Affective disorders in children and adolescents: the dysthymic disorder dilemma

Dysthymia and personality

Data on dysthymia and personality presented here are derived from the Zurich cohort study, which followed 591 subjects from the ages of 20 to 35. From childhood on, dysthymics experienced themselves as far more anxious and less self-confident than did major depressives or controls. They manifested more behavioural problems and high neuroticism and introversion scores. Dysthymics scored low in terms of quality of life, self-esteem and mastery, whereas they scored high in avoiding/denying behaviours. The hypothesis is advanced that behavioural problems, anxiety, high levels of neuroticism and personality disorders constitute risk factors for chronic depression. Evidence is presented of the existence of bipolar dysthymia.

Phenomenology and comorbidity of dysthymic disorder in 100 consecutively referred children and adolescents: beyond DSM-IV

OBJECTIVE

Diagnostic criteria and nosological boundaries of juvenile dysthymic disorder (DD) are under-researched. Two different sets of diagnostic criteria are still discussed in the DSM-IV, the first giving major weight to somatic and vegetative symptoms and the second, included in the appendix, to more affective and cognitive symptoms. The aim of this study was to describe prototypical symptomatology and comorbidity of DD, according to DSM-IV criteria, in a consecutive series of referred children and adolescents, as a function of age and sex.

METHOD

One hundred inpatients and outpatients (36 children and 64 adolescents, 57 males, 43 females, age range 7 to 18 years, mean age 13.3 years) received a diagnosis of DD without comorbid major depressive disorder (MDD), using historical information, the Diagnostic Interview for Children and Adolescents-Revised (DICA-R), and symptoms ratings according to the DSM-IV criteria.

RESULTS

Irritability, low self-esteem, fatigue or loss of energy, depressed mood, guilt, concentration difficulties, anhedonia, and hopelessness were present in more than 50% of subjects. Differences in symptomatic profile between male and female patients were not significant. Anxiety disorders were commonly comorbid with DD, mainly generalized anxiety disorder, simple phobias, and in prepuberal children, separation anxiety disorder. Externalizing disorders were reported in 35% of the patients, with higher prevalence in male patients. Adolescents showed more suicidal thoughts and anhedonia than children.

CONCLUSIONS

The clinical picture of early-onset DD we found, based entirely on a pure sample without current and past MDD, is not totally congruent with the diagnostic criteria according to DSM-IV. A more precise definition of the clinical picture may help early diagnosis and prevention of superimposed mental disorders.

Discriminative validity of the general behavior inventory using youth report

The present study investigated the ability of the General Behavior Inventory (GBI) to discriminate between diagnostic groups using youth self-report. One hundred and ninety-seven youths ages 10-17 years presenting at a midwestern urban outpatient clinic specializing in mood disorders completed the GBI as part of the intake process. Diagnoses were determined by a structured clinical interview (K-SADS) administered by either a child and adolescent psychiatrist or a research assistant trained to a high level of interrater reliability (kappa > .85). Games-Howell post hoc tests showed that the diagnostic groups significantly differed on the GBI's 2 subscales, Depression and Hypomanic-Biphasic. Logistic regression demonstrated that the scales discriminated between bipolar and disruptive behavior disorders, unipolar and bipolar depression, and mood and disruptive behavior disorders or no diagnosis. Receiver Operating Characteristic (ROC) curves further indicated the good diagnostic efficiency of the scales. Results indicate that the GBI's subscales might aid in making traditionally difficult differential diagnoses, such as between bipolar disorder and Attention Deficit Hyperactivity Disorder (ADHD) and between unipolar and bipolar depression.

Major depression and dysthymia in children and adolescents: discriminant validity and differential consequences in a community sample

OBJECTIVES

To evaluate evidence, in a community sample, for discriminant validity between major depression (MDD) and dysthymia (Dy) in children and adolescents and to examine differential consequences of the 2 disorders for functioning.

METHOD

The National Institute of Mental Health (NIMH) Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study consists of probability samples of youths. Data for this study are derived from interviews with 1,285 complete parent-youth pairs aged 9 to 17 years from 4 geographic areas in the United States. Youths with MDD were contrasted with those with Dy and those with both (MDD-Dy) on the NIMH Diagnostic Interview Schedule for Children, Non-Clinician Children's Global Assessment Scale, Columbia Impairment Scale, and the Service Utilization and Risk Factors Module.

RESULTS

Groups with MDD, Dy, or MDD-Dy did not differ on sociodemographic, clinical, or family and life event variables. Youths with combined MDD-Dy were significantly less competent and more impaired than youths with either disorder alone.

CONCLUSIONS

The findings do not provide support for the differentiation of MDD and Dy but strongly suggest the importance of addressing the needs of youths who meet criteria for both MDD and Dy because this combination is likely to be both serious and disruptive of normal developmental processes.

Effects of depression on memory performance and metamemory in children

OBJECTIVE

To investigate the effects of depression on memory performance and metamemory in children.

METHOD

Performance on automatic memory tasks (frequency of occurrence), effortful memory tasks (Children's Auditory Verbal Learning Test), and a Metamemory Battery were examined in 21 unmedicated, depressed children and 21 nondepressed controls (matched for age, gender, and full-scale IQ). Subjects were divided into three groups based on depression severity (high depressed, low depressed, nondepressed).

RESULTS

High depressed patients demonstrated performance deficits relative to nondepressed and low depressed children on the Children's Auditory Verbal Learning Test, Immediate Recall trial. Both groups of depressed children performed more poorly on the Metamemory Battery when compared to nondepressed children. Severity of depression differentiated overall performance. Metamemory performance of depressed subjects indicates possible difficulty with overestimation of memory abilities. No differences were found on automatic memory task performance.

CONCLUSIONS

Memory impairment in depression varies as a function of severity and may be evident only when a certain level of depression is reached. Overestimation of memory ability by depressed children may be an attempt to compensate for feelings of inadequacy or inferiority. It may also lead depressives to use poor judgment in selecting appropriate solutions for problems. Targeting these cognitive distortions could be a focal point of clinical and educational interventions.

Depressive disorders: distinctions in children

OBJECTIVE

The present study examined the distinctions between major depression without dysthymia, dysthymia without major depression, and double depression in child psychiatry inpatients.

METHOD

Sixty-two child inpatients, with current diagnoses of major depression and/or dysthymia, and their mothers were interviewed with the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the Social Adjustment Inventory for Children and Adolescents.

RESULTS

Results suggest that the relationship between the three disorders is complex and varies according to the informant and the domain under examination. Externalizing disorders were present more often in the dysthymic group compared to the major depression and double depression groups. On the other hand, the major depression and double depression groups reported higher rates of depressive symptoms. Regarding social functioning, children with major depression appeared least impaired. Child report was found to be more sensitive to distinguishing between depressive syndromes, and parents reported the most depressive symptomatology.

CONCLUSION

It appears that the presence of major depression plays an important role in the expression of depressive symptomatology and comorbidity, whereas chronicity seems to be the determining factor in social functioning.

Epidemiology of depression

Review of the published literature produces 1-year prevalence rates for major depressive disorder DSM-III between 2.6 and 6.2%, for dysthymia between 2.3 and 3.7%, bipolar disorder 1.0-1.7%. Data from the prospective Zurich Study with four interviews over 10 years give relatively high 10-year prevalence rates for subjects from age 20 to 30 (14.4% major depression, 10.5% recurrent brief depression, 0.9% dysthymia, 3.3% bipolar disorder, 1.3% hypomania). On average, 49% of all these cases received treatment for affective disorder, resulting in a weighted treatment prevalence rate of the population of 11.6% (18% for females and 5% for males). It has to be assumed that lifetime prevalence rates based on recall may greatly underestimate true morbidity.

An appraisal of the DSM-III system

DSM-III is a major document in the history of psychiatry. The DSM-III system is here seen as an instrument that promotes the scientific development of psychiatry and the clarity of communication among psychiatrists. However a major theme of this review is that reliability does not ensure validity. While making this point it is recognized that the major defects in the DSM-III system result from scientific inadequacies inherent in present day psychiatry. This review also may be taken as an amplification of the statement in DSM-III-R that it is not a textbook. In particular the data required to arrive at diagnoses in the DSM-III system do not provide sufficient information to arrive at a comprehensive biopsychosocial case formulation, a shortcoming that has relevance for teaching and clinical practice.