Depression and comorbidities in children and adolescents Yokohama City University Hospital Dept. of child and adolescent psychiatry M.D. Ph.D. Junichi Fujita

Conflicts of Interest (COI) No potential COI to disclose.

Objective It is important for mental health practitioners to focus on depressive disorder among children and adolescents. A previous study showed 40-90% of youth with depressive disorders also have other psychiatric disorders. Their symptoms often differ from adults as children are unable to express their feelings or emotions well. As comorbidities often increase disease burden, a careful assessment is crucial.

Case (10 y.o. boy) 　His mother suffers from schizophrenia, and his father is often violent and under the influence of alcohol. He was abused physically and also psychologically. He exhibited problem behavior such as shoplifting because of hunger and throwing stones at neighbors. His situation was reported to child protection services. He was placed in a foster a home at age 8.

Case (10 y.o. boy) 　　Shortly after entering the foster home, he began to bother other children, and disrupt the classroom with behavior such as singing. It got worse after we was warned. He took out scissors and attempted suicide, wet his bed almost every night, and lost his appetite. School teachers and foster home staff were worn out. He was taken to a psychiatric clinic at age 10.

Case (10 y.o. boy) 　 During the first visit, he tried to express, with his gestures and limited vocabulary, how much he was doing and the things he was good at. This made the staff at the foster home smile. However, once he started talking about his father, he became tearful and spoke in fragments saying. “Dad hit me with a stick or poked my hand with a pencil.” Shoulder shaking and blinking tics were prominent.

Case (10 y.o. boy) Major depressive disorder Post traumatic stress disorder Attention deficit hyperactivity disorder Mild mental retardation (IQ65) Tic disorder Diagnosis Intervention Trauma focused CBT Atypical anti-psychotics, α2A adrenergic agonists

Aim of the study The focus is on comorbid mental disorders, or related conditions among child and adolescent patients in Yokohama city, Japan who suffer from depression.  

Methods We conducted a cross-sectional study of psychiatric first referrals, aged 10-18, at two general child and adolescent mental health services in Yokohama city. 374 patients visited these hospitals, from April 2016 to March 2017. Of these, 363 patients, who presented with various conditions that are described by ICD-10, were analyzed via interview sheets and medical records. Clinical characteristics of patients with depressive disorder, followed by comorbid psychopathology were investigated.

Yokohama Population: 3.7million Size: 437 km2 Elementary school: 340 Berlin Population:3.5million Size: 892km2 Yokohama Population: 3.7million Size: 437 km2 Elementary school: 340 Junior High school: 145 Tokyo Two general hospitals belonging to Yokohama City University (YCU) covers south part of this area. YCU Hospital YCU Medical C.

Result-1 Prevalence of depressive disorder F32 Major depressive disorder 26/41(63.4%) F34 Persistent mood disorder 11/41(26.8%) F33 Major depressive disorder, recurrent 4/41(9.8%) N=363

Result-2 Characteristics (Age, Sex, Living conditions) Depresssive disorder Other diagnosis (N=41) (N=322) Mean SD Age (Years) 14.3 2.3 13.3 2.1 N % Fisher exact test Sex (Male) 19 50.0 170 52.3 Living Conditions Living with both parents 33 80.5 247 79.7 Psychiatric disease with first relatives 11 26.8 75 23.3 Abused 12 29.3 48 15.0 p<0.05

Result-3 Characteristics (Depression severity) Depressive disorder Other diagnosis (N=41) (N=322) Patient Health Questionaire-9 (PHQ-9) N % chi-square test Score 0-14points, None～moderate (n=191) 13 31.7 178 55.2 15-27 points, Moderately severe ～Severe (n=71) 16 39.0 55 17.1 unknown (n=101) 12 29.3 89 23.4 p<0.01 Focusing on patient’s subjective depressive severity…

Result-4 Comorbid psychopathology among depressed patients PHQ-9 15-27 points 0-14 points N % chi-square test Self-harm behavior (n=71) (n=189) 28 29.6 21 11.1 p<0.01 Suicide attempt (n=69) (n=190) 14 19.7 4 2.1 Auditory verbal hallucinations (n=187) 18 25.3 11 5.9 Visual hallucinations (n=70) 20.0 22 11.6 Alcohol or tobacco use (n=68) 7 10.3 3 1.6 　 Violent behavior (n=191) 35 49.3 57 29.8 P<0.01 School absenteeism (>30days) 32 45.1 71 37.2 n.a 　 Anxiety (GAD-7>9) (n=182) 55 78.6 29 15.9 (0-14points, None～Mod., 15-27points, Mod. severe ～ Severe) GAD-7: Generalized Anxiety Disorder Assessment -7

3rd. Depressive disorder (F3) : 16/71(22.5%) Result-5 Diagnosis for patients who are moderately severe, or severe depressed (N=71), Top 4 1st. Neurotic, stress-related and somatoform disorders (F4) : 35/71 (49.3%) 2nd. Disorders of psychological development(F8) + ADHD (F90) : 20/71(28.2%) 3rd. Depressive disorder (F3) : 16/71(22.5%) 4th. Eating disorder (F5): 5/71(7.0%)

< 10 % Prevalence of mood disorder in Japan (10-14 y.o.) A myth, “Children don’t get depression” Atypical symptoms among youth In U.S., 2015 < 10 % Prescription warning for anti-depressants to youth There may be some false negative diagnosis among GPs in Japan… Patient survey 2014, Ministry of Health, Labor and Welfare, Japan

Summary Almost one-tenth of patients aged 10-18 y.o. were diagnosed with depressive disorder. Child abuse was associated with depressive disorder. Patients with depressive disorder answered they were suffered from relatively severe depressive state. Relatively severe depressive state associated with suicidal behavior, psychotic symptoms, anxiety, violent behavior, or substance usage. Patients with relatively severe depressive state often comorbid neurotic disorders, developmental disorders, and others.

Conclusion Regardless of the diagnosis, clinicians should assess depressive state carefully and routinely depressive state among child and adolescent. As depressive state comorbid with relatively serious psychopathologies, such as suicidal behavior.