Self-reported depressive symptoms in inner-city adolescents seeking routine health care

Adolescence, Summer, 1994 by Aric Schichor, Bruce Bernstein, Stephen King

Adolescence is a time of transition with a focus on becoming independent from parents and forming supportive links with peers and other adults. Stress-related problems may become more common and an increase in depression, suicidal ideation, and suicide are seen. Yet few adolescents seek help from counseling or health care facilities in dealing with their mental health needs. They are more likely to receive general medical care. Hawton, Cole, O'grady, & Osborn (1982) reported that 50% of the adolescents in their study who had attempted suicide had seen a physician within one month of the event. By contrast, other studies (Slap, Vorters, Chaudhuri, & Centor, 1989; Shaffer, 1974) indicated that only 27 to 30% of adolescents who manifested suicidal behavior had a prior history of mental health care. The American Academy of Pediatrics Committee on Adolescence (1988) has recommended that pediatricians be familiar with the signs and symptoms of depression.

Adolescents usually seek general health care when they require a physical examination for sports, camp, school, or work, or because of an acute illness. When primary care providers see these adolescents, they tend to underidentify or miss mental health problems (Goldberg, Roghmann, McInerney, & Burke, 1984; Fine, McIntire, & Fain, 1986). Epidemiological studies of adolescents have found that 10 to 30% of teens may be depressed at a given time and that somatic complaints may also be part of their presenting picture (Carlson & Cantwell, 1980; Garrick, Ostrov, & Offer, 1988; Wells, Deykin, & Klerman, 1985; Kandel & Davies, 1982). This study was undertaken to determine the frequency of depression in a group of healthy adolescents who seek care in an inner-city outpatient setting and the relationship between these feelings and somatic complaints. We were also interested in the relationship between these feelings and psychosocial stressors. It was felt that this population needed to be studied because adolescents who may be depressed are generally not seen by mental health providers. Early identification through an increased sensitivity to psychosocial stressors and somatic complaints and subsequent intervention at the primary care level may lead to more effective treatment and prevention of more serious problems.

METHODS

The study population was drawn from youth attending an inner-city adolescent medicine service. Only those teens seeking initial physical examinations for nonacute reasons were included in the study. Prior to being seen, each adolescent completed a confidential, multiple-choice questionnaire designed for a seventh-grade reading level. The adolescents were assured that the questionnaire would not become part of their permanent medical record.

The questionnaire was administered in English. Latino adolescents who had difficulty completing the questionnaire were assisted by a bilingual and bicultural nurse's aide with experience in working with adolescents. Other adolescents who could not read the questionnaire were assisted by the health care provider who saw them. Fewer than 2% of the adolescents who were asked to complete the questionnaire chose not to do so either because of its length or because of the issue of confidentiality.

The questionnaire solicited information about general health, home, school, reproductive health, mental health, and exposure to drugs and alcohol. It was usually completed in 15 minutes. The medical staff who saw these teens consisted of two physicians and a nurse experienced in the care of adolescents, as well as pediatric and family medicine residents and medical students rotating through the service.

All teens were asked if they had ever felt down or depressed and, if so, the frequency of these feelings (e.g., less than once a month; more than once a month; every week; or daily). Those who indicated being down or depressed weekly or daily were compared to the other adolescents. The charts for those teens who indicated being down or depressed weekly or more often were reviewed at the end of the study to determine how these feelings were being addressed by the health providers.

Adolescents identified as being depressed were either counseled by the provider who initially saw them, referred to either the social worker or the psychologist, or to an outside mental health provider after an initial review with the social worker or psychologist. Adolescents referred outside the program included those who lived a significant distance from the facility and preferred a local provider, those needing medication for the treatment of their depression, those who required longer term therapy, and those who indicated a preference for a provider outside the program.

An effort was made to follow up on all mental health referrals, whether within or outside the program. When a referral was not completed, the adolescent was contacted by phone, letter, or through school, depending on the level of confidentiality required.

Data analysis included generation of descriptive statistics and exploration of associations between demographic values and feeling down or depressed frequently. T-tests were used to explore differences in mean numbers of somatic and psychosocial concerns reported by those teens who felt down or depressed frequently as compared to the rest of the population. Relative risk of feeling down or depressed frequently was calculated for the somatic and psychosocial concerns. In order to adjust for the increased probability of finding significant relationships due to multiple comparisons, 99% confidence intervals (more conservative than the conventional 95%) were calculated (Ware, Mosteller, & Ingelfinger, 1986).