Depressive symptoms and life events in physically ill hospitalized adolescents

J O U R N A L OF ADOLESCENT H E A L T H CARE 1986;7:107-111

Depressive Symptoms and Life Ill Hospitalized Adolescents

Events in Physically

STUART L. KAPLANr M . D . r P A U L A GROSSMANI M . D . I BETH L A N D A r Ph. D. I

I. R O N A L D SHENKER~ M . D . r A N D C H A N T A L W E I N H O L D

To study life events and depressive symptoms in adolescents hospitalized for physical illness, we administered the Coddington Life Events Survey and the Beck Depres- sion Inventory (BDI) to 43 acutely ill adolescents, 42 chronically ill adolescents, and 140 adolescents from a general population. There were no differences between the three groups in total BDI, Psychological BDI, and Coddington Life Change Categories adjusted for hospitalization. The Somatic BDI was significantly greater in the acutely ill and chronically ill than in the general population sample (p < 0.01). In the chronically ill, the Family Life Change score correlated with the psychological BDI (r = 0.44, p < 0.01) but the Undesirable Life Change score did not. In the acutely ill and the general population, the Undesirable Life Change Score correlated with the Psy- chological BDI (r = 0.44, p K 0.01), (r = 0.43, p K 0.01) but the Family Life Change Score did not.

KEY WORDS"

Depression Life events Physical illness

Cannon (1) observed that changes in emotions can lead to altered physiology and suggested the concept that emotions can precipitate physical illness. Based on Cannon's work, life event research has become an important area of study regarding the relationship between psychological variables and the onset of physical and psychiatric illness (1,2). Life events

From the Departments of Psychiatry and Pediatrics of the Long Island Jewish-Hillside Medical Center, Schneider Children's Hospital, New Hyde Park, New York.

Address reprint requests to: Stuart L. Kaplan, M.D., Rockland Chil- dren's Psychiatric Center, Convent Road, Orangeburg, NY 10962.

Manuscript accepted June 11, 1985.

such as marriage, divorce, births, job promotion, and moves necessitate change or reorganization of an individual's life, which may lead to stress. Stress may alter physiological states in such a way that the likelihood of becoming physically or psychiatrically ill is increased. According to Holmes and Rahe (3) and Dohrenwend (4), whether a life event is desirable or undesirable is unrelated to whether that event may precipitate an illness because all life events require some interpersonal reorganization on the part of the individual. Most studies of life events in adults have found a minor (r = 0.12-0.3) relationship between life events and physical illness (2).

Heisel et al. (5) and Coddington (6) used the Life Events Scale to study life events in general adolescent, general pediatric, and hospitalized pediatric samples, and in a mixed group of children and adolescents aggregated by diagnosis. They found more life change units in the hospitalized pediatric sample, in hemophilliac children and adolescents with frequent bleeding episodes, in children and adolescents admitted for surgery, and in adolescent psychiatric patients than in the general population sample.

Because of the lack of studies of life events and physical illness in hospitalized adolescents, we de- signed a study to compare the frequency and quality of life events in a hospitalized adolescent sample and in a general adolescent control group and to examine the relationship between life events and depressive symptoms in both groups. We hypothesized that hospitalized adolescents would have more life events than a nonhospitalized sample, and that hospitalized physically ill adolescents would have more depressive symptoms than nonhospitalized adolescents because physical illness and hospital confine- ment would be important undesirable life events.

© Society for Adolescent Medicine, 1986 107 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017 0197-0070/86/$3.50

108 KAPLAN ET AL. JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 2

Materials and Method

The Coddington Life Events Scale is a 50-item self- report life event instrument developed and stan- dardized for children and adolescents (7). The instrument provides three direct category scores: 1) Family Life Events, which inquire about the death, divorce, hospitalization, and change in job and income of family members; 2) Desirable Life Events, which include items such as winning a prize, getting a sum- mer job, and graduating from high school; and 3) Undesirable Life Events, which include breaking up with a girlfriend or boyfriend, failing a grade in school, and hospitalization. We followed Cod- dington's instructions for the computation of these category scores. The frequency of individual life events was multiplied by weights established by Coddington to produce a life change unit raw score, which provides a measure of the social reorganization required by the life event. The raw scores are summed by Coddington's categories and then con- verted to standard scores based on norms developed by Coddington in a s tudy of 748 adolescents (7).

The Beck Depression Inventory (BDI) is a widely used and well-studied clinical and research self-administered measure of depression (8-11). The BDI consists of 21 questions with a 0 response if the depressive symptom is not present, a i if the symptom is present, and a 2 or 3 if the symptom is severe. The total BDI score is the sum of the individual items. The higher the score the greater the amount of depressive symptoms. Standard cut-off points are: 0-9, non- depressed; 10-15, mild depression; 16-23, moderate depression; 24+ severe depression. The BDI can be divided into two subscales: psychological (BDI items 1-13) and somatic (BDI items 14-21). Because the symptoms of physical illness can be identical with some of the physiological symptoms of depression, we employed these subscales to minimize confound- ing the symptoms of physical illness and depression.

One hundred forty-five adolescents who were consecutively admitted to an adolescent medicine in- patient unit were invited on admission to complete the BDI and the Coddington Life Events Scale. Twenty-one of the hospitalized adolescents refused to participate in the study because they felt too ill or regarded the inventories as "too personal." Thus we had 124 clinical subjects. The adolescents were in- structed to complete the Coddington based on their life events during the preceding six months.

A junior and a senior high school near the hospital were chosen to provide an adolescent control sample

that would provide an approximate match for age and social class with the hospitalized sample. On the basis of meetings with the principals and school counselors, classes were selected to meet our estimate of the age and subject number required for our study. Two classes from each of the three grades (seventh, eighth, and ninth) were chosen by the principal based on his estimate of the teachers' will- ingness to participate. One science class from each of the tenth, eleventh, and twelfth grades was chosen because it was thought that science students might have an interest in participating in the study.

Letters describing the study and consent forms were distributed to the students and had to be returned signed by the parent and child prior to the distribution of the questionnaires. Of the 272 consent forms distributed, 168 were signed and returned. Of 104 students who did not return the consent forms, two parents refused to allow their children to participate. We have no data for the reasons the remaining students did not return the signed consent forms. During class time set aside for the research project, a research assistant distributed the questionnaires, the students filled them out, and the research assistant collected them. During the data analysis, 28 subjects of our 168 were excluded from the study because of missing data, leaving us with a total of 140 subjects in the control sample.

Because some forms of chronic illness may be as- sociated with a decreased number of life events as a result of a restricted life style (5), the hospitalized adolescents were divided into two illness groups, acute and chronic, to test for differences in the frequency of life events and depressive symptoms.

Chronic illness was defined as being ill for four months or longer (n = 42) based on chart review, and acute illness was defined as being ill for one month or less (n = 43) based on chart review. Those ill for one to four months were not considered further in the data analysis (n = 39).

Because of the wide variety of illnesses in the hospitalized sample, we were unable to categorize the illnesses easily. Illustrative of the diagnoses found in the acutely ill were 11 cases of infection, one new leukemia, seven trauma, two pregnancy complica- tions, and one new diabetic. Representative of the diagnoses of the chronically ill group were one cystic fibrosis, four oncology, one diabetic, one ulcerative colitis, and one sickle cell anemia.

Results In the analysis of the differences between the groups based on the demographic variables, there were no

MARCH 1986 DEPRESSIVE SYMPTOMS AND LIFE EVENTS 109

sex differences between the three groups but the groups did vary by socioeconomic status (SES) and age, with the chronically ill having a lower social class than the other two groups (p < 0.01), and the nonhospitalized having a younger age than the other two groups (p < 0.01) (see Table 1). The latter finding reflects an excess of junior high school students over high school students in the nonhospitalized control sample, but there is no apparent explanation for the difference in social class between the chronically ill and the other two groups. In the analysis of covariance between the groups for life events and BDI, age and SES were covaried to control statistically for differences between the groups. When analysis of covariance indicated significant differences between the three groups, the Tukey H.S.D. test was used to analyze for group differences.

The analysis of covariance for differences between the three illness groups on life change events did not reveal significant differences in Coddington Life Change Category I (Family Life Change) or Category 2 (Desirable Life Change). There were significant differences by illness groups in Category 3 (Undesirable Life Change), with the chronically ill group having significantly more Undesirable Life Change than the

Table 1. Demographics of Illness Groups

Demographics of illness groups by age in years ~

Illness group X SD df F P

Chronic 15.1 1.9 Acute 15.5 1.7 Nonhospitalized 13.6 1.8

2,222 24 0.01

Demographics of illness groups by SES b,c

Illness group X SD df F P

Chronic 3.2 1.1 Acute 2.7 1.2 Nonhospitalized 2.6 1.2

2,222 5.6 0.01

Demographics of illness groups by sex

Illness group Male Female df X 2 p

Chronic 19 23 2 1.63 Not Acute 25 18 significant Nonhospitalized 68 72

aSignificant group contrasts by Tukey H. S. D.: Chronic versus nonhospitalized (p < 0.01) and acute versus nonhospital ized (p < O.Ol).

bLarger SES number indicates lower social class. cSignificant group contrasts: Chronic versus nonhospital ized

(p < 0.01) and chronic versus acute (p < 0.05).

nonhospitalized group (p < 0.05, df 2,219). Howev- er, when the Coddington Life Change item inquiring about medical hospitalization was deleted and the raw scores were analyzed there were no longer significant differences in Undesirable Life Change between the two illness groups (p < 0.57, df 2,219).

The three illness groups differed only on three of the 50 individual Coddington items. In an analysis of covariance of Coddington items, controlling for age and SES and utilizing the Tukey H.S.D. for significant group contrasts, hospitalization for illness or accident was found more frequently in the chronically ill than in the acutely ill (p < 0.01), in the chronically ill than in the nonhospitalized group (p < 0.01) and in the acutely ill than in the nonhospitalized group (p < 0.01, df 2,219). The death of a friend occurred more frequently in the chronically ill than in the acutely ill and nonhospitalized samples (p < .01, df 2,219). Nonhospitalized subjects reported an increase in parent income more frequently than the chronically ill (p < 0.05) and the acutely ill samples (p < 0.01, df 2,219).

There were no significant differences in total BDI scores between the three groups or in the psychological BDI between the three groups. The acutely ill and chronically ill samples had significantly higher scores on the somatic BDI than the general samples (p < 0.01, df 2,207).

To better understand the differences in depressive symptoms between the three groups, the groups were tested for differences in individual item scores on the BDI with an analysis of covariance controlling for age and SES. The Tukey H.S.D. was employed to test for significant group contrasts when an analysis of covariance indicated significant differences between the three illness groups. Chronically ill patients rated themselves as more unattractive than did acutely ill patients (p < 0.05) and the general sample (p < 0.01, df 2,219), and as having experienced more weight loss (p < 0.05, df 2,217) and more worry about their health than the general sample (p < 0.01, df 2,219). Unexpectedly, the acutely ill were significantly less irritable than the general sample (p < 0.05) and the chronically ill sample, but the latter difference was not significant. In addition the acutely ill had more appetite loss (p < 0.01, df 2,219) and weight loss (p < 0.05, df 2,217) than the general sample.

For each of the three groups the psychological and the somatic subscales of the BDI were correlated par- tial for age and social class in an effort to assess the degree to which the somatic subscales were related to psychological subscales. In the chronically ill, the

110 KAPLAN ET AL. JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 2

somatic and psychological BDI subscales correlated r = 0.72, p ( 0.001; in the acutely ill the correlation was r = 0.68, p ( 0.001. Thus, somatic symptoms of depression and psychological symptoms of depression were highly related in all samples.

The Coddington Life Change categories Family Life Change, Desirable Life Change, and Undesir- able Life Change were correlated with the psychological subscale of the BDI. In the chronically ill, Fam- ily Life Change correlated significantly with the psychological BDI (r = 0.44, p ( 0 . 0 1 ) but did not correlate in the acutely ill (r = 0.19, not significant) and nonhospitalized (r = 0.19, p ( 0 . 0 5 ) samples.

Undesirable Life Change correlated significantly with the psychological BDI in the acutely ill (r = 0.44, p (0 .01) and nonhospitalized samples (r = 0.43, p ( 0.01) but did not correlate significantly in the chronically ill. Desirable Life Change did not correlate significantly with the psychological BDI in the three samples.

Discussion The diagnosis of depression in physically ill adolescents is complicated by the similarity between the somatic symptoms of depression, such as sleep- lessness, irritability, and weight loss, with those symptoms in physical illness. The question of assess- ing whether these symptoms are expressions of depression or physical illness is often a vexing one for the physician attempting to establish a diagnosis of depression using the DSM III criteria (12).

Our data reflect this clinical difficulty. As expected, the physically ill sample had more somatic symptoms than our general sample. Because there were no differences in total BDI between the three groups, the likely explanation for the increase in somatic symptoms of depression in the physically ill sample is that their somatic symptoms were related to their physical illness. On the other hand, there were strong correlations between somatic symptoms of depression and psychological symptoms of depression in both the physically ill and general sam- pies. This suggests that the somatic symptoms are strongly related to the psychological symptoms of depression in all three samples as well as to physical illness in the hospitalized samples. A longitudinal study of a hospitalized population to include the re- peated administration of the BDI during and after hospitalization along with the biological measures of physical illness as dependent variables might clarify the amount of variance in somatic symptoms of depression explained by physical illness versus that explained by depressive symptoms in the physically ill.

Although early clinical studies of chronically ill children and adolescents suggested that they were burdened with a variety of psychological difficulties in excess of what would be expected in a general population, more recent and better controlled studies do not support this clinical assumption (13-16). For example, Kellerman et al. (13) and Zeltzer et al. (14) in a study of 345 adolescents from a general population and 168 mostly outpatient adolescents with a variety of serious chronic illnesses found no differences in self esteem and anxiety between the two groups. The general adolescent sample in the above study complained of as much disruption in their lives from minor illnesses such as colds as did the chronically ill with their serious illnesses. Our findings are consistent with these more empirical studies.

Furthermore, our data suggest that life changes are probably not more frequent in the six months preceding hospitalization of acute and chronically ill adolescents than in a general adolescent sample. Even categorizing life change items into Desirable, Undesirable, and Family Life Change Categories did not reveal significant differences between groups.

The lack of a correlation between Desirable Life Changes and depressive symptoms in our three samples is consistent with the adult studies that report an absent or weak inverse relationship between positive life changes and depressive symptoms (17-21). These same studies report a strong correlation between depressive symptoms and undesirable life changes. The significant correlations we found between the Coddington Undesirable Life Event Cate- gory and the Psychological BDI in the acutely ill and general sample are supported by similar findings in adults. In our chronically ill subjects, the lack of a correlation between the Coddington Undesirable Life Change Category and psychological BDI was an unexpected negative finding, which is discussed below.

The interpretation of the correlations between the psychological BDI and the Family Life Change Cate- gory and the psychological BDI and the Undesirable Life Change Category in the chronically ill may require a more detailed understanding of these two Coddington categories. The Family Life Change Cat- egory is composed of 17 items; 12 are aversive, or "undesirable," widely regarded as causing psychological pain to adolescents. These items include: death of a grandparent, parent, or sibling; divorce or separation of a parent; and hospitalization of a parent or sibling. Because desirable life changes are unrelated to depressive symptoms, the positive correlation between the Family Life Change Category and

MARCH 1986 DEPRESSIVE SYMPTOMS AND LIFE EVENTS 111

the psychological BDI in the chronically ill is probably due to the correlation of aversive or "undesirable" family life events in the Coddington Family Life Change Category with the psychological BDI.

The Coddington Undesirable Life Change Catego- ry refers to life changes that are aversive but are mostly not related to the family, such as failing a grade in school, drug abuse, and breaking up with a boyfriend or girlfriend.

The high correlation between the Family Life Change Category and the psychological BDI in the chronically ill and the lack of correlation between these two variables in the acutely ill and nonhospitalized sample raise the question as to whether the chronically ill are more sensitive to events in their family than are the other two samples. Perhaps chronic illness makes adolescents closer to or more dependent on their families, and thus more vulnera- ble to the vicissitudes of family life.

We gratefully acknowledge the help of Cheryl Weston, R.N. and the many other nurses of Adolescent Medicine, Long Island Jew- ish-Hillside Medical Center, who assisted in our data collection.

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Depressive symptoms and life events in physically ill hospitalized adolescents