Depression and Health Care Behaviors

The impact of depression on treatment adherence has been an important area of investigation. For physically ill children and adolescents, treatment nonadherence is a serious problem, resulting in significant morbidity and mortality (DiMatteo et al. 2000). The relationship between depression and poor treatment adherence has been demonstrated in many pediatric illnesses, including asthma (Norrish et al. 1977), HIV disease (Murphy et al. 2001), renal disease (Brownbridge and Fielding 1994; Simoni et al. 1997), and diabetes mellitus (Ciechanowski et al. 2000). Depression has also been associated with higher rates of adverse health risk behaviors, including overeating, smoking, physical inactivity (Goodman and Whitaker 2002), increased sexual risk behaviors (Lehrer et al. 2006), and substance abuse (Bukstein et al. 1989).

Table 6-3. Selected screening tools used for depression in the pediatric setting

Beck Depression Inventory for Youth (J.S. Beck et al. 2005)

Description: Self-report measure for individuals ages 7-18 years; assesses emotional/social impairment and maladaptive cognitions/behaviors; includes a depression subscale


• Brief and acceptable to youth

• Easy to understand, administer, and score

• Useful for DSM-IV-TR diagnosis

• Good internal consistency, validity, and reliability


• Requires further study in clinical and diverse populations

Behavior Assessment System for Children-2nd Edition (C.R. Reynolds and Kamphaus 2005)

Description: Adult-report measure of behavior, emotional development, personality characteristics, and self-perception for youth ages 2-25 years


• Comprehensive


• Complicated to administer

• Lengthy manual

• Lack of formal reliability and validity scores for 2nd edition because it is relatively new Child Behavior Checklist (Achenbach 1991)

Description: Parent-scored symptom checklist designed to identify competencies and behavioral-emotional problems in preschool-age children (1.5-5.0 years) and in children through adolescents (6-18 years)


• Well-validated psychometric properties in community and clinical samples

• Available in many languages

• Adolescent and Teacher versions

• High sensitivity and specificity when used as screen for psychiatric disorders (non-medically ill)

• Identifies children at risk for psychopathology


• Low sensitivity, positive and negative predictive value, and high specificity when used for physically ill, making it a poor screen for this population (Canning and Kelleher 1994)

• Does not yield diagnosis

Child Depression Inventory (Kovacs 1992)

Description: Self- and parent-report measures assessing depressive symptomatology in children 7-17 years Advantages

• Brief administration

• Well-validated psychometric properties

• Reliably identifies depression in physically ill populations


• Does not yield diagnosis

Children's Depression Rating Scale-Revised (Poznanski and Mokros 1996)

Description: Clinician-administered instrument to assess depression in children ages 6-12 years Advantages

• Easy to administer

• Input from multiple informants (self, parent, clinician)

• Good internal consistency, reliability, and validity

• Commonly used in conjunction with a structured interview

Table 6-3. Selected screening tools used for depression in the pediatric setting (continued)

MacArthur Health and Behavior Questionnaire (Armstrong and Goldstein 2003)

Description: Adult-report measure for symptomatology and adaptive behaviors in children ages 4-8 years Advantages

• Parent and Teacher versions

• Considers close association between mental health and physical health

• High reliability and validity in mental health and primary care settings

• Results correspond to DSM-IV

• Brief and acceptable to parents


• Available only in English

• New instrument with limited data

Patient Health Questionnaire for Adolescents (Johnson et al. 2002)

Description: Self-report screening instrument for identification of common psychiatric disorders in primary care setting among adolescents ages 13-18 years


• Brief and highly acceptable to patients Disadvantages

• Not validated against a gold standard

• No reliability data reported

• High specificity, making measure prone to substantial underdiagnosis of depression and other disorders (Johnson et al. 2002)

Reynolds Adolescent Depression Scale-2nd Edition (W.M. Reynolds 2002)

Description: 30-item self-report scale for depression in adolescents ages 11-20 years Advantages

• High internal consistency and reliability

• Well validated for school-based and clinical populations

• Only measure specifically designed to measure depression in adolescents

Reynolds Child Depression Scale (W.M. Reynolds 1989)

Description: 30-item self-report measure to identify presence and severity of depression in children ages 8-13 years


• Easy to administer and score

• Strong validity and reliability

• Studied in large diverse populations


• Limited data about ability to discriminate emotional distress from depression

Mood disorders have economic implications by altering patterns of medical service use. Youngsters with depression and anxiety have been shown to have higher health care utilization rates and health care costs (Bernal et al. 2000; Haarasalsilta 2003). Spady et al. (2005) used administrative health care data over a 1-year period to examine the relationships between psychiatric and medical comorbidity and health care usage in over 400,000 Canadian youngsters ages 6-17 years. Examining all psychiatric diagnoses and medical illness groups, the authors found a high prevalence of psychiatric disorders

(13.6%); among those children with psychiatric disorders, more than 90% had a physical illness, and those with psychiatric disorders had a greater total use of medical services than those without a psychiatric disorder.

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