Depression

1
Depression
Dr. Aubrey H. Fine
2

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

3

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

4
Diagnosis

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

5
Diagnosis cont

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19
Bipolar Disorder
20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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

33

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

34

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

35

• Treatment of Depression and Bipolar Disorder

36

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

37

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

38

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

39

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

40

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

41

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

42

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

43

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

44

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

45

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

46

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

47

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

48

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

49

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

50

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

51

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

52

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

53

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

54

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

55

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

56

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

57

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

58

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

59

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

60

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

61

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

62

• Youth Suicide

63

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

64

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

65

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

66

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

67

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

68

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

69

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

70

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

71

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

72

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

73

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

74

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

75

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

76

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

77

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

78

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

79

• Universal Approaches to Youth Suicide Prevention

80

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

81

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

82

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

83

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

84

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

85

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

86

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

87

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

88

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

89

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

90

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

91

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

92

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

93

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

94

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

95

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

96

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

97

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

98

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

99

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

100

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

101

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

102

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

103

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

104

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

105

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

106

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

107

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

108

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

109

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

110

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

111

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

112

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

113

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

114

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

115

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

116

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

117

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

118

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

119

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

120

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

121

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

122

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

123

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

124

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

125

• Preventive Interventions and Treatments

126

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

127

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

128

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

129

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

130

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

131

• Currently the CARE intervention expanded to