Research reportThe differentiation between depressive and anxious adolescent females and controls by behavioural self-rating scales
Introduction
A systematic evaluation of the increasing prevalence of self-reported symptoms of anxiety and depression in adolescents is important. The prevalence of self-reported symptoms of anxiety in Swedish adolescents has increased more than three times during the last two decades and was 33.1% in females and 11.9% in males in 2007 (Statistics-Sweden, 2007). International studies reveal great discrepancies in the prevalence of anxiety disorders, with one-year prevalence ranging from 2.8 to 18.4% in 15–18 year olds (Feehan et al., 1994, Fergusson et al., 1993, Goodwin et al., 2004, Lewinsohn et al., 1998, McGee et al., 1990). International studies also show that lifetime prevalence of depression ranges from 9 to 20% at the end of adolescence (Costello et al., 2003, Fergusson et al., 2005, Lewinsohn et al., 1998, Reinherz et al., 1993). In Sweden, the cost of depression has doubled in the past eight years, making it a major public health concern (Sobocki et al., 2007).
Psychiatric self-assessment scales aimed at measuring symptoms of anxiety and depression can serve diverse purposes. Some instruments have been designed for systematic screening, whereby adolescents with psychiatric symptoms are identified at an early stage so that methods for prevention of psychiatric disease progression can be provided. This is of importance, since previous research has shown that mild psychiatric symptoms increase the risk of severe psychiatric disease and suicidal thoughts, minor/sub threshold depression, or dysthymia increase the risk of further severe psychiatric disease (Fergusson et al., 2005, Woodward and Fergusson, 2001).
It is a major advantage in clinical practice to have access to validated instruments to discriminate caseness from non-caseness. By identifying specific threshold scores, the screening instruments can be used for such discriminant purposes. The instruments can then serve as an aid to school health services or general practitioners in identifying adolescents who should be referred for psychiatric assessment and in potentially helping to improve the efficacy of intake routines at open psychiatric units for children and adolescents.
If psychometric requirements for diagnostic indices are fulfilled, specialised instruments can also assist in meeting the clinical challenge of differentiating between anxiety disorders and depression and differentiating between different anxiety disorders, thus serving as a complement to clinical assessment and diagnostic interviews. The instruments can also be used in research and clinical practice for assessing the severity of symptoms, or for measuring the outcome of treatment.
There are several specialised instruments designed to identify symptoms of either depression or anxiety. In this study, we chose instruments which have been translated into Swedish and are most frequently used in Swedish child and adolescent psychiatric clinical practice and mental health services. Beck's Depression Inventory (BDI) is a frequently used rating scale in adolescent psychiatry for screening and measuring symptoms of depression over a two-week period prior to the assessment. A modified version, BDI-II, has been developed and shown good psychometric properties in non clinical adolescent samples (Osman et al., 2008). Likewise, Beck's Anxiety Inventory (BAI) is often used in adolescent research and clinical practice, with good psychometric properties reported (Osman et al., 2002). The Hospital Anxiety and Depression Scale consists of both a depression and an anxiety subscale (HAD-dep, HAD-anx) and was originally created to detect states of depression and anxiety in the setting of a hospital medical outpatient clinic (Zigmond and Snaith, 1983). In a review of the 747 identified papers that used HAD, the instrument was found to perform well in assessing the symptom severity and caseness of anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population (Bjelland et al., 2002).
In addition to the specialised instruments, we also included The Strengths and Difficulties Questionnaire (SDQ) and The Sense of Coherence (SOC) since previous research has shown that the accuracy of general purpose behaviour checklists is high (Aebi et al., 2009, Rey and Morris-Yates, 1992).
SDQ is widely used internationally as a screening instrument for psychiatric symptoms in children and adolescents (Goodman et al., 2004) and currently an agreed core measuring instrument in the international Child and Adolescent Mental Health (CAMH) Outcome Research Consortium (CORC). SDQ covers emotional symptoms, hyperactivity, conduct and peer problems, but the emotional scale (SDQ-em) does not differentiate between symptoms of anxiety and depression. The scores of each subscale can be added to a total difficulties score (SDQ-tot). There is also a subscale measuring pro-social behaviour and a special impact scale (SDQ-imp). Since there are three different versions of the SDQ, it is possible to cross-check information from parents, teachers and self-reports. SDQ was originally designed for children and adolescents up to 16 years of age but has been used for 17–19 year olds in Finland and Norway (Koskelainen et al., 2001, Van Roy et al., 2006). The Swedish self-report version of SDQ for adolescents has been shown to have acceptable psychometric properties (Lundh et al., 2008, Svedin and Priebe, 2008).
SOC is of special interest, as it represents a salutogentic model which focuses on factors that support human health and well-being rather than on factors that cause disease. No psychiatric symptoms are measured but rather the global orientation to one's inner and outer environments, which is hypothesized to be a significant determinant of location and movement on the health ease-disease continuum. It does not refer to a specific type of coping strategy, but to factors which are the basis for successfully coping with stressors. The SOC scale is considered to be a reliable, valid, and cross-culturally applicable instrument (Antonovsky and Sagy, 1986, Eriksson and Lindstrom, 2005), which is strongly related to perceived health, especially mental health (Eriksson and Lindstrom, 2006).
In adolescents, there seem to be manifest psychological differences based on gender which contribute to vulnerability to anxiety disorders and depression. One such difference is for girls to exhibit a greater tendency to engage in ruminative thinking and increased interpersonal sensitivity (Breslau et al., 1995, Nolen-Hoeksema et al., 1999). A dramatic predominance of mood disorders in females emerges at the onset of puberty (Angold et al., 1998). Psychiatric self-assessment scales are used for both boys and girls without taking gender into consideration. Our study did not aim to solve this issue and only focused on girls in order to limit variability in the sample.
The over-all aim of this study was to rank the ability of established psychiatric self-assessment scales to differentiate between cases of affective disorders (one or several anxiety disorders and/or depression) and non-cases in adolescent girls. We also wanted to find the most effective instruments to specifically identify cases of anxiety disorders and depression, and to identify cut-off scores for each scale.
Section snippets
Samples
The clinical sample consisted of adolescent girls (n = 73) with a mean age 16.8 years (range 14.5–18.4 years) who were psychiatric patients and had a primary diagnosis, validated by DAWBA of major depression and/or one or several anxiety disorders (general anxiety syndrome, social phobia, specific phobia, panic disorder, separation anxiety, post-traumatic stress disorder). Patients with severe autism or psychotic symptoms were not included in the study. The subjects had ongoing treatment contact
Sample characteristics
16.7% of the controls were recruited from the small rural town, 21.2% from the affluent northern suburb, 24.2% from the city center, and 37.9% from the southern suburb. Parent unemployment and single-parent status did not differ significantly between the clinical sample and controls, but parents of non-Swedish origin were less frequent in the clinical sample (Table 1).
The median duration of treatment contact was 11 months. The DAWBA interview concluded that 19.2% of the subjects fulfilled the
Discussion
The main finding of this study was that, of the assessed scales SOC and SDQ-em exhibited abilities in the range good-excellent in differentiating between cases of anxiety disorders and/or depression from non-cases. SOC and SDQ-em also had equivalent excellent ability to differentiate between cases of depression and non-cases compared to the specialised scales for depression BDI and HAD-dep. This compares to previous studies investigating the discriminant properties of the Child Behavioural
Role of funding source
Funding for this study was obtained from the Osher Center for Integrative Medicine, Karolinska Institutet, Sweden, Public Health Grants from the Stockholm County Council, The Swedish Society of Medicine, The National Board of Health and Welfare and The Söderström–Königska Foundation. None of these had any involvement in the collection, analysis or interpretation of the data, nor in writing the report or in the decision to submit the paper for publication.
Conflict of interest
All of the authors declare that they have no conflicts of interest.
Acknowledgements
Thanks to all the students and patients who have contributed to this study and to all the teachers, school nurses and staff at the clinics, who have been supporting the work.
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