alpha = 0.53–0.71). In addition, the factor analysis sufficiently confirmed the postulated structure of the SDQ for girls and boys, except for the conduct problems scale of boys, which was fused with emotional symptoms and with hyperactivity. The means of the SDQ self-report total difficulties scores were very similar to those in a previous study in Great Britain. The results provide additional confirmation of the usefulness of the SDQ as a screening instrument in epidemiological research and clinical practice. Accepted: 12 January 2001     

Epidemiology and prognosis of specific disorders of language and scholastic skills

 Data from a prospective longitudinal study on the development of children born at biological and psychosocial risk were utilised to examine language and learning abilities of 320 children at ages 4.5 and 8 years. Following the research criteria of the ICD-10, specific developmental disorders of speech and language and specific developmental disorders of scholastic skills were diagnosed. Data were also provided for a clinical and general low achievement group according to less stringent criteria. Frequencies in the risk population were low for specific disorders (ICD-10) (0.6%–3.7% depending on age and type of disorder). Higher frequencies were found when a clinical definition (0.6%–13.6%) or overall low achievement score (0.6%–18.6%) was chosen. The impact of well-documented organic and psychosocial risks was analysed. Organic risk affected language abilities at 4.5 years of age but neither language nor learning abilities at 8 years of age. Psychosocial aspects of a child's environment proved to be associated with both specific language and learning abilities. Stability of language disorders, association between language and reading/spelling disorders as well as gender effects were investigated. Accepted: 17 December 1999     

Psychological disorders and symptoms in primary care

Background Psychological symptoms that do not reach the threshold for formal diagnosis are disregarded in prevalence rates and are apparently assumed to be transient and of little clinical importance. Method Consecutive primary care attenders (n = 2379) were screened using the 12-item General Health Questionnaire (GHQ-12) and a stratified random sample (n = 704) completed baseline structured diagnostic interview, disability assessment, and the 28-item version of the GHQ (GHQ-28). Subjects with significant psychiatric symptoms and a random sample of those without (n = 263) were evaluated with the same measures 12 months later. Results While 25 % of the baseline sample scored 5 or more on the GHQ-28, only 10 % met the ICD-10 criteria for one or more disorders. At baseline, caseness on either the GHQ or ICD-10 was associated with poor self-rated overall health, interviewer-rated occupational disability and with more disability days in prior month. At 12-month follow-up, being a case on the GHQ at baseline, but not on ICD-10, was associated with disability, poor health perception and high health service utilization. Conclusion Psychological symptoms that may not reach diagnostic threshold are associated with impaired functioning over 12 months. Individuals with such symptoms may be identified using self-report questionnaires for dimensional symptoms, such as the GHQ-28. Accepted: 8 February 2002