Research on Teenage Depression

Increasing Teenage depression in Pakistan

Submitted by: Iqra Jalal
BS-SS IA

TABLE OF CONTENTS:

i. Identifying the causes
a. Parental rejection
b. Acculturation
c. Addictive Internet use
d. Social anxiety and peer pressure ii. Understanding the signs and symptoms
a. Emotional Changes
b. Behavioral Changes iii. Diagnostic tools and screening strategies
a. Forms/Questionnaires
b. Follow ups
c. Monitoring iv. Treatments
v. References

EXECUTIVE SUMMARY:
Suicide is now the third most common cause of death among adolescents between 15-25 years of age and the sixth most common cause among 5-15 years old in Pakistan. It is believed that more than 50 percent of suicides in Pakistan have depression as one of the leading factors. There has been an alarming rise in the depression rates among teenagers in our country. Most of it is thought to be due to pressure to conform to the increasing standards of the society and the parents in both behavior and academics. A lot of it is due to the overuse of internet and little socializing. It is very important that the signs and symptoms of depression are caught early in their stages, proper diagnostic tools like questionnaires and forms are used to screen the patients and then effective treatment is applied to rid the youth of Pakistan from this mental illness.

UNDERSTANDING AND DEALING WITH THE ALARMING RISE IN TEENAGE DEPRESSION IN PAKISTAN.

‘’If the findings of this study are taken to face value then every third Pakistani is expected to be suffering from Depression and Anxiety’’, (Depression in Pakistan: An epidemiological critique, Tutorial Article:10, Journal of Pakistan Psychiatric Society, 2012)
In the socio-cultural context, the youth population serves as a great asset for every nation as they play a pivotal role in nation building. Their energy and towering ambitions can be utilized in various constructive ways. But considering the above stated national data, depression and suicide have become a major public health concern, and are alarmingly affecting the youth of Pakistan. Thus, it is very important to understand the signs and symptoms of depression in teenagers and adolescents, using appropriate diagnostic tools and then proper treatments and preventions to rid our nation of this serious epidemic.

IDENTIFYING THE CAUSES:
a. Parental Rejection:
Parental rejection is considered an important factor for psychological, behavioral and developmental problems of children, adolescents, and adults. Research findings proved that perceived parental rejection has been correlated with development of several psychopathologies including personality maladjustment and depression in adolescents (Rohner, 1986) Researchers (Lefkowitz & Tesiny, 1984) found positive correlation between maternal rejection and depression as assessed by mother, peer and self. The researchers also argued that paternal rejection predicted depression in daughters in future but not sons. Using the similar constructs like rejection and depression,Wichstrom, Anderson, Holte, and Wynne (1996) investigated harmful interpersonal relations concerning perceived rejection of children’s thoughts, emotions and perceptions and its relation with depression and deterioration in general functioning of these children. These researchers found higher level of psychological distress and impaired global functioning in children who were subjected to negative interpersonal communications. Negative interpersonal communication between parents and children is widely studied byRohner, Khaleque & Cournoyer (2007) who presented parental acceptance-rejection theory (PARTheory).
Agnew (2003) describes adolescence as a phase of stress, conflict and detachment between parents and a child. During adolescence period, the child wants autonomy and shows rebellious behavior. If they feel rejection from their parents, they develop different maladjusted behaviors resulting in hostility, aggression, negative worldview and depression (Khaleque & Rohner,2002;Sentse, Lindenberg, Omvlee, Ormel, &Veenstra,2009).
Researches show high associations between adolescents’ emotional, behavioral internalizing problems, depression, maladjustment and rejection from parents (Fotti, Katz, Afifi, & Cox, 2006) Greenberger, Chen, Tally and Dong (2000) also suggested that parental rejection has been associated and implicated in the development of depression and psychological problems. Some researchers (Greenberger & Chen, 1996) suggest that depression as a result of parental rejection is more common in female adolescents in comparison with the male adolescents. It is concluded that parental rejection is a major factor in development of maladjusted personality as well as psychopathology i.e., depressive symptoms in adolescents. Sadly, the query of association between parenting style and personality maladjustment combined with depressive symptoms has not received much attention yet by researchers in Pakistan.
b. Acculturation:
Acculturation is best conceptualized as a dynamic, multifaceted construct influenced by contextual and internal factors (Miller et al., 2006; Zane & Mak, 2003). Berry’s (2003) model of acculturation argues that acculturating individuals exhibits specific acculturative styles, which corresponds to the level of adaption to the culture in which one is embedded, as well as the involvement in behaviors and practices associated with their heritage culture. Mental health outcomes may be related to the congruence between acculturation and one’s environment, because psychosocial and behavioral competencies that are valued and learned within a specific cultural context may at times be either adaptive or evaluated as pathological by one’s environment (Ogbu, 1981). Thus, person-environment fit in relation to the contexts of one’s acculturation is of significant importance to understanding mental health from a cultural perspective.
Acculturation has been found to be associated with physical and mental health outcomes among many cultural groups, including Asian Americans (e.g., Hwang & Ting, 2008; Yen, Robins, & Lin, 2000) and South Asian Americans (e.g., Kumar & Nevid, 2010; Rahman & Rollock, 2004). and has been associated with outcomes such as intergenerational conflict, psychological distress, depression, and anxiety across multiple ethno cultural groups. Empirical research of the relationship between acculturation and mental health outcomes among teenage Muslims is comparatively limited, although recent evidence suggests a significant association between the two. Among Pakistani individuals, stress associated with the process of cultural adaptation, or acculturative stress, was related to lower psychological well-being and poorer subjective general health (Jibeen, 2011).
c. Addictive internet use:
While these studies seem alarming, experts are quick to point out that depression has only been linked to pathological users of the Internet, those with Internet addiction, not the average, everyday user. “One simple factor is that pathological Internet users are not sleeping correctly,” says Joseph Garbely, DO, chief medical officer of Friends Hospital in Philadelphia. “They get less sleep because they’re pathologically using the Internet. They’re also not eating right, not connecting in a healthy way to people (face to face), in socially acceptable ways. They’re getting lost in gaming and fantasy on the Internet, so they’re engaged in secretive behavior.”
With increased frequency, these activities lead Internet abusers down the path to depression, says Frank Barnhill, MD, a board-certified family physician and author of Mistaken for ADHD. “Any activity that limits a person’s interaction with others, with different environments or settings and with acceptable social customs, will lead to social deprivation syndrome. Persons suffering social deprivation develop irritability, mood swings, poor concentration, increased restlessness, possible aggressive behavior and impulsivity, and relationship problems.”

d. Academic Pressure:
Teens are under an enormous amount of pressure to succeed academically, especially as the costs of higher education rise and more families are reliant upon scholarships to help offset the expense. Stressing over classes, grades and tests has been a major cause for the rise of depression amongst adolescents. In Pakistan, it is even more serious because the students are expected to excel at all costs and they, then, begin to struggle with their course load. In such circumstances, if they are not provided with proper career and academic counseling, the burden goes on to becoming a serious issue for them causing mental illnesses like depression very common among teenagers.
e. Social Anxiety or Peer Pressure :
During adolescence, teenagers are learning how to navigate the complex and unsettling world of social interaction in new and complicated ways. Popularity is important to most teens, and a lack of it can be very upsetting. The appearance of peer pressure to try illicit drugs, drinking or other experimental behavior can also be traumatic for teens that aren’t eager to give in, but are afraid of damaging their reputation through refusal.
UNDERSTANDING THE SIGNS AND SYMPTOMS:
The first step to treating depression is recognizing the symptoms, which are sometimes difficult to distinguish from the normal anxiety that accompanies puberty and adolescence. Most of the behavioral and emotional changes are thought to be changes that come with the onset of teen age and adolescence and the main challenge for parents is to recognize the difference between normal teenage behavior and depressed teenage behavior.
Listed following are some of the emotional and behavioral changes in adolescents that might indicate a depressed mind:
EMOTIONAL CHANGES:
Feelings of sadness, which can include crying spells for no apparent reason
Irritability, frustration or feelings of anger, even over small matters
Loss of interest or pleasure in normal activities
Loss of interest in, or conflict with, family and friends
Feelings of worthlessness, guilt, fixation on past failures or exaggerated self-blame or self-criticism
Extreme sensitivity to rejection or failure, and the need for excessive reassurance
Trouble thinking, concentrating, making decisions and remembering things
Ongoing sense that life and the future are grim and bleak
Frequent thoughts of death, dying or suicide

BEHAVIORAL CHANGES:
Tiredness and loss of energy
Insomnia or sleeping too much
Changes in appetite, such as decreased appetite and weight loss, or increased cravings for food and weight gain
Use of alcohol or drugs
Agitation or restlessness — for example, pacing, hand-wringing or an inability to sit still
Slowed thinking, speaking or body movements
Frequent complaints of unexplained body aches and headaches, which may include frequent visits to the school nurse
Poor school performance or frequent absences from school
Neglected appearance — such as mismatched clothes and unkempt hair
Disruptive or risky behavior
Self-harm, such as cutting, burning, or excessive piercing or tattooing

It can be difficult to tell the difference between ups and downs that are just part of being a teenager and teen depression. Talk with your teen. Try to determine whether he or she seems capable of managing challenging feelings, or if life seems overwhelming.
If depression symptoms continue or begin to interfere in your teen 's life, talk to a doctor or a mental health professional trained to work with adolescents. Your teen 's family doctor or pediatrician is a good place to start. If you suspect your teenager is depressed, make a doctor 's appointment as soon as you can. Depression symptoms likely won 't get better on their own — and they may get worse or lead to other problems if untreated. Depressed teenagers may be at risk of suicide, even if signs and symptoms don 't appear to be severe.

DIAGNOSTIC TOOLS:
Given that depression is a widely prevalent but treatable condition among adolescents that creates long-term social, emotional, and economic burdens for the individual and the family, it is highly important to ensure accurate diagnosis, screening, follow-up, and effective treatment planning. Mass screening in primary care could help clinicians identify missed depression cases and initiate appropriate treatment. Screening could also help clinicians identify patients earlier in their course of depression. Current tools for assessing children and adolescents for depression include diagnostic interviews and symptom rating scales. Several of these tools are long and complex and have primarily been evaluated in non-primary care settings. Diagnostic screening tools, however, have been developed which are feasible for use in primary care (Table 1)

QUESTIONNAIRES
There are a variety of options for structured questionnaires that screen for adolescent depressive symptoms, as well as many that screen for general adolescent mental health. The tools listed here are not exhaustive, but do represent the most commonly used depression measures in primary care settings. Important information such as cost, time to administer, completion time, applicability to specific age groups, cutoff scores, and how to obtain them is provided for each screening questionnaire. It is recommended that providers choose a screening option that best fits the needs of their practice, considering their own clinical and patient population.
DEPRESSION-SPECIFIC QUESTIONNAIRES.
Mood and Feelings Questionnaire (MFQ).
The MFQ is a 32-item measure that consists of questions regarding how the adolescent has been feeling or acting within the past 2 weeks. A short version is also available that consists of 11 items and usually takes about 5 to 10 minutes to complete. For adolescents, the cutoff score on the full version for distinguishing those who are likely to have a depressive disorder from those who are not is 12 or higher. The MFQ can be used with children aged 8 to 17 years, and also has a parent version that can be used to assess symptoms based on parental report.
Patient Health Questionnaire (PHQ-9).
The PHQ-9 was originally developed for adults in primary care, with 9 items directly related to each of the criteria listed in the DSM-IV-TR for major depression. The PHQ-9 has been strongly supported for its applicability as a screening tool for adolescent depression in primary care as well as in pediatric hospital settings. The PHQ-9 takes approximately 5 to 10 minutes to complete. The optimal PHQ-9 cutoff score for adolescents is 11 or higher; it has been shown to have a sensitivity of 89.5% and specificity of 77.5% compared with a diagnosis of major depression on a structured mental health interview. There are also algorithms to use to determine if the adolescent meets diagnostic criteria for major depressive disorder or dysthymia.
In addition, the PHQ-2, a very brief depression screening scale consisting of the first 2 items of the PHQ-9, has been found to have good sensitivity and specificity for detecting major depression. The PHQ-2 may be used as a first step for screening. Adolescents who screen positive on the PHQ-2 may be further administered the rest of the PHQ-9.
Beck Depression Inventory (BDI)-II.
The BDI-II is a 21-item instrument for detecting depression that can be completed by adolescents aged 13 years and older. The BDI-II aligns with the depressive symptom criteria of the DSM-IV-TR and takes about 10 minutes to complete. It was specifically constructed to measure the severity of self-reported depression in adolescents. Athough the BDI-II is typically a self-report measure, providers can also verbally administer the measure to adolescents. It contains 21 questions with a scale value of 0 to 3. A cutoff score above 20 suggests moderate depression and a score of 29 or higher suggests severe depression. The BDI-II can be used with patients aged 13 to 80 years and is available in Spanish.
Children’s Depression Inventory (CDI)-2.
The CDI-2 is a 28-item scale used to assess for depressive symptoms in children and adolescents. It is derived from the BDI but modifies some questions to be more appropriate for younger ages. The CDI-2 is a self-report measure that is completed by the child or adolescent and usually takes about 15 to 20 minutes. It can be administered and scored using paper-and-pencil forms or online. It asks about key symptoms of depression, such as a child’s feelings of worthlessness and loss of interest in activities. The results indicate 3 levels of symptoms: 0 (absence of symptoms), 1 (mild or probable symptoms), or 2 (definite symptoms).

FOLLOW UPS, ADMINISTERING AND MONITORING:
The importance of implementing screening is emphasized only when such screening is supported by systems that can assist with further evaluation, including confirming the diagnosis and initiating evidence-based treatments. Thus providers and clinics need to be certain when they institute screening that systems are in place to review screening results and take the next appropriate steps. Among the practical considerations to creating screening protocols, clinics need to determine which staff would be responsible for administering, scoring, and recording the questionnaire, as well as ordering and maintaining the screening supplies.
After assessment for depressive symptoms has been conducted with the assessment tools previously discussed, a provider will have information about the level and severity of the adolescent’s symptoms. If an adolescent endorses symptoms that are consistent with mild depression, providers should engage in active monitoring practices according to the Guidelines for Adolescent Depression—Primary Care (GLAD-PC; http://glad-pc.org/). This is important because more than half of adolescents who screen positive for depression will have resolution of their symptoms without requiring psychotherapy or medications. Key aspects of active monitoring as emphasized by the GLAD-PC guidelines include increasing the frequency of follow-up visits, encouraging the adolescent to engage in regular exercise and activities, and identifying peer and adult support. Providers should also involve parents and engage them in being aware of their child’s symptoms and assisting in problem solving. Adolescents who are treated with active monitoring and who have persistent symptoms 6 to 8 weeks after screening should then receive evidence-based treatment for depression with regular follow-up visits until their symptoms have resolved.

Instrument
Age
Score range
Typical cutoff
Time to complete
(minutes)
Beck Depression Inventory
≥14
0-63
11 (female)
15 (male)
5-10
Center for Epidemiological Studies-Depression Scale for Children
12-18
0-60
None identified
5-10
Children 's Depression Inventory
7-17
0-54
19
5-15
Mood and Feelings Questionnaire
8-18
0-66
29
5-10
Patient Health Questionnaire for Adolescent
13-18
-
Scoring algorithm
5-10
Reynolds Adolescent Depression Scale
13-18
30-120
77
5-15
Strengths and Difficulties Questionnaire
≥12
-
Scoring algorithm
5-10
(Table 1)

TREATMENTS:
If an adolescent endorses symptoms consistent with moderate-to-severe depression, providers should discuss different treatment options, including psychotherapy, medication, or both. Evidence-based psychotherapies for adolescent depression exist; the most common treatments include cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for adolescent depression (IPT-A), both of which have shown effectiveness in treating children and adolescents with depression. Behavioral activation (BA) is also a promising treatment that has been adapted to treating adolescent depression. Providers should be ready with referrals to therapists who can provide these psychotherapeutic treatments.
In advance of implementing screening, clinics can create a list of potential resources for psychological treatment so that this information is readily available when needed. Medication for depression may also be indicated as part of treatment. Specifically, selective serotonin reuptake inhibitors (SSRIs) have proven effective in reducing symptoms of depression in adolescents. Any adolescent, who is started on antidepressants such as SSRIs, as well as his or her parents, should be counseled for the potential increased risk for suicidal behavior and monitored closely in the beginning of medication treatment. Because medications and psychotherapy have similar efficacy, one reasonable approach would be to work with patients and families to determine their treatment preferences and needs of the adolescent. Similar to active monitoring, the key to the use of evidence-based treatments is to monitor adolescents closely and to advance treatment for those who are not improving after 6 to 8 weeks of treatment. If multiple treatment providers are involved in managing the depression, obtaining a waiver of confidentiality to allow communication on progress and needs is ideal.

REFERENCES:
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References: b. Acculturation: Acculturation is best conceptualized as a dynamic, multifaceted construct influenced by contextual and internal factors (Miller et al., 2006; Zane & Mak, 2003)