- Email: [email protected]
Ethnicity, 2011–2012
Journal of Adolescent Health 62 (2018) 716–721
www.jahonline.org Original article
Estimated Prevalence of Psychiatric Comorbidities in U.S. Adolescents With Depression by Race/Ethnicity, 2011–2012 Bridget E. Weller, Ph.D. a,*, Kathryn L. Blanford a, and Ashley M. Butler, Ph.D. b a b
Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, Texas
Article history: Received June 19, 2017; Accepted December 13, 2017 Keywords: Adolescent; Depression; Comorbid: Race; Ethnicity
A B S T R A C T
Purpose: Comorbid psychiatric conditions in adolescents with depression are a public health concern. However, little is known about the prevalence of comorbidities in separate racial/ethnic groups. This study estimated the national prevalence of comorbidities for black, Hispanic, and white adolescents separately, and compared the prevalence of comorbidities between adolescents with and without depression. Methods: This secondary analysis used data from the 2011–2012 National Survey of Children’s Health, a nationally representative, cross-sectional survey of U.S. youth. We restricted the sample to 12–17 year olds, and obtained unweighted and weighted descriptive statistics. Using weighted probit regression models, we examined differences in prevalence of comorbidities by adolescents with and without depression for each racial/ethnic group. Results: For black, Hispanic, and white adolescents with depression, the prevalence of comorbidities ranged from 8% to 61% and varied by race/ethnicity (e.g., depression and anxiety were comorbid for 47% of black, 54% of Hispanic, and 59% of white adolescents). For all racial/ethnic groups, adolescents with depression had a higher prevalence of attention deficit hyperactivity disorder than adolescents without depression. However, only black and Hispanic adolescents with depression had a significantly higher prevalence of anxiety and behavior problems than their counterparts without depression. In each racial/ethnic group, the prevalence of autism spectrum disorder did not differ between adolescents with and without depression. Conclusions: This study detected important differences in the prevalence of comorbid psychiatric conditions by race/ethnicity. Findings highlight the need for targeted interventions for black and Hispanic adolescents with depression that concurrently treat anxiety and behavior problems. © 2018 Society for Adolescent Health and Medicine. All rights reserved.
In the United States, comorbid psychiatric conditions among adolescents with depression are a major public health concern [1,2]. In fact, compared with adolescents without depression, ado-
Conflicts of Interest: The authors have no financial relationships relevant to this article to disclose. * Address correspondence to: Bridget E. Weller, Ph.D., Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, 2608 Erwin Road, Pavilion East Suite 300, Durham, NC 27705-4596. E-mail address: [email protected] (B.E. Weller). 1054-139X/© 2018 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2017.12.020
IMPLICATIONS AND CONTRIBUTION
The prevalence of comorbid psychiatric conditions is not uniform across racial/ethnic groups. Findings extend previous research by underscoring the importance of examining racial/ethnic groups separately in studies that investigate comorbid conditions among adolescents with depression.
lescents with depression face two to three times greater risk for anxiety, attention deficit hyperactivity disorder (ADHD), and behavioral disorders [3–5]. Further, 10% of youth with depression also have an autism spectrum disorder [6–9]. Although studies have illuminated a relatively high prevalence of some comorbid conditions in adolescents with depression, compared with adolescents without depression using racially/ethnically diverse samples, little is known about the pattern of comorbid conditions in specific racial/ethnic groups of adolescents with depression. This gap in knowledge is of concern because it may hide
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differences that have important consequences in the development and availability of tailored preventive and treatment programs. Examination of comorbid conditions in separate racial/ ethnic groups of adolescents with depression is important considering that racial/ethnic variations in comorbid disorders may contribute to disparities in mental health burden among minority youth and have corresponding treatment implications [10,11]. Although few studies have focused on depression in specific racial/ethnic groups of adolescents [12–14], one study found more severe depressive symptoms among black and Hispanic youth compared with white youth [15]. This finding suggests that the presentation of depression might not be uniform across racial/ ethnic groups. Identifying the prevalence of comorbid conditions by race/ ethnicity can aid in addressing gaps in knowledge and guide future mental health disparities research [16]. Specifically, few studies have examined the prevalence of comorbid conditions by race/ ethnicity [7,9,17], although examining differences in prevalence of conditions between groups is an objective of disparities research [16]. This gap leaves an important question unanswered: Do racial/ ethnic minorities with depression experience disproportionate rates of psychiatric comorbidities? Addressing this question will both expand current knowledge on the scope of comorbid conditions and potentially detect additional mental health disparities, which is a cross-cutting theme in the objectives set forth by the National Institute of Mental Health [18]. In turn, information on differential prevalence of psychiatric comorbidities can be useful to both nosology and development of targeted interventions for specific racial/ethnic groups [1,17]. Indeed, a report by the Institute of Medicine highlights the need to develop interventions that can address multiple comorbid conditions [19]. Understanding the prevalence of comorbid conditions in specific racial/ ethnic groups can help determine groups that may benefit most from interventions targeting multiple mental health conditions. National prevalence estimates of psychiatric comorbidities by race/ethnicity for adolescents with depression are particularly needed for ADHD, anxiety problems, autism spectrum disorders, and behavioral issues because these conditions are frequently diagnosed during adolescence [5,20,21], and the prevalence of these conditions, in absence of other psychiatric conditions, often vary by race/ethnicity [7,22,23]. We posit that the prevalence of these conditions will be higher in youth with depression compared with youth without depression, and that the pattern of these associations will be higher among black and Hispanic youth compared with white youth. Therefore, this study sought to first estimate the national prevalence of comorbid psychiatric conditions among U.S. adolescents with depression by race/ethnicity, and then compare the prevalence of these conditions between adolescents with and without depression. Methods This study used data obtained from the 2011–2012 National Survey of Children’s Health (NSCH), which is a nationally representative, cross-sectional survey of youth, 0–17 years old, living in the United States [24,25]. NSCH data were collected using a random-digit dial of landline telephone numbers and augmented with a similar sample of cellphone numbers in 50 states, such as Washington, D.C., and the U.S. Virgin Islands. The NSCH collected data from caregivers living at home together with the children; if multiple children resided in the household, one child was randomly selected as the study target and data were collected for that
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child. Protocols for data collection were approved by the National Center for Health Statistics at the University of Chicago [26]. The present study restricted the sample to adolescents between the ages 12 and 17 years (N = 30,605). We examined four possible comorbid conditions: ADHD, anxiety problems, autism spectrum disorders, and behavior/conduct problems. These conditions and the presence of depression were measured based on caregivers’ responses on two items. Caregivers first provided a yes/no response to the question, “Please tell me if a doctor or other health care provider ever told you that [CHILD’S NAME] had the condition, even if (he/she) does not have the condition now.” A positive response triggered a follow-up prompt for each condition, which was also a dichotomous yes/no question, “Does [CHILD’S NAME] currently have this condition?” We combined caregivers’ responses to these items to create a dichotomous variable representing whether the adolescent sample currently had a condition. We also examined demographic characteristics, including gender, age, parental education level, income, primary language spoken at home, and insurance status. To address the complex sample design, we conducted analyses using Mplus 7.4 [27]. In addition to sampling weights, we included weights attributable to cluster and strata [25], and obtained unweighted and weighted descriptive statistics. We also conducted multivariable probit regression models for each of the three racial/ethnic subgroups (i.e., black, Hispanic, white) to examine differences in the prevalence of conditions by adolescents with and without depression. We used weighted least squares with mean and variance adjustment estimation and specified theta parameterization [27]. Missing data, which were determined to be missing at random, were addressed using the full information method; subsequently, we did not exclude cases with missing data from multivariable models. Based on previous research, we included the following covariates as controls: gender (male and female), age (12–14 and 15–17), and caregiver’s highest level of education (lower than high school, high school graduate, and higher than high school) [4,5,28]. In addition, we conducted sensitivity analyses that included other possible controls such as primary language spoken at home (English and language other than English), insurance status (uninsured and insured), and income (i.e., based on federal poverty level; at or less than 100%, 100%–199%, 200%–299%, 300%–399%, and 400% or more of the poverty level). However, including these controls resulted in either a zero cell or a linear dependence. Results Our results represent the U.S. population of noninstitutionalized adolescents between the ages 12 and 17 years [24]. Although the majority of the study sample consisted of 69.9% white adolescents, it also included 9.4% black and 11.2% Hispanic adolescents. Subgroup analyses showed that among the sample of black adolescents, prevalence of depression was associated with age, income, and primary language spoken at home (see Table 1). In the sample of white adolescents, prevalence of depression was associated with age, poverty, and caregiver’s highest level of education. In the sample of Hispanic adolescents, prevalence of depression was associated only with age. Other demographic characteristics were not associated with prevalence of depression across racial/ethnic groups. Racial/ethnic differences were detected (1) in the prevalence of psychiatric conditions among adolescents with depression, and (2) in the comparison of the prevalence of psychiatric conditions between adolescents with and without depression (see Table 2). In addition, racial/ethnic differences were
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Table 1 Demographic characteristics of U.S. adolescents ages 12–17 by race/ethnicity Unweighted number (weighted %)a
Gender Female Ageb Young adolescent (12–14) Adolescent (15–17) Federal poverty level <100% 100%–199% 200%–299% 300%–399% ≥400% Highest level of educationcHigh school graduate Insurance Uninsured Primary language Other language a b c d
Black
Depression (n = 938)
Without depression (n = 22,709)
459 (50.6)
10,694 (48.1)
320 (33.7) 618 (66.3)
p Valued
Hispanic
Depression (n = 117)
Without depression (n = 3,069)
.59
62 (41.4)
1,427 (49.8)
.28
85 (59.7)
1,742 (48.8)
.26
10,430 (48.1) 12,279 (51.9)
<.001
43 (28.7) 74 (71.3)
1,498 (50.3) 1,571 (49.7)
<.01
54 (23.6) 100 (76.4)
1,852 (53.8) 1,766 (46.2)
<.01
182 (20.5) 192 (26.1) 157 (13.6) 97 (16.7) 291 (23.1)
1,610 (9.0) 2,655 (14.0) 3,859 (18.8) 3,762 (16.3) 10,318 (41.8)
<.001
54 (47.7) 24 (24.5) 14 (10.7) 13 (12.4) 10 (4.7)
839 (34.6) 639 (22.7) 455 (15.3) 314 (9.6) 731 (17.9)
.03
69 (55.1) 34 (19.6) 18 (10.1) 10 (10.0) 21 (5.2)
1,043 (39.0) 817 (25.0) 505 (13.1) 333 (7.3) 823 (15.6)
.08
50 (5.8) 180 (22.2) 626 (72.0)
487 (3.8) 2,980 (16.8) 18,608 (79.4)
<.02
11 (8.9) 29 (37.2) 56 (53.9)
184 (8.1) 639 (27.5) 1,870 (64.5)
.29
21 (32.8) 39 (25.2) 77 (42.0)
777 (35.9) 747 (23.5) 1,926 (40.6)
.79
.45
1 (1.1)
149 (4.5)
.14
11 (18.6)
433 (12.4)
.41
<.001
1 (.2)
40 (1.5)
.03
35 (35.1)
1,384 (50.5)
.12
22 (2.9) 1 (.0)
821 (4.2) 130 (.9)
Weighted percentage represents the U.S. population of noninstitutionalized adolescents. Age range based on developmental stages presented by the Center for Disease Control and Prevention. Highest level of education refers to the caregiver who completed the survey. Chi-square test is a weighted statistic.
p Value
Depression (n = 154)
Without depression (n = 3,618)
p Value
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White
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719
Table 2 Prevalence of psychiatric conditions among adolescents with and without depression by race/ethnicity Psychiatric conditions
Black Prevalencea Depression (n = 117)
ADHD Anxiety Autism spectrum disorder Behavioral or conduct problems Psychiatric conditions
63 (61.1) 59 (47.0) 12 (8.6) 65 (55.2)
276 (9.7) 42 (1.7) 36 (1.1) 118 (3.7)
Depression (n = 154)
Psychiatric conditions
1.587 (1.157, 2.016) 2.107 (1.291, 2.922) .969 (−.440, 2.378) 1.934 (1.422, 2.446)
<.001 <.001 .178. <.001
Adjusted probabilityb (95% CI)
p Value
63 (43.2) 92 (52.9) 11 (5.1) 53 (35.7)
1.442 (.876, 2.009) 2.097 (1.566, 2.628) .543 (−.097, 1.183) 1.637 (1.093, 2.182)
<.001 <.001 .096 <.001
Adjusted probabilityb (95% CI)
p Value
1.035 (.678, 1.391) 2.086 (−.608, 4.780) .716 (−.154, 1.587) 1.556 (−.325, 3.437)
<.001 .129 .107 .105
Without depression (n = 3,618) 235 (5.4) 87 (2.2) 40 (1.5) 83 (2.3)
White Prevalencea
ADHD Anxiety Autism spectrum disorder Behavioral or conduct problems
p Value
Hispanic Prevalencea
ADHD Anxiety Autism spectrum disorder Behavioral or conduct problems
Adjusted probabilityb (95% CI) Without depression (n = 3,069)
Depression (n = 938)
Without depression (n = 22,709)
407 (42.2) 561 (59.2) 102 (8.6) 281 (31.1)
2233 (10.9) 789 (3.3) 298 (1.9) 383 (2.1)
ADHD = attention deficit hyperactivity disorder; CI = confidence interval. a Prevalence includes the actual sample size (n) and weighted percentage. Weighted percentage represents the U.S. population of noninstitutionalized adolescents. b Adjusted probabilities control for gender, age, and highest level of education.
found at the overall subgroup level (i.e., youth with and without depression). For black adolescents with depression, the prevalence of ADHD was substantially higher (61.1%) than either Hispanic (43.2%) or white (42%) youth. However, among adolescents with depression, prevalence of anxiety was higher among Hispanic (52.9%) and white (59.2%) youth than black youth (47.0%). Similar prevalence rates of behavior problems were reported for white (31.1%) and Hispanic (35.7%) youth, whereas black youth (55.2%) had substantial greater prevalence of behavior problems. Prevalence of autism spectrum disorders was similar across black (8.6%), Hispanic (5.1%), and white (8.6%) youth. Further, as shown in Table 2, regardless of race/ethnicity, adolescents with depression had a higher prevalence of ADHD than their same-race/ethnicity counterparts without depression. Black adolescents with depression had a higher prevalence of anxiety (47.0%) and behavior problems (55.2%) than their same-race/ ethnicity counterparts without depression (Table 2). Similarly, as shown in Table 2, Hispanic youth with depression had a higher prevalence of anxiety (52.9%) and behavior problems (35.7%) than their same-race/ethnicity counterparts without depression. However, white adolescents with depression did not have a higher prevalence of anxiety or behavior problems than white adolescents without depression (see Table 2). Further, across all racial/ ethnic groups, prevalence of autism spectrum disorders did not differ between adolescents with and without depression. Discussion The present study estimated the prevalence of comorbid psychiatric conditions among U.S. adolescents with depression among black, Hispanic, and white adolescents separately, and compared the prevalence of these conditions between adolescents
with and without depression in each racial/ethnic group. Overall, we found a large proportion of youth with depression in each racial/ethnic group had comorbidities. For example, ADHD was comorbid with depression for 47% of black, 52% of Hispanic, and 44% of white adolescents. Further, within each of the racial/ ethnic groups examined, adolescents with depression were significantly more likely to have ADHD compared with adolescents without depression. Although anxiety and behavior problems were more prevalent among black and Hispanic adolescents with depression compared with their same-race counterparts without depression, this relationship was not found for white adolescents. Across all racial/ethnic groups, the presence of depression was not associated with an elevated prevalence of autism spectrum disorders. Combined, our results highlight the value of within-racial/ ethnic group analyses to expand previous research focused in samples of combined racial/ethnic groups [4,5,11]. Overall, the findings in this study indicate that the differences in the prevalence of comorbid conditions among adolescents with depression compared with adolescents without depression are not uniform across racial/ethnic groups. Given ADHD, anxiety, and behavior problems were more prevalent in black and Hispanic youth with depression compared with those without depression, future investigation should begin to examine risk factors and social determinants that contribute to multiple mental health conditions that may be more prevalent among or unique to minority adolescents [13]. Uncovering such risk factors can determine important targets of intervention to simultaneously address multiple mental health conditions among minority youth. Findings from this nationally representative sample are mostly consistent with those of previous studies that used national, clinical, and community samples [2,4,5,21,29]. For example, our
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finding that adolescents with depression were at risk of comorbid conditions were similar to those reported in a study using the National Comorbidity Survey–Adolescent Supplement (NCSAS), which examined a combined sample of racially/ethnically diverse youth [4]. However, our findings differed slightly from those of the NCS-AS study regarding which conditions were most prevalent. Whereas the authors of the NCS-AS study found behavior problems to be the most prevalent, followed by anxiety and then ADHD, we found the relative prevalence of these comorbid conditions varied by race/ethnicity. Indeed, black youth had a higher prevalence of behavior problems, followed by ADHD and then anxiety, whereas Hispanic and white youth had higher prevalence of anxiety, followed by ADHD and then behavior problems. Our results are also consistent with research on autism [7–9]: We found depression and autism spectrum disorders to be comorbid in 5%–8% of adolescents. These findings are important because they highlight the need to develop targeted interventions for black and Hispanic adolescents with depression to concurrently treat anxiety and behavior problems. Based on our findings, we offer several recommendations for researchers and practitioners developing interventions to address mental health disparities [18]. Similar to recommendations posited by the Institute of Medicine and Health Resources and Service Administration [30,31], we recommend that practitioners continue to undergo cultural-competency training that focus on how race/ethnicity affects adolescents; this approach might involve identifying cultural frames of reference and whether the presenting symptoms deviate from acceptable functioning and behavior based on those cultural standards [12]. Black and Hispanic youth would likely benefit from treatment approaches that address multiple mental health conditions given the higher rate of comorbid conditions in these racial/ethnic groups of adolescents with depression compared with those without depression. Furthermore, although all youth may benefit from treatment approaches that seek to overcome the negative contribution of risk environments to the development and persistence of multiple mental health conditions, black and Hispanic youth may benefit more from such approaches. This is because of the disproportionate burden of disease affecting racial and ethnic minority communities. Such approaches may include health literacy programs, training programs aimed at increasing the number of mental health providers from traditionally marginalized populations, and community-based interventions [30,31]. Although the present study contributes to the literature, it has several limitations. First, the data used were cross-sectional and based on whether the adolescent currently had a condition, and therefore, we were not able to examine the temporal order of the onset of mental health conditions. Second, the present study used caregiver reports of adolescents’ mental health, and research has indicated discrepancies in parent-reported versus adolescentreported mental health conditions [32–35]. Caregivers may under report internalizing disorders and over report externalizing disorders. Subsequently, interpretation of these findings reflects caregivers’ recall of doctor’s report rather than whether youth indeed have these conditions. In the future, studies should attempt to collect data from multiple sources to reduce the possibility of reporter bias. Third, the findings of the present study might, at least in part, be a reflection of nosology [1]. Fourth, the present study omitted other psychiatric conditions commonly diagnosed among adolescents, including eating disorders [36,37] and substance use disorders [38]. These conditions were omitted because the NSCH survey did not collect these data.
Notwithstanding these limitations, this study provides a foundation for future research. Specifically, our study should be replicated using national data collected directly from adolescents, with an emphasis on adolescents’ experiences with specific depressive disorders (e.g., major depressive disorder vs. disruptive mood dysregulation disorder) [39] and the level of severity of depression [4]. Such research may point to differential exposure to various social determinants of health, which may indicate that prevention and treatment efforts are such that the same program for one group of adolescents may not have the same effect as on another group. Further, research is needed to examine other racial/ethnic groups not included in this study [40] and should also use a nuanced approach to assessing race/ethnicity. For example, rather than using the broad ethnic classification of “Hispanic,” future research should consider to explore prevalence across specific racial/ethnic groups such as Mexican, Puerto Rican, or Cuban because the psychosocial background of a group might influence the prevalence of comorbid conditions. Future research should also examine whether racial/ethnic differences in comorbidities contribute to disparities in mental health burden to determine whether addressing mental health comorbidities may help eliminate disparities. This secondary analysis indicated that the differences in the prevalence of comorbid conditions among adolescents with depression, compared with adolescents without depression, are not uniform across racial/ethnic groups. The study findings extend previous research in this area by underscoring the importance of considering race/ethnicity when documenting comorbid conditions among adolescents with depression.
Funding Sources This work was supported by the Robert Wood Johnson Foundation [grant number 73839, 2016–2017].
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[25] Centers for Disease Control and Prevention, National Center for Health Statistics, State and Local Area Integrated Telephone Survey. 2011–2012 National Survey of Children’s Health frequently asked questions. April 2013. Available at: http://www.cdc.gov/nchs/slaits/nsch.htm. Accessed May 31, 2017. [26] National Center on Health Statistics. NCHS staff manual on confidentiality. 2004. Available at: https://www.cdc.gov/nchs/data/misc/staffmanual2004 .pdf. Accessed May 31, 2017. [27] Muthen LK, Muthen BO. Mplus user’s guide. 7th ed. Los Angeles: Muthen & Muthen; 1998–2015. Available at: https://www.statmodel.com/ download/usersguide/Mplus%20user%20guide%20Ver_7_r3_web.pdf. [28] Klostermann S, Connell A, Stormshak B. Gender differences in the developmental links between conduct problems and depression across early adolescence. J Res Adolesc 2016;26:76–89. doi:10.1111/jora.12170. [29] Cummings CM, Caporino NE, Kendall PC. Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull 2014;140:816–45. doi:10.1037/a0034733. [30] Office of the Surgeon General (US), National Institute of Mental Health (US). Mental health: Culture, race, and ethnicity: A supplement to mental health. A report of the surgeon general. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2001. Available at: https://www.ncbi .nlm.nih.gov/books/NBK44246/. [31] U.S. Department of Health and Human Services. HHS action plan to reduce racial and ethnic disparities: A nation free of disparities in health and health care. Washington (DC): U.S. Department of Health and Human Services.; 2011. Available at: https://minorityhealth.hhs.gov/assets/pdf/hhs/ HHS_Plan_complete.pdf. [32] Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychol Bull 1987;101:213–32. [33] De Los Reyes A. Strategic objectives for improving understanding of informant discrepancies in developmental psychopathology research. Dev Psychopathol 2013;25:669–82. doi:10.1017/S0954579413000096. [34] Rescorla LA, Ginzburg S, Achenbach TM, et al. Cross-informant agreement between parent-reported and adolescent self-reported problems in 25 societies. J Clin Child Adolesc Psychol 2013;42:262–73. doi:10.1080/ 15374416.2012.717870. [35] Breland-Noble A, Weller BE. Examining African American adolescent depression in a community sample: The impact of parent/child agreement. J Child Fam Stud 2012;21:869–76. doi:10.1007/s10826-011-9547-z. [36] Hughes EK. Comorbid depression and anxiety in childhood and adolescent anorexia nervosa: Prevalence and implications for outcome. Clin Psychol (Aust Psychol Soc) 2012;16:15–24. doi:10.1111/j.1742-9552. 2011.00034.x. [37] Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry 2011;68:714–23. doi:10.1001/archgenpsychiatry.2011.22. [38] Green KM, Zebrak KA, Fothergill KE, et al. Childhood and adolescent risk factors for comorbid depression and substance use disorders in adulthood. Addict Behav 2012;37:1240–7. doi:10.1016/j.addbeh.2012.06.008. [39] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington (DC): The Association.; 2013. [40] Whitbeck LB, Johnson KD, Hoyt DR, Walls ML. Prevalence and comorbidity of mental disorders among American Indian children in the Northern Midwest. J Adolesc Health 2006;39:427–34. doi:10.1016/j.jadohealth .2006.01.004.
www.jahonline.org Original article
Estimated Prevalence of Psychiatric Comorbidities in U.S. Adolescents With Depression by Race/Ethnicity, 2011–2012 Bridget E. Weller, Ph.D. a,*, Kathryn L. Blanford a, and Ashley M. Butler, Ph.D. b a b
Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, Texas
Article history: Received June 19, 2017; Accepted December 13, 2017 Keywords: Adolescent; Depression; Comorbid: Race; Ethnicity
A B S T R A C T
Purpose: Comorbid psychiatric conditions in adolescents with depression are a public health concern. However, little is known about the prevalence of comorbidities in separate racial/ethnic groups. This study estimated the national prevalence of comorbidities for black, Hispanic, and white adolescents separately, and compared the prevalence of comorbidities between adolescents with and without depression. Methods: This secondary analysis used data from the 2011–2012 National Survey of Children’s Health, a nationally representative, cross-sectional survey of U.S. youth. We restricted the sample to 12–17 year olds, and obtained unweighted and weighted descriptive statistics. Using weighted probit regression models, we examined differences in prevalence of comorbidities by adolescents with and without depression for each racial/ethnic group. Results: For black, Hispanic, and white adolescents with depression, the prevalence of comorbidities ranged from 8% to 61% and varied by race/ethnicity (e.g., depression and anxiety were comorbid for 47% of black, 54% of Hispanic, and 59% of white adolescents). For all racial/ethnic groups, adolescents with depression had a higher prevalence of attention deficit hyperactivity disorder than adolescents without depression. However, only black and Hispanic adolescents with depression had a significantly higher prevalence of anxiety and behavior problems than their counterparts without depression. In each racial/ethnic group, the prevalence of autism spectrum disorder did not differ between adolescents with and without depression. Conclusions: This study detected important differences in the prevalence of comorbid psychiatric conditions by race/ethnicity. Findings highlight the need for targeted interventions for black and Hispanic adolescents with depression that concurrently treat anxiety and behavior problems. © 2018 Society for Adolescent Health and Medicine. All rights reserved.
In the United States, comorbid psychiatric conditions among adolescents with depression are a major public health concern [1,2]. In fact, compared with adolescents without depression, ado-
Conflicts of Interest: The authors have no financial relationships relevant to this article to disclose. * Address correspondence to: Bridget E. Weller, Ph.D., Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, 2608 Erwin Road, Pavilion East Suite 300, Durham, NC 27705-4596. E-mail address: [email protected] (B.E. Weller). 1054-139X/© 2018 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2017.12.020
IMPLICATIONS AND CONTRIBUTION
The prevalence of comorbid psychiatric conditions is not uniform across racial/ethnic groups. Findings extend previous research by underscoring the importance of examining racial/ethnic groups separately in studies that investigate comorbid conditions among adolescents with depression.
lescents with depression face two to three times greater risk for anxiety, attention deficit hyperactivity disorder (ADHD), and behavioral disorders [3–5]. Further, 10% of youth with depression also have an autism spectrum disorder [6–9]. Although studies have illuminated a relatively high prevalence of some comorbid conditions in adolescents with depression, compared with adolescents without depression using racially/ethnically diverse samples, little is known about the pattern of comorbid conditions in specific racial/ethnic groups of adolescents with depression. This gap in knowledge is of concern because it may hide
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differences that have important consequences in the development and availability of tailored preventive and treatment programs. Examination of comorbid conditions in separate racial/ ethnic groups of adolescents with depression is important considering that racial/ethnic variations in comorbid disorders may contribute to disparities in mental health burden among minority youth and have corresponding treatment implications [10,11]. Although few studies have focused on depression in specific racial/ethnic groups of adolescents [12–14], one study found more severe depressive symptoms among black and Hispanic youth compared with white youth [15]. This finding suggests that the presentation of depression might not be uniform across racial/ ethnic groups. Identifying the prevalence of comorbid conditions by race/ ethnicity can aid in addressing gaps in knowledge and guide future mental health disparities research [16]. Specifically, few studies have examined the prevalence of comorbid conditions by race/ ethnicity [7,9,17], although examining differences in prevalence of conditions between groups is an objective of disparities research [16]. This gap leaves an important question unanswered: Do racial/ ethnic minorities with depression experience disproportionate rates of psychiatric comorbidities? Addressing this question will both expand current knowledge on the scope of comorbid conditions and potentially detect additional mental health disparities, which is a cross-cutting theme in the objectives set forth by the National Institute of Mental Health [18]. In turn, information on differential prevalence of psychiatric comorbidities can be useful to both nosology and development of targeted interventions for specific racial/ethnic groups [1,17]. Indeed, a report by the Institute of Medicine highlights the need to develop interventions that can address multiple comorbid conditions [19]. Understanding the prevalence of comorbid conditions in specific racial/ ethnic groups can help determine groups that may benefit most from interventions targeting multiple mental health conditions. National prevalence estimates of psychiatric comorbidities by race/ethnicity for adolescents with depression are particularly needed for ADHD, anxiety problems, autism spectrum disorders, and behavioral issues because these conditions are frequently diagnosed during adolescence [5,20,21], and the prevalence of these conditions, in absence of other psychiatric conditions, often vary by race/ethnicity [7,22,23]. We posit that the prevalence of these conditions will be higher in youth with depression compared with youth without depression, and that the pattern of these associations will be higher among black and Hispanic youth compared with white youth. Therefore, this study sought to first estimate the national prevalence of comorbid psychiatric conditions among U.S. adolescents with depression by race/ethnicity, and then compare the prevalence of these conditions between adolescents with and without depression. Methods This study used data obtained from the 2011–2012 National Survey of Children’s Health (NSCH), which is a nationally representative, cross-sectional survey of youth, 0–17 years old, living in the United States [24,25]. NSCH data were collected using a random-digit dial of landline telephone numbers and augmented with a similar sample of cellphone numbers in 50 states, such as Washington, D.C., and the U.S. Virgin Islands. The NSCH collected data from caregivers living at home together with the children; if multiple children resided in the household, one child was randomly selected as the study target and data were collected for that
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child. Protocols for data collection were approved by the National Center for Health Statistics at the University of Chicago [26]. The present study restricted the sample to adolescents between the ages 12 and 17 years (N = 30,605). We examined four possible comorbid conditions: ADHD, anxiety problems, autism spectrum disorders, and behavior/conduct problems. These conditions and the presence of depression were measured based on caregivers’ responses on two items. Caregivers first provided a yes/no response to the question, “Please tell me if a doctor or other health care provider ever told you that [CHILD’S NAME] had the condition, even if (he/she) does not have the condition now.” A positive response triggered a follow-up prompt for each condition, which was also a dichotomous yes/no question, “Does [CHILD’S NAME] currently have this condition?” We combined caregivers’ responses to these items to create a dichotomous variable representing whether the adolescent sample currently had a condition. We also examined demographic characteristics, including gender, age, parental education level, income, primary language spoken at home, and insurance status. To address the complex sample design, we conducted analyses using Mplus 7.4 [27]. In addition to sampling weights, we included weights attributable to cluster and strata [25], and obtained unweighted and weighted descriptive statistics. We also conducted multivariable probit regression models for each of the three racial/ethnic subgroups (i.e., black, Hispanic, white) to examine differences in the prevalence of conditions by adolescents with and without depression. We used weighted least squares with mean and variance adjustment estimation and specified theta parameterization [27]. Missing data, which were determined to be missing at random, were addressed using the full information method; subsequently, we did not exclude cases with missing data from multivariable models. Based on previous research, we included the following covariates as controls: gender (male and female), age (12–14 and 15–17), and caregiver’s highest level of education (lower than high school, high school graduate, and higher than high school) [4,5,28]. In addition, we conducted sensitivity analyses that included other possible controls such as primary language spoken at home (English and language other than English), insurance status (uninsured and insured), and income (i.e., based on federal poverty level; at or less than 100%, 100%–199%, 200%–299%, 300%–399%, and 400% or more of the poverty level). However, including these controls resulted in either a zero cell or a linear dependence. Results Our results represent the U.S. population of noninstitutionalized adolescents between the ages 12 and 17 years [24]. Although the majority of the study sample consisted of 69.9% white adolescents, it also included 9.4% black and 11.2% Hispanic adolescents. Subgroup analyses showed that among the sample of black adolescents, prevalence of depression was associated with age, income, and primary language spoken at home (see Table 1). In the sample of white adolescents, prevalence of depression was associated with age, poverty, and caregiver’s highest level of education. In the sample of Hispanic adolescents, prevalence of depression was associated only with age. Other demographic characteristics were not associated with prevalence of depression across racial/ethnic groups. Racial/ethnic differences were detected (1) in the prevalence of psychiatric conditions among adolescents with depression, and (2) in the comparison of the prevalence of psychiatric conditions between adolescents with and without depression (see Table 2). In addition, racial/ethnic differences were
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Table 1 Demographic characteristics of U.S. adolescents ages 12–17 by race/ethnicity Unweighted number (weighted %)a
Gender Female Ageb Young adolescent (12–14) Adolescent (15–17) Federal poverty level <100% 100%–199% 200%–299% 300%–399% ≥400% Highest level of educationc
Black
Depression (n = 938)
Without depression (n = 22,709)
459 (50.6)
10,694 (48.1)
320 (33.7) 618 (66.3)
p Valued
Hispanic
Depression (n = 117)
Without depression (n = 3,069)
.59
62 (41.4)
1,427 (49.8)
.28
85 (59.7)
1,742 (48.8)
.26
10,430 (48.1) 12,279 (51.9)
<.001
43 (28.7) 74 (71.3)
1,498 (50.3) 1,571 (49.7)
<.01
54 (23.6) 100 (76.4)
1,852 (53.8) 1,766 (46.2)
<.01
182 (20.5) 192 (26.1) 157 (13.6) 97 (16.7) 291 (23.1)
1,610 (9.0) 2,655 (14.0) 3,859 (18.8) 3,762 (16.3) 10,318 (41.8)
<.001
54 (47.7) 24 (24.5) 14 (10.7) 13 (12.4) 10 (4.7)
839 (34.6) 639 (22.7) 455 (15.3) 314 (9.6) 731 (17.9)
.03
69 (55.1) 34 (19.6) 18 (10.1) 10 (10.0) 21 (5.2)
1,043 (39.0) 817 (25.0) 505 (13.1) 333 (7.3) 823 (15.6)
.08
50 (5.8) 180 (22.2) 626 (72.0)
487 (3.8) 2,980 (16.8) 18,608 (79.4)
<.02
11 (8.9) 29 (37.2) 56 (53.9)
184 (8.1) 639 (27.5) 1,870 (64.5)
.29
21 (32.8) 39 (25.2) 77 (42.0)
777 (35.9) 747 (23.5) 1,926 (40.6)
.79
.45
1 (1.1)
149 (4.5)
.14
11 (18.6)
433 (12.4)
.41
<.001
1 (.2)
40 (1.5)
.03
35 (35.1)
1,384 (50.5)
.12
22 (2.9) 1 (.0)
821 (4.2) 130 (.9)
Weighted percentage represents the U.S. population of noninstitutionalized adolescents. Age range based on developmental stages presented by the Center for Disease Control and Prevention. Highest level of education refers to the caregiver who completed the survey. Chi-square test is a weighted statistic.
p Value
Depression (n = 154)
Without depression (n = 3,618)
p Value
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White
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Table 2 Prevalence of psychiatric conditions among adolescents with and without depression by race/ethnicity Psychiatric conditions
Black Prevalencea Depression (n = 117)
ADHD Anxiety Autism spectrum disorder Behavioral or conduct problems Psychiatric conditions
63 (61.1) 59 (47.0) 12 (8.6) 65 (55.2)
276 (9.7) 42 (1.7) 36 (1.1) 118 (3.7)
Depression (n = 154)
Psychiatric conditions
1.587 (1.157, 2.016) 2.107 (1.291, 2.922) .969 (−.440, 2.378) 1.934 (1.422, 2.446)
<.001 <.001 .178. <.001
Adjusted probabilityb (95% CI)
p Value
63 (43.2) 92 (52.9) 11 (5.1) 53 (35.7)
1.442 (.876, 2.009) 2.097 (1.566, 2.628) .543 (−.097, 1.183) 1.637 (1.093, 2.182)
<.001 <.001 .096 <.001
Adjusted probabilityb (95% CI)
p Value
1.035 (.678, 1.391) 2.086 (−.608, 4.780) .716 (−.154, 1.587) 1.556 (−.325, 3.437)
<.001 .129 .107 .105
Without depression (n = 3,618) 235 (5.4) 87 (2.2) 40 (1.5) 83 (2.3)
White Prevalencea
ADHD Anxiety Autism spectrum disorder Behavioral or conduct problems
p Value
Hispanic Prevalencea
ADHD Anxiety Autism spectrum disorder Behavioral or conduct problems
Adjusted probabilityb (95% CI) Without depression (n = 3,069)
Depression (n = 938)
Without depression (n = 22,709)
407 (42.2) 561 (59.2) 102 (8.6) 281 (31.1)
2233 (10.9) 789 (3.3) 298 (1.9) 383 (2.1)
ADHD = attention deficit hyperactivity disorder; CI = confidence interval. a Prevalence includes the actual sample size (n) and weighted percentage. Weighted percentage represents the U.S. population of noninstitutionalized adolescents. b Adjusted probabilities control for gender, age, and highest level of education.
found at the overall subgroup level (i.e., youth with and without depression). For black adolescents with depression, the prevalence of ADHD was substantially higher (61.1%) than either Hispanic (43.2%) or white (42%) youth. However, among adolescents with depression, prevalence of anxiety was higher among Hispanic (52.9%) and white (59.2%) youth than black youth (47.0%). Similar prevalence rates of behavior problems were reported for white (31.1%) and Hispanic (35.7%) youth, whereas black youth (55.2%) had substantial greater prevalence of behavior problems. Prevalence of autism spectrum disorders was similar across black (8.6%), Hispanic (5.1%), and white (8.6%) youth. Further, as shown in Table 2, regardless of race/ethnicity, adolescents with depression had a higher prevalence of ADHD than their same-race/ethnicity counterparts without depression. Black adolescents with depression had a higher prevalence of anxiety (47.0%) and behavior problems (55.2%) than their same-race/ ethnicity counterparts without depression (Table 2). Similarly, as shown in Table 2, Hispanic youth with depression had a higher prevalence of anxiety (52.9%) and behavior problems (35.7%) than their same-race/ethnicity counterparts without depression. However, white adolescents with depression did not have a higher prevalence of anxiety or behavior problems than white adolescents without depression (see Table 2). Further, across all racial/ ethnic groups, prevalence of autism spectrum disorders did not differ between adolescents with and without depression. Discussion The present study estimated the prevalence of comorbid psychiatric conditions among U.S. adolescents with depression among black, Hispanic, and white adolescents separately, and compared the prevalence of these conditions between adolescents
with and without depression in each racial/ethnic group. Overall, we found a large proportion of youth with depression in each racial/ethnic group had comorbidities. For example, ADHD was comorbid with depression for 47% of black, 52% of Hispanic, and 44% of white adolescents. Further, within each of the racial/ ethnic groups examined, adolescents with depression were significantly more likely to have ADHD compared with adolescents without depression. Although anxiety and behavior problems were more prevalent among black and Hispanic adolescents with depression compared with their same-race counterparts without depression, this relationship was not found for white adolescents. Across all racial/ethnic groups, the presence of depression was not associated with an elevated prevalence of autism spectrum disorders. Combined, our results highlight the value of within-racial/ ethnic group analyses to expand previous research focused in samples of combined racial/ethnic groups [4,5,11]. Overall, the findings in this study indicate that the differences in the prevalence of comorbid conditions among adolescents with depression compared with adolescents without depression are not uniform across racial/ethnic groups. Given ADHD, anxiety, and behavior problems were more prevalent in black and Hispanic youth with depression compared with those without depression, future investigation should begin to examine risk factors and social determinants that contribute to multiple mental health conditions that may be more prevalent among or unique to minority adolescents [13]. Uncovering such risk factors can determine important targets of intervention to simultaneously address multiple mental health conditions among minority youth. Findings from this nationally representative sample are mostly consistent with those of previous studies that used national, clinical, and community samples [2,4,5,21,29]. For example, our
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finding that adolescents with depression were at risk of comorbid conditions were similar to those reported in a study using the National Comorbidity Survey–Adolescent Supplement (NCSAS), which examined a combined sample of racially/ethnically diverse youth [4]. However, our findings differed slightly from those of the NCS-AS study regarding which conditions were most prevalent. Whereas the authors of the NCS-AS study found behavior problems to be the most prevalent, followed by anxiety and then ADHD, we found the relative prevalence of these comorbid conditions varied by race/ethnicity. Indeed, black youth had a higher prevalence of behavior problems, followed by ADHD and then anxiety, whereas Hispanic and white youth had higher prevalence of anxiety, followed by ADHD and then behavior problems. Our results are also consistent with research on autism [7–9]: We found depression and autism spectrum disorders to be comorbid in 5%–8% of adolescents. These findings are important because they highlight the need to develop targeted interventions for black and Hispanic adolescents with depression to concurrently treat anxiety and behavior problems. Based on our findings, we offer several recommendations for researchers and practitioners developing interventions to address mental health disparities [18]. Similar to recommendations posited by the Institute of Medicine and Health Resources and Service Administration [30,31], we recommend that practitioners continue to undergo cultural-competency training that focus on how race/ethnicity affects adolescents; this approach might involve identifying cultural frames of reference and whether the presenting symptoms deviate from acceptable functioning and behavior based on those cultural standards [12]. Black and Hispanic youth would likely benefit from treatment approaches that address multiple mental health conditions given the higher rate of comorbid conditions in these racial/ethnic groups of adolescents with depression compared with those without depression. Furthermore, although all youth may benefit from treatment approaches that seek to overcome the negative contribution of risk environments to the development and persistence of multiple mental health conditions, black and Hispanic youth may benefit more from such approaches. This is because of the disproportionate burden of disease affecting racial and ethnic minority communities. Such approaches may include health literacy programs, training programs aimed at increasing the number of mental health providers from traditionally marginalized populations, and community-based interventions [30,31]. Although the present study contributes to the literature, it has several limitations. First, the data used were cross-sectional and based on whether the adolescent currently had a condition, and therefore, we were not able to examine the temporal order of the onset of mental health conditions. Second, the present study used caregiver reports of adolescents’ mental health, and research has indicated discrepancies in parent-reported versus adolescentreported mental health conditions [32–35]. Caregivers may under report internalizing disorders and over report externalizing disorders. Subsequently, interpretation of these findings reflects caregivers’ recall of doctor’s report rather than whether youth indeed have these conditions. In the future, studies should attempt to collect data from multiple sources to reduce the possibility of reporter bias. Third, the findings of the present study might, at least in part, be a reflection of nosology [1]. Fourth, the present study omitted other psychiatric conditions commonly diagnosed among adolescents, including eating disorders [36,37] and substance use disorders [38]. These conditions were omitted because the NSCH survey did not collect these data.
Notwithstanding these limitations, this study provides a foundation for future research. Specifically, our study should be replicated using national data collected directly from adolescents, with an emphasis on adolescents’ experiences with specific depressive disorders (e.g., major depressive disorder vs. disruptive mood dysregulation disorder) [39] and the level of severity of depression [4]. Such research may point to differential exposure to various social determinants of health, which may indicate that prevention and treatment efforts are such that the same program for one group of adolescents may not have the same effect as on another group. Further, research is needed to examine other racial/ethnic groups not included in this study [40] and should also use a nuanced approach to assessing race/ethnicity. For example, rather than using the broad ethnic classification of “Hispanic,” future research should consider to explore prevalence across specific racial/ethnic groups such as Mexican, Puerto Rican, or Cuban because the psychosocial background of a group might influence the prevalence of comorbid conditions. Future research should also examine whether racial/ethnic differences in comorbidities contribute to disparities in mental health burden to determine whether addressing mental health comorbidities may help eliminate disparities. This secondary analysis indicated that the differences in the prevalence of comorbid conditions among adolescents with depression, compared with adolescents without depression, are not uniform across racial/ethnic groups. The study findings extend previous research in this area by underscoring the importance of considering race/ethnicity when documenting comorbid conditions among adolescents with depression.
Funding Sources This work was supported by the Robert Wood Johnson Foundation [grant number 73839, 2016–2017].
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