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Depression

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Title: Depression


1
Depression
Dr. Aubrey H. Fine
2
  • For many years, children and adolescents were
    thought incapable of experiencing depression. It
    was considered an adult disease.
  • 1975- National Institute of Mental Health met and
    discussed depression among children.
  • 1977- Diagnosis and existence of depression in
    children and adolescents is recognized.

3
  • Major Depression Disorder (MDD)
  • Age of first onset of major depression is in
    adolescence and young adulthood
  • Adolescent depression is a chronic, recurrent
    and serious illness.
  • Children of depressed parents vs. children of
    non-depressed parents have 2 to 4 fold increased
    risk of depression.
  • Symptoms twice as common in females, substance
    abuse, suicidal behaviors, social, occupational
    and educational disability.

4
Diagnosis
  • 5 or more of the following symptoms must be
    present nearly every day during the same 2-week
    period to diagnose an adolescent with MDD
  • Depressed or irritable mood most of the day
  • Markedly diminished interest or pleasure in
    almost all activities, most of the day
  • Significant weight loss or gain, or change in
    appetite failure to gain expected weight
  • Sleep disturbance
  • Psychomotor agitation or retardation

5
Diagnosis cont
  • Fatigue or loss of energy
  • Feelings of inappropriate guilt or hopelessness
  • Indecisiveness or diminished ability to
    concentrate
  • Recurrent thoughts of death or suicidal
    ideation, suicide attempt.

6
  • At least one of the following two symptoms must
    be present depressed or irritable mood, or
    markedly diminished interest or pleasure in
    almost all activities.
  • MDD can be rated as mild, moderate, severe.
  • Diagnosed s chronic when episodes last more than
    2 years.

7
  • An undetected diagnosis in adolescents is
    dysthymia- depressed or irritable mood that must
    be present for a year or longer and never be
    symptom free for more than 2 months.
  • 2 or more symptoms must be present change in
    appetite, change in sleep, decrease in energy,
    low self-esteem, difficulty making decisions or
    poor concentration, feelings of hopelessness.
  • Adolescents with dysthymic disorder and who
    develop a major depressive episode are considered
    to have a double depression

8
  • Comoribidity
  • When depression is tied up with any number of
    other childhood mental illnesses
  • Anxiety disorders are the most common, with over
    60 of depressed adolescents having a history or
    a concomitant anxiety disorder.
  • Social phobia (pathological self-consciousness)
  • Separation anxiety disorder (marked by fears
    about the well-being of the family)
  • Generalized anxiety disorder (a fear of the
    future and constant worries about ones
    performance)
  • Of those who have both anxiety and depression,
    research indicates that 85 experience anxiety
    first.

9
  • One study at the New York University Child Study
    Center found that among children with anxiety
    disorder as preadolescents, 30 went on to have
    depression later on.
  • Peer relationships is a predictive factor in
    adolescent depression- not so much anxiety about
    relating with ones friends but about whether
    they have friendships.

10
  • Conduct disorder or juvenile delinquency is
    frequently comorbid with depression in young
    people but the relationship between the two is
    controversial. Is the teenager depressed because
    hes been caught doing something illegal or
    improper and is now facing consequences? Or is
    he depressed or demoralized about life, and this
    in turn leads to outrageous, illegal or
    oppositional-defiant conduct?
  • Some young people simply have both disorders at
    the same time.

11
  • Posttraumatic stress disorder (PTSD) also has an
    association with depression.
  • Occurs when a person witnesses or experiences a
    traumatic, fatal, or life-threatening event and
    later relives it, either in his thoughts or
    dreams.
  • Can bring extreme distress-intense fear, agitated
    behavior, flashbacks, and even physical reactions
    that might include re-experiencing smells.
  • A person experiencing PTSD might be jumpy, has
    trouble sleeping, and will take pains to avoid
    anything associated with the trauma.

12
  • Substance abuse in late adolescence with MDD is
    common.
  • Some people feel that depressed adults medicate
    themselves with drugs and alcohol, and that the
    same holds true for teenagers
  • Studies have found an association between
    adolescent depression and obesity, headaches, and
    asthma.

13
  • Risk Factors for Depression in Adolescence
  • Having a parent who has depression. Rates of
    depression are 2-4 times higher in children of
    depressed parents.
  • Having an anxiety disorder, especially in
    preadolescence, or a childhood history of
    depression
  • Being a female
  • Having a serious negative life event or an
    accumulation of damaging experiences (e.g. loss
    of social support systems, loss of a parent, a
    childhood history of physical or sexual abuse)
  • Poverty
  • Exposure to violence

14
  • Cognitive Vulnerability
  • Negative beliefs about themselves, the world and
    their future
  • Tend to make global, stable and internal
    attributions for negative events.
  • When confronted with stressful life events, these
    individuals will appraise the stressors and their
    consequences negatively and hence are more likely
    to become depressed than are individuals who do
    not have such cognitive styles.

15
  • Stress
  • Environmental conditions that threaten to harm
    the biological or psychological well-being of the
    individual
  • May occur either as an acute event or as chronic
    adversity, and as a major life event or as minor
    events with accumulated effects.
  • Events may be normative (school, transition) or
    pathological (abuse)
  • May be independent of, or directly related to an
    thus dependent on, and individuals actions.

16
  • Link between stressful life events and depression
    in children and adolescents.
  • Depressive symptoms and disorders are highly
    associated with minor and major undesirable life
    events in children.
  • Negative life events are more prevalent among
    depressed than non-depressed children.
  • Stress that occurs as early as at conception
    likely contributes to an increased vulnerability
    to depression.

17
  • Examples of Stressors That are Associated with
    Depression
  • Childhood abuse or maltreatment
  • Sexual assault
  • Poverty (depression among low-income mothers is
    twice as high as in the general population)
  • Events such as disappointments, loss, separation,
    and interpersonal conflict

18
  • Interpersonal Relationships
  • Families with a depressed member are
    characterized by less support and more conflict.
  • Family dysfunction increases childrens risk of
    developing depression.
  • Depressed individuals are themselves more
    interpersonally difficult, which results in
    greater problems in their social network.
  • Family dysfunction, parent-child conflict, peer
    difficulties, and interpersonal rejection show
    that social problems precede depression and
    depression contributes to interpersonal
    difficulties.
  • Link between interpersonal vulnerability and
    depression is bidirectional

19
Bipolar Disorder
20
  • Mood Disorders
  • Bipolar disorder belongs to the category of
    mental-health experiences called mood disorders.
  • Primary feature is a significant change or
    disturbance in mood.
  • Mood disorders fall into four groups
  • Depressive disorders
  • Bipolar disorders
  • Mood disorder due to a general medical condition
  • Substance-induced mood disorder

21
  • Diagnosis
  • Pediatric mania tends to be chronic and
    continuous rather than episodic and acute
  • Childhood-onset mania is a non-episodic, chronic,
    rapid-cycling, mixed manic state
  • Early-onset manics are more likely to have
    comorbid behavior disorders in childhood, and
    compared to adult-onset cases of mania, to have
    fewer episodes of remission over a 2 year period

22
  • mixed mania affects 20-30 of adults with
    mania
  • High rate of suicide
  • Poor response to treatment
  • Early history of neuropsychological deficits
    highly suggestive of ADHD

23
  • Criteria to diagnose bipolar disorder
  • A distinct period of abnormally and persistently
    elevated, expansive, or irritable mood lasting at
    least 1 week
  • During the period of mood disturbance, 3 or more
    of the following symptoms have persisted and have
    been present to a significant degree

24
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep
    talking
  • Flight of ideas or subjective experience that
    thoughts are racing
  • Distractibility
  • Increase in goal-directed activity
  • Excessive involvement in pleasurable activities
    that have a high potential for painful
    consequences

25
  • Comorbidity
  • Another mental-health experience overlapping or
    separate from bipolar disorder.
  • May share similarities with bipolar, making them
    challenging to pinpoint or diagnose.
  • It is critical to focus on symptoms, not
    behaviors

26
  • The systematic overlap of childhood mania with
    ADHD is one major source of diagnostic
    controversy. Rates of ADHD range from 60 to 90
    in pediatric patients with mania.
  • Although ADHD has a much earlier onset than
    pediatric mania, the symptomatic syndromatic
    overlap between pediatric mania and ADHD raises a
    fundamental question- do children presenting with
    symptoms suggestive of mania and ADHD have ADHD,
    mania, or both?

27
  • With Conduct Disorder (CD)
  • CD is strongly associated with pediatric mania
  • Comorbidity between CD and major depression
    because pediatric depression often presages mania
  • CD includes violent behavior that may be
    categorized as mild, moderate, or severe.
  • Childhood-onset type (before age 10)
  • Adolescent-onset type (after age 10)

28
  • CD behaviors can start out slowly and build over
    an individuals lifetime, ranging from lying,
    stealing, and physical fights to drug use,
    burglary, rape, and mugging.
  • 20-40 of kids with ADHD have CD
  • One way to distinguish CD from bipolar disorder
    is to determine if outbursts or episodes of manic
    symptoms can seen with other indicators of mania.
    To be diagnosed with CD, your child must be
    significantly sidetracked by the symptoms and
    must have an impaired ability to function
    throughout each day.

29
  • For a diagnosis of CD, your child needs to show a
    regular persisting pattern of violating rules and
    the rights of others
  • 3 of the following must have happened within the
    past year and one must have occurred in the past
    6 months

30
  • Physical cruelty to people or animals
  • Theft from someone in person
  • Forcing someone to engage in sexual activity
  • Violent use of a weapon to cause serious harm
  • Instigating physical fights
  • Bullying or threatening others
  • Arson
  • Destroying others property
  • Breaking into someones house, car, or other
    building
  • Conning or manipulating others
  • Shoplifting, credit card identity theft, forging
    checks
  • Breaking curfew
  • Running away from home overnight at least twice
  • Skipping school before age 13

31
  • With Anxiety Disorders
  • Pediatric studies of youth with panic disorder
    and youth with mania document a bidirectional
    overlap.
  • Subjects with panic disorder and agoraphobia had
    very high rates of mania
  • More panic and other anxiety disorders in
    children with mania.
  • Mania at any age is frequently comorbid with
    severe anxiety that requires additional clinical
    and scientific scrutiny.

32
  • With Substance Use Disorders (SUD)
  • Bidirectional overlap between mania and SUD in
    youth as well as adults
  • Juvenile-onset mania may be a risk factor for SUD

33
  • Risk Factors
  • Risk factors have not been clearly identified
    from community-based studies.
  • The most consistent risk factor for bipolar
    disorder is family history.
  • Offspring of adult bipolar patients has an
    increased risk, over 3-fold, of bipolar disorder
    as well as mood disorders, compared to offspring
    of controls.

34
  • Gender
  • Gender is well known to be an important but
    poorly understood factor influencing the risk of
    MDD. The prevalence of MDD, while equal between
    boys and girls prior to puberty, doubles in young
    women after puberty. This increase in females
    has been hypothesized to be secondary to hormonal
    changes occurring during puberty.

35
  • Treatment of Depression and Bipolar Disorder

36
  • Psychosocial Treatments for MDD
  • Behavior therapy
  • Cognitive therapy
  • Interpersonal therapy

37
  • Behavior Therapy
  • Primary goal is to increase the frequency of
    pleasant activities in the patients life
  • Found to be significantly better than
    psychotherapy, relaxation therapy, and medication
  • An efficacious, but not uniquely effective, acute
    treatment for MDD

38
  • Cognitive Therapy
  • Most widely studied psychotherapy for MDD
  • Treatment is based on the model that the
    cognitions of depressed individuals are
    negatively biased. Negative beliefs about the
    self, the world, and the future.
  • Typically 16-20 sessions over a period of 12-16
    weeks

39
  • Involves both behavioral and cognitive techniques
  • Behavioral techniques serve to help patients
    engage in activities that give them pleasure,
    while cognitive techniques are used to evaluate
    the veracity of their beliefs.
  • An efficacious acute-phase treatment for MDD

40
  • Interpersonal Therapy
  • Depression is usually triggered by problems in
    four interpersonal domains role transition,
    grief, interpersonal deficits, and interpersonal
    disputes.
  • In IPT, the interpersonal problem that triggered
    the current depressive episode is addressed and
    the person is helped to build communication and
    interaction skills to resolve it.
  • The acute phase of IPT typically lasts for 16-20
    sessions.

41
  • Psychopharmacological Treatment for MDD
  • Monotherapy
  • Bupropion- blocks noradrenergic and dopamine
    reuptake.
  • Side effects nausea, insomnia, increased
    anxiety, restlessness, increased incidence of
    seizures. No weight gain or sexual dysfunction.

42
  • SSRIs (Prozac, Zoloft, Luvox, Celexa, Lexapro and
    Paxil)
  • Make the most of the serotonin the body is
    producing at this time
  • The neurotransmitter (serotonin) lingers longer
    on the neuron receptors, giving it more of a
    chance to effectively complete the message it
    needed to send.
  • Rarely associated with fatalities and given its
    safety profile provides an easy treatment option
    for the clinician.
  • Side effects headaches, nausea, dry mouth,
    insomnia, nervousness, sexual dysfunction,
    diarrhea, tiredness, and agitation

43
  • FDA issued an advisory to physicians that the use
    of antidepressant may lead to suicidal thinking
    or attempts in depressed youths.
  • FDA requested that a warning be added to the
    product label of these antidepressants

44
  • Antidepressant medications were not originally
    developed with children and adolescents in mind
    (nor were they tested on this population)
  • In addition to relieving symptoms of depression,
    antidepressants may also be prescribed for
    treating kids who grapple with other issues.
  • Phobias (often-school related)
  • Anxiety
  • Panic attacks
  • Eating disorders
  • ADHD
  • Bedwetting
  • OCD
  • Post-traumatic stress disorder

45
  • Dosages
  • Need to remember that the brains and bodies of
    children and teenagers are still growing and
    developing
  • Because bodies are often smaller than adults, the
    concentration of any medication in their systems
    is much greater
  • May lead to amplified side effects that are more
    intense than those found in adults if great care
    is not exercised

46
  • Careful Monitoring
  • Monitoring and follow-up is critical
  • Each medication has the potential to react
    differently in each child
  • May take weeks before you see any noticeable
    improvement in mood
  • Maintain careful communications with doctor

47
  • Pharmacotherapy for Bipolar Disorders
  • Mood Stabilizers
  • Lithium
  • Side effects tremor, diarrhea, weight gain,
    increased urinary frequency, and gastrointestinal
    distress
  • Divaloproex and Carbamazepine
  • Lamotrigine
  • Antidepressants- should only be used with in
    combination with a mood stabilizer for the
    treatment of bipolar disorder

48
  • Prevention of Depression and Bipolar Disorder
  • The term prevention refers only to interventions
    that occur before the initial onset of a disorder
  • Efforts to identify cases and provide care for
    known disorders is called treatment
  • Efforts to provide rehabilitation and reduce
    relapse and reoccurrence of a disorder were
    called maintenance/interventions.

49
  • Universal mental health prevention interventions
    are defined as efforts that are beneficial to a
    whole population or group.
  • They are targeted to the general public or a
    whole population group that has not been
    designated or identified as being at risk for the
    disorder being prevented.
  • The goal at this level of prevention is the
    reduction of the occurrence of new cases of the
    disorder.

50
  • Selective mental health prevention interventions
    are defined as those efforts that target
    individuals or a subgroup of the population whose
    risk for developing the mental health disorder is
    significantly higher than average.
  • Indicated prevention interventions are defined as
    those efforts that target high-risk individuals
    who are identified as having minimal but
    detectable signs or symptoms that predict the
    mental disorder or biological markers indicating
    predisposition to the disorder.

51
  • The IOM identified three aims or desired outcomes
    for mental health prevention
  • Reduction in the number of new cases of the
    disorder
  • Delay in the onset of illness
  • Reduction in the length of time the early
    symptoms continue as well as halting the
    progression of severity so that individuals
    ultimately do not meet diagnostic criteria.

52
  • Goals of prevention programs
  • To extend the lives of individuals who were at
    risk but did not develop the disorder by reducing
    both the risk of suicide completion and the
    behavioral and biological sequalae of the
    disorder.
  • To teach resiliency to the program participants
  • To develop skills and abilities to spring back
    from or adapt to adversity
  • To enhance and enrich the positive aspects of
    living so individuals who otherwise might have a
    marginally happy life may have the opportunity to
    develop greater self-efficacy and live a more
    successful and adaptive live
  • Emotional intelligence may also be enhanced by
    successful preventive programs.

53
  • Prevention programs for adolescents
  • Preventative strategies are based primarily on
    cognitive behavioral and family-educational
    approaches that seek to reduce risk factors and
    enhance protective and resiliency factors
    associated with depression in youth.

54
  • The IOM suggested that prevention development and
    evaluation proceed through 5 stages.
  • First and second stages are identifying risk
    factors and describing the relative contributions
    of different factors to the disorder.
  • The third stage is applying strategies developed
    in pilot studies and completing efficacy trials
    to evaluate the overall effectiveness of these
    approaches.
  • The fourth stage involves the examination of such
    strategies in multiple sites in large-scale
    investigations under non-ideal, real-world
    conditions.
  • The final stage consists of implementing such
    strategies in large-scale public health campaigns.

55
  • Penn Prevention Program
  • Seligman and colleagues developed and evaluated a
    school-based indicated prevention program
    treating 10-13 year olds in districts in the
    Philadelphia suburbs.
  • The youth were defined as at risk for depression.
  • Participants were assigned to one of three
    treatment programs
  • A cognitive training program
  • A social problem-solving program
  • A combined program

56
  • Results indicated that children who participated
    in any of the treatment groups reported
    significantly fewer depressive symptoms
    immediately following the program and at the 6-
    month and 2-year follow-ups but not at the 12-
    month and 3-year follow-ups.
  • Teacher reports revealed better classroom
    behavior in treatment participants.

57
  • Clarke and Colleagues
  • Among the first to study prevention of MDD among
    adolescents.
  • Study included 150 students from 9th-10th grade
  • Assigned randomly to either a prevention or
    usual-care group.
  • The prevention program entitled Adolescent
    Coping with Stress Course was delivered in
    groups.
  • The 5-week intervention was conducted within the
    adolescents school setting and comprised fifteen
    45-minute group sessions.

58
  • The usual-care youngsters were free to continue
    with preexisting treatment or seek new treatment.
  • This program employed both behavioral and
    cognitive coping techniques designed to reduce
    vulnerability to future depressive episodes.
  • Participants were followed for 1 year and the
    results were positive.
  • The major strengths of this program include
    random assignment of subjects, adequate sample
    sizes, diagnoses of clinical mood disorders and
    encouraging outcomes.

59
  • Beardslee and Associates
  • Prevention program were designed to be public
    health interventions and useful to all families
    in which a parent is depressed.
  • Programs are to be sued by a range of health
    practitioners, including internists,
    pediatricians, school counselors, and nurses, as
    well as by mental health practitioners such as
    child psychiatrists, child psychologists, and
    family therapists.
  • This approach includes a strong emphasis on
    treatment because so much depression is
    undiagnosed and untreated.

60
  • 3 characteristics that described resilient
    children of depressed parents.
  • Support for activities and accomplishment of
    developmental tasks outside of the home
  • A deep involvement in human relationships
  • The capacity for self-reflection and
    self-understanding, in particular, in
    relationship to the parents disorder.

61
  • Resilient youth repeatedly said that
    understanding that their parent was ill, that the
    disorder had a name, and that they were not to
    blame for it contributed substantially to their
    doing well. This, then, became a central part of
    the preventive intervention.
  • Families believe that these programs are
    helpful. Of the first 20 families enrolled,
    promising effects were observed 6 months after
    intervention and a further follow-up report
    showed sustained effects over 3 years.

62
  • Youth Suicide

63
  • Fifty years ago suicide among young people aged
    15-24 was a relatively infrequent event and
    suicides in this age group constituted less than
    5 of all suicides in the U.S.
  • Between the mid-1950s and the late 1970s, the
    rate of suicide rose markedly among this age
    group.
  • This increase was observed most dramatically
    among young males, whose suicide rates more than
    tripled between 1955-1977.
  • Among females ages 15-24, the suicide rate more
    than doubled during this same period.

64
  • By 1980, suicides by 15-24 year olds constituted
    almost 17 of the approximately 30,000 suicides
    in the U.S.
  • 1980-1990 suicide rates continued to rise
  • 1994- reached a peak rate of 13.6 suicides per
    100,000.
  • Began to decline decreasing to 9.9 per 100,000 by
    2002 a drop of over 27.

65
  • Suicide before the age of 12 is rare, but
    increases with every year past puberty.
  • In 2002, 20-24 year olds had a suicide rate of
    12.3 per 100,000 compared to the rate of 7.4
    among 15-19 year olds.
  • 4,010 suicides in 2002
  • 1,513 between the ages of 15-19
  • 2,497 between the ages of 20-24

66
  • Suicide is the 3rd leading cause of death among
    youth only accidents and homicide claim more
    young lives.
  • Among college students specifically, suicide is
    the 2nd leading cause of death, surpassed only by
    accidental injury.

67
  • Increase of youth suicide due to
  • Increase in the rate of depression since the
    1950s
  • Increased availability of firearms
  • Diminishing cohesion of the family observed since
    WWII has been blamed for a wide range of youth
    problems behaviors, including both drug abuse and
    suicide.
  • Greater freedom in sexual behavior since the
    1960s as well as changes in the expectations that
    young men and women had for themselves and for
    their relationships

68
  • Decrease of youth suicide is due to
  • Efforts to restrict firearms availability among
    youth. The proportion of suicides that involve
    firearms has decreased somewhat in recent years,
    although firearms are still used in about 60 of
    all suicide deaths.
  • Increased use of antidepressant medication in
    treating young depressed people.
  • Improved economic conditions in the 1990s have
    been credited for the recent decline, just as
    they were blamed for the high national rates
    during the depression of the 1930s.

69
  • The most current YRBS data indicate that 8.5 of
    U.S. high school youth surveyed (5.4 of males
    and 11.5 of females) made one or more suicide
    attempts in the prior 12-month period 2.9
    percent (2.4 of males and 3.2 of females)
    required medical attention as a result of suicide
    attempt
  • Youth who are not currently attending school have
    been found to be at higher risk for suicide
    attempts and suicide deaths than those who are in
    school.

70
  • Among young people ages 15-24, males die by
    suicide almost six times more frequently than
    females.
  • In 2002, the suicide rate among young men ages
    15-24 was 16.4 per 100,000 and the rate among
    young women was 2.9.
  • Although young males die by suicide more often
    than females, females report suicidal ideation
    and attempts more often than males.

71
  • In 2002, white youth had a suicidal rate of
    10.6 per 100,000 compared to rates of 6.5 for
    African Americans, 6.6 for Hispanic youth, 5.3
    for Asian Americans/Pacific Islanders, and 17.9
    for American Indians and Alaskan Natives.

72
  • Risk Factors
  • Psychopathology
  • Depression
  • Drug and alcohol abuse
  • Aggressive-impulsive behavior
  • Hopelessness
  • Pessimism
  • Conduct Disorder (male)
  • Panic Disorder (female)
  • Family and Genetic
  • Family history of suicidal behavior
  • Parental psychopathology

73
  • Environment
  • Firearm availability
  • Diminished family cohesion
  • Lack of parental support
  • Parent-child conflict
  • Negative life events
  • Child sex abuse
  • Suicidal contagion
  • Biology
  • High 5-HT receptor expression is prefrontal
    cortex and hippocampus
  • Serotonergic dysfunction

74
  • Previous suicidal behavior
  • Suicide attempts
  • Sexual Orientation
  • Same-sex sexual orientation

75
  • Overwhelming evidence that psychopathology is the
    most significant risk factor for both suicide
    deaths and suicide attempts among adolescents.
  • One recent analysis suggested that eliminating
    psychopathology could prevent 78-87 of youth
    suicides.
  • Conduct disorder is also prevalent in young males
    with suicidal behavior, often comorbid with
    substance disorders and anxiety and mood
    disorders.

76
  • Panic disorder has been found to be related to
    suicidal behavior, particularly among girls.
  • Some studies have reported a relationship between
    bipolar disorder and both suicide deaths and
    suicide attempts among youth.
  • Suicide ideation appears to be less directly
    related to psychopathology than either suicide
    attempts or suicide death, perhaps because
    ideation, while occurring with higher frequency,
    is less persistent and may be fleeting.

77
  • Aggressive-impulse behavior has an increased
    association with suicidal behavior, particularly
    in the context of a mood disorder
  • Hopelessness and pessimism are also important
    factors associated with youth suicidal behavior
  • Previous suicide attempts is one of the strongest
    predictors of both subsequent attempts and
    suicide deaths. This relationship is
    particularly strong among youth with mood
    disorders.

78
  • The risk for future suicidal behavior has been
    estimated to increase 3-17 times when a previous
    attempt has occurred.
  • A number of studies report increased rates of
    nonlethal suicidal behavior among youth with
    same-sexual orientation.
  • Stigmatization, victimization, isolation, and
    parental rejection have been identified as
    factors in suicidal behavior among gay, lesbian,
    and bisexual youth.

79
  • Universal Approaches to Youth Suicide Prevention

80
  • The ultimate goal of all suicide prevention
    programs is to reduce death by suicide.
  • Two broad types of universal prevention programs
  • Educational programs that aim to increase
    students knowledge and awareness about suicidal
    behavior, encourage troubled students to seek
    help, and improve recognition of at-risk students
    by teachers, counselors, and other gatekeepers
    within the school or community setting.
  • Screening programs that seek to identify and
    refer to treatment youth who are at risk for
    suicidal behavior.

81
  • A wide range of suicide education and awareness
    programs have been developed.
  • Assumptions underlying such programs are that the
    conditions that contribute to suicide risk in
    adolescents and young adults often go
    unrecognized, undiagnosed, and untreated, and
    that educating students and gatekeepers about the
    warning signs for suicide and appropriate
    responses will result in better identification of
    at-risk youth, and increase in help seeking and
    referrals for treatment.

82
  • Program Examples
  • Such programs are exemplified by those developed
    by Kalafat and colleagues, which incorporate
    education about the warning signs of suicide and
    appropriate help-seeking behaviors into the
    regular physical education or related curricula.
  • Such education has been reported by the program
    developers to result in students increased
    knowledge about suicidal behavior, more positive
    attitudes about talking to friends they believe
    to be suicidal, and seeking of helps from adults.

83
  • In its most fully developed form, the Adolescent
    Suicide Awareness Program (ASAP) includes
    education for teachers, school staff, and
    parents, as well as students.
  • The Sign of Suicide (SOS) program, developed by
    Jacobs and colleagues.
  • Delivers the core message that suicidal behavior
    is directly related to mental illness,
    particularly depression, and needs to be
    responded to as a mental health emergency.
  • The instructional component, which occurs over
    1-2 class periods, may be augmented with
    screening and parent-awareness activities.

84
  • Schools in which the program has been implemented
    have reported substantial increases in students
    help-seeking behavior and high satisfaction with
    the program among school officials.
  • Students who had participated in the SOS program
    reported lower rates of suicide attempts and
    greater knowledge and more adaptive attitudes
    about depression and suicide.

85
  • Dade County, Florida, Public School System
    provide an example of universal programs applied
    on a community wide level.
  • Began in 1989 included related curricula across
    K-12, although only 10th graders received direct
    discussion of suicide and suicide prevention.
  • Also included intervention and postvention
    activities by school-based crisis teams.
  • The annual suicide rate decreased from 12.9
    deaths per 100,000 youth prior to the program to
    4.6 per 100,000 during the 5 years of program
    operation.

86
  • Many states are currently implementing universal
    youth suicide prevention programs that, in
    addition to student education, frequently include
    parent and gatekeeper training.
  • The Suicide Options, Awareness and Relief (SOAR)
    program, for example, trains school counselors to
    identify students at risk of suicide and increase
    the likelihood and effectiveness of their
    interventions.
  • This program has been reported to result in
    improved knowledge and increased comfort and
    confidence in dealing with at-risk students.

87
  • Applied Suicide Intervention Skills Training
    (ASIST) is the most frequently applied gatekeeper
    training program
  • Developed by LivingWorks Education for
    application in a wider community setting.
  • It is a 2 day workshop for teachers, counselors,
    youth leaders, and other community care givers
    that seeks to increase their awareness and
    understanding of suicide, address the associated
    stigma and taboos, develop their readiness and
    ability to use first-aid action to prevent
    suicidal behavior, and network with other
    gatekeepers to improve communication and
    continuity of care.

88
  • Pre- to post-evaluations of participants suggest
    increased knowledge about suicidal behavior,
    greater willingness to intervene, and improved
    competence in dealing with suicidal individuals.
  • In one training program in Australia, more than ¾
    of ASIST workshop participants reported using
    their knowledge and intervention skills directly
    during the 4 months following their participation
    in the program.

89
  • Training for Trainers (T4T)
  • 5 day course, offered worldwide, trains and
    certifies gatekeepers to provide the ASIST
    training in their local communities.
  • Another approach to gatekeeper training has
    involved educating general practitioners to more
    effectively identify suicidal patients.
  • One workshop in Australia sought to encourage
    screening of young patients for psychological
    distress, depression, and suicidal behavior.
  • Reported to have resulted in increased
    identification of distressed, depressed, and
    suicidal adolescents no changes were reported in
    physicians management of such patients.

90
  • Suicide awareness and education programs for
    college students are far less cohesive and
    identifiable than programs addressed to high
    school students.

91
  • One of the few programs that involve more than a
    single campus is Finding Hope and Health,
    developed by the National Mental Health
    Association in 2001.
  • Facilitates partnership between a local mental
    health association and a university to develop
    and implement campus educational programs on
    suicide and related mental health problems.
  • These campus coalitions work with residence
    hall advisers, campus counseling centers,
    relevant academic departments, campus ministries,
    and other student affairs personnel to design
    trainings for students and staff, peer counseling
    programs, and other activities to increase
    knowledge and awareness of mental health
    concerns.

92
  • Another effort that targets colleges and
    universities is the recently produced film
    developed by the American Foundation for Suicide
    Prevention (AFSP), The Truth About Suicide Real
    Stories of Depression in College.
  • The film is accompanied by a Facilitators Guide
    that includes recommendations for its use in
    classrooms, orientation sessions, and dorm
    meetings and at other student activities, as well
    as educational materials to assist faculty and
    other facilitators in guiding student discussions
    and answering specific questions about suicide.

93
  • Critique
  • Most suicide aware ness and suicide education
    programs involve one or a limited number of
    relatively brief sessions focused on suicidal
    behavior, frequently as part of a larger
    curricular effort aimed at reducing multiple
    high-risk behaviors.
  • Although pre- to post-evidence suggests that such
    programs can increase students knowledge and
    awareness of suicide risk and improve their
    help-seeking behaviors, little attention has been
    paid to determining the scientific accuracy of
    program content.

94
  • Generalizable conclusions about the efficacy and
    effectiveness of suicide education programs for
    both high school and college students are further
    limited by the lack of control or comparison
    groups that would make it possible to
    differentiate program impact from broader
    co-occurring trends.
  • In the case of the comprehensive, multilevel
    educational programs, insufficient attention has
    been paid to documenting which program components
    are responsible for the reported outcomes.

95
  • An additional limitation of currently available
    data on the impact of universal education
    programs is their short-term focus.
  • It is not clear if ongoing interventions might
    serve as booster shots to enhance and reinforce
    a programs impact.
  • Follow-up evaluations of these programs have been
    rare, and thus little is currently known about
    their impact on reducing suicidal behavior among
    the targeted group.

96
  • Longitudinal controlled studies that look at
    youth several years after participating in
    educational programs are needed to address the
    question of long-term behavioral change.
  • This will require addressing the fact that
    neither high schools nor colleges currently have
    a reliable system for reporting suicidal
    behaviors among students, thus hampering
    collection of reliable data to determine an
    educational programs impact.
  • Also, students graduate and leave the school
    environment, making follow-up difficult.

97
  • Long-term controlled studies of gatekeeper
    training programs are likewise needed to
    determine the frequency or the effectiveness of
    participants direct interventions during the
    years following the training.
  • Because little is known about particular
    approaches that make referral efforts safe and
    effective, further evaluation is needed of the
    impact of such programs on referral processes,
    adequate treatment, and, in turn, the reduction
    of suicide risk factors and suicidal behavior
    among youth

98
  • Some concerns have been voiced by high school
    personnel and parents that overt discussion of
    suicide in the school curriculum may increase
    suicidal thoughts and behavior, and adequate
    attention has generally not been given by
    evaluators to documenting adverse effects.
  • One study found statistically significant
    increases in hopelessness and maladaptive coping
    resources among some male students after exposure
    to a suicide awareness curriculum.

99
  • Studies by Shaffer and colleagues and Vieland and
    colleagues found that students who had previously
    made a suicide attempt were less likely to
    recommend suicide awareness programs in the
    schools, and were more likely to feel that
    talking about suicide in the classroom would
    increase suicidal behavior among some students.
  • It is essential that school personnel be made
    aware of referral sources in the community and
    for the school to have in place a plan of action
    for identified students that includes a
    debriefing component for peers and faculty who
    are involved in making referrals.

100
  • In the case of college-based programs, concerns
    about effects on the institutions legal
    liability, reputation, and student enrollment
    sometimes encourages campus officials to avoid or
    minimize the problem of student suicide, which
    appears to have limited the development of
    educational programs directed to this population.

101
  • Providing suicide education to college students
    poses unique issues.
  • College students are not generally required to
    take any courses in which education about
    depression and suicide may be appropriately
    incorporated.
  • Other than a few limited number of mandatory
    orientation sessions, few opportunities exist to
    reach large numbers of college students with
    information about mental health issues and
    services.
  • Involvement of parents in educational programs on
    such issues is also extremely limited in most
    college settings.

102
  • Most suicide prevention programs directed to
    young adults are designed specifically for
    college students, who represent less that half of
    all persons aged 18-24 in the United States.
  • Although few research studies have examined
    suicide risk among young adults not in college,
    this population may have particular risk factors,
    including more involvement with substance use, as
    well as less access to mental health resources.

103
  • Screening Programs
  • Universal screening programs as a youth suicide
    prevention strategy are designed to identify
    young people at risk for suicidal behavior and
    refer them to treatment.
  • Some programs focus specifically on identifying
    symptoms of psychopathology known to be related
    to adolescent and young adult suicidal behavior,
    while others assess specifically for signs of
    suicidality.

104
  • The primary assumption underlying screening
    programs is that because anxiety, depression,
    substance abuse, and suicidal preoccupation among
    youth often go unnoticed and untreated, a
    systematic, universally applied effort is needed
    to improve identification of at-risk individuals.
  • Screening programs also rest of the assumptions
    that identification of youth with psychiatric
    disorders will substantially increase the number
    receiving treatment, the treatment will be
    sufficiently effective, and effective treatment
    will decrease suicides.

105
  • Reynolds described one of the first high
    school-based screening programs for youth at risk
    for suicide.
  • The program involved a two stage method, in which
    a general population of students was first
    screened using the Suicide Ideation
    Questionnaire.
  • Students with scores above a defended cutoff
    value were subsequently evaluated clinically with
    the Suicide Behavior Interview, and those
    identified as being at risk were referred
    treatment.

106
  • The program devoted particular attention to
    determining an appropriate cutoff score for
    identifying at-risk youth, comparing two
    different scores with regard to sensitivity (the
    ability to identity correctly those who have the
    problem, with few false negatives) and
    specificity (the ability to identify correctly
    those who do not have the problem, with few false
    positives).
  • Reynolds found that increasing the cutoff score
    led to missing a disproportionate number of at-
    risk youth.
  • The impact of suicidal behavior and the adherence
    to treatment recommendations were not reported.

107
  • The most widely used high school screening
    program, the Columbia TeenScreen Program (CTSP),
    employs a multistage procedure.
  • In one variant of the CTSP, students complete a
    brief, self-report questionnaire.
  • Those who screen positive on this measure are
    given a computerized instrument, the Voice DISC
    2.3, which has been found to accurately identify
    a comprehensive range of psychiatric disorders in
    children and adolescents. This stage of the
    screening is regarded as particularly important
    for avoiding over-identification of students at
    risk.

108
  • In the final stage, youth who have been
    identified through Voice DISC 2.3 as meeting
    specific diagnostic criteria for a psychiatric
    disorder are evaluated by a clinician, who
    determines whether the student needs to be
    referred for treatment or further evaluation.
  • The program also includes a case manager who
    contacts the parents of students who are referred
    and establishes links with a clinic to facilitate
    treatment adherence.

109
  • Evaluation results indicate that most of the
    adolescents identified as being at high risk for
    suicide through the program were not previously
    recognized as such, and very few had received
    prior treatment.
  • About half of the students referred for treatment
    attended at least one treatment visit.
  • The programs requirements of a clinician and a
    case manager may be a resource burden for many
    schools.

110
  • The screening strategy is based on a public
    health prevention model that emphasizes the
    identification of at-risk students on the basis
    of observable behaviors.
  • The first level of screening involves a review
    of high school attendance registers to identify
    students having high absenteeism. Teachers and
    guidance counselors are asked to recommend
    students they deem to be at risk.
  • Identified youth are then assessed by means of
    the Suicide Risk Screen (SRS).
  • Those with elevated risk for suicidal behaviors
    are given an appropriate intervention within the
    school setting or are referred for further
    evaluation and treatment.

111
  • Screening initiatives for college students
    include the Comprehensive College Initiative
    (CCI) developed by Jacobs to identify students at
    risk for depression and facilitate them to get
    treatment.
  • The program has been offered at a large number of
    colleges in conjunction with National Depression
    Screening Day.
  • In addition to the in-person screenings offered
    at this event, the program includes an online
    year-round screening component.

112
  • In campuses where it has been implemented, the
    CCI has been described by its developers as
    effective in identifying at-risk students and
    motivating them to seek treatment.
  • Almost 20 of students taking the screening
    measure scored very likely to be suffering from
    depression and 5 reported persistent suicidal
    ideation.
  • Both student participants and college officials
    were reported to have positive reactions to the
    in-person and online program components.

113
  • Another recent program is the College Screening
    Project developed by the American Foundation for
    Suicide Prevention.
  • This project uses the campus e-mail network to
    target students and encourage them to complete a
    Depression Screening Questionnaire, which has
    been established to be an effective tool for
    identifying depression among community samples.
  • The screening includes depression, items dealing
    with current suicidal ideation, past suicide
    attempts, anxiety and other affects, drugs,
    alcohol, and eating disorders.

114
  • Assisted by a computer program, a clinically
    trained counselor evaluates the responses and
    assigns the student into one of three tiers on
    the basis of their suicide risk.
  • The counselor then writes a personalized reply
    that the student accesses on the Web site.
    Students with significant problems as determined
    by a well-defined set of criteria are urged to
    come in for a face-to-face evaluation.
  • The Web site also contains a Dialogue feature
    that allows students to communicate with the
    counselor online to discuss concerns they may
    have prior to an evaluation.

115
  • During the face-to-face meeting, treatment
    options, including medication and psychotherapy,
    are discussed and referrals are made to
    appropriate services on and off campus.
  • In an effort to evaluate treatment effects, the
    project collects data on an ongoing basis from
    treatment providers on student adherence,
    treatment progress, and disposition.

116
  • Initial reports indicate that about 80 of the
    students who respond to the screening
    questionnaire indicate some mental health
    problems, with almost half of all respondents
    falling into the highest-risk tier.
  • Fewer than 15 of identified students comply with
    recommendations for evaluation, which suggests
    that recommendations need to be refined to make
    them more acceptable, or that innovative
    strategies need to be developed to encourage
    greater number of at-risk students to seek help.

117
  • One other Web-based screening program for college
    students the ULifeLine program, has recently been
    developed by the Jed Foundation.
  • This program provides computer-generated results
    to students who complete the screening
    instrument. Although identified students are
    provided with recommendations regarding treatment
    possibilities, no follow-up is offered.
  • It is not clear whether without a personal
    connection, such Web-based screenings will
    succeed in motivating students in need to seek
    treatment.

118
  • Critique
  • In their basic assumptions, screening programs
    as implemented within both high school and
    college settings closely conform to
    scientifically validated premises regarding the
    causes of suicide i.e., that suicide risk is
    not randomly distributed, but rather is conferred
    by certain factors that are both identifiable
    and, to a considerable extent, alterable.
  • At the same time, such programs face a number of
    challenges.

119
  • Screening measures with acceptable test
    characteristics (e.g., a sensitivity of 80 and a
    specificity of 70, figures similar to screens
    for depression) will necessarily miss some in the
    population who will go on to make suicide
    attempts, while identifying many more as at risk
    when they are not.
  • Given that costs are involved each tome a segment
    of the target is screened, most school-based
    screening programs assess students only once a
    year, and in some cases, only once during a
    several-year period.

120
  • The timing of the screening may increase the
    likelihood of identifying students in need of
    referral (e.g., close to exams, at the beginning
    of high school or college, or during the senior
    year) or at other times may reduce this
    likelihood.
  • Low adherence with treatment recommendations
    among those identified through the screening
    instrument to be at risk due to a range of
    problems that are beyond the scope of the
    screening effort (lack of parental support,
    perceived quality of available treatment, and
    attitudes of treatment providers) additional
    strategies appear to be needed to encourage
    students at risk to access and make effective use
    of needed treatment services.
  • In this regard, better integration of suicide
    education, gatekeeper training programs, and
    screening programs may be helpful.

121
  • All school-based suicide screening programs need
    to be mindful of the availability and quality of
    mental health services for students who are
    identified as at risk.
  • It is estimated that only 38 of colleges provide
    mental health services and most of those that do
    limit the number of sessions or offer only group
    therapy that may not be appropriate for students
    at risk for suicide.
  • Although many colleges require students to have
    health insurance, most students are not
    adequately covered for acute or long-term mental
    health services.

122
  • Even when implemented under ideal conditions,
    there is no clear evidence that screening for
    suicide in general populations improves rate
    reduction outcomes.
  • No data have been reported on the effectiveness
    of high school or college-based screening
    programs in reducing suicide risk factors.
  • Within high schools, there is evidence that
    administrators prefer suicide education and
    awareness programs over screening programs.

123
  • Many colleges and universities have expressed
    reluctance about implementing depression and
    suicide screening programs.
  • This appears to reflect concerns about the
    liability schools may assume in the event that
    students identified as at risk for suicide not
    follow through with treatment recommendations and
    actually engage in suicidal behavior.
  • Identification of at risk students may also put
    universities into a difficult legal and ethical
    position with respect to parents. Parents of
    students over the age of 18 cannot be contacted
    without written permission from the student.
    Although confidentiality can be waived in
    situations in which threat to life is concerned,
    universities are reluctant to become embroiled in
    such matters.

124
  • One complication with Web-based programs is the
    recent Health Insurance Portability and
    Accountability Act (HIPAA) which limits the use
    of electronic technology to transmit identifiable
    health information, because of the potential
    threats to patient confidentiality.
  • This has been interpreted as requiring that a
    students actual identity not be revealed
    online, making it impossible for the counselor to
    intervene to help a student believed to be
    suicidal unless he or she presents in person for
    evaluation.

125
  • Preventive Interventions and Treatments

126
  • School-Based programs for suicidal students
  • The most comprehensive school-based programs are
    those developed and tested by Eggert, Thompson,
    and their colleagues as part of the Reconnecting
    Youth (RY) Prevention Research Program.
  • The interventions are directed at students who
    are deemed to be at risk of dropping out of high
    school, based primarily on school attendance data
    and observations of teachers, counselors, and
    other gate keepers.
  • Such students have been reported to have multiple
    co-occurring problems that, in addition to school
    performance difficulties, include depression,
    suicidality, drug involvement, and aggressive and
    violent behaviors.

127
  • The interventions are based on a theoretical
    model that rests essentially on improving
    students personal resources, leading to an
    enhanced sense of personal control and
    self-esteem, improved decision making, increased
    use of social support resources, and reduced
    suicidal behavior.
  • The early research involved systematic evaluation
    of a semester-long, school based, small group
    intervention called the Personal Growth Class
    (PGC).

128
  • The intervention included life skills training
    using strategies of group process, teacher and
    peer support, goal setting, and weekly monitoring
    of mood management, school performance, and drug
    involvement.
  • Evaluation studies involved 100 high school
    students who screened positive for suicidal
    behavior.
  • The students were randomly assigned to one of
    three conditions
  • Assessment protocol plus one semester of PGC
  • Assessment protocol plus two semesters of PGC
  • Assessment protocol only

129
  • Participants were assessed at baseline and at
    5-10 months post-intervention.
  • Participants in all three groups showed
    significant declines in suicidal behavior.
  • Unlike the students who received the assessment
    protocol only, PGC participants showed
    significant improvement in self-perceived ability
    to manage problem circumstances.
  • Also reported was a significant positive impact
    of both teacher and peer support in decreasing
    suicide risk behaviors and depression.

130
  • Also reported was a significant positive impact
    of both teacher and peer support in decreasing
    suicide risk behaviors and depression.
  • Thompson, Eggert, and colleagues subsequently
    tested two additional school-based prevention
    programs based on the PGC a brief one-on-one
    intervention known as Counselors Care (C-Care)
    and a small group skills-building intervention
    program, Coping and Support Training (CAST)
  • Both interventions were found to reduce suicide
    risk behaviors and depression.
  • CAST was most effective in enhancing and
    sustaining protective factors such as
    problem-solving coping.

131
  • Currently the CARE intervention expanded to
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