Clinical Presentation and Course of Depression in Youth: Does Onset in Childhood Differ From Onset in Adolescence? BORIS BIRMAHER, M.D., DOUGLAS E. WILLIAMSON, PH.D., RONALD E. DAHL, M.D., DAVID A. AXELSON, M.D., JOAN KAUFMAN, PH.D., LORAH D. DORN, PH.D., AND NEAL D. RYAN, M.D. ABSTRACT Objective: To simultaneously and prospectively compare the clinical presentation, course, and parental psychiatric history between children and adolescents with major depressive disorder. Method: A group of prepubertal children (n = 46) and postpubertal adolescents (n = 22) were assessed with structured interviews for psychopathology and parental psychiatric history and followed once every 2 years for approximately 5 years. Results: With the exception of more depressive melancholic symptoms in the adolescents, both groups had similar depressive symptomatology, duration (average 17 months), severity of the index episode, rates of recovery (85%) and recurrence (40%), comorbid disorders, and parental psychiatric history. Female sex, increased guilt, prior episodes of depression, and parental psychopathology were associated with worse longitudinal course. Conclusions: In general, major depressive disorder is manifested similarly in children and adolescents, and both groups have a protracted clinical course and high family loading for psychiatric disorders. J. Am. Acad. Child Adolesc. Psychiatry, 2004, 43(1):63–70. Key Words: major depressive disorder, children, adolescents, longitudinal course. Childhood and adolescent major depressive disorder (MDD) is a protracted illness associated with poor psy- chosocial outcome. In depressed children, the duration of a depressive episode has been reported between 8 and 13 months, with a rate of recovery of 90% and 30% to 70% relapses/recurrences depending on the length of the follow-up and whether the study was done in community or clinical samples (Birmaher et al., 2002). In depressed adolescents, the duration of the index episode has ranged between 3 and 9 months, with a rate of recovery between 50% and 90% and a rate of relapse/recurrence of 20% to 54%, again de- pending on the follow-up period and whether the samples were recruited from clinical or community set- tings (Birmaher et al., 2002). Despite these findings, there is controversy regarding whether childhood-onset MDD is associated with a greater hazard of recurrence (Kovacs et al., 1984a,b) than adolescent-onset MDD (Harrington et al., 1990; Lewinsohn et al., 1999). In fact, some studies (Har- rington et al., 1990; Weissman et al., 1999a,b) but not all (Fombonne et al., 2001) have suggested that ado- lescent MDD is more likely to continue into adulthood than childhood MDD, indicating that the appearance of MDD during adolescence conveys a worse prognosis compared to childhood-onset MDD. A main limitation of the existing longitudinal studies comparing the courses of child-onset and adolescent- onset MDD is that the two have not been examined within the same study. Also, some of these studies have used retrospective catch-up longitudinal designs (Fom- bonne et al., 2001; Harrington et al., 1990; Weissman et al., 1999a,b) and have included small samples of depressed prepubertal children (Fombonne et al., 2001; Harrington et al., 1990). The main objective of this report was to simulta- neously and prospectively examine the results of other Accepted August 25, 2003. From the Department of Child Psychiatry, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh (Drs. Birmaher, Williamson, Dahl, Axelson, Dorn, and Ryan) and the Department of Psychia- try, Yale University, New Haven, CT (Dr. Kaufman). This work was supported by NIMH grant 5 PO1 MH41712. The authors acknowledge the assistance of Carol Kostek in manuscript preparation. Correspondence to Dr. Birmaher, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213; e-mail: birmaherb@upmc.edu. 0890-8567/04/4301–0063©2003 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000096626.64367.3d J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:1, JANUARY 2004 63