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Childhood-onset depressive disorders
Journal OJ Affectwe Elsevier
Disorders,
15 (1988) 245-253
245
JAD 00589
Childhood-onset
depressive
disorders
A follow-up study of rates of rehospitalization and out-of-home among child psychiatric inpatients
Joan R. Asarnow ’ Neuropsychmtric
‘, Michael J. Goldstein *, Gabrielle A. Carlson Susan Bates ’ and Jean Keller ’
j, Sondra
Instrtute, UCLA School of Medicine, .’ Depurtment of Psych&m, University of California. CA. U.S.A. ond ’ State Univewty of New York, Ston_v Brook, NY, U.S.A. (Accepted
placement
Perdue
I,
Los Angeles,
30 May 1988)
Summary
This report describes preliminary outcome data for a sample of child psychiatric inpatients with diagnoses of major depression and/or dysthymic disorder at the time of their hospitalizations. Depressed children were compared with a contrast group of children with schizophrenia spectrum disorders. Results (based on semi-structured telephone interviews) indicate high rates of rehospitalization among our depressed cohort. Depressed children had rehospitalization rates of 35% and 45% respectively in the first and second years after discharge. Out-of-home placement was rarer in the depressed group, and significantly less likely than for children with schizophrenia spectrum disorders. However, 15% of the depressed cohort were placed out of their homes within the first year of discharge. There were no differences between children with major depressive and dysthymic disorders on these outcome variables, underscoring the serious long-term correlates of childhood dysthymic as well as major depressive disorders.
Key words:
Major depression;
Rehospitalization;
Out-of-home
Introduction
Contrary to the former belief that depression in children if it occurred was a transient developmental phenomenon, current evidence indicates
Address for correspondence: Joan R. Asamow, Ph.D., Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, 760 Westwood Plaza, Los Angeles, CA 90024, U.S.A. 0165-0327/88/$03.50
0 1988 Elsevier Science Publishers
placement
high rates of continuing dysfunction and relapse in depressed children (Poznanski et al., 1976; Kovacs et al., 1984a, b; Puig-Antich et al., 1985; Keller, 1986). However, there have been very few studies of outcome in depressed children. The present report describes preliminary outcome data for a sample of children meeting DSMIII criteria for depressive disorders who were hospitalized at the UCLA Neuropsychiatric Institute between 7 and 13 years of age. Most de-
B.V. (Biomedical
Division)
246
pressed children do not become psychiatric inpatients. Consequently, our sample represents a special cohort of severely ill children. Major reasons for hospitalization in our depressed cohort included suicidal behavior, dangerous or uncontrollable behavior, psychosis, and/or major family disruption. Depressed children fell into two groups: children with initial diagnoses of major depressive disorder, and children with initial diagnoses of dysthymic disorder. These groups were compared with a control group of child inpatients with schizophrenia spectrum disorders. Because children with schizophrenic and schizotypal disorders are among the most severely and chronically impaired children admitted to inpatient settings (Asarnow and Ben-Meir, 1988) this contrast group provides a means of assessing the outcomes of depressed children in comparison to a group for whom outcome would be expected to be particularly poor. Since Kraepelin’s ordering of the functional psychoses into the affective disorders and dementia praecox, studies have frequently compared schizophrenia and depression in adults (e.g., McGlashan, 1984). Both of these disorders (or sets of disorders) in adults have been found to be serious with psychotic potential and variable outcomes. However, outcome for schizophrenic disorders tends to be skewed in the direction of deterioration and chronicity, whereas affective disorders are often characterized as relapsing and remitting conditions without deterioration. This report focuses on outcome as measured by rates of rehospitalization and out-of-home placement. This dimension of outcome has major economic and public health implications. Information concerning hospitalization and placement among depressed children is crucial for planning adequate services for these children and provides some indication of the extent to which these children show continuing difficulties. This is the first empirically based study to our knowledge to report on this dimension of outcome for psychiatrically hospitalized depressed children. Subjects
and methods
This report describes the first follow-up data from our comparative study of children with de-
pressive and schizophrenia spectrum disorders. Detailed descriptions of the design, procedures, and sample are available elsewhere (Asarnow and Ben-Meir, 1988; Asarnow et al., 1987). The 46 children described in this report include only children from the larger sample for whom at least a l-year follow-up interval had elapsed since hospital discharge. At the time of their psychiatric hospitalizations (and project intake), the children ranged from 7 to 13 years of age, had been living with their parent(s), had full WISC-R IQs of 70 or above, and received DSM-III diagnoses of major depressive disorder (MDD, n = 20). dysthymic disorder (DD, n = 8) schizophrenia (SZ, n = 12), or schizotypal personality disorder (SPD, n = 6). Diagnoses were made by an experienced child psychologist or psychiatrist (J.A. or G.C.) and represented the consensus judgment of two clinicians based on the following: semi-structured interviews conducted with the child using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-E: Puig-Antich et al., 1983) direct interviews with each parent using the abbreviated Camberwell Family Interview (Vaughn and Leff, 1976) modified to include sections from the K-SADS-E covering the target diagnoses, and reviews of other observations and assessments recorded during hospitalization. Subject and demographic characteristics of children in each diagnostic group are shown in Table 1. Analyses of variance and Fisher’s exact tests comparing children with depressive and schizophrenia spectrum disorders revealed significant differences only in IQ. F(1. 44) = 12.96, P < 0.001. As in most child inpatient samples, some children met criteria for more than one diagnosis. The distribution of the more common codiagnoses in the sample is shown in Table 1. The follow-up interval ranged from 1 to 6 years. Outcome data were obtained as part of a telephone contact initiated for the purpose of maintaining the sample and scheduling intensive follow-up evaluations. A brief semi-structured interview was conducted with the patient’s primary caregiver (usually the mother). Questions were asked concerning whether the patient was hospitalized or placed out of the home following his/her UCLA hospitalization. If rehospitalization or placement had occurred informants were
241 TABLE
I
SUBJECT AND DEMOGRAPHIC SUBJECTS Variable
CHARACTERISTICS
Depressive disorders (n = 28)
N (%) single-parent family 10 (35.71%) N (%) male 19 (67.86%) N (%) white 25 (89.29%) Ful-scale IQ Mean (SD) 106.43 (13.85) Range 81-115 Socioeconomic index (Duncan) 56.61 (20.28) Mean (SD) 18.60-92.10 Range Age (years) Mean (SD) 10.43 (1.53) 7-13 Range Duration hospitalization (days) 91.82 (67.64) Mean (SD) 14-361 Range N (%) codiagnoses None 13 (46%) Conduct/oppositional 9 (32%) Attention deficit 4 (14%) disorder Anxiety 7 (25%) Schizotypal 5 (18%) _ Atypical depression Pervasive developmental Modal number of codiagnoses 0
OF
Schizophrenia spectrum disorders (n=18)
7 (38.89%) 13 (72.22410) 15 (83.33%) 93.00 (9.49) 74-133 56.53 (20.60) 13.70-84.00 10.00 (1.88) 7713 107.11 (36.46) 52-160 4 (22%) 8 (44%) 2 (ll%, 0 6 (33%) 1(5%) 1
Two MDD children and three DD children also met DSM-III criteria for schizotypal personality disorder (SPD). These children were included in the depressed group. Six non-depressed SPD children were included in the schizophrenia spectrum group. The only codiagnoses given to schizophrenic children were conduct disorder and atypical depression. Atypical depression referred to episodes of depression that were relatively brief in duration relative to the characteristic schizophrenic symptoms and occurred after the onset of schizophrenia.
queried regarding why, when, where, and for how long the patient had been hospitalized or placed out of the home. Questions were also asked concerning the frequency and type of treatment that the child had received since discharge. To date about half of this sample has been interviewed directly and records have been obtained on rehospitalizations and placements. These results have
in all cases supported the validity of the telephone interview results. Follow-up data were obtained for all but one of the eligible subjects. This child had moved and we were unable to locate her for this follow-up. Statistical anulysis Survival analysis techniques (SAS, PROC LIFETEST, 1985) were employed to evaluate the association between diagnosis and the risk of rehospitalization and out-of-home placement. The equality of the survival distributions (time to outcome response) for patients in each diagnostic group was evaluated using product-limit estimators of the survival distribution, and the generalized Wilcoxon and logrank statistics. These non-parametric rank tests differ in that the Wilcoxon statistic more heavily weights earlier events, and the logrank statistic more heavily weights later differences. The influence of possible covariates was evaluated using rank tests (that allow for the use of numeric and categorical covariates) adjusted for diagnostic strata. This sequence of tests was employed to assess the effects of gender, age. IQ, ethnicity (white versus minority), family composition (single- versus dual-parent home), presence versus absence of a coexisting externalizing disorder (conduct disorder, oppositional disorder, or attention deficit disorder), length of UCLA hospitalization (logarithmic transformation), and type of post-hospital treatment. Results Treatment All but two children (one DD child and one SPD child) received mental health treatment involving some type of conventional psychotherapy. Pharmacotherapy was also common. Within the depressed cohort, antidepressants (tricyclics or lithium) were used in 14 MDD cases (70%) neuroleptics were used in one DD and one MDD case, and ritalin was given to one DD child for secondary ADD. Neuroleptics were the most common medications in the SZ and SPD groups, and were given to 15 children (83%). One SPD child was treated with a combination of neuroleptic and ritalin. Given the variety of treatments received,
248
hospitalization are also listed for those children who were rehospitalized. For example. the first row of Table 2 indicates that at discharge (day 0) there were 28 depressed children at risk for hospitalization. The second row of Table 2 indicates that 31 days after discharge one MDD child was rehospitalized because of suicidal behavior. depression, and behavioral problems (aggressive destructive behavior). This resulted in a failure rate of 0.04 and 27 children remaining at risk. The second from the last row of Table 2 indicates that at day 692 the eleventh child was rehospitalized, with 10 other children remaining at risk. The other seven cases were censored either because they had not yet been discharged for 692 days, or because they had been placed in RTCs.
form of treatment was classified into three broad categories: psychotherapy plus antidepressant medication (n = 14) psychotherapy plus neuroleptics (n = 17) and other (no treatment, psychotherapy alone, or psychotherapy plus other medication, n = 15). Risk of rehospitalization Table 2 presents data on the cumulative risk of rehospitalization for depressed children and children with schizophrenia spectrum disorders. To control for the decreased likelihood of rehospitalization for children living in residential treatment centers, observations were censored at placement in a residential treatment center (RTC). codiagnoses, Diagnoses, and reasons for re-
TABLE
2
PROBABILITY ORDERS
OF
AND
REHOSPITALIZATION
CHILDREN
WITH
Days since
Cumulative
SE
discharge
probability
FOLLOWING
SCHIZOPHRENIA
DISCHARGE
SPECTRUM
N hospitalized
FOR
CHILDREN
WITH
DEPRESSIVE
DIS-
DISORDERS
N at risk
Diagnosis
Codiagnosis
Reason
DD. Anx, ADD
SU, D. B
of rehospitalization Chrldren
with
depressive
0
dmrders
0
0
0
31
0.04
0.03
1
28 21
MDD
63
0.07
0.05
2
26
MDD
76
0.11
0.06
3
25
DD
SPD, Anx. ADD
B
DD
su
D
135
0.14
0.07
4
24
MDD
207
0.18
0.07
5
22
DD
210
0.22
0.08
6
21
MDD
273
0.26
0.08
7
18
MDD
DD, SPD, CD
B
333
0.30
0.09
8
16
DD
CD
su
342
0.35
0.09
9
15
MDD
DD
D
611
0.40
0.10
10
11
MDD
692
0.45
0.11
11
10
MDD
DD. SPD, Anx
D, B
11
0
sz
Atyp D, CD CD
B
SZ
1998 Mean time to rehospitalization Children
with
schbophrenia
= 515.40
spectrum
days
SE = 49.64
SU, D D
B-Manic
Quartile = 273 days
dmrders
0
0
0
0
18
1
0.11
0.07
2
16
B
375
0.22
0.12
3
7
SPD
CD. ADD
B
872
0.35
0.16
4
5
SPD
ADD
su
1777
4
Mean time to rehospitalization MDD = Major depression; disorder; threat;
Anx = Anxiety B = Behavior
treatment
center.
= 720.00
days
DD = Dysthymic disorder;
out of control;
0 SE = 91.35
disorder;
ADD = Attention D = Depression:
Quartile
= 872 days
SZ = Schizophrenia; deficit
disorder;
F = Family
chaos.
SPD = Schizotypal Atyp
D = Atypical
Observations
personality depression;
are censored
disorder;
CD = Conduct
SU = Suicide
at placement
attempt
or
in a residential
249
Inspection of Table 2 reveals a very high risk of rehospitalization for children with depressive disorders. By the end of the first year after hospital discharge, children with depressive disorders ran a 35% risk of rehospitalization. Within a little less than 2 years, 45% of this cohort were rehospitalized. Most children (81.9%) were rehospitalized because of suicidal behavior or signs of increasing depression. Lengths of stay when rehospitalized varied from very brief (2 days) to more extended (120 days). No significant differences were found between the survival curves of children with depressive disorders and those of children with schizophrenia (S) spectrum disorders. As shown in the bottom section of Table 2, however, only 22% of children with S spectrum disorders were rehospitalized by the end of the 2-year post-discharge period. Within 2.5 years of discharge, the rehospitalization rate for children with S spectrum disorders increased to 35%. Durations of rehospitalization tended to be longer for the S spectrum group. and ranged from 98 days to 324 days. Additionally, half of the rehospitalized S and SPD children were placed in RTCs after rehospitalization. In contrast, with the exception of two children who were placed in RTCs after third hospitalizations, depressed children returned to their homes following rehospitalization. Reasons for rehospitalization also varied across diagnostic groups. Children with S spectrum disorders were generally rehospitalized for out of control behavior. Only one of the four (25%) rehospitalized SZ and SPD children was rehospitalized because of suicidal behavior. As stated above, the impact of possible covariates on rehospitalization rates was evaluated using a series of logrank tests adjusted for the stratification variable. These tests revealed nonsignificant effects for sex, ethnicity, socioeconomic status, age, IQ, single- versus dual-parent family. the presence or absence of a coexisting externalizing disorder, and form of treatment. There was a marginal effect for length of UCLA hospitalization, Wilcoxon x2 = -3.16, P < 0.07; logrank x’ = 3.52, P < 0.07. Children with longer lengths of hospitalization were more likely to be rehospitalized. Comparison of the survival curves of children with MDD and DD revealed no significant group
differences. Thirty-two percent of MDD children were rehospitalized by the end of their first year after discharge, and 49% were rehospitalized within 2 years of discharge. Forty percent of DD children were rehospitalized within the first year of discharge, but no additional DD cases were rehospitalized after the first year. Analyses comparing rehospitalization rates for children with double depression (MDD superimposed on DD, Keller and Shapiro. 1982) and MDD children without histories of DD revealed a trend for children with double depression to run a higher risk of rehospitalization at later points in the survival curve, logrank x’ = 3.29. P -c 0.07. The cumulative probabilities of rehospitalization for children with double depression were 0.60 and 0.80 respectively by the end of the first and second years after discharge from UCLA. In contrast, rehospitalization rates for MDD children without histories of DD were 0.17 and 0.31 respectively by the end of the first and second years after the index hospitalizations. Additionally, within the MDD group (including children with double depression) children with longer UCLA hospitalizations ran a significantly higher risk of rehospitalization, Wilcoxon x’ = -2.98, P < 0.04: logrank x2 = 3.46, P < 0.04. These results must be viewed as tentative given the small sample size for these analyses. Plucement
.
in non-hospitul
out-of-home
setting
The cumulative probabilities of non-hospital out-of-home placement (censoring observations at any rehospitalization) are presented in Table 3. As indicated in Table 3. by the end of the first year after discharge 15% of the depressed group were placed out of their homes. Placement rates increased to 29% within about 4 years of hospital discharge. Three of the five depressed children who were placed out of their homes were placed because of family problems (severe conflict, psychiatric impairment of a parent). the other two were placed because of out of control behavior. However, we know that at least two of these placements were also associated with increasing depression (event 4, at 223 days; and event 5, at 1921 days). Two of the other placed children (event 1, at day 1: and event 2, at 8 days) were rehospitalized shortly after placement in relatives’
250
TABLE
3
PROBABILITY PRESSIVE Days
OF
since
AND
Cumulative
discharge Chrldren
OUT-OF-HOME
DISORDERS
PLACEMENT
CHILDREN
probability
SE
FOLLOWING
WITH
HOSPITAL
SCHIZOPHRENIA
N placed
N at risk
DISCHARGE
SPECTRUM Diagnosis
Codiagnoses
wih
depress~v
0.00
0
28
0.04
0.04
1
27
MDD
8
0.07
0.05
2
26
DD
60
0.11
0.06
3
24
MDD
DD, CD.
223
0.15
0.07
4
19
MDD
CD
1454
0.29
0.14
5
5
DD
ADD.
1921
5 to placement
Reason
Placement
with schrxphrenm
= 1243.82 spectrum
days
SE = 108.58
DD
Family Anx
Opp
Relative
Family
Relative
Behavior
School
Family
Foster
Behavior
Independent
care.
QuartlIe
= 1454 days
disorder.~
0.000
0.00
0
1
0.06
0.05
1
17
SPD
CD
Behavior
RTC
X
0.12
0.08
2
14
SPD
CD. ADD
Behavior
RTC
18
Atyp,
Behavior
RTC
Behavior
Relauve
Behavior
Relative
Behavior
RTC
11
0.18
0.10
3
13
sz
74
0.24
0.11
4
12
sz
130
0.31
0.11
5
11
SPD
CD.
142
0.37
0.12
6
10
sz
CD
243
0.43
0.12
7
9
sz
Atyp
309
0.50
0.12
8
8
373
0.57
0.13
9
6
9
0
SE = 39.23 days
Quartile
1777 time
MDD
= Major
disorder: center.
to placement
Anx
depresslon; = Anxiety
Observations
= 245.67
days
DD = Dysthymic disorder;
are censored
RTC
0 days
0
Mean
DE-
disorder.~
1
time
WITH
type
0.00
Chtldren
CHILDREN
of placement
0
Mean
FOR
DISORDERS
ADD
disorder;
= Attention
ADD
Behavior
RTC
sz
Family
Relative
SPD
Behavior
School
D
= 130 days
SZ = Schizophrenia: deficit
D, CD
disorder;
Atyp
SPD = Schizotypal D = Atypical
personality
depression;
RTC
disorder:
CD = Conduct
= Residential
treatment
at any rehospitalization.
homes because of suicide attempts. Because these placements were in relatives’ homes, as opposed to RTCs, these cases were also included in the risk of rehospitalization analyses and appear as events 4 and 5 (at days 135 and 207 respectively) in Table 3. Durations of placement ranged from 135 days (event 1, relative’s home) to 510 days (event 4. foster care followed by RTC). When compared to depressed children, rates of out-of-home placement were significantly higher for children with S spectrum disorders, logrank x2(1) = 5.84, P < 0.02, Wilcoxon x2(l) = 4.96, P < 0.03. Within 13 months of hospital discharge 57% of children with S spectrum disorders were placed out of their homes. Durations of placement tended to be lengthy in the S spectrum group, ranging from 60 days (event 3) to 730 days, with many children still in placement.
The type of out-of-home placement also varied as a function of diagnosis. When depressed children were placed they were either placed in relatives’ homes or other non-therapeutic settings such as boarding schools or foster homes. In contrast, two thirds of the S spectrum group who were placed out of the home were placed in RTCs. A Fisher’s exact test comparing type of placement (treatment vs. non-treatment setting) in placed children as a function of diagnosis revealed significantly higher rates of non-therapeutic out-ofhome placements in depressed children than in children with S spectrum disorders, P < 0.05. Again no significant differences were found in the survival estimates for children with MDD and children with DD. Within 8 months, 17% of children with MDD were placed. By the end of the 5-year follow-up period no other MDD
251
children were placed. Placement rates were very similar over the first year for children with DD, 12%. However, by the end of the 5-year follow-up period, 42% of the DD group was placed. In the overall analysis comparing rates of outof-home placement in children with depressive and S spectrum disorders, none of the covariates had significant effects. However, when analyses were conducted only within the depressed group, there was a significant age effect, Wilcoxon x2 = -5.15, P < 0.05;logrank xz = 5.92, P < 0.05. Older depressed children were more likely to be placed out of the home than younger depressed children. Children with double depression ran a somewhat higher risk of placement than other MDD children, but these differences were slight and non-significant. Discussion
The present results add to the growing literature indicating that depressive disorders in children may be associated with continuing psychiatric difficulties. Almost half of our depressed sample were rehospitalized within 2 years of discharge, and about 15% of the depressed group was placed out of the home within the first year of discharge. Hospitalization usually occurred because of increasing depression or suicidal behavior. Most depressed children were placed because of out of control behavior and/or severe family conflict. However, we know from our evaluations of symptomatology in this sample (still in progress) that some of these children were in the midst of major depressive episodes at the time of placement. Results of our forthcoming assessments of symptomatology are needed to clarify these relationships. It is important to note that our data are conservative estimates of the level of disturbance in our sample. Some children remained depressed or relapsed during the l-year follow-up period even though they were not rehospitalized. When viewed in conjunction with data indicating l-year relapse rates of 26% in MDD children (Kovacs et al.. 1984b), and l-year recovery rates of between 59% (Kovacs et al., 1984a) and 79% (Keller, 1986). our finding that only 68% of the MDD group remained out of the hospital during the first year
after discharge suggests that outcome for our depressed inpatients may be even poorer than that reported in prior studies of outpatient and community samples. The severity of continuing disturbance shown by our depressed children is underscored by comparison with our sample of schizophrenic and schizotypal children. Schizophrenic and schizotypal disorders are relatively chronic disorders and these children tend to show poor premorbid adjustments and severe impairment at hospitalization (Asarnow and Ben-Meir, 1988). As might be expected from the more chronic patterns of dysfunction among schizophrenic and schizotypal children. placement in residential treatment centers was significantly more likely in this group. However. it is striking that there were no differences in rates of rehospitalization among children with depressive and schizophrenia spectrum disorders. Indeed. there was a tendency for depressed children to have higher rehospitalization rates than schizophrenic and schizotypal children. even when we controlled for lower risks of rehospitalization due to placement in residential treatment centers among SZ and SPD children. These findings are consistent with the view that depressive disorders in childhood tend to have a relatively episodic course, with hospitalization resulting from increasing depressive symptoms and suicidal behavior. DD and MDD were associated with comparably high rates of rehospitalization and placement. As time progressed after discharge, however, children with double depression (MDD superimposed on DD) ran a much higher risk of rehospitalization than other MDD children. Indeed, 2 years after discharge the rehospitalization rate was 80% for children with double depression. When viewed in conjunction with data indicating high rates of subsequent MDD in DD children as well as particularly high rates of recurrent episodes in children with double depression (Kovacs et al., 1984b), these results underscore the serious long-term correlates of childhood dysthymic disorders and the poor outcomes of children with double depression. Like most child samples, some children presented with codiagnoses (comorbidity). This raises questions concerning the impact of comorbidity on outcome. Somewhat surprisingly, except for the
252
findings on double depression noted above, codiagnoses did not have significant associations with our outcome measures. However, our sample size precluded analyses of many patterns of comorbidity and may have lacked sufficient power to detect effects of codiagnoses. Older depressed children were more likely to be placed out of their homes than younger depressed children. This may be associated with the greater difficulties parents encountered controlling their children’s behavior as they entered adolescence. Alternatively, it may have been that placement results from the effects of having had to cope with severely dysfunctional children over a longer period of time. This latter explanation would be consistent with our findings of both more chronic disturbance (Asarnow and Ben-Meir, 1988) and higher rates of out-of-home placement in our schizophrenic and schizotypal sample. Another finding of interest was that, particularly within the MDD group, children with longer initial hospitalizations tended to have higher risks of rehospitalization. Future research is needed to determine the extent to which this association is due to differences in severity of impairment, tendencies to utilize psychiatric hospitals, or other variables. All but two children received continuing treatment following discharge. Thus, the present results describe outcome for treated patients, with most children receiving a combination of pharmacologic and psychosocial therapies. Using our broad categorization, type of treatment was not associated with our outcome measures. However, more fine-grained analyses might reveal treatment effects. Future research with controlled treatment interventions is needed to evaluate the impact of different treatment modalities on outcome. The findings that despite a high risk of rehospitalization most depressed children remained in their homes, with the probability of out-of-home placement increasing with age, suggests that family interventions may be particularly important in treating these children. In conclusion, the present results underscore the severe continuing difficulties experienced by a large proportion of children initially hospitalized with depressive disorders. Our data indicate that at least half of our psychiatrically hospitalized depressed children failed to stay well over the
course of our follow-up period. Most depressed children remained in their homes and did not require long-term therapeutic placements. However, almost half of our depressed children did need episodic hospitalizations. From the vantage point of public health planning, these data underscore the critical need for mental health services for these children including inpatient facilities where they can be treated when suicidal behavior jeopardizes their safety. The severe continuing difficulties observed in this sample highlight the need for further research on the etiology and treatment of these disorders. Acknowledgements
This research was supported by a grant from the John D. and Catherine T. MacArthur Foundation as part of their Network on Risk and Protective Factors in the Major Mental Disorders. The authors wish to thank Gwen Gordon for her computer assistance. References Asamow,
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253 McGlashan, T.H. (1984) The Chestnut Lodge follow-up study II. Long-term outcome of schizophrenia and the affective disorders. Arch. Gen. Psychiatry 41, 586-601. Poznanski, E.O.. Krahenbuhl. V. and Zrull. J.P. (1976) Childhood depression, a longitudinal perspective. J. Am. Acad. Child Psychiatry 15, 491-501. Puig-Antich, J., Orvaschel, H.. Tabrizi, M. and Chambers, W.J. (1983) Schedule for Affective Disorders and Schizophrenia for School-Age Children Epidemiological Version. Unpublished manuscript, New York State Psychiatric Institute. Department of Child and Adolescent Psychiatry, New York, NY. Puig-Antich, J., Lukens. E., Davies, M., Goetz, D., BrennanQuattrock. J. and Todak. G. (1985a) Psychosocial func-
tioning in prepubertal major depressive disorders. I. Interpersonal relationships during the depressive episode. Arch. Gen. Psychiatry 42, 500-510. Puig-Antich. J.. Lukens, E., Davies, M.. Goetz. D., BrennanQuattrock. J. and Todak. G. (1985b) Psychosocial functioning in prepubertal major depressive disorders. II. Interpersonal relationships during the depressive episode. Arch. Gen. Psychiatry 42. 511-517. Russell, A.T.. Bott, L. and Sammons, C. (1986) The phenomenology of childhood schizophrenia. Presentation at the annual meeting of the American Academy of Child Psychiatry. Los Angeles, CA. SAS Institute (1985) SAS User’s Guide: Statistics, 5th edn. Cary. NC.
Disorders,
15 (1988) 245-253
245
JAD 00589
Childhood-onset
depressive
disorders
A follow-up study of rates of rehospitalization and out-of-home among child psychiatric inpatients
Joan R. Asarnow ’ Neuropsychmtric
‘, Michael J. Goldstein *, Gabrielle A. Carlson Susan Bates ’ and Jean Keller ’
j, Sondra
Instrtute, UCLA School of Medicine, .’ Depurtment of Psych&m, University of California. CA. U.S.A. ond ’ State Univewty of New York, Ston_v Brook, NY, U.S.A. (Accepted
placement
Perdue
I,
Los Angeles,
30 May 1988)
Summary
This report describes preliminary outcome data for a sample of child psychiatric inpatients with diagnoses of major depression and/or dysthymic disorder at the time of their hospitalizations. Depressed children were compared with a contrast group of children with schizophrenia spectrum disorders. Results (based on semi-structured telephone interviews) indicate high rates of rehospitalization among our depressed cohort. Depressed children had rehospitalization rates of 35% and 45% respectively in the first and second years after discharge. Out-of-home placement was rarer in the depressed group, and significantly less likely than for children with schizophrenia spectrum disorders. However, 15% of the depressed cohort were placed out of their homes within the first year of discharge. There were no differences between children with major depressive and dysthymic disorders on these outcome variables, underscoring the serious long-term correlates of childhood dysthymic as well as major depressive disorders.
Key words:
Major depression;
Rehospitalization;
Out-of-home
Introduction
Contrary to the former belief that depression in children if it occurred was a transient developmental phenomenon, current evidence indicates
Address for correspondence: Joan R. Asamow, Ph.D., Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, 760 Westwood Plaza, Los Angeles, CA 90024, U.S.A. 0165-0327/88/$03.50
0 1988 Elsevier Science Publishers
placement
high rates of continuing dysfunction and relapse in depressed children (Poznanski et al., 1976; Kovacs et al., 1984a, b; Puig-Antich et al., 1985; Keller, 1986). However, there have been very few studies of outcome in depressed children. The present report describes preliminary outcome data for a sample of children meeting DSMIII criteria for depressive disorders who were hospitalized at the UCLA Neuropsychiatric Institute between 7 and 13 years of age. Most de-
B.V. (Biomedical
Division)
246
pressed children do not become psychiatric inpatients. Consequently, our sample represents a special cohort of severely ill children. Major reasons for hospitalization in our depressed cohort included suicidal behavior, dangerous or uncontrollable behavior, psychosis, and/or major family disruption. Depressed children fell into two groups: children with initial diagnoses of major depressive disorder, and children with initial diagnoses of dysthymic disorder. These groups were compared with a control group of child inpatients with schizophrenia spectrum disorders. Because children with schizophrenic and schizotypal disorders are among the most severely and chronically impaired children admitted to inpatient settings (Asarnow and Ben-Meir, 1988) this contrast group provides a means of assessing the outcomes of depressed children in comparison to a group for whom outcome would be expected to be particularly poor. Since Kraepelin’s ordering of the functional psychoses into the affective disorders and dementia praecox, studies have frequently compared schizophrenia and depression in adults (e.g., McGlashan, 1984). Both of these disorders (or sets of disorders) in adults have been found to be serious with psychotic potential and variable outcomes. However, outcome for schizophrenic disorders tends to be skewed in the direction of deterioration and chronicity, whereas affective disorders are often characterized as relapsing and remitting conditions without deterioration. This report focuses on outcome as measured by rates of rehospitalization and out-of-home placement. This dimension of outcome has major economic and public health implications. Information concerning hospitalization and placement among depressed children is crucial for planning adequate services for these children and provides some indication of the extent to which these children show continuing difficulties. This is the first empirically based study to our knowledge to report on this dimension of outcome for psychiatrically hospitalized depressed children. Subjects
and methods
This report describes the first follow-up data from our comparative study of children with de-
pressive and schizophrenia spectrum disorders. Detailed descriptions of the design, procedures, and sample are available elsewhere (Asarnow and Ben-Meir, 1988; Asarnow et al., 1987). The 46 children described in this report include only children from the larger sample for whom at least a l-year follow-up interval had elapsed since hospital discharge. At the time of their psychiatric hospitalizations (and project intake), the children ranged from 7 to 13 years of age, had been living with their parent(s), had full WISC-R IQs of 70 or above, and received DSM-III diagnoses of major depressive disorder (MDD, n = 20). dysthymic disorder (DD, n = 8) schizophrenia (SZ, n = 12), or schizotypal personality disorder (SPD, n = 6). Diagnoses were made by an experienced child psychologist or psychiatrist (J.A. or G.C.) and represented the consensus judgment of two clinicians based on the following: semi-structured interviews conducted with the child using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-E: Puig-Antich et al., 1983) direct interviews with each parent using the abbreviated Camberwell Family Interview (Vaughn and Leff, 1976) modified to include sections from the K-SADS-E covering the target diagnoses, and reviews of other observations and assessments recorded during hospitalization. Subject and demographic characteristics of children in each diagnostic group are shown in Table 1. Analyses of variance and Fisher’s exact tests comparing children with depressive and schizophrenia spectrum disorders revealed significant differences only in IQ. F(1. 44) = 12.96, P < 0.001. As in most child inpatient samples, some children met criteria for more than one diagnosis. The distribution of the more common codiagnoses in the sample is shown in Table 1. The follow-up interval ranged from 1 to 6 years. Outcome data were obtained as part of a telephone contact initiated for the purpose of maintaining the sample and scheduling intensive follow-up evaluations. A brief semi-structured interview was conducted with the patient’s primary caregiver (usually the mother). Questions were asked concerning whether the patient was hospitalized or placed out of the home following his/her UCLA hospitalization. If rehospitalization or placement had occurred informants were
241 TABLE
I
SUBJECT AND DEMOGRAPHIC SUBJECTS Variable
CHARACTERISTICS
Depressive disorders (n = 28)
N (%) single-parent family 10 (35.71%) N (%) male 19 (67.86%) N (%) white 25 (89.29%) Ful-scale IQ Mean (SD) 106.43 (13.85) Range 81-115 Socioeconomic index (Duncan) 56.61 (20.28) Mean (SD) 18.60-92.10 Range Age (years) Mean (SD) 10.43 (1.53) 7-13 Range Duration hospitalization (days) 91.82 (67.64) Mean (SD) 14-361 Range N (%) codiagnoses None 13 (46%) Conduct/oppositional 9 (32%) Attention deficit 4 (14%) disorder Anxiety 7 (25%) Schizotypal 5 (18%) _ Atypical depression Pervasive developmental Modal number of codiagnoses 0
OF
Schizophrenia spectrum disorders (n=18)
7 (38.89%) 13 (72.22410) 15 (83.33%) 93.00 (9.49) 74-133 56.53 (20.60) 13.70-84.00 10.00 (1.88) 7713 107.11 (36.46) 52-160 4 (22%) 8 (44%) 2 (ll%, 0 6 (33%) 1(5%) 1
Two MDD children and three DD children also met DSM-III criteria for schizotypal personality disorder (SPD). These children were included in the depressed group. Six non-depressed SPD children were included in the schizophrenia spectrum group. The only codiagnoses given to schizophrenic children were conduct disorder and atypical depression. Atypical depression referred to episodes of depression that were relatively brief in duration relative to the characteristic schizophrenic symptoms and occurred after the onset of schizophrenia.
queried regarding why, when, where, and for how long the patient had been hospitalized or placed out of the home. Questions were also asked concerning the frequency and type of treatment that the child had received since discharge. To date about half of this sample has been interviewed directly and records have been obtained on rehospitalizations and placements. These results have
in all cases supported the validity of the telephone interview results. Follow-up data were obtained for all but one of the eligible subjects. This child had moved and we were unable to locate her for this follow-up. Statistical anulysis Survival analysis techniques (SAS, PROC LIFETEST, 1985) were employed to evaluate the association between diagnosis and the risk of rehospitalization and out-of-home placement. The equality of the survival distributions (time to outcome response) for patients in each diagnostic group was evaluated using product-limit estimators of the survival distribution, and the generalized Wilcoxon and logrank statistics. These non-parametric rank tests differ in that the Wilcoxon statistic more heavily weights earlier events, and the logrank statistic more heavily weights later differences. The influence of possible covariates was evaluated using rank tests (that allow for the use of numeric and categorical covariates) adjusted for diagnostic strata. This sequence of tests was employed to assess the effects of gender, age. IQ, ethnicity (white versus minority), family composition (single- versus dual-parent home), presence versus absence of a coexisting externalizing disorder (conduct disorder, oppositional disorder, or attention deficit disorder), length of UCLA hospitalization (logarithmic transformation), and type of post-hospital treatment. Results Treatment All but two children (one DD child and one SPD child) received mental health treatment involving some type of conventional psychotherapy. Pharmacotherapy was also common. Within the depressed cohort, antidepressants (tricyclics or lithium) were used in 14 MDD cases (70%) neuroleptics were used in one DD and one MDD case, and ritalin was given to one DD child for secondary ADD. Neuroleptics were the most common medications in the SZ and SPD groups, and were given to 15 children (83%). One SPD child was treated with a combination of neuroleptic and ritalin. Given the variety of treatments received,
248
hospitalization are also listed for those children who were rehospitalized. For example. the first row of Table 2 indicates that at discharge (day 0) there were 28 depressed children at risk for hospitalization. The second row of Table 2 indicates that 31 days after discharge one MDD child was rehospitalized because of suicidal behavior. depression, and behavioral problems (aggressive destructive behavior). This resulted in a failure rate of 0.04 and 27 children remaining at risk. The second from the last row of Table 2 indicates that at day 692 the eleventh child was rehospitalized, with 10 other children remaining at risk. The other seven cases were censored either because they had not yet been discharged for 692 days, or because they had been placed in RTCs.
form of treatment was classified into three broad categories: psychotherapy plus antidepressant medication (n = 14) psychotherapy plus neuroleptics (n = 17) and other (no treatment, psychotherapy alone, or psychotherapy plus other medication, n = 15). Risk of rehospitalization Table 2 presents data on the cumulative risk of rehospitalization for depressed children and children with schizophrenia spectrum disorders. To control for the decreased likelihood of rehospitalization for children living in residential treatment centers, observations were censored at placement in a residential treatment center (RTC). codiagnoses, Diagnoses, and reasons for re-
TABLE
2
PROBABILITY ORDERS
OF
AND
REHOSPITALIZATION
CHILDREN
WITH
Days since
Cumulative
SE
discharge
probability
FOLLOWING
SCHIZOPHRENIA
DISCHARGE
SPECTRUM
N hospitalized
FOR
CHILDREN
WITH
DEPRESSIVE
DIS-
DISORDERS
N at risk
Diagnosis
Codiagnosis
Reason
DD. Anx, ADD
SU, D. B
of rehospitalization Chrldren
with
depressive
0
dmrders
0
0
0
31
0.04
0.03
1
28 21
MDD
63
0.07
0.05
2
26
MDD
76
0.11
0.06
3
25
DD
SPD, Anx. ADD
B
DD
su
D
135
0.14
0.07
4
24
MDD
207
0.18
0.07
5
22
DD
210
0.22
0.08
6
21
MDD
273
0.26
0.08
7
18
MDD
DD, SPD, CD
B
333
0.30
0.09
8
16
DD
CD
su
342
0.35
0.09
9
15
MDD
DD
D
611
0.40
0.10
10
11
MDD
692
0.45
0.11
11
10
MDD
DD. SPD, Anx
D, B
11
0
sz
Atyp D, CD CD
B
SZ
1998 Mean time to rehospitalization Children
with
schbophrenia
= 515.40
spectrum
days
SE = 49.64
SU, D D
B-Manic
Quartile = 273 days
dmrders
0
0
0
0
18
1
0.11
0.07
2
16
B
375
0.22
0.12
3
7
SPD
CD. ADD
B
872
0.35
0.16
4
5
SPD
ADD
su
1777
4
Mean time to rehospitalization MDD = Major depression; disorder; threat;
Anx = Anxiety B = Behavior
treatment
center.
= 720.00
days
DD = Dysthymic disorder;
out of control;
0 SE = 91.35
disorder;
ADD = Attention D = Depression:
Quartile
= 872 days
SZ = Schizophrenia; deficit
disorder;
F = Family
chaos.
SPD = Schizotypal Atyp
D = Atypical
Observations
personality depression;
are censored
disorder;
CD = Conduct
SU = Suicide
at placement
attempt
or
in a residential
249
Inspection of Table 2 reveals a very high risk of rehospitalization for children with depressive disorders. By the end of the first year after hospital discharge, children with depressive disorders ran a 35% risk of rehospitalization. Within a little less than 2 years, 45% of this cohort were rehospitalized. Most children (81.9%) were rehospitalized because of suicidal behavior or signs of increasing depression. Lengths of stay when rehospitalized varied from very brief (2 days) to more extended (120 days). No significant differences were found between the survival curves of children with depressive disorders and those of children with schizophrenia (S) spectrum disorders. As shown in the bottom section of Table 2, however, only 22% of children with S spectrum disorders were rehospitalized by the end of the 2-year post-discharge period. Within 2.5 years of discharge, the rehospitalization rate for children with S spectrum disorders increased to 35%. Durations of rehospitalization tended to be longer for the S spectrum group. and ranged from 98 days to 324 days. Additionally, half of the rehospitalized S and SPD children were placed in RTCs after rehospitalization. In contrast, with the exception of two children who were placed in RTCs after third hospitalizations, depressed children returned to their homes following rehospitalization. Reasons for rehospitalization also varied across diagnostic groups. Children with S spectrum disorders were generally rehospitalized for out of control behavior. Only one of the four (25%) rehospitalized SZ and SPD children was rehospitalized because of suicidal behavior. As stated above, the impact of possible covariates on rehospitalization rates was evaluated using a series of logrank tests adjusted for the stratification variable. These tests revealed nonsignificant effects for sex, ethnicity, socioeconomic status, age, IQ, single- versus dual-parent family. the presence or absence of a coexisting externalizing disorder, and form of treatment. There was a marginal effect for length of UCLA hospitalization, Wilcoxon x2 = -3.16, P < 0.07; logrank x’ = 3.52, P < 0.07. Children with longer lengths of hospitalization were more likely to be rehospitalized. Comparison of the survival curves of children with MDD and DD revealed no significant group
differences. Thirty-two percent of MDD children were rehospitalized by the end of their first year after discharge, and 49% were rehospitalized within 2 years of discharge. Forty percent of DD children were rehospitalized within the first year of discharge, but no additional DD cases were rehospitalized after the first year. Analyses comparing rehospitalization rates for children with double depression (MDD superimposed on DD, Keller and Shapiro. 1982) and MDD children without histories of DD revealed a trend for children with double depression to run a higher risk of rehospitalization at later points in the survival curve, logrank x’ = 3.29. P -c 0.07. The cumulative probabilities of rehospitalization for children with double depression were 0.60 and 0.80 respectively by the end of the first and second years after discharge from UCLA. In contrast, rehospitalization rates for MDD children without histories of DD were 0.17 and 0.31 respectively by the end of the first and second years after the index hospitalizations. Additionally, within the MDD group (including children with double depression) children with longer UCLA hospitalizations ran a significantly higher risk of rehospitalization, Wilcoxon x’ = -2.98, P < 0.04: logrank x2 = 3.46, P < 0.04. These results must be viewed as tentative given the small sample size for these analyses. Plucement
.
in non-hospitul
out-of-home
setting
The cumulative probabilities of non-hospital out-of-home placement (censoring observations at any rehospitalization) are presented in Table 3. As indicated in Table 3. by the end of the first year after discharge 15% of the depressed group were placed out of their homes. Placement rates increased to 29% within about 4 years of hospital discharge. Three of the five depressed children who were placed out of their homes were placed because of family problems (severe conflict, psychiatric impairment of a parent). the other two were placed because of out of control behavior. However, we know that at least two of these placements were also associated with increasing depression (event 4, at 223 days; and event 5, at 1921 days). Two of the other placed children (event 1, at day 1: and event 2, at 8 days) were rehospitalized shortly after placement in relatives’
250
TABLE
3
PROBABILITY PRESSIVE Days
OF
since
AND
Cumulative
discharge Chrldren
OUT-OF-HOME
DISORDERS
PLACEMENT
CHILDREN
probability
SE
FOLLOWING
WITH
HOSPITAL
SCHIZOPHRENIA
N placed
N at risk
DISCHARGE
SPECTRUM Diagnosis
Codiagnoses
wih
depress~v
0.00
0
28
0.04
0.04
1
27
MDD
8
0.07
0.05
2
26
DD
60
0.11
0.06
3
24
MDD
DD, CD.
223
0.15
0.07
4
19
MDD
CD
1454
0.29
0.14
5
5
DD
ADD.
1921
5 to placement
Reason
Placement
with schrxphrenm
= 1243.82 spectrum
days
SE = 108.58
DD
Family Anx
Opp
Relative
Family
Relative
Behavior
School
Family
Foster
Behavior
Independent
care.
QuartlIe
= 1454 days
disorder.~
0.000
0.00
0
1
0.06
0.05
1
17
SPD
CD
Behavior
RTC
X
0.12
0.08
2
14
SPD
CD. ADD
Behavior
RTC
18
Atyp,
Behavior
RTC
Behavior
Relauve
Behavior
Relative
Behavior
RTC
11
0.18
0.10
3
13
sz
74
0.24
0.11
4
12
sz
130
0.31
0.11
5
11
SPD
CD.
142
0.37
0.12
6
10
sz
CD
243
0.43
0.12
7
9
sz
Atyp
309
0.50
0.12
8
8
373
0.57
0.13
9
6
9
0
SE = 39.23 days
Quartile
1777 time
MDD
= Major
disorder: center.
to placement
Anx
depresslon; = Anxiety
Observations
= 245.67
days
DD = Dysthymic disorder;
are censored
RTC
0 days
0
Mean
DE-
disorder.~
1
time
WITH
type
0.00
Chtldren
CHILDREN
of placement
0
Mean
FOR
DISORDERS
ADD
disorder;
= Attention
ADD
Behavior
RTC
sz
Family
Relative
SPD
Behavior
School
D
= 130 days
SZ = Schizophrenia: deficit
D, CD
disorder;
Atyp
SPD = Schizotypal D = Atypical
personality
depression;
RTC
disorder:
CD = Conduct
= Residential
treatment
at any rehospitalization.
homes because of suicide attempts. Because these placements were in relatives’ homes, as opposed to RTCs, these cases were also included in the risk of rehospitalization analyses and appear as events 4 and 5 (at days 135 and 207 respectively) in Table 3. Durations of placement ranged from 135 days (event 1, relative’s home) to 510 days (event 4. foster care followed by RTC). When compared to depressed children, rates of out-of-home placement were significantly higher for children with S spectrum disorders, logrank x2(1) = 5.84, P < 0.02, Wilcoxon x2(l) = 4.96, P < 0.03. Within 13 months of hospital discharge 57% of children with S spectrum disorders were placed out of their homes. Durations of placement tended to be lengthy in the S spectrum group, ranging from 60 days (event 3) to 730 days, with many children still in placement.
The type of out-of-home placement also varied as a function of diagnosis. When depressed children were placed they were either placed in relatives’ homes or other non-therapeutic settings such as boarding schools or foster homes. In contrast, two thirds of the S spectrum group who were placed out of the home were placed in RTCs. A Fisher’s exact test comparing type of placement (treatment vs. non-treatment setting) in placed children as a function of diagnosis revealed significantly higher rates of non-therapeutic out-ofhome placements in depressed children than in children with S spectrum disorders, P < 0.05. Again no significant differences were found in the survival estimates for children with MDD and children with DD. Within 8 months, 17% of children with MDD were placed. By the end of the 5-year follow-up period no other MDD
251
children were placed. Placement rates were very similar over the first year for children with DD, 12%. However, by the end of the 5-year follow-up period, 42% of the DD group was placed. In the overall analysis comparing rates of outof-home placement in children with depressive and S spectrum disorders, none of the covariates had significant effects. However, when analyses were conducted only within the depressed group, there was a significant age effect, Wilcoxon x2 = -5.15, P < 0.05;logrank xz = 5.92, P < 0.05. Older depressed children were more likely to be placed out of the home than younger depressed children. Children with double depression ran a somewhat higher risk of placement than other MDD children, but these differences were slight and non-significant. Discussion
The present results add to the growing literature indicating that depressive disorders in children may be associated with continuing psychiatric difficulties. Almost half of our depressed sample were rehospitalized within 2 years of discharge, and about 15% of the depressed group was placed out of the home within the first year of discharge. Hospitalization usually occurred because of increasing depression or suicidal behavior. Most depressed children were placed because of out of control behavior and/or severe family conflict. However, we know from our evaluations of symptomatology in this sample (still in progress) that some of these children were in the midst of major depressive episodes at the time of placement. Results of our forthcoming assessments of symptomatology are needed to clarify these relationships. It is important to note that our data are conservative estimates of the level of disturbance in our sample. Some children remained depressed or relapsed during the l-year follow-up period even though they were not rehospitalized. When viewed in conjunction with data indicating l-year relapse rates of 26% in MDD children (Kovacs et al.. 1984b), and l-year recovery rates of between 59% (Kovacs et al., 1984a) and 79% (Keller, 1986). our finding that only 68% of the MDD group remained out of the hospital during the first year
after discharge suggests that outcome for our depressed inpatients may be even poorer than that reported in prior studies of outpatient and community samples. The severity of continuing disturbance shown by our depressed children is underscored by comparison with our sample of schizophrenic and schizotypal children. Schizophrenic and schizotypal disorders are relatively chronic disorders and these children tend to show poor premorbid adjustments and severe impairment at hospitalization (Asarnow and Ben-Meir, 1988). As might be expected from the more chronic patterns of dysfunction among schizophrenic and schizotypal children. placement in residential treatment centers was significantly more likely in this group. However. it is striking that there were no differences in rates of rehospitalization among children with depressive and schizophrenia spectrum disorders. Indeed. there was a tendency for depressed children to have higher rehospitalization rates than schizophrenic and schizotypal children. even when we controlled for lower risks of rehospitalization due to placement in residential treatment centers among SZ and SPD children. These findings are consistent with the view that depressive disorders in childhood tend to have a relatively episodic course, with hospitalization resulting from increasing depressive symptoms and suicidal behavior. DD and MDD were associated with comparably high rates of rehospitalization and placement. As time progressed after discharge, however, children with double depression (MDD superimposed on DD) ran a much higher risk of rehospitalization than other MDD children. Indeed, 2 years after discharge the rehospitalization rate was 80% for children with double depression. When viewed in conjunction with data indicating high rates of subsequent MDD in DD children as well as particularly high rates of recurrent episodes in children with double depression (Kovacs et al., 1984b), these results underscore the serious long-term correlates of childhood dysthymic disorders and the poor outcomes of children with double depression. Like most child samples, some children presented with codiagnoses (comorbidity). This raises questions concerning the impact of comorbidity on outcome. Somewhat surprisingly, except for the
252
findings on double depression noted above, codiagnoses did not have significant associations with our outcome measures. However, our sample size precluded analyses of many patterns of comorbidity and may have lacked sufficient power to detect effects of codiagnoses. Older depressed children were more likely to be placed out of their homes than younger depressed children. This may be associated with the greater difficulties parents encountered controlling their children’s behavior as they entered adolescence. Alternatively, it may have been that placement results from the effects of having had to cope with severely dysfunctional children over a longer period of time. This latter explanation would be consistent with our findings of both more chronic disturbance (Asarnow and Ben-Meir, 1988) and higher rates of out-of-home placement in our schizophrenic and schizotypal sample. Another finding of interest was that, particularly within the MDD group, children with longer initial hospitalizations tended to have higher risks of rehospitalization. Future research is needed to determine the extent to which this association is due to differences in severity of impairment, tendencies to utilize psychiatric hospitals, or other variables. All but two children received continuing treatment following discharge. Thus, the present results describe outcome for treated patients, with most children receiving a combination of pharmacologic and psychosocial therapies. Using our broad categorization, type of treatment was not associated with our outcome measures. However, more fine-grained analyses might reveal treatment effects. Future research with controlled treatment interventions is needed to evaluate the impact of different treatment modalities on outcome. The findings that despite a high risk of rehospitalization most depressed children remained in their homes, with the probability of out-of-home placement increasing with age, suggests that family interventions may be particularly important in treating these children. In conclusion, the present results underscore the severe continuing difficulties experienced by a large proportion of children initially hospitalized with depressive disorders. Our data indicate that at least half of our psychiatrically hospitalized depressed children failed to stay well over the
course of our follow-up period. Most depressed children remained in their homes and did not require long-term therapeutic placements. However, almost half of our depressed children did need episodic hospitalizations. From the vantage point of public health planning, these data underscore the critical need for mental health services for these children including inpatient facilities where they can be treated when suicidal behavior jeopardizes their safety. The severe continuing difficulties observed in this sample highlight the need for further research on the etiology and treatment of these disorders. Acknowledgements
This research was supported by a grant from the John D. and Catherine T. MacArthur Foundation as part of their Network on Risk and Protective Factors in the Major Mental Disorders. The authors wish to thank Gwen Gordon for her computer assistance. References Asamow,
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