Depression is Adolescents* Greatest Risk

2013 An nualChildAbuseCoun cilSpringCon ference
“Strengthening the Social and Emotional Health of Children?”
Depression is Adolescents’ Greatest Risk
Greg Billiard, LMSW
Marilyn Cleary, RN
Randy Koch, LPC
Michael Lucido, PHD
Suicide Prevention Workgroup
Suicide Prevention Workgroup
Human Services Coordinating Body of
Charlevoix & Emmet Counties
In order to lighten then mood…
Mental Health Defined:
Mental health is a state of well-being in which an
individual realizes his or her own abilities, can cope
with the normal stresses of life, can work
productively and is able to make a contribution to
his or her community. In this positive sense, mental
health is the foundation for individual well-being
and the effective functioning of a community.
World Health Organization
If you have good mental wellness you:
• are in control of your thoughts & behaviors;
• feel positive about yourself;
• have good relationships;
• keep problems in perspective;
• have both self-awareness and self-control
Adolescents are exposed to increased rates of
stressful life experiences and there is some evidence
that increases in stressors account, at least in part,
for the increased rates of psychological problems
associated with this developmental period.
Stress and Mental Health Problems
Grant, K.E. at el. 2005
Youth Today
May feel overwhelmed by the emotional & physical changes they
are going through.
• Fitting in
o Relationships
o Body changes
• Bullying especially Cyber-bullying (e.g., facebook)!!!
o Teens/young adults are committing suicide with a
significant history of being victimized in bullying.
o Playground/bus incident-re-victimized
• Performing well
o Academics/job
o Family
o Sports
A Tragedy: Alex Harrison
• Cadillac, MI- Alex was a bright and truly gifted
who was taking college level courses
• He never told anyone about being bullied
o Tennis team called him names- “Creeper”
o Student said, “Don’t you know everyone hates you”
• At the age of 16, he shot himself at 2 am.
• Parents advocate for anti-bullying programs to
prevent more casualties.
When transitioning from childhood into adulthood,
youth may struggle with being dependent while
wanting to be independent. They “try-on” styles,
ideas & friends as they define themselves.
Symptoms of Stress
Feeling tired for no good reason
Headaches; body pains
Eating more or less than usual
Trouble sleeping
More colds than usual
Flashes of anger / tears
Sad, moody, lonely
Forgetful, trouble concentrating, cloudy
Mental disorder is a term for psychophysiological
disorders affecting mood, thought, or behavior.
•1 in 5 will have a mental health disorder.
•1 in 10 will be a severe impairment.
•About 3 children in a class of 30 will have a mental
health condition that needs treatment.
Common in children include:
• Depression
• Anxiety/Phobias/PTSD/OCD
• Bipolar Disorder • Autism Spectrum Conditions
• Conduct Disorder• Tourette’s
• Oppositional Defiant
• Eating Disorders
What is the deadliest mental
disorder for teens?
• Major Depressive Disorder is
the leading disease related
cause of death in the U.S.
for ages 11-24
• More than 90 percent of
people who take their lives
have a diagnosable mental
disorder, most commonly a
depressive disorder and/or
a substance abuse disorder.
National Institute of Mental Health
Terminal Depression: Suicide
• According to the CDC, 1,386 children and adolescents
between the ages 13 to 18 committed suicide.
• According to the Journal of Adolescent Health, 1 in 8
teenagers had persistent suicidal thoughts at some
point and a third of those made an attempt.
• 40% of adolescents who have attempted to take their
own life admitted they first tried to kill themselves prior
to high school.
• A Harvard study found that 55% of adolescents who
plan or attempt suicide have had at least some mental
health treatment prior to the attempt which contradict
the notion that they lacked treatment services.
Bipolar Disorder
• A third of children with depression
have misdiagnosed bipolar
• Often presents as ADHD
• Manic episode must last 1 week
o Typically not up and down throughout the day
• Impulsive, lack judgment
• Rage, defiant, disrespect
• Rapid mood swingsmany times a day
• Elevated, expansive,
irritable mood
• Grandiosity
• “I hate myself!”
Decreased need for sleep
Increased talking
Racing thoughts
Increased activity, agitation
Engage in Risky behaviors
Possible psychosis
Be aware of the factors that
put youth at risk.
• Family history of depression
• Substance abuse, chronic illness, death/loss, disabilities, absent
parent/family conflict
• Personality traits that change dramatically can signal trouble
• Impulsive, obsessiveness, fears, aggression, antisocial, poor
social skills, poor self worth, overachieving, pressure to perform
• Personal competence (learning disability, ADHD)
• Medical conditions such as hypothyroid may increase risk
• Social events that contribute to problems and stress
• Loss experienced, problems with friends, rejection, pregnancy,
financial issues , or relocations/moves to another location
Biological Basis
• Significant genetic
loading with higher
rates when a first
degree relative has
depression of 34%
• Serotonin hypothesis
with dysregulated
• This is the reason for
selective serotonin
reuptake inhibitors
(SSRI) treatment in
Depression Leads to Impaired Immunity and
PET Scan Imaging Comparison
Comparing brain
activity during
depression with
normal brain activity.
o An increase of blue and
green colors, along with
decreased white and
yellow areas, shows
decreased brain activity
due to depression.
o PET scans measures blood
flow and volume, oxygen
usage, tissue acidity (pH), and
glucose metabolism.
Development of Depression
• ADHD diagnosis 4-6 y/o increases risk for depression.
• Children –
Do not verbalize depressive thoughts
More physical complaints or exaggerated when sick or aching
More irritability,
Uncooperativeness, apathy, disinterested
Lower rate of hypersomnia and more psychomotor agitation
• Adolescentso Hopelessness, verbalize symptoms, hypersomnia, weight loss
o Decrease with age- appear depressed, somatic complaints, low selfesteem
o Increase with age-anhedonia, psychomotor retardation, diurnal variation
o Major depressive disorder onset at 14.
• Milder depression seen at around 11
• Girls have longer depressive episodes than boys.
Signs and Symptoms of Depression
Sadness and hopelessness
Most children/adolescents deny depression
Poor performance or failing performance in school
Withdrawal from friends and activities
Lack of enthusiasm, energy or motivation
Anger, overreaction to criticism, problems with authority
Feelings of being unable to satisfy ideals
Poor self-esteem or guilt
Indecision, lack of concentration or forgetfulness
Restlessness and agitation
Changes in eating or sleeping patterns
Substance abuse
Severe symptoms cause paranoia and hallucinations
Depression may co-occur with any of the
mental illnesses mentioned.
Depression impacts:
o Behavioral
o Cognitive
o Emotional
Emotional Signs
Bored or apathetic
Mood swings
Behavioral Signs
Social withdrawal/loss of interests
Falling asleep in class
Low energy/exhaustion
Increase/decrease in appetite
Complains about illnesses & pain
Cuts/burns/bruises (wear sweaters to hide)
Things you may see in school
Unexplained drop in performance
Overly invested in achieving good grades
Loss of interest in activities like sports or games
Turning in poor quality work
Low tolerance for frustration/gives up easily
Complains of being tired and fatigued
Unmotivated/can’t finish work
Changes in attendance
• Cognitive errors
Cognitive Signs
o catastrophizing, personalization,
o Negative triad- self, world, and
Negative self-talk
Problems concentrating
Indecisiveness & Confusion
Negative memory bias
Severe depression leads to
psychotic symptoms such
as hallucinations/delusions
(less common)
Depression Mixed with
Substance Abuse
• What came first, the
chicken or the Egg?
• Self-medication?
• Associated Risks
• Impact of Alcohol
and Marihuana Use
The Survey Says:
• 33 percent of 8th graders & 70 percent of 12th
graders in the United States said they tried alcohol
at some time in their lives (SAMSHA 2012)
• 6.5 percent of 8th graders, 17.0 percent of 10th
graders, and 22.9 percent of 12th graders had used
marijuana in the past month (NIDA 2012)
• Perception of risk: Alcohol ~ 39.3% in 2007 to 40.7% in
2011& Marihuana ~ 11.1% in 2004 to 7.4% in
2011(NSDUH 2012)
• Significant differences by sex in the perceived
danger of using marihuana and alcohol
Perception of Great Risk from Using Selected Substances Once or Twice a Week
Adolescents Aged 12 to 17, by Gender: 2011
• 56.8% of males aged 12 or older were current
drinkers; 47.1% of females (NSDUH 2011)
• Impulsivity and aggression are strongly
implicated in suicidal behavior - Alcohol use
impairs reasoning & increases impulsive
• Evidence suggests association between:
aggression ~ serotonin deficiency AND between
aggression ~ alcohol consumption (Columbia
• 35% of students who reported alcohol use prior
to age 13 had increased risk for violent
behaviors and significant increase in suicide
attempts (SAMHSA 2012)
• THC affects the nerve cells in the part of the brain where
memories are formed
• Marihuana affects self-control & decision making abilities
• Chronic/heavy use (3 or more times per week) increases
likelihood of depression, anxiety and panic attack
• Cannabis dependence = 2.9 times as likely to think
about suicide without attempting it & 2.5 times as likely
to make a suicide attempt (Michael Lynskey, PhD, Washington
University School of Medicine 2012)
• The Double Whammy ~ Cannabis withdrawal increases
anxiety, depression, insomnia, irritability
Other Considerations…
• Alcohol & Marijuana ~ gateways to other
substance use
• Additional risk taking behaviors
• Impaired social and academic functioning
• Increased injury or death from accidents
• Para-suicidal behaviors
• Family History
• Don’t forget the synthetics: Spice/K2 & Bath Salts
Early intervention does begin in early elementary school.
What is professional help?
• Evaluation and diagnosis (Beck’s checklists, CBCL,
Conner’s, MMPI-A, observation reports)
• Psychotherapy
o Individual therapy like cognitive behavioral
o Family therapy (PMTO)
o Group therapy (youth groups)
• Psychopharmacological interventions
• Special academic support
o 504
Who are licensed professionals?
Clinical counselor*
Social worker*
School psychologist*
*(may have limitations for service)
Depression is Treatable
• Early intervention does begin in early elementary school
• Depression can be effectively treated with a
combination of psychotherapy and antidepressants.
• Mild depression may be treated with psychotherapy alone, but serious
episodes may require medication.
• For the treatment to be fully effective, it is critical that
the treatment continue for several months or longer.
• One half of the children diagnosed with depression are
likely to have a relapse over a five-year follow-up
• Young people who suffer from depression are also likely
to suffer from depression in their adult lives.
• Early interventions are critical!
University of Michigan Depression Center (2010)
Psychotropic Intervention
• Antidepressant medications have been historically
• Includes MAOIs, tricyclics, SSRI, SNRI, and other
medications that have similar effects on serotonin.
• May have side effects such as increased irritability
and have “black box” warnings for risk of suicide.
• Only medication proven to be helpful in preventing
suicidal ideations and behaviors was lithium.
• Always monitor and/or administer the medication.
o Often teens are unreliable even with their self care habits.
• Always be sure to right down questions, comments
or other notes prior to talking with the doctor.
Psychotherapy Interventions
• Dialectal behavioral therapy provides reduction in self harm
o Cognitive behavioral therapy approach- acceptance based strategies, skills training,
motivational enhancement, generalization outside of clinical setting, structure of
environment, and group facilitation.
o Very problem-solving focused and on emotional regulation with validation, mindfulness
and acceptance.
• Cognitive Behavioral Therapy (CBT) for Adolescent Depression
o The use of concrete examples to illustrate points, education about the nature of
psychotherapy and socialization to the treatment model, active exploration autonomy
and trust issues, focus on cognitive distortions and affective shifts that occur during
sessions, and acquisition of problem-solving, affect-regulation, and social skills.
o The treatment program is delivered in 12 to 16 weekly sessions.
• Interpersonal Psychotherapy for Depressed Adolescents
o Short term manual driven treatment for ages 12-18 for mild to moderate depression.
o Improves adolescents' communication and social problem-solving skills to increase their
personal effectiveness and satisfaction with current relationships.
o Identifies risk factors like separation from parents, development of dyadic relationships,
death of a relative or friend, peer pressure, single-parent families.
o Parental involvement is strongly encouraged (but not mandatory).
School-Based Interventions
• Red Flags Program
o Mental health awareness program for middle/Jr high schools
o Teaches signs of depression & other mental health issues
o Encourages peers to react and get help for others
• Zippy's Friends
o School-based mental health program for children ages 5-7.
o Teacher 24 weekly sessions, each 45-60 minutes
o Identifying and describing feelings; communication; friendship;
bullying/conflict resolution; change/loss; and coping.
• TeenScreen
o Middle to high school age youth with undetected mental illness.
o 10-minute screen for teens at risk for suicide or mental illness.
o A clinical interview and onsite mental health professional.
o If need is beyond school based support then referral to more in
depth mental health evaluation.
When you suspect a
Ask questions
Don’t ignore the signs
If you have a “hunch”, ask others to gain
perspective. Trust your instincts!
• Educate yourself
• Discuss concern with parent
• Encourage them to get it “checked out”
Teach Young People To…
• Learn to identify problems or stress agents
• Practice coping strategies
o emphasize self-responsibility and offer positive,
nondestructive ways of finding relief
Find good listeners
Express feelings
Communicate problems
Develop problem solving skills
Set goals and make plans to achieve them
Act positively to assist their friends/peers
Recognize their own warning signs
Ask, Care, & Tell
1. ASK
• Take it seriously. 70% of who commit suicide give warnings.
• Be willing to listen.
2. Care
• Voice your concern. Take the initiative to ask what is troubling, and
attempt to overcome any reluctance to talk.
• Let the person know you care and understand.
• Asking about suicide does not cause suicide.
• get professional help immediately.
• If the person is unwilling to accept treatment get them to a local
emergency room or community mental health center.
• They will be more likely to seek help if you accompany.
Stop a Suicide-Screening for Mental Health (2010)
Survivors of Suicide
Support Group
• Attending monthly at the Vital Care Hospice of Little
Traverse Bay in the Hiland Cottage Petoskey, MI
• 6-7:30 pm and every second Tuesday of the month
(next meeting May 14)
• Provides support for after the loss of suicide
• Facilitated by a therapists and survivor
Final Thought
It is through awareness and recognition of adolescent
stress, depression and mental health that parents and
caring adults engage youth positively and
constructively to stimulate their emotional
• Local Healthcare Practitioners
• First line support/referral service
• Third Level Crisis Center
• (800) 442-7315
• North Country CMH Access Center
• (800) 834-3393
• National Suicide Prevention Lifeline
• (800) 273-TALK
• Hospice of Little Traverse Bay-Survivors of Suicide Group
• (231) 487-4825
• Michigan Department of Community Health
• National Institute of Mental Health
• SAMHSA for national resources

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