Stability and Change in Personality Disorder Symptoms in 1-Year Follow-up of Depressed Adolescent Outpatients.

We investigated stability and change in personality disorder (PD) symptoms and whether depression severity, comorbid clinical psychiatric disorders, and social support predict changes in personality pathology among adolescent outpatients. The 1-year outcome of PD symptoms among consecutive adolescent psychiatric outpatients with depressive disorders (N = 189) was investigated with symptom count of depression, comorbid psychiatric disorders, and perceived social support as predictors. An overall decrease in PD symptoms in most PD categories was observed. Decreases in depression severity and in number of comorbid diagnoses correlated positively with decreases in PD symptoms of most PD categories. Social support from close friends predicted a decrease in schizotypal and narcissistic, whereas support from family predicted a decrease in paranoid symptoms. Our results suggest that among depressed adolescent outpatients, PD symptoms are relatively unstable, changes co-occuring with changes/improvement in overall psychopathology. Social support seems a possibly effective point for intervention efforts regarding positive outcome of PD symptoms.

Treatment characteristics and outcome of depression among depressed adolescent outpatients with and without comorbid Axis II disorders.

In the literature, disagreement exists on the impact of Axis II comorbidity on the treatment outcome of depression. The aim of the present study was to examine in a naturalistic treatment setting the 1-year outcome and treatment characteristics of depressed adolescent outpatients with and without comorbid Axis II disorders. The 151 participants were interviewed for Axis I and II diagnoses at baseline and follow-up. Those diagnosed with a personality disorder were significantly more impaired at follow-up than those without. The given treatment did not differ between the two groups in length, intensity, or hospitalization, but the group with Axis II comorbidity received more psychotropic medication. The treatment outcome of depression was poorer for the group with Axis II disorders compared to those without. In conclusion, a personality disorder diagnosis is a sign of more severe overall symptoms. Special attention should be paid to Axis II traits when planning and conducting the treatment of adolescent depression.

Depressed adolescents as young adults - predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up.

BACKGROUND: Clinically derived follow-up studies examining the predictors of suicide attempts (SA) and non-suicidal self-injury (NSSI) among adolescents are scarce. The aims were to study SA and NSSI as predictors of future NSSI and SA, and to study the role of other risk and protective factors, especially alcohol use, and perceived social support from family and peers during a 1-year follow-up and between the 1-year and 8-year follow-ups among consecutively referred depressed adolescent outpatients. METHODS: The Adolescent Depression Study (ADS) is a longitudinal study of depressed adolescent outpatients (mean age at baseline 16.5 years, 81.8% females). The subjects of the present study (n=139, 63.8% of the original study population) were assessed at baseline, at 1-year and 8-year follow-ups using semi-structured diagnostic interviews (K-SADS-PL) for DSM-IV diagnoses, and structured self-report scales for clinical risk factors. RESULTS: In multivariate comparisons, SAs were predicted both in the 1-year follow-up and in the period between the 1- and 8-year follow-ups by alcohol use and low perceived peer support. NSSI in the 1-year of follow-up was predicted by baseline NSSI, younger age and alcohol use, whereas the only significant predictor for NSSI between the 1- and 8-year follow-ups was NSSI. LIMITATIONS: A large majority of the sample were females, limiting the possibility to analyze gender differences. CONCLUSIONS: Among depressed outpatients NSSI is a strong predictor of suicidal behavior, and other factors beyond depression, such as alcohol use and availability of social support, must also be addressed to prevent the recurrence of suicidal behavior.

Sleep complaints in adolescent depression: one year naturalistic follow-up study.

BACKGROUND: Sleep complaints are highly prevalent in adolescents suffering from major depressive disorder (MDD). The aims of this study were to describe the longitudinal course of sleep complaints, and to assess the association between sleep complaints and clinical outcome in a sample of adolescents with MDD during naturalistic follow-up. METHODS: A sample of adolescent outpatients (n = 166; age 13-19 years, 17.5% boys) diagnosed with MDD was followed-up during one year in naturalistic settings. Sleep symptoms and psychiatric symptoms were assessed with interviews and self-report questionnaires. RESULTS: All sleep complaints were less frequent at one-year follow-up compared to baseline. Baseline sleep complaints did not adversely affect clinical outcome at one-year follow-up: severity of the sleep complaints at baseline was associated with a steeper improvement of depressive and anxiety symptoms, suicidality/self-harm symptoms, and overall psychosocial functioning over time. CONCLUSIONS: Our results suggest that sleep disturbances at baseline do not necessarily lead to poorer clinical outcome during follow-up. Larger longitudinal studies combining both subjective and objective measures of sleep in depressed adolescents are needed to clarify the link between sleep and depression further.

Treatment Characteristics and Outcome of Depression Among Depressed Adolescent Outpatients With and Without Comorbid Axis II Disorders.

In the literature, disagreement exists on the impact of Axis II comorbidity on the treatment outcome of depression. The aim of the present study was to examine in a naturalistic treatment setting the 1-year outcome and treatment characteristics of depressed adolescent outpatients with and without comorbid Axis II disorders. The 151 participants were interviewed for Axis I and II diagnoses at baseline and follow-up. Those diagnosed with a personality disorder were significantly more impaired at follow-up than those without. The given treatment did not differ between the two groups in length, intensity, or hospitalization, but the group with Axis II comorbidity received more psychotropic medication. The treatment outcome of depression was poorer for the group with Axis II disorders compared to those without. In conclusion, a personality disorder diagnosis is a sign of more severe overall symptoms. Special attention should be paid to Axis II traits when planning and conducting the treatment of adolescent depression.

Sleep complaints among adolescent outpatients with major depressive disorder.

OBJECTIVE: The objective of our study was to examine the prevalence rates of different sleep complaints among adolescent outpatients with major depressive disorder (MDD). Further, we examined whether depressed adolescents with and without different sleep disturbances differ in terms of severity of depression, the presence of comorbid psychiatric disorders, and the symptom profile of depression. METHODS: A total of 166 Finnish adolescent psychiatric outpatients (age 13-19; mean 16.5 years old; 17.5% boys) diagnosed with unipolar MDD (as defined by DSM-IV criteria) were included in the study. Their sleep complaints were assessed with self-rating scales and clinical research interviews. RESULTS: The prevalence rate of subjective sleep complaints in adolescents with MDD was high: 83% of the adolescents experienced significantly disturbed sleep. The most common types of sleep complaints were nonrestorative sleep (69%) and insomnia (51%). The presence of sleep disturbances was associated with severity of depression: Hamilton Depression Rating Scale (HDRS) and Beck Depression Inventory (BDI) total sum scores were highest in adolescents with multiple sleep disturbances and lowest in adolescents with no sleep problems. Adolescents with multiple sleep disturbances differed most from adolescents with no or minor sleep disturbances in terms of thoughts about death, suicidal thoughts, and anhedonia. CONCLUSIONS: These findings suggest a close link between sleep disturbances and the severity of depression in adolescent outpatients with MDD. In particular, the link between sleep disturbances and thoughts about death and suicidal thoughts calls for attention to sleep problems among depressed adolescents in clinical settings.

Alcohol use and psychiatric comorbid disorders predict deliberate self-harm behaviour and other suicidality among depressed adolescent outpatients in 1-year follow-up.

BACKGROUND: Suicidality, including deliberate self-harm behaviour (DSH), represents one of the most adverse and clinically serious consequences of depression. More detailed longitudinal research is needed in order to find clinical risk factors of DSH and other suicidal behaviour among depressed adolescent outpatients in order to identify those at greatest risk of life-threatening behaviour. AIM: This follow-up study investigated alcohol use, Axis I comorbid disorders, depressive and anxiety symptoms, and psychosocial functioning as risk factors of suicidal behaviour, including DSH, among depressed adolescent outpatients during a 1-year follow-up. METHODS: Consecutive depressed adolescent outpatients (n = 189) aged 13-19 years were interviewed at baseline and at follow-up by using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime (K-SADS-PL) for DSM-IV Axis I diagnoses and self-report questionnaires. Suicidal behaviour was assessed by K-SADS suicidality items. RESULTS: During 1-year follow-up, one-quarter of all participants, and almost three-quarters of suicidal adolescents had DSH. Alcohol use and mood disorder with Axis I comorbidity at baseline predicted both DSH and other suicidal behaviour during follow-up. Mood disorder during follow-up predicted all forms of suicidal behaviour. CONCLUSIONS: Detection and effective treatment of continuing mood disorder, comorbid disorders and alcohol use may significantly improve clinician's ability to identify adolescent outpatients at high risk of subsequent DSH and other suicidal behaviour. Treatment interventions should aim at full recovery of depression.

Differences in Characteristics and Treatment Received among Depressed Adolescent Psychiatric Outpatients with and without Co-Occuring Alcohol Misuse: A 1-Year Follow-Up Study.

Objectives. We aimed at examining the differences between depressed psychiatric adolescent outpatients with and without cooccurring alcohol misuse in psychosocial background, clinical characteristics, and treatment received during one-year followup. Furthermore, we investigated factors related to nonattendance at treatment. Materials and Methods. Consecutive 156 adolescent (13-19 years) psychiatric outpatients with a unipolar depressive disorder at baseline were interviewed using structured measures at baseline and at 12 months. Alcohol misuse was defined as having an AUDIT score of 8 or more points. The outpatients received "treatment as usual" of clinically defined duration. Results. Among depressive outpatients, poor parental support, parental alcohol use and decreased attendance at treatment associated with alcohol misuse. The severity of alcohol use as measured by AUDIT-score was the strongest factor independently predicting nonattendance at treatment in multivariate analysis. Conclusions. Alcohol misuse indicates family problems, has a deleterious effect on treatment attendance, and should be taken into account when managing treatment for depressive adolescent outpatients.

Comorbidity between depression and antisocial behaviour in middle adolescence: the role of perceived social support.

A sample of 3278 students (aged 15-16 years) were surveyed to investigate the interrelations between depression (RBDI; The Finnish modification of the 13-item Beck Depression Inventory), antisocial behaviour (YSR; Youth Self-Report) and perceived social support from family, friends and significant other (PSSS-R; the Perceived Social Support Scale-Revised). The study aimed especially to control for the effect of perceived social support in the comorbidity between depression and antisocial behaviour. The results indicate firstly that decreased perceived social support was associated with both depression and antisocial behaviour in both sexes. Similarly, antisocial behaviour was associated with depression in both sexes. Perceived social support modified comorbidity between depression and antisocial behaviour, but antisocial behaviour still remained independently associated with depression. Thus, perceived social support did not explain the found comorbidity between depression and antisocial behaviour.

Brief Report: Excessive alcohol use negatively affects the course of adolescent depression: one year naturalistic follow-up study.

The impact of alcohol use on the course of adolescent depression over one-year was investigated by following 197 consecutive adolescent outpatients with unipolar depression in a naturalistic treatment setting. Their baseline alcohol consumption was categorized in three groups: excessive use (defined as weekly drunkenness), regular use (monthly use, not weekly drunkenness), and no/occasional use (abstinence/less than monthly use). During the monthly BDI follow-up, the excessive users achieved remission less frequently, and after one year, had poorer psychosocial functioning than the no/occasional users. In conclusion, excessive alcohol use negatively affects the course of adolescent depression and psychosocial functioning. Weekly drunkenness seems to be of predictive value and this can be examined with a few simple questions. Means of reducing alcohol consumption among depressed adolescents are worth further investigations.

Adolescent risk factors for excessive alcohol use at age 32 years. A 16-year prospective follow-up study.

AIMS: To examine which socioeconomic, family, personal and lifestyle risk factors in adolescence were the strongest independent predictors of excessive alcohol use in adulthood. METHODS: In a prospective longitudinal study, all 16-year-olds of one Finnish city completed questionnaires at school, and were followed up by postal questionnaires at 32 years of age [n = 1,471, (females n = 805, males n = 666); response rate 70.3%). The alcohol use disorders identification test (AUDIT) was used to assess alcohol use in adulthood. AUDIT scores of 8 or more for females and 10 or more for males were classified as excessive alcohol use. Adolescent risk factors examined were parental social class, school performance, depressive symptoms, self-esteem, impulsiveness, parental divorce, relationships with parents, parental trust, health behaviour, leisure-time spent with friends, dating, and problems with the law. RESULTS: All the socioeconomic, family, personal, and lifestyle variables in adolescence, except parental social class in both genders and self-esteem among females, showed significant univariate associations with excessive alcohol use at age 32 years. Multivariate logistic regression analysis showed that among adolescent males, parental divorce, moderate and high level of depressive symptoms, leisure-time spent daily among friends and moderate and drunkenness-orientated drinking were the strongest predictors of excessive alcohol use in adulthood. Among females, the strongest adolescent predictors of excessive alcohol use in adulthood were drunkenness-orientated drinking and frequent smoking. CONCLUSIONS: Early interventions for adolescent substance use and a set of specific psychosocial risk factors should be tailored and evaluated as methods for identifying those at high risk of and preventing excessive alcohol use in adulthood.

Factors associated with deliberate self-harm behaviour among depressed adolescent outpatients.

This study examined whether depressed adolescent outpatients with deliberate self-harm behaviour (DSH) differed from non-suicidal depressed adolescent outpatients in depressive and anxiety symptoms, alcohol use, perceived social support and number of negative life-events. Depressed adolescent outpatients (n=155) aged 13-19 years were interviewed using K-SADS-PL for DSM-IV Axis I diagnoses and completed self-report questionnaires. Suicidal behaviour was assessed by K-SADS-PL suicidality items. Depressed adolescents with DSH were younger, perceived less support from the family, had more severe depressive symptoms and used more alcohol than non-suicidal depressed adolescents. Adolescents with DSH and suicidal ideation or suicide attempts had more depressive and anxiety symptoms than adolescents with DSH only. Adolescents with severe internalizing distress symptoms are at risk not only for DSH, but also additional suicidal behaviour. Family interventions may be needed in the treatment of depressed adolescents with DSH.

Significance of family life events in middle adolescence: a survey on Finnish community adolescents.

Finnish middle adolescents (n=3242) were assessed for family characters, family life events, depression and frequent drunkenness. Odds ratios for maladjustment outcomes associated with each event were computed and logistic regression models were used to estimate the effect of confounders. In the presence of serious illness or injury of a family member, increasing conflicts between parents and financial difficulties in the family, the probability of depression was twice as high than without the presence of these events. Parental unemployment, parent getting involved with the law and financial difficulties in the family were associated with frequent drunkenness. The associations between life events and depression were fairly similar among boys and girls. Among girls there were several events associated with frequent drunkenness even when family structure and socio-economic status were accounted for, while among boys there were only few. The significance of associations between family life events and depression may vary between the specific events while the associations between family life events and frequent drunkenness may be better explained with cumulative stress. Both males and females react to family stress, but the symptoms presented may differ. In case of family adversities, both internalizing and externalizing outcomes must be screened for.

Associations between peer victimization, self-reported depression and social phobia among adolescents: the role of comorbidity.

Associations of peer victimization with adolescent depression and social phobia (SP), while controlling for comorbidity between them, have not been sufficiently explored in earlier research. A total of 3156 Finnish adolescents aged 15-16 years participated in a survey study. Self-reported peer victimization, as well as self-reported depression (Beck Depression Inventory), SP (Social Phobia Inventory), and selected background variables were assessed. Frequency of overt and covert peer victimization was examined among four groups: (1) adolescents with depression non-comorbid with SP (DEP), (2) those with SP non-comorbid with depression (SP), (3) those with both SP and depression (SP+DEP), and (4) controls, with neither. A logistic regression analysis controlling for confounding familial (family moving, parental unemployment), and psychopathology (delinquency, aggressiveness, general anxiety) covariates was conducted to confirm the associations between peer victimization and the four groups. Among boys the comorbid SP+DEP group reported the highest rates of both overt and covert victimization, these being significantly higher than among both DEP and SP groups. Among girls covert victimization was again most frequent in the SP+DEP group, but overt victimization was not more frequent in the comorbid group than it was in the DEP and SP groups. In the logistic regression analysis depression without SP did not maintain an independent association with either type of victimization. Instead, SP without depression with ORs from 2.8 to 4.3, and SP comorbid with depression, with ORs between 3.2 and 11.4 had independent associations with peer victimization. In conclusion, overt and covert peer victimization seem to be associated with SP, rather than depression, among adolescents.

One-year course and predictors of outcome of adolescent depression: a case-control study in Finland.

BACKGROUND: Clinical studies on the outcome of adolescent depression beyond treatment trials are scarce. OBJECTIVE: To investigate the impact of characteristics of the depressive episode and current comorbidity on the 1-year outcome of depression. METHOD: A sample of 174 consecutive adolescent psychiatric outpatients (aged 13 through 19 years) and 17 school-derived matched controls, all with unipolar depressive disorders at baseline, were reinterviewed for DSM-IV Axis I and Axis II disorders at 12 months. The study was conducted between January 1998 and May 2002. RESULTS: The outpatients had equal recovery rate and episode duration but shorter time to recurrence than the controls. Among the outpatients, Axis II comorbidity predicted shorter time to recurrence (p = .02). Longer time to recovery was predicted by earlier lifetime age at onset for depression (p = .02), poor psychosocial functioning (p = .003), depressive disorder diagnosis (p

Injury risk in young psychiatric outpatients: an 11-year follow-up of 302 adolescents.

BACKGROUND: Studies investigating the association between injuries and mental health have mainly focused on mental health sequelae of injuries. The aim of this prospective cohort study was to assess the incidence and risk factors of physical injury hospitalisation and poisoning hospitalisation among adolescent psychiatric outpatients. SUBJECTS AND METHODS: Data on 302 consecutively referred Finnish psychiatric outpatients aged 12-22 years (mean 16) were collected at treatment entry. The end-point of the average 11-year follow-up was death or end of follow-up on 31 December 2005. The main outcome variables were physical injury hospitalisation and poisoning hospitalisation. RESULTS: Altogether 111 physical injury hospitalisations occurred in 65 (22% of all) persons during follow-up, incidence being 27.9 (95% CI: 22.7-33.1) per 1,000 person-years. Poisoning hospitalisation occurred in 22 (7.3%) persons, altogether 50 times, incidence being 12.6 (95% CI: 9.1-16.0). Seven injury-related deaths occurred, incidence being 1.8 (95% CI: 0.5-3.1) per 1,000 person-years. The most common physical injury types were fractures (40%), followed by distortions (10%) and wounds (10%), while poisoning for drugs accounted for 72% of the poisonings. Previous inpatient care, psychotropic medication, suicidality, and major depression were associated with poisoning hospitalisation during the follow-up while only gender was associated with physical injury hospitalisation. CONCLUSION: Injuries cause significant morbidity among psychiatric outpatients, but only poisonings seem to be related with suicidality in Finnish adolescent psychiatric outpatients. The high frequency of injuries seems to justify clinicians' attention to these aspects when assessing the need for care among young people.

Continuity, comorbidity and longitudinal associations between depression and antisocial behaviour in middle adolescence: a 2-year prospective follow-up study.

The study investigated continuity, comorbidity and longitudinal associations between depression Beck depression inventory (RBDI) and antisocial behaviour Youth self-report (YSR) in middle adolescence. Data were used from a community sample of 2070 adolescents who participated in a 2-year prospective follow-up study. The results indicate that both depression and antisocial behaviour had considerable continuity, and concurrent comorbidity between these disorders was strong. In contrast to several previous studies, antisocial behaviour did not predict subsequent depression, but conversely, depression predicted subsequent antisocial behaviour among girls. Among boys history of depression seemed to protect from subsequent antisocial behaviour. Gender differences in longitudinal associations are discussed.

Adolescent risk factors for episodic and persistent depression in adulthood. A 16-year prospective follow-up study of adolescents.

BACKGROUND: We examined mid-adolescent psychosocial problems as risk factors for subsequent depression up to adulthood proper, and differences in these for episodic and persistent depression. METHODS: In a 16-year follow-up of an urban Finnish community cohort (547 males and 714 females) from age 16 years risk factors for subsequent depression (S-BDI) were studied. Data were collected with a classroom questionnaire at 16 years and a postal questionnaire at 22 and 32 years. Differences in predictors for episodic depression (only at age of 22 or 32 y) and persistent depression (both at 22 and 32 y) were studied using logistic and multinomial regression analyses. RESULTS: Mid-adolescent depressive symptoms predicted persistent and female sex episodic depression. Low self-esteem, dissatisfaction with academic achievement, problems with the law, having no dating experiences, and parental divorce all predicted both episodic and persistent depression. LIMITATIONS: We had two assessment points in adulthood, but no information about depression between these. CONCLUSIONS: The associations between mid-adolescent psychosocial problems and subsequent depression extended up to adulthood proper, somewhat differently for episodic and persistent depression. Preventive efforts should be focused towards young people at risk.

Depression and school performance in middle adolescent boys and girls.

The study aimed to investigate the associations between different levels of depression with different aspects of school performance. The target population included 2516 7th-9th grade pupils (13-17 years) of whom 90% completed the questionnaire anonymously in the classroom. Of the girls 18.4% and of the boys 11.1% were classified as being depressed (R-Beck Depression Inventory (BDI), the Finnish version of the 13-item BDI). The lower the self-reported grade point average (GPA) or the more the GPA had declined from the previous term, the more commonly the adolescents were depressed. Depression was associated with difficulties in concentration, social relationships, self-reliant school performance and reading and writing as well as perceiving schoolwork as highly loading. The school performance variables had similar associations with depression among both sexes when a wide range of depression was studied but gender differences appeared when studying the severe end of the depression scale. Our study indicates that pupils reporting difficulties in academic performance should be screened for depression.

Detecting suicidality among adolescent outpatients: evaluation of trained clinicians' suicidality assessment against a structured diagnostic assessment made by trained raters.

BACKGROUND: Accurate assessment of suicidality is of major importance. We aimed to evaluate trained clinicians' ability to assess suicidality against a structured assessment made by trained raters. METHOD: Treating clinicians classified 218 adolescent psychiatric outpatients suffering from a depressive mood disorder into three classes: 1-no suicidal ideation, 2-suicidal ideation, no suicidal acts, 3-suicidal or self-harming acts. This classification was compared with a classification with identical content derived from the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) made by trained raters. The convergence was assessed by kappa- and weighted kappa tests. RESULTS: The clinicians' classification to class 1 (no suicidal ideation) was 85%, class 2 (suicidal ideation) 50%, and class 3 (suicidal acts) 10% concurrent with the K-SADS evaluation (gamma2 = 37.1, df 4, p = 0.000). Weighted kappa for the agreement of the measures was 0.335 (CI = 0.198-0.471, p < 0.0001). The clinicians under-detected suicidal and self-harm acts, but over-detected suicidal ideation. CONCLUSION: There was only a modest agreement between the trained clinicians' suicidality evaluation and the K-SADS evaluation, especially concerning suicidal or self-harming acts. We suggest a wider use of structured scales in clinical and research settings to improve reliable detection of adolescents with suicidality.