Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial.

OBJECTIVE: To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression. METHOD: After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores. RESULTS: Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects. CONCLUSIONS: Paroxetine is generally well tolerated and effective for major depression in adolescents.

Unmet needs for substance abuse and mental health services among Northern Plains American Indian adolescents.

Use of mental health and substance abuse services was examined among 109 American Indian adolescents in a Northern Plains reservation community. Each was interviewed to assess psychiatric diagnosis and service use and to determine whether an adult had recognized a problem in the adolescent-a critical determinant of receipt of services. Of the 23 youths who had a disorder, nine (39 percent) reported lifetime service use. Of the 25 who received services, 17 were treated by a school counselor; only one received services from a mental health specialist. Eight of the 25 youths with a psychiatric or substance use diagnosis who did not receive services reported that an adult had recognized a problem.

Twelve-year follow-up study of Khmer youths who suffered massive war trauma as children.

OBJECTIVE: Twenty-seven of 40 Khmer adolescent youths who had survived the horrors of the Pol Pot regime (1975-1979) as children and 4 of 6 who had escaped this war were reinterviewed for the fourth time, during the summer of 1996, to determine their diagnostic status for posttraumatic stress disorder (PTSD) and/or depression and their functional status with regard to occupational and/or educational pursuits. They had been interviewed initially in 1983-1984 and again 3 (1987) and 6 (1990-1991) years later. METHOD: PTSD was determined using the Diagnostic Interview for Children and Adolescents, and depression was assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children. RESULTS: The point prevalence rates of PTSD were comparable with those found 6 years earlier, and rates of depression were much lower but had increased somewhat over the ensuing 6 years. The onset of PTSD was quite variable, with 18% of subjects (7/40) developing PTSD at least 5 years after cessation of the Pol Pot hostilities. Subjects with PTSD were more likely to recall specifically traumatic war memories, whereas those without PTSD were more likely to recall memories of loss and/or displacement. Most subjects were functioning well, regardless of diagnostic status. CONCLUSIONS: Although its onset is quite variable, PTSD persists in war-traumatized Cambodian refugee youths. PTSD and depression appear to follow different pathways over time. PTSD need not be associated with major functional impairment.

Multiple forms of stress in refugee and immigrant children.

The effects of genocidal warfare reverberate long after the bloodshed has stopped. This article focuses on one aspect of the aftermath or war and violence: the transformation of families and children into refugees and immigrants.

Psychiatric disorder among American Indian adolescents: prevalence in Northern Plains youth.

UNLABELLED: This article presents data on the prevalence of psychiatric disorders among American Indian adolescents, using DSM-III-R criteria. OBJECTIVE: To generate current prevalence data using a structured diagnostic instrument, the Diagnostic Interview Schedule for Children, Version 2.1C (DISC-2.1C). METHODS: Youths from a Northern Plains tribe who had participated in an earlier study comprised the sample. At reinterview, respondents were between 14 and 16 years of age, when Indian adolescents are thought to be at particularly high risk for manifesting emotional disorders. One hundred nine of the original sample of 251 were still in schools on the reservation. Trained indigenous lay interviewers administered the DISC-2.1C to respondents in a private setting within the school. RESULTS: The findings indicate that rates of some psychiatric problems (e.g., disruptive behavior disorders, substance-related disorders, and their comorbidity) are high among these high school students. CONCLUSIONS: These data, as well as national statistics, suggest that, compared with non-Indian populations, a greater percentage of Northern Plains adolescents manifest significant psychiatric symptoms which warrant treatment.

The DSM-IV Outline for Cultural Formulation: a critical demonstration with American Indian children.

OBJECTIVE: The publication of DSM-IV is notable for the improved coverage of cultural issues in the diagnosis of mental disorders. In particular, Appendix I of DSM-IV includes an "Outline for Cultural Formulation" (Outline) which assists the clinician in evaluating the impact of an individual's cultural context on diagnosis and treatment. However, the capacity of the Outline to facilitate the development of comprehensive cultural formulations for children and adolescents has not been established. In this article the use of the Outline with American Indian children is reviewed critically. METHOD: Based on the Outline, cultural case formulations for four American Indian children were developed and their comprehensiveness was assessed. RESULTS: Applied to the case material, the Outline provided a clear template for the development of cultural formulations. Nonetheless, several gaps in the material required by the Outline were identified, particularly in the areas concerning cultural identity and cultural elements of the therapeutic relationship. CONCLUSIONS: Clinicians working with children should recognize the strengths as well as the limitations of the Outline and expand their cultural descriptions accordingly. Several additions to the text of the Outline that will facilitate the development of comprehensive cultural formulations specific to children and adolescents are proposed.

Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents.

We examine the lifetime comorbidity among anxiety disorders, and between anxiety disorders and other mental disorders, in a large (n = 1,507) community sample of high school students on whom extensive diagnostic data were available. Three diagnostic groups were formed: those with a lifetime anxiety disorder (n = 134); those with a nonanxiety disorder (n = 510); and those who had never met criteria for a mental disorder (n = 863). The intra-anxiety comorbidity rate was relatively low (18.7%), and was strongly associated with being female (92%). The lifetime comorbidity between anxiety and other mental disorders (primarily MDD) was substantial (73.1%) and was not associated with being female.

Trauma-related symptomatology among American Indian adolescents.

The Diagnostic Interview Schedule for Children (DISC-2.1C), including the postraumatic stress disorder (PTSD) module, was administered to 109 American Indian adolescents from a Northern Plains reservation. In response to the DISC's open-ended probes, 61% of respondents reported at least one traumatic event. Despite high rates of trauma and substantial numbers of subsyndromal PTSD symptoms, the prevalence rate of diagnosable PTSD was found to be only 3%. The reporting of traumatic events was associated with increased prevalence of behavioral disorders and substance abuse or dependence diagnoses. There was, however, no significant difference in academic performance (grade point average or scholastic aptitude test scores) between those who reported traumatic events, or PTSD symptoms, and those who did not.

Does PTSD transcend cultural barriers? A study from the Khmer Adolescent Refugee Project.

OBJECTIVE: To determine whether the factor structure of the posttraumatic stress disorder (PTSD) syndrome in Cambodian refugee youth resembles earlier reported factor studies in Caucasian samples. METHOD: 194 Khmer adolescent refugees who reported prior significant trauma (most of it massive war trauma as children) were administered the PTSD module of the Diagnostic interview for Children and Adolescents, as part of an epidemiological study on the effects of war on this group of refugees. RESULTS: The following four factors were found: arousal, avoidance, intrusion, and numbing. A confirmatory factor analysis using data from the parents of this sample yielded a good fit for the four-factor solution based on the youth data. CONCLUSIONS: The four-factor solution from this sample resembled earlier studies on traumatized Caucasian and African-American adults. These results lend further credibility to the veracity of this diagnosis with refugee samples. PTSD as a result of prior war trauma appears to surmount the barriers of culture and language in this sample.

Cross-sectional and prospective relationships between physical morbidity and depression in older adolescents.

OBJECTIVE: To examine cross-sectional and prospective associations between major depressive disorder (MDD), physical morbidity (disease and injury), health-related reductions in activities, and functional impairment in adolescents. METHOD: Data on depression and health-related variables were available for a sample of 1,410 adolescents (aged 14 to 18 years) at point of entry into the study and approximately 1 year later. RESULTS: Girls were more likely to have been treated for a disease and to have a health-related reduction in activities, whereas boys were more likely to have been treated for an injury. The expected cross-sectional associations were found between disease, reductions in activities, functional impairment, and depression, but the association between injury and depression was not significant. Prospective analyses suggest that functional impairment and disease are risk factors for future MDD and that MDD is a risk factor for future functional impairment and disease. CONCLUSIONS: The robust prospective associations between MDD and functional impairment suggest that the impact of disease on depression is particularly strong when it disrupts important behavior patterns. Clinically, the results emphasize the importance of assessing health-related variables in depressed adolescents and of assessing depression in those with functional impairment or disease.

The Khmer Adolescent Project: III. A study of trauma from Thailand's Site II refugee camp.

OBJECTIVE: To determine the prevalence rates of posttraumatic stress disorder (PTSD) and depression in a sample of 99 Cambodian youths, aged 18 to 25 years, living in the Site II refugee camps along the Thai-Cambodian border; to compare these rates to data collected in a similarly aged sample of Cambodian refugees living in the United States; and to illustrate the findings with case vignettes and a brief description of the refugee camp at Site II. METHOD: The senior author describes the main features of life in the Site II camp while being employed in one of its medical clinics. A Khmer translated version of the depression section of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of Diagnostic Interview Schedule for Children and Adolescents were used in interview format by trained bilingual research assistants. Khmer versions of the Beck Depression Inventory and the Impact of Events Scale were also administered. RESULTS: The enduring nature of PTSD was evident in this sample of Khmer youths who had survived the Pol Pot regime as children. Similar rates of Pol Pot-related PTSD were found when compared to rates from the US sample. Subclinical forms of PTSD were found in those who reported their worst trauma during life in the camp, while the full PTSD syndrome was associated with those who reported trauma occurring during the earlier Pol Pot regime. Extremely high rates of depressive disorder were found which were interpreted as related to the repatriation back to Cambodia as this study was undertaken. CONCLUSION: PTSD in this sample appears to be specifically related to earlier war trauma, while depressive symptoms appear more related to recent stressors. As with other findings from the Khmer adolescent project, this study reaffirms the strong connection between the diagnosis of current PTSD and earlier war trauma in an additional sample of youths at Site II, Thailand. Depressive symptoms, on the other hand, appear to be related to the vicissitudes of recent stressful events in this refugee population.

Multiple forms of stress in Cambodian adolescent refugees.

A sample of 170 Cambodian youth and 80 of their mothers were interviewed regarding DSM-III-R diagnoses of Post Traumatic Stress Disorder (PTSD) and depressive disorders, and the stress of war trauma, resettlement, and recent life events. A consistent relation between earlier war trauma, resettlement stress, and symptoms of PTSD was found. In contrast, the strongest relation with depressive symptoms was found for recent stressful events. Despite the long interval of time since the occurrence of the war trauma, these youth and their parents reported these experiences in a highly consistent fashion. PTSD and depression in refugee youth appear to be different conditions following different pathways during adolescent development.

Posttraumatic stress disorder across two generations of Cambodian refugees.

OBJECTIVE: To examine the expression of war-related trauma as manifested by DSM-III-R rates of posttraumatic stress disorder (PTSD) and major depressive disorder in two generations of Cambodian refugees living in the western United States. METHOD: A probability sample of 209 Khmer adolescents and one of their parents were interviewed using portions of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of the Diagnostic Interview for Children and Adolescents. Interviews were conducted in English by a master's-level clinician with a Khmer interpreter. RESULTS: PTSD was found to be significantly related across parent-child generations. A nonsignificant generational trend was also found for depressive disorders. A number of environmental variables measured in the study (amount of reported war trauma, loss, living arrangements, treatment received, socioeconomic status) were not related to these findings. Parents were more likely to report an earlier onset of PTSD symptoms. CONCLUSIONS: This study suggests that PTSD in refugees may cluster in families. Whether this phenomenon is caused by a genetic susceptibility to trauma awaits further research. PTSD and depressive disorders in refugee populations, while often comorbid, appear to follow different courses over time.

The Khmer Adolescent Project. II: Functional capacities in two generations of Cambodian refugees.

A sample of 206 adolescent Cambodian youth and 159 of their parents were interviewed to determine the extent of their past war trauma during the Pol Pot regime in Cambodia (1975-1979), their resettlement stress, their current diagnostic status, and their functional ability as refugees in the United States. This report focuses on the last of these aims. Overall, these youth were found to be functioning quite well. Their diagnostic status did not relate strongly to their functional status. Parents showed a stronger relationship between diagnostic status and measures of functioning than did adolescents. The implications of these findings for future studies are discussed.

The Khmer Adolescent Project. I. Epidemiologic findings in two generations of Cambodian refugees.

A nonstratified random sample of 209 Khmer adolescents, ages 13 to 25, and a parent or guardian from two Western communities were interviewed to determine their diagnostic status following their survival of the Pol Pot War in Cambodia, from 1975 to 1979. Subjects were administered the posttraumatic stress disorder section of the Diagnostic Instrument for Children and Adolescents and selected sections of the Schedule of Affective Disorders and Schizophrenia for School-Age Children--Epidemiologic Version, with the assistance of a Cambodian translator. Roughly one fifth of the adolescents, over one half of the mothers, and about one third of the fathers qualified for a current diagnosis of posttraumatic stress disorder. There was high comorbidity with depression, but other forms of psychopathology were much less evident. The clinical importance of distinguishing prior trauma from other forms of cultural loss and resettlement stress is discussed.

A 6-year follow-up study of Cambodian refugee adolescents traumatized as children.

Seventy-three percent of a sample of 46 Cambodian youth interviewed in 1984 and 1987 were reinterviewed in 1990 as part of a pretest for a multisite study of Cambodian refugee trauma now under way. An additional sample of convenience of 38 youth were also interviewed to determine reliability and validity of the diagnostic instruments chosen for the larger study. The DSM-III-R diagnosis of post-traumatic stress disorder (PTSD) was found to persist, but the symptoms appeared less intense over time. In contrast, the prevalence of depression dropped markedly since 1987. Subjects remained largely free of comorbid conditions. Diagnostic reliability and validity were satisfactory. The follow-up sample appeared to be functioning well despite their PTSD profiles. The findings are discussed in light of several current controversies surrounding the concept and measurement of PTSD.

Three forms of stress in Cambodian adolescent refugees.

Sixty-nine Cambodian adolescents and young adults were interviewed to determine their experience as children surviving the Pol Pot regime (1975-1979); their first-year experience of resettlement in this country; and their experience of stressful events during the past year. Current DSM-III-R diagnostic status was also determined. A strong relationship between earlier war trauma, resettlement strain, and symptoms of posttraumatic stress disorder (PTSD) was found. In contrast, the strongest relationship with depressive symptoms was found for recent stressful events. These results are discussed in light of current findings from stress and PTSD research.