Determinants of Depression in Recent Onset Pediatric Inflammatory Bowel Disease PATRICK BURKE , M.B. , B.C.H ., PH.D. , SAMUEL A. KOCOSHIS , M.D. , RAMAMURTI CHANDRA, M.D. , MARGARET WHITEWAY , R.N ., B.S . , AND JENNIFER SAUER , B.A .
Abstract. Thirteen children with new-onset inflammatory bowel disease were given a Kiddie-SADS-E interview. Three were depressed at diagnosis. Six mothers had a history of depression based on Adult-SADS-L interviews. The depressed children were less severely ill than the nondepressed children and had not required steroids. However, the depressed children had significantly more life events and their families showed more evidence of conflict than did the nondepressed children . J . Am . Acad. Child Adolesc. Psychiatry, 1990,29, 4:608-610. Key Words: depression, inflammatory bowel disease. An increased prevalence of depression has been reported in children with inflammatory bowel disease (IBD). In a cross-sectional study (Burke et al., 1989a), children with Crohn' s disease had a higher lifetime prevalence of major depression than children with cystic fibrosis, whereas children with ulcerative colitis had a higher lifetime prevalence of dysthymia than either children with cystic fibrosis or children with Crohn ' s disease. Others have shown that children with Crohn's disease or ulcerative colitis experienced more depressive symptoms than normal controls (Raymer et al. , 1984) or their siblings (Wood et al., 1987). Little is known , however , about the determinants of depression in IBD . In one study (Steinhausen and Kies, 1982), growth retardation , but not duration of illness, was associated with increased risk of psychopathology. Others (Wood et al. , 1987) found that level of psychological functioning was not related to disease duration, activity, severity, or growth failure, but to style of psychological functioning, i.e., the degree to which an individual tended to internalize or externalize problem s was associated with measures of disease activity. There is also evidence (Burke et al., 1989b) that children with Crohn' s disease whose mothers had a history of depression were more likely to become depressed than were children whose mothers did not have a history of depression. While stress has been implicated in the onset of IBD and relapses in adults (Gerbert, 1980), stress has not been studied in children newly diagnosed with IBD. The present paper reports preliminary findings on depres-
sion in 13 children newly diagnosed with inflammatory bowel disease who were systematically evaluated shortly after diagnosis. The paper addresses the relationship between depression in the children and illness variables, parental psychiatric history, measures of life events, and family relationships.
Subjects Thirteen subjects who presented consecutively to the gastroenterology service of Children's Hospital of Pittsburgh or the private practice of a consulting gastroenterologist were recruited as part of a pilot , prospective, longitudinal study of psychopatholog y in childhood IBD . One additional family declined to participate in the study. The present report represents the data from the initial evaluation. There were eight subjects with Crohn's disease and five with ulcerative colitis. The mean age of the sample was 12 .28 years, SD = 3.2 1. There were six boys and seven girls. Median duration of illness was 11 months , and the range was 1 to 48 months. Method All subjects and their parents gave informed consent or assent (children under 12 years of age) before entry into the study. The psychiatric evaluation of the child consisted of the Kiddie-SADS-E (the Kiddie Schedule for Affective Disorders and Schizophrenia , Epidemiologic Version) interview (Orvashel et al., 1982), a semistructured interview given first to the parent and then to the child. Mothers were interviewed about their own history using the A-SADS-L (Adult Schedule for Affective Disorders and Schizophrenia, Lifetime Version) interview (Endicott and Spitzer, 1978). Subjects and their mothers also completed the Family Relationship Index Scale (FRI) (Moos and Moos, 1981). The FRI yields measures of cohesion , conflict, and expre ssion in the family. Mothers additionally completed the Family Inventory of Life Events (FILE) (McCubbin et al. , 1981) that gives a score for life events in the preceding year (current total) and a total lifetime score (historical total). Severity of IBD was rated independently by the child's gastroenterologist using the Lloyd-Still and Green (1978) scale. The scale gives a total score that is inversely related to severity of illness .
Accepted November 22 , 1989 . Dr. Patrick Burke, Ms . Whiteway, and Ms . Sauer are with the Behavioral Science Division. Children's Hospital of Pittsburgh, and Western Psychiatric Institute and Clinic. University of Pittsburgh. Dr . Kocoshis is with the Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, and Dr. Chandra is with Mercy Hospital of Pittsburgh. This research was supported by a grant fro m the National Foundationfor Ileitis and Colitis. The authors appreciate the support of Drs. Susan Orenstein and Roy Proujansky who provided clinical ratings on their patients. Request reprints fr om Dr. Burke, Children's Hospital ofPittsburgh, One Children's Place, 3705 Fifth Avenue, Pittsburgh. PA 15213-2583. 0890- 8567/90/2904-060 8$02 .0010© 1990by the American Academy of Child and Adolescent Psychiatry.
DEPRESSION IN INFLAMMATORY BOWEL DISEASE TABLE
1. Depression in Children Newly Diagnosed with Inflammatory Bowel Disease Depressed (N
Steroids o Severity IBD (range 1-100) 89* (less severe) Maternal history of depression 3 Life Events Current total (norm 11) 22.7** Historical total (norm 4) 6.3*** Family relationship index (range 1-9) Mother Cohesion 4.3 Conflict 6.3 Expression 5.7 Child Cohesion 6.7 Conflict 4.3 Expression 3.0 Mann Whitney U Test, * p
Not Depressed (N = 10) 7
70 (more severe) 3
6.9 3.2 5.9 7.0 2.9 4.4
= 0.04; ** P = 0.007; *** P = 0.07.
Results Of the 13 subjects (Table 1), three were given a diagnosis of major depression at the time of evaluation. Two of the three depressed subjects had ulcerative colitis, and had been ill for 1 and 2 months, respectively, before ulcerative colitis was diagnosed. Their depression developed concomitantly with the illness. The third depressed child had Crohn's disease and had been ill for 20 months before diagnosis. This child had dysthymia with a superimposed major depression. Three of the 10 nondepressed children had ulcerative colitis and had been ill for 1 to 4 months. The remaining seven children had Crohn's disease and had been ill for 2 to 48 months. The three depressed subjects were among the least severely ill individuals, ranking 10th, 11th, and 12th in severity. Their mean score on the severity of lED scale was 89 out of a possible 100, compared to a mean score of 70 for the 10 nondepressed children (Mann Whitney U, two-, tailed test, U = 3.0; p = 0.04). None of the three depressed subjects were being treated with or had been treated with steroids. However, seven of the 10 children who were not depressed were receiving 25 to 60 mg of prednisone per day. Six mothers had a history of depression. All but one had their first episode of depression at least 1 to 2 years before her child ever became ill. The mothers of all three of the depressed children had a history of depression (Fisher's Exact Test, P = 0.09). As a group, the 13 subjects had a mean number of current life events on the FILE of 9.2 (SD = 8.9) and a mean historical life events score of 3.5 (SD = 3.1). The corresponding norms for the FILE are 11 (SD = 6.0) and 4 (SD = 3.0). The three depressed children had the highest life J.Am.Acad. Child Adolesc.Psychiatry, 29:4, July 1990
events scores, with a mean current total of 22.67 (SD = 9.5), compared to a mean of 6.1 (SD = 3.9) for the nondepressed subjects (Mann Whitney U, two-tail test, U = 0.0, P = 0.007). The depressed children also had a higher historical life events score than the nondepressed children of6.3(SD = 3.7)versus2.7(SD = 2.5) (Mann Whitney U, two-tailed test, U = 4.5, P = 0.07). Examination of the subscales of the FILE that were evaluated showed that many of the stresses were intrafamiliaI. Mothers of the depressed children rated their family relationships as low in cohesion and high in conflict, in contrast to mothers of the nondepressed children who rated their families as high in cohesion and low in conflict. The depressed and nondepressed children rated their families as high in cohesion, but the depressed children also rated their families as high in conflict.
Discussion The present results confirm previous reports of increased depression in children with lED (Raymer et al., 1984; Wood et al., 1987; Burke et al., 1989a). The results also confirm previous cross-sectional data (Burke et al., 1989b) showing a high lifetime prevalence of depression in mothers of children with inflammatory bowel disease, and confirm that the onset of the mother's depression may precede the child's illness by a considerable period and, thus, is not a reaction to the child's illness. The results additionally suggest that two key variables, steroid use and severity of illness, which might be expected to be positively correlated with depression, are not related to the development of depression, at least at the onset of lED. Previous cross-sectional studies of adults (McKegney et al., 1970; Whybrow and Ferrell, 1973; Helzer et al., 1982) and children (Steinhausen and Kies, 1982; Wood et al., 1987) yield mixed conclusions regarding the correlation of either severity of illness or steroid treatment with psychopathology. Cross-sectional studies, however, are confounded by methodological difficulties in correlating past episodes of psychopathology with measures of disease activity, disease severity, or steroids. The present results suggest that life events are not related to the onset of inflammatory bowel disease, since the group scores were the same as the norm score for the scale used. Life events, however, were significantly related to the development of depression. This finding is consistent with a large body of research that suggests that stressful events can precipitate depression (Lloyd, 1980). Examination of the subscales of the FILE that were elevated suggested that the stresses were intrafamilial. The scores from the PRI showing low cohesion and high conflict in the family relationships of the children, who were depressed at the time of presentation, complement the findings on life events. These findings on life events, family relationships, and maternal psychiatric history are consistent with studies of depression in physically well children (Angold, 1988), and suggest that depression in children newly diagnosed with lED is at least partly the outcome of the interaction of social factors and familial predisposition to depression. Follow-up of these subjects may show that the relative 609
BURKE ET A L.
influence of parental psychiatric history, disease variables, life events, and family relationships , as determinants of depression, will change over the course of the illness. The present report is obviously limited by the small sample size. However, the results are internally consistent in that the depressed children all scored similarly high or low on all parameters tested , and their mean scores were not determined by one particularl y discrepant result. The results suggest that children with lED are at significant risk for depression as early as the time of diagnosis. Careful psychiatric and psychosocial screening of children with lED and their families is warranted as are additional studies to examine the influence of depression and treatment of depression on the course and outcome of lED.
References Angold, A. (1988), Childhood and adolescent depression. Br. J . Psychiatry. 152:601-617. Burke, P. M., Meyer, V. , Kocoshis, S. A. et al. (1989a), Depression and anxiety in pediatric inflammatory bowel disease. J . Am. Acad. Child Adolesc. Psychiatry, 28:948--951. - - Kocoshis, S. A. & Orenstein, D. M. (1989b), Depression and anxiety in pediatricchronic illness. Psychosomatic Medicine, 51:261. Endicott, J. & Spitzer, R. L. (1978), A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch. Gen . Psychiatry. 35:837- 844. Gerbert, B. (1980), Psychological aspects of Crohn's disease. J . Behav, Med .• 3:4 1- 58. Helzer, J. E. , Chammas, S., Norland, C. C., Stillings, W. A. &
Alpers, D. H. (1984), A study of the association between Crohn's disease and psychiatric illness. Gastroenterology, 86:324-330 . --Stillings, W. A., Chammas, S., Norland, C. C. & Alpers, D. H. (1982), A controlled study of the association between ulcerative colitis and psychiatric diagnosis. Dig. Dis. Sci., 27:513-518 . Lloyd, C. (1980), Life events and depressive disorder reviewed. Arch. Gen. Psychiatry. 37:541-54 8. Lloyd-Still, J. D. & Green, D. C. (1978), A clinical scoring system for chronic inflammatory bowel disease in children. Dig. Dis . Sci .• 24:620-624 . McCubbin, H. , Patterson, J. & Wilson, L. (1981), Family Inventory of Life Events and Changes (FILE). St. Paul, MN: University of Minnesota, Family Social Science. McKegney, F. P., Gordon, R. O. & Levine, S. M. (1970), A psychosomatic comparison of patients with ulcerative colitis and Crohn's disease. Psychosom . Med., 32:153-166. Moos, R. & Moos, B. (1981), Manual f or the Family Environment Scale. Palo Alto, CA: Consulting Psychologists Press. Orvaschel, H. , Puig-Antich, J. , Chambers, W. et al.(1982) , Retrospective assessment of prepubertal major depression with KiddieSADS-E. J. Am . Acad. Child Psychiatry. 4:392-397. Raymer, J. , Weininger, O. & Hamilton , J. R. (1984), Psychological problems in children with abdominal pain. Lancet , 1:439-440 . Steinhausen, H. & Kies, H. (1982), Comparative studies of ulcerative colitis and Crohn' s disease in children and adolescents. J . Child Psychol. Psychiatry. 23:33-42. Whybrow, P.C. & Ferrell, R. S. (1973), Psychic factors and Crohn's disease: an overview. In: Emotional Factors in Gastrointestinal Illness. ed. A. E. Lindner. New York: American Elsevier, pp. 8298. Wood, B., Watkins, J . B., Boyle, J. T., Nogueira, J. Zimand, E. & Carroll, L. (1987), Psychologicalfunctioning in children with Crohn's disease and ulcerative colitis: implications for models of psychobiological interaction. J . Am. Acad. Child Adolesc. Psychiatry. 26:774-781.
l .Am.Acad. Child Adolesc. Psychiatry, 29:4.luly 1990