Depression: Plague of the 21st Century

 Depression has been described as the bubonic plague of the twenty-first century.

The World Health Organization estimates that by 2020 it will be one of the most prevalent diseases in the world - second only to heart disease.

The cost to the world economy is phenomenal while the cost to the sufferers and their families is immeasurable.

Following are interesting articles about depression, which, we hope will further your knowledge on this very delicate subject, and which may be useful in helping you cope with depression. Please visit our links on depression for more information.

 

Prayer may heal depression
November 6, 2002 It seems prayer really may have the power to heal.

Moderate levels of prayer and other types of religious coping may help combat depression among spouses of people with lung cancer, says a study in the November-December issue of Psychosomatics.

Using religion to cope
The study included 156 spouses of people with various stages of lung cancer. The spouses were 26 to 85 years old (mean age 63.9 years), and 78 percent of them were women.

Researchers assessed the spouses' levels of religious coping and depression, along with their sense of control over events and level of social support.

The researchers define religious coping as a person's use of religious beliefs or practices to manage stressful life events.

Religious coping includes prayer, drawing comfort from faith, and having support from church members.

The study found that spouses who used moderate levels of religious coping were less depressed than spouses who used lower or higher levels of religious coping.

Turning to religion in need
The connection between depression and high levels of religious coping may reflect an over-reliance on less adaptive religious coping strategies and neglect of other important coping strategies, the researchers say.

They also say that spouses who feel the most desperate may be more likely to turn to religion for comfort. That means those people may already be depressed before they begin using religious coping. - (HealthScout News)

 

A few steps to fight blues

Posted on Tue, Nov. 12, 2002

“Just do it”

It may be a good slogan for athletic shoes. But when offered as a pick-me-up for a friend bound by depression, it's not only simplistic and unhelpful, but possibly even defeating, according to the November issue of Psychology Today's Blues Buster newsletter.

``One effect of being told to `just do it' when you just can't is to feel deep shame for your inability to do what the rest of the world seems easily capable of doing,'' writes counselor Ellen McGrath. ``Expecting to act and finding yourself unable to do so is a big trigger for feelings of inadequacy.''

If you want to offer some encouragement, McGrath offers some better advice to those who are depressed:

• Recognize that any constructive action is better than none at all; no step is too small to take. As your energy level increases, take progressively bigger steps, following a structured plan and clear goals.

``Figure out the smallest step you can take,'' she said. ``If you haven't talked to another person in a day, make a telephone call. If you haven't bathed because you don't care, take a shower.''

• Take inventory of the relationships in your life, identifying those who are ``energy givers'' and those who are ``energy drainers.'' Avoid those who drain your energy. Connect with those who give energy.

• If after a week, you're still unable to act, make an appointment with a physician -- an antidepressant may be needed to give your brain the biological boost it needs.

 

Health & Medicine 11/11/02
The Demons of Childhood
Young brains break. Then comes the broken care system

BY MARIANNE SZEGEDY-MASZAK

When Alex McAbee turned 7, many of the happy accomplishments of childhood were missing from his short, tortured life. Indeed, he had not even learned to read, nor had he doffed a corny cap and gown to graduate from kindergarten. Instead, his milestones included several expulsions from day care, one after he had given a child a concussion. Then there was that dreadful day he poked out the eye of his grandmother's puppy, and the day he chased his younger brother, Hudson, around the house with a butcher knife. Drinking gasoline, rubbing his feces on the walls–the list goes on.

Then there were the routine travails, more than the family cares to count, when he would shriek and hurl his dinner against the wall simply because his hamburger was located in the wrong position on the plate. Or when he would just sit and scratch his face and gnaw on his own arm.

His mother, Kelly Troyer, recognized that Alex desperately needed help, but she discovered that finding psychiatric care for children in Greenville, S.C., was not so easy. "I was at my wits' end," she recalls. "I went through hell trying to get him treatment."

That road through hell is a familiar one for parents of children with emotional disorders. It begins at home and runs through the schools and into the offices of pediatricians, psychiatrists, psychologists, cardiologists, child neurologists, behavioral pediatricians, and social workers. All of these specialists could tell that there was something seriously wrong with Alex, but the problem was figuring out exactly what. Now 9, Alex has been diagnosed at various times as having autism, attention deficit disorder, bipolar disorder, and oppositional defiant disorder. Each diagnosis, of course, required different medicines. Many failed, and some actually exacerbated the problem.

It is impossible to say just how often this kind of story is repeated in homes across the country. But with an estimated 20 percent of all U.S. children and adolescents having a diagnosable psychiatric disorder, and 13 percent of all adolescents experiencing "serious emotional disturbance," one can imagine that it is repeated in most communities every day. Indeed, the surgeon general's National Action Agenda in 2000 detailed a "public crisis in children's mental healthcare." Compounding the problem is the fact that today's children "are sicker, younger," says Richard Sarles, professor of child psychiatry at the University of Maryland and the president-elect of the American Academy of Child and Adolescent Psychiatry. Why? No one knows for certain.

Certainly, budget cuts haven't helped. Hospital beds for children in psychiatric crisis are decreasing, and in most communities, long-term care is virtually nonexistent. Richard Harding, former president of the American Psychiatric Association and a child psychiatrist in Columbia, S.C., calls the national problem a "perfect storm, where budgets are cut, and inpatient facilities are closing, and more children than ever need help."

But Kelly Troyer and her family were unaware of this in 1993 when Alex was born. All she knew after several months was that her sleepless, agitated second son wasn't acting right. And what she knows several years later is that the system that should have been there to help wasn't acting right either.

Kelly Troyer sits in her van in the pickup line at the Pelham Road Elementary School, where Alex attends a special class with six other emotionally ill children. While he still clearly struggles–small setbacks can leave him tearful and frustrated–this has been a good year for Alex. After his diagnosis was finally nailed down, Alex began medication that has stabilized his symptoms. Both he and his younger brother, Hudson, are among an estimated 1 million children with bipolar disorder. Hudson, an impish, sparkling 7-year-old, is in a different school. The oldest brother, 12-year-old Brandon, is not only healthy but enrolled in a program for gifted and talented students.

Alex emerges, a typical little boy lugging a giant backpack. He is, as a report from the Medical University of South Carolina states, "well groomed and quiet with very soft speech," but he also has the slightly haunted look of a child whose brain has exacted a terrible price with its unpredictability.

"How are you doing, honey?" asks Troyer. "Did you have a good day at school?"

"I can read now," he announces proudly, as he searches for a book in his backpack.

"We never thought that would be possible," says Troyer as she drives away from the school. "Given everything else we had to deal with."

When Alex was a baby, he didn't sleep more than two hours a night and had problems eating and digesting food. When he was a year and a half, he began to hurt himself and other children at the day-care center, and he was kicked out. Troyer took him to the pediatrician, who "discounted everything I said." Alex, the doctor told her, was a normal kid, just colicky or in the midst of the terrible twos. All that was needed, suggested the pediatrician, was "different parenting skills." Troyer recalls: "I kept saying, you don't understand, this is a child who would rage and not sleep."

Unfair as this appears, and maddening as it is for parents, Troyer's difficulties also reveal the complexities of diagnosing severe mental illness in children, especially when it is manifest at a very early age. The conundrum with mental disorders is linking a clinical presentation–wild and frightening behavior, for example–with a diagnosis and suitable treatment. "We have improving, but not perfect, diagnostic schemes," says James Scully, the chair of the department of neuro- psychiatry and behavioral science at the University of South Carolina School of Medicine. Diagnosis is based on observation and clinical experience rather than some measure of underlying physiology or cell pathology, and "there is a huge range of 'normal.' We need to figure out if the child is experiencing a developmental process versus a developmental delay versus a real illness."

When Troyer's marriage broke up in 1997, she moved with her three sons into her parents' house in Greenville. Eventually, her mother and the boys' grandmother, Cindy Troyer, quit work as a nurse in order to help Troyer with the children, and Troyer's father, Tom, became a father figure to the boys, playing basketball, teaching them carpentry, and providing essential male ballast to their lives. Alex continued to be impossible to control, and Troyer thought she might finally get help from the family pediatrician in Greenville. The pediatrician recommended the popular antidepressant Prozac. Yet "it made him about 100 times worse," recalls Troyer.

Pediatricians and family practitioners prescribe over 85 percent of the psychiatric drugs today and, according to the surgeon general's report, two thirds of mental health visits are to primary-care physicians. "Clearly, half the patients I see have some kind of serious emotional problem," says pediatrician David Kaplan, chief of adolescent medicine at Children's Hospital in Denver. "Over the last five years I have been prescribing and managing more and more kids on psychotropic medication. It's a huge change in practice for us in adolescent medicine."

And not for the better. Kaplan and other pediatricians point out that the combination of more difficult cases and few available child psychiatrists leads them to dole out medicine they are neither trained in nor comfortable with prescribing. Some pediatricians, like Kaplan, who are affiliated with large hospitals or academic institutions, can consult with the child psychiatrist down the hall when confronted with a vexing case. But most don't have that luxury.

Before grim experience teaches them otherwise, desperate parents of mentally ill children assume that mental health services, like those for physical ailments, will proceed through some relatively predictable steps. The pediatrician refers you to a specialist, you get an appointment within a few weeks, the child is examined, medication is prescribed or a procedure is scheduled, and everything is reimbursed by insurance.

This model goes terribly wrong from the start. According to the American Academy of Child and Adolescent Psychiatry, there is a "crisis in the workforce." Only 6,300 child psychiatrists practice nationally, whereas, according to the Council on Graduate Medical Education, the nation needs more than 30,000 to serve those in need. Also, more than 20 percent of child and adolescent psychiatry residency programs were unfilled in 1999, and the number of child and adolescent psychiatry residents did not increase at all in the '90s. One problem is that to become a child psychiatrist, a young doctor must complete a three-year residency in adult psychiatry plus an additional two-year fellowship in child psychiatry. At the end of all that education, child psychiatrists typically end up on the bottom of the pay scale compared with other specialists.

The result is a massive maldistribution of services, with especially limited options for troubled children in rural or low-income areas.For example, there is less than 1 child psychiatrist per 100,000 young people in Mississippi, while there are nearly 20 per 100,000 in Massachusetts. Nebraska reported this year that it has barely enough mental health specialists to help children who are suicidal or in crisis.

Even if there is access to a mental health provider, there is the other problem of paying for the care. Although almost half of all children have some sort of private insurance coverage, the vast majority of those with psychiatric disorders are covered only by specialized "behavioral health carve-outs." What this means is that insurance companies have split off mental health care from primary care. Rather than a physician simply authorizing services, a "reviewer" or "gatekeeper" working for the insurance company determines what care will be reimbursed, in effect determining both the quality and the nature of the care. A recent Rand Health Program study showed that eliminating gatekeepers would most likely not raise costs for HMOs, but insurers have lobbied hard against equal treatment for mental disorders.

Many parents are stunned to learn that their insurance will not cover psychiatric medical care for what is clearly a seriously ill child. "If a child had cancer we would be infuriated if parents were made to beg for care," says child psychiatrist Harding. Kelly Troyer has what she calls "excellent private insurance" and secondary Medicaid as well. But even with that, Alex was refused treatment because the psychiatrist did not take Medicaid. When Troyer said that she had private insurance and would pay out of pocket, she was told that this, too, was impossible.

Care and reimbursement problems are further complicated because children who are mentally ill typically have a whole range of other needs. Alex also needed speech therapy and help with his learning disabilities and auditory processing problems. In a perfect world, a child psychiatrist would monitor both the medication and these other therapists, teachers, even the child's pediatrician.

A few communities are experimenting with ways to better coordinate all the services–what's called "continuum of care" or "wraparound" services. But in most places corollary services remain badly fragmented, and parents like Troyer are left to search on their own. When Alex became psychotic–"talking about blood and guts and gore"–Troyer had to turn to the Internet. Online she discovered Robert DeLong, a child neurologist at Duke University Medical Center. She E-mailed him, and magically he responded that he could squeeze Alex in for an appointment that week. She drove the four hours to Duke and finally got Alex the kind of care that had eluded him. DeLong took a detailed family history, evaluated Alex, and concluded that he had bipolar disorder. He then started him on new medications, including lithium and Depakote.

Even with this good fortune, Alex still had trouble getting continuity in his care. He at first seemed to get better, but a month later, on a Monday, the pediatrician gave him a blood test to see how he was tolerating the Depakote. The doctor was alarmed at the level of enzymes that can indicate liver damage, so he changed Alex's medication. Tuesday Alex began acting up at school, and by Wednesday he had tried to stab his teacher with a pencil. Alex and his mother and grandmother ended up at the Greenville Memorial Hospital emergency room.

Alex was completely out of control. In fact, Troyer had never seen him so violent. Finally, he was strapped down and dosed with Versed, a light anesthetic. It did nothing. Alex needed to be hospitalized, but there was no place in Greenville that had available beds, and the psychiatrists whom the ER staff called did not answer. So he was taken by ambulance to Charter Hospital in Augusta, Ga., 21/2 hours away. He screamed the whole trip.

Many families end up in the emergency room when their child loses control. In most states, community services are so scarce that the system becomes clogged, creating a kind of gridlock of care. According to a 2001 report by the Baselon Center for Mental Health Law, children in crisis are brought to an emergency room where they remain until a bed opens up in the psych ward, but there are fewer and fewer such beds. Residential programs, which would be the natural next step, are often full because children cannot be discharged into communities that have no intensive services. It's a classic Catch-22, because children in the community don't get the care they need, and end up in crisis, in the ER–and the cycle goes on and on. "Over and over again I have patients who get shuttled from hospital to hospital to get even the most basic mental health services that they need," says Richard Barthel, a child psychiatrist at Children's Hospital of Wisconsin in Milwaukee. "The consequences on these children and their families are devastating."

Alex was treated at Charter for a week. At one point a social worker told Troyer that she needed to place him in a long-term-care facility. The strain of keeping him at home would destroy the family, Troyer was told. "When she told me that, it fueled the fire in me," says Troyer. "I was so determined that this was not going to happen, I said, 'I don't care what needs to be done because we are not going to do that.' "

Even if she had wanted to institutionalize Alex, her options would have been limited. Across the country, long-term-care facilities for mentally ill children–and adults for that matter–have disappeared. State hospitals have closed, and most private long-term options are colossally expensive.

The talk of institutionalization frightened Troyer. She turned to DeLong and asked what the outcomes for children like Alex could be. DeLong, who has worked with bipolar disorder in children for over 30 years, acknowledged that in the end, each child is different. Some become Eagle Scouts, others commit suicide, others finally are forced to live in long-term facilities. Then he looked her straight in the eye and said, "Alex will be OK." It was all Troyer needed.

It is 5:45 in the morning and still dark when Alex gets ready to catch the 6:00 bus to his school. While the trip is less than half an hour by car, this bus is for disabled children throughout Greenville and stops at several different schools and neighborhoods. Alex is the first picked up and the last dropped off, so by the time he arrives he has been riding, and napping, for an hour and a half. His clothes are carefully laid out on the chair in the order in which he needs to put them on. He dresses quickly and goes into the kitchen, where Troyer gives him his medicine.

Every day, twice a day, Alex takes the anticonvulsant Depakote to stabilize his mood; lithium to calm the excitability of bipolar disorder and ease his symptoms; Risperdal, which is a major tranquilizer and antipsychotic; and clonidine, an antidepressant. Risperdal alone costs $700 a month, and the others bring the total medication cost to nearly $1,500 a month. Including Hudson's medicine, the monthly bill for medication is several thousand dollars. "I tell people that if anyone broke into our house their best bet would be to go for the drugs," jokes Troyer. Alex responded well to the lithium. Hudson, however, was a different story.

Even Troyer didn't see a problem with Hudson early on. But after Alex chased Hudson around the house with a butcher knife, the happy 3-year-old was transformed into a withdrawn and moody child almost overnight. The family had no idea what had happened until several weeks later, when Alex admitted what he had done. In some cases such a trauma can trigger an underlying disorder that might never have appeared otherwise.

Hudson began to act out in school, urinating on his classmates. Troyer had been so accustomed to the profound dysfunction of Alex that she didn't realize Hudson was beginning the dramatic slide into bipolar disorder as well. "I would have all these thoughts going through my head really, really fast," says Hudson. "Then they would start buzzing like bees until it got louder and louder, so I couldn't stand it." At 51/2, Hudson was in the midst of pediatric mania. DeLong recalls that Hudson couldn't calm down when they first met, and his words came out garbled and giddy. He was not as neurologically damaged or developmentally delayed as his older brother, but it's likely they share genetic predisposition to the illness. Now Hudson, too, takes a small pile of pills with his morning and evening glass of milk. In the beginning one of them was lithium. It had worked so well with Alex, Hudson was likely to benefit too.

But one day, the school called and said Hudson was not well. He had dropped his pencil and seemed unable to hold it. By the time his grandmother Cindy appeared, he couldn't walk. He was having a rare but horrible reaction to the lithium and was nearly paralyzed by the time they got him to the emergency room, where he lay incapacitated for three days.

Alex and Hudson literally embody the profound complexity of prescribing some of these powerful drugs for developing young bodies and brains. While they are miracle drugs for many, for others they can produce horrible side effects. As DeLong says, "The medicine can turn these cases around pretty quickly; the challenge is to keep them turned around."

For nine years Kelly, Tom, and Cindy Troyer have received a painful education in the field of children's mental health. With the two bipolar boys now in school, doing well, having dif- ficult days but generally on the road to productive lives–Alex looks forward to "getting married and having my own kids"–the family now tries to help others by working with the Federation of Families of South Carolina. The first Tuesday evening of every month, they convene a parent group at the Allen Bennett Memorial Hospital in near- by Greer.

Fourteen parents are there this Tuesday evening. Couples sit together and hold hands; others are alone. Everyone looks exhausted as they talk about the dramas and tortures of living with children who have emotional disorders. One mother is applauded for finally qualifying for Medicaid. Another describes a harrowing night of violence with her daughter in which she finally was so fearful she called the police. Brushes with the law and encounters with the juvenile-justice system loom in many of their stories.

Alex and Hudson will most likely not end up in the juvenile-justice system, but they are the lucky ones. According to Karen Stern, a program manager in the Office of Juvenile Justice and Delinquency Prevention: "Prior to 1990, mental health problems weren't given much thought, or it was assumed to be a very small number of incarcerated kids. Since then there's been a growing recognition of the number. It's of great significance." According to a report submitted to Congress by the Coalition for Juvenile Justice, an estimated 50 percent to 75 percent of the 2.5 million youths under age 18 who are arrested suffer from mental health problems. It has often been said that the Los Angeles County Jail is the largest mental institution in the country; that phenomenon is also reflected in the juvenile-justice system.

It is the end of the day. The boys are back from school, the family therapist has come and gone, Alex and Hudson are playing outside with a neighbor's child, and Brandon is getting ready to go to a church function with friends. A stew simmers on the stove. Tom Troyer, 56, sits in an easy chair in the living room of the house he shares with his extended family. A tall man with the sturdy competence of his Hoosier upbringing, Troyer concedes he never gave mental illness a second thought until it afflicted his family. He has since become a passionate advocate for the mentally ill. "I remember that someone in our church once said that Alex was probably possessed by the Devil," he recalls. "Now don't get me wrong, I believe in demonic possession. But that is not what is wrong with Alex and Hudson. They are ill. It's that simple. And the illness is as medical as diabetes."

In the end, Troyer's simple statement encapsulates much of what has gone wrong in the care for children with a serious mental illness. His grandsons are representative of both the promise and the crisis in children's mental health. The old cliché that children are the future holds special resonance in these cases, but troubling questions linger: Which children and, more important, what kind of future?

Depression strikes teens hard

 10/30/02

By Sue Morris

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 One out of every eight teenagers go through depression of several weeks each year, according to Jim DeMuth, executive director of Plains Area Mental Health Center. DeMuth was the featured speaker at Friday’s meeting of the Plymouth County Health Planning Committee.

 “All of us have our ups and downs,” DeMuth explained. “Things happen and we’re sad.”

 Depression is beyond such sadness. It refers to serious change of mood which may last from two or three weeks to six months.

 One definition DeMuth provided for depressions is: “Turning inward when the world outside no longer seems to be charged with meaning and purpose.”

 The teen years are so full of change even professionals find it difficult to recognize when teenagers are depressed, he indicated. Often their parents will deny the problem is depression or long-term.

 “You can’t snap out of depression. You just can’t do it,” said DeMuth.

 Girls are more likely than boys to become so depressed they have no interests any more. Researchers theorize it may be the physical and emotional changes of the teenage years which can lead to depression, DeMuth indicated. Only about 20 percent of depressed teens get the help they need.

 Depression is the “number one” phychological disorder. By the year 2020, it is expected to be second only to heart disease as a world-wide disease, DeMuth told the group of professionals and students.

 Depression is 10 times more common today than in 1945. The average onset is between 25 and 29 years of age.

 DeMuth said the reason for the increase in depression is that everyone is affected by current events such as 9-11, the sniper shootings and the kidnapping recently in Plymouth County. People see the news on TV and in papers. They see the reactions of their parents.

 While most people have such basic needs as food and water, they don’t have the emotional support needed, according to DeMuth.

 “There’s more emphasis on who you are and how much money you have, than what kind of person you are,” he told the group.

 Cultures such as the Amish or a locale in New Guinea show no depression because their group takes care of the individual when there is a problem, DeMuth indicated.

 Asked what can help, DeMuth said talk therapy is necessary and medication can help.

 “Sometimes, that’s [medication is] too easy an out,” he cautioned.

 One way Plains Area tries to help depressed persons, besides talk therapy, is to get them out of the house and doing activities. Just sitting and watching TV can increase depression, DeMuth indicated. If someone seems depressed, he urged the group members to tell the individual they are concerned and why.

 “The only way we heal is by getting it out,” DeMuth said of talk therapy’s benefits.

 Jackson Recovery Center has seen more double diagnoses recently, according to Linda ________, ______. An individual might be referred for an addition plus a mental health diagnosis.

 An alternate explanation for the increase in depression was suggested by Dr. Todd Wendt, superintendent of Le Mars Community School District. He proposed crediting the success of the many referral services whom depressed persons can call to the increased number of contacts. Wendt said school counselors appreciate the many resources available when problems appear beyond their level.

 Counselors are often busy with career counseling and class scheduling and other duties, noted Steve Shanks, Gehlen High School principal. They appreciate being able to refer students with problems to community resources.

 DeMuth agreed with group members that there is still an unfortunate stigma to seeking mental health services.

 “Society has changed. We have to be prepared because there’s going to be a lot more change in society,” said DeMuth.

 “We’re not very connected as families any more,” said Carol Schneider, education director for Plymouth County Extension. “There’s no mom or grandma waiting after school.”

 Programs such as mentoring at LCS, several after-school programs and The Asylum’s Teen Center were listed as places which could help provide connections for young people.

 Teenage depression symptoms Jim DeMuth, executive director of Plains Area Mental Health Center, provided this partial list of symptoms of teenage depression:

 • A downward trend in performance at school or college.

 • A change in personal hygiene and appearance.

 • Destructive and/or defiant behavior.

 • Hallucinations or unusual beliefs.

 • Appetite or weight gain or loss to a substantial level.

 • May appear restless, agitated (pacing, wringing hands) or has slowed down (e.g., spends hours staring in front, finds it hard to move).

 • Has lost a lot of energy; complains of feeling tired all the time.

 • Complains of feeling guilty or worthless (“Everything is my fault” or “I am bad.”).

 • Believes that live is not worth living.

  

Depression in Childhood and Adolescence: Working to Prevent Despair - Part 1

The incidence and nature of depression during childhood and adolescence has been a topic of some controversy (Esman, 1982). From the traditional psychoanalytic position, depression is a manifestation of conflict between the ego and superego. But neither the ego nor the superego is thought to be fully present before late adolescence (Garrison, Shoenbach, & Kaplan, 1985). Thus for decades, mental health researchers and practitioners discounted the existence of depressive disorders during childhood and early adolescence. Currently, however, depression in youth is viewed as a significant problem that affects approximately 30% of the adolescent population (Lewinsohn, Hops, Roberts, Seeley, & Andrew, 1993). In fact, one in five youngsters report a minimum of one episode of major depression by the age of 18 (Lewinsohn et al., 1993). Furthermore, the prevention of depression in childhood and adolescence is critical to reducing the high cost of treating this disorder among adults (King, 1991). Therefore, child and adolescent depression is a major phenomenon and deserves the full attention of mental health and educational professionals.

This article focuses on the problem of child and adolescent depression. First presented are some of the definitional and diagnostic issues in child and adolescent depression. Next, the story of Esteban, a Latino adolescent who is struggling with depression, illustrates some of its causes and related intervention strategies. Some of the causal factors associated with this disorder are discussed, as are the prevention and treatment strategies that have been found to be effective for children and youth suffering from depression. The strategies discussed include family, individual, school, and community approaches. The feature concludes with an exploration of how the various prevention and treatment strategies discussed can be combined to form a responsible and comprehensive response to young people experiencing depression.

PROBLEM DEFINITION AND DIAGNOSTIC ISSUES

The clinical syndrome of depression in childhood and adolescence has not been well addressed in the psychological literature. Early concepts, such as adolescent turmoil and the masked depression model either led practitioners to discount depression or hindered their understanding of depression in childhood and adolescence. For example, adolescent turmoil suggests that all adolescents go through a period of turmoil that may appear to be pathological. But the symptoms of inner unrest and deviant behavior that characterize adolescent turmoil were thought to be a normal part of adolescence and, therefore, clinically unimportant (Garrison et al., 1985). The notion of masked depression also confused, rather than clarified, this clinical problem. This model suggested that although depression is experienced in childhood and adolescence, it is not manifested as such. Instead, it is masked by other behaviors associated with depression, such as irritability and hyperactivity, aggressiveness and delinquency, somatic complaints and hypochondriasis, anorexia nervosa, obesity, poor school performance, school phobia, loss of initiative, social withdrawal, and sleep difficulties (Carlson, 1981; Carlson & Cantwell, 1980; Davis, 1983; Husain & Vandiver, 1984).

Current research, however, challenges these concepts. For example, no common picture of adolescent turmoil has emerged, and no consistent period of difficult psychological adjustment seems to exist. Indeed, similar behavioral manifestations of turmoil may be found in adult populations, and many adolescent problems or maladjustments are not transitory at all but lead to significant disturbances in adulthood (Garrison et al., 1985). Likewise, masked depression is difficult to validate, is controversial, and has been refuted by research (Carlson & Cantwell, 1980; Kovacs & Beck, 1977). Masking behaviors are actually better conceptualized as presenting complaints that to the astute clinician will not be classified as other problems but seen as symptoms of depression. These criticisms have led to current acceptance in the research literature that depression exists across all age groups (Puig-Antich, 1982; Reynolds, 1984). Given this consensus, it is appropriate to further describe the procedures for the diagnosis of depression among young populations.

For the last four decades, the most widely used diagnosis and classification system has been the Diagnostic and Statistical Manual of Mental Disorders. The revised, third edition of the manual, the DSM-III-R, was published in 1987 (American Psychiatric Association, 1987). The DSM-III-R system of classification helped to ameliorate the problems and controversies associated with general classification concepts such as adolescent turmoil and masked depression. Such clarification was accomplished by providing a description of the diagnostic categories of depression without projecting specific philosophical orientations or presenting specific arguments regarding depression classification (Coyne, 1986; Levitt, Lubin, & Brooks, 1983). The DSM-IV, published in 1994, added further clarity to the diagnosis of depression in childhood and adolescence (American Psychiatric Association, 1994).

The DSM-IV has addressed differential aspects of adolescent depressive symptomology as opposed to common symptoms experienced or evident in adults. In addition, further symptom delineation has been made between prepubescent children and adolescents. For example, children commonly display irritable mood rather than depressed mood, somatic complaints, and social withdrawal. Depressed adolescents typically display psychomotor retardation and hypersomnia.

Prior research indicated that depressed adolescents do show different symptomology than adults, including fewer suicide attempts and behaviors (Hawton, 1986), more social withdrawal (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984), more irritability (Puig-Antich, 1987), and fewer verbal expressions of depression or guilt (Puig-Antich, 1987). The DSM-IV noted that prepubertal children typically display major depressive episodes in conjunction with disruptive behavior disorders, attention-deficit disorders, and anxiety disorders. Adolescent depression is more commonly associated with disruptive behavior disorders, attention-deficit disorders, anxiety disorders, substance-related disorders, and eating disorders.

As compared to the DSM-III-R, the DSM-IV has made numerous changes and additions in the classification of mood disorders. Specifically, in the DSM-IV the mood disorders are divided into three major categories: depressive disorders, bipolar disorders, and mood disorders due to a general medical condition. The depressive disorders include major depressive disorder, characterized by one or more depressive episodes without history of mania, and dysthymic disorder, characterized by conditions indicating mood disturbance that has been chronic or intermittent for at least 2 years but without the degree of severity to warrant a diagnosis of major depressive disorder. Bipolar disorders include bipolar I disorder, bipolar II disorder, and cyclothymic disorder. The bipolar disorders are distinguished by the presence of a manic episode. Cyclothymia, a milder form of bipolar disorder, is indicated by the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The final category includes mood disturbances judged to be of medical etiology. This condition is found with increasing frequency among younger populations. The DSM-IV also included seasonal pattern indicators (such as seasonal affective disorder) in which people become more depressed during certain times of the year. Practitioners should also pay attention to adjustment disorders that may be accompanied by depressed mood as another important diagnostic category. In sum, the DSM-IV can be a useful tool for the clarification and diagnosis of childhood and adolescent depression. It certainly can be helpful for assisting the young man in the following story.

 

CASE STUDY: ESTEBAN'S STORY

Esteban was a 15-year-old Mexican American high school sophomore who is referred to counseling at a community mental health center by his mother after he threatened to kill her with a kitchen knife. He had straight black hair, long on top and shaved from 1 inch above his ears on down. He had crooked teeth, jeans that were fashionably oversized, and an untucked flannel shirt. Esteban attended a school where the majority of students were European American from middle-class backgrounds. In our first session, Esteban sat silently and played with his hands while his mother provided information about the family and described her concerns.

Esteban had two sisters, Reynalda (Reina), age 16, and Catalina, 13. His mother, Irma, and his father, Reynaldo, were married when they were 18 and 20, respectively. According to Irma, Reynaldo began a series of extramarital affairs shortly after Esteban was born. He had always been a heavy drinker, and he lost his job with the mining company after "too many Monday flus." The family environment described by Irma included harsh and inconsistent discipline by Reynaldo and guilt-induced permissiveness by Irma, in a context of poverty, frequent moves, and anxiety regarding Reynaldo's next binge. On several occasions, Reynaldo hit Irma in front of the children and was frequently verbally abusive toward her. Irma had finally divorced Reynaldo 3 years ago, and within 2 months he was remarried to an 18-year-old. Currently, Irma was working the 3 to 11 p.m. shift at a factory. Reynaldo's contact with his children since the divorce had been intermittent. Reina and Esteban "hated" his new wife, Tina, and Reynaldo refused to spend time with them apart from Tina.

Irma described Esteban as a sweet little boy who had grown into a monster like his father. When he entered high school 1 year ago, his average grades began slipping, he started to smoke, and he skipped classes. Whenever Irma confronted him, she reported that Esteban used the same verbally abusive language that his father used, such as "It's none of your business, your dirty whore." He refused to help out around the house and spent most of his time locked in his room listening to Madonna tapes with "a girl who dresses like a boy." When asked whether she had concerns about sexual activity between Esteban and this young woman, Irma said scornfully, "Even if she did want it--and that girl don't want it--he wouldn't know what to do." Esteban visibly flinched as she said this--his first overt reaction since arriving in the office.

Irma made the appointment for Esteban after an argument in which he shouted "If you don't leave me alone, I'm going to come after you with that big old knife. Everybody hates you, and if I killed you they would laugh." Irma said that although she didn't think Esteban would kill her or even attempt to hurt her, she was frightened by the hatred in his voice. When asked what she hoped counseling would accomplish, she said "Find my sweet little boy and bring him back to me.

The remainder of that first session was spent alone with Esteban. As soon as his mother left, he asked if he could smoke. That was his only question and his only spontaneous communication. It quickly became obvious that he was painfully shy, embarrassed, and very nervous. His brief answers to my questions did not seem to convey hostility or resentment but a profound sense of frustration and inadequacy. The additional information that slowly emerged in the one-on-one meeting included the following: His mother had a string of boyfriends none of whom he liked; he communicated very little with his siblings and knew nothing of how they felt or how they saw things; he had only one friend--the aforementioned "girl who don't want it"--who did, in fact, "want it" but so far had only permitted him to lie in bed naked with her. This they did regularly while listening to Madonna tapes and smoking cigarettes. When asked how he felt toward others--his mother, teachers, people at school--he stated, unconvincingly, that he hated them. He frequently stated, more convincingly, that he didn't care or didn't know about much of what was going on around him most of the time.

In subsequent sessions, Esteban began to communicate more openly, using longer sentences and asking more questions. It was clear that Esteban lacked many basic social skills. He spent much of his time at home while his mother worked. Often, her current boyfriend would hang out there while she worked. He didn't like this, but it was the only time that he would talk with his sisters--they would hang out in his room to avoid the boyfriends. There were no indications of any attempted sexual contact between any of the boyfriends and the three children. Esteban indicated that he was embarrassed to ask his teacher for help and so never tried to talk to them. He also reported that he felt responsible for his father's behavior--that if he wasn't the way that he was, his father would not have been a drunk and been so violent.

Esteban seemed to hate himself as much, if not more, than others around him. He was clearly experiencing a great deal of pain, frustration, guilt, and depression. Although he did not want to feel so isolated from others, he felt "stuck" and had never been taught the skills to move forward.

 
CAUSAL FACTORS

Esteban's depression could have been caused by any number of factors. In this section, some of the more central causal and conceptual models of depression biological, psychodynamic, behavioral, cognitive, and family and how each of these models might apply to Esteban are described. In the next section, how these causal models flow into effective prevention and treatment is discussed.

Biological Models of Depression
Biological models of depression can be divided into two main categories: those that focus on the role of genetic factors and those that emphasize biochemical aspects of depression. Genetic factors in depression have been examined through twin/adoption studies among adults. Research has provided some interesting evidence for a genetic component of depression. For example, there is an average concordance rate of 76% for affective disorders in identical twins versus 19% for nonidentical twins (Kashani et al., 1981). Also, adoptees who experienced greater depression were more likely to have biological parents who suffered from an affective disorder. The specific nature of genetic transmission has not been determined, nor has the role of genetic factors in the etiology of depression among adolescents been systematically researched.

Another biological model of depression focuses on biochemical processes. Neurotransmitter actions and their interactions with antidepressant medications have been the focus of much biochemical research on depression. Whether a primary cause of depression or a secondary component, some evidence suggests that abnormalities in the metabolism of neurotransmitters are present in people who are depressed and can be counteracted with antidepressant drugs (Kashani et al., 1981).

In Esteban's case, evidence suggests that both of his parents may have experienced depression. His mother's patterns of developing relationships and his father's alcoholism and abusiveness both support the notion that they suffered from a lack of coping skills and poor self-esteem--which is almost always a concomitant of depression. The weakness of this model in explaining Esteban's depression is that it does not attend to the profound impact of Esteban's environment in forming his behavior and feelings about himself and others.

Psychodynamic Models of Depression
According to the classical analytic model of depression, a distinction is made between grief, a normal response to loss of a love object, and melancholia, an intensely ambivalent love-hate relationship resulting from the real or imagined loss of a love object. Individuals predisposed toward melancholia are highly dependent. This dependency creates hostility toward the focus of the dependency, but these negative feelings of anger are repressed and ultimately converted into self-hostility. Depression results from the negative impact of this anger turned inward on the self. The reliance of this model on untestable, intrapsychic constructs has prevented its validation. Nevertheless, the psychoanalytic perspective provides an important conceptualization of the depression phenomenon that can be useful for practitioners.

For example, in Esteban's case, the guilt and feelings of loss that he feels toward his father may cause him to blame himself for the family's problems. His guilt and loss are confused with feelings of anger toward and abandonment by both parents. These feelings, over time, have been turned inward and have severely damaged Esteban's self-esteem. Thus he becomes depressed. In order for Esteban to resolve his depression, he must recognize the loss he has suffered and express his feelings directly instead of turning them in on himself.

Behavioral Models of Depression
Similar to the psychodynamic model, behaviorists view depression as a result of significant loss (Kovacs & Beck, 1977; Schwartz & Johnson, 1985). Whether this is through changes in the environment, the loss of a reinforcing interpersonal relationship, or failure to encourage and arrange for positive reinforcement, depression is seen as the consequence of inadequate or insufficient reinforcement (Ferster, 1973; 1974).

Lewinsohn's social learning theory provides a concise behavioral model of depression. This theory suggests that depressive behaviors are determined by the presence or absence of reinforcers and maintained through the reduction of response-contingent reinforcing events (Lewinsohn & Hoberman, 1985). Depression may be the result of limited positive reinforcement for the individual, which is determined by the number of potentially reinforcing events, the number of these events available in the environment, and the individual's social skills to elicit accessible reinforcers (Levitt et al., 1983). Depression may also result from an excess in punishment, especially when it occurs at high rates, when the individual is highly sensitive to punishment, and when necessary coping skills to terminate punishment are limited (Lewinsohn & Hoberman, 1985). Unfortunately, the depressive behaviors stimulated by inadequate reinforcement are further reinforced by the concern for sympathy expressed by significant others. Eventually though, others avoid the depressed person because of the nature of his or her depressive behaviors, which minimize positive reinforcement and further exacerbates the depression (Lewinsohn & Hoberman, 1985).

To illustrate this model, Esteban receives almost no positive reinforcement, except perhaps from his female friend. Further, his lack of social skills does nothing to elicit positive reactions from others. On the contrary, his surly manner elicits negative reactions from others, so that he never receives the social reinforcement he so desperately needs to help lift his feelings of depression. He feels more and more isolated, less liked by others, and subsequently more depressed.

Cognitive Models of Depression
Research has also supported the role of cognition in depression (Beck, 1967; Rehm, 1977; Seligman, 1974, 1975). Three cognitive models of depression are helpful in understanding this perspective.

The first model, proposed by Beck (1967), suggests that cognition and affect are interactive, and that the prior occurrence of cognition determines a person's affective response to an event. If cognitions are distorted or inaccurate, the individual's emotional response is inappropriate. Dysphoria may be the affective response of an individual's tendency to interpret experiences and events as negative or self-devaluative, indicating a cognitive role in the experience of depression.

Beck, Rush, Shaw, and Emery (1979) pointed to three cognitive components central to depression: the cognitive triad, schemas, and cognitive errors. The cognitive triad are three negative thought patterns: a negative view of self, of the world, and of the future. Schemas, like personality traits, represent a stable cognitive pattern that individuals create in order to organize and evaluate information and events. People who experience depression develop schemas that distort environmental stimuli to coincide with a derogatory self-image. These dysfunctional or negative schemas are often created and exacerbated by faulty information processing, or consistent errors in logic, called cognitive errors. The person suffering from depression uses these automatic cognitive errors to evaluate events, often leading to negativistic, categorical, absolute, and judgmental thinking (Levitt et al., 1983; Lewinsohn & Hoberman, 1985).

The second model of depression, Seligman's (1974, 1975) learned helplessness model, contends that depression exists in people who perceive that they have no control over their environment. They develop self-defeating attributions. They make internal (feeling responsible for an event), stable (the causes of an event remain constant), and global (event outcomes impact all areas of life) attributions for failure. In contrast, they attribute successful outcomes to external (caused by others), unstable (causes of events are transitory), and specific (situation specific) causes (Kaslow & Rehm, 1983). According to this model, this self-defeating attributional style results in the lowered motivation and reduced self-esteem common in depressed clients (Kaslow & Rehm, 1983). Self-defeating attributional style has been correlated with depression (Lewinsohn & Hoherman, 1985).

The third cognitive model of depression is represented by Rehm's (1977) self-control theory. Problems of self-control are manifested through deficits in three cognitive processes: self-monitoring, self-reinforcement, and self-evaluation. Depressed clients fail to view situations with an orientation to the future, and tend to concentrate on immediate consequences of events (Gilbert, 1984). They selectively attend to negative outcomes and focus on immediate reinforcements. A negative view of the self, the environment, and the future results.

Similarly, depressed individuals tend to attribute negative events to either external causes beyond their control or to internal, unchangeable deficits in the skills that are necessary to create change. They tend to set high standards for positive self-evaluation and at the same time have low standards for negative self-evaluation. Reduced self-esteem and increased feelings of helplessness and depression result from these maladaptive structures of self-evaluation (Lewinsohn & Hoberman, 1985).

In accord with this model, cognitions play a key role in Esteban's depression. For example, Esteban maintains the faulty belief that he is responsible for his father's behavior and for the demise of his family. Likewise, he attributes negative outcomes to deficiencies in himself (a negative internal attribution) instead of to the dysfunctional family and unstable economic environment around him. An effective intervention for Esteban must focus on these and other self-destructive and self-defeating cognitions..

Family Models of Depression
Finally, an ecological approach to understanding the development of childhood and adolescent depression is to attend to family dynamics and the family environment. These dynamics are of considerable importance. Proponents of this perspective suggest that young people who experience depression are symptoms of family malfunction. The homeostasis of a maladaptive family system is maintained when a child or adolescent performs the role of the sick family member. In accord with this model, other family members often resist any positive change in the adolescent because it risks upsetting the homeostasis of the family. This reality necessitates the involvement of the entire family system in treatment interventions (Guttman, 1983).

For Esteban, it seems critical that his entire family be involved in the treatment process. Although Esteban's concerns may be more acute right now, his sisters are both at risk for a variety of behavioral problems as well. Family intervention may help to not only resolve his issues but also prevent future problems among the other siblings. Furthermore, the behaviors and messages of Esteban's mother and father must be explored in order for each family member to recognize the resulting consequences. Clearly, the ideal is for Esteban's mother and father to be involved in treatment and to make changes. But if his father is no longer involved with the core family, at least Esteban's mother needs to understand and modify her patterns of communication and behavior. It is also important that the entire family receive support and validation in treatment, especially given the economic marginalization and racial victimization they experience. If family members are unwilling to be involved in treatment, any intervention focused solely on Esteban is likely to be ineffective.

In part two we will tackle some approaches to prevention and treatment of childhood and adolescent depression, and continue the analysis of Esteban's case.

 

Excerpted from
Youth at Risk: A Prevention Resource for Counselors, Teachers, and Parents, Second Edition
copyright © 1997, by the American Counseling Association
Edited by David Capuzzi, PhD and Douglas R. Gross, PhD
Article Authors: Benedict T. McWhirter, J. Jeffries McWhirter, and Irit Gat

 

Depression in Childhood and Adolescence: Working to Prevent Despair - Part 2

Editor's Note: In part one, the authors examined causal factors for depression in youth and looked at several models of depression. They also began the case study of Esteban which is concluded in part two of our feature.

 


APPROACHES TO PREVENTION AND TREATMENT

A conceptual model for understanding and intervening with at-risk youth has been proposed by McWhirter, McWhirter, McWhirter, and McWhirter (1993). This model is based on two key assumptions: (a) being at risk for problematic behavior reflects not only a current condition but also in element prediction for future problems and (b) at-riskness must be viewed not so much as discrete and unitary hut rather as a series of steps along a continuum. This continuum begins with youth who are at minimal risk for problematic behavior, proceeds through remote risk, high risk, and imminent risk, and ends with youngsters already engaged in category activity. Category activity refers to participation in one or more destructive behaviors such as drug use delinquent activity, and sexual promiscuity. A youngster's placement along the at-risk continuum is mediated by demographics, family and school environments, psychosocial stressors, and personal characteristics of the youth. This model also proposes that prevention, early intervention, and treatment must involve the family, school, and community. In short, interventions must attend to current problems, to the potential for future difficulty, and to multiple aspects of a young person's life.

Using the McWhirter et al. (1993) model, for example, Esteban can be considered at imminent risk. He has a very negative family environment, comes from a poor socioeconomic background, experiences a great many psychosocial stressors including subtle and direct racial discrimination, and does not have effective coping skills or clear goals for his future. Further, he has already developed gateway behaviors, such as smoking, being sexually explorative, and having violent outbursts, that highly predict category behavior.

In accord with this model, practitioners should (a) use generic skills training prevention programs for children in early elementary grades, (b) move into more focused and topic-specific prevention/intervention efforts for youth around middle-school age or earlier if risk factors demand it, and (c) use more topic-specific treatments and second-chance programs for older youth or youngsters already engaged in category activity. At the prevention end of the continuum, efforts are focused on the building of general skills, such as assertiveness, communication, recognizing feelings, and resolving conflict. At the treatment end of the continuum, interventions are focused on resolving specific problems that are already developed, such as depression, drug use, or delinquency, as well as on techniques that enhance a broad range of skills in order to prevent more serious problems from emerging as youth become young adults. For instance, Esteban needs treatment focused specifically on his depression and on its root causes but also focused on helping him develop skills for dealing with future problems in a wide range of areas. He could be helped by interventions for the entire family, by cognitive and behavioral strategies focused on him individually, by school intervention programs, and by community-based treatment approaches.

The core components of prevention as well as more specific treatment strategies can be applied to youth at risk for depression. These prevention and treatment strategies focus on the family, individual, school, and community.

Family Approaches to Prevention and Treatment

The role of the family in the successful treatment of the depressed child or adolescent is crucial. Counselors using only an individually based intervention strategy may, in fact, be doomed to failure because from this perspective the entire family needs to change its system. Mental health workers must also be aware that normal nurturance and family care may not be effective in dealing with the depressed child or adolescent (Robbins & Kashani, 1986). Clinicians must be prepared to work with all family members, especially parents who may also suffer from an affective disorder, in order to be successful. In Esteban's family, if his mother and sisters are not engaged in treatment, he is likely to continue to suffer from the same environment that contributed to his depression in the first place.

In many circumstances parent training can benefit the family and help prevent depression and other problems. Workshops for parents can be particularly useful and cost effective, especially those that focus on developing communication skills, enhancing family interactions, and sharing information about issues (such as birth control and signs of drug use). Workshops also offer parents a forum for discussing fears, concerns, and frustrations with other parents and with a professional facilitator. These types of training can increase parental confidence and comfort with discussing many issues with their children. With greater dysfunction, therapeutic programs attending to child abuse and neglect, parental dysfunction, and family violence may also be extremely beneficial.

Parent training may be utilized as prevention as well as treatment for many problems. In addition to childhood and adolescent depression, parent training topics of interest to many families include behavioral management and discipline, sex education, nutrition, family budgeting, and prevention of chemical dependency (DeMarsh & Kumpfer, 1986).

Parent effectiveness training (PET) and family effectiveness training (FET) are two models of parent training that have proven to be very effective for preventing depression. These programs have also been reviewed elsewhere as methods of empowering youngsters via counseling (McWhirter, 1994).

Parent effectiveness training. Parent effectiveness training (Gordon, 1975, 1977) is a method of parent training based on the Rogerian principles of positive regard and empathy. PET combines lectures, role-playing, readings, and homework exercises to train parents in confrontation skills, conflict resolution, active listening, and giving "I" messages. Parents have the opportunity to practice and refine each of these skills throughout the sessions. Ultimately, problems in the family are handled more constructively and with more open and healthy communication.

Family effectiveness training. Szapocznik, Santisteban, Rio, Perez-Vidal, and Kurtines (1986a, 1989) developed a preventative training model for Hispanic families of preadolescents at risk for future drug abuse. FET can also be modified to deal specifically with other child and adolescent behavior problems. The entire training consists of 13 sessions that last from 1.5 hours to 2 hours; the entire family is present for each session. Family effectiveness training is designed to address three problems that often serve as antecedents to adolescent behavior problems: maladaptive family interactions, intergenerational conflict, and intercultural conflict. It is one of few empirically tested programs that directly addresses cultural differences. The model has three components.

The first component, family development, helps the family to negotiate the childhood-to-adolescence transition. All family members learn constructive communication skills and take increased responsibility for their own behaviors. Parents become educated about drugs so that they can teach their children; they also learn the skills to become democratic rather than authoritarian leaders.

The second component, bicultural effectiveness training (BET) (Szapocznik, Santisteban, Kurtines, Perez-Vidal, & Hervis, 1984; Szapocznik et al., 1986b), is designed to bring about family change by (a) temporarily placing the blame for the family's problems on the cultural conflict within the family and (b) establishing alliances among family members through the development of bicultural skills and mutual appreciation of the values of both cultures. The family learns to handle cultural conflicts more effectively, and the likelihood that such conflicts will occur is reduced. BET represents an excellent parent training program in and of itself. This program could be particularly helpful for Esteban s family whose members contend with acculturation issues and overt and covert racism on a daily basis.

The third component of FET is the implementation of brief strategic family therapy. Based on the work of Minuchin (1974), this component involves a series of family therapy sessions and is the most experiential aspect of this didactic/experiential model.

Parental training programs will be helpful for Esteban, but because he already shows clear signs of depression, direct therapeutic intervention with the whole family is called for. Helping Irma and her children communicate more effectively with each other has the potential of creating a great deal of change in the family. In addition, helping each of the children to see his or her value and significance in the family is important. The family can become a primary source of support and encouragement when family members can share their needs, wants, and feelings more effectively.

Individual Approaches to Prevention and Treatment

Counselors and other mental health and education professionals in diverse settings can typically pursue individual approaches to prevention and treatment, and practitioners should follow their own orientation in attending to child and adolescent depression. The focus here is on cognitive-behavioral approaches that can be preventive and that have been effective with individuals already suffering from depression. A discussion of pharmacological intervention, another individualized treatment, is included.

Cognitive-behavioral treatments for depression flow directly from the cognitive and behavioral models described earlier in this chapter in the discussion of causal factors. For example, Beck et al. (1979) developed a therapy with both behavioral and cognitive components designed to reduce automatic negative cognition with the goal of challenging the assumptions that maintain these faulty cognitions. Because clients often have difficulty utilizing cognitive tasks, behavioral strategies should be used first in the therapeutic process. Similarly, positive activities should be established and augmented through role-playing, graduated task assignments, assertiveness training, activity schedules, and behavioral rehearsal before cognitive interventions are employed (Lewinsohn & Hoberman, 1985).

Behavioral strategies are important because depression results not only from the limited reinforcement of poor social skills but also from the lack of reinforcement that occurs when sufficiently learned and appropriate social skills are not utilized (Kaslow & Rehm, 1983). Increasing an individual's activity level and, therefore, the frequency of potentially rewarding activities may also increase the level of response-contingent reinforcement. This process may, in turn, reduce the behavioral symptoms associated with depression (Kaslow & Rehm, 1983). This behavioral intervention appears to be very appropriate for Esteban. Unless he becomes more involved in more positive peer interactions and in pleasant activities, he may have great difficulty in improving his depressed mood and in learning more positive cognitions.

Programs designed to increase activity levels include establishing an activity baseline, identifying current positive activities, increasing activities that are potentially reinforcing, decreasing activities associated with negative mood, and establishing environmental contingencies to reinforce both increased positive and decreased negative activities (Kaslow & Rehm, 1983). Scheduling more activity and using either self-managed or externally controlled reinforcement programs also help to increase positive activities.

After these strategies are successfully utilized, emphasis is moved to cognitive interventions that emphasize identifying, testing, and modifying cognitive distortions. Strategies that have been successfully used include (a) recognizing the connection between cognition, affect, and behavior; (b) monitoring negative automatic thoughts; (c) examining evidence related to distorted automatic cognition; (d) substituting a more realistic interpretation for distorted cognition; and (e) learning to identify and modify dysfunctional beliefs (Ellis, 1962; Ellis & Bernard, 1983; Kaslow & Rehm, 1983; Kolko, 1987). Such strategies could be implemented with Esteban as part of individual treatment. Of course, these strategies could also be used as part of a prevention program in the school setting.

Another intervention is Seligman's (1981) treatment approach, which is 'in outgrowth of his learned helplessness model of depression. It challenges the faulty attributions of control and efficacy that depressed individuals often make (Kolko, 1987). Focus is placed on enriching the environment to assist in effecting more desired outcomes while decreasing unwanted ones, developing expectations of control through control training, reducing preference for unobtainable outcomes through resignation training, and changing attributions to replace unrealistic ones.

The final cognitive-behavioral approach for depression is based on Rehm's self-control model. This intervention has been described as a primary prevention method, useful in teaching the skills necessary to avoid depression (Kaslow & Rehm, 1983). Kolko (1987) recommended that treatment in self-control involve specific training to, for example, monitor positive events and self-statements, engage in positive behaviors and cognitions, emphasize long-term positive consequences and develop more realistic and achievable goals, make more legitimate attributions, and create more frequent self-reinforcement. In Esteban's case, the depression is current. Devising ways to help him increase his positive and decrease his negative self-talk is important.

There are two cognitive-behavioral techniques that we have found to be particularly helpful. First, ask the child or adolescent to repeat a standard, positive phrase, such as "I am a good person every time he or she takes out a pen from his or her backpack. Second, ask the client to write down on three-by-five cards a positive, affirming self-statement (e.g., "I am an honest and decent person," "I am attractive and caring."). When three or four cards are completed, add one blank card and place them inside the client's class notebook. Each time the notebook is used, the client silently reads one of the cards. When the blank card turns up, the client must spontaneously make up a new, positive sentence.

Pharmacological interventions are, in some cases, required with depressed clients. Since the 1960s, trycyclic antidepressants have been prescribed for young patients (Hodgman, 1985). Monoamine oxidase (MAO) inhibitors and lithium carbonate have also been used to a lesser degree (Reynolds, 1985). Although frequently used in the clinical setting, the effectiveness of antidepressants has not yet been completely established through controlled research. Uncontrolled studies have reported positive results (Robbins & Kashani, 1986), but antidepressant use with children and adolescents should be carefully monitored. Counselors and psychologists need to have a referral network available so that this aspect of treatment is not neglected.

A combination of pharmacological intervention and therapy might be most useful with some adolescent clients suffering from depression (Cytryn & McKnew, 1985). In the case of bipolar disorders it is probably essential. The effectiveness of lithium carbonate with this type of depressive disorder has been well established. Of course, during a severe manic episode the behavior often causes problems that result in hospitalization. With adolescents, counselor and other practitioners need to be attentive to less severe mood swings or problems with a view to referral. Although the existence of a bipolar disorder does not seem probable in Esteban's situation, a medical referral for his depression may still be important.

School-Based Approaches to Prevention and Treatment

The increased rates of depression among children and adolescents support the need for early prevention and intervention in the school setting (Forrest, 1983). In fact, schools are an ideal setting for prevention: most children and youth can be reached, and most can be taught critical life skills as an integral part of the curriculum. Training in life skills can reduce existing problems as well as prevent more serious ones from occurring. As such, school-based programs can prevent child and adolescent depression and many other problems.

In responding to depression, school-based prevention programs engage multiple strategies. School counselors should use depression assessment instruments. To be effective, assessment should consider the youngster's cognitive and affective characteristics, environmental stressors, and current coping mechanisms (Forrest, 1983). School prevention and treatment should also include a mixture of affective, cognitive, and behavioral strategies, an approach that has been found to be effective (Coats & Reynolds, 1983). Further, group interventions are central to many school-based prevention programs because of their ability to reach a large number of children and their adaptability to the classroom format.

Early prevention in the schools can take the form of educational programs focused on forming friendships, nonviolent conflict resolution, assertiveness, relating to adults, and dealing with peer pressure. Broad-based skills training programs such as these not only prevent depression but also help to prevent other critical problems faced by youth, such as teenage pregnancy and drug use. Schools are important focal points in building these prevention programs because they provide access to both families and communities. In Esteban's case, such programs might have provided the social skills training that he did not receive at home.

The core components of good prevention programs, that is, training in life skills, include interpersonal communication, strategies for cognitive change, coping with stress, and managing health (McWhirter et al., 1993). Life skills are those that involve behaviors and attitudes necessary for coping with academic challenges, communicating with others, forming healthy and stable relationships, and making good decisions. Life skills training programs emphasize the acquisition of generic social and cognitive skills. The theoretical foundation of life skills training includes Bandura's (1977) Social Learning Theory and Jessor and Jessor's (1977) Problem Behavior Theory. In accord with these perspectives, children and adolescents are not blamed for causing their problems, but are viewed as capable of learning new ways to behave that reduce the likelihood of future problems.

Counselors and other mental health professionals can all be involved in teaching life skills. Procedures for teaching life skills resemble those used in the teaching of any other skill. Overall tasks are broken down into smaller stages or component parts and taught systematically, moving from simple to more complex skills. Each life skills session follows a five-step model: instruction (teach); modeling (show); role-play (practice); feedback (reinforce); and home-work (apply). Within this general framework, steps may be modified in accord with the needs of the group. Three broad skill categories are usually included in basic life skills programs:

·        interpersonal communication skills, including assertiveness and refusal skills;

·        cognitive change strategies, including problem-solving, decision-making, self-management and self-control skills, and cognitive-behavioral restructuring approaches; and

·        anxiety coping approaches, including relaxation, imagery training, and exercise.

Learning effective social skills is core to life skills training because it improves and increases the positive feedback and reinforcement that is received from others (Lewinsohn, Biglan, & Zeiss, 1976). Treatment here focuses on the improvement of interpersonal style and on the development of skills, such as improved eye contact (Kaslow & Rehm, 1983). Modeling, feedback, role-playing, instruction, situation logs, and homework practice are all utilized to help augment social skills and minimize the depression caused by an inability to elicit positive consequences. The prevalence of social skills deficits and the results of social skills training among children and adolescents have received limited attention. Nevertheless, such an approach seems especially appropriate for Esteban. Given the fact that he has had relatively little peer group interaction, preferring to be by himself, he has not developed effective social skills with his peer group. Indeed, he seems unable to cope with the responses of his classmates and family. Thus social skills training should be a useful strategy to help lift his depression.

Life skills training can also be achieved through leadership training programs. For example, students provided with leadership opportunities exercise decision-making skills and learn the importance of self-control (What schools can..., 1987). Some researchers have found positive effects from improving adolescent students' problem-solving and decision-making skills (Beyth-Matom, Fischhoff, Jacobs, Furby, 1989). Specifically, schools have reported marked reduction in disruptive behaviors after teaching students to mediate disputes on their own (Lane & McWhirter, 1992). The ability of students to solve their own problems and peacefully settle disputes directly and positively impacts student climate and reduces the likelihood of violence. The development of school mediation programs has been especially helpful in this regard.

School peer mediation (Lane & McWhirter, 1992; Schrumpf, Crawford, & Usadel, 1992) is a mode of student conflict management employed by students for the purpose of resolving conflicts. Trained peer mediators work in pairs to facilitate problem solving between disputants. Student involvement in the mediation process insures practice with critical thinking, problem solving, and self-discipline, all skills that prevent depression and other problems. The element of student participation in self- and peer-behavior change is directly related to the developmental construct of self-regulation. Further, awareness of socially approved behaviors is a critical feature of the concept.

In a similar way, peer counseling (sometimes referred to as peer leadership, peer mentoring, or peer helping) provides a helpful tool for increasing the impact and efficiency of prevention programs. Peer counseling is a process in which trained and supervised students perform interpersonal helping tasks--listening, supporting, providing alternatives, and other verbal and nonverbal interactions--that qualify as counseling functions with similar-aged clients who either have referred themselves or have been referred by others. Peer mediation and peer counseling programs help diminish the negative effects of peer pressure and promote more positive norms for adolescent behaviors (Corn & Moore, 1992; Garner, Martin, & Martin, 1989).

Interpersonal communication skills center around training in verbal and nonverbal communication and focus on healthy friendships, avoidance of misunderstandings, and development of long-term love relationships. Training in general assertiveness, an important part of effective communication skills, is a psychoeducational procedure designed to help adolescents deal effectively with others. Assertiveness training helps reduce the maladaptive anxiety that prevents adolescents from expressing themselves directly, honestly, and spontaneously. Nonverbal communication such as loudness of voice, fluency of spoken words, facial and body expression, and eye contact are important components of the way a message is delivered and interpreted.

Cognitive-behavioral strategies are seen as vital components of an individual's emotional health. Early exposure to cognitive techniques allows for a lifetime of practice and mastery of skills that have been shown to be highly effective in many types of mental difficulties including depression. Cognitive restructuring, self-management, self-control, problem solving, and decision making are important components. The cognitive approaches discussed in the section on causal factors are central here.

Stress and anxiety affect many young people. Techniques that enhance their ability to cope with and reduce stress and anxiety can be an important part of preventing depression. Specific techniques include relaxation training, biofeedback, autogenic training, meditation, the quieting reflex, affirmations, and guided visual imagery.

Finally, exercise, nutrition, and additional self-care habits are helpful but often ignored in prevention efforts. In a study by Brown, Welsh, Labbe, Vitulli, and Kulkarni (1992) a group of psychiatrically institutionalized adolescent boys and girls were assigned to a 9-week aerobic exercise program. The treated girls showed lower incidence of depression, anxiety, hostility, confused thinking, and fatigue, and both the adolescent males and females in the aerobics program showed improved vigor and self-efficacy. The added benefits of employing exercise and nutritional strategies with youth are multifold because forming healthy habits early in life is easier than changing habits later in adulthood.

School-based small group intervention programs for depression and other psychosocial problems have not often been rigorously evaluated, but existing outcome studies indicate some positive results. Groups to help adolescents deal with parental divorce have proven to be effective in ameliorating loneliness (Lesowitz, Kalter, Pickar, & Chethik, 1987) and have helped raise self-esteem and a sense of control in life (Omizo & Omizo, 1987). Groups for violent youth have also shown several positive effects in reducing school behavior problems (Roth, 1991). However, although such results are promising, more research is needed.

Community Approaches to Prevention and Treatment

Many of the family, individual, and school approaches for the prevention and treatment of childhood and adolescent depression discussed in this chapter could easily be employed by counselors, psychologists, social workers, and other mental health professionals who work in community treatment agencies. But approaches that specifically involve the larger community acknowledge the role of the larger context in which depression and other problems of childhood and adolescence emerge. This section focuses on a larger community program. Given the high correlation between delinquency and depression (McWhirter et al., 1993), Teencourt, the community program described here, can be seen as both a treatment and as a prevention measure for depression and other concerns.

Teencourt is used in Gila County, Arizona, for first-time juvenile offenders between the ages of 8 and 17 who have committed a misdemeanor offense, status offense, or minor traffic violation (McWhirter, 1994; McWhirter et al., 1993). The Teencourt program models an empowerment philosophy and incorporates leadership skills, critical thinking, career exploration, taking responsibility, and influencing peer norms. Youth referred to Teencourt have a choice of (a) pleading guilty, participating in the program, and keeping their record clean, or (b) going through the traditional juvenile court system. Teencourt sentencing is designed to fit the offense, and usually includes community service, tutoring, attending workshops, and/or traffic survival school.

Each session of Teencourt lasts 4 months and involves six attorneys, 20 jurists, one court clerk, and three bailiffs, all of whom are trained high school students. Thus offenders passing through Teencourt are tried by their peers; the judge is the only adult representative of the legal system. All defendants are required to serve a term of jury duty after their own sentencing. This is consistent with the goals of Teencourt, which include preventing repeat offenses among those who are tried, preventing first time offenses among the many students who voluntarily participate (as attorneys, jurists, clerks, and bailiffs), educating adolescents about the legal system, and utilizing peer pressure to evoke conformity to positive behaviors. The recidivism rate for Teencourt participants is well below both state and national averages (McWhirter, 1994).

Thus far, Esteban has not been accused of any legal violation. However, his involvement in some offense will not be surprising given his current alienation, anger, and apathy. Participation in a program such as Teencourt as an offender and then as a jury member could have a considerable positive effect. Teencourt's philosophy of empowerment is manifested in a variety of ways: by increasing adolescents' awareness of the legal system; by providing specific skills training as well as the broader experience of leadership; by utilizing peers--of equal power status--rather than adults; by involving adolescents with community organizations; by tailoring sentences to individual offenses; and by emphasizing responsibility for behavior (McWhirter, 1994). In the context of Seligman's 1974 model of learned helplessness, the Teencourt program addresses many of the deficiencies and apathetic responses from which Esteban suffers.

 



Comprehensive Intervention for Esteban

Esteban is a depressed 15-year-old who needs attention and support. For him and for other depressed youth, we propose an eclectic, multidimensional model for intervention built on the foundation of a solid interpersonal relationship between the depressed child or adolescent and the potential helpers in his or her environment: counselors, teachers, and parents. This relationship must incorporate the basic core conditions of empathy, warmth, and genuineness as well as respect for differences. It must also incorporate multicultural awareness and sensitivity. In Esteban's case, multicultural sensitivity involves more than a knowledge of Mexican-American cultural norms and needs to include an awareness of societal influences such as racism, oppression, and economic marginalization and of the effects of these influences on people of color and on their communities. However, this necessary interpersonal relationship is not sufficient for the successful treatment of depression.

Esteban's depression involves a complex pattern of cognitions, behaviors, affect, family dynamics, and larger environmental issues. The nature and severity of his apparent depression should be assessed thoroughly, via a family intake and measures of anxiety, depression, anger, and self-esteem. These factors combine to influence and be influenced by family dynamics, poor school performance, fear of interaction with others, peer rejection, and overt and covert racism that he experiences regularly.

Given the complexity of Esteban's present problems and the threat of future overtly violent behaviors, our multidimensional model indicates the employment of a comprehensive intervention plan. This plan should be responsive to Esteban's degree of risk along the continuum included in the conceptual model for understanding and intervening with at-risk youth (McWhirter et al., 1993) that is presented in the section on approaches to prevention and treatment. Esteban is clearly beyond prevention strategies; but attending directly to his depression involves skill building--which is basic to any prevention program and important for preventing future problems. In Esteban's case, effective intervention should include a behavioral component with both life skills training and activity level increase; a cognitive component designed to identify, test, and modify his dysfunctional beliefs related to himself, his family, his environment, and his future, and to help him monitor self-control; family interventions designed to improve the communication within the family and to improve his mother's consistency; and school interventions designed to attend to Esteban 's poor performance, relationships with peers, and poor self-esteem. Finally, some understanding and use of biological and pharmacological interventions may be necessary.

 


SUMMARY

Depression is a significant and complicated mental health problem among children and adolescents. Its manifestation in childhood varies, but in adolescence depression is similar to that found in adulthood. It is often linked to other at-risk factors such as suicide, school attrition, and behavior problems, which further augments the difficulty in making appropriate diagnosis and establishing effective treatment interventions. Additional research is clearly needed to gain a better understanding of the frequency and severity of this disorder and of the effectiveness of depression prevention and treatment among children and adolescents.

What is very clear is that depression can have a catastrophic effect on youngsters and on those around them. This is true for young Esteban. The interventions described in this chapter involve the family, individual, school, and community and can be employed in a comprehensive way to help tackle the depression that Esteban--and many other youngsters--experience. Parents, counselors, teachers, and other school personnel who play primary roles in the lives of children and adolescents must be especially aware of and responsive to the symptoms, causes, and problems associated with depression. Recognizing and responding quickly to depression and to its root causes is important in avoiding the potentially devastating effects of this disorder on the young people with whom we live and work.

 

Excerpted from
Youth at Risk: A Prevention Resource for Counselors, Teachers, and Parents, Second Edition
copyright © 1997, by the American Counseling Association
Edited by David Capuzzi, PhD and Douglas R. Gross, PhD
Article Authors: Benedict T. McWhirter, J. Jeffries McWhirter, and Irit Gat

Living with dignity

"17 years ago I decided I could no longer face life. I wanted to die - a strong wish that lasted over 10 years. If euthanasia were legal then, I would no longer be here to write this. But I have changed my outlook on life"

Alison Davis
Sunday November 10, 2002

Deborah Annetts, writing last week, lamented the fact that a man with cancer went to Switzerland in order to end his life, and suggested that a euthanasia law with "strict legal safeguards" would be an ideal way to deal with the problems faced by people who are "suffering unbearably from an incurable illness." I have good reason to disagree. Had the sort of law she proposes been in place some 17 years ago I would not now be writing this.

I have spina bifida, emphysema and osteoporosis. I use a wheelchair full time, and suffer severe spinal pain on a daily basis. This pain is not always well controlled even with morphine. All the conditions I have are incurable, and it is very likely that my pain will get worse over time. When the pain is at its worst I cannot think or speak, and this can go on for hours, with no prospect of relief. Taking morphine often makes me feel sick, and severe nausea is an added burden.

17 years ago I decided I could no longer face life. I wanted to die - a strong wish that lasted over 10 years. During the first 5 of those years I seriously attempted suicide, by various methods (cutting my wrists, taking overdoses of painkillers with large amounts of alcohol, etc). I wanted to sleep for ever and never hurt again. On the most serious of those occasions I was taken to hospital after my friends found me and called 999. I was treated against my will in hospital, and was extremely angry with the friends who had initiated life-saving treatment.

I was of sound mind. My decision was voluntary. I had several incurable conditions, I had severe pain which could not be remedied, and I had a "settled wish." At the time some doctors thought I had only a short time to live - one suggested 6 months - but I continued to live and had a settled wish to die for about 10 years.

Had a Dutch-type euthanasia law been in place I would have requested death. Under the "strict legal safeguards" which apply there, I would have qualified for euthanasia. Criteria like these are not "safeguards" at all, despite the insistence of those who support euthanasia that they are. They just separate those who are considered "right to want to die" from those considered "wrong to want to die." Those in the latter group receive help to live. Those in the former are killed. The criteria cited as "safeguards" are simply value judgements by those who think they know what sort of person is, in effect, "better off dead."

Pro-euthanasia campaigners have sometimes suggested that I would not, in fact, have qualified for euthanasia under a Dutch model law, because I was not terminally ill, and because they claim I was "depressed." These suggestions are easily refuted. Quite apart from the doctors' (incorrect) estimation of my remaining life-span, the Dutch law does not specify that the patient must be terminally ill, only that s/he must have an incurable condition, be "suffering unbearably" and that there be no alternative way of alleviating the suffering.

Leaving aside the arrogance of those who claim the ability to gauge my mental state at a time when they did not even know of my existence, the Dutch law also does not exclude depression as a reason for allowing euthanasia. Indeed there have been cases of euthanasia in Holland in which the patient's only condition was depression. Deborah Annetts, in her Commentary, cited the aims of the VES as "we campaign for a more humane law in the UK limited to competent adults, suffering unbearably from an incurable illness who are making an informed choice." That statement also does not specify that the person must be terminally ill and not be depressed. I would qualify for euthanasia under those criteria too. Now, some seven years after the wish to die receded I still have the same disabilities and my spinal pain is equally as severe as it was when I wanted to die. What changed was my outlook on life.

I went to India with Colin Harte, my full time assistant, to visit a new project to help disabled children, little knowing that it would change my life for ever. Many of the children are so disabled they can barely manage to crawl in the dust. They are unwanted and unloved by their families, but it is true to say that they saved my life. The first time I visited the children they called me "Mummy." They hugged and loved me, and as I was playing with them, I suddenly loved them all, overwhelmingly and fiercely, as if they really were my own. When we left I said to Colin "I think I want to live." It was the first time I had thought that for over 10 years.

As a result of that visit, I founded and now run a charity called Enable (Working in India) to help those and, now, many more disabled children. "My" children have given me a reason to live. They love me overwhelmingly, just as I am. They too have incurable conditions, and many suffer much pain. But they can and do give and receive a tremendous love, which transformed my life.

Euthanasia would have robbed me of the last 17 years of my life, and it would have robbed "my" Indian children of the chance in life they now have. While the VES speak only of a right to "die with dignity" what people like me really need is help and support to live with dignity until we die naturally.

· Alison Davis runs Enable (Working in India).

For more information on anti-euthanasia campaigns, see Very Much Alive, a group of disabled people who oppose euthanasia, and Alert, a group campaigning against euthanasia.

Send us your views

You can write to the author of this piece at Alison.Davis2@btinternet.com.

Email Observer site editor Sunder Katwala at observer@guardianunlimited.co.uk with comments on articles or ideas for future pieces.

 

LINKS

Following are very helpful links for more insight on Depression.

 http://www.depress.com/
Information on how to deal with depression in all european languages.

www.hoptechno.com/book34.htm
Learn about the leading causes and common symptoms of depression. Includes advice on how to deal with a suicidal friend. What to do when a friend is depressed. Advice for teenagers.

http://www.med.nyu.edu/Psych/screens/depres.html
Online depression screening test. NYU School of Medicine. Department of Psychiatry.

http://www.questia.com/Index.jsp?CRID=depression&OFFID=se1
Questia has dozens of books and journal articles on depression. Click on a book or article title below to preview that publication. Subscribe to read the entire work, and all of our over 70,000 books and articles.

http://health.discovery.com/convergence/fires/depression.html
Comprehensive depression resources at discoveryhealth.com.

http://www.psycom.net/depression.central.html
Clearing house for information on all types of depressive disorders and the most effective treatments.

http://depression.about.com/
Find practical details about living with depression. Includes advice on depression disorders and treatment, on suicide, and on seeking help.

http://www.depressionalliance.org/
Information about the symptoms and treatment of depression from Depression Alliance, a UK charity for people with clinical depression and anxiety.

  http://www.depression.org/
Severe depression is a biochemical illness ... Depression can disrupt, disable, and kill. People want help. Symptoms are easy to recognize...

http://www.wingofmadness.com/
Wing of Madness is a consumer's guide to depression, with articles, links, a message board and chat.

http://www.apa.org/monitor/feb00/suicide.html
"Eight Factors Found Critical In Assessing Suicide Risk"
Researchers identify eight critical risk factors for suicide in patients with major depression.

http://www.athealth.com/Consumer/disorders/ChildDepression.html
"Depression in Children and Adolescents"
Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that concerning adults, a number of studies - mostly conducted in the last four to five years - have confirmed the short-term efficacy and safety of treatments for depression in children.

http://www.nodepression.net/
The official site of No Depression.net

http://www.have-a-heart.com/
A rest stop from depression and thoughts of suicide. Articles help bipolar disorder, PTSD, suicidal thoughts, and major depression

http://www.depress.com/
Information on how to deal with depression in all european languages.