The presence of co-morbid mental health problems in a cohort of adolescents with CFS (2017) Chalder et al.

[hixxy]

Clin Child Psychol Psychiatry. 2017 Oct 1:1359104517736357. doi: 10.1177/1359104517736357. [Epub ahead of print]

The presence of co-morbid mental health problems in a cohort of adolescents with chronic fatigue syndrome.

Loades ME, Rimes KA, Ali S, Lievesley K, Chalder T.

Abstract

OBJECTIVE:
To report on the prevalence of mental health disorders in adolescents with chronic fatigue syndrome (CFS) and to compare the diagnoses identified by a brief clinician-administered psychiatric interview with self-report screening questionnaires.

DESIGN:
Cross-sectional study.

SETTING:
Consecutive attenders to specialist CFS clinics in the United Kingdom.

PATIENTS:
N = 52 adolescents, age 12-18 years with CFS.

MEASURES:
Self-report questionnaires and a brief structured psychiatric diagnostic interview, administered by a researcher.

RESULTS:
On the psychiatric interview, 34.6% met a diagnosis of major depressive disorder and 28.8% had an anxiety disorder. Of these, 15% had co-morbid anxiety and depression. Those with a depression diagnosis reported significantly greater interference on the school and social adjustment scale. They also scored significantly higher on trait anxiety, but not on state anxiety. There were no differences between those who had an anxiety disorder and those who did not on fatigue, disability or depressive symptoms. Children's Depression Inventory (CDI) score was associated with a depression diagnosis on the psychiatric interview. However, neither the state nor the trait subscale of the State-Trait Anxiety Inventory (STAI) was associated with an anxiety diagnosis.

CONCLUSION:
Clinicians should assess for the presence of anxiety and depressive disorders in adolescents with CFS using a validated psychiatric interview. Treatment should be flexible enough to accommodate fatigue, depression and anxiety. Transdiagnostic approaches may suit this purpose. Goals should include pleasurable activities particularly for those who are depressed.


KEYWORDS:
CFS/ME; Chronic fatigue syndrome; MINI-KID; adolescents; anxiety; depression

https://www.ncbi.nlm.nih.gov/pubmed/29096528
http://journals.sagepub.com/doi/10.1177/1359104517736357

 

[Snowdrop]

They're teenagers. The very definition of anxiety and volatile mood.

 

[Hutan]

They're teenagers. The very definition of anxiety and volatile mood.

Yes, and teenagers who are forced to be way more dependent on their parents than the average young person.

Teenagers who are wondering what the hell is happening to them as they see their peers carry on doing the things they want to be doing, while they struggle to get out of bed.

Teenagers who are being fed a whole lot of psychobabble about being behaviourally or morally deficient.

And a researcher doing 'psychiatric diagnostic interviews' who has a bias towards finding plenty of issues to report.

 

[Luther Blissett]

There is also a question as to the accuracy of diagnosis of mental health problems in adolescents (and adults) with regard to gender bias. Different genders as a group have different ways of showing problems with thinking, feeling, and behaving.

Is there a mention of the adolescents in this study having other health problems? Can't see it.

If you think about the proportion of us with IBS and the the link between IBS and Anxiety, that would make a difference. (I mean this in the way that IBS naturally causes anxiety)

Three Crawley studies in the References, and at least 1 FITNET too.

 

[Adrian]

I couldn't find the CDI questions but it does seem to be tested on a small group

Wiki says: https://en.wikipedia.org/wiki/Children's_Depression_Inventory

Most research on the CDI has been conducted with Caucasian participants of middle to lower class socioeconomic status throughout the world.[1] The CDI can be given to children and youth across cultures, though its "internal consistency and factorial structure vary somewhat in different juvenile cohorts."[1] Kovacs and other researchers have reported obtaining higher CDI scores for African-Americans (particularly boys),[21] Japanese (substantially higher),[1][22] Hispanic (significantly higher),[1][23] and Egyptian[10] individuals when compared to Caucasians.

Additionally, test scores for older children (aged 13 years old or older) tend to be higher than those of younger children (under 12 years old), though the difference is small and not significant.[1] This is explained with the consideration of the development and maturation of children at this age level,[1] with changes occurring in brain structure occurring at these ages. One study, however, reported that the CDI scores of younger (aged 6–11) children were higher than those of older (aged 12–18) children.[24]

In an analysis of interview data of children who are diabetic, CDI score results may mimic those of having depressive symptoms.[1] However, important to keep in mind is that diabetes "elicits noticeable emotional upheaval (mostly in the depressive symptoms domain) that nonetheless resolves in about six months."[1]

The comment on diabetic children suggests that as a scale it is not robust to co-morbid conditions.

Given the issues with questionnaires etc I find it hard to take these papers too seriously.

 

[Luther Blissett]

The comment on diabetic children suggests that as a scale it is not robust to co-morbid conditions.

Very important.

I recently read a comment piece about how, in adolescent boys, the scales are more accurate for these kind of questionnaires if a parent filled in the form, than if the adolescent did. (Can't find the comment or paper!)

This would make a big difference in the studies that Crawley likes to publish for example. Without a gender breakdown, the figures could massively influence the success rates of using CBT and GET.

There's also a suspicious difference between diagnosed rates and completed suicide rates in my layman's view. (At least for adults, not sure about younger)

 

[Dolphin]

Wiki says: https://en.wikipedia.org/wiki/Children's_Depression_Inventory


The comment on diabetic children suggests that as a scale it is not robust to co-morbid conditions.

In an analysis of interview data of children who are diabetic, CDI score results may mimic those of having depressive symptoms.[1] However, important to keep in mind is that diabetes "elicits noticeable emotional upheaval (mostly in the depressive symptoms domain) that nonetheless resolves in about six months."[1]

Given the issues with questionnaires etc I find it hard to take these papers too seriously.

It's not clear from the CFS study but these sorts of assessments are usually done soon after attending a service when people could be distressed about what is happening. Or somebody might get referred when most distressed so over time there could be a sort of regression to the mean effect. Also good chance they went to the service soon after diagnosed when quite likely to be distressed.

Like with those with diabetes, results might be quite different at another time point.

 

[Dolphin]

Biased sample?


There were two centres used

Ethical approval
This study was approved by a National Health Service (NHS) research ethics committee (LREC, ref. 08/H0807/107), and the Research and Development departments at the Institute of Psychiatry, South London and Maudsley NHS Trust, and Great Ormond Street Hospital.

South London and Maudsley NHS Trust service is run by psychologists and psychiatrists. I think it is in the mental section of the hospital. If a child/teenager, their parents or their doctor didn't think a psychiatric issue is involved they might be less likely to be referred there.


Don't know much about GOSH service except recall it being criticised by the TYMES Trust

 

[Dolphin]

Estimates of the prevalence of co-morbid depression vary considerably between 17% (Nijhof et al., 2013) and 42% (Walford, Nelson, & McCluskey, 1993), most likely as a result of differences in sampling strategies, cut-offs for identifying depression and study settings.

Using self-report questionnaires has drawbacks. The questionnaires most commonly used include items such as restlessness, lack of energy and fatigue which may be confounded with CFS.

 

[Dolphin]

They didn't use the gold standard psychiatric interview:

Psychiatric diagnoses. The MINI-KID (Sheehan et al., 1998) is a structured diagnostic schedule, which covers 20 psychiatric diagnoses from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) in a relatively brief time, taking an average of 34 minutes to administer (Sheehan et al., 2010). The MINI-KID has demonstrated good concurrent validity when compared to the gold standard psychiatric interview, the KSADS (Sheehan et al., 2010) and substantial to excellent inter-rater and test–retest reliability.

This study used a structured psychiatric interview to diagnose depression and anxiety. However, the MINI-KID, while brief, lacks the depth and flexibility of a diagnostic tool such as the KSADS. Diagnostic outcomes on the MINI-KID depend on algorithms and not clinician judgement, and symptoms are rated as present or absent, without further detail regarding severity or frequency.

 

[Dolphin]

Participation in Life – The 5-item Work and Social Adjustment Scale (WSAS) (Mundt, Marks, Shear, & Greist, 2002) instructs respondents to rate the extent to which their problem interferes with their ability to undertake work, domestic, social and leisure activities and how it affects their close relationships. In this context, ‘work’ was replaced by ‘school or college’ to ensure its appropriateness for adolescents, and will henceforth be referred to as the school and social adjustment scale (SSAS).

Here are the questions that make up the Work and Social Adjustment Scale

Mundt JC1, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002 May;180:461-4. http://bjp.rcpsych.org/content/180/5/461.long
Work and Social Adjustment Scale

Rate each of the following questions on a 0 to 8 scale: 0 indicates no impairment at all and 8 indicates very severe impairment.

1. Because of my [disorder], my ability to work is impaired. 0 means not at all impaired and 8 means very severely impaired to the point I can't work.

2. Because of my [disorder], my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired. 0 means not at all impaired and 8 means very severely impaired.

3. Because of my [disorder], my social leisure activities (with other people, such as parties, bars, clubs, outings, visits, dating, home entertainment) are impaired. 0 means not at all impaired and 8 means very severely impaired.

4. Because of my [disorder], my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired. 0 means not at all impaired and 8 means very severely impaired.

5. Because of my [disorder], my ability to form and maintain close relationships with others, including those I live with, is impaired. 0 means not at all impaired and 8 means very severely impaired.

 

[Dolphin]

Anxiety – The State-Trait Anxiety Inventory (STAI) (Speilberger, Gorsuch, & Lushene, 1970), is a 40-item scale which measures the intensity of felt anxiety, both state anxiety (temporary, experienced in particular situations) and trait anxiety (a general tendency to perceive situations as threatening). Each item is rated on a 1–4 scale.

Judging by the numbers, I think there is an error here and they were rated 0-3

 

[Dolphin]

In total, 22 (47.8%) of the 46 participants for whom complete data was available did not meet any anxiety disorder or depressive disorder diagnoses.

 

[Dolphin]

At least one person had a SF-36 physical functioning score of 100 which would cause me to question the diagnosis (but who knows how they read the questions)

 

[Dolphin]

One of the big findings for me is how poor the match between the anxiety scales and structured diagnostic interview was:

Those who met the criteria for an anxiety disorder on the MINI-KID did not differ significantly from those who did not on the STAI. Neither STAI anxiety state score nor STAI trait anxiety score was found to be significantly associated with a diagnosis of anxiety on the MINI-KID (χ2 = 0.176, df = 2, p < .916, R2 = .004–.006), see Table 5.

---

Furthermore, the STAI was not useful in discriminating anxiety disorders. This could be because all the participants were relatively anxious, with the no anxiety disorder group containing a lot of subthreshold anxiety, consistent with previous findings of high levels of anxiety in CFS patient samples (Crawley et al., 2009; Garralda & Rangel, 2005). The STAI trait scale also assesses symptoms of depression (Bieling, Antony, & Swinson, 1998), which may explain why those who are depressed scored significantly higher on this measure.

The STAI was not useful in discriminating between those who had an anxiety disorder and those who did not.

 

[Dolphin]

Having depression appeared to impact on school and social functioning. This highlights how important it is to detect and treat depression in this patient population, who are already likely to miss significant time at school (Crawley & Sterne, 2009; Rangel et al., 2000).

They are suggesting depression causes school absence and social functioning problems. But the direction of causality could be in the other direction i.e. missing school and time with friends causes depression. Or both could correlate with severity.

 

[Dolphin]

It is possible that the higher rates of anxiety and depression in CFS reflect the experiences of adolescents with chronic illnesses more broadly, rather than being specific to CFS. This seems unlikely as previous studies have found that participants with CFS have higher rates of anxiety and depression than those with other chronic illnesses, for example, migraine (Smith, Martin-Herz, Womack, & Marsigan, 2003) and arthritis (Garralda & Rangel, 2004), and a meta-analysis showed that depressive symptoms appear to be higher in CFS than in other childhood chronic illnesses (Pinquart & Shen, 2011). However, in this study, the lack of a comparison group precludes definitive conclusions about this.

Were these comparisons controlled for severity of impairment?

 

[Dolphin]

CBT was not mentioned by name nor CBT/GET theories so I found it less annoying than some papers from those of the CBT school of thought.

 

[Sean]

There is also a question as to the accuracy of diagnosis of mental health problems in adolescents (and adults) with regard to gender bias.

There is also a question as to the accuracy of diagnosis of mental health problems in adolescents (and adults) with regard to gender bias.

FTFY.

 

[Luther Blissett]

There is also a question as to the accuracy of diagnosis of mental health problems in adolescents (and adults) with regard to gender bias.

FTFY.

I was trying to be very generous

CBT was mentioned by name nor CBT/GET theories so I found it less annoying than some papers from those of the CBT school of thought.

Thank you for the expanded posts you do about papers.

I find they tend to make me a little feisty, so don't know how you can go through them.