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Prospective cohort study.
Follow up period:
One year, and when participants were aged 24.
Nine high schools in two urban and three rural communities in Oregon, USA; recruitment from 1987 to 1989.
1709 people recruited in high school, of whom 941 completed assessments at baseline, 1 year follow up, and at age 24. At 1 year follow up, 351 people with a history of MDD, 293 people with a history of non-affective disorder, and 457 people with no history of mental disorder, were selected. Average age of participants at final follow up was 24.2 years. 89% of participants were white, 1% black, 3% Hispanic, 3% American Indian, 3% Asian, and 2% “other”. 61% of participants were single, 34% married, 3% divorced, and 2% separated. 97% had graduated high school or received a general educational development diploma, and 31% had received at least a bachelors degree.
Baseline assessment and 1 year assessment were by face-to-face diagnostic interview and questionnaire, while final follow up (at age 23–25 years) was by mailed questionnaire and diagnostic telephone interview. At baseline, a modified Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) interview was used to derive a DSM-III-R diagnosis. At 1 year and final follow up, the Longitudinal Interval Follow-Up Evaluation (LIFE) interview was used and diagnosis made according to DSM-IV criteria.
Young adult psychosocial functioning (YAPF) variables assessed at final follow up were marital status, parenting, mental health use, smoking habits, global level of functioning (DSM-III-R/DSM-IV), years of school completed, unemployment history, income, relationships with friends and family, social network, minor daily hassles (based on Unpleasant Events Schedule), major adversity (based on Social Readjustment Rating Scale and Psychiatric Epidemiology Research Inventory), physical health, and life satisfaction.
Adolescent MDD was significantly associated with low global functioning (p<0.001), low quality of relations with family (p<0.01), small social network (p<0.01), minor daily hassles (p<0.001), major adversity (p<0.001), low life satisfaction (p<0.001), and mental health treatment use (OR 1.78, 99% CI 1.11 to 2.87; analyses adjusted for comorbid non-affective disorder and demographic variables significantly associated with adolescent MDD). Low life satisfaction was the only YAPF variable more strongly associated with adolescent MDD than adolescent non-affective disorder (p<0.001). After further adjustment for stability of psychosocial functioning, and depressive symptomatology at the time of young adult assessment, no significant association remained between adolescent MDD and any YAPF measure. 24 participants who did not complete the mailed questionnaire were excluded from analysis.
Young adults who have experienced an episode of adolescent MDD experience impairments in many areas of psychosocial functioning.
During and around the time of the episode, adolescent major depression is associated with psychological suffering, impairment in social roles, and increased risk for suicide. In this paper, Lewinsohn and colleagues show that adolescents with depression have poorer psychosocial functioning than never depressed adolescents—as reviewed in their article, this exactly parallels similar findings in other studies. The impairment shown in this work was broad, spanning occupational performance, interpersonal functioning, quality of life, and physical well being. The important contribution of this particular paper is in the examination of the specificity of this relationship and of alternative causal models.
In their examination, most of the psychosocial impairment appears to be associated with psychopathology in general and not with depression per se. While this perhaps should come as no surprise, the demonstration provided in this paper is elegant and convincing.
The deeper question is whether or not both the depression and the psychosocial impairment arise from common risk factors or whether the depression “causes” (at least in part) the psychosocial deficits. In other words, will treating depression more effectively or sooner decrease these psychosocial impairments or do we need to address them in a different fashion? Ultimately this question is not completely answered or answerable by this data. The good news is that adolescent MDD alone, when other factors (adolescent comorbidity, young adult psychopathology, current depressive symptoms, etc) were co-varied out, did not predict psychosocial impairment. To oversimplify that analysis, a single episode of depression in adolescence did not appear to lead to significantly worse young adult functioning. However, as depression is, in many individuals, a recurrent disorder, this gives only modest comfort.
At the very least, in addition to further improving our treatments for adolescent major depression, this work suggests that treatment that targets long term psychosocial impairment may be as necessary as treatment that targets the depressive syndrome itself.
For correspondence: Peter M Lewinsohn, Oregon Research Institute, Franklin Boulevard, Eugene, Oregon, USA;
Source of funding: This study was funded in part by the National Institute of Mental Health.
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