Journal of Abnormal Psychology 1991, Vol. 100, No.

2, 214-222

Copyright 1991 by the American Psychological Association, Inc. 0021-843X/91/S3.00

Comorbidity of Unipolar Depression: II. Comorbidity With Other Mental Disorders in Adolescents and Adults
Paul Rohde, Peter M. Lewinsohn, and John R. Seeley Oregon Research Institute, Eugene, Oregon
The current and lifetime comorbidity of depressive (i.e., major depressive disorder and dysthymia) with other common mental disorders was examined in community samples of older adolescents (n - 1,710) and adults ( = 2,060). Current and lifetime histories of depression in the adolescents were highly comorbid with several other mental disorders. The adults had a lower but statistically significant degree of comorbidity, primarily with substance use disorder. Depression in both groups was more likely to occur after the other disorder rather than to precede it. Comorbidity did not affect the duration or severity of depression. Comorbidity in the adolescents was associated with greater frequency of suicidal behavior and treatment seeking. The findings suggest that earlyonset depression is associated with a greater degree of comorbidity and may represent a more serious form of the disorder.

In this article, which is the second in a series on the comorbidity of unipolar depression, we examine the degree to which unipolar depression (i.e., major depression and dysthymia) is comorbid with other psychiatric disorders in adult and adolescent community samples. To the extent that depression is comorbid with specific disorders, the temporal order of the two disorders (i.e., does depression more often precede the disorder or vice versa?) and the impact of the presence of the second disorder on the phenomenology of depression (e.g., age at onset of first depression and duration and severity of depressive episodes) are described.

Prevalence of Comorbidity
The comorbidity of depression with other psychiatric disorders is a rather recent area of investigation; however, research has suggested that many, perhaps even most, persons who experience depression have at least one comorbid psychiatric disorder at some point in their life. Although empirical evidence is still being gathered, a survey of the current literature indicates that depression is thought to be comorbid with a number of mental disorders, which include anxiety disorders (Leckman, Weissman, Merikangas, Pauls, & PrusofF, 1983; Maser & Cloninger, 1990; Regier, Burke, & Burke, 1990), substance abuse (Weissman, Myers, & Harding, 1980; Winokur, Black, & Nasrallah, 1988), conduct disorder in child patients (Kovacs, Paulauskas, Gatsonis, & Richards, 1988), and somatic disorders (Cadoret, Widmer, & Troughton, 1980; Katon, Kleinman, & Rosen, 1982).
Preparation of this article was supported in part by National Institute of Mental Health Grants MH33572, AG1449, MH35672, and MH40501. We gratefully acknowledge the assistance of the three anonymous reviewers for their comments on a draft of this article. Correspondence concerning this article should be addressed to Paul Rohde, Oregon Research Institute, 1715 Franklin Boulevard, Eugene, Oregon 97403-1983.

Of the various psychiatric disorders, the comorbidity of depression with anxiety disorders has received the most research attention. Consistent evidence for the co-occurrence of depression and anxiety disorders has been reported in numerous community (e.g., Angst & Dobler-Mikola, 1985; Angst, Vollrath, Merikangas, & Ernst, 1990; Boyd et al, 1984; Kashani et al., 1987; Murphy, Sobol, Neff, Olivier, & Leighton, 1984) and patient samples (e.g., Barlow, DiNardo, Vermilyea, Vermilyea, & Blanchard, 1986; Dealy, Ishiki, Avery, Wilson, & Dunner, 1981). Most research studies have focused on major depression. An important exception is the work of Weissman, Leaf, Bruce, and Florio (1988). Using data from the large community-based Epidemiologic Catchment Area (ECA) studies, Weissman et al. examined the degree of comorbidity between dysthymia and other psychiatric disorders. The majority (77.1%) of those persons with a lifetime diagnosis of dysthymia also had an additional lifetime disorder (most commonly major depression, anxiety, substance abuse, and bipolar disorders) according to Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) criteria. The fact that fewer than one quarter of the persons were pure dysthymics led the researchers to question the utility of dysthymia as a separate diagnostic entity. Elevated rates of comorbidity for dysthymia were also reported in other community (Weissman & Myers, 1978) and patient samples (Keller & Shapiro, 1982; Klein, Taylor, Harding, & Dickstein, 1988; Mezzich, Ahn, Febrega, & Pilkonis, 1990).

Temporal Order of Disorders

Given that depression is comorbid with another disorder, the extent to which the comorbid disorder is more likely to precede or to follow the depressive episode is important for the reasons mentioned earlier. When the temporal order of comorbid depressive and anxiety disorders has been examined, anxiety disorders generally have been found more often to precede rather than to follow the
214

COMORBIDITY OF DEPRESSION

215

depression (e.g., Alloy, Kelly, Mineka, & Clements, 1990; Angst et al., 1990). However, this temporal ordering has not been consistently noted (e.g., Breier, Charney, & Heninger, 1984,1985). Alloy et al. suggested that such predominant temporal ordering may correspond to the manner in which persons respond to major life stressors; one's first response is characterized by anxiety and agitation, followed by despair and depression (Bowlby, 1960; Seligman, 1975).

Impact of Comorbid Disorders on Depression

Comorbidity may effect the onset age, presentation, course, and consequences of the depressive episode. These effects may be universal across all psychiatric disorders or differ for specific disorders. As may be expected when one assumes that having two disorders is worse than having one, the impact of the presence of a comorbid disorder on depression has often been negative. Gersh and Fowles (1979) reviewed several investigations that examined the degree of comorbidity between anxiety and depression. They concluded that patients in whom depression and anxiety are comorbid are characterized by an earlier onset age, a more chronic course, greater likelihood of relapse, poorer response to antidepressant treatment, and stronger suicidal tendencies. Similarly, Keller and colleagues (Keller et al., 1984; Keller, Lavori, Lewis, & Klerman, 1983) have found that the presence of a comorbid disorder in patients with major depression was associated with longer episode duration. Other investigators have also reported that depressed persons with a comorbid psychiatric disorder are more likely to have suicidal ideation and a younger onset age (Andreasen & Winokur, 1979; Winokur et al., 1988). Hirschfeld, Hasin, Keller, Endicott, and Wunder (1990) compared pure depressed patients with depressed patients with concurrent alcoholism. The comorbid depressed persons differed on several demographic characteristics. They were older, less likely to be married, and more likely to be men; they also had significantly lower ratings of global adjustment at follow-up. However, they did not have a significantly longer episode duration, nor were they more likely to relapse once recovered. In related research, also with patient samples, Kupfer and Carpenter (1990) reported that although the presence of a comorbid alcoholism increased the time needed for recovery from an episode of recurrent major depression, the comorbid and pure depressed persons were equally likely to recover from the depression within the follow-up period of the study.

depression, especially when the onset age was less than 21. In many respects the three depressed groups (i.e., pure major depression, pure dysthymia, and comorbid major depression and dysthymia) were not significantly different from each other. Of greatest relevance to our research was the finding that persons within the three groups did not differ in their rates of comorbidity with other psychiatric disorders. Therefore, we felt justified in forming one group of depressed persons and examining the comorbidity of unipolar depression with other psychiatric disorders. Extensive diagnostic data are available from four large community-based samples of older adolescents and adults. The age range, sample size, and composition of the samples as well as the use of comprehensive and reliable diagnostic procedures provided us with the opportunity to examine the rates of current comorbidity (i.e., simultaneous co-occurrence of two disorders) and lifetime comorbidity (i.e., degree to which persons with a lifetime history of one disorder are likely to have experienced another disorder) of depression with various mental disorders that occurred with sufficient frequency in the samples. Given that depressed persons have been found to be at an elevated risk for having a particular psychiatric disorder or a cluster of them, we were interested in the temporal order of the two disorders and whether the presence of the comorbid disorder significantly affected the age at onset, course, or presentation of the depressive episode. Method Participants
The subjects for this study were selected from two data sets that comprised large samples of adolescents and adults, which were described in detail in Lewinsohn et al. (1991). Briefly, the adolescent sample consisted of 1,710 older adolescents (ages 14-18) who had completed a questionnaire and participated in a diagnostic interview (additional details about this sample were provided in Lewinsohn, Hops, Roberts, & Seeley, 1988). The adult sample consisted of 2,060 participants who were a subset selected for diagnostic interview from three separate longitudinal studies (Studies 1, 2, and 3) in which 6,742 community residents participated by completing an extensive questionnaire. Written informed consent was obtained from all participants and from parents of the adolescents.

Assessment of Depression and Other Mental Disorders

Diagnoses of all current and past episodes of depression and other mental disorders were based on information gathered in standardized semistructured interviews. Diagnoses according to the revised DSMIII (DSM-1II-R; American Psychiatric Association, 1987) in the adolescent sample were based on information obtained with a modified form of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children that combined the Epidemiologic (Orvaschel, Puig-Antich, Chambers, & Johnson, 1982) and the Present Episode versions. Information in the adult samples was gathered with the Schedule for Affective Disorders and Schizophrenia-Lifetime version (Endicott & Spitzer, 1978), and diagnoses were based on criteria provided by the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978,1985). As described in Lewinsohn et al. (1991), the majority of adults originally diagnosed with RDC intermittent depression or

Present Study
As part of this series of analyses to examine the extent to which psychiatric disorders are comorbid in community samples, we reported the current and lifetime comorbidity between major depression and dysthymia in large community samples of adolescents and adults (Lewinsohn, Rohde, Seeley, & Hops, 1991). To briefly summarize those results, the two depressive disorders were significantly but not completely comorbid. Most depressed persons (approximately 80%) experienced only an episode of major depression, 10% experienced only dysthymia, and 10% experienced both disorders. When the two disorders were comorbid, dysthymia was most likely to precede major

216

P. ROHDE, P. LEWINSOHN, AND J. SEELEY gathered as part of the diagnostic interviews. If any attempt had occurred, the diagnostic interviewers noted whether the attempt occurred during a period of depression, as opposed to other mental problems such as conduct disorder, mania, substance abuse, schizophrenia, and so forth. Data Analysis The degree of comorbidity was measured by the prevalence odds ratio (POR), a measure of the association between a binary variable (or risk factor) and the occurrence of an event. A POR of 1.00 indicates that the likelihood of two disorders co-occurring is equal to chance, given the base rates of the two disorders. An estimate of the asymptotic standard error of the odds ratio can be used to approximate the confidence interval (CI) boundaries. If the value 1.00 falls within the 95% CI, the odds ratio is not significant at p < .05.

minor depression of at least 2-years duration were reclassified as having experienced dysthymia in DSM-HI-R terms. The adults also completed the Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). The CES-D, which was specifically designed for use with general community samples, is a self-report measure of the frequency of 20 depressive symptoms during the previous week. It was used in the research reported herein as a measure of the current severity of depression.

Diagnostic Classification
Although the RDC was a forerunner of the DSM-IIf-R, and the two diagnostic systems share many similarities, several important differences need to be noted. The diagnosis of major depression in the RDC, although similar to the DSM-III-R, is somewhat more stringent (see Lewinsohn et al., 1991, for more details). In the RDC the occurrence of panic, phobic, or obsessive-compulsive disorders cannot be limited in time to an episode of major depressive disorder; that is, if the person experiences the symptoms of anxiety only during the depressive episode, only the depressive episode is diagnosed. This restriction is not made in the DSM-III-R, and a person can receive concurrent diagnoses. In both systems a diagnosis of generalized anxiety disorder can be made in the presence of depression, if the anxiety symptoms are clearly distinguished from the other disorder. In conclusion, as compared with the RDC, the possibility of the concurrent occurrence of depression and anxiety disorders is greater with DSM-III-R diagnoses. Because of the relatively low frequency of occurrence, we combined the categories of abuse and dependence of various psychoactive substances (including alcohol) to create a single category labeled substance use disorders. Similarly, we combined panic, phobic, obsessive-compulsive, and generalized anxiety disorders to form a cluster labeled anxiety disorders. For the adolescents, separation anxiety and overanxious disorders, two anxiety disorders of childhood and adolescence, were included in the cluster of anxiety disorders. Conduct and oppositional-defiant disorders in the adolescents were combined into a category labeled disruptive behavior disorders. On the basis of diagnostic information, four groups were formed for the analyses: (a) persons with one or more lifetime episodes of depression and no other psychiatric disorders (pure depressed); (b) persons with no lifetime episodes of depression but one or more episodes of another psychiatric disorder (pure other); (c) persons who had experienced episodes of both depression and another psychiatric disorder at some point during their life (comorbid); and (d) persons with no reported episodes of any psychiatric disorder (never mentally ill).

Results Prevalence of Current and Lifetime Comorbidity

Adolescents. As shown in the upper portion of Table 1, adolescents who were depressed at the time of the diagnostic interview were more likely than expected by chance to have an additional current mental disorder, except bipolar disorder. The latter diagnosis had an extremely low prevalence rate. When the young women and men were examined separately, the patterns of current comorbidity with depression were comparable in regard to the presence of any psychiatric disorder and specifically in regard to current anxiety or substance use disorders. Gender differences were noted for the comorbidity of current depression with disruptive behavior and eating disorders. Currently depressed young men were significantly more likely than the nondepressed men to have a current diagnosis of conduct or oppositional disorder (POR = 18.24, 95% CI = [5.20, 63.98 ]). A similar degree of comorbidity was not present for the currently depressed young women (POR = 0.99, CI = [0.98, 1.00]). Conversely, currently depressed young women had significantly greater odds of having a comorbid eating disorder as compared with the never depressed young women (POR = 51.00, CI = [4.51, 576.29]). Eating disorders were extremely rare in the young men, regardless of whether or not they were depressed. As shown in Table 1, similar patterns were noted in the adolescent sample with regard to the rates of lifetime comorbidity of depression with other disorders for the total sample. In comparing lifetime comorbidity rates separately for the young women and young men, one significant difference was noted. As in the case of current comorbidity, lifetime depression was significantly comorbid with eating disorders only for the young women (POR = 12.53, CI= [2.69, 58.40]). However, a lifetime history of depression was comorbid with disruptive behavior disorders for both young men and young women. Adults. The rates of current and lifetime comorbidity of depression with other psychiatric disorders in the adult sample are shown in Table 2. With regard to current comorbidity with depression, only substance use disorders were significantly comorbid. As indicated by the POR, currently depressed persons were over three times more likely than expected by chance to also have a current substance use disorder.

Assessment of Treatment Seeking, Suicidal Ideation, and Suicide Attempts

Treatment for depression was denned as receiving outpatient psychotherapy or counseling, being prescribed antidepressant medications or lithium, being hospitalized, or receiving electroshock therapy during a depressive episode. Treatment for other mental disorders was defined as psychotherapy, counseling, medications, or hospitalization for any disorder other than depression. During the diagnostic interview the adolescents reported whether they had received any form of treatment for a current or past psychiatric disorder. The adults in Study 3 provided treatment information as part of their diagnostic interview. Although the adults in Studies 1 and 2 provided similar information in response to a questionnaire, we only used treatment information from Study 3 data, so that the measures of treatment received in the adolescent and adult samples would be comparable. For the teenage participants, information about the number of suicide attempts and the adolescent's highest level of suicidal ideation was

COMORBIDITY OF DEPRESSION

217

Table 1 Frequency of the Prevalence Odds Ratio for Current and Lifetime Comorbidity of Other Mental Disorders With Depression in the Adolescent Sample
Depressed Disorder n % Not depressed n % FOR CI

Current comorbidity Bipolar Anxiety Disruptive behavior Substance use Eating Any disorder

0 9
4

( == 50)

( n = 1;,660)

0.0
18.0

8.0
14.0

7 2 21

4.0
42.0

5 45 27 33 1 117

0.3 2.7 1.6 2.0 0.1 7.0

1.00 7.88 5.26 8.03 69.12 9.55

0.99, 1.00 3.61, 17.18 1.77, 15.65 3.36, 19.16 6.16,775.47 5.28, 17.27

Lifetime comorbidity Bipolar Anxiety Disruptive behavior Substance use Eating Any disorder

3 73 42 69 9 149

( = 347)

0.9

8
77

( = 1,363)

21.0 12.1 19.9

2.6
42.9

83 73 4 290

0.6 5.6 6.1 5.4 0.3

21.3

1.48 4.45 2.12 4.39 9.05 2.78

0.39, 5.60 3.15,6.29 1.44,3.14 3.08, 6.25 2.77, 29.55 2.17,3.57

Note. FOR = prevalence odds ratio; CI = 95% confidence interval.

The likelihood that an adult with a lifetime history of depression had an additional psychiatric disorder at some point in his or her life was significantly greater than expected by chance. As with the adolescents, lifetime depression was significantly comorbid with substance use disorders. The two lifetime comorbidity findings remained significant when the women and men were examined separately.

Temporal Order ofComorbid Disorders Adolescents. Given that depression was significantly comorbid with other psychiatric disorders, we examined which of the two disorders was most likely to occur first. For a small proportion of the comorbid adolescent depressives (6.7%), the two disorders began during the same time period, and therefore we

Table 2 Frequency of and Prevalence Odds Ratio for Current and Lifetime Comorbidity of Other Mental Disorders With Depression in the Adult Sample
Depressed Disorder n % Not depressed n % FOR CI

Current comorbidity
(n = 196)

( n = l ,864)

Bipolar Schizophrenia Anxiety Antisocial personality Substance use Any disorder

3 0 2 0 5 15

1.5 0.0 1.0 0.0 2.6

7.7

16 6 67 2 13 131

0.9 0.3 3.6 0.1 0.7 7.0

1.80 0.90 0.28 0.90 3.73 1.10

0.52, 6.22 0.89, 0.92 0.07, 1.14 0.89, 0.92 1.31, 10.57 0.63, 1.91

Lifetime comorbidity Bipolar Schizophrenia Anxiety Antisocial personality Substance use Any disorder Note.

22 2 93 1 93 221

( = 869)

2.5 0.2 0.1

10.7 10.7 25.4

17 9 106 2 66 202

( = 1,191)

1.4 0.8 8.9 0.1 5.5

17.0

1.79 0.30 1.23 1.37 2.04 1.67

0.95, 3.40 0.07, 1.41 0.91, 1.64 0.09,21.95 1.47,2.84 1.35,2.07

FOR = prevalence odds ratio; CI = 95% confidence interval.

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P. ROHDE, P. LEWINSOHN, AND J. SEELEY

were unable to determine a clear temporal order of onset. The temporal order for the remaining comorbid depressed adolescents is shown in the upper portion of Table 3. Depression in the comorbid teenagers was significantly more likely to follow than to precede all but one of the other psychiatric disorders. The one exception was eating disorders, which had an extremely low prevalence rate. The predominant temporal pattern in which depression followed the other disorder was especially striking with the anxiety disorders. In 85.1% of these comorbid cases, the depression began after the onset of the anxiety disorder. Adults. The temporal order of comorbid disorders in the adult sample appears in the lower portion of Table 3. When all other mental disorders were combined into one category, comorbid depression was more likely to follow than to precede the other disorder. No significant temporal pattern emerged between depression and substance use disorders.

differ on mean CES-D score at the time of the interview (32.1 and 33.9, respectively), F(\, 48) = 1.30, ns. The comorbid adolescents, however, were significantly more likely than the pure depressed teenagers to have had more than one depressive episode thus far in their life. Adults. The lower portion of Table 4 contains information about the onset age and duration of first depression and the number of depressive episodes in the pure depressed and comorbid adults. Like the adolescents the adults did not differ on duration of depressive episode. For severity level of current depression, the current pure depressed (n = 181) and comorbid (wt= 15) adults did not significantly differ on mean CES-D scores (21.3 and 26.3, respectively), F(l, 193) = 1.49, ns. In contrast to the findings for adolescents, the comorbid adults had a significantly earlier age for the first depressive episode but did not have significantly more depressive episodes.

Treatment Seeking and Suicidal Behavior Impact ofComorbidity on Depression

Differences between the pure depressed and comorbid depressed groups for the onset age and duration of the first depressive episode and the number of depressive episodes were examined and are shown in Table 4. In addition, the current pure depressed and comorbid depressed subjects were compared on severity of depression as measured by the CES-D. From the assumption that the presence of another psychiatric disorder indicates more serious psychopathology, we predicted that the depressed subjects who had another mental disorder would have an earlier depression-onset age, a longer duration for the first depressive episode, a greater number of depressive episodes, and a more severe current depression, in addition to having other psychiatric disorders. Results for the adolescent and adult samples appear in Table 4. Adolescents. As shown in the upper portion of Table 4, the comorbid teenagers did not differ significantly on onset age or duration of depressive episode. The current pure depressed (n = 29) and comorbid (n = 21) adolescents did not significantly Adolescents. Table 5 presents information about treatment seeking and suicidal behavior in the four diagnostic groups. The groups differed dramatically in whether they had received treatment for a mental disorder. Two post hoc contrasts were subsequently conducted. Compared with the never mentally ill group, the three adolescent groups with mental disorders had a significantly higher rate of treatment seeking, x 2 (l, N= 1710) = 276.50, p < .001. Second, the three diagnosed groups significantly differed among themselves in treatment seeking, x2(2, N = 637) = 18.15, p < .001; the comorbid group was most likely and the pure depressed group was the least likely to have received treatment. As can be seen in Table 5, the four groups differed in the proportion of adolescents who had attempted suicide. The never mentally ill group had significantly lower rates than the other groups, X2(l, N = 1710) = 99.77, p < .001. The three groups with a diagnosis differed among themselves in the percentage with a history of suicide attempt, x2(2, N = 637) = 25.22, p < .001. Adolescents with disorders other than depres-

Table 3 Temporal Order of Depression and Other Mental Disorders in the Adolescent and Adult Samples
Depression preceded other disorder Disorder Adolescents Anxiety Disruptive behavior Substance use Eating Any disorder Other disorder preceded depression

10 11 22 3 29

14.9 28.2 35.5 50.0 20.9

Adults

57 28 40 3 110

85.1 71.8 64.5 50.0 79.1

5.62** 2.57* 2.59* 1.00 6.78**

Substance use Any disorder **p<;.001.

36 68

50.7 37.2

35 115

49.3 62.8

0.05 3.38*

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219

Table 4 Comparison of Pure Depressed Versus Comorbid Adolescents and Adults on Characteristics of Depressive Episode
Pure depressed Characteristic Comorbid

SD
Adolescents

SD

Test

(n = 198)
Age of first depression onset Duration of first depressive episode (in weeks) No. depressive episodes
14.01

2.89
15.09 0.40

( = 149) 13.69 3.06

F( 1,345)= 1.02 U= 11,375.5 F(l, 345) = 9.42*

8.41 1.15

10.19 1.32

20.32 0.56

Adults Age of first depression onset Duration of first depressive episode (in weeks) No. depressive episodes

(n = 648) 38.45 15.86

1 10.29 1.52

(n = 221)
34.10 15.45

F(l,867) = 12.61** V = 79,988.0 F( 1,867)= 1.08

182.68 0.76

128.01 1.46

198.96 0.64

*p<.01.

sion were least likely to have made a suicide attempt; pure depressed teenagers had an intermediate rate; and comorbid teenagers had the highest likelihood of making a suicide attempt. Approximately one quarter of the comorbid adolescents had a history of at least one suicide attempt. The diagnosis present at the time the comorbid adolescents attempted suicide was examined next. A total of 37 comorbid teenagers had made a suicide attempt. Most of the attempts (30 of 37, or 81.1 %) were made during a period of depression rather than during an episode of the other mental disorder. The four groups also differed significantly in regard to the highest level of suicidal ideation they had experienced. Scheffe post hoc analyses indicated that all four groups significantly differed from each other: The comorbid subjects had the highest level of suicidal ideation, followed by the pure depressed and by pure other disorder groups, who were significantly higher on the measure than the never mentally ill group. Adults. The lower portion of Table 5 shows the proportion of

subjects in each of the adult groups who received some form of treatment for a mental disorder. As expected, the four groups differed significantly from each other. The never mentally ill adults were significantly less likely to have sought treatment than adults with a mental disorder, x2(l, 7V= 1008) = 152.92, p < .001. In addition, the three groups of diagnosed adults significantly differed in their rates of treatment seeking, x2(2, N = 448) = 28.53, p < .001. Compared with the adults with a disorder other than depression, the comorbid and pure depressed groups were much more likely to have received treatment at some time in their life. Discussion The results unequivocally show that depressed persons, both adolescents and adults, have an elevated rate of other mental disorders. It is noteworthy, however, that these findings were much stronger in the adolescent sample. Almost half (42%) of

Table 5 Likelihood of Receiving Treatment and Suicidal Behavior

Variable Comorbid Pure depressed Pure other Never mentally ill Test

Adolescents % who received treatment % with history of suicide attempt Worst mean suicidal ideation
(n = 149) 45.0 24.8 1.62a (n = 198) 23.7 17.7 1.33b (n = 290) 30.3

7.6 0.52C
Adults

(n = 1,073) 3.1 2.1 0.1 5d

X2(3, N= 1710) = 309.66* X 2 (3,JV = 1710)= 149.54* F(3, 1706)= 168.31*

> who received treatment

(n = 221) 39.0

( = 648) 35.4

(n = 202) 6.2

(n = 989) 2.7

X 2 (3,7V= 1008) = 200.14*

Note. Means with different subscript letters were significantly different from each other in a Scheffe post hoc test. */><;.001.

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P. ROHDE, P. LEWINSOHN, AND J. SEELEY

the adolescents who experienced an episode of depression at the time of the diagnostic interview were experiencing one or more of the other mental disorders examined. With the omission of eating disorders, which were relatively rare, the PORs for current comorbidity with specific disorders ranged from 5.26 for disruptive behavior disorders to 8.03 for substance use disorders. The results for the adolescents can be contrasted with the findings of a study by Kashani et al. (1987), in which a much smaller (N = 150) sample of community-residing adolescents were interviewed. In that study, 12 teenagers (8% of the sample) met DSM-III criteria for depressive disorders, and all of these adolescents had an additional diagnosis (i.e., the current comorbidity rate was 100%). As we also found in our study, the depressed adolescents had an elevated rate of anxiety, disruptive behavior, and substance use disorders. Thus, the results from the two studies corroborate each other in the kinds of disorders that are comorbid with depression but differ in the rate of current comorbidity (42% versus 100%). Several possible explanations for this difference may be suggested. First, the relatively small sample size of the Kashani et al. study may have resulted in an unrepresentative sample. Second, the very high rate of current comorbidity reported by Kashani et al. may have been due to the severity level of their depressed adolescents. In addition to meeting DSM-III criteria, all of the 12 depressed teenagers were rated by the interviewer and two child psychiatrists as showing impaired functioning and as being in need of treatment. Consistent with these potential explanations for the differences in results from our study and from the Kashani et al. study is the fact that they also found a greater overall prevalence of all disorders. Although 26% of their subjects with no affective disorder had another disorder, only 7% of the nondepressed adolescents in our sample had a diagnosed disorder. It is important to recognize that even though the rate of current comorbidity for the adolescent sample in our study was not as elevated as that reported by Kashani et al., the level still is quite high. Although a statistically significant degree of comorbidity was found for the adults, the levels of current and lifetime comorbidity were low. The difference between the adults and the adolescents may be related to the fact that the adults were diagnosed according to RDC criteria, whereas the adolescents were diagnosed according to DSM-III-R criteria. The current and lifetime occurrence of depression in the adults was significantly comorbid only with substance use disorders. As expected, there was a somewhat higher lifetime occurrence of anxiety disorders in the depressed adults but this elevation was not significant. To put our findings in perspective, it may be useful at this point to compare the lifetime rates of mental disorders in the adolescents and adults in our samples with those from the EGA studies, which were based on a large sample of persons 18 years of age or older (Regier et al., 1988). These data appear in Table 6. As can be seen, our adult sample had a much higher lifetime prevalence of depression, which of course is to be expected because many of the adults were chosen to be interviewed on the basis of an elevated CES-D score. However, the lifetime prevalence of major depression in the adolescent sample was also higher than that reported for the ECA data. Several possible reasons for this discrepancy can be offered.

Table 6 Lifetime Prevalence of Disorders in the Epidemiologic Catchment Area (ECA) Data Set and in the Adult and Adolescent Samples From This Study
Disorder

ECA'
.06 .03 .01 .02 .12 .02 .12 .16

Adults
.38 .09 .01" .01 .04 .01 .001 .08

Adolescents
.18 .03 .001 .005 .04 .01 .08

Major depression Dysthymia

Schizophrenia Obsessive-compulsive

Phobia Panic Antisocial personality Substance use

" Standardized lifetime prevalence rates for persons 18 years of age and older in the ECA data set (taken from Regier et al, 1988). b Category
combines lifetime prevalence of schizophrenia and schizoaffective disorders.

As was suggested by Parker (1987), the ECA lifetime prevalence rates for depression are discordant with previous findings (e.g., Murphy et al, 1984; Weissman & Myers, 1978) and are also too low in comparison with the 6-month prevalence figures. The fact that our lifetime rates for depression for the adolescents are higher than those of the ECA for the adults may also reflect differences in the interview procedures between the National Institute of Mental Health Diagnostic Interview Schedule and the Schedule for Affective Disorders and Schizophrenia. Another difference is that the total prevalence of anxiety disorders in both our adult and adolescent samples is much lower than in the ECA studies. This difference appears to be due primarily to the higher prevalence of phobias in the ECA studies. The prevalence of substance use disorders in our adult sample is also much lower than in the ECA samples. This may be due to two factors. First, we oversampled the elderly. Thus we had many participants born early in this century, and it is likely that these birth cohorts have particularly low rates of substance use disorders. Second, substance dependent adults, regardless of their age, may have been less likely to participate in our studies. These assumptions may also account for the low prevalence of antisocial personality disorders in our adult sample. It is important to note that we could not study the comorbidity of depression with disorders that occurred with very low frequency in our samples, such as schizophrenia, serious substance abuse problems, and antisocial personality disorder. Even though a large number of subjects were interviewed, the number of participants with these disorders was very small, and negative findings need to be interpreted with caution. To examine the comorbidity of depression with less frequent disorders would have required oversampling for these disorders in the general population. As expected, the frequency of suicide attempts and the degree of suicidal ideation was elevated in the depressed teenagers, and both measures of suicidal behavior were especially high in the comorbid depressed adolescents, one fourth of whom had made a suicide attempt. Compared with purely depressed teenagers, teenagers with a disorder other than depression had a lower rate of suicide attempts and a much lower degree of suicidal ideation. These findings suggest that al-

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though depression is an important factor in adolescent suicide, those adolescents who have another mental disorder in conjunction with depression are at greatest risk. Although the comorbidity of depression with another mental disorder did not significantly impact the duration and severity of the depression in either adolescents or adults, it apparently acted as a stimulus for the adolescents to receive treatment: 45% of the comorbid adolescents had received treatment, compared with 30% of those with other disorders and 24% of the pure depressed. The results suggest that the presence of the other disorder substantially augmented the likelihood that a depressed adolescent received treatment. The pattern of treatment seeking among the adult groups was noticeably different. Unlike the teenagers, adults were most likely to have sought treatment when depressed; the presence of another mental disorder did not substantially increase treatment utilization. The findings with regard to temporal order are of theoretical importance. For most comorbid adolescents the other mental disorder preceded the depression. Similarly, depression in the adults was more likely to follow than to precede the other mental disorder in general, although this pattern did not apply to substance use disorders. The fact that depression was more likely to follow the occurrence of another mental disorder is consistent with theoretical formulations, such as that of Lewinsohn, Hoberman, Teri, and Hautzinger (1985), which conceptualize the depressive episode as being evoked by the occurrence of stressful events, that is, events that disrupt person-environment interactions and ongoing behavioral patterns. It is reasonable to assume that the development of a mental disorder is likely to be disruptive to interactions between persons and their environment and consequently to increase their likelihood of becoming depressed. In interpreting the results of any study, one must ask whether the findings can be generalized to other populations or are unique to the particular sample. It is probably fair to say that no sample is ever perfectly representative of the larger population from which it was drawn, and ours likewise is not. Our interest in generating a large number of adults with a history of depression may have resulted in biased samples. For the adolescents, however, we made a strong effort to have a representative and random sample of the population of high school students from which they were chosen, and the adolescent results probably are generalizable to other community samples. Perhaps the most important finding to emerge from this study is the high degree of comorbidity in the depressed adolescents. This finding clearly has important clinical and theoretical implications. Clinically, the possibility of comorbidity in depressed adolescents needs to be seriously considered and incorporated into assessment procedures and may require a more extensive treatment plan. Theoretically, a number of issues need to be addressed. First, why is the rate of comorbidity in depressed teenagers so high? Second, is the degree of comorbidity as elevated for other disorders? In other words, are all disorders in adolescence highly comorbid, or is this finding unique to depression? In conclusion, the significance of this finding presents a challenge that will need to be replicated and addressed in future research. The fact that depressed adolescents are much more likely to have a comorbid mental disorder than persons

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Received April 27,1990 Revision received November 20,1990 Accepted November 21,1990