Frequency and patterns of mental health services utilization among adolescents with anxiety and depressive disorders

The main aim of this study was to examine the frequency and patterns of mental health services utilization among 12- to 17-year-old adolescents with anxiety and depressive disorders. Another aim was to examine the factors associated with the use of mental health services. The study population comprised 1,035 adolescents randomly recruited from 36 schools. Anxiety and depressive disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Only 18.2% of the adolescents who met DSM-IV criteria for anxiety disorders, and 23% of those with depressive disorders, used mental health services. Among adolescents with anxiety disorders, mental health services utilization was associated with past suicide attempt, older age, the presence of comorbid disorders, as well as parental anxiety and depression. The only factor that predicts the use of mental health service among adolescents with depressive disorder was a history of suicide attempt. The implication of the results in terms of tailoring services for children and adolescents with anxiety and depressive disorders are discussed.     

Posttraumatic stress disorder symptoms in adolescents: risk factors versus resilience moderation

Background

Exposure to community violence and trauma, stress, and childhood abuse and neglect have been identified as risk factors for the development of posttraumatic stress disorder (PTSD) symptoms among adolescents. Although evidence suggests that resilience may moderate the relationship between some of these risk factors and PTSD symptoms, no studies to date have examined these risk factors collectively.

Aims

Our first aim was to examine the relationship between exposure to community violence, childhood abuse and neglect, perceived stress, and PTSD symptoms. Our second aim was to examine the extent to which resilience moderated the relationship between risk factors and PTSD symptoms.

Method

A convenience sample of 787 participants was drawn from 5 public secondary schools in the Cape Town metropole of South Africa. The participants were invited to complete a battery of questionnaires on a single occasion.

Results

Of the participants, 48.3% were Black, 58.6% were female, and 31.6% were in grade 8. After controlling for covariates, we found that exposure to community violence, perceived stress, and childhood abuse and neglect together accounted for 33.4% of the variance in PTSD symptoms (F_8,778 = 71.06, P < .001). Nevertheless, resilience moderated the relationship between childhood abuse and symptoms of PTSD (β = .09, t₇₈₆ = 2.88, P < .001), where the independent effect of childhood abuse and neglect on PTSD symptoms was significantly reduced with increasing resilience. Resilience did not, however, interact with exposure to community violence or perceived levels of stress to influence PTSD symptoms.

Conclusion

High levels of exposure to community violence, perceived stress, and childhood abuse and neglect may contribute to the development of PTSD symptoms in South African adolescents. However, high levels of resilience may buffer the negative effects of childhood abuse and neglect.     

Differentiating symptoms of social anxiety and depression in adults with social anxiety disorder

Although studies have suggested a strong overlap between social anxiety disorder and depression, this is the first study to examine the ability of commonly used measures to differentiate symptoms of these disorders in a sample of clients with social anxiety disorder. Structural equation modeling revealed that commonly used measures of social anxiety and depression can differentiate the two constructs, rather than simply reflecting a single construct of overall distress. Logistic regression analyses indicated that scores on depressive symptom measures could predict which socially anxious clients met criteria for a comorbid depressive disorder.     

Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization

OBJECTIVE: This study estimates the prevalence of posttraumatic stress disorder (PTSD) and describes the relationships among PTSD status and health indices in a civilian primary care patient sample. METHODS: Participants (N = 232) completed a paper-and-pencil survey of life events, PTSD symptoms, physical symptoms and health functioning. Utilization was assessed from medical records. RESULTS: Nine percent of the participants met the criteria for full PTSD (based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) and another 25% were defined as partial PTSD. The full-PTSD group evidenced higher rates of medical utilization, more intense physical symptoms and poorer health functioning than the no-PTSD group. The partial-PTSD group more closely resembled the full-PTSD group. CONCLUSIONS: This study, although limited by sample size and diagnosis by questionnaire vs. diagnostic interview, suggests research directions for enhancing our understanding of PTSD among civilian primary care patients and for developing appropriate interventions that can be conducted in the primary care setting.     

Treating adolescents with social anxiety disorder in schools

As is evident from the topic of this issue, schools can play an important role in addressing the unmet mental health needs of youth. Social anxiety disorder is particularly suited to being treated in the school setting. This article describes an empirically supported school-based intervention for social anxiety disorder, skills for academic and social success, and provides specific strategies to school counselors, teachers and community practitioners for implementing these methods. This article focuses on practical approaches for working with socially anxious adolescents in the school setting and how to increase awareness of social anxiety with parents and school personnel.     

Social anxiety disorder and victimization in a community sample of adolescents

Despite high prevalence rates of social anxiety disorder (SAD) and high rates of victimization in adolescents, studies on the relationship between these phenomena are missing. In the present study we report associations between SAD and multiple victimization experiences in a community sample of adolescents. A cross-sectional study was conducted on 3211 Swedish high-school students. The prevalence rate of self-reported SAD was 10.6% (n = 340). Significantly higher rates of lifetime victimization was found in subjects with self-reported SAD compared to non-cases, on the total score on the Juvenile Victimization Questionnaire, and on the subscales maltreatment, sexual victimization and victimization from peer/siblings. Different results emerged due to gender. In females, maltreatment and peer/sibling victimization was associated with an increased risk of SAD and, in males peer/sibling victimization increased the risk of reporting SAD. Further studies are needed to elaborate developmental models on SAD and to add to modification of prevention- and treatment interventions.     

Posttraumatic stress symptoms in parentally bereaved children and adolescents

OBJECTIVE: To compare parentally bereaved children with a disaster comparison group and a nontrauma control group on measures of emotional adjustment. METHOD: Children and adolescents who had lost a parent (n = 39), had experienced a tornado disaster (n = 69), or were coping with an ongoing social or academic stressor (n = 118) completed measures of posttraumatic stress disorder (PTSD) symptoms, anxiety, and depression. Risk factors for symptoms among the bereaved children also were evaluated. RESULTS: Parentally bereaved children reported significantly more PTSD symptoms than the disaster and nontrauma control groups. Among the bereaved children, girls, younger children, and children living with a surviving parent who scored high on a measure of posttraumatic stress reported more symptoms. CONCLUSION: Children and adolescents who have lost a parent could be vulnerable to PTSD symptoms.     

Posttraumatic stress disorder among African Americans in an inner city mental health clinic

This study examined 184 African-American outpatients in a mental health clinic in the inner city to define the rate of occurrence of traumatic experience and posttraumatic stress disorder (PTSD). This population experienced a high rate of severe trauma. Forty-three percent were found to have PTSD, as measured by the PTSD Symptom Scale. Finally, a chart review of 72 participants found that only 11 percent of participants who met DSM-IV criteria for PTSD also had a chart diagnosis of PTSD. PTSD is a common yet underrecognized and undertreated source of psychiatric morbidity in this urban community of African Americans with low socioeconomic status.     

Patterns of utilization of outpatient mental health services by children and adolescents.

Although as many as one-fifth of children and adolescents may meet DSM-III criteria for at least one psychiatric diagnosis, data from the Minnesota Department of Human Services for 1988 show that only 20 to 38 percent of children and adolescents in the state who are eligible for medical assistance and who are potentially in need of psychiatric care are referred for or seek treatment. A study of publicly funded mental health care for youths under 18 found that in 1988 the average cost for state-supported psychiatric services per outpatient case was $520, compared with $8,556 per inpatient case. However, overall cost of state-supported mental health services for youths under 18 increased by 28 percent between 1987 and 1988, primarily due to increases in payments for inpatient care of patients with dual diagnoses of mental illness and chemical dependency.     

Posttraumatic stress disorder symptoms influence health status of deployed peacekeepers and nondeployed military personnel

Posttraumatic stress disorder (PTSD) is associated with depression and alcohol abuse. PTSD symptoms also contribute to poor health among military veterans. The aim of the present study was to test models pertaining to the direct and indirect influences of PTSD symptoms on the health status of deployed and sociodemographically comparable nondeployed military personnel. Participants were 1,187 deployed male peacekeepers and 669 nondeployed male military personnel who completed a battery of questionnaires, including measures of PTSD symptoms, depression, alcohol use, and general health status. Structural equation modeling was used to test predictions regarding the direct and indirect influences of PTSD symptoms on health status. Results indicate that PTSD symptoms have a direct influence on health, regardless of deployment status. PTSD symptoms also indirectly promote poorer health through influence on depression, but not alcohol use, in deployed and nondeployed peacekeepers. Increased alcohol use did not contribute to poorer health beyond the contribution of PTSD symptoms alone. Future research directions are discussed.     

Posttraumatic stress disorder in adolescents after Typhoon Morakot-associated mudslides

The aims of this study were to examine prevalence rate of post-traumatic stress disorder (PTSD), its associated factors and co-occurring psychological problems in a group of displaced adolescents 3 months following Typhoon Morakot in Taiwan. The relationship of trauma dimension and PTSD was also explored. A total of 271 adolescents who had been evacuated from their homes participated in this school-based survey. Adolescents were interviewed using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Subjects themselves completed the following questionnaires: an inventory of exposure experiences to Typhoon Morakot, the Chinese version of Impact of Events Scale-Revised, the Center for Epidemiological Studies Depression Scale, and the Family APGAR Index. Teachers completed the Teacher's Report Form in the Achenbach system of Empirically Bases Assessment. Results revealed that the prevalence of PTSD related to Typhoon Morakot was 25.8%. Adolescents who were female, had PTSD related to previous traumatic events before Typhoon Morakot, had more exposure experiences, were physically injured, or had family member in same household died or seriously injured were more likely to have the diagnoses of PTSD. Meanwhile, adolescents with PTSD had more severe depression, internalizing, externalizing, social, thought, and attention problems than those without PTSD. Our findings indicate that specialized trauma services are needed for these youngsters to lessen prolonged vulnerabilities.     

Generalized anxiety disorder in adolescents and young adults with mild mental retardation

This report examines clinical features of generalized anxiety disorder in adolescents and young adults with mild mental retardation (MR), compared with children and adolescents with normal IQ. Frequency of symptoms, comorbidity, agreement between reports of subjects and parents, correlation between IQ and severity of disorder, and comparison between frequency of symptoms in the experimental and control groups are described. Twenty-two subjects with MR (12 males and 10 females aged 11-25 years; mean age = 16.3), 30 children (19 males and 11 females aged 7-11.11; mean age = 10), and 30 adolescents (18 males and 12 females aged 12.1-18; mean age = 15.2) participated in the study. All the subjects were comprehensively diagnosed with diagnostic interviews (K-SADS or DICA-R). According to our data, generalized anxiety disorder can be diagnosed in adolescents with mild MR, with high agreement between self-reports and parent reports. Phenomenology of GAD in mildly developmentally delayed persons grossly paralleled that of normal IQ people, except for brooding, somatic complaints, and sleep disorders. Number and severity of symptoms did not correlate with Full Scale and Verbal IQs. High rates of comorbidity with depression were evident both in normal IQ and in developmentally delayed subjects.     

广泛性焦虑症患者应对方式、社会支持与心理健康的关系

目的 探讨广泛性焦虑症患者应对方式、社会支持与心理健康的关系.方法 采用一般情况问卷、简易应对方式问卷(SCSQ)、社会支持评定量表(SSRS)、症状自评量表(SCL-90),对221例广泛性焦虑症患者进行问卷调查.结果 (1)广泛性焦虑症患者SCL-90得分与积极应对、主观支持、客观支持、支持利用度得分呈负相关(P＜0.05),与消极应对正相关(P＜0.01).(2)结构方程模型分析结果显示:积极应对对社会支持有直接(正向)效应(β=0.47,P＜0.01),对SCL-90得分有直接(负向)效应(β=-0.28,P＜0.01);消极应对对社会支持有直接(负向)效应(β=-0.23,P＜0.01),对SCL-90得分有直接(正向)效应(β=0.22,P＜0.01);社会支持对SCL-90得分有直接(负向)效应(β=-0.33,P＜0.01);积极应对和消极应对还可以通过社会支持间接影响心理健康.结论 应对方式对广泛性焦虑患者的心理健康有直接效应和间接效应;社会支持作为中介变量调节应对方式与心理健康的关系.运用积极应对、减少消极应对既可直接改善患者的心理健康水平,又可通过提高患者的社会支持来改善患者心理健康状况.     

Cyber victimization by peers: Prospective associations with adolescent social anxiety and depressive symptoms

Peer victimization that occurs via electronic media, also termed cybervictimization, is a growing area of concern for adolescents. The current study evaluated the short-term prospective relationship between cybervictimization and adolescents' symptoms of social anxiety and depression over a six-week period. Participants were 839 high-school aged adolescents (14–18 years; 58% female; 73% Hispanic White), who completed measures of traditional peer victimization, cybervictimization, depression, and social anxiety at two time points. Findings supported the distinctiveness of cybervictimization as a unique form of peer victimization. Furthermore, only cybervictimization was associated with increased levels of depressive symptoms over time, and only relational victimization was associated with increased social anxiety over time, after controlling for the comorbidity of social anxiety and depression among youth. Cybervictimization appears to be a unique form of victimization that contributes to adolescents' depressive symptoms and may be important to target in clinical and preventive interventions for adolescent depression.     

Determinants of self-reported mental health and utilization of mental health services in Canada

Research evidence suggests that the prevalence of mental health conditions in Canada has increased while a considerable percentage of people with a mental health issue do not seek professional mental health services. Weighted logistic regression models were used to determine whether age, sex, income, and education predict the self-reported mental health status of Canadians and their odds of utilizing mental health services. This study found clear disparities in reporting mental health and utilization of mental health services. Young adults (aged 25 to 44) have 1.4 times (95% CI: 1.3 to 1.6 times) higher odds of reporting poorer mental health status than seniors (aged 65 or older). Females are 2.7 times (95% CI: 2.3 to 3.1 times) more likely to utilize mental services than males. The lowest income group (<$15,000) has 2.2 times (95% CI: 1.9 to 2.4 times) higher odds of rating poorer mental health status than the highest income group (>$80,000). The least educated group (<high school education) has 1.5 times (95% CI: 1.3 to 1.6 times) higher odds of reporting poorer mental health status than the highest educated group (post-secondary education). However, the highest educated group is 1.6 times (95% CI: 1.3 to 2.0 times) more likely to utilize mental health services than the least educated group. Even in a country that has a universal health insurance system such as Canada, disparities and inequities associated with mental health burden and health care utilization persist, specifically among groups with lower education, lower income, and males.     

Neuroendocrine responses to psychological stress in adolescents with anxiety disorder

Neurotransmitter-neuroendocrine and cardiovascular responses to the administration of a psychologically stressful mixed-model test (Mental Arithmetic, Stroop Color Word Interference Task, Trier Social Stress Test) were examined in 20 male peripubertal subjects affected by anxiety disorder (group A: 14 with generalized anxiety disorder, 6 with generalized anxiety disorder and separation anxiety disorder) and 20 junior school adolescents, matched for age, without overt psychological disorders (group B). Plasma levels of norepinephrine (NE), epinephrine (EPI), adrenocorticotropic hormone (ACTH), beta-endorphin (beta-EP), cortisol (CORT), growth hormone (GH), prolactin (PRL) and testosterone (Te) were measured immediately before the beginning of the tests and 30 min later at their end. Mean prestress values of GH, PRL, beta-EP and ACTH were significantly higher in anxious subjects than in controls. There was no difference in NE, EPI, CORT and Te prestress levels in the two groups. After the psychological stress session NE, GH and Te concentrations increased significantly in anxious subjects (A), but not in controls. In contrast, beta-EP and PRL decreased significantly during the psychological stress session in anxious subjects, and were unaffected by stress in the subjects without anxiety. No significant changes were found in ACTH, CORT and EPI during the challenge either in anxious subjects or in controls, which may be attributed to the late time of poststress blood sampling. In contrast to controls, heart rate and systolic blood pressure increased significantly in anxious subjects after psychological stress testing. Our data support the hypothesis that the hyperactivity of the noradrenergic system in response to stress is associated with anxiety disorders in adolescents and might influence the responses of GH and Te. High prestress basal values of stress hormones seem to be induced in anxious subjects by the anticipation of the task or by a persistent hyperactivity of the noradrenergic system. Further studies are needed to investigate in more detail the involvement of the HPA axis in anxious adolescents by a more refined resolution of time points of blood sampling.     

Posttraumatic stress disorder and the structure of common mental disorders

Krueger [1999: Arch Gen Psychiatry 56:921-926] identified a three-factor structure of psychopathology that explained the covariation or grouping of common mental disorders found in the U.S. National Comorbidity Survey (NCS) [Kessler et al., 1994: Arch Gen Psychiatry 51:8-19]. These three fundamental groupings included an externalizing disorders factor and two internalizing disorders factors (anxious-misery and fear). We extended this research through the examination of additional data from a large subsample of the NCS (n=5,877) that contained diagnostic information on posttraumatic stress disorder (PTSD). Factor analytic findings revealed that PTSD showed no affinity with the fear factor defined by panic and phobic disorders, and instead loaded on the anxious-misery factor defined primarily by mood disorders. An identical pattern of results emerged for both lifetime PTSD and 12-month PTSD prevalence figures. Implications of these findings for the classification of PTSD and research on its etiology are briefly discussed.