Research report
Major depressive disorder in adolescents: Family psychiatric history predicts severe behavioral disinhibition

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Abstract

Background

Major Depressive Disorder (MDD) becomes increasingly prevalent during adolescence and is associated with substantial psychiatric comorbidity and psychosocial impairment. The marked behavioral heterogeneity evident among adolescents with MDD suggests the possibility of distinct subtypes. This study was designed to determine whether family psychiatric histories differ between groups of MDD adolescents defined by the presence or absence of severe behavioral disinhibition.

Methods

Adolescents with MDD (n = 71) completed the Buss–Durkee Hostility Inventory—Adapted, Adolescent Aggressive Incidents Interview (AAII), Measure of Aggression, Violence, and Rage in Children, Diagnostic Interview Schedule for Children, Suicidal Ideation Questionnaire-JR., Suicidal Behavior Inventory, and Reynolds Adolescent Depression Scale. Parents completed the Family Informant Schedule and Criteria, Children's Affective Liability Scale, AAII, and a partial DISC. Behavioral disinhibition (BD) measures were used to assign adolescents to MDD + BD (n = 41) and MDD  BD (n = 30) groups.

Results

The MDD + BD group had a higher prevalence of drug use disorders in biological fathers than the MDD  BD group. The MDD + BD group also had higher proportions of paternal second degree relatives with alcohol use disorders, drug use disorders, and psychiatric hospitalizations, and a higher proportion of maternal second degree relatives with antisocial personality disorder.

Limitations

Limitations include reliance on single informants for family psychiatric histories and the failure to distinguish between child- and adolescent-onset depression.

Conclusions

Family psychiatric histories differentiated MDD adolescents grouped by the presence or absence of behavioral disinhibition, suggesting possible etiologic mechanisms. Further research on subtypes or comorbid presentations may assist in the development of targeted treatment strategies.

Introduction

Rates of depression rise sharply during adolescence (Petersen et al., 1993), with the risk of developing a depressive disorder being particularly high among older adolescents (Burke et al., 1991). Point prevalence and lifetime prevalence rates of Major Depressive Disorder (MDD) among adolescents are approximately two to four percent (e.g., Garrison et al., 1997) and 20% (Lewinsohn et al., 1993), respectively. A disorder of substantial public health significance, MDD in adolescents is associated with a wide range of psychiatric comorbidity (Kovacs, 1996), substantial psychosocial impairment (Puig-Antich et al., 1993), and risk of suicide (Marttunen et al., 1991, Rao et al., 1993).

This study was designed to determine whether or not family psychiatric histories differ between groups of MDD adolescents defined by the presence or absence of severe behavioral disinhibition. Adolescents diagnosed with MDD are characterized by diverse behavioral phenotypes. One such phenotype includes severe behavioral disinhibition, which is defined as a deficit in self-regulation characterized by severe acts of aggression, impulsive-aggression, and affective lability with aggression. The possibility of multiple diatheses for behavioral phenotypes is consistent with developmental models of depression, which are dimensional and transactional (e.g., Cicchetti et al., 1994), and with the possibility of depressive subtypes (e.g., Rende et al., 1997, Winokur and Morrison, 1973, Winokur, 1997). To the extent that distinct etiologies and developmental pathways exist, identification and validation of these variants would inform research on etiology and course, as well as efforts to develop preventive interventions.

Comorbid conditions are common among adolescents with MDD and undoubtedly account for some of the observed behavioral heterogeneity (e.g., Brady and Kendall, 1992, Fleming and Offord, 1990, O'Connor et al., 1998). Large-scale community-based studies (Lewinsohn et al., 1993, Rohde et al., 1991) indicate that the most common comorbid conditions are anxiety disorders, substance use disorders, and disruptive behavior disorders. Of particular relevance to behavioral disinhibition, Rohde et al. (1991) reported lifetime comorbidity rates of 12.1% for disruptive behavior disorders and 19.9% for substance use disorders. Similarly, in a study of children and adolescents referred to a psychopharmacology clinic, Biederman et al. (1995) reported that youth with both mild and severe forms of MDD were more likely to meet criteria for Conduct Disorder than were normal controls.

Distinct depression subtypes may also account for some behavioral heterogeneity among adolescents with MDD. Williamson et al. (1995) found a higher rate of antisocial personality disorder among relatives of adolescents with depression and conduct disorder than among relatives of adolescents with depression only. More recently, Marmorstein and Iacono (2004) found that the presence of either Conduct Disorder or MDD in adolescents was associated with increased rates of maternal MDD and paternal antisocial behavior. In terms of age of onset, Rende et al. (1997) examined the prevalence of non-depressive disorders in the first-degree relatives of 18 early-onset and 115 adult-onset depressed outpatients. They identified higher rates of comorbid alcoholism and depression, and higher rates of comorbid antisocial personality and depression, in the first-degree relatives of early-onset probands. These studies suggest that family psychiatric history and age-of-onset may be meaningful markers for subtypes of early onset depression. It is important to note that adult depressive subtypes have been proposed for many years. These have been similarly based on factors such as family psychiatric history (e.g., Behar et al., 1980, Winokur and Morrison, 1973, Winokur et al., 1978), age of onset (e.g., Rende et al., 1997), and the presence of anger attacks (Rosenbaum et al., 1993, Rosenbaum, 1999, Tedlow et al., 1999).

Finally, models of personality that have consistently received empirical support (e.g., Cloninger et al., 1993, Eysenck, 1990) include dimensions or traits related to behavioral undercontrol and disinhibition. Cloninger et al. propose that brain systems of behavioral activation and inhibition relate to heritable dimensions of personality. Such dimensions have been consistent predictors of substance use disorders and externalizing problems (Sher et al., 2000).

These areas of inquiry provide a strong backdrop for the study of behavioral disinhibition among adolescents with MDD. The potential etiologic and predictive validity of behavioral disinhibiton is supported by emerging data concerning family psychiatric histories, the presence of a depressive subgroup in adults defined by anger attacks (e.g., Tedlow et al., 1999), the predictive validity of behavioral disinhibition (e.g., Sher et al., 2000), and associations between serotonergic dysfunction and impulsive aggression (e.g., Coccaro, 1989). The present study builds upon Rende et al.'s (1997) findings concerning early-versus late-onset depression by including a larger sample of patients, all of whom are characterized by early-onset depression. We hypothesized that MDD adolescents with severe behavioral disinhibition would have stronger family histories of disorders suggestive of externalizing behaviors and behavioral disinhibition, such as alcohol/drug use and antisocial personality disorders.

Section snippets

Participants

Participants were recruited from a child and adolescent psychiatric hospital at a major university medical center. The sample included 71 adolescents (19 males; 52 females), age 13–17 years old with a diagnosis of Major Depressive Disorder (MDD) and two living biological parents. The diagnosis of MDD was rendered using the SCID (First et al., 1995).

The age of participants ranged from 13 to 17 years (M = 15.1, SD = 1.2). The racial/ethnic composition was 95.7% Caucasian, 2.9% African American, and

Behavioral disinhibition

The means and standard deviations on behavioral disinhibition measures for BD groups and the total sample are displayed in Table 1. Highly significant differences (p < .001) were found between MDD+BD and MDD-BD groups on adolescent-and parent-report measures of behavioral disinhibition. A One-Way MANOVA using the four Buss–Durkee subscales resulted in a statistically significant main effect for group status, F (4, 68) = 4.79, p < .01. Univariate analyses indicated significant differences between BD

Discussion

The possibility of identifiable subtypes or meaningful variants of early onset depression was supported by study findings. Family psychiatric history differentiated groups of MDD adolescents defined by the presence or absence of severe disinhibitory behavioral disturbance. Higher prevalences of drug use disorders and antisocial personality disorder were evident in the first and second degree relatives of MDD adolescents with disinhibitory behavioral disturbance. In addition, a higher prevalence

Acknowledgements

This study was supported by a grant from the American Foundation for Suicide Prevention. The assistance of Diane Koram, Steven Katz, Sarah DeGue, Katherine Bailey, David Mustalish, Jodi Kleinman, and Phillip Walker with data collection and data entry is gratefully acknowledged.

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