© Borgis - New Medicine 4/2009, s. 104-108
*Ildikó Baji1, 3, Nestor L. Lopez-Duran2, Maria Kovacs2, Charles J. George2, László Mayer3, Krisztina Kapornai3, Enikő Kiss3, Marike Vuga4, Julia Gádoros1, Ágnes Vetró3
The relations of age, sex and symptom characteristics of childhood depression in a Hungarian clinical sample
1Vadaskert Hospital, Budapest, Hungary
Head: Dr Julia Gadoros, PhD
2University of Pittsburgh School of Medicine, Department of Psychiatry, Pittsburgh, Pennsylvania
Head: Prof. Dr Maria Kovacs PhD
3Department of Child and Adolescent Psychiatry, University of Szeged, Szeged, Hungary
Head: Dr Agnes Vetro PhD
4University of Pittsburgh, Department of Public Health, Pittsburgh, Pennsylvania
Head: Dr Maria Kovacs PhD
Objective.We examined age, sex, and age-by-sex interaction effects in depressive symptoms in a clinical sample of children and adolescents.
Method. The sample included 559 children (247 females) with major depressive disorder (mean age = 11.69 years; range = 7 to 14). Participants were recruited from 23 mental health facilities in Hungary. Symptom rates were obtained via the Interview Schedule for Children and Adolescents – Diagnostic Version (ISCA-D). Final diagnosis was rendered via the best-estimate diagnostic procedure based on DSM-IV diagnostic criteria.
Results. Six symptoms increased with age: depressed mood (OR=1.01 p <.05), hypersomnia (OR=1.17 p <.05), psychomotor retardation (OR=1.11 p <.05), fatigue (OR=1.13 p <.01), thoughts of death (OR=1.11 p <.05), and suicidal ideation (OR=1.18 p <.01). Only psychomotor agitation decreased with age (OR=0.91 p <.05). Three symptoms were less common in males: anhedonia (OR=0.95 p <.05), insomnia (OR=0.96 p <.05), and hypersomnia (OR=0.93 p <.05). Only psychomotor agitation was more common in males (OR=2.24 p <.01). No age-by-sex interactions were noted.
Conclusion. The symptom profile of depression appears to become more neurovegetative as children get older, and girls display more affective and atypical symptoms across all age groups.
A large body of research has shown that children and adolescents can meet diagnostic criteria for major depressive disorder as defined in standard diagnostic manuals (e.g., DSM-IV; see review Birmaher et al.) (1). Questions have remained about the appropriateness of such criteria for younger age groups. Are DSM criteria for major depressive disorder (MDD) able to accommodate age-related differences in the likelihood of particular symptoms, and are there different symptoms with MDD as a function of a child´s age, sex, and age-by-sex interactions?
A small number of studies have examined developmental differences in rates of specific symptoms across depressed children and adolescents. There are some discrepant findings, for example, Ryan et al. (2) reported that, compared to depressed children, adolescents with major depressive disorder were more likely to display hopelessness, hypersomnia, and weight gain/loss, and less likely to display psychomotor agitation. In a similar study, Yorbik et al. (3) found that depressed adolescents displayed significantly higher rates of hopelessness, fatigue, hypersomnia, weight loss, and suicidal thoughts than depressed children. However, Mitchell et al. (4) found hypersomnia to be the only symptom more frequent in depressed adolescents than in depressed children.
Examination of sex differences in child and adolescent depression, for example, Mitchell et al. (4), found no sex differences in rates of various depressive symptoms in a sample of children and adolescents with major depression. Similarly, Roberts et al. (5) failed to find sex differences in symptom presentation in a small community-based sample of adolescents meeting criteria for major depression. For example, Williamson et al.6 found higher rates of weight gain among depressed girls compared to boys. Similarly, Yorbik et al. (3) reported that girls with MDD had higher rates of increased appetite than did boys. Ryan et al. (2), however, failed to find sex differences in weight gain or appetite changes, although they found that pre-adolescent boys experienced more fatigue symptoms than pre-adolescent girls.
Our first aim was to examine developmental differences in depressive symptom presentation using age as a continuous variable. Our second aim was to examine sex differences, as well as sex-by-age effects, in symptomatology. Further, given that there is overlap in some symptoms between depression and other disorders (e.g., ADHD), we examined the effect of co-morbid diagnoses on one depressive symptom: psychomotor agitation.
The sample included 559 children (247 females) who have been enrolled in a study of genetic and psychosocial risk factors for childhood onset depression. The mean age at evaluation was 11.69 years (SD: 2.00 years). Ethnic composition was representative of the ethnic composition of Hungary: 93.9% white, 3.6% gypsy (Roma), 2.3% multiracial, and 0.2% African. Subjects were recruited from 23 mental health facilities across Hungary. Inclusion criteria have been described in detail in previous publications (8, 9).
Measures and Procedures
Enrolment and assessment procedures have been described in detail in previous publications (8, 9). Clinical evaluations were conducted with the semi-structured Interview Schedule for Children and Adolescents – Diagnostic Version (ISCA-D), an extension of the Interview Schedule for Children and Adolescents (ISCA10). Each clinician interviewed the parent and the child separately and rendered an overall severity rating for each symptom. Good inter-rater reliability for symptom ratings has been reported (8, 9). Final diagnoses were rendered by experienced psychiatrists using the best-estimate diagnostic procedure (BED) (11). Only those meeting criteria for major depressive disorder at the time of the evaluation were included in the present analysis. We examined the presence or absence of 15 DSM-IV criterion symptoms from the ISCA-D (see table 1). We used clinicians´ overall ratings and dichotomized them as clinically significant (entered into a given diagnosis) versus subclinical or absent.
Table 1. Unadjusted rates (%) of depressive symptoms across age groups.
| ||Age at Interview||Statistic|
|7||8||9||10||11||12||13||14||c2 (1 d.f.)|
|Sample Size||N= 16|| 46|| 70||70||91||91||92||83|
|Feelings of Worthlessness||44||50||59||57||59||63||60||63|
|Impaired Decision Making||75||65||73||76||70||70||67||75|
|Thoughts of Death||44||35||59||61||55||68||55||65||6.69**|
* p <0.05, ** p <0.01, *** p<0.001 Mantel-Haenzel χ2
To estimate the effect of age, sex, and age-by-sex interactions on symptom presentation, we used alternating logistic regression (ALR) (7), fitting a multivariate model of age and sex on the 15 symptoms of interest. ALR is a type of generalized estimating equations (GEE)12 that allows us to simultaneously model the endorsement of each of the 15 symptoms while accounting for the possible inter-correlation of symptoms within participants. This method was initially created for analysis of inter-correlated cluster data (13) and has been extended to the analysis of inter-correlated outcomes (14).
Unadjusted rates of specific depressive symptoms by age and sex
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