Nordic Journal of Psychiatry
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the Short Mood and Feelings Questionnaire Bo Larsson, JoMagne Ingul, Thomas Jozefiak, Einar Leikanger & Anne Mari Sund To cite this article: Bo Larsson, JoMagne Ingul, Thomas Jozefiak, Einar Leikanger & Anne Mari Sund (2016): Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the Short Mood and Feelings Questionnaire, Nordic Journal of Psychiatry, DOI: 10.3109/08039488.2015.1109137 To link to this article: http://dx.doi.org/10.3109/08039488.2015.1109137
Published online: 27 Jan 2016.
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Date: 17 February 2016, At: 06:55
NORDIC JOURNAL OF PSYCHIATRY, 2016 http://dx.doi.org/10.3109/08039488.2015.1109137
RESEARCH ARTICLE
Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the Short Mood and Feelings Questionnaire Bo Larssona, JoMagne Ingulb,d, Thomas Jozefiaka,c, Einar Leikangera,e and Anne Mari Sunda,c a
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Regional Centre for Child and Youth Mental Health and Child Welfare – Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; bDepartment of Child and Adolescent Psychiatry, Levanger Hospital, Levanger, Norway; cDepartment of Child and Adolescent Psychiatry, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway; dDepartment of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; eDepartment of Child and Adolescent Psychiatry, Helse Sunnmøre HF, Volda Hospital, Volda, Norway
ABSTRACT
ARTICLE HISTORY
Background In numerous surveys the prevalence of depressive symptoms in adolescents has been examined in single sites and at one time point. Aims We examined depressive symptoms among adolescents aged 10–19 years in four different large school samples including two cohorts over a 10-year period in different locations in the same health region in central Norway including a total of 5804 adolescents. Two cohorts were retested within a 1-year time period to predict high versus low depressive symptom scores. Changes over a 6-year period in depressive symptom levels were examined in two of the samples of 12–14-year olds. Methods Depressive symptoms were estimated by the 13-item Short Mood and Feelings Questionnaire (SMFQ). Covariates were student age, sex, school size and location. Results ‘‘Miserable or unhappy’’, ‘‘Tired’’, ‘‘Restlessness’’ and ‘‘Poor concentration’’ were the most commonly reported depressive symptoms. Depressive symptom levels and proportions of high scoring students were consistently higher among girls, in particular in mid and late adolescence. Poisson regression analysis showed that all SMFQ items significantly predicted total scores for the whole sample, while sex (girls having a higher risk) emerged as a consistent 1-year predictor of high depressive symptom levels. Conclusions The SMFQ constitutes a short, practical and feasible measure. We recommend that this standardized measure should be used in the assessment of depressive symptoms among adolescents in school, primary care and clinical settings but also to evaluate treatment outcome. High scorers should be evaluated in subsequent clinical interviews for the presence of a depressive disorder.
Received 23 March 2015 Revised 6 October 2015 Accepted 8 October 2015 Published online 18 January 2016
About 5–6% of adolescents in the general population experience an episode of depression at some point in time, while lifetime prevalence is as high as 20% (1–4). The prevalence rates of depressive symptoms increase at the age of 12 years with girls reporting more symptoms than boys (4,5). Depression causes significant impairment across psychosocial domains, increased risk of suicidality and adverse outcomes in adulthood (6,7). While several comprehensive and standardized self-report measures exist to assess depressive symptoms in children and adolescents, the development of shorter versions for screening and research purposes as well as use in community or health care services is an important next step. The US Preventive Services Task Force (8) recommended screening for depression in adolescents aged 12 to 17 years (9), restricted, however, to the existence of service systems to ensure accurate diagnosis, psychotherapy and follow-up. Suitable for such a purpose is an abbreviated form of the Mood and Feelings Questionnaire (MFQ) including 13 items,
KEYWORDS
Adolescence; Depressive symptoms; Epidemiology; Longitudinal design.
the Short FQ (SMFQ), which was developed to evaluate core depressive symptoms in children and adolescents (10,11). In factor analytic studies of children in clinic and community samples, the SMFQ has been found to be a unidimensional scale (12–14). It correlates highly with the full version of the MFQ (r ¼ 0.95–0.96) (11,13) and also with total CDI (Children’s Depression Inventory) scores and with DISC-C interview depression scores. The internal consistency of the SMFQ is adequate and the measure discriminates between depressed and non-depressed children (4,6,11,13,15). Aside from age and sex, little is known about which school demographics are related to adolescent reports of depressive symptoms on the SMFQ, for example, school location and size. In a previous school-based study using the full version of the measure, the MFQ, students in coastal districts reported higher scores than those living inland and in a city (16). A related issue is whether the SMFQ can be used to predict future high levels of depressive symptoms. In a large-scale longitudinal study of early school adolescents in Australia and
CONTACT Bo Larsson [email protected] Regional Centre for Child and Youth Mental Health and Child Welfare – Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway ß 2016 Taylor & Francis
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the USA, McKenzie and collaborators (7) using the SMFQ reported that feelings of self-hatred and being unloved predicted high depressive symptom levels 1 year later. Feelings of sadness and moodiness have also been found to be highly predictive of adolescent depression 1 year later (17), and the two core ICD/DSM symptoms of depression in adolescents, depressed mood and anhedonia as well as feelings of worthlessness, were highly predictive of major depression in adulthood (18). To date, limited research exists regarding which depressive symptom types best contribute to total symptom scores in cross-sectional surveys of community samples of adolescents. Further validation of the predictive power of specific SMFQ items in short-term perspectives is another important research issue (7). There is also a great need to identify individuals with high levels of depressive symptoms that persist over time in adolescence in order to offer them effective help. We addressed the following specific aims: (1) relationships between depressive symptoms and sex, age, school size and location (area and urban versus semirural/rural); (2) 1-year prediction of high versus low depressive symptom scores using a cut-off score of 11 (see below); and (3) changes in depressive symptom levels across a 6-year period among adolescents aged 10–19 years in the general population.
Table 1. Number and percentages of adolescents by sex, age group, school size and location, means and SDs within parentheses of total SMFQ scores (N ¼ 5804). Sex Girls Boys Age (years) 10–12 13–15 16–19 Mean age (SD) School size Small (5280) Medium (280–335) Large ( 336) Location Urban Semi-rural/rural SMFQ Total scores Girls Boys
N 2997 (51.6%) 2797 (48.3%) 790 (13.6%) 4200 (72.4%) 814 (14.0%) 13.8 (1.67) % 32.7 33.8 33.5 42.3 57.7 mean (SD) 4.50 (4.72) 5.56 (5.24) 3.38 (3.78)
SD, Standard deviation, SMFQ, Short Mood and Feelings Questionnaire.
(4,5,7), high levels of depressive symptoms among adolescents were here defined by a cut-off score of 11 or higher.
Statistics
Methods Sample and procedures Four school samples of adolescents aged 10–19 years were collected during a 10-year period between the fall of 1998 and 2008 in three counties in the same health region in central Norway including one of the largest cities in the country and semirural/rural areas in the region (details provided elsewhere, 19–22). The response rates varied from 71–88%. In two of the samples adolescents were retested after 1 year with a response rate of 77–84% (19,21).
Assessment Adolescent sex, age, school location (urban and semirural/ rural), and school size (small5280 students, medium 280-335 students, and large 4335 students) was assessed (see Table 1). In 2012, 97% of students attended public schools. The SMFQ is a short form of the 33-item Mood and Feelings Questionnaire (MFQ) designed for children and adolescents from 8 to 18 years to report on depressive symptoms experienced during the previous 2 weeks (15). The MFQ covers affective, melancholic, vegetative, cognitive and suicidal aspects of depression as specified by the DSM-III-R diagnostic system. Responses are made to statements on a three-point scale (0 ¼ ‘‘not true’’, 1 ¼ ‘‘sometimes true’’ and 2 ¼ ‘‘true’’). The SMFQ consists of 13 items from the MFQ (listed in Table 2) yielding a total score range of 0–26) (Table 2). Following previous research (7,10) a binary recoding was employed of ‘‘not true’’ versus ‘‘sometimes true’’ and ‘‘true’’ categories. In line with two surveys in Australia and the USA
Descriptive statistics included means, standard deviation (SD), number and percentages. Missing values in the four samples varied across SMFQ items from 0.7–4.4%. Students with more than two missing values per item (15%) were deleted from the analysis (0.7% to 3.4%), and for the rest, the EM algorithm was used for imputation (23). Associations between categorical variables were estimated by chi-square test. Logistic regression models were used to analyse the relative power of the SMFQ items to predict caseness of depression based on cut-off scores at the 1-year follow-up (in samples 1 and 2). Due to the pronounced skewness of distribution of total SMFQ scores, Poisson regression analysis was used to identify the most powerful items to predict total SMFQ scores, while controlling for sex, age, school size and location (24). In this analysis, Poisson distribution was tested against a negative binomial model with a link function using deviance value (optimal model close to 1.0), Akaikes’ (AIC) and Bayesian Information criteria (BIC) to estimate optimal model fit with the lowest values chosen as criteria in the comparison. All analysis was conducted with SPSS 20.0 (25). A p value of 50.05 was used to indicate statistical significance except for analysis in the combined sample in which a more conservative p value of 50.01 was used due to its large sample size and enhanced power.
Ethics The separate studies were all approved by the Regional Committee for Medical Research Ethics in Central Norway, and the handling of sensitive data was in accordance with guidelines developed by the Norwegian Data Inspectorate.
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Table 2. Percentages of adolescents reporting ‘‘sometimes true’’ or ‘‘true’’ on the SMFQ items. Sex
Age group
Item
All N ¼ 5804 (%)
Girls n ¼ 2991 (%)
Boys n ¼ 2793 (%)
10–12 years n ¼ 782(%)
13–15 years n ¼ 4198 (%)
16–19 years n ¼ 814 (%)
1. Miserable or unhappy 2. Didn’t enjoy anything 3. Tired 4. Restlessness (couldn’t sit still) 5. No good 6. Cried a lot 7. Poor concentration 8. Hated myself 9. Bad person 10. Lonely 11. Unloved 12. Never be any good 13. Did everything wrong
41.9 26.1 46.9 44.2 23.6 18.7 43.2 19.6 22.3 29.4 15.5 20.8 18.1
54 28.8 51.5 48.5 29.9 26.6 49.5 27.4 29.0 36.7 19.9 26.4 22.2
29 23.2 42 39.6 16.8 10.4 36.4 11.2 15.1 21.5 10.9 14.9 13.7
34.4 26.2 41.2 38.6 22.6 16.2 44.4 18.8 17.5 27.6 16.6 23.8 17.9
42.3 24.8 50.7 49.4 23.9 14.3 46.3 19.2 19.0 26.5 15.9 20.1 16.9
46.8 32.6 33.2 23.0 22.7 44.1 26.0 22.5 43.9 45.9 12.5 22.0 24.8
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SMFQ, Short Mood and Feelings Questionnaire.
Parent consent was needed for adolescents younger than 16 years.
Results The distributions of participants by sex, age group, school size and location (urban versus semirural/rural) as well as mean total SMFQ scores are presented in Table 1 for the total sample. Boys displayed a small U-shaped form whereas girls displayed a linear positive relationship between age group and SMFQ scores (see Fig. 1).
A more detailed analysis showed that only girls increased their experience of ‘‘Miserable and unhappy’’ and ‘‘Hated myself’’ from 10–12 years of age to older age but also increased ‘‘Didn’t enjoy anything’’ between middle and late adolescence. During the latter time interval both sexes increased their reports of ‘‘Cried a lot’’, ‘‘Bad person’’, ‘‘Lonely’’, and ‘‘Did everything wrong’’ but also a decrease of experience of ‘‘Poor concentration’’. Both sexes reported an increase of feelings of ‘‘Tired’’ and ‘‘Restless’’ between early and middle adolescence, then a decrease of these symptoms. Changes in the other three items, ‘‘Unloved’’, ‘‘Never be any good’’ and ‘‘No good’’ between age groups were minor.
Endorsement of SMFQ items High depressive symptom levels Proportions of students who reported ‘‘somewhat true’’ (1) and ‘‘true’’ (2) on the 13 items are presented in Table 2. The most commonly reported items in the whole sample were: ‘‘Miserable or unhappy’’, ‘‘Tired’’, ‘‘Restlessness’’ and ‘‘Poor concentration’’ (see Table 2). Girls reported significantly higher levels on all 13 items compared with boys, with strong relationships between sex and SMFQ item endorsement (all p values 50.001). Two items, ‘‘Miserable and unhappy’’ and ‘‘Didn’t enjoy anything’’, reflect the primary DSM-criteria for major depression. For the former, 54% of girls endorsed high levels compared to 29% of boys, whereas for the latter item, the gender difference was smaller at 28.8% versus 23.2%, respectively. The oldest age group (ages 16–19 years) reported high levels significantly more often than the younger ones on the following items: ‘‘Didn’t enjoy anything’’, ‘‘Cried a lot’’, ‘‘Bad person’’, ‘‘Lonely’’, and ‘‘Did everything wrong’’. The two oldest age groups (ages 13–15 and 16–19) also endorsed high symptom levels on ‘‘Miserable and unhappy’’ significantly more frequently than the youngest ones. For the items ‘‘Tired’’ and ‘‘Restless’’, about half of the middle age group (13–15) reported high levels being significantly different from the youngest age group (10–12), who in turn reported such levels significantly more often than the oldest age group. High levels of ‘‘Poor concentration’’ were reported significantly more frequently by the two youngest age groups compared to the oldest.
Using a cut-off point of 11, 11.2% in the total sample had high and 88.6% had low SMFQ levels. Of the girls, 16% scored high, as did 6.1% of the boys, a significant difference, 2 (1) ¼ 144.14, P50.001. A significant age difference, 2 (1) ¼ 12.16, P50.01, was also found in that 14.6% of the students aged 16–19 years reported high scores compared to 10.8% among 13–15-year olds and 9.6% among 10–12-year olds. Students in counties 2 (12.3%) and 3 (14.4%) reported significantly higher proportions of high scores than those in county 1 (9.5%). However, school size and localization (urban versus semirural/rural areas) were not related to high SMFQ scores.
Prediction of total SMFQ scores by sex, age, school size and location A detailed preliminary check showed that the Poisson regression model was optimal based on deviance, AIC and BIC values. While sex, age group, school size and location were not significant predictors, all 13 SMFQ items significantly predicted total SMFQ scores (see Table 3).
One-year stability, incidence and predictors Differences in mean total SMFQ scores across a 1-year period were examined for 12–14-year olds and 13–15 olds in two of the samples. In both samples there was a significant time effect
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Figure 1. Total mean SMFQ scores by age group and sex.
in that on 1-year-older adolescents had significantly higher mean total SMFQ scores at the follow-up as compared to baseline (sample 1: M ¼ 4.94 versus M ¼ 3.98), t (2341) ¼ 10.29, P50.001; sample 2: M ¼ 5.84 versus M ¼ 5.07), t (906) ¼ 4.39, P50.001). Associations between low versus high levels on the SMFQ at the two test points were strong and significant (sample 1: 2 (1) ¼ 289.89, P50.001 and sample 2: 2 (1) ¼ 137.36, P50.001). Both samples increased the proportion of high scorers from baseline to the 1-year follow-up (sample 1: 8.6 15.5%; sample 3: 13.8 18.1%).
Stability and incidence of depressive symptoms In sample 1, 56.9% were high SMFQ scorers both at baseline and the 1-year retest, whereas 11.6% were incident cases over this period; in sample 2, the corresponding figures were 55.0% and 12.2%, respectively. The stability of being a high scorer at both assessments in sample 1 was higher among girls than boys (65.0% versus 28.9%) as was the incidence (17.0% versus 6.6%), and there were significant associations over the 1-year interval for both genders, (girls: 2 (1) ¼ 166.07, P50.001, and boys: 2 (1) ¼ 29.28, P50.001). While significant associations also were found for age group in sample 2, the differences in proportions were negligible. By contrast, the stability of being a high scorer in sample 2 was approximately the same for girls and boys (55.6% versus 51.7%), but the incidence was higher in
girls than boys (17.4% versus 6.6%), again with significant associations across the 1-year follow-up in both genders, (girls: 2 (1) ¼ 63.20, P50.001 and boys: 2 (1) ¼ 61.46, P50.001, respectively).
One-year multivariate prediction of depressive symptoms For sample 1, the omnibus test showed that the model was highly significant, 2 (16) ¼ 427.65, P50.001, with a Nagelkerke’s pseudo-R2 of 0.29 and a non-significant HosmerLemeshow’s test. Overall, the classification accuracy of students into low-moderate or high scorers was 86.7% but only 31.0% of those with high scores at the 1-year follow-up were correctly classified. Out of the 13 SMFQ items, three items listed in Table 4 were significant predictors of high scores one year later, while another three approached significance (p ¼ 0.06). For sample 2 the model was also significant, 2 (16) ¼ 199.00, P50.001, with a Nagelkerke’s pseudo-R2 of 0.32 and a significant Hosmer-Lemeshow’s test, 2 (8) ¼ 19.57, P50.05. Overall, the classification accuracy of students into low, moderate or high scorers was 83.4% but only 32.7% of those with high scores at the 1-year follow-up were correctly classified. While three of the SMFQ items at baseline emerged as significant predictors of low versus high SMFQ scores, they were different in the two samples.
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Table 3. Results of Poisson regression analysis of total SMFQ scores for all four samples combined (ages 10–19 years) (N ¼ 5783).
Sex Age School size Location (urban/semirural-rural) SMFQ item 1. Miserable or unhappy 2. Didn’t enjoy anything 3. Tired 4. Restless (couldn’t sit still) 5. No good 6. Cried a lot 7. Poor concentration 8. Hated myself 9. Bad person 10. Lonely 11. Unloved 12. Never be any good 13. Did everything wrong
OR (CI99%)
B
SE
0.01 0.85 0.05 0.05
0.10 0.21 0.11 0.10
0.89 1.09 1.05 1.05
(0.77–1.26)ns (0.64–1.85)ns (0.80–1.38)ns (0.82–1.35)ns
0.84 0.40 0.46 0.25 0.47 0.27 0.69 0.66 0.67 0.53 0.57 0.48 0.45
0.17 0.10 0.12 0.10 0.13 0.09 0.16 0.14 0.14 0.12 0.12 0.11 0.11
2.31 1.49 1.59 1.29 1.61 1.31 2.00 1.94 1.96 1.70 1.77 1.62 1.57
(1.50–3.58)** (1.17–1.90)** (1.16–2.17)** (1.00–1.65)* (1.16–2.22)** (1.03–1.67)* (1.34–2.98)** (1.36–2.77)** (1.39–2.78)** (1.24–2.33)** (1.31–2.38)** (1.22–2.15)** (1.19–2.07)**
*P50.01; **P50.001; ns, not significant. B, unstandardized beta coefficients; CI: Confidence interval; SE, standard error; OR, odds ratio; SMFQ, Short Mood and Feelings Questionnaire.
Table 4. One-year predictors of high versus low total SMFQ scoresa for samples 1 and 2 (ages 12–15 years) for sex and SMFQ items. Results of logistic regression analysis.
Sample 1 (n ¼ 2339) Sex SMFQ item 2. Didn’t enjoy anything 3. Tired 8. Hated myself 11. Unloved 12. Never be any good 13. Did everything wrong Sample 2 (n ¼ 926) Sex SMFQ item 1. Miserable or unhappy 11. Unloved 12. Never be any good 13. Did everything wrong
B
SE
OR (CI95%)
0.89
0.15
2.42 (1.81–3.24)***
0.49 0.58 0.26 0.28 0.60 0.33
0.18 0.16 0.14 0.15 0.17 0.18
1.64 1.79 1.30 1.33 1.82 1.40
0.69
0.23
2.00 (1.28–3.12)**
0.67 0.72 0.53 0.53
0.25 0.29 0.28 0.27
1.95 2.06 1.69 1.70
(1.16–2.31)** (1.31–2.45)*** (0.99–1.69)b (0.98–1.80)b (1.30–2.55)** (0.99–1.97)b
(1.19–3.20)** (1.17–3.61)* (0.97–2.94)b (1.00–2.91)*
a
Using a cut-off of 11 on total SMFQ scores. P ¼ 0.06. *P50.05; **P50.01; ***P50.001. B, unstandardized beta coefficients; CI, confidence interval; OR, odds ratio; SE, standard error; SMFQ, Short Mood and Feelings Questionnaire.
b
Depressive symptoms over a 6-year interval The results showed that differences in total mean SMFQ scores (M ¼ 4.10 versus 4.23, respectively) and proportions of high scorers (9.3% versus 11.0%, respectively) across the 6-year time period in the two samples of 12–14-year olds were not significant.
Discussion First, our results showed that total mean SMFQ scores varied from 4.1 to 5.2 in the four samples with a strong sex difference. The difference in proportion of adolescents reporting high levels of total SMFQ scores (using a cut-off of 11) was even
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more striking with 16% of girls as compared to 6.1% of boys. Older adolescents reported a greater prevalence of high scores (14.6%) than those in mid adolescence (10.8%) who in turn had somewhat higher levels than the youngest group (9.6%). Whereas all SMFQ items significantly predicted total scores in our cross-sectional analysis, overall the relationships were modest, with adjusted ORs varying from 1.11 for ‘‘Unloved’’ to 1.48 for ‘‘Miserable and unhappy’’, one of the core ICD/DSM symptoms of depression. In comparison with outcomes of similar large scale epidemiological surveys conducted in the USA and Australia, our mean total SMFQ values were lower than those reported for somewhat younger students by McKenzie and collaborators (7), and somewhat higher than reported by Angold et al. (4) for a broader age range (8–17 year olds) in the Eastern USA, with reported SMFQ means of 3.8 and 3.2 for girls and boys (in both samples), respectively. In these studies a striking difference at the age of 12 was noted after which point girls reported increasing levels of depressive symptoms, whereas boys reported somewhat decreasing levels. Our results support these findings, however, with a small U-shaped age curve for boys and a linear relationship between age and SMFQ scores for girls. In the present study we used a cut-off score of 11 on the SMFQ mean totals to increase comparability of outcomes with the community studies conducted in the USA and Australia (4,5,7). Here, 11.2% of all students aged 10–19 years reported high SMFQ levels roughly corresponding to the 90th percentile with a strong preponderance of girls (16%) compared to boys (6.1%). The proportion of high scorers also increased by age. In the study by Angold et al. (4), 6% of the 8–17-year-olds were high scorers, with the proportion of girls being about twice (7.5%) the for boys (3.5%). The finding of a lower proportion of high scorers and lower SMFQ total means are reasonably expected given that a younger group of children were also included in the Angold et al. (4) study than in our study. By contrast, McKenzie et al. (7) found that about a quarter of the somewhat younger adolescents experienced high levels of depressive symptoms on the SMFQ (using the same cut-off score of 11). Given the similarities in school-based sampling strategies in McKenzie et al. (7) and the present large-scale study, we can only assume that the differences in outcomes are likely to depend on variations in cultural and socio-economic factors. It should be noted that recommended optimal cut-off points for total SMFQ scores based mostly on ROC analyses have varied greatly from 4 to 12 in various studies (11,13,15,26,27). Clearly more research is needed to obtain more solid information on optimal cut-off points, in particular when differentiating adolescents with a depressive disorder from those who are not depressed. A consistent finding in the present study was that girls reported higher levels on all 13 SMFQ items than did boys. Angold et al. (4) reported an entire shift to the right in the distribution of SMFQ scores in older girls, not only of extreme scores in a small group of individuals. Here, the most commonly endorsed items on the 13 SMFQ items, were ‘‘Miserable or unhappy’’, ‘‘Tired’’, ‘‘Restlessness’’ and ‘‘Poor concentration’’, while the item ‘‘Didn’t enjoy anything’’ (anhedonia) was endorsed by a smaller portion of adolescents
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(26%). Reports of being ‘‘Miserable or unhappy’’ were also more common among older adolescents in contrast to the other three common items which were more prevalent in early and mid adolescence. Only girls increased their experience of ‘‘Miserable and unhappy’’ and ‘‘Hated myself’’ from early to mid adolescence, while reports of feelings of anhedonia (‘‘Didn’t enjoy anything’’) increased later on up to late adolescence. It is likely that changes in these symptoms primarily reflect specific hormonal changes during puberty in girls (28,29), and that the emergence of other depressive symptoms included in the SMFQ relate more to sociocultural and peer influences. In further analysis of 1-year predictors in two of the samples, the risk for being a high scorer was about twice as high for girls than boys. However, while three of the SMFQ items were found to be significant predictors of low versus high scores at the 1year follow-up, they differed in contents, with one common item in each sample reflecting feelings of self-depreciation. In the school-based survey of adolescents aged 10–15 years in the general population in Australia and the USA, McKenzie and colleagues (7) also noted that ‘‘Hated myself’’ was most predictive of high depressive symptom levels 1 year later. Two other combinations of SMFQ items were also predictive: ‘‘Never be any good’’ and ‘‘Unloved’’ in the first combination, and ‘‘Tired’’ together with ‘‘Never be any good’’ in a second combination. In a longitudinal study of adolescents conducted in a longer perspective, Wilcox and Anthony (18) reported that persistent feelings of worthlessness and anhedonia were highly predictive of major depression in adulthood. Feelings of sadness and moodiness have also been found to be highly predictive of adolescent depression one year later (17). McKenzie and collaborators emphasized that other symptoms not reflecting core problems and symptoms in the ICD and DSM diagnoses of depression, such as feelings of being unloved, are also important to consider in the assessment of adolescents. Our study results support these findings and underline how feelings of worthlessness, but also possible early signs of cognitive distortions such as ‘‘Feeling unloved’’ are forerunners of high levels of depressive symptoms later on in these age groups. We further noticed that estimates of depressive symptoms over a 6-year period in the same health region were largely unchanged among 12–14-year olds. This finding concurs well with outcomes of prevalence studies of depressive disorders (3), in which minor changes were observed in prevalence rates among children born during a 30-year period. One limitation of the present study was that different age groups were recruited from different parts of the region and at different times during the 10-year period. However, depressive symptom levels were consistent across time and areas within this region. The response rates in the four samples and crosssectional surveys also varied from 71–88%, and in the 1-year follow-ups they were 77–84%. Dropout rates were partly due to the requirement of obtaining parent consent for younger adolescents. Here only adolescent reports of depressive symptoms were used and the cut-off criterion was based on findings in previous surveys conducted in Australia and the UK. The strengths of the present study covering the whole period of adolescence were the large combined sample of
adolescents recruited in the same health region in the middle of Norway during a 10-year period. The validity of our findings is strengthened by the inclusion of one of the largest cities in Norway, towns of various sizes and semirural/rural areas covering the whole health region.
Conclusions The SMFQ is a very practical measure that can be easily completed by children aged 8 years and older in 5 minutes in busy clinical settings and in community-based surveys. To the best of the authors’ knowledge, it is also the shortest existing standardized measure to assess depressive symptoms in children and adolescents. The results of the present study can serve as reference data in the assessment of adolescents in clinical and primary care settings as well as in controlled trials. Further validation of the SMFQ is needed to improve information on its discriminative power in clinical settings but also to obtain more precise information on optimal cut-off scores.
Acknowledgements The authors gratefully appreciate the assistance of all school personnel and the cooperation of all students participating in the various surveys conducted over the 10-year period.
Declaration of interest The data collection was partially funded by financial support from various sources, the Norwegian Research Council (NFR), the National Council for Mental Health Norway, SINTEF Unimed, Department of Child and Adolescent Psychiatry at St. Olav Hospital, the Norwegian University of Technology and Science (NTNU) in Trondheim, and the Department of Research and Development at Helse-MR in A˚lesund.The authors declare that they have no other conflict of interest.
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9. Willliams SB, O’Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics 2009;123:e716–35. 10. Angold A, Costello EJ, Messer SC, Pickles A, Winder F, Silver D. The development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Int J Method Psychiatr Res 1995;5:1–12. 11. Messer SC, Angold A, Costello E, Loeber R, van Kammen W, Stouthammer- LM. Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Factor composition and structure across development. Int J Method Psychiatr Res 1995;5:251–62. 12. Kuo ES, Stoep AV, Stewart DG. Using the Short Mood and Feelings Questionnaire to detect depression in detained adolescents. Assessment 2012;12:374–83. 13. Sharp C, Goodyer IM, Croudace TC. The Short Mood and Feelings Questionnaire (SMFQ): a unidimensional item response theory and categorical data factor analysis of self-report ratings from a community sample of 7-through 11-year-old children. J Abnorm Psychol 2006;34:379–91. 14. Katon W, Russo J, Richardson L, McCauley E, Lozano P. Anxiety and depression screening for youth in a primary care population. Ambul Pediatrics 2008;8:182–8. 15. Angold A, Costello EJ, Pickles EJ, Winder F. The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Medical research council, London; 1987. 16. Sund AM, Larsson B. Psychosocial correlates of depressive symptoms among 12-14-year-old Norwegian adolescents. J Child Psychol Psychiatry 2003;44:588–97. 17. Van Voorhees BW, Paunesku D, Gollan J, Kuwabara S, Reinecke M, Basu A. Predicting future risk of depressive episode in adolescents: the Chicago Adolescent Depression Risk Assessment (CADRA). Ann Fam Med 2008;6:503–11.
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18. Wilcox HC, Anthony JC. Child and adolescent clinical features as forerunners of adult-onset major depressive disorder: retrospective evidence from an epidemiological sample. J Affect Dis 2004;82:9–20. 19. Sund AM, Larsson B, Wichstro¨m L. Depressive symptoms among young Norwegain adolescents as measured by the Mood and Feelings Questionnaire (MFQ). Eur Child Adolesc Psychiatr 2001;10:222–9. 20. Jozefiak T, Larsson B, Wichstrøm L, Mattejat F, Ravens-Sieberer U. Quality of Life as reported by school children and their parents: a cross-sectional survey. Health Qual Life Outcomes 2008;6:34, doi: 10.1186/1477-7525-6-34. 21. Leikanger E, Ingul JM, Larsson B. Sex and age-related anxiety in a community sample of Norwegian adolescents. Scand J Psychol 2012;53:150–157. 22. Ingul JM, Klo¨ckner CA, Silverman WK, Nordal HM. Adolescent school abseenteism: modeling social and individual risk factors. Child Adolesc Ment Health 2012;17:93–100. 23. Little RJA, Rubin DB. Statistical analysis with missing data. John Wiley and Sons, New York; 1987. 24. Cameron AC, Trivedi PK. Regression analysis of count data. Cambridge University Press, UK; 1998. 25. IBM SPSS Statistics 20. New York; 2011. 26. Rhew IC, Simpson K, Tracy M, Lymp J, McCauley E, Tsuang D, et al. Criterion validity of the Short Mood and Feelings Questionnaire and one- and two-item depression screens in young adolescents. Child Adolesc Psychiatry Ment Health 2010;4:8 9: doi: 10.1186/17532000-4-8. 27. Rothon C, Edwards P, Bhui K, Viner RM, Taylor S, Stansfeld SA. Physical activity and depressive symptoms in adolescents: a prospective study. BMC Med 2010;8:3228; doi: 10.1186/1741-7015-8-32. 28. Angold A, Costello EJ, Worthman CM. Puberty and depression: the roles of age, pubertal status and pubertal timing. Psychol Med 1998;28:51–61. 29. Angold A, Costello EJ, Erkanli A, Worthman CM. Pubertal changes in hormone levels and depression in girls. Psychol Med 1999;29: 1043–53.
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the Short Mood and Feelings Questionnaire Bo Larsson, JoMagne Ingul, Thomas Jozefiak, Einar Leikanger & Anne Mari Sund To cite this article: Bo Larsson, JoMagne Ingul, Thomas Jozefiak, Einar Leikanger & Anne Mari Sund (2016): Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the Short Mood and Feelings Questionnaire, Nordic Journal of Psychiatry, DOI: 10.3109/08039488.2015.1109137 To link to this article: http://dx.doi.org/10.3109/08039488.2015.1109137
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Date: 17 February 2016, At: 06:55
NORDIC JOURNAL OF PSYCHIATRY, 2016 http://dx.doi.org/10.3109/08039488.2015.1109137
RESEARCH ARTICLE
Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the Short Mood and Feelings Questionnaire Bo Larssona, JoMagne Ingulb,d, Thomas Jozefiaka,c, Einar Leikangera,e and Anne Mari Sunda,c a
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Regional Centre for Child and Youth Mental Health and Child Welfare – Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; bDepartment of Child and Adolescent Psychiatry, Levanger Hospital, Levanger, Norway; cDepartment of Child and Adolescent Psychiatry, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway; dDepartment of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; eDepartment of Child and Adolescent Psychiatry, Helse Sunnmøre HF, Volda Hospital, Volda, Norway
ABSTRACT
ARTICLE HISTORY
Background In numerous surveys the prevalence of depressive symptoms in adolescents has been examined in single sites and at one time point. Aims We examined depressive symptoms among adolescents aged 10–19 years in four different large school samples including two cohorts over a 10-year period in different locations in the same health region in central Norway including a total of 5804 adolescents. Two cohorts were retested within a 1-year time period to predict high versus low depressive symptom scores. Changes over a 6-year period in depressive symptom levels were examined in two of the samples of 12–14-year olds. Methods Depressive symptoms were estimated by the 13-item Short Mood and Feelings Questionnaire (SMFQ). Covariates were student age, sex, school size and location. Results ‘‘Miserable or unhappy’’, ‘‘Tired’’, ‘‘Restlessness’’ and ‘‘Poor concentration’’ were the most commonly reported depressive symptoms. Depressive symptom levels and proportions of high scoring students were consistently higher among girls, in particular in mid and late adolescence. Poisson regression analysis showed that all SMFQ items significantly predicted total scores for the whole sample, while sex (girls having a higher risk) emerged as a consistent 1-year predictor of high depressive symptom levels. Conclusions The SMFQ constitutes a short, practical and feasible measure. We recommend that this standardized measure should be used in the assessment of depressive symptoms among adolescents in school, primary care and clinical settings but also to evaluate treatment outcome. High scorers should be evaluated in subsequent clinical interviews for the presence of a depressive disorder.
Received 23 March 2015 Revised 6 October 2015 Accepted 8 October 2015 Published online 18 January 2016
About 5–6% of adolescents in the general population experience an episode of depression at some point in time, while lifetime prevalence is as high as 20% (1–4). The prevalence rates of depressive symptoms increase at the age of 12 years with girls reporting more symptoms than boys (4,5). Depression causes significant impairment across psychosocial domains, increased risk of suicidality and adverse outcomes in adulthood (6,7). While several comprehensive and standardized self-report measures exist to assess depressive symptoms in children and adolescents, the development of shorter versions for screening and research purposes as well as use in community or health care services is an important next step. The US Preventive Services Task Force (8) recommended screening for depression in adolescents aged 12 to 17 years (9), restricted, however, to the existence of service systems to ensure accurate diagnosis, psychotherapy and follow-up. Suitable for such a purpose is an abbreviated form of the Mood and Feelings Questionnaire (MFQ) including 13 items,
KEYWORDS
Adolescence; Depressive symptoms; Epidemiology; Longitudinal design.
the Short FQ (SMFQ), which was developed to evaluate core depressive symptoms in children and adolescents (10,11). In factor analytic studies of children in clinic and community samples, the SMFQ has been found to be a unidimensional scale (12–14). It correlates highly with the full version of the MFQ (r ¼ 0.95–0.96) (11,13) and also with total CDI (Children’s Depression Inventory) scores and with DISC-C interview depression scores. The internal consistency of the SMFQ is adequate and the measure discriminates between depressed and non-depressed children (4,6,11,13,15). Aside from age and sex, little is known about which school demographics are related to adolescent reports of depressive symptoms on the SMFQ, for example, school location and size. In a previous school-based study using the full version of the measure, the MFQ, students in coastal districts reported higher scores than those living inland and in a city (16). A related issue is whether the SMFQ can be used to predict future high levels of depressive symptoms. In a large-scale longitudinal study of early school adolescents in Australia and
CONTACT Bo Larsson [email protected] Regional Centre for Child and Youth Mental Health and Child Welfare – Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway ß 2016 Taylor & Francis
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the USA, McKenzie and collaborators (7) using the SMFQ reported that feelings of self-hatred and being unloved predicted high depressive symptom levels 1 year later. Feelings of sadness and moodiness have also been found to be highly predictive of adolescent depression 1 year later (17), and the two core ICD/DSM symptoms of depression in adolescents, depressed mood and anhedonia as well as feelings of worthlessness, were highly predictive of major depression in adulthood (18). To date, limited research exists regarding which depressive symptom types best contribute to total symptom scores in cross-sectional surveys of community samples of adolescents. Further validation of the predictive power of specific SMFQ items in short-term perspectives is another important research issue (7). There is also a great need to identify individuals with high levels of depressive symptoms that persist over time in adolescence in order to offer them effective help. We addressed the following specific aims: (1) relationships between depressive symptoms and sex, age, school size and location (area and urban versus semirural/rural); (2) 1-year prediction of high versus low depressive symptom scores using a cut-off score of 11 (see below); and (3) changes in depressive symptom levels across a 6-year period among adolescents aged 10–19 years in the general population.
Table 1. Number and percentages of adolescents by sex, age group, school size and location, means and SDs within parentheses of total SMFQ scores (N ¼ 5804). Sex Girls Boys Age (years) 10–12 13–15 16–19 Mean age (SD) School size Small (5280) Medium (280–335) Large ( 336) Location Urban Semi-rural/rural SMFQ Total scores Girls Boys
N 2997 (51.6%) 2797 (48.3%) 790 (13.6%) 4200 (72.4%) 814 (14.0%) 13.8 (1.67) % 32.7 33.8 33.5 42.3 57.7 mean (SD) 4.50 (4.72) 5.56 (5.24) 3.38 (3.78)
SD, Standard deviation, SMFQ, Short Mood and Feelings Questionnaire.
(4,5,7), high levels of depressive symptoms among adolescents were here defined by a cut-off score of 11 or higher.
Statistics
Methods Sample and procedures Four school samples of adolescents aged 10–19 years were collected during a 10-year period between the fall of 1998 and 2008 in three counties in the same health region in central Norway including one of the largest cities in the country and semirural/rural areas in the region (details provided elsewhere, 19–22). The response rates varied from 71–88%. In two of the samples adolescents were retested after 1 year with a response rate of 77–84% (19,21).
Assessment Adolescent sex, age, school location (urban and semirural/ rural), and school size (small5280 students, medium 280-335 students, and large 4335 students) was assessed (see Table 1). In 2012, 97% of students attended public schools. The SMFQ is a short form of the 33-item Mood and Feelings Questionnaire (MFQ) designed for children and adolescents from 8 to 18 years to report on depressive symptoms experienced during the previous 2 weeks (15). The MFQ covers affective, melancholic, vegetative, cognitive and suicidal aspects of depression as specified by the DSM-III-R diagnostic system. Responses are made to statements on a three-point scale (0 ¼ ‘‘not true’’, 1 ¼ ‘‘sometimes true’’ and 2 ¼ ‘‘true’’). The SMFQ consists of 13 items from the MFQ (listed in Table 2) yielding a total score range of 0–26) (Table 2). Following previous research (7,10) a binary recoding was employed of ‘‘not true’’ versus ‘‘sometimes true’’ and ‘‘true’’ categories. In line with two surveys in Australia and the USA
Descriptive statistics included means, standard deviation (SD), number and percentages. Missing values in the four samples varied across SMFQ items from 0.7–4.4%. Students with more than two missing values per item (15%) were deleted from the analysis (0.7% to 3.4%), and for the rest, the EM algorithm was used for imputation (23). Associations between categorical variables were estimated by chi-square test. Logistic regression models were used to analyse the relative power of the SMFQ items to predict caseness of depression based on cut-off scores at the 1-year follow-up (in samples 1 and 2). Due to the pronounced skewness of distribution of total SMFQ scores, Poisson regression analysis was used to identify the most powerful items to predict total SMFQ scores, while controlling for sex, age, school size and location (24). In this analysis, Poisson distribution was tested against a negative binomial model with a link function using deviance value (optimal model close to 1.0), Akaikes’ (AIC) and Bayesian Information criteria (BIC) to estimate optimal model fit with the lowest values chosen as criteria in the comparison. All analysis was conducted with SPSS 20.0 (25). A p value of 50.05 was used to indicate statistical significance except for analysis in the combined sample in which a more conservative p value of 50.01 was used due to its large sample size and enhanced power.
Ethics The separate studies were all approved by the Regional Committee for Medical Research Ethics in Central Norway, and the handling of sensitive data was in accordance with guidelines developed by the Norwegian Data Inspectorate.
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Table 2. Percentages of adolescents reporting ‘‘sometimes true’’ or ‘‘true’’ on the SMFQ items. Sex
Age group
Item
All N ¼ 5804 (%)
Girls n ¼ 2991 (%)
Boys n ¼ 2793 (%)
10–12 years n ¼ 782(%)
13–15 years n ¼ 4198 (%)
16–19 years n ¼ 814 (%)
1. Miserable or unhappy 2. Didn’t enjoy anything 3. Tired 4. Restlessness (couldn’t sit still) 5. No good 6. Cried a lot 7. Poor concentration 8. Hated myself 9. Bad person 10. Lonely 11. Unloved 12. Never be any good 13. Did everything wrong
41.9 26.1 46.9 44.2 23.6 18.7 43.2 19.6 22.3 29.4 15.5 20.8 18.1
54 28.8 51.5 48.5 29.9 26.6 49.5 27.4 29.0 36.7 19.9 26.4 22.2
29 23.2 42 39.6 16.8 10.4 36.4 11.2 15.1 21.5 10.9 14.9 13.7
34.4 26.2 41.2 38.6 22.6 16.2 44.4 18.8 17.5 27.6 16.6 23.8 17.9
42.3 24.8 50.7 49.4 23.9 14.3 46.3 19.2 19.0 26.5 15.9 20.1 16.9
46.8 32.6 33.2 23.0 22.7 44.1 26.0 22.5 43.9 45.9 12.5 22.0 24.8
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SMFQ, Short Mood and Feelings Questionnaire.
Parent consent was needed for adolescents younger than 16 years.
Results The distributions of participants by sex, age group, school size and location (urban versus semirural/rural) as well as mean total SMFQ scores are presented in Table 1 for the total sample. Boys displayed a small U-shaped form whereas girls displayed a linear positive relationship between age group and SMFQ scores (see Fig. 1).
A more detailed analysis showed that only girls increased their experience of ‘‘Miserable and unhappy’’ and ‘‘Hated myself’’ from 10–12 years of age to older age but also increased ‘‘Didn’t enjoy anything’’ between middle and late adolescence. During the latter time interval both sexes increased their reports of ‘‘Cried a lot’’, ‘‘Bad person’’, ‘‘Lonely’’, and ‘‘Did everything wrong’’ but also a decrease of experience of ‘‘Poor concentration’’. Both sexes reported an increase of feelings of ‘‘Tired’’ and ‘‘Restless’’ between early and middle adolescence, then a decrease of these symptoms. Changes in the other three items, ‘‘Unloved’’, ‘‘Never be any good’’ and ‘‘No good’’ between age groups were minor.
Endorsement of SMFQ items High depressive symptom levels Proportions of students who reported ‘‘somewhat true’’ (1) and ‘‘true’’ (2) on the 13 items are presented in Table 2. The most commonly reported items in the whole sample were: ‘‘Miserable or unhappy’’, ‘‘Tired’’, ‘‘Restlessness’’ and ‘‘Poor concentration’’ (see Table 2). Girls reported significantly higher levels on all 13 items compared with boys, with strong relationships between sex and SMFQ item endorsement (all p values 50.001). Two items, ‘‘Miserable and unhappy’’ and ‘‘Didn’t enjoy anything’’, reflect the primary DSM-criteria for major depression. For the former, 54% of girls endorsed high levels compared to 29% of boys, whereas for the latter item, the gender difference was smaller at 28.8% versus 23.2%, respectively. The oldest age group (ages 16–19 years) reported high levels significantly more often than the younger ones on the following items: ‘‘Didn’t enjoy anything’’, ‘‘Cried a lot’’, ‘‘Bad person’’, ‘‘Lonely’’, and ‘‘Did everything wrong’’. The two oldest age groups (ages 13–15 and 16–19) also endorsed high symptom levels on ‘‘Miserable and unhappy’’ significantly more frequently than the youngest ones. For the items ‘‘Tired’’ and ‘‘Restless’’, about half of the middle age group (13–15) reported high levels being significantly different from the youngest age group (10–12), who in turn reported such levels significantly more often than the oldest age group. High levels of ‘‘Poor concentration’’ were reported significantly more frequently by the two youngest age groups compared to the oldest.
Using a cut-off point of 11, 11.2% in the total sample had high and 88.6% had low SMFQ levels. Of the girls, 16% scored high, as did 6.1% of the boys, a significant difference, 2 (1) ¼ 144.14, P50.001. A significant age difference, 2 (1) ¼ 12.16, P50.01, was also found in that 14.6% of the students aged 16–19 years reported high scores compared to 10.8% among 13–15-year olds and 9.6% among 10–12-year olds. Students in counties 2 (12.3%) and 3 (14.4%) reported significantly higher proportions of high scores than those in county 1 (9.5%). However, school size and localization (urban versus semirural/rural areas) were not related to high SMFQ scores.
Prediction of total SMFQ scores by sex, age, school size and location A detailed preliminary check showed that the Poisson regression model was optimal based on deviance, AIC and BIC values. While sex, age group, school size and location were not significant predictors, all 13 SMFQ items significantly predicted total SMFQ scores (see Table 3).
One-year stability, incidence and predictors Differences in mean total SMFQ scores across a 1-year period were examined for 12–14-year olds and 13–15 olds in two of the samples. In both samples there was a significant time effect
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Figure 1. Total mean SMFQ scores by age group and sex.
in that on 1-year-older adolescents had significantly higher mean total SMFQ scores at the follow-up as compared to baseline (sample 1: M ¼ 4.94 versus M ¼ 3.98), t (2341) ¼ 10.29, P50.001; sample 2: M ¼ 5.84 versus M ¼ 5.07), t (906) ¼ 4.39, P50.001). Associations between low versus high levels on the SMFQ at the two test points were strong and significant (sample 1: 2 (1) ¼ 289.89, P50.001 and sample 2: 2 (1) ¼ 137.36, P50.001). Both samples increased the proportion of high scorers from baseline to the 1-year follow-up (sample 1: 8.6 15.5%; sample 3: 13.8 18.1%).
Stability and incidence of depressive symptoms In sample 1, 56.9% were high SMFQ scorers both at baseline and the 1-year retest, whereas 11.6% were incident cases over this period; in sample 2, the corresponding figures were 55.0% and 12.2%, respectively. The stability of being a high scorer at both assessments in sample 1 was higher among girls than boys (65.0% versus 28.9%) as was the incidence (17.0% versus 6.6%), and there were significant associations over the 1-year interval for both genders, (girls: 2 (1) ¼ 166.07, P50.001, and boys: 2 (1) ¼ 29.28, P50.001). While significant associations also were found for age group in sample 2, the differences in proportions were negligible. By contrast, the stability of being a high scorer in sample 2 was approximately the same for girls and boys (55.6% versus 51.7%), but the incidence was higher in
girls than boys (17.4% versus 6.6%), again with significant associations across the 1-year follow-up in both genders, (girls: 2 (1) ¼ 63.20, P50.001 and boys: 2 (1) ¼ 61.46, P50.001, respectively).
One-year multivariate prediction of depressive symptoms For sample 1, the omnibus test showed that the model was highly significant, 2 (16) ¼ 427.65, P50.001, with a Nagelkerke’s pseudo-R2 of 0.29 and a non-significant HosmerLemeshow’s test. Overall, the classification accuracy of students into low-moderate or high scorers was 86.7% but only 31.0% of those with high scores at the 1-year follow-up were correctly classified. Out of the 13 SMFQ items, three items listed in Table 4 were significant predictors of high scores one year later, while another three approached significance (p ¼ 0.06). For sample 2 the model was also significant, 2 (16) ¼ 199.00, P50.001, with a Nagelkerke’s pseudo-R2 of 0.32 and a significant Hosmer-Lemeshow’s test, 2 (8) ¼ 19.57, P50.05. Overall, the classification accuracy of students into low, moderate or high scorers was 83.4% but only 32.7% of those with high scores at the 1-year follow-up were correctly classified. While three of the SMFQ items at baseline emerged as significant predictors of low versus high SMFQ scores, they were different in the two samples.
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Table 3. Results of Poisson regression analysis of total SMFQ scores for all four samples combined (ages 10–19 years) (N ¼ 5783).
Sex Age School size Location (urban/semirural-rural) SMFQ item 1. Miserable or unhappy 2. Didn’t enjoy anything 3. Tired 4. Restless (couldn’t sit still) 5. No good 6. Cried a lot 7. Poor concentration 8. Hated myself 9. Bad person 10. Lonely 11. Unloved 12. Never be any good 13. Did everything wrong
OR (CI99%)
B
SE
0.01 0.85 0.05 0.05
0.10 0.21 0.11 0.10
0.89 1.09 1.05 1.05
(0.77–1.26)ns (0.64–1.85)ns (0.80–1.38)ns (0.82–1.35)ns
0.84 0.40 0.46 0.25 0.47 0.27 0.69 0.66 0.67 0.53 0.57 0.48 0.45
0.17 0.10 0.12 0.10 0.13 0.09 0.16 0.14 0.14 0.12 0.12 0.11 0.11
2.31 1.49 1.59 1.29 1.61 1.31 2.00 1.94 1.96 1.70 1.77 1.62 1.57
(1.50–3.58)** (1.17–1.90)** (1.16–2.17)** (1.00–1.65)* (1.16–2.22)** (1.03–1.67)* (1.34–2.98)** (1.36–2.77)** (1.39–2.78)** (1.24–2.33)** (1.31–2.38)** (1.22–2.15)** (1.19–2.07)**
*P50.01; **P50.001; ns, not significant. B, unstandardized beta coefficients; CI: Confidence interval; SE, standard error; OR, odds ratio; SMFQ, Short Mood and Feelings Questionnaire.
Table 4. One-year predictors of high versus low total SMFQ scoresa for samples 1 and 2 (ages 12–15 years) for sex and SMFQ items. Results of logistic regression analysis.
Sample 1 (n ¼ 2339) Sex SMFQ item 2. Didn’t enjoy anything 3. Tired 8. Hated myself 11. Unloved 12. Never be any good 13. Did everything wrong Sample 2 (n ¼ 926) Sex SMFQ item 1. Miserable or unhappy 11. Unloved 12. Never be any good 13. Did everything wrong
B
SE
OR (CI95%)
0.89
0.15
2.42 (1.81–3.24)***
0.49 0.58 0.26 0.28 0.60 0.33
0.18 0.16 0.14 0.15 0.17 0.18
1.64 1.79 1.30 1.33 1.82 1.40
0.69
0.23
2.00 (1.28–3.12)**
0.67 0.72 0.53 0.53
0.25 0.29 0.28 0.27
1.95 2.06 1.69 1.70
(1.16–2.31)** (1.31–2.45)*** (0.99–1.69)b (0.98–1.80)b (1.30–2.55)** (0.99–1.97)b
(1.19–3.20)** (1.17–3.61)* (0.97–2.94)b (1.00–2.91)*
a
Using a cut-off of 11 on total SMFQ scores. P ¼ 0.06. *P50.05; **P50.01; ***P50.001. B, unstandardized beta coefficients; CI, confidence interval; OR, odds ratio; SE, standard error; SMFQ, Short Mood and Feelings Questionnaire.
b
Depressive symptoms over a 6-year interval The results showed that differences in total mean SMFQ scores (M ¼ 4.10 versus 4.23, respectively) and proportions of high scorers (9.3% versus 11.0%, respectively) across the 6-year time period in the two samples of 12–14-year olds were not significant.
Discussion First, our results showed that total mean SMFQ scores varied from 4.1 to 5.2 in the four samples with a strong sex difference. The difference in proportion of adolescents reporting high levels of total SMFQ scores (using a cut-off of 11) was even
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more striking with 16% of girls as compared to 6.1% of boys. Older adolescents reported a greater prevalence of high scores (14.6%) than those in mid adolescence (10.8%) who in turn had somewhat higher levels than the youngest group (9.6%). Whereas all SMFQ items significantly predicted total scores in our cross-sectional analysis, overall the relationships were modest, with adjusted ORs varying from 1.11 for ‘‘Unloved’’ to 1.48 for ‘‘Miserable and unhappy’’, one of the core ICD/DSM symptoms of depression. In comparison with outcomes of similar large scale epidemiological surveys conducted in the USA and Australia, our mean total SMFQ values were lower than those reported for somewhat younger students by McKenzie and collaborators (7), and somewhat higher than reported by Angold et al. (4) for a broader age range (8–17 year olds) in the Eastern USA, with reported SMFQ means of 3.8 and 3.2 for girls and boys (in both samples), respectively. In these studies a striking difference at the age of 12 was noted after which point girls reported increasing levels of depressive symptoms, whereas boys reported somewhat decreasing levels. Our results support these findings, however, with a small U-shaped age curve for boys and a linear relationship between age and SMFQ scores for girls. In the present study we used a cut-off score of 11 on the SMFQ mean totals to increase comparability of outcomes with the community studies conducted in the USA and Australia (4,5,7). Here, 11.2% of all students aged 10–19 years reported high SMFQ levels roughly corresponding to the 90th percentile with a strong preponderance of girls (16%) compared to boys (6.1%). The proportion of high scorers also increased by age. In the study by Angold et al. (4), 6% of the 8–17-year-olds were high scorers, with the proportion of girls being about twice (7.5%) the for boys (3.5%). The finding of a lower proportion of high scorers and lower SMFQ total means are reasonably expected given that a younger group of children were also included in the Angold et al. (4) study than in our study. By contrast, McKenzie et al. (7) found that about a quarter of the somewhat younger adolescents experienced high levels of depressive symptoms on the SMFQ (using the same cut-off score of 11). Given the similarities in school-based sampling strategies in McKenzie et al. (7) and the present large-scale study, we can only assume that the differences in outcomes are likely to depend on variations in cultural and socio-economic factors. It should be noted that recommended optimal cut-off points for total SMFQ scores based mostly on ROC analyses have varied greatly from 4 to 12 in various studies (11,13,15,26,27). Clearly more research is needed to obtain more solid information on optimal cut-off points, in particular when differentiating adolescents with a depressive disorder from those who are not depressed. A consistent finding in the present study was that girls reported higher levels on all 13 SMFQ items than did boys. Angold et al. (4) reported an entire shift to the right in the distribution of SMFQ scores in older girls, not only of extreme scores in a small group of individuals. Here, the most commonly endorsed items on the 13 SMFQ items, were ‘‘Miserable or unhappy’’, ‘‘Tired’’, ‘‘Restlessness’’ and ‘‘Poor concentration’’, while the item ‘‘Didn’t enjoy anything’’ (anhedonia) was endorsed by a smaller portion of adolescents
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(26%). Reports of being ‘‘Miserable or unhappy’’ were also more common among older adolescents in contrast to the other three common items which were more prevalent in early and mid adolescence. Only girls increased their experience of ‘‘Miserable and unhappy’’ and ‘‘Hated myself’’ from early to mid adolescence, while reports of feelings of anhedonia (‘‘Didn’t enjoy anything’’) increased later on up to late adolescence. It is likely that changes in these symptoms primarily reflect specific hormonal changes during puberty in girls (28,29), and that the emergence of other depressive symptoms included in the SMFQ relate more to sociocultural and peer influences. In further analysis of 1-year predictors in two of the samples, the risk for being a high scorer was about twice as high for girls than boys. However, while three of the SMFQ items were found to be significant predictors of low versus high scores at the 1year follow-up, they differed in contents, with one common item in each sample reflecting feelings of self-depreciation. In the school-based survey of adolescents aged 10–15 years in the general population in Australia and the USA, McKenzie and colleagues (7) also noted that ‘‘Hated myself’’ was most predictive of high depressive symptom levels 1 year later. Two other combinations of SMFQ items were also predictive: ‘‘Never be any good’’ and ‘‘Unloved’’ in the first combination, and ‘‘Tired’’ together with ‘‘Never be any good’’ in a second combination. In a longitudinal study of adolescents conducted in a longer perspective, Wilcox and Anthony (18) reported that persistent feelings of worthlessness and anhedonia were highly predictive of major depression in adulthood. Feelings of sadness and moodiness have also been found to be highly predictive of adolescent depression one year later (17). McKenzie and collaborators emphasized that other symptoms not reflecting core problems and symptoms in the ICD and DSM diagnoses of depression, such as feelings of being unloved, are also important to consider in the assessment of adolescents. Our study results support these findings and underline how feelings of worthlessness, but also possible early signs of cognitive distortions such as ‘‘Feeling unloved’’ are forerunners of high levels of depressive symptoms later on in these age groups. We further noticed that estimates of depressive symptoms over a 6-year period in the same health region were largely unchanged among 12–14-year olds. This finding concurs well with outcomes of prevalence studies of depressive disorders (3), in which minor changes were observed in prevalence rates among children born during a 30-year period. One limitation of the present study was that different age groups were recruited from different parts of the region and at different times during the 10-year period. However, depressive symptom levels were consistent across time and areas within this region. The response rates in the four samples and crosssectional surveys also varied from 71–88%, and in the 1-year follow-ups they were 77–84%. Dropout rates were partly due to the requirement of obtaining parent consent for younger adolescents. Here only adolescent reports of depressive symptoms were used and the cut-off criterion was based on findings in previous surveys conducted in Australia and the UK. The strengths of the present study covering the whole period of adolescence were the large combined sample of
adolescents recruited in the same health region in the middle of Norway during a 10-year period. The validity of our findings is strengthened by the inclusion of one of the largest cities in Norway, towns of various sizes and semirural/rural areas covering the whole health region.
Conclusions The SMFQ is a very practical measure that can be easily completed by children aged 8 years and older in 5 minutes in busy clinical settings and in community-based surveys. To the best of the authors’ knowledge, it is also the shortest existing standardized measure to assess depressive symptoms in children and adolescents. The results of the present study can serve as reference data in the assessment of adolescents in clinical and primary care settings as well as in controlled trials. Further validation of the SMFQ is needed to improve information on its discriminative power in clinical settings but also to obtain more precise information on optimal cut-off scores.
Acknowledgements The authors gratefully appreciate the assistance of all school personnel and the cooperation of all students participating in the various surveys conducted over the 10-year period.
Declaration of interest The data collection was partially funded by financial support from various sources, the Norwegian Research Council (NFR), the National Council for Mental Health Norway, SINTEF Unimed, Department of Child and Adolescent Psychiatry at St. Olav Hospital, the Norwegian University of Technology and Science (NTNU) in Trondheim, and the Department of Research and Development at Helse-MR in A˚lesund.The authors declare that they have no other conflict of interest.
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