Maternal and paternal psychosocial risk factors for clinical depression in a Norwegian community sample of adolescents
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T. AGERUP, S. LYDERSEN, J. WALLANDER, A. M. SUND
Agerup T, Lydersen S, Wallander J, Sund AM. Maternal and paternal psychosocial risk factors for clinical depression in a Norwegian community sample of adolescents. Nord J Psychiatry 2015;69:35–41. Background: Parental characteristics can increase the risk of the development of adolescent depression. In this study, we focus on the parental factors of parents in a non-intact relationship, dissatisfaction with personal economy, physical illness or disability, and internalizing and externalizing problems. The aim is to examine which of these parental risk factors, separately for mothers and fathers, are associated with clinical depression in adolescents in a community sample. Methods: In the Youth and Mental Health study, 345 adolescents (mean age ⫾ standard deviation 15.0 ⫾ 0.6 years, range 13.8–16.6 years; 72.5% girls) and their parents (79% at least one parent) completed questionnaires and the diagnostic interview KiddieSchedule for Affective Disorders and Schizophrenia—Present and Lifetime version (K-SADS-PL). Adolescents were classified into current major depressive disorder or dysthymia (n ⫽ 46), depression not otherwise specified (n ⫽ 48), or no depression (n ⫽ 251). The parental risk factors were based on interview and the Adult Self-Report. Risk factors associated with mothers (n ⫽ 267) and fathers (n ⫽ 167) were separately analyzed using ordinal logistic regression with current depression category as the dependent variable. All analyses were adjusted for youth sex and age. Results: Mothers’ economical dissatisfaction, physical illness/ disability, internalizing problems and externalizing problems were associated with adolescent current depression (P ⱕ 0.02). Adjusting for all other factors, only mothers’ internalizing problems (P ⬍ 0.001) remained significantly associated with adolescent depression. Fathers’ risk factors were not associated with adolescent depression. Conclusion: Characteristics of mothers are associated with adolescent current depression. Mothers’ internalizing problems is independently strongly associated with increased risk of current adolescent depression. Clinicians should assess mothers’ mental health when treating depressed adolescents. • Adolescent, Depression, Parental, Risk factors. Tea Agerup, Norwegian University of Science and Technology, The Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), PO Box 8905, MTFS, N-7491 Trondheim, Norway, E-mail: [email protected]; Accepted 23 April 2014.
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arental characteristics can contribute towards the development of problems such as depression in adolescents (1–4). However, it is not sufficiently understood whether mothers and fathers contribute the same risk factors, and whether the risk associated with maternal and paternal factors vary depending on the sex of the adolescent. Improved knowledge about potentially differential risk factors due to sex of parent and adolescent can inform more targeted intervention for clinical depression in young people. The prevalence of depression through adolescence is estimated at 5.8% (5), with a sharp rise after puberty (6). The Diagnostic and Statistical Manual IV includes three categories of depression (7):
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major depressive disorder (MDD), dysthymia and depressive disorder not otherwise specified (NOS). However, most studies on adolescents with clinical depression have focused on MDD (8, 9), and few have addressed milder forms of depression (10–12). Given the centrality of parents in both normative and atypical development, there is a need to further examine parental factors that may be associated with adolescent depression. Little research has included both parents when examining risk factors for adolescent depression. Therefore we conduct secondary analysis of a set of parental risk factors for adolescent depression that were measured in both mothers and fathers in the Youth and DOI: 10.3109/08039488.2014.919021
T AGERUP ET AL.
Mental Health Study (10), including whether biological parents live in an intact relationship, dissatisfaction with economy, somatic illness or disability, and internalizing and externalizing problems.
Parents not living together
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Parental divorce or not living together may be associated with adolescent and childhood depression (4, 13–16) because these conditions can indicate relationship instability and changes in family structure (17). The studies on diagnosed depression find parental divorce a risk factor specifically for MDD (9, 18).
Economic dissatisfaction Findings on the association between depression in childhood and lower socio-economic status (SES) have been inconsistent (2, 19). It may be more fruitful to examine perceived economic circumstances because this reflects economic issues regardless of income, educational level and level of employment. Economic issues in families at all SES levels can be a source of family conflict, marital discord, abuse, anger, hopelessness and depression (20–23). Perceived economic dissatisfaction can provide a nuanced perspective as a risk factor for adolescent depression (24, 25) particularly in a country such as Norway, where objective SES differences in the population are relatively small.
Physical disability Parental physical illness or disability can be regarded as a risk factor because children of parents with, for example, multiple sclerosis (26), cancer (3), brain injury (27) and chronic pain (28) have been found to have more emotional problems including depressive symptoms. However, these studies have not represented fathers well nor addressed clinical depression in the children.
Parental mental health Parental depression is one of the most influential risk factors for adolescent depression (6), and even more so when both parents report poor mental health (29). In addition, children of parents with comorbid psychiatric disorders and depressive disorder had higher levels of depressive symptoms than children of parents with only depression (1, 30, 31). There is a need for a broader perspective on mental health as a risk factor for adolescent depression, such as subsumed in the broad-spectrum internalizing and externalizing problems. Parental internalizing problems are clearly implicated in research, whereas the role of externalizing problems has been much less examined. Although both maternal and paternal risk factors could be salient for adolescent depression, previous research has rarely considered both. Furthermore, findings suggesting a differential role of maternal and paternal factors in the
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development of their male and female children (32, 33) point to the need to examine interactions between sex of parent and adolescent pertaining to depression. Finally, there is a need to examine diagnosable depression in adolescents in the community (34), rather than in a clinical setting, to obtain the broadest representation of the manifestations in clinical depression. Therefore, the major aim is to examine the association of hypothesized parental risk factors with the range of diagnosed depression in a community sample of adolescents. We hypothesize that the following parental risk factors are positively associated with clinical depression in adolescents: parents not living together, economical dissatisfaction, physical illness/disability, and internalizing as well as externalizing mental health problems. In addition, because there is an insufficient basis to pose additional hypotheses, we explore 1) whether the effect of these risk factors differs among mothers and fathers and 2) whether this is dependent on the sex of the adolescent.
Method Participants and procedure The Youth and Mental Health Study (10) is a longitudinal study of depressive symptoms and disorders in the population from two counties in Central Norway. The first wave (T1) was conducted in 1998 when a total population of 9292 youths attended public and private schools. A representative sample of 2792 8th and 9th graders from 22 schools was selected, with a clustered sample method using the schools as sampling units, as detailed elsewhere (10). With a response rate of 88.3%, 2464 adolescents (mean age ⫾ standard deviation 13.7 ⫾ 0.5 years), 94.2% with at least one parent born in Norway, completed the Mood and Feelings Questionnaire (MFQ, see below) (35) at T1, and were reassessed 1 year later (1999, mean age 14.9 ⫾ 0.5 years) with the same questionnaire (T2). Attrition rate from T1 to T2 was 4.3%, n ⫽ 2432 at T2. The questionnaires were administered by teachers following provided instructions at school. Both assessments were approved by the Regional Committee for Medical Research Ethics, Central Norway, as well as the local school authorities. Written informed consent, based on the Norwegian Data Inspectorate Standards, was obtained from parents and students prior to the first wave. At T2, only the high MFQ scorers (ⱖ 26), as well as a matched sample selected at random from those with low and middle scores on the MFQ (⬍ 26) continued with the clinical interview phase. There was a match of one low/middle scorer on age and gender for every two high scorers. Of the sample, n ⫽ 345 (72.5% females) completed the clinical interview (36), including 220 with high and 124 with low/middle MFQ scores, and excluding one missing score on the MFQ. A detailed participant NORD J PSYCHIATRY·VOL 69 NO 1·2015
MATERNAL AND PATERNAL RISK FACTORS FOR
flow-chart along with socio-demographics (reported in Table 1) are reported elsewhere (10). The parents of the adolescents in the subset identified in this manner were also invited to complete questionnaires and interviews about both themselves and their adolescent, including 240 mothers and 159 fathers. In 274 cases (79%), at least one parent participated. The parents were first interviewed at the local school by trained clinicians and were given a questionnaire to fill out at home and return by mail.
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Measures ADOLESCENT QUESTIONNAIRE Depressive symptom level was measured by the Mood and Feelings Questionnaire (MFQ), which covers the DSM-III-R criteria for major depression with 34 items. The total score ranges 0–68, with higher scores reflecting a higher symptom level. Studies of psychometric properties of the MFQ indicate an internal consistency of α ⫽ 0.90 and test–retest stability (intra-class correlation) of 0.75 (37, 38). Moreover, in the original study sample, we found internal consistency α ⫽ 0.91 and 2-month test–retest reliability r ⫽ 0.80, and correlation r ⫽ 0.91 with the Beck Depression Inventory (BDI) (39, 40). Validity is supported by the MFQ identifying mood disorders in youth of diverse demographic and clinical characteristics (41). Table 1. Socio-demographics of the interview sample (n ⫽ 345).
Gender Girls Boys Geographics Inner city Suburb Rural–coast Rural–inland Parental SES Professional leader (upper class) Upper middle class Lower middle class Primary industry Manual worker No information Ethnicity Both parents born in Norway One parent born in Norway Both parents born outside Norway Living arrangement Living with both parents Living with mother Living with father With one parent and stepparent Sharing time between parents Living with grandparents/fosterparents
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n
%
250 95
72.5 27.5
66 66 51 162
19.1 19.1 14.8 47.0
33 85 53 27 142 5
9.6 24.6 15.4 7.8 41.2 1.4
316 9 20
91.6 2.6 5.8
221 47 15 47 11 4
64.1 13.6 4.3 13.6 3.2 1.2
DEPRESSION
DIAGNOSTIC INTERVIEW The Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL) (36) was used to assess clinically significant symptoms of psychopathology on Axis I of the DSM-IV. The interviews were conducted by experienced clinicians trained in psychopathology and the use of K-SADS-PL. Detailed descriptions of the blinded interviews and inter-rater reliability have been presented (42). Inter-rater reliability for all K-SADS screening symptoms at the end of training was good [Cohen’s κ ⫽ 0.71 for all and κ ⫽ 0.75 for affective symptoms, utilizing an experienced child psychiatrist as the standard (co-author AMS)]. Interview integrity was maintained at a high level (average κ ⫽ 0.83). Summary symptom scores and diagnostic assessments were based on information obtained from the adolescents and their parents. In this study, the DSM-IV criteria for MDD and dysthymia, as well as the milder diagnosis of depressive disorder NOS (10), were applied. Functional impairment, defined as Children’s Global Assessment Scale (43) score below 71, or reduced function in one of the areas of family, school or friendship, was a requirement for a diagnosis of MDD or dysthymia. Based on previous research indicating that MDD and dysthymia have similar characteristics (44) and to provide an adequate size of the group with relatively more severe depression, MDD (n ⫽ 25) and dysthymia (n ⫽ 9; both diagnoses n ⫽ 12) were pooled for analysis. Thus adolescents were classified into one of three categories: MDD or dysthymia (n ⫽ 46), depression NOS (n ⫽ 48), or no depression (n ⫽ 251). PARENTAL QUESTIONNAIRE The Adult Self-Report (ASR) (45) is a broad assessment of adults’ emotional and behavioral problems based on 114 self-report items. Each problem is rated on a 3-point scale (0 ⫽ not true, 1 ⫽ partly true or sometimes true, 2 ⫽ very/often true). The internalizing problems scale combines anxious/depressed, withdrawn/depressed and somatic complaints syndrome scores (range ⫽ 0–78) and the externalizing problems scale combines rule-breaking behaviors, aggressive behavior and intrusive syndrome scores (range ⫽ 0–70). Analyses were conducted on the raw scale scores. Psychometric properties have been reported to be good for these two scales (45). PARENTAL INTERVIEW Three additional variables were measured based on independent items included in the parental interview: 1) perceived economic satisfaction was reported by the parent on a 5-point scale (1 ⫽ very satisfied, 5 ⫽ very dissatisfied); 2) marital status of the biological parents, which was classified as living together (i.e. married, cohabitating) vs. not (i.e. never married, divorced); 3) long-term physical illness or disability was determined
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as present vs. not based on one item asking about experiencing long-term illness or disability during the last year. Parent socio-economic status (SES) was measured by classifying mothers’ and fathers’ occupations using the ISCO-88 (46) on a 5-point scale ranging from professional leader/upper class to manual worker.
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Statistical analysis With three categories representing the outcome variable (MDD/dysthymia, depression NOS, no depression), we used proportional odds, ordinal logistic regression to study the association with parental risk factors. This treats the outcome as a three-level ordinal variable. The OR in proportional odds logistic regression has the same interpretation as the OR in standard (binary) logistic regression, if a cut-off is made between any two categories of the dependent variable. All analyses were adjusted for the adolescent age as well as sex. The five parental risk factors were examined separately for mothers and fathers. The parental variables were analyzed one at a time as well as simultaneously. We also examined interactions between sex and significant parental risk factors. Two-sided P-values ⬍ 0.05 were considered significant, and 95% confidence intervals (CI) were reported where relevant. Missing values in the regression analyses were handled by multiple imputations (MI) using chained equations, imputing m ⫽ 100 data sets (47) including all variables and interactions to be studied in the analyses, as well as the MFQ score. All analyses were performed using Stata 12 on the 267 cases with data on mothers and the 167 cases with data on fathers.
Results Descriptive statistics are shown in Table 2. The prevalence in the present sample for girls and boys respectively was 16.0% and 6.0% with MDD/dysthymia and 15.6% and 9.5% with depression NOS, leaving 68.4% and 84.0% with no depression. As can be seen in Table 3, when examined independently and adjusted for sex and age of the adolescent, four of the five risk factors for current adolescent depression were significant correlates for mothers: economical dissatisfaction (OR ⫽ 1.60, 95% CI 1.12–2.29, P ⫽ 0.009), physical illness/disability (OR ⫽ 2.05, 95% CI 1.12–3.77, P ⫽ 0.009), internalizing problems (OR ⫽ 1.09, 95% CI 1.05–1.13, P ⫽ 0.001), externalizing problems (OR ⫽ 1.09, 95% CI 1.02–1.16, P ⫽ 0.01) and male sex of the child (OR ⫽ 0.46, 95% CI 0.23–0.93, P ⱕ 0.05). None of the risk factors for fathers was significant. In the multivariable analyses shown in Table 3, when adjusted for sex and age of the adolescent as well as the other risk factors, only mothers’ internalizing problems was a significant correlate of depression in adolescents (OR ⫽ 1.08, 95% CI 1.02–1.14, P ⫽ 0.006). No other risk factors for mothers or fathers were significantly associated with adolescent depression in the multivariable analyses. However, fathers’ economical dissatisfaction and physical illness/disability had approximately the same effect-estimate (OR) when compared with mothers, whereas internalizing and externalizing problems in the father had relatively smaller effect-estimates compared with those in the mother. Yet none of the results for father reached statistical significance. In order to examine
Table 2. Descriptive statistics with 95% CI for participants (n ⫽ 345). MDD∗/dysthymia Mothers Females, n (%)† Males, n (%) Adolescent mean age Parent mean age Parents not living together‡, % 95% CI Econom. diss.§, Mean 95% CI Physical ill./disab.¶, % 95% CI Int. prob.||, Mean 95% CI Ext. prob.∗∗, Mean 95% CI
Fathers
40 (16.0%) 6 (6.3%) 15.1 39.0 43.9 48.0% 39.0% 0.28–0.68 0.16–0.62 2.63 2.41 2.26–3.00 1.93–2.90 35.0% 37.4% 0.17–0.53 0.09–0.66 8.23 8.04 4.64–11.82 4.75–11.33 5.35 5.35 2.82–7.88 2.82–7.88
Depression NOS Mothers
Fathers
39 (15.6%) 9 (9.5%) 15.0 42.8 45.0 37.5% 19.0% 0.20–0.55 0.01–0.36 2.41 2.39 2.15–2.66 2.13–2.66 43.0% 35.0% 0.25–0.60 0.13–0.57 10.16 9.63 5.76–14.57 5.68–13.59 5.58 6.60 2.69–8.46 4.03–9.18
No depression Mothers
Fathers
171 (68.4%) 80 (84.2%) 14.9 40.5 43.5 40.5% 27.0% 0.33–0.48 0.19–0.35 2.22 2.16 2.10–2.33 2.02–2.29 25.5% 24.0% 0.19–0.32 0.15–0.33 6.25 6.42 5.01–7.48 5.24–7.60 4.69 4.75 3.81–5.57 3.89–5.62
Overall Mothers
Fathers
250 (72.5%) 95 (27.5%) 15.0 40.7 43.5 40.9% 27.3% 0.35–0.47 0.20–0.34 2.29 2.22 2.19–2.39 2.10–2.34 29.0% 27.3% 0.23–0.35 0.19–0.35 8.47 7.10 7.48–9.45 6.00–8.20 5.01 5.11 4.46–5.56 4.32–5.90
∗MDD, major depressive disorder. †Rows
from “females, n (%)” to “Parent mean age” are complete case analyses. from “Parents not living together” to “Externalizing problem score” are multiple imputed data analyses. §Economical dissatisfaction. ¶Physical illness or disability. ||Internalizing problem score (range ⫽ 0–78). ∗∗Externalizing problem score (range ⫽ 0–70). ‡Rows
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DEPRESSION
Table 3. Ordinal logistic regression of parental risk factors on adolescent depression.
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Adjusted for sex and age only
Mothers (n ⫽ 267) Male sex of child Age of child Parents sep.∗ Economy diss. Illness/disability.† Intern. probl.‡ Ext. problem.§ Fathers (n ⫽ 186) Male Sex of child Age of child Parents sep.∗ Economy diss. Illness/disability.† Intern. probl.‡ Ext. problem.§
Adjusted for all other variables
OR
Lower CI
Upper CI
P-value
OR
Lower CI
Upper CI
P-value
0.460 1.160 1.065 1.603 2.052 1.089 1.090
0.230 0.730 0.586 1.124 1.117 1.048 1.021
0.930 1.850 1.935 2.288 3.770 1.131 1.164
0.030 0.530 0.836 0.009 0.020 0.000 0.010
0.452 1.113 0.947 1.192 1.377 1.078 0.997
0.214 0.683 0.501 0.800 0.710 1.022 0.912
0.958 1.813 1.795 1.777 2.670 1.137 1.090
0.038 0.668 0.869 0.388 0.344 0.006 0.945
0.410 1.410 1.083 1.422 2.048 1.036 1.038
0.180 0.820 0.485 0.928 0.857 0.996 0.979
0.950 2.440 2.418 2.179 4.889 1.078 1.101
0.038 0.216 0.845 0.106 0.107 0.082 0.212
0.397 1.432 1.033 1.275 1.550 1.016 1.011
0.161 0.809 0.445 0.800 0.524 0.944 0.916
0.975 2.532 2.396 2.032 4.577 1.095 1.116
0.044 0.218 0.941 0.307 0.428 0.663 0.830
OR, odds ratio; CI, confidence interval. Bold OR indicates significance at P ⬍ 0.05. ∗Parents not living together. †Physical illness/disability. ‡Internalizing problems. §Externalizing problems.
whether the risk factors were stronger correlates for girls than boys, we completed the same analyses with the addition of the interaction between the adolescent’s sex and the significant maternal predictor variables of economic dissatisfaction, physical illness/disability, internalizing problems and externalizing problems one at a time. However, none of the interactions was significant (all P-values ⬎ 0.15).
Attrition of parents Twenty-one percent of the parents did not participate in the clinical interview assessment. There was a significant difference (P ⫽ 0.05) in the prevalence of depression diagnosis in the present sample between adolescents whose parents participated in the clinical interview vs. parents who did not. Adolescents with participating parents were more likely to have minor depression (15% vs. 8.5%) and less likely to have major depression (11% vs. 21%). In addition, participating parents were more often in the higher SES categories than not participating parents (P ⬍ 0.01), who were more likely to be in the working class category.
Discussion Mothers’ economical dissatisfaction, physical illness/ disability, internalizing problems and externalizing problems were separately associated with current depression in adolescents. However, only mother’s internalizing problems were uniquely associated with adolescent NORD J PSYCHIATRY·VOL 69 NO 1·2015
depression. Although father’s economical dissatisfaction and physical illness/disability had approximately the same effect-estimate as for mothers, these did not reach statistical significance. There were no differences in these associations between adolescent boys and girls. Mothers who report being anxious/depressed, withdrawn and having somatic complaints are thus at increased risk of having an adolescent with clinical depression. We hypothesize that internalizing problems in mothers may interfere with the quality of parenting (48). Mothers who scored high on internalizing problems may possibly experience depression ranging from sub-clinical to MDD. Maternal depression may be of a particular concern given that the lifetime prevalence of MDD in women is up to three times higher than in men (49). Several other maternal risk factors were associated with adolescent depression in this study, including externalizing problems, economic dissatisfaction and physical illness/disability, yet these associations were diminished when considered jointly with internalizing problems. This may reflect statistical suppression due to multicollinearity among the risk factors. Alternatively, this finding may lead to a hypothesis that the former factors represent relatively more distal influences on the adolescent and the mother’s affective well-being is the more proximal influence. Lastly, these findings, although significant only among mothers, might reflect the strain and anxiety that parents may experience when having a depressed adolescent, facing the passivity, sad mood, school problems and in some cases increased risk of suicide among affected adolescents.
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The strengths of this study include that the adolescents were sampled from a school-based representative sample in a region of Norway. This study attempted to enroll an equal number of fathers and mothers from the subset giving equal opportunity for both parents to participate. Also, the clinical diagnosis of depression was based on a commonly used semi-structured interview (10). Limitations include missing parental data, especially for fathers, which meant that associations had to be stronger to reach significance. A related issue is that the fathers who participated do not perfectly represent the general population of fathers, but are biased towards those who are healthier and more engaged with their families. The attrition of fathers who had the worst risk factors may have weakened the test of paternal risk factors. Although this study set out to collect substantial father data, the difficulty engaging fathers in research is underscored (32, 33, 50–54). The research would have been strengthened with the inclusion of direct measures of parental clinical depression. Additional limitations include examining five risk factors, leaving out other parental factors that may also be important. Some of the parental risk factors were assessed with single items, which may jeopardize their reliability. A relatively small geographical region in Norway served to represent the general population. Furthermore, the study was performed on a selected sample consisting of mainly high-scoring individuals on a depression symptom measure (MFQ), and about 70 medium and 50 low scorers. Adolescents who were diagnosed with no depression in this sample still had mean symptom scores that were higher than the general population (55). Finally, discussion of causality is necessarily limited as with all correlational studies.
Future directions and implications More research is needed on adolescents including both parents, especially fathers, who are under-represented in studies on adolescent depression. We need to know more about how risk factors interact over time and contribute to clinical depression in adolescence and into young adulthood. When a child experiences problems, this may come to the attention of a parent, but also teachers, school nurses or counselors, and medical practitioners. These professionals should be encouraged to consider the mother’s situation when an adolescent is referred. It might not be sufficient only to treat the adolescent with depression if maternal risk factors are present. Our findings suggest it can be important to query the adolescent about the family situation, in particular mothers’ affective state and possibly physical health and economic dissatisfaction. Extending the treatment to include the mother, if indicated, could be more efficient in the long run. When adolescents are insufficiently treated, this necessarily affects their development and preparation for adulthood.
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Role of funding source Research was supported by a grant from the Liaison Committee between the Central Norway Regional Health Authority (RHA) and the Norwegian University of Science and Technology (NTNU) (Samarbeids-organet). Acknowledgement—The valuable contributions and support from the participating adolescents, parents and school staff is gratefully acknowledged. The authors gratefully acknowledge Kyrre Svarva from the IT department of Social and Psychology Studies at the Norwegian University of Science and Technology for his invaluable help with the data files.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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MATERNAL AND PATERNAL RISK FACTORS FOR 18. Nomura Y, Wickramaratne PJ, Warner V, Mufson L, Weissman MM. Family discord, parental depression, and psychopathology in offspring: Ten-year follow-up. J Am Acad Child Adolesc Psychiatry 2002;41:402–9. 19. Melchior M, Chastang JF, Walburg V, Arseneault L, Galera C, Fombonne E. Family income and youths’ symptoms of depression and anxiety: A longitudinal study of the French GAZEL Youth cohort. Depress Anxiety 2010;27:1095–103. 20. Elder GH, Conger RD, Foster EM, Ardelt M. Families under economic pressure. J Family Issues 1992;13:5–37. 21. Falconier MK, Epstein NB. Female-demand/male-withdraw communication in Argentinian couples: A mediating factor between economic strain and relationship distress. Pers Relation 2011;18:586–603. 22. Conger RD, Conger KJ, Elder GH, Jr, Lorenz FO, Simons RL, Whitbeck LB. A family process model of economic hardship and adjustment of early adolescent boys. Child Dev 1992;63:526–41. 23. Tausig M, Fenwick R. Recession and well-being. J Health Soc Behav 1999;40:1–16. 24. Elstad JI, Pedersen AW. The impact of relative poverty on Norwegian adolescents’ subjective health: A causal analysis with propensity score matching. Int J Environ Res Public Health 2012;9:4715–31. 25. Solantaus T, Leinonen J, Punamaki RL. Children’s mental health in times of economic recession: Replication and extension of the family economic stress model in Finland. Dev Psychol 2004;40:412–29. 26. Diareme S, Tsiantis J, Kolaitis G, Ferentinos S, Tsalamanios E, Paliokosta E, et al. Emotional and behavioural difficulties in children of parents with multiple sclerosis: A controlled study in Greece. Eur Child Adolesc Psychiatry 2006;15:309–18. 27. Oppenheim-Gluckman H, Marioni G, Chambry J, Aeschbacher MT, Graindorge C. Personal experience of adolescents with a braininjured parent: Preliminary study. Ann Readapt Med Phys 2005;48: 650–61. 28. Kaasboll J, Lydersen S, Indredavik MS. Psychological symptoms in children of parents with chronic pain—The HUNT study. Pain 2012. 29. Kahn RS, Brandt D, Whitaker RC. Combined effect of mothers’ and fathers’ mental health symptoms on children’s behavioral and emotional well-being. Arch Pediatr Adolesc Med 2004;158:721–9. 30. Williamson DE, Ryan ND, Birmaher B, Dahl RE, Kaufman J, Rao U, et al. A case–control family history study of depression in adolescents. J Am Acad Child Adolesc Psychiatry 1995;34:1596–607. 31. Goldstein RB, Weissman MM, Adams PB, Horwath E, Lish JD, Charney D, et al. Psychiatric disorders in relatives of probands with panic disorder and/or major depression. Arch Gen Psychiatry 1994; 51:383–94. 32. Reeb BT, Conger KJ, Wu EY. Paternal depressive symptoms and adolescent functioning: The moderating effect of gender and father hostility. Fathering 2010;8:131–42. 33. Weitzman M, Rosenthal DG, Liu YH. Paternal depressive symptoms and child behavioral or emotional problems in the United States. Pediatrics 2011;128:1126–34. 34. Dinya E, Csorba J, Grosz Z. Are there temperament differences between major depression and dysthymic disorder in adolescent clinical outpatients? Compr Psychiatry 2012;53:350–4. 35. Angold A, Costello EJ, Pickles EJ, Winder F. The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. London: Medical Research Council; 1987. 36. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 1997;36:980–8. 37. Costello EJ, Angold A. Scales to assess child and adolescent depression: Checklists, screens, and nets. J Am Acad Child Adolesc Psychiatry 1988;27:726–37. 38. Costello EJ, Benjamin R, Angold A, Silver D. Mood variability in adolescents: A study of depressed, nondepressed and comorbid patients. J Affect Disord 1991;23:199–212.
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39. Sund AM, Larsson B, Wichstrom L. Depressive symptoms among young Norwegian adolescents as measured by the Mood and Feelings Questionnaire (MFQ). Eur Child Adolesc Psychiatry 2001;10:222–9. 40. Beck AT. Cognitive therapy of depression: New perspectives. In: Clayton PJB, Barrett JE, editors. Treatment of depression: Old controversies and new approaches. New York: Raven Press; 1983. p. 256–84. 41. Daviss WB, Birmaher B, Melhem NA, Axelson DA, Michaels SM, Brent DA. Criterion validity of the Mood and Feelings Questionnaire for depressive episodes in clinic and non-clinic subjects. J Child Psychol Psychiatry 2006;47:927–34. 42. Nrugham L, Holen A, Sund AM. Associations between attempted suicide, violent life events, depressive symptoms, and resilience in adolescents and young adults. J Nerv Ment Dis 2010;198:131–6. 43. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, et al. A Children’s Global Assessment Scale (CGAS). Arch Gen Psychiatry 1983;40:1228–31. 44. Goodman SH, Schwab-Stone M, Lahey BB, Shaffer D, Jensen PS. Major depression and dysthymia in children and adolescents: Discriminant validity and differential consequences in a community sample. J Am Acad Child Adolesc Psychiatry 2000;39:761–70. 45. Achenbach TM, Rescorla LA. Manual for the ASEBA Adult Forms & Profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth and Families; 2003. 46. ISCO-1988. International Standard Classification of Occupation Geneva; 1990. 47. Carpenter JR, Kenward MG, Multiple imputation and its application, 1st edition. Chichester: John Wiley & Sons; 2013. 48. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: A meta-analytic review. Clin Psychol Rev 2000;20:561–92. 49. Kessler RC, The epidemiology of depression among women. In: Keyes CLM, Goodman SH, editors. Women and depression: A handbook for the social, behavior, and biomedical sciences. New York: Cambridge University Press; 2006. p. 22–40 50. Reeb BT, Conger KJ. The unique effect of paternal depressive symptoms on adolescent functioning: Associations with gender and father-adolescent relationship closeness. J Fam Psychol 2009;23:758–61. 51. Weissman MM, Wickramaratne P, Nomura Y, Warner V, Pilowsky D, Verdeli H. Offspring of depressed parents: 20 years later. AJ Psychiatry 2006;163:1001–8. 52. Ramchandani P, Psychogiou L. Paternal psychiatric disorders and children’s psychosocial development. Lancet 2009;374:646–53. 53. Cassano M, Adrian M, Veits G, Zeman J. The inclusion of fathers in the empirical investigation of child psychopathology: An update. J Clin Child Adolesc Psychol 2006;35:583–9. 54. Kane P, Garber J. The relations among depression in fathers, children’s psychopathology, and father–child conflict: A metaanalysis. Clin Psychol Rev 2004;24:339–60. 55. Sund AM, Larsson B, Wichstrom L. Role of physical and sedentary activities in the development of depressive symptoms in early adolescence. Soc Psychiatry Psychiatr Epidemiol 2011;46: 431–41. T. Agerup, Faculty of Medicine, The Regional Centre for Child and Adolescent Mental Health (RBUP), Norwegian University of Science and Technology (NTNU), Trondheim, Norway. S. Lydersen, Faculty of Medicine, The Regional Centre for Child and Adolescent Mental Health (RBUP), Norwegian University of Science and Technology (NTNU), Trondheim, Norway. J. Wallander, Faculty of Medicine, The Regional Centre for Child and Adolescent Mental Health (RBUP), Norwegian University of Science and Technology (NTNU), Trondheim, Norway, and University of California, Merced, CA, USA. A.M. Sund, Faculty of Medicine, The Regional Centre for Child and Adolescent Mental Health (RBUP), Norwegian University of Science and Technology (NTNU), Trondheim, Norway, St.Olav Hospital, Trondheim, Norway.
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T. AGERUP, S. LYDERSEN, J. WALLANDER, A. M. SUND
Agerup T, Lydersen S, Wallander J, Sund AM. Maternal and paternal psychosocial risk factors for clinical depression in a Norwegian community sample of adolescents. Nord J Psychiatry 2015;69:35–41. Background: Parental characteristics can increase the risk of the development of adolescent depression. In this study, we focus on the parental factors of parents in a non-intact relationship, dissatisfaction with personal economy, physical illness or disability, and internalizing and externalizing problems. The aim is to examine which of these parental risk factors, separately for mothers and fathers, are associated with clinical depression in adolescents in a community sample. Methods: In the Youth and Mental Health study, 345 adolescents (mean age ⫾ standard deviation 15.0 ⫾ 0.6 years, range 13.8–16.6 years; 72.5% girls) and their parents (79% at least one parent) completed questionnaires and the diagnostic interview KiddieSchedule for Affective Disorders and Schizophrenia—Present and Lifetime version (K-SADS-PL). Adolescents were classified into current major depressive disorder or dysthymia (n ⫽ 46), depression not otherwise specified (n ⫽ 48), or no depression (n ⫽ 251). The parental risk factors were based on interview and the Adult Self-Report. Risk factors associated with mothers (n ⫽ 267) and fathers (n ⫽ 167) were separately analyzed using ordinal logistic regression with current depression category as the dependent variable. All analyses were adjusted for youth sex and age. Results: Mothers’ economical dissatisfaction, physical illness/ disability, internalizing problems and externalizing problems were associated with adolescent current depression (P ⱕ 0.02). Adjusting for all other factors, only mothers’ internalizing problems (P ⬍ 0.001) remained significantly associated with adolescent depression. Fathers’ risk factors were not associated with adolescent depression. Conclusion: Characteristics of mothers are associated with adolescent current depression. Mothers’ internalizing problems is independently strongly associated with increased risk of current adolescent depression. Clinicians should assess mothers’ mental health when treating depressed adolescents. • Adolescent, Depression, Parental, Risk factors. Tea Agerup, Norwegian University of Science and Technology, The Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), PO Box 8905, MTFS, N-7491 Trondheim, Norway, E-mail: [email protected]; Accepted 23 April 2014.
P
arental characteristics can contribute towards the development of problems such as depression in adolescents (1–4). However, it is not sufficiently understood whether mothers and fathers contribute the same risk factors, and whether the risk associated with maternal and paternal factors vary depending on the sex of the adolescent. Improved knowledge about potentially differential risk factors due to sex of parent and adolescent can inform more targeted intervention for clinical depression in young people. The prevalence of depression through adolescence is estimated at 5.8% (5), with a sharp rise after puberty (6). The Diagnostic and Statistical Manual IV includes three categories of depression (7):
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major depressive disorder (MDD), dysthymia and depressive disorder not otherwise specified (NOS). However, most studies on adolescents with clinical depression have focused on MDD (8, 9), and few have addressed milder forms of depression (10–12). Given the centrality of parents in both normative and atypical development, there is a need to further examine parental factors that may be associated with adolescent depression. Little research has included both parents when examining risk factors for adolescent depression. Therefore we conduct secondary analysis of a set of parental risk factors for adolescent depression that were measured in both mothers and fathers in the Youth and DOI: 10.3109/08039488.2014.919021
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Mental Health Study (10), including whether biological parents live in an intact relationship, dissatisfaction with economy, somatic illness or disability, and internalizing and externalizing problems.
Parents not living together
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Parental divorce or not living together may be associated with adolescent and childhood depression (4, 13–16) because these conditions can indicate relationship instability and changes in family structure (17). The studies on diagnosed depression find parental divorce a risk factor specifically for MDD (9, 18).
Economic dissatisfaction Findings on the association between depression in childhood and lower socio-economic status (SES) have been inconsistent (2, 19). It may be more fruitful to examine perceived economic circumstances because this reflects economic issues regardless of income, educational level and level of employment. Economic issues in families at all SES levels can be a source of family conflict, marital discord, abuse, anger, hopelessness and depression (20–23). Perceived economic dissatisfaction can provide a nuanced perspective as a risk factor for adolescent depression (24, 25) particularly in a country such as Norway, where objective SES differences in the population are relatively small.
Physical disability Parental physical illness or disability can be regarded as a risk factor because children of parents with, for example, multiple sclerosis (26), cancer (3), brain injury (27) and chronic pain (28) have been found to have more emotional problems including depressive symptoms. However, these studies have not represented fathers well nor addressed clinical depression in the children.
Parental mental health Parental depression is one of the most influential risk factors for adolescent depression (6), and even more so when both parents report poor mental health (29). In addition, children of parents with comorbid psychiatric disorders and depressive disorder had higher levels of depressive symptoms than children of parents with only depression (1, 30, 31). There is a need for a broader perspective on mental health as a risk factor for adolescent depression, such as subsumed in the broad-spectrum internalizing and externalizing problems. Parental internalizing problems are clearly implicated in research, whereas the role of externalizing problems has been much less examined. Although both maternal and paternal risk factors could be salient for adolescent depression, previous research has rarely considered both. Furthermore, findings suggesting a differential role of maternal and paternal factors in the
36
development of their male and female children (32, 33) point to the need to examine interactions between sex of parent and adolescent pertaining to depression. Finally, there is a need to examine diagnosable depression in adolescents in the community (34), rather than in a clinical setting, to obtain the broadest representation of the manifestations in clinical depression. Therefore, the major aim is to examine the association of hypothesized parental risk factors with the range of diagnosed depression in a community sample of adolescents. We hypothesize that the following parental risk factors are positively associated with clinical depression in adolescents: parents not living together, economical dissatisfaction, physical illness/disability, and internalizing as well as externalizing mental health problems. In addition, because there is an insufficient basis to pose additional hypotheses, we explore 1) whether the effect of these risk factors differs among mothers and fathers and 2) whether this is dependent on the sex of the adolescent.
Method Participants and procedure The Youth and Mental Health Study (10) is a longitudinal study of depressive symptoms and disorders in the population from two counties in Central Norway. The first wave (T1) was conducted in 1998 when a total population of 9292 youths attended public and private schools. A representative sample of 2792 8th and 9th graders from 22 schools was selected, with a clustered sample method using the schools as sampling units, as detailed elsewhere (10). With a response rate of 88.3%, 2464 adolescents (mean age ⫾ standard deviation 13.7 ⫾ 0.5 years), 94.2% with at least one parent born in Norway, completed the Mood and Feelings Questionnaire (MFQ, see below) (35) at T1, and were reassessed 1 year later (1999, mean age 14.9 ⫾ 0.5 years) with the same questionnaire (T2). Attrition rate from T1 to T2 was 4.3%, n ⫽ 2432 at T2. The questionnaires were administered by teachers following provided instructions at school. Both assessments were approved by the Regional Committee for Medical Research Ethics, Central Norway, as well as the local school authorities. Written informed consent, based on the Norwegian Data Inspectorate Standards, was obtained from parents and students prior to the first wave. At T2, only the high MFQ scorers (ⱖ 26), as well as a matched sample selected at random from those with low and middle scores on the MFQ (⬍ 26) continued with the clinical interview phase. There was a match of one low/middle scorer on age and gender for every two high scorers. Of the sample, n ⫽ 345 (72.5% females) completed the clinical interview (36), including 220 with high and 124 with low/middle MFQ scores, and excluding one missing score on the MFQ. A detailed participant NORD J PSYCHIATRY·VOL 69 NO 1·2015
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flow-chart along with socio-demographics (reported in Table 1) are reported elsewhere (10). The parents of the adolescents in the subset identified in this manner were also invited to complete questionnaires and interviews about both themselves and their adolescent, including 240 mothers and 159 fathers. In 274 cases (79%), at least one parent participated. The parents were first interviewed at the local school by trained clinicians and were given a questionnaire to fill out at home and return by mail.
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Measures ADOLESCENT QUESTIONNAIRE Depressive symptom level was measured by the Mood and Feelings Questionnaire (MFQ), which covers the DSM-III-R criteria for major depression with 34 items. The total score ranges 0–68, with higher scores reflecting a higher symptom level. Studies of psychometric properties of the MFQ indicate an internal consistency of α ⫽ 0.90 and test–retest stability (intra-class correlation) of 0.75 (37, 38). Moreover, in the original study sample, we found internal consistency α ⫽ 0.91 and 2-month test–retest reliability r ⫽ 0.80, and correlation r ⫽ 0.91 with the Beck Depression Inventory (BDI) (39, 40). Validity is supported by the MFQ identifying mood disorders in youth of diverse demographic and clinical characteristics (41). Table 1. Socio-demographics of the interview sample (n ⫽ 345).
Gender Girls Boys Geographics Inner city Suburb Rural–coast Rural–inland Parental SES Professional leader (upper class) Upper middle class Lower middle class Primary industry Manual worker No information Ethnicity Both parents born in Norway One parent born in Norway Both parents born outside Norway Living arrangement Living with both parents Living with mother Living with father With one parent and stepparent Sharing time between parents Living with grandparents/fosterparents
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n
%
250 95
72.5 27.5
66 66 51 162
19.1 19.1 14.8 47.0
33 85 53 27 142 5
9.6 24.6 15.4 7.8 41.2 1.4
316 9 20
91.6 2.6 5.8
221 47 15 47 11 4
64.1 13.6 4.3 13.6 3.2 1.2
DEPRESSION
DIAGNOSTIC INTERVIEW The Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL) (36) was used to assess clinically significant symptoms of psychopathology on Axis I of the DSM-IV. The interviews were conducted by experienced clinicians trained in psychopathology and the use of K-SADS-PL. Detailed descriptions of the blinded interviews and inter-rater reliability have been presented (42). Inter-rater reliability for all K-SADS screening symptoms at the end of training was good [Cohen’s κ ⫽ 0.71 for all and κ ⫽ 0.75 for affective symptoms, utilizing an experienced child psychiatrist as the standard (co-author AMS)]. Interview integrity was maintained at a high level (average κ ⫽ 0.83). Summary symptom scores and diagnostic assessments were based on information obtained from the adolescents and their parents. In this study, the DSM-IV criteria for MDD and dysthymia, as well as the milder diagnosis of depressive disorder NOS (10), were applied. Functional impairment, defined as Children’s Global Assessment Scale (43) score below 71, or reduced function in one of the areas of family, school or friendship, was a requirement for a diagnosis of MDD or dysthymia. Based on previous research indicating that MDD and dysthymia have similar characteristics (44) and to provide an adequate size of the group with relatively more severe depression, MDD (n ⫽ 25) and dysthymia (n ⫽ 9; both diagnoses n ⫽ 12) were pooled for analysis. Thus adolescents were classified into one of three categories: MDD or dysthymia (n ⫽ 46), depression NOS (n ⫽ 48), or no depression (n ⫽ 251). PARENTAL QUESTIONNAIRE The Adult Self-Report (ASR) (45) is a broad assessment of adults’ emotional and behavioral problems based on 114 self-report items. Each problem is rated on a 3-point scale (0 ⫽ not true, 1 ⫽ partly true or sometimes true, 2 ⫽ very/often true). The internalizing problems scale combines anxious/depressed, withdrawn/depressed and somatic complaints syndrome scores (range ⫽ 0–78) and the externalizing problems scale combines rule-breaking behaviors, aggressive behavior and intrusive syndrome scores (range ⫽ 0–70). Analyses were conducted on the raw scale scores. Psychometric properties have been reported to be good for these two scales (45). PARENTAL INTERVIEW Three additional variables were measured based on independent items included in the parental interview: 1) perceived economic satisfaction was reported by the parent on a 5-point scale (1 ⫽ very satisfied, 5 ⫽ very dissatisfied); 2) marital status of the biological parents, which was classified as living together (i.e. married, cohabitating) vs. not (i.e. never married, divorced); 3) long-term physical illness or disability was determined
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as present vs. not based on one item asking about experiencing long-term illness or disability during the last year. Parent socio-economic status (SES) was measured by classifying mothers’ and fathers’ occupations using the ISCO-88 (46) on a 5-point scale ranging from professional leader/upper class to manual worker.
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Statistical analysis With three categories representing the outcome variable (MDD/dysthymia, depression NOS, no depression), we used proportional odds, ordinal logistic regression to study the association with parental risk factors. This treats the outcome as a three-level ordinal variable. The OR in proportional odds logistic regression has the same interpretation as the OR in standard (binary) logistic regression, if a cut-off is made between any two categories of the dependent variable. All analyses were adjusted for the adolescent age as well as sex. The five parental risk factors were examined separately for mothers and fathers. The parental variables were analyzed one at a time as well as simultaneously. We also examined interactions between sex and significant parental risk factors. Two-sided P-values ⬍ 0.05 were considered significant, and 95% confidence intervals (CI) were reported where relevant. Missing values in the regression analyses were handled by multiple imputations (MI) using chained equations, imputing m ⫽ 100 data sets (47) including all variables and interactions to be studied in the analyses, as well as the MFQ score. All analyses were performed using Stata 12 on the 267 cases with data on mothers and the 167 cases with data on fathers.
Results Descriptive statistics are shown in Table 2. The prevalence in the present sample for girls and boys respectively was 16.0% and 6.0% with MDD/dysthymia and 15.6% and 9.5% with depression NOS, leaving 68.4% and 84.0% with no depression. As can be seen in Table 3, when examined independently and adjusted for sex and age of the adolescent, four of the five risk factors for current adolescent depression were significant correlates for mothers: economical dissatisfaction (OR ⫽ 1.60, 95% CI 1.12–2.29, P ⫽ 0.009), physical illness/disability (OR ⫽ 2.05, 95% CI 1.12–3.77, P ⫽ 0.009), internalizing problems (OR ⫽ 1.09, 95% CI 1.05–1.13, P ⫽ 0.001), externalizing problems (OR ⫽ 1.09, 95% CI 1.02–1.16, P ⫽ 0.01) and male sex of the child (OR ⫽ 0.46, 95% CI 0.23–0.93, P ⱕ 0.05). None of the risk factors for fathers was significant. In the multivariable analyses shown in Table 3, when adjusted for sex and age of the adolescent as well as the other risk factors, only mothers’ internalizing problems was a significant correlate of depression in adolescents (OR ⫽ 1.08, 95% CI 1.02–1.14, P ⫽ 0.006). No other risk factors for mothers or fathers were significantly associated with adolescent depression in the multivariable analyses. However, fathers’ economical dissatisfaction and physical illness/disability had approximately the same effect-estimate (OR) when compared with mothers, whereas internalizing and externalizing problems in the father had relatively smaller effect-estimates compared with those in the mother. Yet none of the results for father reached statistical significance. In order to examine
Table 2. Descriptive statistics with 95% CI for participants (n ⫽ 345). MDD∗/dysthymia Mothers Females, n (%)† Males, n (%) Adolescent mean age Parent mean age Parents not living together‡, % 95% CI Econom. diss.§, Mean 95% CI Physical ill./disab.¶, % 95% CI Int. prob.||, Mean 95% CI Ext. prob.∗∗, Mean 95% CI
Fathers
40 (16.0%) 6 (6.3%) 15.1 39.0 43.9 48.0% 39.0% 0.28–0.68 0.16–0.62 2.63 2.41 2.26–3.00 1.93–2.90 35.0% 37.4% 0.17–0.53 0.09–0.66 8.23 8.04 4.64–11.82 4.75–11.33 5.35 5.35 2.82–7.88 2.82–7.88
Depression NOS Mothers
Fathers
39 (15.6%) 9 (9.5%) 15.0 42.8 45.0 37.5% 19.0% 0.20–0.55 0.01–0.36 2.41 2.39 2.15–2.66 2.13–2.66 43.0% 35.0% 0.25–0.60 0.13–0.57 10.16 9.63 5.76–14.57 5.68–13.59 5.58 6.60 2.69–8.46 4.03–9.18
No depression Mothers
Fathers
171 (68.4%) 80 (84.2%) 14.9 40.5 43.5 40.5% 27.0% 0.33–0.48 0.19–0.35 2.22 2.16 2.10–2.33 2.02–2.29 25.5% 24.0% 0.19–0.32 0.15–0.33 6.25 6.42 5.01–7.48 5.24–7.60 4.69 4.75 3.81–5.57 3.89–5.62
Overall Mothers
Fathers
250 (72.5%) 95 (27.5%) 15.0 40.7 43.5 40.9% 27.3% 0.35–0.47 0.20–0.34 2.29 2.22 2.19–2.39 2.10–2.34 29.0% 27.3% 0.23–0.35 0.19–0.35 8.47 7.10 7.48–9.45 6.00–8.20 5.01 5.11 4.46–5.56 4.32–5.90
∗MDD, major depressive disorder. †Rows
from “females, n (%)” to “Parent mean age” are complete case analyses. from “Parents not living together” to “Externalizing problem score” are multiple imputed data analyses. §Economical dissatisfaction. ¶Physical illness or disability. ||Internalizing problem score (range ⫽ 0–78). ∗∗Externalizing problem score (range ⫽ 0–70). ‡Rows
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DEPRESSION
Table 3. Ordinal logistic regression of parental risk factors on adolescent depression.
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Adjusted for sex and age only
Mothers (n ⫽ 267) Male sex of child Age of child Parents sep.∗ Economy diss. Illness/disability.† Intern. probl.‡ Ext. problem.§ Fathers (n ⫽ 186) Male Sex of child Age of child Parents sep.∗ Economy diss. Illness/disability.† Intern. probl.‡ Ext. problem.§
Adjusted for all other variables
OR
Lower CI
Upper CI
P-value
OR
Lower CI
Upper CI
P-value
0.460 1.160 1.065 1.603 2.052 1.089 1.090
0.230 0.730 0.586 1.124 1.117 1.048 1.021
0.930 1.850 1.935 2.288 3.770 1.131 1.164
0.030 0.530 0.836 0.009 0.020 0.000 0.010
0.452 1.113 0.947 1.192 1.377 1.078 0.997
0.214 0.683 0.501 0.800 0.710 1.022 0.912
0.958 1.813 1.795 1.777 2.670 1.137 1.090
0.038 0.668 0.869 0.388 0.344 0.006 0.945
0.410 1.410 1.083 1.422 2.048 1.036 1.038
0.180 0.820 0.485 0.928 0.857 0.996 0.979
0.950 2.440 2.418 2.179 4.889 1.078 1.101
0.038 0.216 0.845 0.106 0.107 0.082 0.212
0.397 1.432 1.033 1.275 1.550 1.016 1.011
0.161 0.809 0.445 0.800 0.524 0.944 0.916
0.975 2.532 2.396 2.032 4.577 1.095 1.116
0.044 0.218 0.941 0.307 0.428 0.663 0.830
OR, odds ratio; CI, confidence interval. Bold OR indicates significance at P ⬍ 0.05. ∗Parents not living together. †Physical illness/disability. ‡Internalizing problems. §Externalizing problems.
whether the risk factors were stronger correlates for girls than boys, we completed the same analyses with the addition of the interaction between the adolescent’s sex and the significant maternal predictor variables of economic dissatisfaction, physical illness/disability, internalizing problems and externalizing problems one at a time. However, none of the interactions was significant (all P-values ⬎ 0.15).
Attrition of parents Twenty-one percent of the parents did not participate in the clinical interview assessment. There was a significant difference (P ⫽ 0.05) in the prevalence of depression diagnosis in the present sample between adolescents whose parents participated in the clinical interview vs. parents who did not. Adolescents with participating parents were more likely to have minor depression (15% vs. 8.5%) and less likely to have major depression (11% vs. 21%). In addition, participating parents were more often in the higher SES categories than not participating parents (P ⬍ 0.01), who were more likely to be in the working class category.
Discussion Mothers’ economical dissatisfaction, physical illness/ disability, internalizing problems and externalizing problems were separately associated with current depression in adolescents. However, only mother’s internalizing problems were uniquely associated with adolescent NORD J PSYCHIATRY·VOL 69 NO 1·2015
depression. Although father’s economical dissatisfaction and physical illness/disability had approximately the same effect-estimate as for mothers, these did not reach statistical significance. There were no differences in these associations between adolescent boys and girls. Mothers who report being anxious/depressed, withdrawn and having somatic complaints are thus at increased risk of having an adolescent with clinical depression. We hypothesize that internalizing problems in mothers may interfere with the quality of parenting (48). Mothers who scored high on internalizing problems may possibly experience depression ranging from sub-clinical to MDD. Maternal depression may be of a particular concern given that the lifetime prevalence of MDD in women is up to three times higher than in men (49). Several other maternal risk factors were associated with adolescent depression in this study, including externalizing problems, economic dissatisfaction and physical illness/disability, yet these associations were diminished when considered jointly with internalizing problems. This may reflect statistical suppression due to multicollinearity among the risk factors. Alternatively, this finding may lead to a hypothesis that the former factors represent relatively more distal influences on the adolescent and the mother’s affective well-being is the more proximal influence. Lastly, these findings, although significant only among mothers, might reflect the strain and anxiety that parents may experience when having a depressed adolescent, facing the passivity, sad mood, school problems and in some cases increased risk of suicide among affected adolescents.
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T AGERUP ET AL.
The strengths of this study include that the adolescents were sampled from a school-based representative sample in a region of Norway. This study attempted to enroll an equal number of fathers and mothers from the subset giving equal opportunity for both parents to participate. Also, the clinical diagnosis of depression was based on a commonly used semi-structured interview (10). Limitations include missing parental data, especially for fathers, which meant that associations had to be stronger to reach significance. A related issue is that the fathers who participated do not perfectly represent the general population of fathers, but are biased towards those who are healthier and more engaged with their families. The attrition of fathers who had the worst risk factors may have weakened the test of paternal risk factors. Although this study set out to collect substantial father data, the difficulty engaging fathers in research is underscored (32, 33, 50–54). The research would have been strengthened with the inclusion of direct measures of parental clinical depression. Additional limitations include examining five risk factors, leaving out other parental factors that may also be important. Some of the parental risk factors were assessed with single items, which may jeopardize their reliability. A relatively small geographical region in Norway served to represent the general population. Furthermore, the study was performed on a selected sample consisting of mainly high-scoring individuals on a depression symptom measure (MFQ), and about 70 medium and 50 low scorers. Adolescents who were diagnosed with no depression in this sample still had mean symptom scores that were higher than the general population (55). Finally, discussion of causality is necessarily limited as with all correlational studies.
Future directions and implications More research is needed on adolescents including both parents, especially fathers, who are under-represented in studies on adolescent depression. We need to know more about how risk factors interact over time and contribute to clinical depression in adolescence and into young adulthood. When a child experiences problems, this may come to the attention of a parent, but also teachers, school nurses or counselors, and medical practitioners. These professionals should be encouraged to consider the mother’s situation when an adolescent is referred. It might not be sufficient only to treat the adolescent with depression if maternal risk factors are present. Our findings suggest it can be important to query the adolescent about the family situation, in particular mothers’ affective state and possibly physical health and economic dissatisfaction. Extending the treatment to include the mother, if indicated, could be more efficient in the long run. When adolescents are insufficiently treated, this necessarily affects their development and preparation for adulthood.
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Role of funding source Research was supported by a grant from the Liaison Committee between the Central Norway Regional Health Authority (RHA) and the Norwegian University of Science and Technology (NTNU) (Samarbeids-organet). Acknowledgement—The valuable contributions and support from the participating adolescents, parents and school staff is gratefully acknowledged. The authors gratefully acknowledge Kyrre Svarva from the IT department of Social and Psychology Studies at the Norwegian University of Science and Technology for his invaluable help with the data files.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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