Predicting the risk of future depression among school-attending adolescents in Nigeria using a model developed in Brazil

Prospective Follow-Up of Adolescents With and at Risk for Depression: Protocol and Methods of the Identifying Depression Early in Adolescence Risk Stratified Cohort Longitudinal Assessments

Objective

To present the protocol and methods for the prospective longitudinal assessments-including clinical and digital phenotyping approaches-of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo) study, which comprises Brazilian adolescents stratified at baseline by risk of developing depression or presence of depression.

Method

Of 7,720 screened adolescents aged 14 to 16 years, we recruited 150 participants (75 boys, 75 girls) based on a composite risk score: 50 with low risk for developing depression (LR), 50 with high risk for developing depression (HR), and 50 with an active untreated major depressive episode (MDD). Three annual follow-up assessments were conducted, involving clinical measures (parent- and adolescent-reported questionnaires and psychiatrist assessments), active and passive data sensing via smartphones, and neurobiological measures (neuroimaging and biological material samples). Retention rates were 96% (Wave 1), 94% (Wave 2), and 88% (Wave 3), with no significant differences by sex or group (p > .05). Participants highlighted their familiarity with the research team and assessment process as a motivator for sustained engagement.

Discussion

This protocol relied on novel aspects, such as the use of a WhatsApp bot, which is particularly pertinent for low- to-middle-income countries, and the collection of information from diverse sources in a longitudinal design, encompassing clinical data, self-reports, parental reports, Global Positioning System (GPS) data, and ecological momentary assessments. The study engaged adolescents over an extensive period and demonstrated the feasibility of conducting a prospective follow-up study with a risk-enriched cohort of adolescents in a middle-income country, integrating mobile technology with traditional methodologies to enhance longitudinal data collection.

Inflammation and immune system pathways as biological signatures of adolescent depression-the IDEA-RiSCo study

The biological mechanisms underlying the onset of major depressive disorder (MDD) have predominantly been studied in adult populations from high-income countries, despite the onset of depression typically occurring in adolescence and the majority of the world's adolescents living in low- and middle-income countries (LMIC). Taking advantage of a unique adolescent sample in an LMIC (Brazil), this study aimed to identify biological pathways characterizing the presence and increased risk of depression in adolescence, and sex-specific differences in such biological signatures. We collected blood samples from a risk-stratified cohort of 150 Brazilian adolescents (aged 14-16 years old) comprising 50 adolescents with MDD, 50 adolescents at high risk of developing MDD but without current MDD, and 50 adolescents at low risk of developing MDD and without MDD (25 females and 25 males in each group). We conducted RNA-Seq and pathway analysis on whole blood. Inflammatory-related biological pathways, such as role of hypercytokinemia/hyperchemokinemia in the pathogenesis of influenza (z-score = 3.464, p < 0.001), interferon signaling (z-score = 2.464, p < 0.001), interferon alpha/beta signaling (z-score = 3.873, p < 0.001), and complement signaling (z-score = 2, p = 0.002) were upregulated in adolescents with MDD compared with adolescents without MDD independently from their level of risk. The up-regulation of such inflammation-related pathways was observed in females but not in males. Inflammatory-related pathways involved in the production of cytokines and in interferon and complement signaling were identified as key indicators of adolescent depression, and this effect was present only in females.

An MRI-based morphometric and structural covariance network study of Brazilian adolescents stratified by depression risk

OBJECTIVE

To explore differences in regional cortical morphometric structure between adolescents at risk for depression or with current depression.

METHODS

We analyzed cross-sectional structural neuroimaging data from a sample of 150 Brazilian adolescents classified as low-risk (n=50) or high-risk for depression (n=50) or with current depression (n=50) through a vertex-based approach with measurements of cortical volume, surface area and thickness. Differences between groups in subcortical volumes and in the organization of networks of structural covariance were also explored.

RESULTS

No significant differences in brain structure between groups were observed in whole-brain vertex-wise cortical volume, surface area or thickness. Also, no significant differences in subcortical volume were observed between risk groups. In relation to the structural covariance network, there was an indication of an increase in the hippocampus betweenness centrality index in the high-risk group network compared to the low-risk and current depression group networks. However, this result was only statistically significant when applying false discovery rate correction for nodes within the affective network.

CONCLUSION

In an adolescent sample recruited using an empirically based composite risk score, no major differences in brain structure were detected according to the risk and presence of depression.

Identifying Depression Early in Adolescence: assessing the performance of a risk score for future onset of depression in an independent Brazilian sample

OBJECTIVE

The Identifying Depression Early in Adolescence Risk Score (IDEA-RS) was recently developed in Brazil using data from the Pelotas 1993 Birth Cohort to estimate the individualized probability of developing depression in adolescence. This model includes 11 sociodemographic variables and has been assessed in longitudinal studies from four other countries. We aimed to test the performance of IDEA-RS in an independent, community-based, school-attending sample within the same country: the Brazilian High-Risk Cohort.

METHODS

Standard external validation, refitted, and case mix-corrected models were used to predict depression among 1442 youth followed from a mean age of 13.5 years at baseline to 17.7 years at follow-up, using probabilities calculated with IDEA-RS coefficients.

RESULTS

The area under the curve was 0.65 for standard external validation, 0.70 for the case mix-corrected model, and 0.69 for the refitted model, with discrimination consistently above chance for predicting depression in the new dataset. There was some degree of miscalibration, corrected by model refitting (calibration-in-the-large reduced from 0.77 to 0).

CONCLUSION

IDEA-RS was able to parse individuals with higher or lower probability of developing depression beyond chance in an independent Brazilian sample. Further steps should include model improvements and additional studies in populations with high levels of subclinical symptoms to improve clinical decision making.

The Effect of Calligraphy as an Art Therapy Intervention Containing Religious Motifs, on the Anxiety and Depression in Adolescent Psychiatric Patients

This research was conducted to determine the effect of calligraphy on the anxiety and depression levels of adolescent psychiatric patients. It was conducted with adolescent psychiatric patients ages 14-17 in Turkey's Eastern Anatolia Region. They were allocated a calligraphy (n = 40) or a wait-list (n = 39) group. Those in the calligraphy group participated in 60-min calligraphy sessions for three weeks. The state anxiety levels of adolescents who applied calligraphy decreased gradually when compared with adolescents in the control group. The difference between the third-week mean post-test state anxiety scores of the adolescents in the calligraphy and control groups was significant (t = 2.34, p = .02). The trait anxiety scale and depression scale mean post-test scores of the adolescents in the calligraphy group were lower than in the control group. The difference between two groups was significant. Calligraphy can be potentially used as a beneficial method for reducing anxiety and depression.

Frontolimbic Network Topology Associated With Risk and Presence of Depression in Adolescents: A Study Using a Composite Risk Score in Brazil

BACKGROUND

There have been significant challenges in understanding functional brain connectivity associated with adolescent depression, including the need for a more comprehensive approach to defining risk, the lack of representation of participants from low- and middle-income countries, and the need for network-based approaches to model connectivity. The current study aimed to address these challenges by examining resting-state functional connectivity of frontolimbic circuitry associated with the risk and presence of depression in adolescents in Brazil.

METHODS

Adolescents in Brazil ages 14 to 16 years were classified into low-risk, high-risk, and depressed groups using a clinical assessment and composite risk score that integrates 11 sociodemographic risk variables. After excluding participants with excessive head movement, resting-state functional magnetic resonance imaging data of 126 adolescents were analyzed. We compared group differences in frontolimbic network connectivity using region of interest-to-region of interest, graph theory, and seed-based connectivity analyses. Associations between self-reported depressive symptoms and brain connectivity were also explored.

RESULTS

Adolescents with depression showed greater dorsal anterior cingulate cortex (ACC) connectivity with the orbitofrontal cortex compared with the 2 risk groups and greater dorsal ACC global efficiency than the low-risk group. Adolescents with depression also showed reduced local efficiency and a lower clustering coefficient of the subgenual ACC compared with the 2 risk groups. The high-risk group also showed a lower subgenual ACC clustering coefficient relative to the low-risk group.

CONCLUSIONS

These findings highlight altered connectivity and topology of the ACC within frontolimbic circuitry as potential neural correlates and risk factors of developing depression in adolescents in Brazil. This study broadens our understanding of the neural connectivity associated with adolescent depression in a global context.

Psychological and contextual risk factors for first-onset depression among adolescents and young people around the globe: A systematic review and meta-analysis

AIM

Identifying predictors for future onset of depression is crucial to effectively developing preventive interventions. We conducted a systematic review and meta-analysis to identify risk factors for first-onset depression among adolescents and young people.

METHODS

We searched MEDLINE (Ovid), PsycINFO, Cochrane Database, Web of Science, Lilacs, African Journals Online and Global Health (July 2009 to December 2020) for longitudinal studies assessing risk factors for first-onset depression among adolescents and young people aged 10-25 years. Meta-analyses generated summary odds ratio (OR) estimates.

REGISTRATION

PROSPERO CRD42018103973.

RESULTS

Nineteen studies representing 21 unique populations were included in the meta-analysis. Among studies reporting race/ethnicity, 79% of participants were of White/European descent. Seventeen studies were from high-income countries, with only two from an upper-middle-income country (China). Odds for first-onset depression were significantly greater for girls compared to boys (n = 13; OR = 1.78 [1.78, 2.28], p < 0.001) and for youth with other mental health problems at baseline (n = 4; OR = 3.20 [1.95, 5.23], p < 0.001). There were non-significant associations for negative family environment (n = 8; OR = 1.60 [0.82, 3.10], p = 0.16) and parental depression (n = 3; OR = 2.30 [0.73, 7.24], p = 0.16).

CONCLUSIONS

Most longitudinal studies do not report risk factors specifically for first-onset depression. Moreover, predictive data are limited to predominantly White populations in high-income countries. Future research must be more ethnically and geographically representative. Recommendations are provided for consistent and comprehensive reporting of study designs and analyses of risk factors for first-onset depression.

Challenges in simultaneous validation of mental health screening tools in multiple languages: Adolescent assessments in Hausa and Pidgin in Nigeria

Background

With growing global recognition of the need to address mental health, a key challenge is determining who needs mental health services. Most self-report screening tools were developed in English-speaking high-income settings, and this cultural milieu influences the types and content of items, the manner in which items are asked, and the options for responding to items. Approaches have been developed for transcultural translation and validation. However, these approaches are typically applied in one language at a time, which is of limited utility in linguistically diverse settings.

Methods

To address challenges in cross-cultural validation, we undertook a unique process of simultaneously validating tools in two languages in Nigeria. Through this dual-language validation, we explored how cultural and contextual differences may influence what is considered valid for a mental health tool. We validated the Depression Self Rating Scale, Child PTSD Symptom Scale (CPSS), and Disruptive Behavior Disorders Rating Scale with a community sample of 330 adolescents aged 12-17. Validity was assessed in Hausa and Pidgin, two languages commonly spoken in Nigeria. Clinical psychologists used the Kiddie-Schedule for Affective Disorders and Schizophrenia to establish caseness.

Results

Most items had good discriminant validity, except on the CPSS, on which only 8 of 17 items discriminated by caseness. Findings indicate the influence of culture (e.g., linguistic differences in translatability of items) and context (e.g., items that reflect experiences of hunger or foodborne illness; different PTSD caseness by language might reflect differential trauma exposure between populations). We also identified items that operated differently between languages.

Conclusion

We identified shortcomings in cross-cultural validation procedures with regard to determining whether language, context, or or other differences influence performance of items. For future validation efforts, we recommend systematically collecting information on context and stressful/traumatic exposures as a way to contextualize interpretation of the validity findings.

Acronyms

Depression Self Rating Scale (DSRS), Child PTSD Symptom Scale (CPSS), Disruptive Behavior Disorders Rating Scale (DBDRS), Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Area Under the Curve (AUC), Diagnostic Odds Ratio (DOR), Low- and Middle-Income Countries (LMICs), Posttraumatic Stress Disorder (PTSD).

Detection of risk for future depression among adolescents: Stakeholder views of acceptability and feasibility in the United Kingdom

AIM

Depression is one of the most common mental illnesses globally and a leading cause of disability. It is often established by late adolescence and thus identifying which adolescents are most at risk is crucial to enable early intervention to prevent depression onset. We have previously developed a risk calculator to stratify which adolescents are at high risk of developing depression and in this study explore the views of stakeholders to ascertain the acceptability and feasibility of implementing such a tool in the UK.

METHODS

Semi-structured interviews were conducted with 60 UK-based stakeholders (12 healthcare workers, 12 social workers, 12 school workers, 12 policymakers and 12 parents). Interviews were audio-recorded and transcribed verbatim. Transcripts were analysed drawing on framework analysis techniques in NVivo 12.

RESULTS

Six overarching themes were identified: facilitators of acceptability; barriers to acceptability; role of stakeholders in implementing risk screening; feasibility of delivering the risk calculator in practice; barriers to implementation; and policy and system implications of using it in the current UK health and social care climate. The implementation of a depression risk calculator in the UK was seen as largely acceptable and feasible by most respondents. There was a strong emphasis on the utility of schools to implement this risk calculator, although it was recognized that training and support would be essential.

CONCLUSIONS

Stakeholders were generally positive about utilizing a tool to screen for risk of future depression among adolescents in the UK but raised important concerns which should be taken into account before implementation.

Identifying adolescents at risk for depression: Assessment of a global prediction model in the Great Smoky Mountains Study

The Identifying Depression Early in Adolescence Risk Score (IDEA-RS) has been externally assessed in samples from four continents, but North America is lacking. Our aim here was to evaluate the performance of the IDEA-RS in predicting future onset of Major Depressive Disorder (MDD) in an adolescent population-based sample in the United States of America - the Great Smoky Mountains Study (GSMS). We applied the intercept and weights of the original IDEA-RS model developed in Brazil to generate individual probabilities for each participant of the GSMS at age 15 (N = 1029). We then evaluated the performance of such predictions against the diagnosis of MDD at age 19 using simple, case-mix corrected and refitted models. Furthermore, we compared how prioritizing the information provided by parents or by adolescents affected performance. The IDEA-RS exhibited a C-statistic of 0.63 (95% CI 0.53-0.74) to predict MDD in the GSMS when applying uncorrected weights. Case-mix corrected and refitted models enhanced performance to 0.69 and 0.67, respectively. No significant difference was found in performance by prioritizing the reports of adolescents or their parents. The IDEA-RS was able to parse out adolescents at risk for a later onset of depression in the GSMS cohort with above chance discrimination. The IDEA-RS has now showed above-chance performance in five continents.

Exploring the role of immune pathways in the risk and development of depression in adolescence: Research protocol of the IDEA-FLAME study

Extensive research suggests a role for the innate immune system in the pathogenesis of depression, but most of the studies are conducted in adult populations, in high-income countries and mainly focus on the study of inflammatory proteins alone, which provides only a limited understanding of the immune pathways involved in the development of depression. The IDEA-FLAME study aims to identify immune phenotypes underlying increased risk of developing depression in adolescence in a middle-income country. To this end, we will perform deep-immunophenotyping of peripheral blood mononuclear cells and RNA genome-wide gene expression analyses in a longitudinal cohort of Brazilian adolescents stratified for depression risk. The project will involve the 3-year follow-up of an already recruited cohort of 150 Brazilian adolescents selected for risk/presence of depression on the basis of a composite risk score we developed using sociodemographic characteristics (50 adolescents with low-risk and 50 with high-risk of developing depression, and 50 adolescents with a current major depressive disorder). We will 1) test whether the risk group classification at baseline is associated with differences in immune cell frequency, phenotype and functional status, 2) test whether baseline immune markers (cytokines and immune cell markers) are associated with severity of depression at 3-year follow-up, and 3) identify changes in gene expression of immune pathways over the 3-year follow-up in adolescents with increased risk and presence of depression. Because of the exploratory nature of the study, the findings would need to be replicated in a separate and larger sample. Ultimately, this research will contribute to elucidating key immune therapeutic targets and inform the development of interventions to prevent onset of depression among adolescents.

Prediction models for child and adolescent mental health: A systematic review of methodology and reporting in recent research

BACKGROUND

There has been a rapid growth in the publication of new prediction models relevant to child and adolescent mental health. However, before their implementation into clinical services, it is necessary to appraise the quality of their methods and reporting. We conducted a systematic review of new prediction models in child and adolescent mental health, and examined their development and validation.

METHOD

We searched five databases for studies developing or validating multivariable prediction models for individuals aged 18 years old or younger from 1 January 2018 to 18 February 2021. Quality of reporting was assessed using the Transparent Reporting of a multivariable prediction models for Individual Prognosis Or Diagnosis checklist, and quality of methodology using items based on expert guidance and the PROBAST tool.

RESULTS

We identified 100 eligible studies: 41 developing a new prediction model, 48 validating an existing model and 11 that included both development and validation. Most publications (k = 75) reported a model discrimination measure, while 26 investigations reported calibration. Of 52 new prediction models, six (12%) were for suicidal outcomes, 18 (35%) for future diagnosis, five (10%) for child maltreatment. Other outcomes included violence, crime, and functional outcomes. Eleven new models (21%) were developed for use in high-risk populations. Of development studies, around a third were sufficiently statistically powered (k = 16%, 31%), while this was lower for validation investigations (k = 12, 25%). In terms of performance, the discrimination (as measured by the C-statistic) for new models ranged from 0.57 for a tool predicting ADHD diagnosis in an external validation sample to 0.99 for a machine learning model predicting foster care permanency.

CONCLUSIONS

Although some tools have recently been developed for child and adolescent mental health for prognosis and child maltreatment, none can be currently recommended for clinical practice due to a combination of methodological limitations and poor model performance. New work needs to use ensure sufficient sample sizes, representative samples, and testing of model calibration.

CYP2B6 Functional Variability in Drug Metabolism and Exposure Across Populations-Implication for Drug Safety, Dosing, and Individualized Therapy

Adverse drug reactions (ADRs) are one of the major causes of morbidity and mortality worldwide. It is well-known that individual genetic make-up is one of the causative factors of ADRs. Approximately 14 million single nucleotide polymorphisms (SNPs) are distributed throughout the entire human genome and every patient has a distinct genetic make-up which influences their response to drug therapy. Cytochrome P450 2B6 (CYP2B6) is involved in the metabolism of antiretroviral, antimalarial, anticancer, and antidepressant drugs. These drug classes are commonly in use worldwide and face specific population variability in side effects and dosing. Parts of this variability may be caused by single nucleotide polymorphisms (SNPs) in the CYP2B6 gene that are associated with altered protein expression and catalytic function. Population variability in the CYP2B6 gene leads to changes in drug metabolism which may result in adverse drug reactions or therapeutic failure. So far more than 30 non-synonymous variants in CYP2B6 gene have been reported. The occurrence of these variants show intra and interpopulation variability, thus affecting drug efficacy at individual and population level. Differences in disease conditions and affordability of drug therapy further explain why some individuals or populations are more exposed to CYP2B6 pharmacogenomics associated ADRs than others. Variabilities in drug efficacy associated with the pharmacogenomics of CYP2B6 have been reported in various populations. The aim of this review is to highlight reports from various ethnicities that emphasize on the relationship between CYP2B6 pharmacogenomics variability and the occurrence of adverse drug reactions. In vitro and in vivo studies evaluating the catalytic activity of CYP2B6 variants using various substrates will also be discussed. While implementation of pharmacogenomic testing for personalized drug therapy has made big progress, less data on pharmacogenetics of drug safety has been gained in terms of CYP2B6 substrates. Therefore, reviewing the existing evidence on population variability in CYP2B6 and ADR risk profiles suggests that, in addition to other factors, the knowledge on pharmacogenomics of CYP2B6 in patient treatment may be useful for the development of personalized medicine with regards to genotype-based prescription.

The Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo): Rationale, Methods, and Baseline Characteristics

Background: The characterization of adolescents at high risk for developing depression has traditionally relied on the presence or absence of single risk factors. More recently, the use of composite risk scores combining information from multiple variables has gained attention in prognostic research in the field of mental health. We previously developed a sociodemographic composite score to estimate the individual level probability of depression occurrence in adolescence, the Identifying Depression Early in Adolescence Risk Score (IDEA-RS). Objectives: In this report, we present the rationale, methods, and baseline characteristics of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo), a study designed for in-depth examination of multiple neurobiological, psychological, and environmental measures associated with the risk of developing and with the presence of depression in adolescence, with a focus on immune/inflammatory and neuroimaging markers. Methods: Using the IDEA-RS as a tool for risk stratification, we recruited a new sample of adolescents enriched for low (LR) and high (HR) depression risk, as well as a group of adolescents with a currently untreated major depressive episode (MDD). Methods for phenotypic, peripheral biological samples, and neuroimaging assessments are described, as well as baseline clinical characteristics of the IDEA-RiSCo sample. Results: A total of 7,720 adolescents aged 14-16 years were screened in public state schools in Porto Alegre, Brazil. We were able to identify individuals at low and high risk for developing depression in adolescence: in each group, 50 participants (25 boys, 25 girls) were included and successfully completed the detailed phenotypic assessment with ascertainment of risk/MDD status, blood and saliva collections, and magnetic resonance imaging (MRI) scans. Across a variety of measures of psychopathology and exposure to negative events, there was a clear pattern in which either the MDD group or both the HR and the MDD groups exhibited worse indicators in comparison to the LR group. Conclusion: The use of an empirically-derived composite score to stratify risk for developing depression represents a promising strategy to establish a risk-enriched cohort that will contribute to the understanding of the neurobiological correlates of risk and onset of depression in adolescence.