WCW's Women Change Worlds Blog

Over the past few years, you may have read about the crisis in youth mental health. In October 2021, the American Academy of Pediatrics declared a national emergency in child and adolescent mental health, and in December 2021, the U.S. surgeon general highlighted the urgent need to address the nation’s youth mental health crisis. Just this month, the U.S. Preventive Services Task Force recommended screening for depression in adolescents aged 12 to 18.

October is National Depression and Mental Health Screening Month, so we’d like to highlight one of the tools WCW has been using to approach the youth mental health crisis that is in line with that recommendation: school-based mental health screenings.

Mood Check, our program, partners with schools to screen all students in designated grades and offers additional support to adolescents at high risk for depression and/or suicidal behaviors. We have a multi-pronged approach: We offer resources that increase the school community’s mental health awareness and literacy, which serves as a prevention tool. Then we provide two-level screening for students, including universal, self-reported screening for all students followed by in-depth interviews with students who are identified as high risk. We communicate with parents and guardians about youth depression and resources, and provide more significant follow-up (both immediate and long-term) for parents and guardians of high-risk teens. Finally, we offer referral access for all school families who need to find a mental health professional to help their teen moving forward.

This past school year, we screened a total of 2,078 middle and high school students in the greater Boston area for both depression and anxiety. We met one-on-one with 646 students (about 31%); 237 students (about 11%) revealed to us that they had current or past thoughts of suicide, and 57 students reported that they revealed suicidal thinking or behavior to an adult for the first time when meeting with a clinician on our team. For those who reported suicidal thinking/behavior, we introduced safety plans: a way to identify warning signs, internal coping strategies, supportive people and places, how to make the environment safe, and a motivator for living, along with providing the Suicide Prevention Lifeline phone number. Students retained a copy of the plan that they could reference themselves and/or share with parents, providers, or trusted adults.

A review of our data over time suggests that Mood Check is associated with decreased depressive symptoms in at-risk adolescents and may encourage families to seek treatment for students we identify. This kind of success in a school setting is in line with other research, which shows that teens prefer to receive mental health services in schools, rather than in mental health specialty settings. Anecdotally, we’ve found that teens are more willing to speak with us, because they know they won’t see us again; it can be easier to tell the truth to a stranger than to a parent, teacher, or guidance counselor. We’re glad to provide that listening ear for them.

School screenings alone cannot solve the crisis in youth mental health. But they are an important tool to be used in combination with depression prevention efforts and expanded access to treatment. Our goal is for more teens to be able to get the help they need in order to live healthier and happier lives.

Tracy R. G. Gladstone, Ph.D., is research director, an associate director and a senior research scientist at the Wellesley Centers for Women, where she leads the Depression Prevention Research Initiative.

In 2018, I began a multi-year clinical trial to compare the effectiveness of two approaches to preventing depression in teens. One of the approaches is an online intervention -- an app -- called CATCH-IT and the other is an in-person group therapy intervention.

When we started recruiting teens to participate in the trial just this past winter, we encountered a number of challenges. It was difficult to get teens and their parents to commit to attending the weekly group therapy sessions, and to fill out the assessments we needed for our evaluation. Because we planned to hold these sessions at the clinics where our participants received their primary care, geography determined who could participate. We were busy working through these challenges throughout the early spring.

Then the pandemic hit, and with it we noticed a spike in the number of teens we were encountering who were reporting significant struggles with depression and suicidal thinking. At this point it’s too early to determine whether or not the stress of COVID accounts for the symptoms we are identifying, but regardless, we have been busy referring teens to therapists in their communities, rather than enrolling them in our study. Clearly these teens need more than we can offer in a prevention trial. We are grateful that we have been able to identify so many teens who are in need of immediate support, and to facilitate their connection to those who can offer them the help they need.

For teens with milder symptoms who are at risk of depression, and who are therefore good candidates for our study, we’ve had to reassess the way we had originally planned to conduct our research. The challenges of COVID have tied many researchers’ hands -- not being able to see people in person can prevent a lot of research from happening at all. But for us, despite the challenges presented by COVID, we have also recognized that the pandemic has allowed us to make our interventions more accessible, and has enabled us to more easily reach participants for enrollments and assessments.

The main change we had to make in our research strategy was to switch our in-person group therapy model to live online sessions. Fortunately, research shows that telehealth is just as effective as in-person therapy, even for groups, and the pandemic has made telehealth much more widely accepted and available. For our purposes, moving our in-person groups to an online format improves our study design by making the two programs we are comparing much more similar: instead of comparing the CATCH-IT app to in-person sessions, we’re now comparing two online interventions to see which is more effective and for whom.

Moving everything online has also made the group therapy much more accessible. Teens and their parents no longer need to drive to a clinic on a Sunday evening, squeezing the session in between soccer practice and homework. Since life has slowed down and schedules have eased up, teens and their families have more time, and in many cases more motivation to participate. Some teens are more comfortable interacting through a screen than sitting in a room with strangers. So far in our trial, every participant has come to every online group session, and has completed every piece of paperwork we need -- an unheard-of scenario in pre-COVID times.

In addition, we’ve been able to open up the study to more teens in more locations, and to run groups across communities. Urban, suburban, and rural teens, previously separated by geography into separate group sessions, now meet together online (very successfully, I might add). Those who live too far away to have the option of a group therapy model can now participate in it. Since we can’t be in doctors’ offices to recruit participants, we’ve changed our strategy there, too, introducing a public health campaign that reaches anyone who is interested across three states.

Although COVID has been challenging for many teens and has challenged us from a study design perspective, the current circumstances have enabled us to identify and refer many more teens with serious mental health concerns, and also have enabled more teens from different places to access our interventions. We’ll continue to follow the participants in our programs over the next 18 months and will assess how they’re doing. Even after the pandemic ends, we are planning to use what we’ve learned during this difficult time so that we’re able to make prevention interventions accessible to more people in the future. Having to adjust our methods has given us better data, and eliminated many of the barriers to mental health care for teens and their families.

Tracy Gladstone, Ph.D., is an associate director and senior research scientist at the Wellesley Centers for Women, as well as the inaugural director of the Robert S. and Grace W. Stone Primary Prevention Initiatives, which aim to research, develop, and evaluate programs to prevent the onset of depression and other mental health concerns in children and adolescents.

The teen sitting across from me avoided making eye contact as he responded to my questions. He provided thoughtful answers in a soft voice as he looked down at the rubber band in his hands, stretching and turning it repeatedly. Clearly this young man was struggling with symptoms of depression such that he was disengaged from his friends, skipping track practices, missing homework assignments, sleeping too much. Yet when I asked him if I could share his symptoms with his guidance counselor so that he could get some support in school, he quickly replied, “No,” saying that he didn’t want anyone at school to know. “I’m only telling you about this, “ he insisted, “because I’ll never see you again.”

My colleagues and I routinely hear such statements from the adolescents we screen for depression and suicidal thoughts. Although these teens readily reveal their symptoms and struggles to us, adults who enter their middle and high schools for a few weeks each year and then leave as quickly as we arrive, they are reluctant to reveal their inner thoughts and feelings to the people they see every day: parents, teachers, school counselors. And the parents of these teens repeatedly tell us that they do not want us to share the results of our screening efforts with school personnel who could provide support during the school day. Consistent with our experiences in schools, research suggests that, even when adults in school are educated about the signs and symptoms of youth depression and are prepared to support teens who are struggling, such gatekeeper education programs often do not increase the likelihood that teens, who, for example, are experiencing suicidal thoughts, will seek out adults for support. Moreover, one study revealed that most teens who have made a suicide attempt said they would not share this fact with a counselor or other adult at school, and that they believed their parents would not want them to do so.

How significant of a problem is depression and suicidal behavior among adolescents? A recent Pew Research Center poll indicates that adolescents view depression and anxiety as key concerns for themselves and their peers, and as even more significant concerns than drug/alcohol abuse and bullying. We know that rates of depression in youth are quite high, with as many as 11% experiencing a Major Depressive Disorder by the end of adolescence. Suicide is the second leading cause of death among those ages 10-19, and depression is common among adolescents who exhibit suicidal thoughts and behaviors. In fact, suicidal thinking has been found to be elevated even among adolescents who experience symptoms of depression without meeting full diagnostic criteria for Major Depressive Disorder.

If the many adolescents who are struggling with mental health concerns are not willing to seek support from school personnel, where are they getting the information and support they need? How can we provide teens with tools to promote health and wellbeing?

We know that teens are turning to sources outside of their homes and school communities for information about youth depression, and for indications of how best to manage strong feelings they may be experiencing. For example, a new study indicates that teens may be gathering information about managing suicidal thoughts from television programming, and we have long been warned about the effects of modeling on suicidal behavior among youth, leading to clusters of suicide in a community. In the context of so many unhealthy personal and media examples of teens managing depression, there is much we can do to support the teens in our lives, both those we know well and those we know less well.

In fact, warm interpersonal relationships, and the presence of a close relationship with an adult outside of the home, have been found to be significant sources of strength and to promote resilience in children at risk for depression. For example, in a study of children of depressed parents who maintain good mental health over time, high-quality social relationships were identified as a protective factor. More specifically, researchers in Ireland found that, in a study of risk and protective factors for depression and anxiety in a community sample of adolescents, the presence of “one good adult” in a teen’s life was identified as a protective factor.

You can serve as that “one good adult” and influence adolescents you know toward health and wellbeing: your own children, your children’s friends, and the children of your friends. You can provide a safe source of support to teens in your community, and you can contribute toward reducing the stigma associated with depression, anxiety, and other forms of mental illness. How can you do this? Talk directly to the teens you encounter, and express interest in them, their relationships, and their activities. Talk to the teens you are shuttling to practice in the back of your car, and listen carefully to their conversations. Ask teens how they are feeling, and what they think about, and what they worry about. Listen to their responses, and express caring and concern. Reinforce the value of mental health treatment, and reinforce the value of parents, school counselors, and others in the community who can provide mental health supports. Don’t be afraid to ask teens who report feelings of hopelessness or depression if they ever experience suicidal thoughts—asking this question will not encourage suicidal behavior. Share concerns with parents and others who are directly involved in an at-risk teen’s daily care. Support your children in establishing meaningful relationships with neighbors, an aunt or uncle, and encourage your children to share their feelings openly.

In this month of May, Mental Health Awareness Month, we have the opportunity to be intentional in our support of the adolescents we encounter in our communities, and to recognize the power we have to support their healthy growth and development.

Tracy Gladstone, Ph.D., is an associate director and senior research scientist at the Wellesley Centers for Women as well as the inaugural director of the Robert S. and Grace W. Stone Primary Prevention Initiatives, which aims to research, develop, and evaluate programs to prevent the onset of depression and other mental health concerns in children and adolescents. She is also an assistant in psychology at Boston Children’s Hospital, an instructor at Harvard Medical School, and a research scientist at Judge Baker Children’s Center. Gladstone leads depression prevention programs in two greater Boston school districts, to identify and connect adolescents to appropriate services who report depressive symptoms, self-injury, and suicidal thinking.

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Avenevoli, S., Swendsen, J., He, J.P., Burstein, M., & Merikangas, K.R. (2015). Major depression in the national comorbidity survey-adolescent supplement: Prevalence, correlates, and treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 37-44.

Balazs, J., Miklosi, M., Kereszteny, A., Hoven, C.W., Carli, V., Wasserman, C., Apter, A.,…Wasserman, D. (2013). Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk. Journal of Child Psychology and Psychiatry, 54, 670-677.

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Bridge, J.A., Greenhouse, J.B., Ruch, D., Stevens, J., Ackerman, J., Shefftall, A.H., Horowitz, L.M.,…Campo, J.V. (in press). Association between the release of Netflix’s 13 Reasons Why and suicide rates in the United States: An interrupted time series analysis. Journal of the American Academy of Child and Adolescent Psychiatry.

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Nock, M.K., Green, J.G., Hwang, I., McLaughlin, K.A., Sampson, N.A., Zaslavsky, A.M., & Kessler, R.C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents. JAMA Psychiatry, 70, 300-310.

Silk, J.S., Vanderbilt-Adriance, E., Shaw, D.S., Forbes, E.E, Whalen, D.J., Ryan, N.D. & Dahl, R.E. (2007). Resilience among children and adolescents at risk for depression: Mediation and moderation across social and neurobiological contexts. Development and Psychopathology, 19, 841-865.

Whitney, S.D. Renner, L.M., Pate, C.M., & Jacobs, K.A. (2011). Principals’ perceptions of benefits and barriers to school-based suicide prevention programs. Children and Youth Services Review, 33, 869-877.

Wyman, P.A., Brown, C.H., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., & Pena, J.B. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76, 104-115.

By now, parents and professionals have reacted to the new Netflix series, 13 Reasons Why. Mental health advocates and school administrators have highlighted the risks of depicting suicide as a means of revenge, of dramatizing teen suicide, and of showing school counselors as uncaring and ineffective. I would be remiss if I did not add my voice to others' by expressing my dismay that this program exposes teens to such unhealthy messages about such an important topic, and that teen depression is presented as a malady that can only be addressed through suicide.

Rather than repeating the many critiques of this series, my purpose here is to share correct messages about adolescent depression and suicide that we, as professionals and parents, should know and should be sharing with our children. Of course this is a difficult topic to broach with adolescents, but given that so many teens have watched this series already, we must embrace this opportunity to teach our children, and ourselves, about youth depression and suicide. This conversation is particularly important now, in the midst of Mental Health Awareness Month.

In fact, suicide is the third leading cause of death among adolescents, and rates of suicidal thinking and behavior are particularly high among Lesbian, Gay, and Bisexual youth. While youth depression and youth suicide are distinct concerns, approximately half of all teens that die by suicide have a mood disorder, such as depression, at the time. Adolescent depression is quite common, with approximately 11 percent of all teens experiencing depression during adolescence. Although youth depression is prevalent and impairing, we now have available numerous depression prevention and treatment protocols that work. Thus, most teens who struggle with depression go on to lead healthy and productive lives.

How do we know if a teen might be experiencing depression or considering suicide? Among other symptoms, signs of youth depression include low mood or irritability, lack of interest in activities, a change to sleep or eating patterns, reduced concentration, fatigue, low self-esteem, and thoughts of death or suicide. Of course all teens experience such symptoms now and then. We worry about teens that experience a cluster of these symptoms, and when these symptoms persist over a period of at least two weeks.

Likewise, we worry about teens that exhibit signs of suicide. Sometimes these signs are subtle, such as giving away prized possessions, withdrawing from friends, or exhibiting significant behavioral changes, such as intense fights with family and friends. Teens thinking about suicide may also provide verbal cues, such as, “I wish I were dead” and “It’s not worth it anymore.” Also, many people who contemplate suicide do so because they believe they are a burden to others, and that they will be doing others a favor if they are no longer here. Thus, if you hear a teen say, “My family would be better off without me,” it is important to take action. Remember that 50-70 percent of people who make a suicide attempt communicate their intent prior to acting, mostly through such actions or verbal cues. Thus, if you recognize any of these signs, it is important to ASK. Although many of us find it scary to ask about suicide, or worry that asking about suicide will give someone the idea to attempt suicide, we know from numerous studies that talking about suicide will not lead to suicidal behavior.

How do you ask a teen if s/he might be thinking about suicide? Ask the question directly. It is okay to ask a teen if s/he has ever felt like it would be better if they were dead, or if, when very upset, they have experienced suicidal thoughts. If a teen acknowledges suicidal thoughts, s/he should be provided reassurance that help is available, and should be brought for an evaluation and treatment immediately. It’s important to remember that most people who talk about suicide do not really want to die. In fact, most suicides are not impulsive acts, and most people who contemplate suicide give many cues of their intentions, making suicide a largely preventable form of death in the United States.

The primary danger of 13 Reasons Why is that it reinforces damaging myths about youth depression and suicide. Now that this series has been released, and knowing that our teens may well have watched it, our best course of action is to counter those damaging myths by sharing important truths about teen depression and suicide.

Tracy Gladstone, Ph.D. is an associate director and senior research scientist at the Wellesley Centers for Women at Wellesley College, as well as the director of the Robert S. and Grace W. Stone Primary Prevention Initiatives, which focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

References:

Avenevoli, S., Swendsen, J., He, J., Burstein, M., & Merikangas, K. R. (2015). Major depression in the national comorbidity survey–adolescent supplement: Prevalence, correlates, and treatment. Journal of The American Academy Of Child & Adolescent Psychiatry, 54(1), 37-44. doi:10.1016/j.jaac.2014.10.010
Berkowitz, Larry (2017). Suicide Assessment and Intervention Training for Mental Health Professionals [PowerPoint slides]. NEAS, 2400 Post Road, Warwick, RI.
Burton, C. M., Marshal, M. P., Chisolm, D. J., Sucato, G. S., & Friedman, M. S. (2013). Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: A longitudinal analysis. Journal of youth and adolescence, 42(3), 394-402.
Gould, M.S., Marrocco, F.A., Kleinman, M., Thomas, J.G., Mosstkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: A randomized controlled trial. JAMA, 293(13), 1635-43.
Joiner, T. (2009). The interpersonal-psychological theory of suicidal behavior: Current empirical status. Psychological Science Agenda, 23(6).
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Nadworny, E. (2016). Middle School Suicides Reach an All-Time High. www.NPR.org
Nock, M.K., Green, J.G., Hwang, I., McLaughlin, K.A., Sampson, N.A., Zaslavsky, A.M., & Kessler, R.C. (2013). Prevalence, correlates, and treatment of lifetime suicide behavior among adolescents: results from the Nation Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70(3), 300-10.
QPR Institute. QPR Online Gatekeeper Training for ORGANIZATIONS [Training modules]. Retrieved from https://www.qprinstitute.com/organization-training
Robins, E., Gassner, S., Kayes, J., Wilkinson Jr, R. H., & Murphy, G. E. (1959). The communication of suicidal intent: a study of 134 consecutive cases of successful (completed) suicide. American Journal of Psychiatry, 115(8), 724-733.
The JED Foundation. (2017). 13 Reasons Why: Talking Points [Leaflet]. Retrieved from https://www.jedfoundation.org/13-reasons-why-talking-points/
World Health Orgranization. (2004, September 8). Suicide huge but preventable public health problem, says WHO [Online forum post]. Retrieved from WHO Media centre website: http://www.who.int/mediacentre/news/releases/2004/pr61/en/

This policy brief originally appeared in the Spring/Summer 2016 Research & Action Report from the Wellesley Centers for Women as part of the multi-media series Advancing the Status of Women & Girls, Families & Communities: Policy Recommendations for the Next U.S. President.

Depression is Prevalent but Prevention Programs Are Limited

According to the World Health Organization, depression is the leading cause of disability worldwide—it is the most common psychiatric disorder in the U.S., and is particularly common among lower income populations, and among women beginning in adolescence. The average age of onset for depression is 15, and about 20 percent of all people will have experienced an episode of depression by the end of adolescence. Youth depression is associated with a host of negative and long-term consequences, including poorer school performance, difficult peer and family relationships, increased risk of substance abuse, and poorer functional outcomes in adulthood. Of particular note is the connection between youth depression and suicide. Although not all people who commit suicide were depressed at the time, depression and suicidal behavior are indeed linked. Suicide is a tremendous problem in the U.S. and is the second leading cause of death among American adolescents.

Although depression is among the most treatable of all mental illnesses, and although we have evidence-based treatment approaches for depressed youth, the reality is that only about half of all depressed children and adolescents ever receive treatment, and only about half of those who do receive treatment actually improve as a result. Nearly all of those who recover from depression will experience a subsequent depressive episode within a few years. Specifically, 40 percent of youth who have experienced a past episode of depression will relapse within two years, and 75 percent will relapse within five years. This means that a typical 15 year-old who develops an episode of depression, if she is fortunate enough to receive treatment and benefit from it, will experience another depressive episode while she is graduating from high school and transitioning to adulthood.

Although nearly one in five young people experience an episode of depression by the end of adolescence, treatment protocols for youth depression only help about half of those they target, and relapse is common and debilitating. Funding for depression prevention efforts is limited, and preventive programs are difficult to access.

Promising Prevention Efforts

Youth depression is a problem of major proportions, affecting millions of children and families and interfering with children’s social, emotional, and academic functioning. Although evidence-based treatments for youth depression have been found to work well, treatment resources often are difficult to access. Most adolescents who recover experience relapse, and the long-term consequences of youth depression are significant.

Recently, promising research has suggested that depression is among the most preventable of major mental illnesses. We now know of strategies that work to prevent youth depression, including providing cognitive behavioral interventions to adolescents at high risk and helping youth to strengthen social relationships. Based on this research, many European colleagues now encourage a focus on preventive efforts for youth at risk for depression. Although funders and policymakers in the U.S. support preventive efforts for medical concerns, such as healthy eating and exercise to address heart disease, prevention, unfortunately, is often overlooked in mental health. Researchers, policymakers, and practitioners should focus attention on identifying youth at risk for depression, providing evidence-based preventive interventions to at-risk youth and families, and assisting at-risk youth in accessing preventive and/or treatment resources, as needed.

Approaches & Recommendations

Recommendations for enhancing a focus on the prevention of youth depression include:

• Increase use of depression prevention interventions by increasing funding for research. Although several depression prevention interventions have been found to decrease the onset of depressive symptoms or disorders among at-risk youth, such programs are still not readily available in community-based mental health settings, and many practitioners do not know how to implement evidence-based protocols. More funding is needed for large-scale effectiveness trials that examine ways of disseminating evidence-based interventions in real-world settings and for large-scale trials that compare the efficacy of different evidence-based programs for different populations.

• Attend to family processes that influence depression risk and that promote depression prevention. Research suggests that parental depression is a significant risk factor for depression onset in youth, and that family processes both maintain and may help alleviate depression. Policymakers, funders, and practitioners must attend to the important role of families in identifying and supporting youth at risk for depression who are appropriate for preventive efforts. In addition, interventions to prevent youth depression may benefit from a focus on enhancing family understanding of youth depression, improving parenting skills, and also on addressing parental depressive symptoms that may affect the efficacy of interventions targeting at-risk youth.

• Integrate youth depression prevention efforts into places where youth are most readily accessed. Efforts to prevent youth medical concerns are an established focus of public health strategies, resulting in, for example, vaccinations from physicians and auditory screenings Integrate youth depression prevention efforts into places where youth are most readily accessed. Efforts to prevent youth medical concerns are an established focus of public health strategies, resulting in, for example, vaccinations from physicians and auditory screenings at school. Unfortunately, routine screening for depression and suicide risk is generally overlooked both in primary care and in schools, although these are the places that youth are most readily accessed and serviced. Policymakers, funders, and practitioners must support additional training for school and medical personnel in identifying at-risk youth, evaluating youth for mental health concerns, and connecting youth to appropriate mental health services. Additionally, research is needed to evaluate primary care and school-based depression prevention interventions, so that, when at-risk adolescents are identified, evidence-based depression prevention services are readily available in locations that are comfortable and accessible to those in need.

Tracy Gladstone, Ph.D. is an associate director and senior research scientist at the Wellesley Centers for Women as well as the director of the Robert S. and Grace W. Stone Primary Prevention Initiatives, which focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

This is a repost from an article originally published on this blog September 6, 2013.

National Suicide Prevention Week (September 8-14) is a time to both raise awareness of suicide as a national public health issue, and to think critically about how suicide can be prevented. In the United States, suicide is the second leading cause of death among adolescents (Hoyert & Xu, 2012), and, in 2011, nearly 16 percent of adolescents in the United States reported seriously considering suicide. When thinking about preventing adolescent suicide, it is important to consider factors that increase the risk of suicidal thoughts and behaviors, such as depression. Suicidal thinking is a symptom of depression, and over half of the adolescents who completed suicide had a mood disorder at the time (Bridge, Goldstein & Brent, 2006; Nock et al., 2013). Fortunately, a number of researchers have developed empirically-supported interventions to prevent the onset of depression in teens, and prevention efforts that target adolescents at risk for depression may ultimately prove helpful in preventing suicidal behaviors as well. During this national week of suicide prevention awareness, it is important to recognize the link between depressive illness and suicide in youth, and the promising role of depression prevention in potentially preventing suicidal behavior.

Most of us bring our children to see their doctors annually, because prevention-focused well-child care is a cornerstone of pediatric practice. Unfortunately, prevention is generally not part of the equation when it comes to youth mental health. With limited health care dollars and limited mental health resources available, clinicians and policymakers tend to focus on alleviating mental health concerns once they arise. Yet research suggests that many young people do NOT get treatment for mental health concerns once they arise, and mental health concerns, such as depression, are associated not only with suicide risk, but also with long-term adverse impacts on educational attainment, relationship functioning, risk of substance abuse, and future depressive episodes, even among those who receive treatment. Moreover, of those teens who DO receive treatment for depression, only about half fully recover and, among those who do recover, relapse is quite common.

Treating youth depression once it emerges may be much more distressing, and much less effective, than identifying early symptoms of illness and treating them before they develop into a full-blown disorder. Prevention approaches have the potential to reach a large number of adolescents, and may be more acceptable than treatment because services can be rendered in non-clinical settings (e.g., schools, primary care settings), and do not require adolescents to identify themselves as ill.

So how can adolescent depression be prevented? The core of many depression prevention programs is resilience. Not all adolescents with risk factors for depression develop the disorder; the ones who do not develop depression are resilient, which means they have the emotional skills and/or the social supports to “bounce back” from adversity. Many programs to prevent adolescent depression are designed to teach coping and emotional regulation skills, and/or to strengthen supportive relationships, in order to provide youth at elevated risk with the tools they need to be resilient.

Research on the prevention of youth depression is quite encouraging! For example, in our longitudinal, multi-site study of adolescents at risk for depression, we found that teens who participated in a group cognitive-behavioral prevention program were less likely to experience a depressive disorder at nine- (Garber et al., 2009) and 32- (Beardslee et al., in press) months follow-up, relative to at-risk teens who were assigned to a treatment-as-usual control group. Likewise, our colleagues working on the Penn Resiliency Project have found that children and adolescents who participate in their school-based cognitive-behavioral program are less likely to experience depressive symptoms than are children and adolescents assigned to control conditions. Similarly, in a study of Interpersonal Psychotherapy approaches to preventing youth depression, Young and colleagues found that teens who participated in a skills-based intervention targeting interpersonal role disputes, role transitions and interpersonal deficits reported fewer depressive symptoms at six-months follow-up than teens who were assigned to a school counseling control group.

Here at WCW, we are currently studying the efficacy of a primary-care, Internet-based depression-prevention program for adolescents who are at risk for the development of depression, based on a past history of depression and/or current symptoms of depressive disorder. While many of these youth depression prevention programs are still being evaluated in randomized controlled research trials, early results suggest that prevention programs may work. It seems we can indeed provide teens with strategies that they can use over time, as they encounter stress and challenging life events, so that they are able to stay healthy and avoid the onset of significant mental health concerns.

What are the risks for depression in adolescents? When should you be worried about your teen? When we talk about risks for depression, we often think in terms of specific factors (i.e., factors identified through empirical research to be associated specifically with increased risk for youth depression) and nonspecific factors (i.e., factors that are associated with increased risk for a range of disorders, including depression). Specific risk factors for adolescent depression include having low self-esteem, being female, developing a negative body image, low social support, a negative cognitive style, and ineffective coping. The strongest specific risk factor for the development of depression, above and beyond these other factors, is having a parent with depressive illness. In fact, offspring of depressed parents are at about a two- to four-fold increased risk of developing depressive disorders, relative to children of parents without depression. Nonspecific risk factors that also increase risk of youth depression include poverty, exposure to violence, social isolation, child maltreatment, and family breakup.

Although the presence of these risk factors is associated with an increased risk for youth depression, as noted above, many at-risk children are resilient and never develop a depressive disorder. Having supportive adults present, strong family relationships, strong peer relationships, coping skills, and skills in emotion regulation all can contribute to resiliency. Even depressed parents can promote resilience in their teens by encouraging teens to engage in outside activities, maintain supportive relationships, and recognize themselves as separate from issues and concerns that are affecting other family members.

How can you recognize signs and symptoms of depression in your child, and how can you help? Depressed teens are often sad or irritable, and may exhibit a range of additional symptoms, such as withdrawal from friends and usual activities, sleep difficulties (i.e., difficulty sleeping or sleeping all the time), somatic complaints (i.e., headaches, stomach aches), poor school performance, self-critical talk, changes in eating patterns, difficulty sitting still, and may start writing or thinking about death. If you are concerned about your teen, then express your concern openly and honestly. Tell your child that you care, and that you want to help. Don’t be afraid to ask your child if he is experiencing suicidal thoughts – asking will NOT make him contemplate suicide or take his own life. Reach out to your child’s pediatrician for assistance and referrals. Let your child know that treatments are available, and that you are going to work together to get your child the help she needs.

National Suicide Prevention Week is an opportune time to consider the many ways that suicidal thoughts and actions can be combated, including preventing the onset of depression in adolescents, and getting teens help if they are depressed already.

Tracy Gladstone, Ph.D. is a Senior Research Scientist and Director of the Robert S. and Grace W. Stone Primary Prevention Initiatives at the Wellesley Centers for Women at Wellesley College. The Stone Primary Prevention Initiatives focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

References:

Beardslee, W.R., Brent, D.A., Weersing, V.R., Clarke, G.N., Porta, G., Hollon, S.D., Gladstone, T.R.G., Gallop, R., Lynch, F.L., Iyengar, S., DeBar, L., & Garber, J. (in press). Prevention of depression in at-risk adolescents: Longer-term effects. Journal of the American Medical Association Psychiatry.

Bridge, J. A., Goldstein, T. R., & Brent, D. A. (2006). Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry, 47(3‐4), 372-394.

Centers for Disease Control and Prevention. (2012). Youth Risk Behavior Surveillance- United States 2011. Morbidity and Mortality Weekly Report, 61(4), 1-168.

Garber, J., Clarke, G.N., Weersing, V.R., Beardslee, W.R., Brent, D.A., Gladstone, T.R.G., DeBar, L.L., Lynch, F.L., D’Angelo, E., Hollon, S.D., Shamseddeen, W., & Iyengar, S. (2009). Prevention of depression in at-risk adolescents: A randomized controlled trial. Journal of the American Medical Association, 301, 2215-2224.

Hoyert, D. L., & Xu, J. (2012). Deaths: preliminary data for 2011. National Vital Statistics Report, 61(6), 1-65.

Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA: The Journal of the American Medical Association Psychiatry, 70(3), 300-310.  

National Suicide Prevention Week (September 8-14) is a time to both raise awareness of suicide as a national public health issue, and to think critically about how suicide can be prevented. In the United States, suicide is the second leading cause of death among adolescents (Hoyert & Xu, 2012), and, in 2011, nearly 16 percent of adolescents in the United States reported seriously considering suicide. When thinking about preventing adolescent suicide, it is important to consider factors that increase the risk of suicidal thoughts and behaviors, such as depression. Suicidal thinking is a symptom of depression, and over half of the adolescents who completed suicide had a mood disorder at the time (Bridge, Goldstein & Brent, 2006; Nock et al., 2013). Fortunately, a number of researchers have developed empirically-supported interventions to prevent the onset of depression in teens, and prevention efforts that target adolescents at risk for depression may ultimately prove helpful in preventing suicidal behaviors as well. During this national week of suicide prevention awareness, it is important to recognize the link between depressive illness and suicide in youth, and the promising role of depression prevention in potentially preventing suicidal behavior.

Most of us bring our children to see their doctors annually, because prevention-focused well-child care is a cornerstone of pediatric practice. Unfortunately, prevention is generally not part of the equation when it comes to youth mental health. With limited health care dollars and limited mental health resources available, clinicians and policymakers tend to focus on alleviating mental health concerns once they arise. Yet research suggests that many young people do NOT get treatment for mental health concerns once they arise, and mental health concerns, such as depression, are associated not only with suicide risk, but also with long-term adverse impacts on educational attainment, relationship functioning, risk of substance abuse, and future depressive episodes, even among those who receive treatment. Moreover, of those teens who DO receive treatment for depression, only about half fully recover and, among those who do recover, relapse is quite common.

Treating youth depression once it emerges may be much more distressing, and much less effective, than identifying early symptoms of illness and treating them before they develop into a full-blown disorder. Prevention approaches have the potential to reach a large number of adolescents, and may be more acceptable than treatment because services can be rendered in non-clinical settings (e.g., schools, primary care settings), and do not require adolescents to identify themselves as ill.

So how can adolescent depression be prevented? The core of many depression prevention programs is resilience. Not all adolescents with risk factors for depression develop the disorder; the ones who do not develop depression are resilient, which means they have the emotional skills and/or the social supports to “bounce back” from adversity. Many programs to prevent adolescent depression are designed to teach coping and emotional regulation skills, and/or to strengthen supportive relationships, in order to provide youth at elevated risk with the tools they need to be resilient.

Research on the prevention of youth depression is quite encouraging! For example, in our longitudinal, multi-site study of adolescents at risk for depression, we found that teens who participated in a group cognitive-behavioral prevention program were less likely to experience a depressive disorder at nine- (Garber et al., 2009) and 32- (Beardslee et al., in press) months follow-up, relative to at-risk teens who were assigned to a treatment-as-usual control group. Likewise, our colleagues working on the Penn Resiliency Project have found that children and adolescents who participate in their school-based cognitive-behavioral program are less likely to experience depressive symptoms than are children and adolescents assigned to control conditions. Similarly, in a study of Interpersonal Psychotherapy approaches to preventing youth depression, Young and colleagues found that teens who participated in a skills-based intervention targeting interpersonal role disputes, role transitions and interpersonal deficits reported fewer depressive symptoms at six-months follow-up than teens who were assigned to a school counseling control group.

Here at WCW, we are currently studying the efficacy of a primary-care, Internet-based depression-prevention program for adolescents who are at risk for the development of depression, based on a past history of depression and/or current symptoms of depressive disorder. While many of these youth depression prevention programs are still being evaluated in randomized controlled research trials, early results suggest that prevention programs may work. It seems we can indeed provide teens with strategies that they can use over time, as they encounter stress and challenging life events, so that they are able to stay healthy and avoid the onset of significant mental health concerns.

What are the risks for depression in adolescents? When should you be worried about your teen? When we talk about risks for depression, we often think in terms of specific factors (i.e., factors identified through empirical research to be associated specifically with increased risk for youth depression) and nonspecific factors (i.e., factors that are associated with increased risk for a range of disorders, including depression). Specific risk factors for adolescent depression include having low self-esteem, being female, developing a negative body image, low social support, a negative cognitive style, and ineffective coping. The strongest specific risk factor for the development of depression, above and beyond these other factors, is having a parent with depressive illness. In fact, offspring of depressed parents are at about a two- to four-fold increased risk of developing depressive disorders, relative to children of parents without depression. Nonspecific risk factors that also increase risk of youth depression include poverty, exposure to violence, social isolation, child maltreatment, and family breakup.

Although the presence of these risk factors is associated with an increased risk for youth depression, as noted above, many at-risk children are resilient and never develop a depressive disorder. Having supportive adults present, strong family relationships, strong peer relationships, coping skills, and skills in emotion regulation all can contribute to resiliency. Even depressed parents can promote resilience in their teens by encouraging teens to engage in outside activities, maintain supportive relationships, and recognize themselves as separate from issues and concerns that are affecting other family members.

How can you recognize signs and symptoms of depression in your child, and how can you help? Depressed teens are often sad or irritable, and may exhibit a range of additional symptoms, such as withdrawal from friends and usual activities, sleep difficulties (i.e., difficulty sleeping or sleeping all the time), somatic complaints (i.e., headaches, stomach aches), poor school performance, self-critical talk, changes in eating patterns, difficulty sitting still, and may start writing or thinking about death. If you are concerned about your teen, then express your concern openly and honestly. Tell your child that you care, and that you want to help. Don’t be afraid to ask your child if he is experiencing suicidal thoughts – asking will NOT make him contemplate suicide or take his own life. Reach out to your child’s pediatrician for assistance and referrals. Let your child know that treatments are available, and that you are going to work together to get your child the help she needs.

National Suicide Prevention Week is an opportune time to consider the many ways that suicidal thoughts and actions can be combated, including preventing the onset of depression in adolescents, and getting teens help if they are depressed already.

Tracy Gladstone, Ph.D. is a Senior Research Scientist and Director of the Robert S. and Grace W. Stone Primary Prevention Initiatives at the Wellesley Centers for Women at Wellesley College. The Stone Primary Prevention Initiatives focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

References:

Beardslee, W.R., Brent, D.A., Weersing, V.R., Clarke, G.N., Porta, G., Hollon, S.D., Gladstone, T.R.G., Gallop, R., Lynch, F.L., Iyengar, S., DeBar, L., & Garber, J. (in press). Prevention of depression in at-risk adolescents: Longer-term effects. Journal of the American Medical Association Psychiatry.

Bridge, J. A., Goldstein, T. R., & Brent, D. A. (2006). Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry, 47(3‐4), 372-394.

Centers for Disease Control and Prevention. (2012). Youth Risk Behavior Surveillance- United States 2011. Morbidity and Mortality Weekly Report, 61(4), 1-168.

Garber, J., Clarke, G.N., Weersing, V.R., Beardslee, W.R., Brent, D.A., Gladstone, T.R.G., DeBar, L.L., Lynch, F.L., D’Angelo, E., Hollon, S.D., Shamseddeen, W., & Iyengar, S. (2009). Prevention of depression in at-risk adolescents: A randomized controlled trial. Journal of the American Medical Association, 301, 2215-2224.

Hoyert, D. L., & Xu, J. (2012). Deaths: preliminary data for 2011. National Vital Statistics Report, 61(6), 1-65.

Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA: The Journal of the American Medical Association Psychiatry, 70(3), 300-310.