Prevalence and risk indicators of depressed mood in on-reserve first nations youth.

Lemstra, Mark E. ; Rogers, Marla R. ; Thompson, Adam T. 等

The Canadian Community Health Survey (CCHS 1.1 and 2.1) from Statistics Canada found that 7.1% of the Canadian population aged 12 and over likely had a major depressive episode in the previous 12 months, in comparison to 13.2% of the self-declared Aboriginal population. (1) There are two limitations worth noting. First, the CCHS excludes anyone living on an Indian reserve in Canada and, as such, the results can only be generalized to the off-reserve population. (2) Second, data from the CCHS are too limited to examine specific subgroups, such as the Aboriginal adolescent population. (3)

Based on a literature review on the mental health of Aboriginal people, most studies determine prevalence of mood disorder through health service utilization data, and those data are flawed because many Aboriginal people do not seek professional treatment. The authors conclude there have only been two epidemiological studies reviewing psychiatric prevalence rates among Aboriginal people in Canada, and neither of these two studies included youth. (4) Additionally, both studies used brief, non-validated measures and, as such, the results can only be interpreted as crude estimates of general distress.

As an example of crude estimates, the First Nations Regional Longitudinal Health Survey has national data on First Nations youth aged 12 to 18, but the measure to assess depressed mood was a single question asking if youth felt sad, blue or depressed for two weeks in a row in the previous 12 months. (5) From this survey, 27.2% of youth reported that they had.

In regard to health services data, information on depressed mood does not exist for First Nations youth. However, a report from Health Canada concluded that suicide accounted for 22% of all deaths among First Nations youth aged 10-19 years old in Canada in the year 2000. (6) In that year, the suicide rate among First Nations youth was 24.1 per 100,000 population, in comparison to the national average of 13.2.

One study from Saskatoon, Canada compared the prevalence of depressed mood in urban, off-reserve Aboriginal (First Nations and Metis) youth aged 10-15 years old versus in Caucasian youth. Using a validated tool with a sample size of 4,093 youth, it was found that 8.9% of Caucasian youth had depressed mood in comparison to 21.6% of Aboriginal youth. (7)

Due to limited data, the first objective of our study was to determine the prevalence of depressed mood in First Nations youth in grades 5 through 8 (aged 10-16 years) in the seven reserve communities that constitute the Saskatoon Tribal Council (STC). The second objective was to determine the unadjusted and adjusted risk indicators associated with depressed mood in on-reserve First Nations youth.

METHODS

STC consists of seven on-reserve First Nations communities within 250 kilometres of the city of Saskatoon, Canada. Based on the 2006 census, the median income per household is $8,572, the percentage of adults who receive all of their income from government transfers is 37.1%, the percentage of lone-parent families is 26.3%, the high school graduation rate among adults is 50.7% and the adult unemployment rate is 27.5% for men and 20.7% for women. (8)

The research project was led by the Saskatoon Tribal Council with assistance from the School of Public Health and the departments of Psychiatry and Pediatrics at the University of Saskatchewan.

Students in grades 5 through 8 within STC were asked to complete a youth health survey in May 2010. It should be noted that of the seven schools, only four schools had grade 8 students. Among the seven schools, 271 students were eligible to participate. Based on consultation with the Acting Director of Education at STC, the true population is 274 so the attendance rate for these middle schools is 98.9%.

Prior to conducting the study, the Chief, Band Councilors, and Health Directors from each of the seven First Nation communities, as well as the Education Director, had to give written consent to proceed. The principal of each school and the teacher of each classroom had to give verbal consent. Additionally, each parent and each youth participant had to give written, informed consent prior to the youth's participation in the survey. Ethics approval was obtained from the University of Saskatchewan Behavioural Research Ethics Board (BEH#10-14).

Questions on demographics and socio-economic status were taken from Statistics Canada's National Longitudinal Survey of Children and Youth (NLSCY). This comprehensive health survey was designed to collect information about factors that influence a youth's social, emotional and behavioural development. The NLSCY has been validated for youth aged 10 to 13 years old. (9)

The instrument used to measure depressed mood was the Center for Epidemiological Studies Depression Scale. (10) This scale has good internal consistency and content validity with a Cronbach's alpha of .85. (11,12) The scale questions mood within the last seven days, to which the participant answers with one of the following responses: rarely or none of the time (less than 1 day), some or a little of the time (1 to 2 days), occasionally or a moderate amount of the time (3 to 4 days), or most or all of the time (5 to 7 days). A summary score of 16 or higher is traditionally used as the cut-off for depressive mood although some suggest using a cut-off of 23 or higher in order to reduce the number of false positives. (11)

The main instrument to measure the determinants of depressed mood was the Reasons for Depression Questionnaire. (13) This scale has nine subscales for adults; these were reduced to six and then five subscales for children. The subscales for children include characterological, interpersonal conflict, physical, intimacy and childhood. This instrument has demonstrated good validity for adolescent populations (.77 - .91) and reliability (.69 - .86). (14,15)

Parenting questions came from the Parenting Relationship Scale that was used in the Health Behaviour in School-Aged Children (HBSC) study. Although validity and reliability have never been published, the scale has been used in an international project facilitated by the World Health Organization. (16)

Self-esteem and social support were measured using questions from the NLSCY.9 Questions for the self-esteem scale used in the NLSCY come from the Marsh Self Description Questionnaire, which has a coefficient alpha reliability range of .80 to .94. (2,17)

The prevalence of being bullied was measured using the Safe School Survey which was developed by the Canadian Public Health Association and the National Crime Prevention Strategy drawn from the HBSC study used by the World Health Organization. (18,19)

Seven questions were included from the First Nations Regional Longitudinal Health Survey on culture. (5) These questions included: what language do you speak most often in your daily life?; Can you understand or speak a First Nations language?; List which First Nations languages you speak; Describe how well you understand and speak the language; Explain how important it is to speak that language; Describe how important traditional cultural events are; and, Do you take part in your local community's cultural events?

Cross-tabulations were performed initially between depressed mood and: demographics, socio-economic status, reasons for depression, relationship with parents, self-esteem, social support, bullying and cultural participation. After these initial cross-tabulations, binary logistic regression was used to determine the independent association between the outcome variable of having depressed mood (in comparison to not) and the potential explanatory variables. Due to the smaller sample size of the study, the unadjusted effect of each covariate was determined and then entered one step at a time based on changes in the -2 log likelihood and the Wald test.20 The final results are presented as adjusted odds ratios with 95% confidence intervals.

Only statistically significant associations appear in the tables due to space limitations.

RESULTS

Of 271 students eligible to participate in grades 5 through 8, 204 youth completed the eight-stage consent protocol and the pen and pencil survey for a response rate of 75.3%.

Of those 204 youth participants, 33.3% were in grade 5, 26.5% were in grade 6, 21.6% were in grade 7, and 17.6% were in grade 8. In regard to demographics, 10.3% were 10 years old, 48% were between 11 and 12 years old, and 40.2% were between 13 and 16 years old; 44.1% were male (55.9% female). In regard to socio-economic status, 36.3% had an unemployed father and 92.6% of the employed fathers worked in a non-professional occupation (non-management or occupation not requiring a degree); 44.6% had an unemployed mother and 73.6% of the employed mothers worked in a non-professional occupation. Of the youth, only 43.6% lived with both their mother and father; living with a guardian (21.6%) and living with the mother alone (20.1%) were the next most common answers. During the previous 30 days, 27% of youth were hungry at least some of the time because there was not enough food to eat.

Comparing response rates to Canadian Census information, 44.1% of all STC youth in grades 5 through 8 were male versus 50.7% in the Census.

Using a summary score of 16 or higher from the CES-D 12, 25% of the youth had moderate depressive symptoms. Using a summary score of 23 or higher from the CES-D 12, 7.8% of the youth had severe depressive symptoms.

Reviewing cross-tabulations with demographics and socioeconomic status, only one survey variable (being hungry in the past 30 days some of the time or more often) was associated with depressed mood (Table 1).

After cross-tabulation, 10 variables from the Reasons for Depression Questionnaire (Table 2), 3 social support variables (Table 3), 1 self-esteem variable (Table 3), 5 parental relationship variables (Table 3) and 3 bullying variables (Table 4) had statistically significant associations with depressed mood.

None of the questions on cultural participation from the First Nations Regional Longitudinal Health Survey were associated with depressed mood.

After initial cross-tabulations, binary logistic regression was used to determine four independent risk indicators associated with having depressed mood in First Nations youth. The covariates included: 1) not having worked through things that happened during childhood, 2) not having someone who shows love and affection, 3) having a lot of arguments with parents, and 4) being physically bullied at least once per week (Table 5).

There was no confounding or effect modification in the final regression model. The R2 for the final model was .331 suggesting reasonable explanation of the proportion of variance in the outcome variable explained by the knowledge of the explanatory variables. The goodness of fit test result (p=0.694) suggests that the final model is appropriate and that the predicted values are accurate representations of the observed values in an absolute sense.

DISCUSSION

Depression has been linked to multiple negative outcomes in youth. One study found that having depression in adolescence significantly increased the risk for major depression later in life as well as for anxiety disorders, suicide attempts, nicotine dependence, alcohol dependence, educational under-achievement, unemployment and early parenthood. (21)

According to data from the CCHS 1.1, the 12-month prevalence of depression among Canadian adolescents aged 12-19 years old was 6.5% for males and 9.8% for females in 2001. (22) Despite a younger age group, our study found higher rates of depressed mood, as 25% of on-reserve Saskatoon Tribal Council (STC) First Nations youth in grades 5 through 8 (10-16 years old) had moderate depressive symptoms. Part of the difference might be explained by the use of different survey tools.

In a study from the city of Saskatoon using the same measure of depressed mood (CES-D) in the same school grades of 5 through 8 (9-15 years old), 8.9% of Caucasian youth and 21.6% of off-reserve Aboriginal youth (First Nations and Metis) had depressed mood. (7) The slightly higher rates of depressed mood within First Nations youth who live on-reserve, in comparison to First Nations and Metis youth who live up to 250 kilometres away in a city, appears to be a new finding worthy of additional study.

A review of three large American population-based studies suggests that depressive symptoms start at approximately 12 years of age and peak between 15 and 17 years of age. (23) In our study, the prevalence of depressive symptoms was already quite common at age 10 (26.3%) and continued to increase as age increased (32.1% within age group 13-16). The suggestion that on-reserve First Nations youth may have earlier onset of depressive symptoms has important implications on the implementation of effective prevention strategies.

Although First Nations girls had slightly more depressed mood than First Nations boys, the results were not statistically significant. This is inconsistent with the common finding of differences in the prevalence of depressed mood by gender, even among adolescents. (24-27)

The association between SES and the prevalence of depressed mood has been well described in previous literature. (28-33) A surprising finding in our study is the lack of association between socioeconomic status (SES) and the prevalence of depressed mood, although the presence of hunger was found to be important in this study as well as the urban study from Saskatoon. (7) A possible explanation might be that low SES is the norm on reserves, and as the latter are fairly isolated, there are no relative differences in SES to create the perceptions of social inequality that lead to poor health. (34)

After regression analysis, one childhood trauma variable, one social support variable, one parental relationship variable and one bullying variable were independently associated with depressed mood in First Nations youth. The association between childhood trauma and depression has been documented previously. (35) A prospective study found that a lack of social support from family members and family conflict contributed to adolescent depression. (36) The association between bullying and depression has been well documented. (37,38)

The lack of association between self-esteem and depressed mood in our study is inconsistent with the literature. (24)

In our study, we found that questions on cultural participation, such as taking part in local Aboriginal community cultural events, were not associated with depressed mood. Although there are no studies that review depressed mood and culture, the findings from other studies reviewing suicidal ideation and cultural participation are inconsistent. (39,40)

With regard to prevention, one literature review found beneficial long-term effects of up to two years for comprehensive depression prevention programs that included: a) cognitive skills, b) social problem-solving skills and c) training in assertiveness, negotiation and coping skills. (41,42)

A large meta-analysis of 30 studies addressing the prevention of childhood depression found these programs to have greater efficacy when applied selectively to at-risk youth rather than universally. (33)

There are three study limitations to discuss. First, the study was cross-sectional and cannot determine causation. Second, although a valid dimensional survey was used to measure depressed mood, a diagnostic interview was not conducted. Third, our sample has the potential to have a small selection bias by gender.

Our study found high rates of depressed mood within on-reserve First Nations youth living in Saskatchewan. These youth may be at increased risk for problems later in life. Our study provides knowledge of specific risk factors in order to contribute to developing successful prevention programs.

Acknowledgements: We thank the leaders, teachers, parents and children in the seven reserve communities within the Saskatoon Tribal Council. This research was paid for by a grant from the Public Health Agency of Canada.

Conflict of Interest: None to declare.

Received: October 27, 2010

Accepted: February 3, 2011

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Correspondence: Dr. Mark Lemstra, Department of Pediatrics, University of Saskatchewan, Health Sciences Building, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Tel: 306-966-2108, E-mail: mark.lemstra@usask.ca

Mark E. Lemstra, PhD, [1-4] Marla R. Rogers, MPA, [3] Adam T. Thompson, BA, [3] Lauren Redgate, MD, (2) Meghan Garner, MD, [2] Raymond Tempier, MD, []1 John S. Moraros, PhD [4]

Author Affiliations

[1.] Department of Psychiatry, University of Saskatchewan, Saskatoon, SK

[2.] Department of Pediatrics, University of Saskatchewan, Saskatoon, SK

[3.] Saskatoon Tribal Council, Saskatoon, SK

[4.] School of Public Health, University of Saskatchewan, Saskatoon, SK

Table 1. Depressed Mood by Demographics and SES (9)

Demographics and SES               Depressed Mood
                                 Prevalence   P-value

Age (Years)                                   0.491
10                                26.3%
  11-12                           22.8%
  13-16                           32.1%
Gender                                        0.673
  Male                            25.3%
  Female                          28.0%
Father is employed                            0.210
  Yes                             23.8%
  No                              32.4%
Father's occupation                           0.610
  Professional (manager or        14.3%
  employment requiring degree)
  Non-professional                24.4%
  Unemployed                      32.9%
Mother is employed                            0.779
  Yes                             26.7%
  No                              28.6%
Mother's occupation                           0.909
  Professional (manager or        22.7%
  employment requiring degree)
  Non-professional                24.6%
  Unemployed                      28.9%
Who do you live with?                         0.368
  Both mother and father          27.7%
  Mother only                     23.7%
  Father only                     41.7%
  Half with mother,               50.0%
  half with father
  Guardian                        19.5%
  Other                           33.3%
During the past 30 days, how
often did you go hungry
enough food?
because there was not                         0.023
  Always                          60.0%
  Most of the time                50.0%
  Some of the time                36.6%
  Rarely                          34.5%
  Never                           18.7%

Table 2. Depressed Mood by Reasons (12,13)

When I am depressed (or sad)     Depressed Mood
it is because...                 Prevalence   P-value

I don't feel loved                             0.000
  Definitely not a reason           9.8%
  Probably not a reason            37.2%
  Probably a reason                51.4%
  Definitely a reason              50.0%
My family treats me poorly                     0.000
  Definitely not a reason          10.2%
  Probably not a reason            47.4%
  Probably a reason                50.0%
  Definitely a reason              64.7%
Other people isolate me                        0.000
  Definitely not a reason          12.8%
  Probably not a reason            37.0%
  Probably a reason                46.7%
  Definitely a reason              47.0%
Other certain things happened                  0.000
to me as a child
  Definitely not a reason           5.6%
  Probably not a reason            28.6%
  Probably a reason                42.3%
  Definitely a reason              53.8%
Other people criticize me                      0.000
  Definitely not a reason          15.5%
  Probably not a reason            27.3%
  Probably a reason                39.0%
  Definitely a reason              62.5%
I haven't worked through
things that happened
to me as a child                               0.000
  Definitely not a reason          18.6%
  Probably not a reason            22.5%
  Probably a reason                41.3%
  Definitely a reason              60.0%
I've had a difficult childhood                 0.001
  Definitely not a reason          16.9%
  Probably not a reason            42.5%
  Probably a reason                25.0%
  Definitely a reason              52.6%
I can't make friends                           0.014
  Definitely not a reason          20.3%
  Probably not a reason            46.7%
  Probably a reason                38.9%
  Definitely a reason              38.5%
People treat me poorly                         0.010
  Definitely not a reason          18.3%
  Probably not a reason            36.6%
  Probably a reason                38.1%
  Definitely a reason              50.0%
People don't give me the                       0.000
respect I deserve
  Definitely not a reason          12.1%
  Probably not a reason            38.9%
  Probably a reason                26.9%
  Definitely a reason              53.1%

Table 3. Depressed Mood by Social Support, Self-esteem
and Parental Relationship Variables

                                 Depressed Mood
Social Support (9)             Prevalence   P-value

I can count on someone                      0.002
when I need help
  All of the time                11.8%
  Most of the time               32.8%
  Some of the time               40.6%
  Almost none of the time        38.9%
I have someone who shows                    0.000
me love and affection
  All of the time                15.5%
  Most of the time               30.3%
  Some of the time               50.0%
  Almost none of the time        52.6%
I have someone I can confide                0.000
in when I need to talk
  All of the time                14.3%
  Most of the time               30.0%
  Some of the time               38.1%
  Almost none of the time        58.3%
Self-esteem (2,15)                          0.000
  Low self-esteem                57.1%
  Normal self-esteem             21.0%
Parental Relationship14
  My parents understand me                  0.000
  Strongly agree                 21.3%
  Agree                          20.3%
Neither agree nor disagree       33.3%
  Disagree                       72.7%
  Strongly disagree              80.0%
I have a happy home life                    0.000
  Strongly agree                 16.7%
  Agree                          26.2%
Neither agree nor disagree       25.9%
  Disagree                       71.5%
  Strongly disagree              71.4%
I have a lot of arguments                   0.000
with my parents
  Strongly agree                 60.0%
  Agree                          44.4%
Neither agree nor disagree       15.0%
  Disagree                       22.0%
  Strongly disagree              14.3%
There are times when I                      0.000
would like to leave home
  Strongly agree                 48.9%
  Agree                          31.3%
Neither agree nor disagree       26.1%
  Disagree                       11.4%
  Strongly disagree               7.4%
What my parents think of                    0.006
me is important
  Strongly agree                 15.7%
  Agree                          36.8%
Neither agree nor disagree       32.0%
  Disagree                       37.1%
  Strongly disagree              33.3%

Table 4. Depressed Mood by Bullying Victimization (16,17)

During the past 4 weeks, how       Depressed Mood
often have you been bullied by   Prevalence   P-value
the other students.

Physically                                     0.001
  Never in 4 weeks                 21.1%
  Once or twice in 4 weeks         31.4%
  Every week                       37.5%
  Many times a week                36.4%
Verbally                                       0.145
  Never in 4 weeks                 18.2%
  Once or twice in 4 weeks         29.5%
  Every week                       38.9%
  Many times a week                38.1%
Socially                                       0.047
  Never in 4 weeks                 18.9%
  Once or twice in 4 weeks         31.7%
  Every week                       37.5%
  Many times a week                47.1%
Electronically                                 0.035
  Never in 4 weeks                 22.0%
  Once or twice in 4 weeks         33.3%
  Every week                       40.0%
  Many times a week                42.5%

Table 5. Independent Risk Indicators Associated With Depressed Mood
in STC Youth

Independent Variables            Odds Ratio       95%      P-value
                                              Confidence
                                               Interval

I have not worked through
  things that happened to me,      3.260       1.43-7.46    0.005
  Definitely a reason or
  probably a reason

I have someone who shows me
  love and affection,              4.823      2.04-11.39    0.000
  Almost none of the time or
  some of the time

I have a lot of arguments with
  my parents, Strongly agree       1.754       1.45-1.89    0.001
  or agree

Physically bullied,
  Many times a week                1.688       1.09-2.61    0.004
    or once a week

Reference categories

I have not worked through things that happened to me--probably not a
reason or definitely not a reason;

I have someone who shows me love and affection--most of the time or
all of the time;

I have a lot of arguments with my parents--neither agree nor disagree
or disagree or strongly disagree;

Physically bullied--once or twice in four weeks or never in four weeks

[R.sup.2] = .331

Hosmer Lemeshow Test = .694