Depressive symptoms amongst adolescent primary care attenders

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1 Soc Psychiatry Psychiatr Epidemiol (2004) 39 : DOI /s y ORIGINAL PAPER Peter Yates Tami Kramer Elena Garralda Depressive symptoms amongst adolescent primary care attenders Levels and associations Accepted: 19 February 2003 SPPE 792 Abstract Background High rates of depressive disorder have been documented amongst adolescents attending general practitioners (GPs) in urban areas. However, little is known about the associations of adolescent depression in primary care. Method We completed a cross-sectional questionnaire survey of adolescents, their parents and general practitioners, following adolescent attendance at the surgery. Results We found high levels of depressive symptoms to be present in adolescent attenders of a broad range of social backgrounds. Depressive symptoms were associated with the following demographic and contextual factors: older age, female gender and parental psychiatric symptoms. They were also associated with the presence of physical symptoms causing psychosocial impairment, with health risks (use of cannabis and exposure to drugs) and with use of services (both primary care and mental health services). Levels of depressive symptoms were similar in urban and suburban groups. However, associations of depressive symptoms with smoking, exposure to drugs, cannabis use and primary care attendance were demonstrated in the suburban group and not the urban group. Conclusion Adolescent GP attenders have high levels of depressive symptomatology. GP recognition and intervention should have the potential to impact on adolescent depression and on associated risks. P. Yates, MD Great Ormond St Hospital for Children London, UK T. Kramer, MD Imperial College London, UK Prof. E. Garralda, MD Academic Unit of Child & Adolescent Psychiatry Imperial College Norfolk Place, Paddington London, W2 1PG, UK e.gerralda@imperial.ac.uk Key words adolescent depression primary care associations rates Introduction About half of young adolescents are likely to consult their general practitioner (GP) in the course of 1 year (Kramer et al. 1997). Although only a small proportion consult for psychiatric symptoms, there is evidence that associated psychopathology, most prominently depressive disorders, are present in a considerable proportion of attenders (Monck et al. 1994; Kramer and Garralda 1998). There are also indications that psychiatric and psychosomatic concerns are more prominent in those who are comparatively frequent attenders (Kramer et al. 1997). General practice is, therefore, in a position to intervene for these disorders. Little is known about the associations of adolescent depression in primary care. A better understanding would not only enhance our knowledge of adolescent depression, it should also helpfully inform its recognition and management by general practitioners. Adolescent depression amongst GP attenders may have similar, but also different, characteristics and associations to depression as seen in other settings, with high levels of physical symptoms but less severity of depression and less conduct disorder co-morbidity than in psychiatrically referred youngsters (Kramer and Garralda 1998). It has also been found to be associated with predictors of drug use. This work has, however, been based in urban samples. Since geographical areas with different degrees of psychosocial disadvantage display differences in childhood psychopathology (Rutter et al. 1975; Costello et al. 1996; Breton et al. 1999), its generalisability needs to be confirmed in areas with a broader socio-economic background. In this study, we examine the frequency and associations of depressive symptoms in adolescents consulting GPs in a combined sample of urban and suburban areas. We examine separately associations reflecting demo-

2 graphic or contextual factors (age, gender, ethnicity, social class, family composition, parental psychiatric symptoms, family composition and urban vs. suburban location) and those reflecting health risks, physical symptoms and service use. Subjects and methods Sample General practices in an urban area (inner London) and a suburban area (Hertfordshire) were approached by letter asking for volunteers. One urban practice and two in suburban practices agreed to take part. The urban general practice comprised eight GPs who all took part in the study. Two participating suburban surgeries comprised a total of 16 GPs.All except three GPs agreed to participate (which only resulted in the loss of five consulting adolescents during the time of the study). Data were collected until 200 participants were included in each area. All adolescents aged years consecutively attending the GP were selected for study. After attending, they were contacted by letter to request their participation. A second letter was sent to those who did not respond. Adolescent attenders and their parents were approached for agreement to take part in the study. They completed questionnaires on mental and physical health and on psychosocial circumstances. London adolescents also received a psychiatric interview after completing the questionnaires. G Ps completed feedback questionnaires as part of the consultation with the adolescent. Instruments Adolescents, their parents and GPs completed the following measures. Adolescent measures Demographic data and service use data. Depressive symptoms: The Moods and Feelings Questionnaire (MFQ), a 32-item well-validated, self-report instrument (Angold et al. 1987) was used dimensionally to determine levels of depressive symptomatology.a dimensional approach was considered indicated for the study because mood symptoms occur as a continuum within the community (Kendler and Gardner 1998), thresholds for different risks may occur at different levels, and the power of the sample is, thus, increased (Pickles 1995). MFQ data were also used categorically to estimate the proportion of high scoring respondents using two different cut-offs to define high scores at the extreme end of the distribution: (i) a cut-off of 26 or more which has been established as the optimal cut-off to screen for depressive disorders in clinical samples (Wood et al. 1995); (ii) a cut-off of 17 or more, the optimal cut-off detection of depressive disorder in a general practice attending sample. The optimal cut-off for this population has not previously been calculated. We calculated this within the urban group using K-SADS DSM-IV diagnoses, generated from psychiatric interview (Kramer and Garralda 1998), together with MFQ data, to generate a Receiver Operator Characteristic Curve (Swets 1998) which demonstrates the point of optimal sensitivity and specificity. To assess associated somatic symptoms,adolescents completed the Child Symptom Inventory (CSI). The CSI obtains information on a variety of physical symptoms experienced in the previous 2 weeks (Garber et al. 1991). Respondents are asked to indicate to what extent they have been bothered by each of the symptoms on a scale from 0 (not at all) to 4 (a whole lot). The instrument yields a total score, quantifying the sum of scores for all symptoms endorsed, i. e. total number of symptoms with intensity of symptoms. In addition, respondents were asked to indicate whether these physical symptoms impaired their school performance, 589 concentration and enjoyment, and whether they were related to stress. The Westminster Drugs and Alcohol Questionnaire was administered to evaluate substance abuse related health risk behaviour (Swadi 1992). Parent-completed questionnaires To assess the presence of parent-rated emotional and behavioural problems, parents completed the Child Behaviour Checklist (CBCL), an instrument of well-established validity and reliability (Achenbach 1991). Raw Total, Internalising and Externalising scores were calculated. To explore parental psychopathology,parents completed the General Health Questionnaire (GHQ-28), a commonly used questionnaire of proven validity and reliability (Goldberg 1978). A cut-off of 5 or more was used to indicate likely psychopathology. GP-completed questionnaire GPs completed a brief questionnaire for each adolescent attendance.this documented the presenting complaint,the presence of associated psychological factors, and of adolescent psychiatric disorder (defined as a handicapping abnormality of emotion, behaviour or relationships). Analysis Data were analysed using SPSS for Windows. Associations of mood symptoms were explored in the whole group and in urban and suburban areas separately, by comparing the median number of mood symptoms on the MFQ in relation to the presence or absence of the independent variables. Chi squared, Mann Whitney U, Kruskall Wallis, and Spearman s Rho statistics were used. Because the study aimed to identify factors that could aid GP identification of depressive symptoms and have potential clinical relevance, univariate analysis is reported. Results Response rates and sample characteristics A total of 413 adolescents attended the GPs during the course of the study; 391 (95 %) GPs, 276 (67 %) adolescents and 237 (57 %) parents returned questionnaires. The mean age for all attenders was 14 years 9 months, 244/413 (59 %) being female. In all 197/267 (74 %) adolescents came from white English/Scottish/Welsh backgrounds, while 70/267 (26 %) came from other ethnic groups; 143/261 (55 %) came from social classes 1 and 2, while 118/261 (45 %) came from social classes 3 and 5 or had unemployed parents; 190/267 (71 %) adolescents were living with both natural parents; and 130/267 (49 %) lived in London, while 137/267 (51 %) lived in Hertfordshire.Almost all the adolescents presented with minor physical complaints (such as respiratory problems, ill-defined signs and symptoms, skin disorders, etc.) and only 4/413 (0.9 %) presented primarily with an emotional or behavioural complaint. These included drug use, depression and behaviour problems.

3 590 Level of depressive symptoms The median score on the MFQ was 10.0 (quartiles 5.0:19.0) for the group as a whole. In all, 87/267 (33 %) were high scorers using a cut-off of 17 or above, and 41/267 (15 %) using a cut-off of 26 or above. Demographic risks for depressive symptoms Table 1 shows that older age, female gender and presence of parental psychiatric symptoms (according to the GHQ) were significantly associated with higher scores on the MFQ. Ethnicity, social class, family composition and location (urban or suburban) were not. Associations of depressive symptoms Table 1 Associations of depressive symptoms (MFQ scores) with demographic risk factors MFQ Scores Median (quartiles) Statistics Age: (N = 262) 13/14 years (N = 129) 10.0 (4.0:17.0) Mann Whitney U 15/16 years (N = 133) 11.0 (6.0:22.5) p < Gender: (N = 267) Male (N = 109) 7.0 (3.0:13.0) Mann Whitney U Female (N = 158) 13.5 (8.0:23.3) p < Parental GHQ: (N = 230) >or=5 (N = 58) 17.5 (8.0:26.0) Mann Whitney U < or = 5 (N = 172) 10.0 (4.0:16.8) p < Ethnicity: (N = 267) White English/Scottish/Welsh 10.0 (5.0:19.0) Mann Whitney U (N = 197) Non significant Other (N = 70) 10.5 (6.0:19.3) p < Social class: (N = 261) 1 2 (N = 143) 11.0 (6.0:19.0) Kruskall Wallis 3 5 (N = 99) 10.0 (5.0:19.0) Non significant Unemployed (N = 19) 16.0 (9.0:26.0) p < Family composition: (N = 267) Both natural parents (N = 190) 10.0 (5.0:19.0) Kruskall Wallis One natural parent (N = 73) 12.0 (6.0:18.5) Non significant Other (N = 4) 18.5 (2.0:40.3) p < Location: (N = 267) Mann-Whitney U Urban (N = 130) 11.0 (6.0:18.0) Non significant Suburban (N = 137) 10.0 (4.0:22.0) p < The median total score for physical symptoms on the CSI was 12.0 (quartiles 7.0:21.0). Mood symptoms (MFQ score) were significantly correlated with levels of physical symptoms (CSI score) (Spearman s Rho correlation co-efficient = 0.595, p < 0.000). Mood symptoms were also significantly associated with the presence of impairment from physical symptoms, including impairment of school performance, concentration and enjoyment (Table 2). Presence of mood symptoms was associated with recognition that the physical symptoms were worse with stress. A number of health risks were significantly associated with mood symptoms (Table 2). These included use of cannabis and exposure to drugs (i. e. best friend uses drugs, knows anyone who uses drugs, been offered drugs by friends or relatives, been offered drugs by strangers). Table 2 also shows that mood symptoms were significantly associated with some types of health service use. Levels were higher in those that were in contact with a mental health professional and in GP attenders who had Table 2 Associations of depressive symptoms with physical symptoms, health risks and service use MFQ Scores Median (quartiles) Statistics Impairment from physical symptoms School performance No/a bit (N = 251) 10.0 (5.0:19.0) Mann Whitney U Yes (N = 11) 22.0 (11.0:29.0) p < Concentration No/a bit (N = 243) 10.0 (5.0:19.0) Mann Whitney U Yes (N = 21) 20.0 (10.0:37.0) p < Enjoyment No/a bit (N = 238) 10.0 (5.0:19.0) Mann Whitney U Yes (N = 26) 15.5 (8.0:31.3) p < Worse with stress No/A bit (N = 189) 9.0 (4.0:16.0) Mann Whitney U Yes (N = 72) 19.0 (12.0:26.0) p < Health risks: smoking, drugs and alcohol Smoking Daily (N = 26) 11.0 (6.8:23.3) Non significant Never/infrequently (N = 235) 10.0 (5.0:19.5) p < Alcohol Regularly (N = 50) 11.0 (6.8:18.3) Non significant Never/occasionally (N = 213) 10.0 (5.0:19.5) p < Drugs Best friend uses drugs No (N = 198) 10.0 (4.8:18.0) Mann Whitney U Yes (N = 47) 16.0 (7.0:26.0) p < Know anyone who uses drugs No (N = 69) 8.0 (4.5:16.5) Mann Whitney U Yes (N = 192) 11.5 (6.0:22.0) p < Been offered drugs by friends/relatives No (N = 150) 8.5 (4.0:16.0) Mann Whitney U Yes (N = 113) 14.0 (7.5:26.0) p < Been offered drugs by strangers No (N = 183) 9.0 (4.0:18.0) Mann Whitney U Yes (N = 79) 14.0 (9.0:26.0) p < Cannabis Have used (N = 72) 15.0 (7.3:25.0) Mann Whitney U Never used (N = 193) 10.0 (4.0:17.0) p < Service use Contact mental health professional No (N = 228) 10.0 (5.0:18.0) Mann Whitney U Yes (N = 39) 18.0 (11.0:27.0) p < GP visits in last year No (N = 178) 9.0 (4.0:18.0) Mann Whitney U Yes (N = 87) 12.0 (8.0:22.0) p < 0.003

4 consulted four or more times in the previous year. Mood symptoms were not associated with attendance at Accident & Emergency Departments, paediatricians, dermatologists, surgeons, physiotherapists, orthopaedic surgeons, or other medical professionals. Recognition of possible psychiatric problems by others GP recognition GPs recognised psychiatric disorder in 28/257 or 11 % of the sample, and psychological problems associated with the presentation in 65/262 or 25 %. GP identification of psychiatric disorder was not associated with mood symptoms. However, their assessment of psychological factors associated with the presentation approached statistical significance. Median MFQ scores were 13.0 (quartiles 6.0:23.5) in the group assessed to have associated psychological factors, and 10.0 (quartiles 5.0:18.0) in the rest (Mann Whitney U, p < 0.051). Parent recognition Parental ratings of emotional and behavioural problems in youngsters were assessed with the use of the CBCL questionnaire. The median raw scores were as follows: Total = 20.0 (quartiles 11.0:35.8), Internalising = 6.0 (quartiles 3.0:12.0), Externalising = 6.0 (quartiles 2.0:11.0). Total and internalising scores were modestly, but significantly, correlated with adolescent-rated mood symptoms (Spearman s Rho = 0.203, p < 0.002; Spearman s Rho = 0.239, p < 0.000, respectively). Urban (London) vs. suburban (Hertfordshire) comparison We wanted to ascertain whether mood symptom rates and their associations differed in urban and suburban areas. For this analysis, we divided our sample accordingly into urban and suburban groups. Response rates and sample characteristics Within urban and suburban groups, adolescent (68 % vs. 66 %) and GP (97 % vs. 92 %) participation rates were similar.parental participation rates were lower in the urban group (49 % vs. 65 %, χ 2 = 11.1; p < 0.001, 1 d. f.). Psychosocial disadvantage was higher in the urban sample. Thus, the groups differed significantly in terms of socio-economic class (social classes 1 and 2: urban = 33 %, suburban = 76 %; social classes 3 5: urban = 54 %, suburban = 22 %; unemployed: urban = 13 %, suburban = 2 %, χ 2 = 49.73, d. f. = 2, p < 0.000), ethnicity (White English/Scottish/Welsh: urban = 50 %, suburban = 96 %, χ 2 = 78.71, d. f. = 1, p < 0.000), home composition (living with both natural 591 parents: urban = 57 %, suburban = 85 %, χ 2 = 24.93, d. f. = 1, p < 0.000) and presence of parental psychiatric symptoms (GHQ 5: urban = 35 %, suburban = 16 %, χ 2 = 8.49, d. f. = 1, p < 0.004). Reasons for attendance were similar,although all four cases with primarily emotional or behavioural complaints were in the urban group. Levels of depressive symptoms Medians and the proportion of high scorers were comparable in both urban and suburban groups. The urban group had a median MFQ score of 11.0 (quartiles 6.0:18.0) and suburban of 10.0 (quartiles 4.0:22.0) (Mann Whitney U: p < 0.798), with 38/130 (29 %) of the urban group and 49/137 (36 %) of the suburban group being above the 17 cut-off (Chi sq. = 1.297, 1 d. f., p<0.255), and 17/130 (13 %) of the urban group and 24/137 (18 %) of the suburban group being above the 26 cut-off (Chi sq. = d. f., p < 0.314). Associations of depressive symptoms Total CSI physical symptom scores in urban and suburban groups were similar (median urban = 13.0; quartiles 7.0:21.0 vs. median suburban = 12.0; quartiles 6.25:21.0). In both groups, physical symptom scores correlated highly significantly with mood symptoms on the MFQ (urban: Spearman correlation co-efficient = 0.694, p<0.000; suburban: Spearman correlation coefficient = 0.523, p < 0.000). Impairment from physical symptoms was significantly associated with mood symptoms in both groups although this was more widespread in the suburban group. In both groups, mood symptoms were significantly associated with impairment of concentration (Mann Whitney U: urban p < and suburban p<0.025), and with recognition that the physical symptoms were worse with stress (Mann Whitney U: urban p<0.003 and suburban p < 0.000); only in the suburban group were they associated with impairment of school performance and enjoyment (Mann Whitney U: p < and p < 0.003, respectively). Health risks were significantly associated with mood symptoms only in the suburban group. This included daily smoking, having a best friend using drugs, being offered drugs by friends and by strangers, and cannabis use (Mann Whitney U: p < 0.03). In urban adolescents, mood symptoms were associated only with contact with a mental health professional (Mann Whitney U, p < 0.000), while, in suburban adolescents, they were associated only with four or more visits to the GP (Mann Whitney U, p < 0.001). Recognition of possible psychiatric problems by others GP recognition. In the urban group, GP s recognition of associated psychological factors was associated with adolescent MFQ rated mood symptoms (Mann Whitney

5 592 U, p<0.010),whereas,in the suburban group,neither GP recognition of psychiatric disorder nor of associated psychological factors was associated with levels of mood symptoms. Parent recognition. There were differences between the two groups on the parentally rated CBCL scores with significantly higher total, externalising and to a lesser extent internalising scores in the urban group (median Total score: urban = 28.0; quartiles 12.0:45.0 vs. suburban=15.0; quartiles 10.0:26.0, Mann Whitney U, p < 0.000; median Internalising score: urban = 10.0; quartiles 4.0:15.0 vs. suburban = 6.0; quartiles 3.0:10.0, Mann Whitney U, p < 0.003; median Externalising score: urban = 7.5; quartiles 4.0:14.0 vs. suburban = 4.0; quartiles 2.0:9.0, Mann Whitney U, p < 0.000). Correlations between adolescent-rated MFQ mood symptoms and parentally rated Total CBCL scores were stronger in the urban than in the suburban groups (urban group: Spearman Rho r = p < vs. suburban r = p < 0.146), but the correlations with CBCL internalising scores were comparable (urban group: r = p < vs. suburban r = and p < 0.005). Discussion Our study confirms high levels of mood symptoms amongst adolescents attending GPs in socio-demographically diverse areas and it identifies a variety of socio-demographic and health associations. We found older age and female gender,but not ethnicity, to be significantly associated with adolescent depressive symptoms. Monck et al. (1994) established a link in adolescent girls, between mood disorders and general practice attendance increasing with age. The age and gender associations are in line with those from the largest community study (Angold et al. 2002). Ethnicity was not associated with mood symptoms in our study population. Within other populations, ethnicity per se has not consistently been shown to be associated with depressive symptoms (Sund et al. 2003; Meltzer et al. 2000), although higher rates of symptoms have been reported within minority or immigrant adolescents (Roberts and Chen 1995; Sack et al. 1999), probably reflecting a different set of psychosocial stressors. In terms of contextual factors, we found an association with parental psychiatric symptoms, but not with other social and family adversity factors (i. e. social class, family composition and urban vs. suburban location). This runs counter to the findings of a large community sample in New Zealand, where Fergusson et al. (1995) established that the connection between maternal depressive symptoms and depressive symptoms in adolescent girls was largely explained by the association of both measures with social disadvantage, marital discord and family adversity and to findings from other community studies of links between child depressive symptoms, disorder and poverty (Goodman 1999; Schraedley et al. 1999; Costello et al. 1996). The discrepancies could be due to differences in the measures of adversity used: for example, our measure of social class, defined by the occupation of the head of household, may fail to reflect family poverty. Alternatively, the lack of associations may be specific to those who use primary care services. It seems plausible for social factors to be of less relevance for adolescent depression in this setting than in the general population or as seen in specialist clinics, and for links with physical symptoms to be heightened in primary care. A different study design would, however, be required to clarify associations that are settingspecific. Frequency of mood symptoms amongst attenders Mood symptom levels comparable to those seen in clinically referred samples were present in over one in ten of young people attending general practice. This is higher than the expected 5 % general population rates (Harrington et al. 1994) and suggests that they contribute to the decision to consult. The fact that most presentations were ostensibly for physical complaints would support the appropriateness of screening for depressive symptoms amongst adolescent attenders. Demographic and contextual factors associated with depressive symptoms Health risks, physical symptoms and service use As in other recent population surveys in the UK, depressive symptoms in attenders were associated with exposure to drugs and cannabis use (Boys et al. 2003). Identification of those with depressive symptoms can, therefore, help raise suspicion of increased risk of substance misuse, and interventions to decrease depressive symptoms may have additional benefits of decreasing risk for substance misuse. Mood symptoms were also significantly correlated with the presence of physical symptoms and related impairment across a wide range of domains. Similar associations have been described in other samples (Bernstein et al. 1997; McCauley et al. 1991). They are likely to account for a reduced sense of well-being and contribute to help seeking within primary care. However, the fact that few adolescents presented their psychological distress for consultation indicates that they may not regard this aspect of their suffering as a valid reason for presentation (Jacobson et al. 2002). The association of mood symptoms with use of primary care services and mental health services indicates that the presence of depressive symptoms may have implications for service provision. Adolescents in our study who consulted primary care four or more times

6 had higher levels of mood symptom. We found links between GP recognition of psychological factors associated with the consultation and adolescent mood symptoms. Further research is needed to determine whether explicit recognition of this hidden morbidity by GPs would alter the pattern or nature of consultations. GPs may require specific training to improve detection of adolescent depression (Gledhill et al. 2003). 593 (68 % and 66 %, respectively). Parental participation rates were, however, lower in the urban than in the suburban sample. To ascertain whether this could have biased parental ratings of adolescent psychopathology on CBCL questionnaires, we compared adolescent-rated MFQ depressive scores in those with and without parent questionnaires, but found these to be similar, suggesting a lack of any substantial bias. Urban (London) vs. suburban (Hertfordshire) comparison We failed to find urban/suburban differences in adolescent depressive symptoms. This in itself is not surprising.a recent national mental health survey in the UK reported little in the way of links between disorder and location (metropolitan vs. non-metropolitan areas) (Metzer et al. 2000), and when urban rural differences in psychiatric disorder have been reported, they have been accounted for by associated psychosocial disadvantage (Rutter et al. 1975; Costello et al. 1996). It may seem more surprising, however, given the higher rates of psychosocial disadvantage (in terms of social class, home composition, and the presence of parental psychiatric symptoms) in our urban area. As already discussed, only one of these (parental psychiatric symptoms) was shown to be a relevant risk for depressive symptoms in our sample. It is possible nevertheless that the heightened psychosocial disadvantage accounted for the increased parentally reported emotional and behavioural symptoms on the CBCL (possibly indicating more co-morbidity) in the urban group, and that this in turn was linked to the enhanced recognition of associated psychosocial factors by GPs and more use of mental health services in this group. We found significant associations of mood symptoms with risk for substance misuse and frequent surgery attendance in the suburban group only. Whilst the lack of association with risk for substance misuse in the urban group may be an artefact of higher base rates in this group, the findings suggest that GPs may have a heightened role in the identification and management of adolescent mood changes and associated health risks in suburban psychosocially advantaged areas. Limitations Our findings apply to mood symptoms rather than depressive disorders, which may have different associations. They relate to those adolescents attending the GP. We did not include a non-attending group for comparison and, therefore, cannot exclude the possibility that psychosocial disadvantage would show different associations with depressive symptoms in the group of adolescents who do not consult the GP. In terms of adolescent participants, we achieved a reasonable response rate which was similar in urban and suburban samples Conclusion High levels of depressive symptoms are present in adolescent primary care attenders of a broad range of social backgrounds. These are associated with older age, female gender, parental psychiatric symptoms, physical symptoms with psychosocial impairment and health risks.improved GP recognition and intervention has the potential to impact on depressive symptoms and associated risks. References 1. Achenbach TM (1991) Manual for the Child Behaviour Checklist 4 18 and 1991 Profile.University of Vermont Department of Psychiatry, Burlington, VT 2. 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