Obsessive-compulsive symptoms in adolescents with major depressive disorder: prevalence, clinical correlates, and association with childhood trauma

Abstract

Background

A substantial line of research has demonstrated that obsessive-compulsive symptoms (OCS) often cooccur with major depressive disorder (MDD). Such cooccurrence possibly exacerbates depressive symptoms and leads to a poor prognosis. We explored the rate of OCS in adolescents with MDD as well as the clinical correlates associated with concomitant OCS in adolescent MDD patients, especially childhood trauma.

Methods

We enrolled a total of 190 adolescent patients. General demographic information was collected from all participants; the 17-item Hamilton Rating Scale for Depression scale (HAMD-17) was used to assess depressive symptoms; the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to assess OCS; and the Adolescent Self-Rating Life Events Check (ASLEC) and Child Trauma Questionnaire (CTQ) were used to assess relevant clinical characteristics.

Results

Among 190 adolescents with depression, 70 (36.8%) had OCS. Significant differences in family relationships, age at onset, ASLEC scores, CTQ scores, and HAMD-17 scores were observed between MDD adolescents with and without OCS. Furthermore, according to the logistic regression analysis, MDD patients who had more severe depressive symptoms, or had previous experiences of childhood trauma, especially emotional abuse, were more probable to have OCS.

Conclusions

Our findings emphasize the importance of drawing familial, educational, and societal attention to these influential factors. A number of effective and proactive interventions could be actively pursued to achieve early detection and treatment of OCS with depression.

Introduction

Major depressive disorder (MDD) is a chronic, extremely recurring disorder with a worldwide prevalence of 4.4% [1, 2]. It is estimated that depression will be the most prevalent illness worldwide by 2030 [3]. Depression substantially contributes to the global disease burden and imposes a high burden on patients and their families [4, 5]. In recent years, there has been a downward trend in the age of onset for depression, and the proportion of adolescent patients suffering from depression has increased [6]. According to epidemiological surveys, the prevalence of MDD among adolescents ranges between 15% and 20% [7]. In addition, adolescent depression has more severe impacts than adult depression. For instance, adolescent depression lasts longer, has higher rates of relapse and associated disability, has more episodes, and has more severe symptoms [8–10].

The presence of comorbidities in patients with depression often predicts a poor prognosis [11]. Clinical studies have revealed that anxiety and depression are the most common complications of obsessive-compulsive disorder (OCD) and that depression is frequently accompanied with obsessive-compulsive symptoms (OCS) [11, 12]. It has been reported that OCS occurs in 15–43% of depressed patients. Additionally, the presence of OCS is linked to increased intensity of depressive symptoms and has a detrimental impact on the progression of depression [11, 13, 14]. Studies have found that patients with OCS or anxiety have more severe depression, risk of suicide, and impairment in somatic and emotional functioning than patients without [15, 16]. The presence of OCS makes depressed patients have a worse prognosis and are more likely to relapse, which means that standardized screening of patients with depressive disorders associated with OCS may help to identify patients with a poor prognosis and a high risk of relapse [11].

Studies have found that traumatic childhood experiences are strongly correlated with various psychiatric disorders in adolescents [17], especially depressive mood. Traumatic childhood experiences are predisposing factors for depressive episodes [18, 19]. According to certain research, traumatic events like physical abuse and neglect as a child might cause significant depressive episodes [20]. Adolescents who had experienced emotional abuse as children showed much higher rates of depression and anxiety than normal controls [21]. Childhood trauma is also one of the essential factors for OCD [22]. Research has indicated that an individual’s susceptibility to psychopathological symptoms, such as OCS, increases with the severity of their traumatic childhood experiences [23, 24]. Childhood trauma correlates favorably with the severity of OCS [25–27]. Compared to healthy controls, OCD patients tend to have experienced more childhood trauma. Additionally, OCS are differentially influenced by types of childhood trauma, with emotional abuse having a greater impact [28, 29].

However, previous studies have focused more on OCS as the primary disorder and depression as the secondary symptom. When OCS are secondary to depressive disorders, little research has been done on their pathogenesis and clinical relevance. Previous studies have concentrated more on the co-occurrence of OCS and MDD in adults, with fewer similar studies in adolescents. Our study is intended to fill the gaps in two ways. First, we investigated the prevalence of OCS in adolescents with MDD. Second, we identified meaningful clinical correlates associated with concurrent OCS in adolescents with MDD. One particular correlate was childhood trauma.

Materials and methods

Participants

This research was conducted in six hospitals in cities of northern Anhui (Chaohu, Hefei, Suzhou, Fuyang, Bengbu, and Bozhou) and one hospital in a city in southern Anhui (Ma’anshan) from October 2020 to February 2022. Patients that satisfied the following criteria were recruited sequentially: (1) diagnosed with MDD according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), criteria; (2) aged between 12 and 18 years; and (3) Han Chinese ethnicity. The exclusion criteria were the following: (1) severe physical illness, infectious disease, or immune system disorders; (2) severe neurological disorders or intellectual disability; (3) inability to cooperate with the assessment. Prior to the study’s start, The Fourth Affiliated Hospital’s Medical Ethics Committee, which is affiliated with Anhui Medical University, authorized the research protocol (202009-kyxm04), and all patients and their guardians completed an informed consent form.

Assessments

All patients independently completed a questionnaire that collected sociodemographic information and included scales to assess mental health. Two standardized trained psychiatrists made the clinical assessments, with intraclass correlation coefficients greater than 0.9.

Sociodemographic characteristics

Sociodemographic characteristics included sex, age, and only child status; age of onset and duration of MDD; relationships with classmates, teachers, and family (good, average, or bad); and antidepressant use.

17-item hamilton rating scale for depression (HAMD-17)

The HAMD-17 is an examiner-rated scale that evaluates the severity of depression in a patient; it contains 17 items and has a total score of 52. Depressive symptoms are more severe when HAMD-17 scores are higher. According to a recent reliability analysis, the Cronbach’s α for the HAMD-17 was 0.83 [30].

Yale-brown obsessive-compulsive scale (Y-BOCS)

This scale contains 10 items divided into two factors: obsessions and compulsions. Each item is graded on a four-point scale, from 0 representing no symptoms to 4 representing severe symptoms. The overall score is a measure of how severe the current OCS are. The Chinese version of the Y-BOCS had a Cronbach’s α of 0.78. In our study, a Y-BOCS score under 7 was considered to indicate the absence of OCS [31].

Childhood trauma questionnaire (CTQ)

This questionnaire includes 28 items scored on a 5-point scale that cover five dimensions: emotional abuse, emotional neglect, physical neglect, physical abuse, and sexual abuse. Higher scores indicate more serious trauma. Cronbach’s α for the Chinese version of the CTQ is 0.83, indicating excellent psychometric properties [32, 33].

Adolescent self-rating life events check list (ASLEC)

This checklist is applied to evaluate the occurrence and impact of life events in adolescents. It includes 27 questions about events that may have happened to the patient or patient’s family in the past year. The score (on a 5-point scale) represents the impact of the event on the patient (numbers 0 through 5 represent the absence of any occurrence, mild, moderate, severe, and very severe impacts). Higher scores indicate a deeper impact of life events. The scale’s Cronbach’s α was 0.85, showing strong internal consistency [34].

Statistical analysis

The statistical analysis was conducted using SPSS 26.0. We present count (n) and proportion (%), as well as means and standard deviations (SDs) for sociodemographic and clinical variables. Between the OCS and non-OCS groups, every sociodemographic and clinical feature was compared. We employed chi-square tests for categorical data, whereas independent-sample t tests or Mann-Whitney U tests were used for continuous variables. After we identified variables that were significantly different between groups in the univariate analysis, we included them in two logistical regression analyses to explore their influence on OCS. These potential influencing factors for OCS were as follows: relationship with family, relationships with classmates, age at onset of MDD, ASLEC score, HAMD-17 score, CTQ total score, and CTQ factor scores (emotional abuse, emotional neglect, physical abuse, and physical neglect). We created two regression models to avoid the collinearity of the CTQ total score and its factor scores. Model 1 included the CTQ total score. Model 2 included the CTQ factor scores. Finally, the receiver operating characteristic curve (ROC) analysis was utilized to assess the predictive power of the significant independent factors found in the logistic regression model for adolescent patients with depression accompanied with OCS. Results were considered statistically significant if their p-value was less than 0.05.

Results

Sociodemographic characteristics and clinical variables

In total, 190 adolescents with MDD were enrolled, with a mean age of 15.3 ± 1.5 years. Among these patients, 49 (25.8%) were male, 81 (42.6%) were only children, 83 (43.7%) were in middle school, and 107 (56.3%) were in high school. Antidepressant use in 190 patients was as follows: 71 patients took no medication (37.4%), 97 took a selective serotonin reuptake inhibitor (SSRI) or a serotonin noradrenaline reuptake inhibitor (SNRI) (51.1%), 7 took both an SSRI and SNRI (3.7%), and 15 were categorized as other (n = 15, 7.9%). More details are provided in Table 1.

Table 1.

Comparison of participants with and without OCS on the socio-demographic and clinical variables

	Total (N = 190)	MDD with OCS (N = 70)	MDD without OCS (N = 120)
	n (%)	n (%)	n (%)	x2	P
Gender				0.498	0.480
Male	49 (25.8%)	16 (22.9%)	33 (27.5%)
Female	141 (74.2%)	54 (77.1%)	87 (72.5%)
Only child	81 (42.6%)	29 (41.4%)	52 (43.3%)	0.066	0.798
Education level				3.791	0.052
Middle school	83 (43.7%)	37 (52.9%)	46 (38.3%)
High school	107 (56.3%)	33 (47.1%)	74 (61.7%)
Relationship with classmates				4.833	0.089
Good	31 (16.3%)	7 (10.0%)	24 (20.0%)
Average	107 (56.3%)	46 (65.7%)	61 (50.8%)
Bad	52 (27.4%)	17 (24.3%)	35 (29.2%)
Relationship with teachers				0.460	0.795
Good	29 (15.3%)	10 (14.3%)	19 (15.8%)
Average	119 (62.6%)	46 (65.7%)	73 (60.8%)
Bad	42 (22.1%)	14 (20.0%)	28 (23.3%)
Relationship with families				12.283	0.002
Good	59 (31.1%)	11 (15.7%)	48 (40.0%)
Average	105 (55.3%)	48 (68.6%)	57 (47.5%)
Bad	26 (13.7%)	11 (15.7%)	15 (12.5%)
Type of antidepressant use				1.517	0.707
No antidepressant use	71 (37.4%)	26 (37.1%)	45 (37.5%)
Only SSRI/SNRI	97 (51.1%)	37 (52.9%)	60 (50.0%)
SSRI + SNRI	7 (3.7%)	1 (1.4%)	6 (5.0%)
Others	15 (7.9%)	6 (8.6%)	9 (7.5%)
	Mean (SD)	Mean (SD)	Mean (SD)	t/z	P
Age (years)	15.3 (1.5)	15.0 (1.5)	15.4 (1.6)	−1.782	0.075
BMI	20.9 (3.8)	21.1 (4.2)	20.8 (3.6)	−0.232	0.816
Age at onset (years)	13.7 (1.8)	13.3 (1.9)	13.9 (1.8)	−2.239	0.025
Duration of illness (months)	20.4 (18.0)	23.6 (20.5)	18.6 (16.2)	−1.491	0.136
ASLEC score	55.6 (20.6)	58.9 (16.5)	53.7 (22.5)	−2.071	0.038
HAMD-17 score	20.0 (5.7)	22.7 (4.8)	18.5 (5.6)	−4.700	< 0.001
CTQ score	51.5 (12.8)	57.4 (11.1)	48.0 (12.5)	−4.908	< 0.001
Emotional abuse	11.8 (4.6)	13.9 (4.5)	10.6 (4.2)	−4.800	< 0.001
Physical abuse	7.2 (2.7)	7.7 (2.8)	6.9 (2.7)	−2.245	0.025
Sexual abuse	5.9 (2.4)	5.9 (2.5)	5.9 (2.3)	−0.034	0.973
Emotional neglect	15.9 (5.1)	18.0 (4.5)	14.7 (5.0)	−4.246	< 0.001
Physical neglect	10.7 (3.5)	12.0 (3.4)	9.9 (3.3)	−3.915	< 0.001

MDD Major depressive disorder, OCS Obsessive-compulsive symptoms, BMI Body mass index, SSRI Selective serotonin reuptake inhibitor, SNRI Serotonin noradrenaline reuptake inhibitor, HAMD-17 17-item Hamilton Rating Scale for Depression, ASLEC Adolescent Self-Rating Life Events Check List, CTQ Childhood Trauma Questionnaire

Comparison of participants with and without OCS

Table 1 shows that the prevalence of OCS in depressed adolescents was 36.8%. In addition, the univariate results guided our selection of variables to include in the logistic regression models. Given the significantly differences in the groups’ relationships with family and age at onset of MDD, it would seem that these two factors are linked to the development of OCS, with the family relationship variable remaining significant at a p-value after Bonferroni correction. Additionally, the ASLEC, CTQ, HAMD-17, emotional abuse, emotional neglect, physical abuse, and physical neglect scores significantly differed. These variables were included in two logistic regression models.

Independent correlates associated with OCS

Table 2 presents the results of two logistic regression models. The statistical inference for each variable implies its effect in the model while controlling for other covariates. We retained significant variables to derive the final models, which explained the relationship between the occurrence of OCS in adolescents with MDD and other independent variables. The results of Model 1 indicated that after controlling for the age of onset, family relationship and ASLEC score, the odds of OCS increased by 12.8% for every 1-point increase in HAMD score (p = 0.001, OR = 1.128, 95% CI: 1.052–1.210), and the odds of OCS increased by 5.1% (p = 0.005, OR = 1.051, 95% CI: 1.015–1.089) for each 1-point increase in the CTQ total score. The 95% confidence interval (95% CI) did not cross 1, suggesting that the result was statistically significant, that is, the HAMD score and the total CTQ score were independent factors for adolescent depression with OCS. Similarly, the results of Model 2 indicated that after controlling for the age of onset, family relationship, and ASLEC score, for every 1-point increase in the HAMD score, the odds of OCS increased by 14.7% (p < 0.001, OR = 1.147, 95% CI: 1.065–1.235), and for every 1-point increase in the score of emotional abuse, the odds of OCS increased by 16.3% (p = 0.004, OR = 1.163, 95% CI: 1.049–1.291). The 95% CI also did not include 1, indicating that the HAMD score and the emotional abuse score were independent factors for adolescent depression with OCS.

Table 2.

Binary logistic regression analysis of independent factors associated with OCS

Independent Variable	Model 1a				Model 2b
	P	OR	OR95%CI		P	OR	OR95%CI
			Lower	Upper			Lower	Upper
Relationship with families	—	—	—	—	—	—	—	—
Good	Ref	—	—	—	Ref	—	—	—
Average	0.854	1.124	0.324	3.902	0.568	1.511	0.366	6.239
Bad	0.277	1.732	0.643	4.661	0.195	1.993	0.703	5.648
Age at onset	0.514	0.939	0.777	1.135	0.531	0.941	0.777	1.139
ASLEC score	0.355	0.991	0.973	1.010	0.255	0.989	0.970	1.008
HAMD score	0.001	1.128	1.052	1.210	<0.001	1.147	1.065	1.235
CTQ total score	0.005	1.051	1.015	1.089	—	—	—	—
Emotional abuse score	—	—	—	—	0.004	1.163	1.049	1.291
Physical abuse score	—	—	—	—	0.123	0.898	0.783	1.030
Emotional neglect score	—	—	—	—	0.567	1.031	0.929	1.144
Physical neglect score	—	—	—	—	0.164	1.089	0.966	1.228

^aModel 1 incorporates total CTQ scores into the regression equation

^bModel 2 incorporates the factor scores of the CTQ into the regression equation

Predictive analysis of whether adolescent patients with MDD accompanied by OCS

ROC curve analysis of the independent variables in the logistic analysis results showed that the area under the curve for the CTQ score was 0.714 (95% CI: 0.641 ~ 0.786, P < 0.001), and for the HAMD score, it was 0.704 (95% CI: 0.629 ~ 0.779, P < 0.001). We also conducted a combined analysis of the CTQ score and the HAMD score with an area under the curve of 0.760 (95% CI: 0.694 ~ 0.827, P < 0.001). The findings of the ROC curve analysis suggested that both the HAMD score and the CTQ score had good predictive value for adolescent patients with depression complicated with OCS, and the combination of the two had a better predictive ability (Fig. 1).

Fig. 1.

ROC curve of CTQ score, HAMD score and their combination

Discussion

As far as we are aware, the purpose of this study is to examine the prevalence of OCS in adolescents with MDD and the clinical correlates of concurrent OCS in adolescent MDD patients.

Regarding the prevalence of OCS in MDD, most of the previous studies focused on adults, and their results were not consistent. Some studies have shown that the prevalence of OCS in MDD is 20–30% [11, 35], while others have concluded that the prevalence is as high as 54% [36]. A study called Sequenced Treatment Alternatives to Relieve Depression (STAR*D) found that OCS was present in at least 50% of depressive outpatients [13]. In our study, we determined the prevalence of OCS among adolescents with depression treated in an outpatient or inpatient setting. The prevalence was 36.8%, which is close to that reported in an earlier study on OCS in depression and bipolar disorder (35.2%) [14]. There might be various reasons for such differences: the population we selected, the diagnostic criteria for depression, the severity of symptoms, and so on.

We discovered a substantial difference in relationships with family across patients with and without OCS. This outcome is consistent with research showing that adolescents with OCD are more likely to encounter family discomfort or disruptions in family functioning, including decreased levels of cohesion, emotional support, and familial closeness [37–40]. These results suggest that parenting practices directly impact adolescents’ development of OCS. For instance, overprotective and interfering parenting styles experienced by patients were associated with compulsive washing behaviors, and excessive parental blame and rejection were associated with repetitive checking behaviors [41]. All the aforementioned results suggest that treatments which bolster relationships with family may be useful. By creating more positive interactions with family members, the mental health of MDD patients with OCS may be improved. On the other hand, we also found that participants with OCS had an earlier onset age of MDD than those without OCS. Similarly, earlier onset of OCD has been linked with more symptoms, a higher incidence of repetitive ritual behavior, more severe OCS, and a greater need for treatment, according to earlier studies [42]. Thus, greater attention to OCS in children with an early onset age of MDD is merited in light of our findings. Greater care and patience could facilitate early detection and treatment.

Life events, a cause of psychosocial stress, have a variety of effects on the physical and emotional well-being of adolescents. Our study showed that depressed patients with OCS had experienced more negative life events than those without OCS, as indicated by higher ASLEC scores. The number of adverse life experiences that teenagers have encountered increases significantly after the age of 13 [43], such negative life events include failing a test, obtaining unsatisfactory grades, or an excessive academic load. Remarkably, some studies have reported that approximately 53% of adolescents with OCD have experienced some stressful event prior to the illness [44]. Previous research has identified negative life events as risk factors for OCD, demonstrating that OCS are more severe in individuals with OCD who have experienced negative life events [45, 46]. Therefore, schools should take additional steps to prevent heavy academic loads (e.g., heavy homework loads) in adolescents. While there are many ways to achieve this, one possible avenue is to design outdoor activities for children to bolster their physical and mental health.

In our study, MDD patients with OCS had a higher HAMD score than MDD patients without OCS, suggesting that OCS may worsen depressive symptoms. Logistic regression analysis even showed that the severity of depression was an influential factor in depressed patients with OCS. These findings are consistent with those of prior research. In previous studies, researchers have observed a positive correlation between the number of OCS and depression scores but a negative correlation between remission rates and OCS [13]. The severity of depressive episodes in patients with comorbid anxiety and depression is associated with the presence of OCS [11]. A recent study found that levels of depression and anxiety predicted the presence of OCS [47]. These results suggest that the relationship between OCS and depression may not be unidirectional, but rather exhibit a “bidirectional” dynamic pattern. A longitudinal study by Bolhuis et al. also demonstrated a significant bidirectional relationship between OCS and depressive symptoms in both adolescents and adults, and this relationship was mainly explained by shared genetic factors [48]. In addition, it was found that OCS may precede depressive symptoms, especially in adolescents [49]. These findings suggest that, on the one hand, we can provide early screening and intervention for depression in adolescents with the presence of OCS, and on the other hand, when assessing adolescents with depression, we should also consider the presence of OCS in order to develop more effective treatment programs.

Extensive evidence shows that children who have undergone childhood trauma are more prone to develop depression [50–53]. Among female subjects, OCD was positively correlated with childhood trauma, particularly emotional neglect [54]. Emotional abuse may be associated with increased OCS scores, and emotional trauma (such as abuse or neglect) is believed to play a significant role in the clinical development of OCS [55]. However, very few studies have examined whether childhood trauma is associated with OCS in patients with depression, and even fewer have done so in adolescents. We found a strong correlation between the development of OCS in depressed adolescents and childhood trauma. As indicated by CTQ scores, the patients with and without OCS exhibited significant differences in emotional abuse, emotional neglect, physical abuse, and physical neglect. The logistic regression analysis further indicated that emotional abuse was an independent influencing factor for OCS. The results of a review that included 5,603 subjects also indicated a significant association between childhood trauma and OCS. The higher the level of exposure to childhood trauma (especially emotional abuse and neglect), the higher the severity of OCS [56]. There are various hypotheses about the mechanism underlying the association between childhood trauma and later OCS. Some studies have linked the development of OCS to poor parenting practices, such as overcontrol, overprotection, and emotional rejection, which may be associated with emotional abuse and emotional neglect [57, 58]. Felitti et al. proposed a pyramid model of the lifelong effects of childhood adverse experiences, suggesting that childhood adverse experiences can lead to physical and mental illness through impairment of individuals’ cognitive functions [59]. Furthermore, some studies have indicated that mood disorders including depression and anxiety may mediate the relationship between childhood trauma and OCD [60]. Anatomy paves another potential way to the question. Some researchers have found that traumatic experiences in childhood can lead to structural abnormalities in the brain, such as structural and functional changes in the frontal cortex and hippocampus [61, 62]. A study on the interaction between brain-derived neurotrophic factor (BDNF) levels and childhood trauma showed that childhood trauma, especially emotional neglect and emotional abuse, significantly increased the risk of OCD, and the interaction between BDNF levels and emotional abuse also increased the risk of OCD [28].

In our sample, 74% were female, which reflects the dominance of females among adolescent depression patients [63]. Studies have shown that males experience symptoms of OCS earlier in childhood, while it is more common in females in adolescence or adulthood [64]. However, some studies have found that gender differences in OCD are not significant in certain aspects, such as in the severity of symptoms and treatment response [65]. Male patients were more likely to exhibit compulsions related to sex, religion, and order, while females were more likely to exhibit compulsive behaviors related to pollution and cleaning [66]. In addition, female patients were more likely to have co-morbid symptoms such as depression and anxiety. These differences may be related to changes in hormone levels such as estrogen and progesterone [67]. These findings also suggest that future studies may be able to stratify analyses by gender and explore whether early estrogen exposure modulates the trajectory of depression with OCS.

In our study, antidepressant treatment was almost exclusively administered with SSRIs or SNRIs. Medication itself is a first-line treatment for depression. For OCS, antidepressants such as fluoxetine, sertraline, and paroxetine can also improve OCS by increasing the concentration of 5-hydroxytryptamine in the synaptic gap [68, 69]. Studies have shown that antidepressants have certain therapeutic effects in the treatment of OCD. A systematic retrospective study pointed out that antidepressant drugs (such as fluoxetine and fluvoxamine) have potential efficacy in the treatment of OCD [70]. The study also found that antidepressant medications resulted in symptomatic improvement in approximately 50–80% of patients with OCD when treated with antidepressants [71]. Antidepressants are also often used in combination with other psychological treatment methods, such as cognitive behavioral therapy (CBT) and group therapy. Studies have shown that combining antidepressants with CBT can further improve treatment outcomes [72]. Since this study is a cross-sectional study, more future research is needed on the specific efficacy of antidepressant medications in treating adolescent patients with or without OCS, as well as the related mechanisms.

Our study also has some shortcomings. First, because of the cross-sectional design, causal relationships between variables could not be established. Second, we lacked a healthy control group. Therefore, it is unclear whether there are differences in sociodemographic and clinical characteristics among depressed patients with OCS, depressed patients without OCS, and healthy individuals without OCS or MDD. Third, some of the data were self-reported by patients in this study, which might result in recall bias. Fourth, Because we relied on Y-BOCS scale scores derived from self- and parent-report, rather than a structured diagnostic interview, our results are biased from the true prevalence of OCD. Therefore, any prevalence figures cited in this study should be interpreted as reflecting “possible obsessive-compulsive symptoms” rather than “definite obsessive-compulsive disorder”. Finally, there were significantly more female participants in this study than males, which might weaken the representativeness of the samples. As the subjects of this study were depressed adolescents aged between 12 and 18 years, and adolescent depression is correlated with sex, this sex ratio may be unavoidable [73]. Thus, in future studies, we plan to recruit healthy subjects and conduct follow-up investigations on patients to further improve and extend our study results.

Conclusions

We thoroughly analyzed 190 adolescent patients for this investigation. We focused on the prevalence of OCS in this special population. We examined the relationship between clinical and sociodemographic characteristics and the occurrence of OCS. Based on our analysis, OCS are a common comorbidity among adolescents with MDD. The presence of OCS was predicted by the severity of depressive symptoms and traumatic childhood experiences. Childhood trauma, an influential factor commonly studied in psychiatric disorders, was given particular attention.

Our results indicate that during clinical diagnosis and treatment, a dedicated test to evaluate OCS in children with MDD is urgently needed. To achieve the early implementation of prevention and intervention strategies in psychological settings, additional cohort studies of adolescents with depression are needed. Our research also highlights the importance of familial, educational, and social contributions in the care of adolescent patients. Some effective and positive interventions can be implemented in a preventive manner.

Authors’ contributions

HL oversaw the design, and the critical reading and revision of the manuscript. ZL analyzed and interpreted the data; and drafted the manuscript. ZL, XS, YF, CC, ZL, FG, JW, XL, XW finished designing the preliminary questionnaire and gathering the results. LX helped coordinate the study. All authors reviewed and approved the final manuscript.

Funding

Anhui Health Research Project (Grant No. AHWJ2024Aa10004).

National Natural Science Foundation of China(Grant No. 82401798).

Research Fund Project of Anhui Translational Research Institute (No. 2022zhyx-B01).

Data availability

The corresponding author can provide the datasets used and/or analyzed in this study upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of The Fourth Affiliated Hospital of Anhui Medical University (202009-kyxm-04). All procedures were conducted in accordance with the ethical standards of the 2013 Declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki/).

All patients were informed of the relevant information of the experiment by their physicians before enrollment, and signed the informed consent form after obtaining the consent of themselves and their guardians.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.