Do we miss depressive disorders and suicidal behaviours in clinical practice?

Clinical utility of new cut-off scores for the world health organization ADHD self-report scale among adolescents in psychiatric outpatient care

Previous analyses of the proposed cut-off score for the 18-item World Health Organization ADHD Self-Report Scale (ASRS-18) among psychiatrically referred adolescents have shown limited clinical utility. This prospective study examined the diagnostic accuracy and clinical utility of new cut-off scores of the ASRS-18 in a consecutive sample of 111 Swedish adolescent psychiatric outpatients. Using the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS) as the reference standard and based on predefined sensitivity and specificity criteria, multiple new general and sex-specific cut-off scores were evaluated. Results showed that clinical utility was greater for sex-specific cut-off scores than for general cut-off scores. The greatest change in pre-test to post-test probability of ADHD diagnosis was observed with a balanced, high-specificity diagnostic cut-off score for girls, where the probability of ADHD increased from 40% pre-test to 82% post-test. The proposed new cut-off levels for the ASRS-18 are useful for the detection and identification of ADHD among adolescents in general psychiatric outpatient settings.

Psychometric validation of two versions of the adolescent Depression Self-Rating Scale (DSRS-A and DSRS-A Screener)

AIM

Examination of psychometric properties and diagnostic accuracy of the Depression Self-Rating Scale for Adolescents (DSRS-A) as well as development and evaluations of a shorter version, DSRS-A-Screener.

METHODS

Analyses of component structure and internal consistency were performed in a community-based sample of adolescents N = 4,506 and among consecutive outpatients from three child psychiatric settings in Sweden (n = 137). Concurrent validity was measured as a correlation between a summation index of the scale items and the total major depressive disorder (MDD) symptom severity score from the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS). Diagnostic accuracy was examined in the clinical sample, with the K-SADS interview as the reference test, by receiver operating characteristic analysis (ROC), calculations of sensitivity, specificity among other measures. With the purpose to select items for a shorter scale, associations between scale items and MDD were examined with binary logistic regression. This shorter scale was thereafter examined similarly.

RESULTS

Based on association with MDD, five items were selected for the brief DSRS-A Screener that showed one component structure, internal consistency Cronbach's alpha .80 and.82, respectively. In the clinical population concurrent validity was Spearman's rho .63 and ROC analysis showed AUC .84 (95% CI .78-.91; p < .001). The optimal cut-off for screening was 2 with sensitivity .85 and specificity of .64.

CONCLUSION

The DSRS-A Screener compared to the original scale, maintained or improved reliability, validity, and showed moderate diagnostic accuracy.

Assessment of oppositional defiant disorder and oppositional behavior in children and adolescents with Down syndrome

INTRODUCTION

Children and adolescents with intellectual disability (ID) exhibit higher rates of oppositional defiant disorder (ODD) than typically developing (TD) peers. However, studies focusing on the investigation of ODD prevalence in youth with Down syndrome (DS) are still limited.

METHODS

The current study aimed to investigate the prevalence of ODD clinical and subclinical symptoms in a group of 101 youth with DS (63 boys, 38 girls) ranging in age from 6 to 18 years. Moreover, the prevalence of ODD symptoms, as detected by means of three parent-report questionnaires, was compared with that detected by a semi-structured psychopathological interview, namely, the Schedule for Affective Disorders and Schizophrenia for School Aged Children Present and Lifetime (K-SADS) Version Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).

RESULTS

We found that 17% of participants met diagnostic criteria for ODD on the K-SADS, whereas 24% exhibited subclinical symptoms. Results also suggest good specificity of Swanson, Nolan, and Pelham-IV Rating Scale (SNAP-IV), Conners' Parent Rating Scales Long Version (CPRS) and Child Behavior Checklist (CBCL) in detecting ODD symptoms. The investigation of the agreement in the prevalence rates of clinical and subclinical symptoms of ODD between K-SADS and the parent-report questionnaires indicated CPRS as the parent-report questionnaire with the best agreement with K-SADS.

DISCUSSION

This study provides support for the use of parent-report questionnaires to assess ODD symptoms in children and adolescents with DS by evaluating their levels of agreement with a semi-structured psychopathological interview. In particular, our results suggest that CPRS could be considered a suitable screening tool for ODD clinical and subclinical symptoms in youth with DS.

Diagnostic accuracy of the Montgomery-Åsberg Depression Rating Scale parent report among adolescent psychiatric outpatients

BACKGROUND

The diagnostic accuracy of the parent report of the Montgomery-Åsberg Depression Rating Scale (MADRS-P) for the screening of major depressive disorder (MDD) in adolescents has not been evaluated.

AIM

The aim was to explore the psychometric properties and diagnostic accuracy of the MADRS-P in general child and adolescent psychiatric outpatient services in Sweden.

METHOD

The study was a validation and a diagnostic accuracy study. Consecutive adolescent psychiatric patients (n = 101, 45 males, mean age 15 years) were assessed with a diagnostic interview, the Kiddie Schedule of Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version (K-SADS-PL), as a reference test. Thereafter, their parents reported on the MADRS-P. Both categorical MDD diagnoses and dimensional MDD symptom severity scores were obtained from the K-SADS-PL.

RESULTS

The internal consistency of the MADRS-P, measured with Cronbach's alpha, was 0.846. The concurrent validity, assessed by Spearman's rho as a correlation between the K-SADS MDD symptom severity score and the MADRS-P score, was 0.580. The area under the curve in a receiver operating characteristic analysis for all participants was 0.786 (95% confidence interval 0.694-0.877, p < .001). At a cut-off of 10, sensitivity was 0.86, specificity 0.54, positive predictive value 0.59 and negative predictive value 0.84.

CONCLUSIONS

The parent-rated MADRS-P showed similar psychometric properties as previously shown for the self-rated MADRS-S in adults. Although the MADRS-P has acceptable diagnostic accuracy for screening for MDD in adolescents in a general psychiatric setting, it cannot be used alone for diagnosing MDD.

General Practitioners' experience of child and adolescent suicidal ideation and behaviour - a survey

OBJECTIVES

A major cause of death in Irish men aged 15-24 is suicide and the rates for those aged 15-19 are amongst the highest in Europe. Despite concerns over suicidal ideation or behaviour, little research has been done in the Irish primary care context. We therefore aimed to carry out a study of Irish General Practitioners (GPs)' experience regarding suicidal ideation or behaviour in children and adolescents.

METHODS

The study design was a descriptive, cross-sectional, questionnaire survey. We randomly selected 480 GPs and invited them to participate via post.

RESULTS

In total, 198 GPs replied, representing a response rate of 41% with a sampling error of ±6.8%. In total, 184 of respondents (93%) saw more than 50 children and adolescent patients annually, however, presentations of suicidal ideation and behaviour were relatively rare, with 36% reporting seeing none, 58% seeing between one and five and 6% seeing more than five such presentations annually. In total, 119 (62%) of GPs reported a willingness to prescribe antidepressants for this age group. In total, 66% of GPs felt this was either 'always' or 'usually' a difficult patient group to manage, and the single most commonly reported difficulty by GPs was access to services [n=48 (33%)].

CONCLUSIONS

GPs reported that their management of children and adolescents with suicidal ideation or behaviour is often difficult. GPs play a key liaison role in the area of child and adolescent mental health, but our results indicate that GPs are also involved in the treatment of this patient group. However, ongoing education was not a priority according to GPs themselves.

Recent trends in primary-care antidepressant prescribing to children and young people: an e-cohort study

BACKGROUND

Concerns relating to increased use of psychotropic medication contrast with those of under-treatment and under-recognition of common mental disorders in children and young people (CYP) across developed countries. Little is known about the indications recorded for antidepressant prescribing in primary care in CYP.

METHOD

This was an electronic cohort study of routinely collected primary-care data from a population of 1.9 million, Wales, UK. Poisson regression was undertaken to model adjusted counts of recorded depression symptoms, diagnoses and antidepressant prescriptions. Associated indications were explored.

RESULTS

3 58 383 registered patients aged 6-18 years between 1 January 2003 and 31 December 2013 provided a total of 19 20 338 person-years of follow-up. The adjusted incidence of antidepressant prescribing increased significantly [incidence rate ratio (IRR) for 2013 = 1.28], mainly in older adolescents. The majority of new antidepressant prescriptions were for citalopram. Recorded depression diagnoses showed a steady decline (IRR = 0.72) while depression symptoms (IRR = 2.41) increased. Just over half of new antidepressant prescriptions were associated with depression (diagnosis or symptoms). Other antidepressant prescribing, largely unlicensed, was associated with diagnoses such as anxiety and pain.

CONCLUSION

Antidepressant prescribing is increasing in CYP while recorded depression diagnoses decline. Unlicensed citalopram prescribing occurs outside current guidelines, despite its known toxicity in overdose. Unlicensed antidepressant prescribing is associated with a wide range of diagnoses, and while accepted practice, is often not supported by safety and efficacy studies. New strategies to implement current guidance for the management of depression in CYP are required.

Measurement Issues: Is standardised diagnostic assessment feasible as an adjunct to clinical practice? A systematic review

BACKGROUND

A standardised diagnostic assessment (SDA) is a comprehensive assessment of psychiatric disorder that provides a label according to established diagnostic criteria. While standardised assessments are considered essential in child and adolescent mental health research, they are rarely applied systematically in routine clinical practice.

METHOD

A systematic review of studies that assessed the utility, feasibility and acceptability of SDAs in the assessment of psychopathology among children and young people in routine clinical practice.

RESULTS

Eight papers were identified that applied mixed research methods. Overall, attitudes towards SDAs were positive, with lack of training in administration and interpretation of SDAs and a concern for the validity of diagnostic categories being key barriers. Two randomised control trials and a case series suggest that SDAs might aid the detection of emotional disorders in particular.

CONCLUSION

The current evidence is not yet sufficient to recommend that SDAs should be universally adopted as an adjunct to clinical practice, but our findings suggest that can they be used if applied cautiously and mindfully pending further evaluation.

Validation of the parent version of the World Health Organization Adult ADHD Self-Report Scale for adolescents

OBJECTIVE

To investigate the validity of a parent version of the World Health Organization Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale for adolescents (ASRS-AP) and the 6-question screening version (ASRS-AP-S).

METHODS

Adolescent psychiatric outpatients (N = 112, mean age 15 years, 40% boys) and their parents were interviewed with the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS), and the parents reported on the ASRS-AP/ASRS-AP-S.

RESULTS

Internal consistency (Cronbach's alpha) was 0.93 for ASRS-AP and 0.85 for ASRS-AP-S, 0.91 and 0.87 for the inattention subscale, and 0.91 and 0.72 for the hyperactivity subscale, respectively. The concurrent validity (Spearman's correlation coefficient) between the total K-SADS ADHD symptom severity score and the sum of the score on the ASRS-AP/ASRS-AP-S was 0.75 and 0.66, respectively. Diagnostic accuracy measures for the ASRS-AP and ASRS-AP-S were 78% and 80% sensitivity, 75% and 74% specificity, 73% and 71% positive predictive value (PPV), and 81% and 82% negative predictive value (NPV), respectively.

CONCLUSIONS

The ASRS-AP and ASRS-AP-S showed high internal consistency and concurrent validity in relation to total K-SADS ADHD symptom severity score. Both scales showed favourable diagnostic accuracy measures.

Measurement Issues: Depression measures in children and adolescents

BACKGROUND

Since the recognition of youth depression, numerous instruments have been developed, but there is little consensus regarding their use. In recent years, a national programme for outcome measurement has been introduced in the United Kingdom.

METHOD

A pragmatic literature search was conducted to select instruments commonly used to measure depression either in research or as recommended by UK national bodies.

RESULTS

15 depression rating scales were identified. Diagnostic instruments and rating scales are described.

CONCLUSIONS

Recent large depression trials have produced additional new data, and UK national organisations have made recommendations regarding the implementation of certain instruments.

Validation of the World Health Organization Adult ADHD Self-Report Scale for adolescents

BACKGROUND

The World Health Organization Adult ADHD Self Report Scale (ASRS) is a widely used diagnostic tool for assessment of attention-deficit hyperactivity disorder (ADHD) symptoms in clinical psychiatry in Sweden. The ASRS consists of 18 questions, the first six of which can be used as a short screening version (ASRS-S). There is a version for adolescents-ASRS-Adolescent (ASRS-A)-and the corresponding screening version (ASRS-A-S), which has not been validated to date.

AIM

The aim was to validate the ASRS-A and the ASRS-A-S for use in adolescent clinical populations.

METHODS

Adolescent psychiatric outpatients (n = 134, mean age 15 years, 40% boys) reported on the ASRS-A, and were interviewed with the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS), a semi-structured interview, together with a parent.

RESULTS

Internal consistency was 0.79 for the ASRS-A-S and 0.92 for the ASRS-A (Cronbach's alpha). Internal consistency values were 0.79 and 0.87 for the inattention subscale, and 0.68 and 0.89 for the hyperactivity subscale, respectively. Concurrent validity values, measured with Spearman's correlation coefficient, between the total K-SADS ADHD symptom severity score and the sum of ASRS-A-S and ASRS-A total scores were 0.51 and 0.60, respectively. Psychometric properties of the ASRS-A-S and the ASRS-A were: sensitivity 74% and 79%; negative predictive value 81% and 84%; specificity 59% and 60%; and positive predictive value 49% and 51%, respectively. Both versions showed better properties for girls than for boys.

CONCLUSION

Both the ASRS-A-S and the ASRS-A showed promising psychometric properties for use in adolescent clinical populations.

Food for thought: understanding the value, variety and usage of management algorithms for major depressive disorder

By 2020, depression is projected to be among the most important contributors to the global burden of disease. A plethora of data confirms that despite the availability of effective therapies, major depressive disorder continues to exact an enormous toll; this, in part, is due to difficulties reaching complete remission, as well as the specific associated costs of both the disorder's morbidity and mortality. The negative effects of depression include those on patients' occupational functioning, including absenteeism, presenteeism, and reduced opportunities for educational and work success. The use of management algorithms has been shown to improve treatment outcomes in major depressive disorder and may be less costly than "usual care" practices. Nevertheless, many patients with depression remain untreated. As well, even those who are treated often continue to experience suboptimal quality of life. As such, the treatment algorithms in this article may improve outcomes for patients suffering with depression. This paper introduces some of the principal reasons underlying these treatment gaps and examines measures or recommendations that might be changed or strengthened in future practice guidelines to bridge them.

Suicide-related events in young people following prescription of SSRIs and other antidepressants: a self-controlled case series analysis

OBJECTIVES

We aimed to examine the temporal association between selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressant (TCA) prescriptions and suicide-related events in children and adolescents.

DESIGN

Self-controlled case series.

SETTING

Electronic health records were used from 479 general practices in The Health Improvement Network (THIN) UK primary care database from 1995 to 2009.

PARTICIPANTS

81 young people aged 10-18 years with a record of completed suicide, 1496 who attempted suicide, 1178 with suicidal ideation and 2361 with intentional self-harm.

MAIN OUTCOME MEASURES

Incidence Rate Ratios (IRRs) for completed and attempted suicide, suicidal ideation and intentional self-harm.

RESULTS

For non-fatal suicide-related behaviour, IRRs were similar for the time the person was prescribed either SSRIs or TCAs: IRRs increased during pre-exposure, peaked on prescription day, were stable up to the fourth prescription-week, and decreased after the prescriptions were stopped. For both types of antidepressants, IRRs were lower or similar to pre-exposure levels during the period of prescription. For SSRIs, there was an increase in the IRR for completed suicide on the day of prescription (N=5; IRR=42.5, 95% CI 4.5 to 403.4), and during the fourth week of SSRI prescription (N=2; IRR=11.3, 95% CI 1.1 to 115.6).

CONCLUSIONS

We found that a very small number of young people were prescribed antidepressants and that there was an absence of a sustained increase in rates of suicide-related events in this group. There were no systematic differences between the association of TCAs and SSRIs and the incidence risk ratios for attempted suicide, suicidal ideation or intentional self-harm and, apart from the day of prescription, rates did not exceed pre-exposure levels. The pattern of IRR for suicide for SSRIs was similar to that found in non-fatal suicide-related events. Our results warrant a re-evaluation of the current prescription of SSRIs in young people. We recommend the creation of a pragmatic registry for active pharmacovigilance.

Prevalence and comorbidities of adolescent depression in Germany. An analysis of Health Insurance Data

OBJECTIVE

Data on the prevalence of depressive disorders in adolescents are scarce. We aimed to examine the administrative prevalence of depressive disorders and related comorbidities in German adolescents. A second objective of was to assess potential regional (East vs. West Germany) differences in depression prevalence.

METHOD

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years of age with diagnosed depression during a one-year-period (2009) were identified.

RESULTS

The population at risk consisted of 140,563 adolescents. Of these, 4,295 (41.2% male; mean age: 15.5 years) had a diagnosis of depression. This equates to a prevalence of 3.1% (females: 3.7%, males: 2.5%). There were no significant differences between East and West Germany. Of all adolescents with depression, 62.5% had at least one comorbid psychiatric diagnosis, with anxiety and emotional disorders (23.7%), somatoform disorders (16.8%), hyperkinetic disorders (16.2%) and posttraumatic stress disorder (10.0%) being most frequently diagnosed.

CONCLUSIONS

The depression prevalence in this sample was lower than that in studies of clinical samples. There was a marked prevalence of psychiatric comorbidities, especially of internalizing disorders. In adolescents, the risk of depression seems to be comparable in both East and West Germany.