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

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

3. 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.

4. 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.

5. 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.

6. 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.

7. 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

8. 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.

9. 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.

10. 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.

11. 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

12. 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

13. 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…

14. 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

15. 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%)

16. < 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

17. Summary
Almost one-tenth of patients aged 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.

18. 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.