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Diurnal cortisol profiles and evening cortisol in post-pubertal adolescents scoring high on the Children's Depression Inventory

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Summary

Early-onset mood disorders have become a significant public health problem in recent years. The Children's Depression Inventory (CDI) is a commonly used self-report measure. We studied the relation of CDI cut-offs to biological markers of depression such as the diurnal cortisol rhythm and evening cortisol. In 58 post-pubertal adolescents (29 boys and 29 girls, Mage = 15.1 years), the diurnal cortisol profile was derived from three saliva samples, collected at awakening, at noon and in the evening on a week-end day. Longitudinal repeated measurements regression revealed that the group with CDI > 18 (high depressive symptoms) clearly had a higher and flatter diurnal rhythm with elevated evening cortisol compared to either the group with CDI between 13 and 18 (moderate depressive symptoms) or CDI < 13 (low depressive symptoms). Multinomial logistic regression indicated that evening cortisol was useful in classifying the adolescents in the high depressive symptoms group, while awakening and noon cortisol were not. Our results indicate that the type of high flattened profiles sometimes seen in individuals who are clinically depressed according to diagnostic interviews can also be identified with a self-report inventory, at high levels of symptom reporting. Given the complexity of conducting diagnostic interviews, this result bears clinical relevance.

Introduction

Early-onset mood disorders have become a significant public health problem in recent years. Miller (2007) reviewed epidemiological studies involving more than 2500 youngsters and concluded that approximately 2% of young children, 4% of young adolescents and 16% of older adolescents suffer from a major depressive disorder each year. Early-onset depression is a serious burden for an individual's health for the following reasons: (a) the functional problems of depressed youngsters suggest that the disorder can interfere with developmental milestones; (b) these individuals are likely to show symptoms of anxiety and to develop additional co-morbid disorders such as conduct disorders or substance abuse; (c) early-onset depression may persist into adulthood. Therefore, it is clear that the early recognition of mood disorders should be a priority in primary health care (Hyman, 2001) and that more research on depression prevention and intervention is needed (Kovacs, 2006, Adam et al., 2008). Although clinical interviews are obligatory to diagnose depression, in primary health care and research settings other sound yet less complex and time-consuming instruments are often used. The Children's Depression Inventory (Kovacs, 1992), containing 27 items scored from 0 to 2, is a commonly used self-report measure. As an index of severity of depressive symptoms, a cut-off score of 19 has been found to identify major depressive disorder/clinically depressed children and adolescents, whereas levels between 13 and 18 are regarded as a subclinical or minor depressive episode (Kovacs, 1992).

The usefulness of the CDI (and its cut-off scores) has not been studied in relation to important, non-invasive biological markers of depression such as cortisol assessed with saliva samples; our current study is a preliminary investigation of this issue. For example, depression in adolescent outpatients has been associated with a high, flattened diurnal profile (with elevated afternoon/evening cortisol and awakening levels that may be somewhat lower; Shirtcliff and Essex, 2008) or with elevated evening (peri-sleep-onset) cortisol levels (e.g., Dahl et al., 1991, Goodyer et al., 2001, Kaufman and Charney, 2001, Forbes et al., 2006). Our aims were to examine: (1) the association between the degree of depressive symptomatology (i.e., CDI < 13; CDI between 13 and 18 and CDI > 18) and the diurnal cortisol profile, i.e., whether and in what way the CDI can detect a high flattened diurnal cortisol profile (2) the relative importance of awakening, noon and/or evening cortisol in classifying adolescents into the CDI groups.

Section snippets

Participants

The current study involves 58 participants (29 boys and 29 girls, Mage = 15.1 years, S.D. = .26 years; range = 14.5–15.5), whose mothers were recruited during pregnancy in a prospective follow-up study on the association between maternal anxiety during pregnancy and offspring development (Van den Bergh et al., 2008). Most of them had reached Tanner stage four of pubertal development (M = 4.13; S.D. = .526). The local ethical committee approved the study and we obtained informed consent from all

Aim 1

Fig. 1 shows the average cortisol profiles for the three CDI groups. The 95% confidence intervals were obtained using the bias-corrected bootstrap method using 1000 bootstrap samples to account for skewness and to ensure non-negative intervals (Efron and Tibshirani, 1993). The profile for HDSG (n = 5; n = 4 females) was flatter and higher than the profiles for MDSG (n = 8; n = 4 females) or LDSG (n = 45; n = 21 females). The LRM (see Table 1) revealed that the log-transformed cortisol level decreased

Discussion

The results regarding our two aims suggest that: (1) there is an association between the degree of depressive symptomatology and the diurnal coritosl profile: adolescents with a CDI > 18 showed a high, flattened cortisol profile; (2) evening cortisol is useful in identifying adolescents with CDI > 18 while morning and noon cortisol are not.

Depression has been linked with changes in the activity of the hypothalamus–pituitary–adrenocortical (HPA)-axis activity and several lines of evidence indicate

Role of funding source

Funding for this study was provided by Grant n° G.0211.03 of the Fund for Scientific Research—Flanders (Belgium), and by grants IMPH/06/GHW and IDO 05/010 EGFMRI of Katholieke Universiteit Leuven (K.U. Leuven). None of these organisations had a further role in the study design, in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

None of the authors has a potential conflict of interest.

Acknowledgement

Ben Van Calster is postdoctoral researcher of the Research Foundation - Flanders (FWO). We are very grateful to the adolescents who took part in this study.

References (17)

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