Predictors of Persistence After a Positive Depression Screen Among Adolescents

Article (PDF Available)inPEDIATRICS 130(6) · November 2012with14 Reads
DOI: 10.1542/peds.2012-0450 · Source: PubMed
Abstract
Objective: To examine predictors of depression persistence after a positive screening test to inform management protocols for screened youth. Methods: We conducted a cohort study of 444 youth (aged 13-17 years) from a large health care delivery system. Youth with depressive symptoms, based on a 2-item depression screen, were oversampled for the baseline interview. Baseline assessments included the Patient Health Questionnaire 9-item (PHQ-9) depression screen as well as clinical factors that were hypothesized to influence depression persistence (family history of depression, functional impairment, perceived social support, anxiety symptoms, externalizing symptoms, and medical comorbidity). Logistic regression analysis was used to examine factors associated with the persistence of depression at 6 months postbaseline. Results: Of 113 youth with a positive baseline screen (PHQ-9 ≥11), 47% and 35% continued to be positive at 6-week and 6-month follow-up, respectively. After controlling for treatment status, only 2 factors were significantly associated with depression persistence at 6 months: baseline depressive symptom score and continuing to have a positive screen at 6 weeks. For each 1-point increase on the PHQ-9 score at baseline, youth had a 16% increased odds of continuing to be depressed at 6 months (odds ratio: 1.16, 95% confidence interval: 1.01-1.34). Youth who continued to screen positive 6 weeks later had almost 3 times the odds of being depressed at 6 months (odds ratio: 2.89, 95% confidence interval: 1.09-7.61). Conclusions: Depressive symptom severity at presentation and continued symptoms at 6 weeks postscreening are the strongest predictors of depression persistence. Patients with high depressive symptom scores and continued symptoms at 6 weeks should receive active treatment.
Predictors of Persistence After a Positive Depression
Screen Among Adolescents
WHATS KNOWN ON THIS SUBJECT: Adolescents have high
placebo response rates in depression treatment trials. Screening
for depression will likely detect youth with a broad range of
symptom severity, including some who would benet from
watchful waiting but might not require active treatment.
WHAT THIS STUDY ADDS: The strongest predictors of symptom
persistence are depr essive symptom severity at presentation and
continued symptoms on repeat screening 6 weeks later. These results
provide important information for the development of postscr eening
management protocols in the primary care setting.
abstract
OBJECTIVE: To examine predictors of depression persistence after
a positive screening test to inform management protocols for
screened youth.
METHODS: We conducted a cohort study of 444 youth (aged 1317
years) from a large health care delivery system. Youth with depres-
sive symptoms, based on a 2-item depression screen, were over-
sampled for the baseline interview. Baseline assessments included
the Patient Health Questionnaire 9-item (PHQ-9) depression screen as
well as clinical factors that were hypothesized to inuence depression
persistence ( family history of depression, functional impairment,
perceived social suppor t, anxiety symptoms, externalizing symptoms,
and medical comorbidity). Logistic regression analysis was used to
examine factors associated with the persistence of depression at 6
months postbaseline.
RESULTS: Of 113 youth with a positive baseline screen (PHQ-9 $11),
47% and 35% continued to be positive at 6-week and 6-month follow-
up, respectively. After controlling for treatment status, only 2 factors
were signicantly associated with depression persistence at 6 months:
baseline depressive symptom score and continuing to have a positive
screen at 6 weeks. For each 1-point increase on the PHQ-9 score at
baseline, youth had a 16% increased odds of continuing to be depressed
at 6 months (odds ratio: 1.16, 95% condence interval: 1.011.34). Youth
who continued to screen positive 6 weeks later had almost 3 times the
odds of being depressed at 6 months (odds ratio: 2.89, 95% condence
interval: 1.097.61).
CONCLUSIONS: Depressive symptom severity at presentation and con-
tinued symptoms at 6 weeks postscreening are the strongest predictors
of depression persistence. Patients with high depressive symptom
scores and continued symptoms at 6 weeks should receive active treat-
ment. Pediatrics 2012;130:e1541e1548
AUTHORS: Laura P. Richardson, MD, MPH,
a
,
b
,
c
Elizabeth
McCauley, PhD,
b
,
d
Carolyn A. McCarty, PhD,
a
,
b
David C.
Grossman, MD, MPH,
c
,
e
Mon Myaing, PhD,
b
Chuan Zhou,
PhD,
a
,
b
Julie Richards, MPH,
c
Carol Rockhill, MD, MPH,
b
,
d
and Wayne Katon, MD
d
Departments of
a
Pediatrics, and
d
Psychiatry and Behavioral
Sciences, University of Washington School of Medicine, Seattle,
Washington;
b
Seattle Childrens Hospital Center for Child Health,
Behavior and Development, Seattle, Washington;
c
Group Health
Research Institute, Seattle, Washington; and
e
Department of
Health Services, University of Washington School of Public Health,
Seattle, Washington
KEY WORDS
adolescent depression, screening, primary care
ABBREVIATIONS
GHGroup Health
PHQ-9Patient Health Questionnaire 9-item screen
PHQ-2Patient Health Questionnaire 2-item screen
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0450
doi:10.1542/peds.2012-0450
Accepted for publication Jul 30, 2012
Address correspondence to Laura Richardson, MD, MPH, Center
for Child, Health, Behavior and Development, Seattle Childrens
Hospital Research Institute, 2001 8th Ave, M/S CW8-6 PO Box 5371,
Seattle, WA 98121. E-mail: laura.richardson@seattlechildrens.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Katon has received payment for
lectures from the following manufacturers of antidepressant
medications: Lilly, Pzer, and Forrest; the other authors have
indicated they have no nancial relationships relevant to this
ar ticle to disclose.
FUNDING: This work was supported by grants from the Group
Health Community Foundation Child and Adolescent Grant
Program, the University of Washington Royalty Research Fund,
a Seattle Childrens Hospital Steering Committee Award, and
a K23 award to Dr Richardson from the National Institute of
Mental Health (grant 5K23 MH069814). Funded by the National
Institutes of Health (NIH).
PEDIATRICS Volume 130, Number 6, December 2012 e1541
ARTICLE
by guest on December 26, 2015Downloaded from
The US Preventive Services Task Force
recommends screening for depression
among adolescents in primary care
when systems are in place to ensure
accurate diagnosis, treatment, and
follow-up.
1
However, few studies have
been conducted examining the psycho -
metric properties of depression screen-
ing tests in primary care,
25
and no
studies have been conducted examining
the course of depression among youth in
primary care who screen positive.
There is evidence that, for many youth,
depressive symptoms resolve without
active treatment. Antidepressant med-
ication trials have consistently dem-
onstrated high placebo response rates
(50%60%), with the steepest decline
in depressive symptoms during the
rst 6 weeks of treatment.
68
Placebo
response rates have also been shown
to be inversely correlated with de-
pression severity in the population
studied,
9
suggesting that some placebo
response may be due to spontaneous
recovery in less severely affected indi-
viduals. To avoid potentially unneces-
sary treatment and to target treatment
of youth who would most benet, pro-
viders need strategies to identify youth
who are likely to have persistent symp-
toms as well as those who are likely to
have spontaneous symptom resolution.
The purpose of this study is to identify
clinical and demographic predictors of
depression persistence after a positive
depression screen among adolescents
in primary to develop strategies to
identify youth who would most benet
from early engagement in active treat-
ment versus watchful waiting.
METHODS
The AdoleSCent Health Study was de-
veloped by researchers at the Univer-
sity of Washington and the Group Health
(GH) Research Institute. The main pur-
poses were to evaluate the performance
of depression screening instruments
and to examine predictors of persistence
of depressive symptoms after a positive
screen. All procedures were approved by
the GH Institutional Review Board.
Survey Methods
Between September 2007 and June
2008, study staff randomly selected
4000 13- to 17-year-olds who had seen
a GHprovider intheprevious12 months.
GH is a nonprot health care organi-
zation that serves .660 000 residents
of Washington State and Idaho. The
parents/guardians of selected enroll-
ees received an invitation letter, a con-
sent form, and a brief survey. Parents
were asked to sign the consent form
and give the survey to their child to
complete privately. The child received
a $2 preincentive. Completion of the
survey was considered assent to par-
ticipate by the child. Parents of youth
who did not respond received a second
mailing and follow-up phone calls.
The brief survey included 10 items about
age, gender, weight, height, sedentary
behaviors, overall health, functional
impairment, and depressive symptoms
(the Patient Health Questionnaire 2-item
Depression Scale [PHQ-2]). In a previous
study using these same data, we found
that a score of $3 on the PHQ-2 had
a sensitivity of 73% and a specicity of
75% for detecting major depression
compared with structured psychiatric
interviews among adolescents.
3
Figure 1 details study enrollment pro-
cedures. Of the original 4000 invited
youth, 3775 were eligible and 2291
completed the brief survey. A subset of
youth (n = 499) was invited to partici-
pate in a longitudinal phone interview
study, including assessment of de-
pressive symptoms, functional impair-
ment, and health behaviors. Youth with
a PHQ-2 $3(n = 271) and an age and
gender frequency-matched sample of
youth with a PHQ-2 #2(n = 228) were
invited to participate. Consent for the
longitudinal phone study was obtained
from both the parent and the child.
Phone interviews were conducted at
baseline, 6 weeks, and 6 months. Youth
received $20, $10, and $15 for comple-
tion of the baseline, 6-week, and
6-month interviews, respectively.
Youth who indicated thoughts of death
or dying more than half the days in the
past week on the PHQ-9 received addi-
tional assessment by a study clinician.
For youth who were judged to have an
elevated risk for suicide, the study clini-
cian helped connect the youth and par-
ent with treatment resources. No other
treatment or feedback on screening
was provided through this study.
Baseline phone interviews were com-
pleted with 444 youth (89.5% of invited
youth). Of the 444 youth in the baseline
sample, 436 (98%)completed the 6-week
assessment and 433 (97.5%) completed
the 6-month assessment. Given the low
level of missingness, only youth with
completedataattherelevanttime points
were included in analyses.
Depression Measures, Baseline
The baseline child phone interview in-
cluded the Patient Health Questionnaire
9-item (PHQ-9) screener and the Di-
agnostic InterviewSchedule for Children
depression modules. The PHQ-9 is a self-
administered version of the PRIME-MD
depression interview,
10
which uses Di-
agnostic and Statistical Manual of
Mental Disorders, Fourth Edition crite-
ria to assess for depression.
11
In a pre-
vious study using these data, we found
that at a score of $11, the PHQ-9 had
a sensitivity of 89.5% and a specicity of
77.5% for detecting youth with major
depression.
4
To assess for persistence
of depressive symptoms, the PHQ-9
was repeated at both the 6-week and
6-month follow-up assessments.
Other Predictors of Persistence
Potentialpredictorswereselectedbased
onliteraturereviewoffactorsassociated
with depression persistence. Because
there have been no previous longitudinal
studies of depression persistence
e1542 RICHARDSON et al
by guest on December 26, 2015Downloaded from
among adolescents i n primary care,
potential predictors were selected
based on the results of studies among
adults in primary care and adolescents
in specialty settings. In primary care
samples of adults, predictors of persis-
tent disorder include increased initial
severity, comorbid anxiety disorder or
medical disorder, duration of depressive
symptoms, and previous history of re-
current depression.
1216
Predictors of
depression persistence in adolescent
specialty samples include older age,
17
female gender,
18
presence of comor-
bid anxiety disorder
17,19
or substance
abuse,
17
poor quality of friendships,
20
higher depression severity at baseline,
18
and poor parental relationships.
17,21
We
also included externalizing symptoms
based on the high prevalence of exter-
nalizing and depression comorbidity in
this age group. Specicmeasuresfor
each of these constructs, all collected at
the baseline interview, are outlined in the
following subsections.
Functional Impairment
The 13-item Columbia Impairment Scale
was used to measure impairment in
school, family, and peer relationships
and has been shown to correlate with
the clinician-rated Childrens Global
Assessment Scale.
22
Comorbid Mental Health Disorders
The 5-item youth self-report version of
the Screen for Child Anxiety Related
Emotional Disorders was used to screen
for anxiety comorbidity.
23
Acutoffof$3
on the brief version of this measure
has been shown to have a sensitivity of
74% an d a specicity of 73% for iden-
tifying youth with clinically signicant
anxiety.
23
To assess for externalizing symptom-
atology, parents were asked to complete
the Brief Pediatric Symptom Checklist.
The externalizing component (at a cut
point of $7) has a sensitivity of 62% and
aspecicity of 89% for detecting youth