Research reportMental health outcome of long-term and episodic adolescent depression: 15-year follow-up of a community sample
Introduction
It is widely documented that adolescent depression is associated with continued mental health problems in early adulthood. Both clinical and population-based studies have shown that depressed adolescents are more likely than their non-depressed peers to subsequently have depression, as well as non-mood disorders (Fergusson and Woodward, 2002, Harrington et al., 1990, Lewinsohn et al., 1999, Rao et al., 1995). In the Oregon Adolescent Depression Project, a large scale population-based follow-up of adolescent depression, 45% of the adolescents with MD reported at least one recurrent episode in early adulthood (age 19–24 years), while 33% reported a non-mood disorder and 62% reported any axis I diagnosis (Lewinsohn et al., 1999). Although this implies substantial continuity, it also illustrates that a large proportion of depressed adolescents appears to not have significant mental health problems in early adulthood—an impression that is reinforced by other follow-ups of clinical and population-based samples (Fergusson and Woodward, 2002, Harrington et al., 1990, Rao et al., 1995). This underlines the importance of identifying factors that can predict continued mental health problems following adolescent depression.
Recent studies have indicated that the persistence of adolescent depressive symptoms is predictive of subsequent mental health. A forty-year follow-up of the 1946 British birth cohort showed that adolescents with internalizing disorders at both age 13 and 15 were more likely than healthy adolescents to have adult mental disorders and to be treated for mental disorders in adulthood, while this was not the case for adolescents with an internalizing disorder at only one of these time-points (Colman et al., 2007). Similar results are reported from a study in which depressive symptoms were measured at three points in adolescence and young adulthood (Steinhausen et al., 2006). Episodic adolescent depression (high scores at only one of the time-points in adolescence) was not associated with abnormal psychosocial and mental functioning in early adulthood, while persistent high scores throughout the three time-points was. Further, results from the Oregon Adolescent Depression Project suggest that both number of depressive episodes and duration (defined as 9 weeks or more) predicts recurrence of depression in early adulthood (Lewinsohn et al., 2000).
In addition, studies on adult samples have highlighted the relevance of distinguishing between chronic and episodic forms of depression (Klein, 2008). Both clinical and population-based studies have shown that dysthymia and double depression (dysthymia with superimposed MD) in adults have a more protracted course and a higher risk of relapse than episodic MD (Klein et al., 2006, Rhebergen et al., 2009). Further, it has been reported that patients with chronic forms of depression have greater suicidality and receive more treatment (Klein et al., 2000). Comorbidity with non-mood disorders has also been reported to be more common in chronic forms of depression (Holm-Denoma et al., 2006, Rhebergen et al., 2009), as has somatic problems and role-impairment (Angst et al., 2009).
Thus, it seems that the duration of depression could have a major impact on the continued course. A long duration of depression in adolescence, a period of rapid mental development and acquisition of knowledge and social skills, might be particularly devastating to future mental health. However, covariates of long-term depression might also have an influence on the continued course; chronic forms of depression have been reported to differ from episodic depression on a number of clinically and etiologically important variables, such as family history of depression, high level of neuroticism, early adversities, and comorbid mental disorders (Angst et al., in press, Klein, 2008, Klein et al., 2009). In addition, the severity of a depressive episode has been reported to be predictive of recurrence and relapse (Klein, 2008).
A recent three-year follow-up of adults with dysthymia, double depression, and episodic MD, suggests that factors such as family history, childhood adversities, neuroticism, and comorbidity do not account for the difference in the natural course of chronic and non-chronic forms of depression (Rhebergen et al., 2009). To what extent this might be true also for adolescents has not yet been extensively studied. Investigation of the mental health outcome of adolescents with long-term MD and episodic MD, while taking potential confounders into account, could clarify this issue.
The general aim of this study was to investigate adult mental health outcome of adolescent depression. First, we intended to explore the outcome of subgroups of adolescent depression and non-depressed peers; we expected that longstanding adolescent depression in particular, both long-term MD and dysthymia, would predict a broad range of mental health problems in adulthood. Second, we hypothesized that the continued mental health problems would be more persistent, pervasive and severe in adolescents with long-term MD as compared to those with episodic MD. Third, we hypothesized that the difference in outcome between adolescents with long-term MD and episodic MD would remain after adjustment for clinically and etiologically relevant factors, such as severity of the adolescent depression, family-related adversities, trait anxiety, and comorbid mental disorders with an early onset.
Section snippets
Study population and procedure
The present study followed-up an investigation of adolescent depression, carried out in 1991–93 in the Swedish university town of Uppsala. In the original investigation (Olsson and von Knorring, 1999), all first-year students in upper secondary school (16–17 years old) were asked to participate. School dropouts of the same age group were also invited. Out of a total of 2465 adolescents in the age group, 2300 (93%) participated in a screening with two self-evaluations of depression, the Beck
Baseline characteristics
All subgroups of adolescent depression differed from the non-depressed group regarding adolescent mental health problems and family-related adversities. The difference was most pronounced for the subgroup with long-term MD, and less pronounced for the dysthymia and subthreshold groups. The adolescents with long-term MD were more likely than the adolescents with episodic MD to report physical abuse, large conflicts with parents, disruptive disorder, childhood anxiety disorder, and a high level
Discussion
The results of the present study, in which we followed-up a community sample of adolescents with depression, are clearly in line with the growing literature on the unfavourable course of chronic/long-term depression (Colman et al., 2007, Klein et al., 2006, Rhebergen et al., 2009, Steinhausen et al., 2006). Long-term MD in adolescence proved to be a powerful predictor of a broad range of adult mental health problems. Not only were the adolescents with long-term MD more likely than peers with
Role of funding sources
Funding for this study was provided by the Swedish Council for Working Life and Social Research (FAS), the Märta and Nicke Nasvell Foundation, and the Foundation in Memory of Professor Bror Gadelius; neither of these had any role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Conflicts of interest
All authors declare that they have no conflicts of interest.
Acknowledgement
We thank Ylva Lindborg, Melina Johansson, and Iman Alaie, who all conducted a large proportion of the diagnostic interviews. We also thank Hans Arinell for statistical support.
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