Depressive symptoms among young Norwegian ... - Springer Link

European Child & Adolescent Psychiatry 10:222–229 (2001) © Steinkopff Verlag 2001

A. M. Sund B. Larsson L. Wichstrøm

Accepted: 6 March 2001

A. M. Sund, MD () · B. Larsson, MD, PhD Department of Child and Adolescent Psychiatry Faculty of Medicine The Norwegian University of Science and Technology Trondheim, Norway Tel.: +47-73-55 15 09 Fax: +47-73-55 15 39 e-mail: [email protected] L. Wichstrøm, PhD Department of Psychology The Norwegian University of Science and Technology Trondheim, Norway

ORIGINAL CONTRIBUTION

Depressive symptoms among young Norwegian adolescents as measured by The Mood and Feelings Questionnaire (MFQ)

■ Abstract In a stratified random and representative sample of 2560 13- to 14-year-old Norwegian girls and boys, depressive symptoms were assessed by means of the Mood and Feelings Questionnaire (MFQ). The MFQ showed a good internal consistency (α), and testretest correlations (r) for threeweek and three-month intervals were 0.84 and 0.80 respectively. Convergent and discriminative validity were also assessed. The mean total MFQ score for the whole sample was 10.6 (SD 9.5). The results showed a significant sex by age interaction effect in that girls increased their mean total MFQ sum score by age while the boys’ scores decreased slightly. Reports of unattractiveness, restlessness, indecisiveness and transient feelings of low mood were common in the total sample, while unhappiness, irritability, self-

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Introduction Today, it is widely accepted that depression exists in childhood and increases throughout adolescence (3, 12, 16, 32). However, measuring depressive symptoms in adolescence is challenging because many young people experience lowered mood for a shorter period of time. For example, in the Isle of Wight Study, Rutter and his colleagues (33) found that as many as 40–50 % of 14- to 15-year-olds suffered from depressive symptoms. Several international studies have examined the

dislike and concentration problems were common among high-scoring subjects. Girls experienced more often lowered mood, were more concerned with their appearance and had more self-depreciatory notions than boys, while boys more often than girls had lower school satisfaction. Girls were preponderant among the high-scoring subjects. The results of logistic regression analyses showed that concentration problems were the strongest predictor of high scores. The findings are discussed in view of similar epidemiological studies in which DSM-IV criteria have been used in the assessment of depressive symptoms and disorders among adolescents. ■ Key words Depressive symptoms – epidemiology – gender difference

prevalence of depressive symptoms in adolescents. Using the Beck Depression Inventory (BDI) or the Center for Epidemiologic Studies Depression Scales (CES-D) (13, 19, 30) rates have varied between 20 and 28 % for mildly depressed subjects, and 1–4 % have been regarded as having severe symptoms. In Scandinavia, Larsson et al. (24) reported 8 % of school adolescents aged 13–18 years as having a moderate, and 2 % a severe depressive symptom level. Kaltiala-Heino (17) found that 9 % had moderate or severe depressive symptoms on the BDI. Olsson and von Knorring (27, 28) reported a higher level of depressive

M. Sund et al. Depression in young adolescents

symptoms using the BDI and the CES-D for older adolescents. Wichstrøm (36) reported that 5.3 % showed serious depressive symptomatology using a six-item measure of depressed mood (18). In community samples, prevalence rates for depressive disorders vary from 2 to 3 % before puberty to 5 to 8 % after puberty (12, 26). Although there is some evidence that high-scoring adolescents on self-report symptom measures in many cases also suffer from a depressive disorder, these estimates depend on sex, age, definitions of cut-off scores and sampling procedures (9, 28, 37). Before puberty, boys and girls have similar rates for depressive disorders (2), but the rates for girls, both for symptoms and disorders, increase throughout adolescence (9, 15, 31, 36). Teri (34) and Kaplan (19), however, found no sex difference using the BDI, while Kovacs (23), using the Children’s Depression Inventory (CDI), reported that adolescent boys had higher depressive symptom scores than girls. Reports of age differences regarding depressive symptoms in children and adolescents are inconsistent. For example, Kovacs (23) found no increase in depressive symptoms with age, while Larsson et al. (25) reported an increase up to 16 years of age. Neither reported interaction between age and gender. Using a short form of the Mood and Feelings Questionnaire (SMFQ), Angold (5) reported decreasing depressive symptoms for boys within the 9–17 age range, while the girls’ scores fell from age 9 to age 11 and then increased from age 12 to age 17. Wichstrøm (36) reported no sex difference until the age of 13, thereafter the sex difference was stable with increasing scores in both sexes throughout adolescence. Using the MFQ sample including only girls aged 11–16, Cooper and Goodyer (9) reported increasing mean scores between the ages of 11 and 15. In the same sample, the prevalence rate of major depression was 3.6 %, and the proportion of subjects with major depressive disorder increased by age and with increasing MFQ scores. So early adolescence seems to be a particularly vulnerable age group for emerging depressive symptoms, especially among girls. It is now well documented that both children and adolescents can suffer from various depressive disorders as defined by DSM- IV criteria (2). However, many of the screening instruments used in epidemiological studies do not cover all the DSM-IV criteria and do not always have appropriate wording for early adolescence. Further, Roberts et al. (30) reported that neither the CES-D nor the BDI were well suited for detecting “true” cases. This emphasises the need for developing instruments that pay greater attention to the criterion-related validity of the items chosen. There is a paucity of studies on the prevalence both of depressive symptoms and disorders in large representative community samples. Without such informa-

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tion it is not possible to estimate accurately the prevalence, phenomenology and significance of depressive symptoms in children and adolescents (31). The purposes of the present study were to examine: 1. The prevalence of depressive symptoms as reported by 13- to 14-year-old girls and boys on the MFQ in a large representative school sample from urban and rural areas in central Norway. 2. Which items of the MFQ were the best predictors of being a high scorer on the MFQ. 3. Reliability, convergent and discriminant validity, and utility of the MFQ. 4. Test-retest reliability of the MFQ for three-week and three-month intervals.

Methods ■ Background The present study was conducted in September 1998 as part of a longitudinal study of depressive symptoms and disorders in young adolescents in two counties in the middle of Norway, South and North Trøndelag. These areas comprised a population of 400 000 inhabitants and included one large city, Trondheim, with 140 000 inhabitants.

■ Sampling procedure The total population of 13- to 14-year-old adolescents attending 8th and 9th grade in private or public schools during the autumn of 1998 in South and North Trøndelag was 9292, and among these pupils 98.5 % attended public schools. The schools are highly integrated, i. e. also including students with reading difficulties, behavioural disturbances and mildly retarded and physically handicapped adolescents. Thirty-eight pupils who attended special schools were excluded from the study. Out of the total population 5.7 % attending the smallest schools in the catchment area were not included for practical reasons. The sample was stratified according to urbanity and geography: 1.City of Trondheim (N=484, 19.6 %), 2. Suburbs of Trondheim (N=432, 17.5 %), 3: Coast (N=405, 16.4 %), 4: Inland (N=1144, 46.4 %). Schools were drawn with a probability according to size (proportional allocation) within each stratum. This resulted in a representative sample of 2813 pupils from 22 schools. Twentyone pupils (0.7 %) were not eligible for various reasons, such as hospital admission, being temporarily abroad, or lacking sufficient knowledge of Norwegian. Thus, a total of 2792 adolescents were eligible for the study. Of these subjects, 2465 adolescents (88.3 %) participated in the study.

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European Child & Adolescent Psychiatry, Vol. 10, No. 4 (2001) © Steinkopff Verlag 2001

The non-responders (n=327) were significantly more often boys (χ2 (1) = 22.11, p 13.7 Total sample

* Age groups divided by median split.

t (1217) =10.1 p < 0.001 t (2441) =11.86 p < 0.001

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Fig. 1 Mean total MFQ scores by age and sex

a two-way ANOVA showed a significant sex by age effect, F(1,2439) = 7.06, p < 0.001. Subsequent t-test showed that girls increased their mean score significantly by age (p < 0.01),while boys showed a slightly lower mean score in the older age group as compared to the younger ones (ns) (See Fig. 1). When applying the proportions for major depression in different MFQ and age groups as reported by Cooper & Goodyer (9), prevalence rates of 2.6 % for the total sample and 3.3 % for the girls were obtained in the present sample. Table 2 presents the percentage of subjects reporting the presence of a depressive symptom at the two severity levels (”Sometimes true” and “True”) for each MFQ item and for the two sexes in the study. The following items received proportionally higher frequency of severe scores: “I felt so tired I just sat around and did nothing”,“I was very restless”,“I did not have fun at school”, “I was less hungry than usual”, “It was hard for me to make up my mind”, “I felt grumpy and cross with my parents”, “I thought I looked ugly”. The girls reported severe problems more frequently (p < 0.01) than did the boys on 18 of the 34 items. The difference between the sexes was largest on the following items: “I hated myself ”, “I cried a lot” and “I thought I looked ugly”. The boys reported severe problems more frequently (p < 0.01) only on one item,“I didn’t have any fun at school”. The 90th percentile score on the MFQ was 24 for the whole sample.About three times as many girls than boys reached this cut-off (14.9 % vs. 50.3 %), χ2 (3) = 61.9 (p < 0.001). The following symptoms were most prevalent, i. e. present in more than 80 % of the high scorers at any of the two severity levels: “I felt miserable or unhappy”, “I felt so tired I just sat around and did nothing”,“It was hard for me to make up my mind”, “I felt grumpy and cross with my parents”, “I found it hard to think properly or concentrate”,“I hated myself ”,“I felt I was a bad person”,“I thought I looked ugly”. Boys had severe scorings more often than girls on 20 of the 34 items. However, the sex difference was statistically significant only for the items concerning school satisfaction and sleep-

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Table 2 Frequency distribution of the MFQ items in percent by sex and for the total sample. 1 = “Sometimes true”, 2 = “True”, during the last two weeks. MFQ ITEM

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

I felt miserable or unhappy I didn’t enjoy anything at all I was less hungry than usual I ate more than usual I felt so tired I just sat around and did nothing I was moving and walking more slowly than usual I was very restless I felt I was no good any more. I sometimes blamed myself for things that were not my fault It was hard for me to make up my mind I felt grumpy and cross with my parents I felt like talking less than usual I was talking more slowly than usual I cried a lot I thought there was nothing good for me in the future I thought that life wasn’t worth living I thought about death or dying I thought my family would be better off without me I thought about killing myself I didn’t want to see my friends I found it hard to think properly or concentrate I thought bad things would happen to me I hated myself I felt I was a bad person I thought I looked ugly I worried about aches and pains I felt lonely I thought nobody really loved me I didn’t have any fun at school I thought I could never be as good as other kids I did everything wrong I didn’t sleep as well as I usually sleep I slept a lot more than usual I was not as happy as usual even when praised or rewarded

Table 3 The results of logistic regression analysis including the most powerful MFQ items to predict subjects as low- or high-scorers (MFQ score < or > 24)

Boys (N= 1199)

Girls (N= 1244)

Total (N= 2443)

1

1

2

1

2

49.2 23.1 29.1 23.9 39.8 13.7 40 24.2 24.4 51.1 48.6 21.2 5.5 14.5 15.1 9.9 16.9 10.9 5.1 14 40.6 23.7 22.8 21.1 46.7 21.7 26.6 15.2 31.1 16.6 18.1 18.4 21.1 19.5

4.5 4.4 14.1 4.9 8.8 2.3 10.3 5.8 9.7 12.5 14.5 6.5 1.6 5.4 5.5 3.5 5 3.3 2.3 2.1 8.3 6 7.1 5.9 19.8 5.5 8 4.7 8.4 5.5 2.7 8 7.4 4.2

38.3 20.9 25.3 23.2 36.5 12 34.6 18.4 21.3 45.4 43.8 18.6 5 8.9 13.7 7.2 12.2 8.3 4 10.6 34.5 18.6 15.4 15.1 33.7 19.4 20.5 11.5 28.7 13.5 14.3 16.3 22.8 16.5

3.1 4.4 10.7 6.0 8.8 2.8 9.7 4.2 8.0 11.3 11.9 5.6 1.6 3.0 4.2 2.8 3.9 2.4 1.9 2.1 6.5 4.1 4.5 4.0 11.9 4.4 5.2 3.3 10.3 4.4 2.4 6.3 8.0 3.4

26.9 18.7 21.3 22.4 33 10.3 29 12.4 18.1 39.4 38.9 15.9 4.4 3 12.2 4.3 7.3 5.7 2.8 7.1 28.2 13.3 7.7 8.8 20.3 16.9 14.3 7.7 26.1 10.3 10.3 14.2 24.6 13.3

2 1.7 4.4 7.2 7.2 8.8 3.3 9.2 2.5 6.3 10 9.1 4.7 1.5 0.6 2.8 2.2 2.8 1.5 1.4 2.2 4.7 2.1 1.8 2 3.7 3.3 2.3 1.8 12.3 3.2 2.1 4.6 8.7 2.6

Item

B*

SE

OR

CI 95 %

15. 16. 18. 21. 23. 24. 25. 27. 28. 30.

0.91 1.14 1.23 1.88 0.80 1.18 0.77 1.12 0.93 0.87

0.21 0.25 0.26 0.25 0.24 0.24 0.21 0.21 0.23 0.20

2.48 3.12 3.42 6.54 2.22 3.27 2.16 3.07 2.53 2.39

2.08–2.88 2.63–3.61 2.91–3.93 6.05–7.03 1.99–2.45 2.8–3.74 1.75–2.57 2.66–3.48 2.07–2.99 2.0–2.78

I thought there was nothing good for me in the future I thought that life wasn’t worth living I thought my family would be better off without me I found it hard to think properly or concentrate I hated myself I felt I was a bad person I thought I looked ugly I felt lonely I thought nobody really loved me I thought I could never be as good as other kids

* All independent variables were significant at p < 0.001

ing and eating more than usual (p < 0.05). The girls scored significantly more frequently severe on the following items: “I felt miserable or unhappy”, “I cried a lot” and “I thought I looked ugly” (p < 0.05). A further analysis was carried out to examine the MFQ items that predicted being a low- or a high-scoring subject. After screening with chi-square analyses for

each of the 34 MFQ items, 11 items were chosen. These items were selected for subsequent logistic regression analyses, in addition to sex. The results of these analyses showed that all the included MFQ items, except for one, “I felt I was no good any more”, contributed significantly to the prediction of outcome, but sex did not (see Table 3). The Odds Ratios

M. Sund et al. Depression in young adolescents

varied between 2.1 and 6.5, the strongest predictor was: “I found it hard to think properly or concentrate”. Overall, 97 % of the total sample could be correctly classified; however, a smaller proportion, i. e. 78 % of the high-scoring subjects, could be correctly classified on the basis of information from these ten items.

Discussion The purposes of the present study were to examine the prevalence of depressive symptoms among 13- to 14year-old Norwegian girls and boys in a large representative school sample, in addition to assessment of reliability and validity of the Mood and Feelings Questionnaire. The MFQ showed a good convergent validity both with the Beck Depression Inventory and with the Depressive/anxious scale of the YSR. MFQ also correlated positively and moderately high with the Aggressive syndrome and Externalising scale of the YSR. A possible interpretation of this finding might be that young people suffering from depressive symptoms often have concurrent behavioural symptoms (8, 21). Weak correlation with the Social Desirability scale gives support to the discriminative validity of the MFQ. The high test-retest correlations both after eight weeks and after three months suggest that the total MFQ scores are reliable across these intervals. In the present study, the MFQ items with the highest item-total correlations reflected concentration problems, hopelessness and self-depreciatory ideas. However, in a study of older school adolescents in which the CES-D was used (28), quite different items reflecting depressed mood showed the strongest correlations. These discrepancies between studies could reflect both differences in age groups and screening measures. The mean total MFQ score for girls in our sample is lower than that reported by Cooper and Goodyer (9), i. e. 12.0 vs. 14.7 among the 13-year-olds and 13.7 versus 15.1 among the 14-year-olds. The estimated prevalence rate of 3.3 % of the girls having a major depression in the present study was similar to the 3.6 % rate obtained in the UK study for girls only. The prevalence rate of 2.6 % for the total sample was somewhat lower than the estimate of 4 % reported from another Scandinavian study of self-reported depressive symptoms in 13- to 18-yearold adolescents (25). These small discrepancies could be due to differing methods and differences between age groups in that our sample included younger adolescents lending support to the notion that the rates of depressive symptoms and disorders are rising throughout adolescence. The frequency distribution of the items for the total sample mirrors the early adolescent period; a large proportion of the adolescents in our study showed some degree of dissatisfaction with their appearance, restless-

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ness, irritability, fatigue, feelings of indecisiveness and periods with lowered mood in line with findings of other authors (13, 24). In the present study the girls most frequently reported irritability and dissatisfaction with their appearance while the boys reported most frequently irritability and indecisiveness. Olsson and von Knorring (28) found crying and unattractiveness among girls and crying and irritability among boys being more frequently reported among older adolescents. In their interview study, Goodyer and Cooper (9) reported depressed mood, withdrawal, increased appetite, irritability and nihilistic ideas to be present in more than 60 % of 11- to 16-year-old girls with a partial depressive syndrome (9 % of their sample), a finding similar to depressed mood, fatigue, irritability and self-depreciation being present in more than 80 % of the high-scoring girls in the present sample.In a community sample of somewhat older adolescents, Roberts, Lewinsohn and Seeley (31) reported that the most frequent symptoms among the cases diagnosed with DSM-IV criteria were depressed mood, sleeping and concentration problems also resembling those problems reported by the high-scoring adolescents in the present study. In line with the results of previous studies of community or school samples of adolescents, the girls had higher total mean scores, were more often high-scorers and reported more often severe scores than did the boys. In addition, their mean total score increased with age. Such sex difference is in line with reports by other authors using the MFQ (3) or other screening measures (27). The interaction between age and sex found in the present study has been reported by other authors (5, 36). However, the boys had only a tendency to falling figures as reported by other authors (5,23) Although being a minority in the high-scoring group the boys reported severe scores as often as the girls. Which MFQ items contribute to the prediction of subjects categorised as low-or high-scorers? One item,“I found it hard to think properly or concentrate” was found to be the strongest predictor, while nine other items only had moderately elevated ORs. The content of these predictors was characterised by self- depreciation, hopelessness and loneliness reflecting negative thinking associated with depression, but no vegetative or suicidal symptoms emerged as potent predictors. This is in line with the known low suicide rate before 15 years of age. In line with the findings of Kent & Vontaris (20), who evaluated the MFQ as a screening instrument for clinically depressed children and adolescents, the items “I found it hard to think properly or concentrate” and “I thought I looked ugly” could best predict the severity of depression. Across all MFQ groups girls reported frequently lowered mood, irritability and dissatisfaction with their appearance, while boys frequently were dissatisfied with their school and reported indecisiveness and irritability.

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These latter symptoms are much weaker predictors of severe problems than problems with concentration, hopelessness, self-dislike and loneliness. High-scoring boys are as seriously affected as high-scoring girls. Our findings could contribute important knowledge for schools and health staff when evaluating common complaints among adolescents. Some limitations of the present study were that only one geographical region in Norway was covered including only one moderately sized city, and that depressive symptoms were assessed solely in a restricted age range and by a self-report measure.

The strength of this study is the large representative sample with a high response rate and that the MFQ used in the assessment covers all DSM-IV criteria for a major depressive disorder. The utility of the MFQ seemed very good and the phrasing of the items was appropriate for this age group. In future research in community samples the MFQ ought to be further validated against semistructured interviews. ■ Acknowledgements This study was supported by grants from the Research Council of Norway and from the National Council for Mental Health – Norway.

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