Follow-up of childhood depression: historical factors

J. Hynes and N. McCune

Child and Family Clinic, Bocombra Lodge, 2 Old Lurgan Road, Portadown BT63 5SG, UK

The study by Fombonne et al (2001), following adolescents with diagnoses of major depressive disorder into adulthood, raises some questions pertaining to the era when they were diagnosed (1970-1983).

First, it was only in the early 1980s that child abuse began to come into the awareness of professionals and, a few years later, the general public. Therefore, it is possible that some of the young people identified with depressive disorders may have had a history of sexual abuse which was not disclosed or enquired about. This raises the question of what would have been the outcome in those young people who had been sexually abused had they made disclosures and had appropriate therapeutic intervention for this. It is well known that childhood sexual abuse is a significant factor in the histories of some adults presenting with depressive syndromes.

Second, this period was also a time when attention-deficit hyperactivity disorder (ADHD) was not recognised and hyperkinetic disorder was only rarely diagnosed. Some of the young people, especially those in the comorbid conduct disorder/major depressive disorder group, may have had undiagnosed and untreated ADHD. Certainly this was long before the use of psychostimulants on a wider basis in the UK and it is possible that some of these young people untreated may have been more vulnerable to development of depressive syndromes because of untreated attentional and other behavioural problems impacting on their self-esteem.

Third, although antidepressants were in use by child and adolescent psychiatrists when the diagnosis was major depressive disorder, they may not always have been used in young people with major depressive disorder with comorbid conduct disorder because of the risks of overdose in such a population. Tricyclic antidepressants were the predominant antidepressants used at that time in this population. With the advent of selective serotonin reuptake inhibitors, child and adolescent psychiatrists probably began prescribing more anti-depressants in the comorbid conduct disorder/major depressive group because of the lower risk of serious harm in overdose. This raises the possibility that more effective treatment of these young people might also have an impact on their outcomes in adult life.

EDITED BY KHALIDA ISMAIL

REFERENCES

Fombonne, E., Wostear, G., Cooper, V., et al (2001) The Maudsley long-term follow-up of child and adolescent depression. I. Psychiatric outcomes in adulthood. British Journal of Psychiatry, 179, 210-217.[Abstract/Free Full Text]


 

Author's reply

E. Fombonne

McGill University, Department of Psychiatry, Montreal Children's Hospital, 4018 Ste-Catherine West, Montreal H3Z IP2, Canada

EDITED BY KHALIDA ISMAIL

The comments of Hynes & McCune raise pertinent questions. As they point out, it is possible that sexual abuse in childhood might have influenced the onset of juvenile depression, and also the likelihood of adult depression recurrence in our sample. In this study, we have collected data on sexual abuse, using both a review of medical charts at the time of Maudsley attendance and from adult interviews based on the Childhood Experience of Care and Abuse (CECA) measure. The effect of sexual abuse in childhood on patterns of adult depression recurrence will be investigated in the next analyses of this data-set, with particular attention given to differential risk processes according to childhood comorbidity.

Regarding comorbid ADHD as a risk factor for adolescent depression, particularly in the depression group with comorbid conduct disorder, we found a significantly increased rate of ADHD in the comorbid group, as we reported (Fombonne et al, 2001a, Table 2). Yet, it is plausible that the rate of ADHD in this sample was underestimated as many cases were ascertained before ADHD or hyperkinetic disorders were fully recognised as valid diagnostic entities. Nevertheless, our findings suggest that it is possible that ADHD might have been implicated in the development of conduct symptoms in the comorbid group although, because of the small sample size and likely underestimation of ADHD in that group, we cannot test for the specific contribution of (untreated) ADHD in the onset and recurrence of depression.

We had provided explicit data on the use of tricyclic antidepressant drugs during childhood years and found that the rate of prescriptions of these drugs was significantly higher in the non-comorbid group than do the comorbid group (48.4% v. 30.2%, P=0.032; see Fombonne et al, 2001a). Most of these prescriptions were for amitriptyline and relied on dosages much lower than those considered appropriate by today's standards. Although the rate of antidepressant use was lower in the comorbid group, antidepressants were nevertheless often prescribed in that group too. Obviously, we could not assess whether or not use of tricyclic medications in that sample influenced long-term out-comes, since our study relied on an observational design. The interesting aspect of these data was to point to the frequent use by practising child psychiatrists of antidepressant drugs (irrespective of their known efficacy) in this sample of youths with depression assessed in the 1970s at a time when child and adolescent depression was largely ignored in professional training and in the literature. Furthermore, the data indirectly validated our diagnostic procedures.

Most of the comments by Hynes & McCune raise questions about the mechanisms underlying recurrence of depression in adulthood following a first episode in childhood or adolescence. The findings of our study (Fombonne et al, 2001a,b) indicated that relapse rates were similar, irrespective of the presence of comorbid conduct disorder in childhood. This result is important in its own right as it refutes previous hypotheses that depression, when occurring in the context of conduct disturbances, reflected mostly local psychosocial circumstances and was not associated with long-term heightened risk of affective disorders in adulthood.

This study was designed to assess mechanisms underlying recurrence of depression in adult life and further reports will address the role of early childhood experiences (such as sexual abuse), life events, family history and individual psychological characteristics on the patterns of adult depressive recurrence. It could well be that, in spite of having similar rates of relapse in adulthood, the mechanisms of depressive recurrence differ for the two groups included in this study, according to childhood comorbidity.

REFERENCES

Fombonne, E., Wostear, G., Cooper, V., et al (2001a) The Maudsley long-term follow-up of child and adolescent depression. 1. Psychiatric outcomes in adulthood. British Journal of Psychiatry, 179, 210-217.[Abstract/Free Full Text]

Fombonne, E., Wostear, G., Cooper, V., et al (2001b) The Maudsley long-term follow-up of child and adolescent depression. 2. Suicidality, criminality and social dysfunction in adulthood. British Journal of Psychiatry, 179, 218-223.[Abstract/Free Full Text]





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