Natural course of cannabis use disorders.

BACKGROUND: Despite its importance as a public health concern, relatively little is known about the natural course of cannabis use disorders (CUDs). The primary objective of this research was to provide descriptive data on the onset, recovery and recurrence functions of CUDs during the high-risk periods of adolescence, emerging adulthood and young adulthood based on data from a large prospective community sample. METHOD: Probands (n = 816) from the Oregon Adolescent Depression Project (OADP) participated in four diagnostic assessments (T1-T4) between the ages of 16 and 30 years, during which current and past CUDs were assessed. RESULTS: The weighted lifetime prevalence of CUDs was 19.1% with an average onset age of 18.6 years. Although gender was not significantly related to the age of initial CUD onset, men were more likely to be diagnosed with a lifetime CUD. Of those diagnosed with a CUD episode, 81.8% eventually achieved recovery during the study period. Women achieved recovery significantly more quickly than men. The recurrence rate (27.7%) was relatively modest, and most likely to occur within the first 36 months following the offset of the first CUD episode. CUD recurrence was uncommon after 72 months of remission and recovery. CONCLUSIONS: CUDs are relatively common, affecting about one out of five persons in the OADP sample prior to the age of 30 years. Eventual recovery from index CUD episodes is the norm, although about 30% of those with a CUD exhibit a generally persistent pattern of problematic use extending 7 years or longer.

Co-morbidity between major depressive disorder and anxiety disorders: shared etiology or direct causation?

BACKGROUND: Major depressive disorder (MDD) and anxiety disorders (ANX) are debilitating and prevalent conditions that often co-occur in adolescence and young adulthood. The leading theoretical models of their co-morbidity include the direct causation model and the shared etiology model. The present study compared these etiological models of MDD-ANX co-morbidity in a large, prospective, non-clinical sample of adolescents tracked through age 30. METHOD: Logistic regression was used to examine cross-sectional associations between ANX and MDD at Time 1 (T1). In prospective analyses, Cox proportional hazards models were used to examine T1 predictors of subsequent disorder onset, including risk factors specific to each disorder or common to both disorders. Prospective predictive effect of a lifetime history of one disorder (e.g. MDD) on the subsequent onset of the second disorder (e.g. ANX) was then examined. This step was repeated while controlling for common risk factors. RESULTS: The findings supported relatively distinct profiles of risk between MDD and ANX depending on order of development. Whereas the shared etiology model best explained co-morbid cases in which MDD preceded ANX, direct causation was supported for co-morbid cases in which ANX preceded MDD. CONCLUSIONS: Consistent with previous research, significant cross-sectional and prospective associations were found between MDD and ANX. The results of the present study suggest that different etiological models may characterize the co-morbidity between MDD and ANX based upon the temporal order of onset. Implications for classification and prevention efforts are discussed.

A computer-assisted depression intervention in primary care.

BACKGROUND: The clinical benefit for depression of an interactive computer-assisted cognitive-behavioral program on CD-ROM, the Wellness Workshop (WW), was evaluated in a randomized controlled trial. METHOD: A total of 191 individuals referred by primary-care physicians were randomly assigned to a control group, where physician-directed treatment as usual (TAU) was provided, or to a treatment group, where TAU was supplemented with the WW CD-ROM, delivered by mail (WW+TAU). Data were collected at baseline, at 6 weeks' post-intervention, and at a 6-month follow-up assessment. Participants were given a strong incentive by a reimbursement of $75 for completion of each assessment. Measures included symptom ratings obtained via structured clinical diagnostic interviews, as well as a battery of self-report questionnaires on symptoms specifically targeted by the intervention. RESULTS: Analysis of results demonstrated evidence for skill acquisition for improving dysfunctional thinking and reducing anxiety. Among those who met diagnostic criteria for depression, WW+TAU participants were three times more likely to remit at 6 weeks' post-test than TAU participants. CONCLUSIONS: The evidence supports the conclusion that the WW intervention added benefit to traditional care for depression. No placebo comparison group was included and the WW+TAU participants received slightly more attention (a supportive telephone contact, ≤ 5 min from a psychologist 2 weeks after receiving the program). Overall, the findings add support to the accumulating evidence for the potential clinical benefit of computer-assisted behavioral health interventions.

A family study of major depressive disorder in a community sample of adolescents.

BACKGROUND: Family studies provide a useful approach to exploring the continuities and discontinuities between major depressive disorder (MDD) in children and adolescents and MDD in adults. We report a family study of MDD in a large community sample of adolescents. METHODS: Probands included 268 adolescents with a history of MDD, 110 adolescents with a history of nonmood disorders but no history of MDD through age 18 years, and 291 adolescents with no history of psychopathology through age 18 years. Psychopathology in their 2202 first-degree relatives was assessed with semistructured direct and family history interviews, and best-estimate diagnoses were derived with the use of all available data. RESULTS: The relatives of adolescents with MDD exhibited significantly elevated rates of MDD (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.46-2.31), dysthymia (HR, 1.79; 95% CI, 1. 11-2.87), and alcohol abuse or dependence (HR, 1.29; 95% CI, 1.05-1. 53), but not anxiety disorders, drug abuse or dependence, or antisocial and borderline personality disorder. In contrast, anxiety, substance use, and disruptive behavior disorders in adolescents were not associated with elevated rates of MDD in relatives. However, the relatives of probands with anxiety and substance use disorders exhibited elevated rates of anxiety and substance use disorders, respectively. CONCLUSIONS: The results provide evidence of the familial aggregation of adolescent MDD, and also indicate that there is a considerable specificity in the pattern of familial transmission. In addition, we found preliminary evidence of the familial aggregation of adolescent anxiety and substance use disorders.

Comparability of telephone and face-to-face interviews in assessing axis I and II disorders.

OBJECTIVE: The present study examined the comparability of data obtained by telephone and face-to-face interviews for diagnosing axis I and II disorders. METHOD: Sixty young adults from the community were interviewed face-to-face and over the telephone regarding axis I disorders; another 60 subjects were interviewed twice regarding axis II disorders. The order of interviews was counterbalanced, and subjects with a history of disorder were oversampled. Agreement between telephone and face-to-face interviews was contrasted with interrater values, which were obtained by having a second interviewer rate a recording of the original interview. RESULTS: Interrater reliability was excellent. Agreement between telephone and face-to-face assessment was excellent for anxiety disorders and very good for major depressive disorder and alcohol and substance use disorders; agreement was problematic, however, for adjustment disorder with depressed mood. Strong support was shown for the validity of the axis II telephone assessment format. Small but consistent trends were noted for lower rates of psychopathology reported in the second interview. CONCLUSIONS: This is the first study in which telephone and face-to-face assessments of axis I and II psychopathology were conducted with the same subjects assigned to conditions in a counterbalanced manner. The present findings provide qualified justification for the use of telephone interviews to collect axis I and II data. The apparent concerns do not appear sufficient to override the economic and logistic advantages of telephone interviewing.

Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults.

OBJECTIVE: The primary purpose was to identify factors related to the recurrence of major depressive disorder during young adulthood (19-23 years of age) in a community sample of formerly depressed adolescents. METHOD: A total of 274 participants with adolescent-onset major depressive disorder were assessed twice during adolescence and again after their 24th birthday. Lifetime psychiatric information was obtained from their first-degree relatives. Adolescent predictor variables included demographic characteristics, psychosocial variables, characteristics of adolescent major depressive disorder, comorbidity, family history of major depressive disorder and nonmood disorder, and antisocial and borderline personality disorder symptoms. RESULTS: Low levels of excessive emotional reliance, a single episode of major depressive disorder in adolescence, low proportion of family members with recurrent major depressive disorder, low levels of antisocial and borderline personality disorder symptoms, and a positive attributional style (males only) independently predicted which formerly depressed adolescents would remain free of future psychopathology. Female gender, multiple major depressive disorder episodes in adolescence, higher proportion of family members with recurrent major depressive disorder, elevated borderline personality disorder symptoms, and conflict with parents (females only) independently predicted recurrent major depressive disorder. Comorbid anxiety and substance use disorders in adolescence and elevated antisocial personality disorder symptoms independently distinguished adolescents who developed recurrent major depressive disorder comorbid with nonmood disorder from those who developed pure major depressive disorder. CONCLUSIONS: Formerly depressed adolescents with the risk factors identified in this study are at elevated risk for recurrence of major depressive disorder during young adulthood and therefore warrant continued monitoring and preventive or prophylactic treatment.

Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders.

The prevalence of suicidal attempts and ideation and the co-occurrence of attempts with psychiatric disorders were examined in a community sample of 1710 older adolescents. Structured interviews using rigorous diagnostic criteria were conducted in two annual assessments. Lifetime prevalence of attempts was 7.1% and ideation was 21.1%. Almost 90% of those who attempted also evidenced suicidal ideation. Suicide attempts occurred in conjunction with depressive, substance use, and disruptive behavior disorders but not with panic disorders. Results indicate that risk factors for an attempt are the following: being female, from a home without a father, poor education of the father, previous attempts, suicidal ideation, and mental disorders.

Psychosocial characteristics of adolescents with a history of suicide attempt.

The purpose of this study was to identify psychosocial risk factors uniquely associated with past suicide attempts. Data assessing a large number of variables were available from a representative sample of older adolescents (N = 1,710). Most independent variables were associated with past suicide attempts; variables that remained associated with past attempts after controlling for current depression level included externalizing and internalizing problem behaviors, past psychiatric disorders, depressotypic cognitions, coping, school problems, health problems, and gender. The probability of having made an attempt increased dramatically as a function of the number of risk factors. Females had more risk factors and showed a greater vulnerability to the factors than did males.

Continuity of psychopathology in a community sample of adolescents.

OBJECTIVE: To examine the continuity between the primary (first) diagnosis and secondary (second) diagnosis of those adolescents who have more than one episode of psychiatric disorder. Data were examined to determine whether the second episode "breeds true" (i.e., remains within the same diagnostic category as the first) or involves a different disorder. METHOD: The sample consisted of 236 youngsters selected from the larger (n = 1,507) population of adolescents (aged 14 through 18 years) from the Oregon Adolescent Depression Project who had been assessed on two occasions, approximately 1 year apart. RESULTS: Results support the continuity hypothesis for the categories of disorder studied (major depression, anxiety, disruptive, substance use), with the exception of dysthymia. Primary dysthymia did not result in the diagnosis of secondary dysthymia, because most adolescents who had dysthymia had not recovered within the time frame of the study and were chronic cases, often with secondary anxiety. Also presented are data on age of onset of disorder (lowest for anxiety and highest for substance use) and information on remission intervals between episodes (well time) (lowest for substance use and highest for anxiety). CONCLUSIONS: The findings are interpreted as providing support for the "breed true" hypothesis, although clearly not all second episodes are identical with the first. While the psychosocial factors examined did not predict the nature of the second disorder, this clearly needs further study.

Psychiatric comorbidity with problematic alcohol use in high school students.

OBJECTIVE: To delineate the degree to which various levels of problematic alcohol use are associated with psychiatric disorders in adolescents. METHOD: The lifetime occurrence of psychiatric disorders was examined in a community sample of 1,507 older adolescents (aged 14 through 18 years) who were categorized according to their alcohol use (i.e., abstainers, experimenters, social drinkers, problem drinkers, and abuse/dependence group). RESULTS: Increased alcohol use was associated with the increased lifetime occurrence of depressive disorders, disruptive behavior disorders, drug use disorders, and daily tobacco use. There was a trend for increased alcohol use in girls to be associated with anxiety disorders. More than 80% of adolescents with alcohol abuse/dependence had some other form of psychopathology. Alcohol disorders, in general, followed rather than preceded the onset of other psychiatric disorders. Comorbidity was associated with an earlier age of alcohol disorder onset and with greater likelihood of mental health treatment utilization. CONCLUSIONS: Rates of psychiatric comorbidity with problematic alcohol use in adolescents are striking and represent an important therapeutic challenge.

Are adolescents changed by an episode of major depression?

OBJECTIVE: This study examined whether adolescents having a first onset of major depression are changed by the experience (i.e., does having an episode of depression result in residual effects that did not exist before the episode?). METHOD: Among 1,507 community adolescents assessed at two time points approximately 1 year apart 45 experienced and recovered from a first episode of depression between the two assessments. These adolescents were contrasted with never-depressed control subjects on an array of depression-related psychosocial variables before and after the episode. RESULTS: Psychosocial scars (characteristics evident after but not before the episode) included internalizing behavior problems, stressful major life events, excessive emotional reliance on others, cigarette smoking and subsyndromal depression symptoms. Both before and after the episode, the depressed adolescents reported an elevated level of physical health problems. CONCLUSIONS: More scars were found in the present study than in previous research with formerly depressed adults. This is consistent with the hypothesis that early-onset depression is a more pernicious form of the disorder that may impact adolescents more severely than adults.

Adolescent psychopathology: III. The clinical consequences of comorbidity.

OBJECTIVE: To describe the clinical consequences associated with the lifetime occurrence of comorbid psychiatric disorders. METHOD: In a community sample of 1,507 older adolescents (aged 14 through 18 years), subjects with "pure" and comorbid forms of four major psychiatric disorders (depression, anxiety, substance use, and disruptive behavior) were compared on six clinical outcome measures. RESULTS: The impact of comorbidity was strongest for academic problems, mental health treatment utilization, and past suicide attempts; intermediate on measures of role functioning and conflict with parents; and nonsignificant on physical symptoms. The greatest incremental impact of comorbidity was on anxiety disorders; the least was on substance use disorders. Although some patterns of comorbidity were much more common in boys (e.g., substance use and disruptive behavior disorder) or in girls (e.g., depression and anxiety), the impact of specific comorbid disorders on the clinical measures was not different for females and males. The effect of comorbidity was not due to current psychopathology. CONCLUSIONS: The significance of comorbidity differs across specific comorbid disorders and across outcome measures, with some comorbid disorders being much more detrimental, and some outcome measures much more affected, than others.

The OADP-CDS: a brief screener for adolescent conduct disorder.

OBJECTIVES: To examine the ability of a very brief (6-item) self-report screener, the Oregon Adolescent Depression Project Conduct Disorder Screener (OADP-CDS), to identify adolescents with a lifetime diagnosis of conduct disorder and to examine its ability to predict antisocial personality disorder by age 24. Relevant scales from the Yough Self-Report and the Child Behavior Checklist were examined for comparison purposes. METHOD: A total of 1,709 high school students completed an initial questionnaire and diagnostic interview assessment (T1); 1,507 participants returned approximately 1 year later for a second assessment (T2). A third (T3) assessment was conducted with selected T2 participants (n = 940) after they had turned 24 years of age. RESULTS: The OADP-CDS had good internal consistency, test-retest stability, and screening properties. Differences in the screening ability of the OADP-CDS as a function of gender and social desirability were nonsignificant. The efficacy of the measure as a screener did not differ significantly from that of longer adolescent- and parent-report measures. Perhaps most importantly, the OADP-CDS was able to identify future cases of antisocial personality disorder in young adulthood. CONCLUSIONS: Results suggest that self-report screening for conduct disorder with older adolescents is possible and should be explored further.

Screening for adolescent depression: a comparison of depression scales.

The ability of two depression scales, the Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI), to identify cases of DSM-III-R major depression and dysthymia was investigated in a large, community sample of high school students. Receiver operating characteristics analyses indicated that different caseness criteria should be used for boys and girls for both the CES-D and the BDI. Internal consistency-reliability and sensitivity and specificity for detecting current episodes of current depression and dysthymia were adequate and comparable to those found with adult samples, but both the CES-D and the BDI generated many false positives. Multiple screening using the "serial" strategy increased positive predictive power substantially for both the CES-D and the BDI, whereas using the "parallel" strategy had very little effect on the efficacy of the two screeners. The results indicate that neither the BDI nor the CES-D should be used by themselves as methods for case ascertainment in either epidemiological or experimental studies, although the BDI does function somewhat better than the CES-D as a screener.

Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course.

OBJECTIVE: The purpose of this study was to examine the prevalence, clinical characteristics, and mental health treatment services utilization of adolescents with bipolar disorders and manic symptoms. METHODS: Structured diagnostic interviews were administered to a representative community sample of 1,709 older adolescents (aged 14 through 18 years). RESULTS: The lifetime prevalence of bipolar disorders (primarily bipolar II disorder and cyclothymia) was approximately 1%. An additional 5.7% of the sample reported having experienced a distinct period of abnormally and persistently elevated, expansive, or irritable mood even though they never met criteria for bipolar disorder ("core positive" subjects). The rate of manic symptoms in these subjects was similar to that reported in clinical samples, and the course of bipolar disorder was relatively chronic. Compared with adolescents with a history of major depression (n = 316) and a "never mentally ill" group (n = 845), the bipolar and core positive subjects both exhibited significant functional impairment and high rates of comorbidity (particularly with anxiety and disruptive behavior disorders), suicide attempts, and mental health services utilization. CONCLUSIONS: These data highlight the clinical and public health significance of even the milder and subthreshold cases of bipolar disorder in adolescence.

Symptoms of DSM-III-R major depression in adolescence: evidence from an epidemiological survey.

OBJECTIVE: To examine the phenomenology of DSM-III-R major depression among adolescents diagnosed as "cases" in a community-based epidemiology study. METHOD: A representative sample (N = 1,710) of older adolescents from several Oregon communities were interviewed using structured diagnostic schedules and DSM-III-R criteria in two annual assessments. Although the focus was depression, diagnoses were made for most child and adolescent psychiatric disorders. RESULTS: Nearly 30% of the sample at baseline had at least one current symptom of DSM-III-R major depression, but only 2.6% received a diagnosis. The most prevalent symptoms at baseline were depressed mood, sleep, and thinking problems. For new, or incident cases, the most frequent symptoms involved depressed mood, anhedonia, and thinking problems. Among those adolescents who had experienced two episodes of major depression, there was low concordance across episodes for both diagnostic criteria and specific symptoms. Comparisons with six studies of adolescent patients indicate our community "cases" are phenomenologically very similar to clinical cases of major depression in treatment settings. CONCLUSIONS: The results presented, along with those from other studies of adults and children, provide strong evidence that DSM criteria for major depression are appropriate for adolescents. That is, DSM-III-R symptom criteria are manifested by both youths and adults, although the relative frequency of these criterion symptoms appear to be age-related.

Natural course of adolescent major depressive disorder: I. Continuity into young adulthood.

OBJECTIVE: To examine the course of adolescent major depressive disorder (MDD) by comparing rates of mood and non-mood disorders between age 19 and 24 years in participants with a history of adolescent MDD versus participants with adolescent adjustment disorder with depressed mood, nonaffective disorder, and no disorder. METHOD: Participants from a large community sample who had been interviewed twice during adolescence completed a third interview assessing Axis I psychopathology and antisocial and borderline personality disorders after their 24th birthday: 261 participants with MDD, 73 with adjustment disorder, 133 with nonaffective disorder, and 272 with no disorder through age 18. RESULTS: MDD in young adulthood was significantly more common in the adolescent MDD group than the nonaffective and no disorder groups (average annual rate of MDD = 9.0%, 5.6%, and 3.7%, respectively). Adolescents with MDD also had a high rate of nonaffective disorders in young adulthood (annual nonaffective disorder rate = 6.6%) but did not differ from adolescents with nonaffective disorder (7.2%). Prevalence rates of dysthymia and bipolar disorder were low (< 1%). Adolescents with adjustment disorder exhibited similar rates of MDD and nonaffective disorders in young adulthood as adolescents with MDD. CONCLUSIONS: This study documents the significant continuity of MDD from adolescence to young adulthood. Public health implications of the findings are discussed.

Major depression in community adolescents: age at onset, episode duration, and time to recurrence.

OBJECTIVE: This paper presents retrospective and prospective data regarding time course parameters of major depressive disorder (MDD) in community adolescents (14 to 18 years old): time to onset and recovery and, among those who recovered, time to recurrence. METHOD: Diagnostic interviews were conducted with 1,508 randomly selected high school students. Three hundred sixty-two had experienced at least one past or current episode of MDD. RESULTS: Mean age at onset of first episode was 14.9 (SD = 2.8). Early MDD onset was associated with female gender and suicidal ideation. MDD episode duration ranged from 2 to 520 weeks, with a mean of 26.4 weeks (SE = 3.3) and a median of 8.0 weeks. Longer episodes were observed in those whose depression occurred early (at or before age 15), whose depression had been accompanied by suicidal ideation, and for whom treatment was sought. Of the adolescents who recovered, 5% relapsed within 6 months, 12% within 1 year, and approximately 33% within 4 years. Shorter time to recurrence was associated with prior suicidal ideation and attempt and with later first onset. CONCLUSIONS: Risk of MDD is low in childhood, increasing substantially with adolescence. The majority of episodes in community adolescents are relatively brief, although the risk of recurrence is substantial. Suicidal behaviors are important mediators of episode duration and of recurrence.

Adolescent psychopathology: IV. Specificity of psychosocial risk factors for depression and substance abuse in older adolescents.

OBJECTIVE: To determine the specificity to major depressive disorder (MDD) of a wide array of psychosocial risk factors in older adolescents (aged 14 through 18 years). METHOD: Diagnostic and psychosocial assessments were conducted with 1,507 randomly selected high school students at T1 and after approximately 1 year (T2). Three diagnostic groups were compared: those who had an episode of MDD during that year (n = 90), those who had an episode of substance use disorder during that year (SUD) (n = 42), and a control group with no disorder (n = 1,189). RESULTS: Risk factors specific to MDD were stress (minor and major events), emotional reliance, physical symptoms and disease, history of suicide attempt, and a past episode of depression or anxiety disorder. Risk factors specific to SUD were tobacco use, academic difficulties, and a past episode of SUD. Risk factors that were shared were current depression symptoms, internalizing and externalizing behavior problems, coping skills, interpersonal conflict with parents, and dissatisfaction with grades. CONCLUSIONS: By determining the number of risk factors for MDD, for SUD, or those that are general to both disorders, clinicians can make informed predictions concerning the probable future onset of a full-fledged episode of MDD and/or SUD in individual cases. The results of this study allow for the identification of adolescents who are at elevated risk for MDD and SUD. The results also have implications for the design of interventions aimed at preventing the occurrence of these disorders. Such interventions should target change on risk factors of the type identified in this study.

Gender differences in suicide attempts from adolescence to young adulthood.

OBJECTIVE: To examine associations of age, gender, and psychosocial factors during adolescence with risk of suicide attempt between ages 19 and 23 years. METHOD: Initial assessments were conducted with 1,709 adolescents (aged 14-18) in western Oregon between 1987 and 1989. One year later, 1,507 participants returned for a second assessment. A subset of participants (n = 941; 57.2% women) had a third diagnostic assessment after turning 24 (between 1993 and 1999). Information on suicidal behavior, psychosocial risk factors, and lifetime DSM-III-R psychiatric diagnosis was collected at each assessment. RESULTS: The suicide attempt hazard rate for female adolescents was significantly higher than for male adolescents (Wilcoxon chi 2(1)[n = 941] = 12.69, p < .001). By age 19, the attempt hazard rate for female adolescents dropped to a level comparable with that of male adolescents. Disappearance of the gender difference for suicide attempts by young adulthood was not paralleled by a decrease in the gender difference for major depression. Adolescent suicidal behavior predicted suicide attempt during young adulthood for female, but not male, participants. Adolescent psychosocial risk factors for suicide attempt during young adulthood were identified separately for girls and boys. CONCLUSIONS: Unlike depression, the elevated incidence rate of suicide attempts by adolescent girls is not maintained into young adulthood. Screening and prevention implications are discussed.