Posttraumatic stress disorder and the use of health services.

OBJECTIVE: Prior research has demonstrated increased use of medical services among persons with anxiety and depression. This investigation examined the possible association of posttraumatic stress disorder (PTSD) with the use of nonmental health services. METHOD: A case-comparison design enrolled 102 high users of health services and 54 low users who were assessed for PTSD diagnosis and severity of PTSD symptoms. Subjects were male veterans receiving services from the primary care clinics of the VA Boston Healthcare System during an 18-month period. Data were collected by interview by use of standardized instruments including the Clinician Administered PTSD Scale for DSM-IV, the Life Events Checklist, and the Beck Depression Inventory. Data analysis employed odds ratios, linear and logistic regression, and path analyses. RESULTS: High users of health care were almost twice as likely as low users (27.5% vs. 14.8%) to meet diagnostic criteria for current PTSD. The two groups differed significantly on both symptom frequency and intensity. Path analyses showed an indirect positive association between PTSD and health services use, with physician-diagnosed health conditions as a mediating variable. Auxiliary analysis demonstrated that the combined mental health burden of PTSD and depression symptoms also is positively associated with number of health conditions. CONCLUSIONS: The findings indicate that PTSD, alone and in combination with depression, has a direct negative relationship with physical health that, in turn, is associated with more frequent use of primary health care services. These results do not suggest that PTSD leads to inappropriate (eg, distress-motivated) use of services.

Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents.

OBJECTIVE: This study ascertained the prevalence of posttraumatic stress disorder (PTSD) among chemically dependent adolescents and identified factors that influence the risk of PTSD after a qualifying trauma. METHOD: The study group consisted of 297 adolescents aged 15-19 years who met the DSM-III-R criteria for dependence on alcohol or other drugs and who were receiving treatment in seven publicly funded Massachusetts facilities. PTSD and other axis I diagnoses were assessed by the Diagnostic Interview Schedule. Data on risk factors were collected by a specially constructed interview schedule. RESULTS: The lifetime prevalence of PTSD was 29.6% (24.3% for males and 45.3% for females), and the current prevalence was 19.2% (12.2% for males and 40.0% for females). These prevalences reflect a high occurrence of traumatic exposures and a high case rate among those who experienced trauma. The risk of PTSD varied with the nature of the trauma, the number of traumas experienced, psychiatric comorbidity, and familial characteristics. The higher rate of PTSD among females was due to a greater frequency of rape, which carries a high risk of PTSD development, and to a high rate of comorbid conditions. CONCLUSIONS: The lifetime prevalence of PTSD among these chemically dependent adolescents is five times that reported for a community sample of adolescents. This extremely high rate provides new understanding of the etiologic connection between PTSD and chemical dependence and has implications for their treatment.

Suicidal ideation and attempts among chemically dependent adolescents.

OBJECTIVES: Suicidal ideation and attempts were examined in a population of chemically dependent adolescents, a group at high risk of self-destructive behavior. METHODS: The prevalence and correlates of suicidality and of major depressive disorder were assessed by the Diagnostic Interview Schedule and a structured family and social history interview with 300 addicts aged 15 through 19 years. RESULTS: Suicidal ideation was reported by 31% to 75% of the subjects and suicide attempts were reported by 28% to 61%, with females predominating. Thoughts of suicide combined with prolonged thoughts of death in general and a desire to be dead were highly associated with suicide attempts. Exposure to physical or sexual abuse was associated with a significantly increased risk of suicide attempts for males but not for females. CONCLUSIONS: The probability of a suicide attempt increases when thoughts of suicide coincide with morbid ideation of extended duration, suggesting that risk assessment should be based on duration as well as presence of morbid thoughts. Substance abuse treatment requires an assessment of suicidal potential and counseling for those whose potential is high, with special attention to males exposed to abuse.

Depressive symptoms and employment status among Belgian adolescents.

The association of employment status and depressive symptoms was assessed by means of the Center for Epidemiological Studies-Depression (CES-D) scale in a population of 898 male and female subjects aged 16 to 21. The unemployed subjects (N = 300) scored significantly higher on depressive symptoms than did the students (N = 300) or the employed workers (N = 298) even when gender was controlled. Although the quantity of depressive symptoms differed, the nature of the symptoms experienced was similar in the three groups. Affective symptoms were more common than symptoms in somatic or interpersonal areas, suggesting that in adolescence and young adulthood there is a high degree of affective disturbance. We conclude that primary unemployment is associated with a substantial degree of depressive morbidity.

Depressive illness among chemically dependent adolescents.

OBJECTIVE: The purpose of this study was to investigate the prevalence and correlates of depression among adolescents being treated for chemical dependence. METHOD: Using the National Institute of Mental Health Diagnostic Interview Schedule, the authors interviewed 223 adolescents, aged 15-19 years, who were in residential treatment for alcohol or drug dependence diagnosed according to DSM-III-R criteria. Data on sociodemographic characteristics, school and social performance, past history, family composition, familial alcohol and drug abuse, and previous victimization of the subjects were also gathered. RESULTS: Fifty-four (24.7%) of the subjects met the DSM-III-R criteria for depression. Very few of the traditional correlates of depression discriminated depressed from nondepressed subjects, suggesting that the presence of chemical dependence overrides other predictors of depression. Only female gender, paternal psychopathology, and victimization (physical abuse, sexual abuse) emerged as important variables associated with depression. However, subjects whose onset of depression preceded their chemical dependence had different characteristics from those whose depression began after their chemical dependence. CONCLUSIONS: The prevalence of depressive illness in these chemically dependent adolescents was approximately three times that reported for nonreferred groups of similar age. This high rate of depression reflects the contributions of two distinct groups--those with primary depression and those with depression subsequent to chemical dependence--whose characteristics differed, suggesting the possibility of two pathologic processes, similar in manifestation but with different associated features and possibly with distinct etiologies. Confirmation of these findings in further research could indicate that the two forms of depression may require different treatment approaches.

Suicidality, depression, and substance abuse in adolescence.

The authors assessed the occurrence of suicidal ideation, suicide attempts, major depression, and substance abuse in a sample of 424 apparently healthy college students 16-19 years old. Major depression and substance abuse were independent and interactive risk factors for suicidal ideation and for suicide attempts; substance abuse had a particularly deleterious effect on men. A prolonged desire to be dead was a more specific risk factor for a suicide attempt than was a thought of suicide. The authors conclude that suicidal ideation in the presence of major depression and/or substance abuse in older adolescents should call forth greater concern for lethality.

Adolescent depression, alcohol and drug abuse.

The Diagnostic Interview Schedule was employed to ascertain the prevalence of major depressive disorder (MDD), alcohol and substance abuse in a sample of 424 college students aged 16 to 19 years. Applying DSM III criteria, the prevalence of MDD was 6.8 per cent; of alcohol abuse, 8.2 per cent; and of substance abuse 9.4 per cent. Alcohol abuse was associated with MDD, but not with other psychiatric diagnoses. Substance abuse was associated both with MDD and with other psychiatric diagnoses as well. The onset of MDD almost always preceded alcohol or substance abuse suggesting the possibility of self-medication as a factor in the development of alcohol or substance abuse.

Adolescent suicidal and self-destructive behavior. Results of an intervention study.

This study evaluates an intervention program designed to reduce suicidal, self-destructive behavior among high-risk adolescents aged 13- to 17 years. The intervention combined a program of community education and direct service to youth who had required emergency care for self-inflicted injuries. The intervention program was effective in increasing subjects' compliance with medical regimen. To a lesser degree, the intervention also facilitated early help seeking among adolescents with suicidal thoughts and appeared to diminish slightly the overall occurrence of emergency room admissions for suicidal behaviors. However, the intervention program had no demonstrable effect on the occurrence of repeat suicidal episodes.

A pilot study of the effect of exposure to child abuse or neglect on adolescent suicidal behavior.

The authors designed a pilot study to test if exposure to child abuse or neglect is associated with suicidal behavior in adolescence. Each of 159 adolescents who had attempted suicide was age- and sex-matched with two comparison subjects who had been treated for medical conditions unrelated to suicide attempts. The registry of the Massachusetts Department of Social Services was searched for the names of the subjects and comparison subjects. For both sexes prior contact with the Department of Social Services was three to six times more likely for probands than for the comparison subjects.

Risk factors for depression in adolescence.

Public health concern regarding depression has recently increased as a result of the rise in the rate of adolescent suicide, with a probable concomitant rise in the rate of depression in this age group. The rise appears to be both a period effect, in that increased rates are now observed across age categories, and a cohort effect, in that being born after 1960 also contributes to the increase. The clinical phenomena and epidemiology of depression in adolescence are reviewed. Diagnostic criteria for depressive mood and depressive syndrome are similar to those in adults. However, the predictive value of a depressive episode in adolescence, and whether the occurrence of depression in adolescence is a transient developmental experience or whether it predicts a particular subtype of future depression, are at present unknown. The familial, social and personal risk factors for adolescent depression are reviewed, The major factors are: parental history of affective illness, childhood experience of parental loss, and female gender. Other factors, such as birth order and sibling factors, socio-economic status, race, religion, geography, concomitant medical illness, intelligence, career aspirations, substance abuse and life events, are reviewed, although their relative contributions as risk factors are less clear-cut. It is proposed that cross-sectional, retrospective and longitudinal studies are required to clarify important areas of uncertainty.

Non-fatal suicidal and life-threatening behavior among 13- to 17-year old adolescents seeking emergency medical care.

In suicidal behavior emergency room admissions of 13- to 17-year olds at the Brockton Hospital (Massachusetts), females predominated over males by almost two to one. For subclassification of life-threatening behaviors, frequency was about the same for males and females, but for suicide attempts and suicide gestures, female frequency was two to four times that of males. Repeat episodes of self-inflicted injury were more common among females. The type of the initial episode was a powerful predictor of a repeat occurrence.

Pregnancy, delivery, and neonatal complications among autistic children.

An investigation of the prenatal, delivery, and neonatal experience of 145 autistic children matched with 330 unaffected siblings revealed that among the propositi there was a preponderance of first-born children. Obstetrical records, which had been made prior to the diagnosis of autism, indicated that autistic children were more likely than their siblings to have experienced at least one untoward event during their mothers' gestations and deliveries. Similarly, the autistic children had an increased risk of neonatal complications. Despite the significant excess of total reproductive complications in the autistic series, there was no single event or a combination of biologically related complications that could reasonably account for any large number of cases of autism. While it is possible that autism may be the product of several diverse deleterious events experienced in utero, during delivery, or in the early neonatal period, our finding could be a chance occurrence or could signal the presence of a unknown factor responsible both for autism and for a variety of reproductive complications.

The incidence of seizures among children with autistic symptoms.

The authors examined 183 children with autistic symptoms and found that the age-specific incidence rates of seizures in this sample were between 3 and 28 times the rates for children in the general population. The subjects classified as totally autistic were at high risk of developing seizure from early childhood well into adolescence, but especially so at puberty. The partially autistic children had an increased risk of seizures only up to age 10. The authors suggest that the high incidence of seizures at puberty observed in this study may be specific to children with total autistic symptomatology and may represent a distinct pathological process associated with autism.