title: A qualitative study of the prodrome to first-episode major depressive disorder in adolescents.
abstract: BACKGROUND
  Currently, we lack a clear picture of the evolution of major depressive disorder (MDD) in adolescents. The period of disturbance preceding MDD can be conceptualised as the prodrome. The aim of the study was to explore the prodrome of first-episode MDD retrospectively in a group of help-seeking adolescents using qualitative methodologies.
  
  
  METHODS
  Consecutively referred adolescents (15-18 years of age) with first-episode MDD were recruited for this study from Orygen Youth Health, Melbourne, Vic., Australia. After using quantitative methodologies to confirm the index episode of MDD and measure the extent of recovery, the prodrome was investigated in depth using qualitative techniques.
  
  
  RESULTS
  Twenty-nine adolescents (20 females and 9 males) and 7 informants (6 mothers and 1 grandmother) participated. All 29 participants had a prodrome of varying lengths (between 6 days and 4 years). The most noticeable symptoms initially were perplexity and confusion and, thereafter, sadness and irritability. A common pattern was a reduction in their ability to fulfil their role accompanied by guilt, self-blame and reduced self-esteem. Around half of the participants had increased thoughts of suicide and increased anxiety. There were gender differences in the patterns of symptoms noticed, with males more commonly noticing a change in how they related to the world and females more commonly noticing a change in the way that they related to others. All informants noticed a prodrome of varying lengths; in 2 cases longer, in 2 cases shorter and in 3 cases around the same time period as that noticed by the participant. The changes most commonly noticed by informants were sadness, upset, irritability and reduced self-esteem. The symptoms were fewer in number and sometimes varied from those noticed by the adolescents themselves.
  
  
  CONCLUSIONS
  Whilst we recognise that this study is vulnerable to autobiographical bias, we took all reasonable measures to minimise this. Symptoms not included in the diagnostic criteria for depression were the earliest changes noticed by the adolescents themselves and are, therefore, potentially important in informing prevention strategies, as is the finding that there are gender differences in the patterns of changes noticed. In addition, parents may provide an additional avenue to help seeking.
authors.affiliation: Orygen Youth Health, Melbourne, Vic., Australia.
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Syed Sheriff
authors.forename: Patrick D
authors.initials: PD
authors.lastname: McGorry
authors.forename: Sue
authors.initials: S
authors.lastname: Cotton
authors.forename: Alison R
authors.initials: AR
authors.lastname: Yung
mesh_terms: D000293:Adolescent; D001007:Anxiety / Q000523:psychology; D003865:Major Depressive Disorder / Q000175:diagnosis* / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male; D010290:Parents; D036301:Qualitative Research; D012649:Self Concept; D057566:Self Report; D059020:Suicidal Ideation; D013850:Thinking; D013997:Time Factors; D055815:Young Adult