Problems Related to the Identifying, Diagnosis and Assessment of Adolescent Depression

Problems Related to the
Identifying, Diagnosis and
Assessment of Adolescent
Depression

Corna Olivier
Student number 6919596
University of South Africa

Table of Contents
Pg
Title page………………………………………………………………………….. 1
Table of Contents ……………………………………………………………… 2
Introduction………………………………………………………………………. 3
Adolescent Depression and the DSM-IV-TR ….………………………….

5

Gender differences in Adolescent Depression ……………………………… 7
Culture and other environmental influences …………………………………. 9
Conclusion ………………………………………………………………………..10
List of References ……………………………………………………………….. 11
Plagiarism Declaration …………………………………………………………. 13

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Introduction
Depression in adolescents has become very prominent in recent years. The impression that the increase in depression cases amongst adolescents has taken on epidemic proportions, has been successfully refuted (Costello,
Erkanli, & Angold, 2006) but nevertheless it remains concerning. Add to this the more worrying notion that many cases of adolescent depression may go unnoticed, or be misdiagnosed, and one can see why it has become important to try and find the reasons behind these difficulties. Because only once we have correctly identified the problems we can start working on finding solutions. Depression as a medical disorder is hard to diagnose, even among adults.
Doctor A.J. Mitchell reported that in a meta-analysis undertaken by a group of affiliates from The Clinical Advisor it was found that clinicians correctly diagnosed only half of the cases in the study who were clinically depressed.
Furthermore they diagnosed 20% the control group – people who did not suffer from depression, incorrectly, as depressed.

(Mitchell, 2009)

adolescent phase is a turbulent time in every human’s development.

The
In this

phase the brain starts to release hormones which cause physical, emotional and cognitive changes in the person.

It is also in this period when

mainstream schools have the young person move from junior school to middle and senior school. This is the phase in a human’s development when gender awareness and differences reaches its peak. It is only to be expected then, that depression may quite probably manifest differently in boys than what it
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does in girls.

One also has to consider that environmental factors, for

example, nationality, ethnic groupings and the socioeconomic environment of the adolescent all may influence the ultimate correct identification, diagnosis and assessment of the depressive state of the teen.

Depression is a broad term but clinically the following categories exist:
MDE (Major Depressive Episode)
ADHD (Attention Deficit Hyperactivity Disorder)
Bipolar Disorder
Depression
Depressive disorder not otherwise specified.

In this short paper I looked at the difficulties around the identifying, diagnosis and assessment of depression in adolescents. I have read various scholarly articles, magazine articles and on-line articles dealing with the topic. I have also stumbled upon a highly entertaining talk posted on YouTube. Using the data gathered by the authors I present this discussion paying specific attention to the possible influences of gender and other contextual differences on the problem in question.

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Adolescent Depression and the DSM-IV-TR
The first and most apparent difficulty lies in the classification of depression.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and used widely by psychologists and psychiatrists to help identify and classify mental disorders and diseases.
The current form of the manual (DSM-IV-TR) has last been updated in 2000 and according to an article in the Scientific American (Jaber,2013) the latest updated manual should be released in May 2013. At the present time the criteria for a MDE is listed as: (The PYC4802/PSY481U Team, 2013)
1. Depressed mood.
2. Markedly diminished interest or pleasure in all or almost all activities.
3. Significant (>5% body weight) weight loss or gain, or increase or decrease in appetite.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.

 Must have a total of 5 symptoms for at least 2 weeks.
 One of the

7. Feelings of worthlessness or inappropriate guilt.
8. Diminished concentration or indecisiveness.

symptoms must be depressed mood or loss of interest.

9. Recurrent thoughts of death or suicide.

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In a descriptive study of the characteristics of adolescent depression (Crowe,
Ward, Dunnachie, & Roberts, 2006) involving more than 500 adolescents a
Mood and Feeling Questionnaire (MFQ) was used as part of the tools to gather data. The MFQ is a 32-item questionnaire based on the criteria for depression as identified in the DSM-III-R (Chalmers, 2011) adjusted to be used for children ages 8-18.

According to Crowe et al

(2006) the ten

questions most often marked as TRUE by adolescents suffering from depression in order from most frequent (1) to least frequent (10) were:
1. I felt grumpy and cross with my parents i.e. Irritability
2. I found it hard to think properly or concentrate i.e. Diminished concentration 3. It was hard for me to make up my mind i.e. Indecisiveness
4. I felt like talking less than usual i.e. Social withdrawal
5. I didn’t sleep as well as I usually sleep i.e. Insomnia
6. I felt lonely i.e. Feeling of isolation
7. I felt miserable or unhappy i.e. Depressed mood
8. I hated myself i.e. Feelings of worthlessness or inappropriate guilt.
9. I felt so tired I just sat around and did nothing i.e. Fatigue or loss of energy. 10. I didn’t have any fun at school i.e. Markedly diminished interest or pleasure in all or almost all activities

From this we can clearly see that the most marked sign of adolescent depression is irritability.

In their conclusion Crowe et al stated that “The

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significance of irritability increased with the severity of the depression.” In contrast with this, irritability is not listed as a criterion for depression in the
DSM-IV-TR. Social withdrawal and feelings of isolation were also reported with high frequency by adolescents suffering from depression, but these two symptoms are also not listed by the DSM-IV-TR.

The DSM-IV-TR require in order for an episode to be classified as a MDE a total of 5 symptoms from the list of criteria must be present for at least 2 weeks and one of the symptoms must be depressed mood or loss of interest.
Although markedly diminished interest or pleasure in all or almost all activities as well as depressed mood were reported by some of the adolescents, from the ranking of the statements – Depressed Mood only 7th, for instance, it is clear that some depressed adolescents did not report this and would possibly not have been classified as depressed if the DSM-IV-TR criteria were strictly adhered to.

Gender differences in Teen Depression
In the same study Crowe et al compared differences in responses between boys and girls. The differences in responses are shown in Table 1. The most reported symptom for boys were “I felt like talking less than usual.” I.e. Social withdrawal while for girls it was “I felt grumpy and cross with my parents” i.e.
Irritability.

Neither of these is on the DSM-IV-TR list.

The second most

common reported symptom for depressed girls namely “I felt lonely,” or feeling isolated is also not on the DSM-IV-TR criteria list.
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Boys

Girls

1

I felt like talking less than usual

I felt grumpy and cross with my parents

2

I found it hard to think properly or concentrate

I felt lonely

3

It was hard for me to make up my mind

I hated myself

4

I felt grumpy and cross with my parents

I cried a lot

5

I didn’t sleep as well as I usually sleep

I felt miserable or unhappy

Table 1: Comparison between depresses boys’ and - girls’ top 5 symptoms most frequently reported as “TRUE” on the MFQ

The most marked difference between girls and boys is that a larger part of the symptoms endorsed by depressed girls as “TRUE” are internal – therefore less likely to be noticed by a parent, teacher or caregiver.

Depressive symptoms in boys are markedly more external and one would therefore think that depression in adolescent boys is more likely to be accurately diagnosed. Recent research suggests however, that symptoms traditionally associated with depression in boys, such as social withdrawal, inability to concentrate, insomnia and a markedly diminished interest or pleasure in all or almost all activities are all symptoms of addiction – specifically - addiction to internet pornography.(Wilson, 2012.)

An additional

danger which exists is that depression or depressive symptoms may be ascribed to mood swings due to normal hormonal changes during adolescence. Hirsch and Brizendine (2007) suggested that successful

identification and treatment of adolescent girls’ depression may require a gender specific approach.
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Culture and other environmental influences
In order to accurately identify, diagnose and assess the depressed adolescent, the young person need to first of all be seen. In all countries around the world public schools are overcrowded. Teachers are less likely to become concerned about a teen who has become withdrawn. On the home front both parents are working and in a large number of cases parents are working shifts which reduce the amount of time spend with their children even more. In their study “Maternal and paternal parenting styles in adolescents:
Associations with self-esteem, depression and life-satisfaction study”
Milevsky, Schlechter, Netter, and Keehn (2007) noted:

“The majority of work on adolescents and their families, employing “active” consent procedures (i.e. requiring written consent from parents before their adolescents participant in the study), has screened out a disproportionate number of potential participants from neglectful homes since the “neglectful” parents may be less likely to respond to the researchers’ request.”
In order to get around this obstacle the researchers have gone ahead and used a passive consent, whereby the parents needed to let them know if they didn’t want their child to be included in the study. It worked for their study, but where does it leave the depressed adolescent whose parents hardly ever get into contact with them?

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The absent or neglectful parent is a modern environmental problem.
Awareness and added vigilance could be helpful in overcoming it. Programs to help adolescents cope with feelings that lead to depression such as intervention strategies employed at schools may be effective in solving this problem. (Page & Hall, 2009).

The DSM-IV(1994) states that : “Culture can influence the experience and communication of symptoms of depression.” In cultures across the world depression is embraced in some quarters and in others abhorred.

For

instance in traditional Roman Catholic homes depression (sloth) is considered to be one of the seven deadly sins and therefore much less likely to be reported as a condition where the young person suffering may be able to receive treatment. Marsella (2003) thinks that when we use a western style set of criteria by which to identify, diagnose and assess depression we ignore the diversity of world cultures, thus removing the anchors to traditions which we all need in order to survive.
Conclusion
Many researchers concluded that the way in which we identify, diagnose and assess depression in adolescents at this point in time is far from ideal. The
DSM classification need to be updated, we hope that the changes about to be released will reflect that. It also became clear that identification, diagnosis, assessment and even treatment of depression need, not only a gender specific, but also a culturally unbiased approach.
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References
Angold, A., Costello, E. J., Messer, S. C., Pickles, A., Winder, F., & Silver, D.
(1995) The development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of
Methods in Psychiatric Research, 5, 237 - 249.
Burwell, R.A., & Shirk, S.R. (2006). Self-processes in adolescent depression:
The role of selfworth contingencies. Journal of Research on Adolescence, 16(3),
479-490.
Chalmers, A (2011). Mood and Feelings Questionnaire (MFQ) retrieved from http://www.cebc4cw.org/assessment-tool/mood-and-feelings-questionnaire-mfq/ Costello, E.J., Erkanli, A., & Angold, A., (2006). Is there an epidemic of child or adolescent depression? Journal of Child Psychology and Psychiatry, 47(12),
1263-1271.
Crowe, M., Ward, N., Dunnachie, B., & Roberts, M. (2006). Characteristics of adolescent depression. International Journal of Mental Health Nursing, 15, 1018.
Han, W.J., & Miller, D.P. (2009). Parental work schedules and adolescent depression. Health Sociology Review, 18, 36-49.
Hirsch, D., Brizendine, L. (2007). Teen girl brain: High drama, high risk for depression. The Journal of Family Practice, 6(5) Retrieved from http://www.jfponline.com/Pages.asp?AID=5038 Jaber, F. (2013, May). Neuroscience Beyond Symptoms. Scientific American,
308(5), 8.
Marsella, A. J. (2003). Cultural Aspects of Depressive Experience and
Disorders. Online Readings in Psychology and Culture, 10(2). http://dx.doi.org/10.9707/2307-0919.1081 Mash, E.J., & Wolfe, D.A. (2010). Abnormal child psychology (4th ed.). Belmont:
Wadsworth Cengage Learning.
Milevsky, A., Schlechter, M., Netter, S., & Keehn, D. (2007). Maternal and paternal parenting styles in adolescents: Associations with self-esteem, depression and life-satisfaction. Journal of Child and Family Studies 16, 39-47.
Mitchell, A.J. (2009, December) Why Depression is hard to Diagnose. The
Clinical Advisor,12(9). Retrieved from http://www.clinicaladvisor.com/whydepression-is-hard-to-diagnose/article/159796/#

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Page, R.M., & Hall, C.P (2009). Psychosocial distress and alcohol use as factors in adolescent sexual behaviour among sub-saharan African adolescents.
Journal of School Health, 79(8),369-379.
The PYC4802/PSY481U Team, (2013),Tutorial letter PYC4802/101/0/2013, 3135
Wilson, G. (2012, May 16). The Great Porn Experiment: Gary Wilson at TEDx
Glasgow
[Video file]. Retrieved from http://www.youtube.com/watch?v=wSF82AwSDiU

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PLAGIARISM DECLARATION (The PYC4802/PSY481U Team, 2013)

1. I know that plagiarism is wrong. Plagiarism is using another’s work and pretending that it is one’s own work.

2. I have used the American Psychological Association (APA) as the convention for citation and referencing. Each significant contribution to, and quotation in, this assignment from the work, or works of other people has been attributed and has been cited and referenced.

3. This assignment is my own work.

4. I have not allowed, and will not allow, anyone to copy my work with the intention of passing it off as his or her own work.

5. I acknowledge that copying someone else 's assignment, or part of it, is wrong, and declare that this assignment is my own work.

Because I am submitting this assignment electronically I am typing my name and declare that to be as binding as my signature of agreement
SIGNATURE: ____ Corna Olivier _______

DATE: ___24 May 2013 ______________

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References: (1995) The development of a short questionnaire for use in epidemiological studies of depression in children and adolescents Burwell, R.A., & Shirk, S.R. (2006). Self-processes in adolescent depression: The role of selfworth contingencies Chalmers, A (2011). Mood and Feelings Questionnaire (MFQ) retrieved from http://www.cebc4cw.org/assessment-tool/mood-and-feelings-questionnaire-mfq/ Costello, E.J., Erkanli, A., & Angold, A., (2006). Is there an epidemic of child or adolescent depression? Journal of Child Psychology and Psychiatry, 47(12), Crowe, M., Ward, N., Dunnachie, B., & Roberts, M. (2006). Characteristics of adolescent depression Han, W.J., & Miller, D.P. (2009). Parental work schedules and adolescent depression Hirsch, D., Brizendine, L. (2007). Teen girl brain: High drama, high risk for depression Marsella, A. J. (2003). Cultural Aspects of Depressive Experience and Disorders Milevsky, A., Schlechter, M., Netter, S., & Keehn, D. (2007). Maternal and paternal parenting styles in adolescents: Associations with self-esteem, Mitchell, A.J. (2009, December) Why Depression is hard to Diagnose. The Clinical Advisor,12(9) Std no 6919596 Page, R.M., & Hall, C.P (2009) The PYC4802/PSY481U Team, (2013),Tutorial letter PYC4802/101/0/2013, 3135 Wilson, G Std no 6919596 PLAGIARISM DECLARATION (The PYC4802/PSY481U Team, 2013)