Elsevier

Journal of Affective Disorders

Volume 238, 1 October 2018, Pages 513-521
Journal of Affective Disorders

Prevalence of Childhood Affective disorders in Turkey: An epidemiological study

https://doi.org/10.1016/j.jad.2018.05.014Get rights and content

Highlights

  • Affective disorders are the third most common mental health condition in children and adolescents.

  • Major depressive disorder is the most common affective disorder among Turkish children in this nationwide epidemiological study.

  • There are no statistically significant gender differences for depression in pre-adolescent children.

  • Maternal depression and parental physical disease interventions are important in the prevention of depression in children.

Abstract

Aim: To determine the prevalence of affective disorders in Turkey among a representative sample of Turkish population.

Methods: This study was conducted as a part of the “The Epidemiology of Childhood Psychopathology in Turkey” (EPICPAT-T) Study, which was designed by the Turkish Association of Child and Adolescent Mental Health. The inclusion criterion was being a student between the second and fourth grades in the schools assigned as study centers. The assessment tools used were the K-SADS-PL, and a sociodemographic form that was designed by the authors. Impairment was assessed via a 3 point-Likert type scale independently rated by a parent and a teacher.

Results: A total of 5842 participants were included in the analyses. The prevalence of affective disorders was 2.5 % without considering impairment and 1.6 % when impairment was taken into account. In our sample, the diagnosis of bipolar disorder was lacking, thus depressive disorders constituted all the cases. Among depressive disorders with impairment, major depressive disorder (MDD) (prevalence of 1.06%) was the most common, followed by dysthymia (prevalence of 0.2%), adjustment disorder with depressive features (prevalence of 0.17%), and depressive disorder-NOS (prevalence of 0.14%). There were no statistically significant gender differences for depression. Maternal psychopathology and paternal physical illness were predictors of affective disorders with pervasive impairment.

Conclusion: MDD was the most common depressive disorder among Turkish children in this nationwide epidemiological study. This highlights the severe nature of depression and the importance of early interventions. Populations with maternal psychopathology and paternal physical illness may be the most appropriate targets for interventions to prevent and treat depression in children and adolescents.

Introduction

The majority of the mental disorders have their age of onset in childhood or adolescence. Because of the fact that the early interventions delay or prevent onset (Catalano et al., 2012, Thapar et al., 2012) of many of the mental disorders, the number of studies on the prevalence of mental disorders in children in the general population has significantly increased over the last several years (Achenbach et al., 2012, Rescorla et al., 2012).  Nevertheless, compared with the increasing number of youth in the general population, little is known about the prevalence of mental disorders among children and adolescents.

One of the latest epidemiologic studies of child psychopathology pointed out that almost 20% to 49% of children and adolescents suffer from some form of psychiatric disorders (Kieling et al., 2011). Among these, with a prevalence of 14%, affective disorders, especially depression, constitute the third most common mental health condition in children and adolescents (Merikangas et al., 2009).

In a meta-analytic study, data of 41 studies from 27 countries were evaluated, a meta-regression analysis was performed to estimate the effect of population, and  the worldwide-pooled prevalence of any depressive disorder was found to be 2.6% (95% CI 1.7–3.9) (Polanczyk et al., 2015). In a meta-analytic study by Bronsard et al. (2016), where data from eight studies in the child welfare system, including 3104 subjects, were evaluated, the estimated prevalence of any depressive disorder ranged from 3% to 38%. Subsequent analyses revealed that the prevalence of major depressive disorder (MDD) estimates ranged from 1% to 23% (Bronsard et al., 2016). In a recent study from Cyprus, 439 school children from 15 public elementary schools were assessed, and it was found that 10.25% of school children reported clinical depressive symptoms (Sokratis et al., 2017). In another study, the prevalence of depressive disorder in school-age children was reported to be 3.13%, with 0.81% MDD, 1.51% dysthymia and 0.81% depressive disorder not otherwise specified (NOS) (Sarkar et al., 2012). On the other hand, prevalence studies of mood disorders have been limited in Turkey. Toros et al. (2004) reported the prevalence rate of depression to be 12.5% in an adolescent school population. The prevalence of depressive disorder in children and adolescents was 4.2% in urban population sample (Demir et al., 2011). In the same study, the prevalence rates of dysthymic disorder and depressive disorder NOS were 1.75% and 0.60%, respectively. Another study including 417 children 6–14 years of age revealed that the prevalence of MDD, was 2.9% without considering impairment and was 1.4% if impairment was considered (Bilac et al., 2014). In addition, when impairment was taken into account, the prevalence of mood disorders was 2.6% in girls and 0.4% in boys. However, a large body of evidence indicates that underdiagnoses and undertreatment are major public health problems for depression in child populations all around the world (Merikangas et al., 2013, Morris et al., 2011).

There are several risk factors for affective disorders, such as low socioeconomic status and the presence of psychiatric disorders (including depression) among parents. About 40% of the depressed children have a family history of psychiatric disorders (Beardslee et al., 1993). Also, age has been identified as an essential correlate of affective disorders (Grey et al., 2002, Kryspin-Exner and Felnhofer, 2012). Many studies have shown that prevalence rates of depressive disorders were higher in adolescents than in preadolescents. A large-scale European epidemiological study assessing approximately 12,000 adolescents from 11 countries estimated the prevalence of depression was 10.5%, and subthreshold depression 29.2% (Balazs et al., 2013). On the other hand, one-year prevalence of MDD in pre-pubertal-age children was reported to be between 1.4% and 3.4% (e.g. Merikangas et al., 2009, Vicente et al., 2012). Gender has also been identified as an-other correlate of affective disorders. Depressive disorder was more prevalent among adolescent girls than boys (e.g. Grey et al., 2002, Kryspin-Exner and Felnhofer, 2012, Toros et al., 2004).

Comorbidity in child populations is one of the factors that have an impact on chronicity and concomitant economic costs to society. Commonly reported comorbid conditions were anxiety disorders, conduct/oppositional defiant disorders and attention deficit hyperactivity disorder (ADHD) in children with MDD, anxiety disorders being the most common comorbidity (Harpold et al., 2005). Studies also indicated higher comorbid rates with ADHD (Turgay and Ansari, 2006).

A basic principle of epidemiology is that the treatment and prevention depend on etiological factors. For example, depression is the second leading cause of disability worldwide, but little is known about its etiology (Mathers and Loncar, 2006). With its high rates of chronicity and concomitant economic costs to society, depression ranges among the most prevalent mental disorders. Also, children and adolescents with MDD are at greater risk for suicide and are more likely to initiate alcohol and other drug use than children and adolescents without MDD (Nock et al., 2013, SAMHSA, 2014), and the majority of children and adolescents with MDD do not have diagnoses or receive depression care (Cummings et al., 2014). In addition, it is known that several trials have succeeded in demonstrating the beneficial effects of early depression prevention programs for otherwise healthy children and adolescents (Cummings et al., 2014, Kieling et al., 2011, Mathers and Loncar, 2006, Polanczyk et al., 2015). On this point, childhood seems to be a window of opportunity for prevention of mental, emotional, and behavioural disorders. Effective mental health strategies for the prevention and detection of depression depend on an initially accurate estimate of affective disorders in the target population.

Multi-center epidemiological studies are very important for determination of the prevalence, epidemiological factors and effective mental health strategies for the prevention and detection of affective disorders in children. There were no multi-center epidemiological studies assessing these epidemiological parameters in pre-pubertal children. Pre-pubertal period is a critical developmental period of which, many of the affective disorders have their onset, if we can detect at the initial phase of the affective disorder, we can treat it more effectively

The aim of this study is to define the epidemiological correlates of affective disorders as a part of the “The Epidemiology of Childhood Psychopathology in Turkey” (EPICPAT-T). When combined with the results of recent national and international epidemiological studies of affective disorders in children (e.g., Achenbach et al., 2012, Demir et al., 2011, Rescorla et al., 2012), these data will provide a valuable empirical basis for the development of health policies.

Section snippets

Methods

This study is a part of the “The Epidemiology of Childhood Psychopathology in Turkey” (EPICPAT-T) Study. The study was planned by the Turkish Association of Child and Adolescent Mental Health to evaluate the prevalence of psychopathology among primary school students in Turkey for the 2014-2015 academic year. The data of the study was obtained by the authors in 31 study centers from 7 geographical regions. Every center had a coordinator (See “The Epidemiology of Childhood Psychopathology in

Data collection tools

  • 1.

    Sociodemographic Form

The sociodemographic form was developed by the study coordinators and included questions on parental education and vocation, physical/mental illnesses in the family, and identifying information on sampled offspring.

  • 2.

    Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children- Present and Lifetime Version (K-SADS-PL)

This is a semi-structured interview developed by Kaufman and colleagues (1997) to evaluate present and lifetime psychopathology in children

Statistical analyses

The data were entered into a database prepared with SPSS for WindowsTM version 22.0 (IBM Inc.). Sociodemographic variables were entered along with dummy variables for diagnoses according to K-SADS-PL. Impairments and DSM-IV-Based Screening Scale for Disruptive Behavior Disorders in Children and Adolescents scores were entered as Likert scales. Unconditional ICCC (intra-cluster correlation) showed that county-level variables explained 3.5% of the variance for any psychopathology with impairment

Results

  • a)

    Descriptive features of the cases with affective disorders:

In the present study, the final sample included 5842 children (51.7% male). The mean ages of children, mothers, and fathers were 8.7 (S.D. = 1.2), 35.3 (S.D. = 5.5), and 39.3 (S.D. = 6.5) years, respectively. Mean ages of children and their mothers and fathers with mood disorders with impairment were 8.9 (S.D. = 1.2), 34.3 (S.D. = 6.0), and 38.8 (S.D. = 5.8) years, respectively. The corresponding ages for those without mood disorders

Discussion

The present study is the first multi-center epidemiological study using a semi-structured interview for the diagnosis of affective disorders in children in Turkey. This study is a part of the “The Epidemiology of Childhood Psychopathology in Turkey” (EPICPAT-T) Study. We found out that the prevalence of any affective disorder was 2.5% without considering impairment and 1.6% when impairment was considered. In our sample, the diagnosis of BP was lacking, thus depressive disorders constituted all

Limitations

Our findings should be taken into consideration in the light of the study's major limitation, which is the age range. Besides being a nationwide sample, the participants were within an age range of 8 to 10 years. Since it limits us to generalize our findings into different developmental stages, studies including adolescents are warranted. Follow-up studies should be done in order to increase our knowledge about the epidemiology of affective disorders in children and adolescents.

Conclusion

Major depressive disorder was the most common depressive disorder among Turkish children in this nationwide epidemiological study. This highlights the severe nature of depression and the importance of early interventions. Populations with maternal psychopathology and paternal physical illness may be the most appropriate targets for interventions to prevent and treat depression in children and adolescents.

Role of funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgments

We are grateful to all the children and their parents and teachers who participated in the study.

Author Statement Contributors

All of the authors participating in the study have contributed to the manuscript and approved the final version of the manuscript.

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