CBHSQ Data Review: Comparison of Physical Health Conditions among Adolescents Aged 12 to 17 with and without Major Depressive Episode

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Banner image for CBHSQ Data Review, Center for Behavioral Health Statistics and Quality

Comparison of Physical Health Conditions among Adolescents Aged 12 to 17 with and without Major Depressive Episode

Authors

SAMHSA: Sarra L. Hedden, Gary Blau, Rachel Lipari, and Lisa Rubenstein; RTI International: Valerie L. Forman-Hoffman and Cristie Glasheen

Abstract

Research suggests that physical health conditions, particularly asthma and diabetes, may be more common among people with a history of depression. However, studies of the association between depression and physical health conditions among adolescents are rare and tend to use only samples recruited from treatment settings. The purpose of this report is to examine the association between major depressive episode (MDE), self-rated overall health, and selected health conditions (including asthma, bronchitis, pneumonia, obesity, and diabetes) among adolescents in a U.S. nationally representative sample.

Combined data from the 2005 to 2014 National Surveys on Drug Use and Health (NSDUHs) showed worse overall health ratings among those with past year MDE compared with those without past year MDE. Asthma, bronchitis, and pneumonia were more likely among adolescents with past year MDE compared with adolescents without past year MDE. Results were similar by age, gender, race/ethnicity, and poverty status, which showed relatively consistent findings with one notable exception. Past year asthma did not differ significantly among adolescent males with MDE and males without MDE. Female adolescents with MDE had a higher prevalence of obesity and a lower prevalence of normal weight status compared with females without MDE. Lifetime diabetes estimates were higher among female adolescents with MDE compared with those without MDE, among adolescents aged 14 years or older with MDE compared with those without MDE, and among adolescents with MDE among non-Hispanic white and non-Hispanic black adolescents compared with their counterparts without MDE.

Although an association between MDE and these physical health conditions was observed, the cause of these associations cannot be determined using NSDUH data. Because NSDUH is a cross-sectional dataset, temporality cannot be assessed. More research would be needed to determine whether having a physical health condition causes depression or vice versa. However, information in this report on the association between physical health conditions and depression can be used to provide information that can guide prevention, early identification, and treatment of these co-occurring health conditions. These findings may also motivate future research into whether treating depression helps improve physical health conditions and if treating physical health conditions can improve depression. For example, treating depression may improve adolescents' ability to engage in activities needed to monitor and care for chronic conditions like diabetes, and asthma treatment might lead to improved quality of life, which might help reduce depression.

Highlights

Data from the National Surveys on Drug Use and Health show that asthma, bronchitis, pneumonia, obesity (in females only), and diabetes are associated with past year major depressive episode (MDE) among adolescents.
Adolescents with past year MDE were significantly more likely to self-report having fair or poor overall health and were less likely to report having excellent, very good, or good health than those without past year MDE in the past year.
Estimates of past year and lifetime asthma, bronchitis, and pneumonia were all higher among adolescents with past year MDE compared with those without past year MDE.
Lifetime diabetes estimates were significantly higher among adolescents with MDE compared with those without MDE.
Female adolescents with MDE were more likely to be obese than those without MDE. This association did not hold for males.

1. Introduction

Major depressive episodes (MDEs) are characterized by having a period of at least 2 weeks of depressed mood or loss of interest or pleasure in daily activities, with additional symptoms such as difficulties with sleeping, eating, energy, concentration, or self-worth.¹ In 2014, about 11.4 percent of adolescents aged 12 to 17^a experienced an MDE in the past year, and 8.2 percent had an MDE with severe impairment that greatly affected their ability to function well at home, school, or work or to get along with friends or family.² Mental distress and functional impairment are associated with MDE, which can also have substantial consequences for health and well-being, including increased risk of substance use or use disorders, poor academic achievement, impaired social functioning, and suicide.^3,4 Depression during adolescence has been linked to decreased levels of overall health in young adulthood, even after controlling for current depression levels.^5,6,7 A growing body of evidence from population-based studies shows that MDE may be associated with other physical health conditions, including asthma, obesity, and diabetes.^8,9,10,11,12

Although this research suggests that there may be an association between physical health conditions and MDE, research has been mixed—particularly regarding respiratory health conditions—and only a few studies have begun to explore whether characteristics such as gender or race/ethnicity moderate the associations. Understanding whether these associations differ based on age, gender, or race/ethnicity is important for targeting preventive and clinical initiatives. The purpose of this report is to examine the prevalence of MDE among adolescents with varying levels of self-rated overall health and with and without three respiratory health conditions (asthma, bronchitis, pneumonia), body mass index category (including overweight and obesity), and diabetes using data from a nationally representative household sample, the National Survey on Drug Use and Health (NSDUH). These health conditions were examined because, based on prior research, they have been shown to be associated with depression. This study also takes the next step of furthering knowledge about whether the associations between depression and physical health conditions differ among particular populations by exploring whether these associations differ by age, gender, race/ethnicity, and poverty status.

The remainder of this report is organized as follows. Chapter 2 presents the methods, including descriptions of the sample, measures, and data analysis. Chapters 3 to 6 present the main results of the study in describing the association between MDE and overall health status (Chapter 3), respiratory health conditions (Chapter 4), body mass index (Chapter 5), and diabetes (Chapter 6). An overview of studies that have examined associations between depression and the outcome of interest is also presented, followed by current study findings among all adolescents, by age, gender, race/ethnicity, and poverty status. Chapter 7 summarizes the overall findings, implications, strengths and limitations, and future directions for this area of research.

2. Methods

2.1 Sample

Data used in these analyses are from the 2005 to 2014 National Surveys on Drug Use and Health (NSDUHs). NSDUH is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and is an annual face-to-face household interview survey of the civilian, noninstitutionalized population of the United States aged 12 or older. The annual survey has approximately 65,000 respondents per year, with about 17,000 adolescents aged 12 to 17.

After a screening process that determines eligible households and household members, zero, one, or two residents aged 12 or older are selected for the interview, which is mostly conducted via audio computer-assisted self-interviewing (ACASI) to encourage accurate reporting of potentially sensitive topics such as substance use and mental health. Each respondent reads questions or listens to questions via headphones and answers the questions directly on a laptop computer.

Interviewers collect data that require a lower degree of sensitivity via computer-assisted personal interviewing methods, where interviewers read questions to the respondent and enter the respondent's responses on a laptop computer.

The annual weighted interview response rate for adolescents identified as potential NSDUH participants from 2005 to 2014 ranged from 80.0 to 87.1 percent. Further details about the NSDUH design and methods can be found online at https://www.samhsa.gov/data/. Approximately 208,100 adolescents completed the 2005 to 2014 NSDUHs. Because height and weight were not added to the NSDUH questionnaire until 2013, the obesity-depression analyses used combined data from only the 2013 to 2014 NSDUHs, in which there were approximately 35,800 adolescents.

2.2 Measures

2.2.1 Major Depressive Episode

In NSDUH, lifetime major depressive episode (MDE) is assessed using clinical criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.¹³ The questions asked in the adolescent module were adapted from the depression section of the National Comorbidity Survey Replication Adolescent Supplement.^b Respondents were assessed for the presence of either of the core depression symptoms (Have you ever in your life had a period of time lasting several days or longer when most of the day you felt sad, empty, or depressed? and Have you ever had a period of time lasting several days or longer when most of the day you felt very discouraged or hopeless about how things were going in your life?), and then they were given an assessment of the remaining seven symptoms and questions verifying that the duration of 2 weeks or longer was met. Respondents who met criteria for lifetime MDE had at least one core symptom with at least four additional symptoms, present nearly every day, lasting 2 weeks or longer. Past year MDE was assessed among those with lifetime MDE by asking the respondents if they had a period of 2 weeks or longer in the past 12 months where they experienced the core symptom while experiencing some of the other depression symptoms. No exclusions were made for MDE caused by medical illness, bereavement, or substance use disorders. Specific question wording for the NSDUH depression module can be found in other documentation.¹⁴ This report focuses on past year MDE. The average annual prevalence of past year MDE among adolescents aged 12 to 17 in the 2005 to 2014 NSDUHs was 8.9 percent. Results on overall health, respiratory health conditions, body mass index (BMI), and diabetes by lifetime MDE were similar and are displayed in tables in Appendices A through D.

2.2.2 Physical Health Conditions

Selection of the physical health conditions from NSDUH for this report was based on prior research that indicated that these conditions may be associated with depression. Self-rated health (overall health), asthma, bronchitis, pneumonia, diabetes, and obesity (BMI category, including underweight, normal weight, overweight, and obese) were selected for further investigation.

Current overall health is assessed in the ACASI portion of the NSDUH interview using the following text: "This question is about your overall health. Would you say your health in general is excellent, very good, good, fair, or poor?"

Respiratory health conditions and diabetes were assessed as part of a series of questions about several physical health conditions. Respondents were first shown a list of 20 health conditions (including asthma, bronchitis, pneumonia, and diabetes) and asked whether a doctor or other medical professional had ever told them that they had that health condition. They were then given another list to assess whether a doctor or other medical professional had told them that they had these health conditions in the past year. The diabetes question did not differentiate between type 1 diabetes and type 2 diabetes.

BMI category (including overweight and obese) was assessed by asking each respondent to self-report height and weight. NSDUH did not begin collecting height and weight information until the 2013 survey, so all analyses on BMI category use only 2013 to 2014 data. Categorizations were made by calculating BMI from the height and weight variables (defined as kilograms divided by meters, squared). BMI category corresponded with the BMI-for-age percentiles listed in the 2000 Centers for Disease Control and Prevention growth charts.¹⁵

2.3 Analysis

Four outcome variables were created based on substantive knowledge of the physical health condition, sample size considerations, and sample distributions of a particular condition:

Overall health ratings were dichotomized into excellent, very good, and good versus fair and poor.
Respiratory health conditions were categorized as no lifetime disorder, lifetime but not past year disorder (herein referred to as "lifetime"), and past year disorder.
BMI was categorized into four groups: BMI at or below the 5th percentile = underweight, BMI over the 5th percentile up to the 85th percentile = normal weight, BMI at or above the 85th percentile and below the 95th percentile = overweight, and BMI at or above the 95th percentile = obese.
Diabetes was categorized as no lifetime diabetes versus lifetime diabetes because diabetes is a chronic condition (i.e., there are no instances of lifetime but not past year).

Estimates of each outcome were computed by past year MDE status among all adolescents and separately by age group (12 or 13, 14 or 15, and 16 or 17), gender (male and female), race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic),^c and poverty status (less than 100 percent of the federal poverty level [FPL], 100 to 199 percent of the FPL, and 200 percent or more of the FPL). Proportions of health outcomes were compared among those with and without MDE overall and among each covariate group (e.g., among males, among females) using t-tests, which reflect the test statistic under finite sample sizes in complex survey data.¹⁶ Multiple logistic regression models were run to confirm that significant bivariate associations between past year MDE and each outcome remained after adjusting for age group, gender, race/ethnicity, and poverty status.

3. Overall Health

Studies conducted from samples of middle-aged or elderly adults have indicated a significant association between self-rated health and depression^17,18 independent of physical health status. More recently, Bauldry and colleagues¹⁹ analyzed data from three waves of panel data from the National Longitudinal Study of Adolescent Health (Add Health) to confirm a significant association between self-rated health and depressive symptoms among adolescents initially enrolled in grades 7 to 12 as they transition to young adulthood.

To further explore and update these findings to include associations between self-rated health and depression among adolescents enrolled and not enrolled in school, overall health ratings among adolescents with and without a past year major depressive episode (MDE) were examined. Current overall health status among all adolescents is presented first, followed by estimates specific to age, gender, race/ethnicity, and poverty status, which are factors included in the prior study conducted by Bauldry and colleagues. These factors were also measured in the National Survey on Drug Use and Health (NSDUH) data.¹⁹

All Adolescents

Adolescents with past year MDE were more likely to rate their overall health as fair or poor and were less likely to rate their overall health as excellent, very good, or good than those without past year MDE (Figure 3.1). For example, 6.9 percent of adolescents with past year MDE reported having fair or poor health compared with 3.3 percent of adolescents without past year MDE. Associations between past year MDE and overall health remained significant after adjusting for age group, gender, race/ethnicity, and poverty status (data not shown).

Figure 3.1 Estimates of Overall Health among Adolescents Aged 12 to 17, by Past Year Major Depressive Episode (MDE) Status, Percentages and 95 Percent Confidence Intervals: NSDUH 2005-2014

* Difference between Past Year MDE and No Past Year MDE is statistically significant at the p < .05 level.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2005-2014.

By Age Group

Adolescents with past year MDE were more likely to have fair or poor overall health ratings and less likely to have excellent, very good, or good overall health ratings than those without past year MDE among all age groups (12 or 13, 14 or 15, and 16 or 17) (Figure 3.2). For example, 6.4 percent of adolescents aged 12 or 13 with past year MDE reported having fair or poor health compared with 2.9 percent of adolescents aged 12 or 13 without past year MDE.

Figure 3.2 Estimates of Overall Health among Adolescents Aged 12 to 17, by Age Group and Past Year Major Depressive Episode (MDE) Status, Percentages and 95 Percent Confidence Intervals: NSDUH 2005-2014

By Gender

Adolescents with past year MDE were more likely to rate their health as fair or poor and were less likely to rate their health as excellent, very good, or good than those without past year MDE, regardless of gender (Figure 3.3). For example, 7.5 percent of male adolescents with past year MDE reported having fair or poor health compared with 3.5 percent of male adolescents without past year MDE.

Figure 3.3 Estimates of Overall Health among Adolescents Aged 12 to 17, by Gender and Past Year Major Depressive Episode (MDE) Status, Percentages and 95 Percent Confidence Intervals: NSDUH 2005-2014

By Race/Ethnicity

Adolescents with past year MDE were more likely to have fair or poor health ratings and were less likely to have excellent, very good, or good health ratings than those without past year MDE, regardless of race/ethnicity (Figure 3.4). For example, 7.9 percent of Hispanic adolescents with past year MDE reported having fair or poor health compared with 4.7 percent of Hispanic adolescents without past year MDE.

Figure 3.4 Estimates of Overall Health among Adolescents Aged 12 to 17, by Race/Ethnicity and Past Year Major Depressive Episode (MDE) Status, Percentages and 95 Percent Confidence Intervals: NSDUH 2005-2014

* Difference between Past Year MDE and No Past Year MDE is statistically significant at the p < .05 level.
NOTE: Non-Hispanic adolescents who were not white or black were not included in this figure.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2005-2014.

By Poverty Status

Adolescents with past year MDE were less likely to be in excellent, very good, or good health than those without past year MDE, regardless of poverty status (Figure 3.5). For example, 8.9 percent of adolescents in families with incomes less than 100 percent of the federal poverty level with past year MDE reported having fair or poor health compared with 5.4 percent of adolescents in families with incomes less than 100 percent of the federal poverty level without past year MDE.

Figure 3.5 Estimates of Overall Health among Adolescents Aged 12 to 17, by Poverty Status and Past Year Major Depressive Episode (MDE) Status, Percentages and 95 Percent Confidence Intervals: NSDUH 2005-2014

4. Respiratory Health Conditions

This chapter describes associations between depression and respiratory conditions, including asthma, bronchitis, and pneumonia.

Several studies have indicated associations between asthma and depression. A literature review that focused on eight recent population-based studies among adolescents that examined asthma and depression symptoms found that estimates of depression symptoms were double among adolescents with asthma compared with those without.²⁰ Also, the likelihood of adolescents with asthma developing depression symptoms was twice as high as that for adolescents without asthma. In the literature review, the association between asthma and depression symptoms was stronger among non-Hispanic white adolescents compared with adolescents of other races/ethnicities.^11,21 In another population-based study of almost 6,000 Dutch adolescents, the study authors found that adolescents with asthma had more feelings of depression compared with those without asthma and that depression symptoms increased as asthma severity increased.²²

Not all studies consistently found an association between asthma and major depressive episode (MDE) or other depression-related outcomes among adolescents. For example, the Canadian Community Health Survey showed a positive association between asthma and depression in females aged 12 to 19 but a negative association (i.e., asthma was associated with lower odds of depression) among males in this age group.⁸ Another study of adolescents aged 11 to 17 found a significant association between major depression and asthma, but after adjusting for other characteristics, the association was no longer statistically significant. This suggests that the association between depression and asthma may be due to other shared factors.²³ Similarly, a study of middle school students aged 10 to 13 in Italy found that depressive mood was not associated with asthma.²⁴

Bronchitis is a respiratory health condition that may be associated with depression. The three forms of bronchitis are acute, asthmatic (a complication of asthma), and chronic. Although there is ample evidence that depression is related to chronic bronchitis in adults,²⁵ there is less research on the relationship between depression and having experienced one or more episodes of bronchitis among adolescents. The only identified study conducted among adolescents was the Canadian Community Health Survey, which found that chronic bronchitis is significantly associated with depression in males and females aged 11 to 17.⁸ That study found that adolescents with bronchitis had higher estimates of depression than their counterparts without bronchitis (a 73.0 percent higher estimate for males and a 32.0 percent higher estimate for females).

Pneumonia is closely related to bronchitis, and both health conditions are associated with higher asthma rates.²⁶ Although no prior research examines the association between pneumonia and depression, pneumonia's close relation to bronchitis and asthma (conditions known to be associated with depression) suggests the importance of studying the pneumonia-depression association.