Download Depression and Evidence- Based Treatments in School Mental Health

Depression and EvidenceBased Treatments in School
Mental Health
Michael Lindsey, PhD, MSW, MPH
Associate Professor, School of Social Work
Faculty Affiliate, Center for School Mental Health, School of Medicine
University of Maryland, Baltimore
Overview

Context: Prevalence of adolescent depression and
correlates

Identifying depression (and its varying types)
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Its varying types
Signs and symptoms

Relationship between suicide and depression
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Treatment (with some practice! )
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Common elements
CBT vs IPT-A

Family engagement and depression

Resources
How might adolescents
exhibit depressive
symptoms?
How Depression Might Look…
(When feeling down or hurt inside…) “I just deal
with it. There’s nothing -- I mean it’s just life. I
go through… I don’t seek help. I don’t talk to
anybody or nothing. I just go on with whatever
I’m doing.”
(Referring to his mother…) She’s making me go
[to a MH professional]. If I had a choice or my
say so, all this wouldn’t be going on because I’m
cool. I don’t feel there’s anything wrong. I don’t
need help. She asked me if I did. I laughed at
her…”
These adolescents
had elevated depression
symptoms based on the
CES-D symptom screen.
Depression
Epidemiology

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2.5% of children, up to 5% of adolescents (Some
indicate as much as 8.3% of adolescents)
Prepubertal-1:1/F:M; adolescence-3:1/F:M
Average length of untreated Major Depressive
Disorder – 7.2 months
Recurrence rates-40% within 2 years
Heredity
 Most important risk factor for the
development of depressive illness is having
at least one affectively ill parent
Depression Triples between the
Ages of 12 and 15 among
Adolescent Girls: 2008 to 2010
• 1.4 million girls aged 12-17 (12%)
experienced a major depressive episode
(MDE)
• 3 times the rate of their male peers
(4.5%)
• The percentage of girls tripled between
the ages of 12 and 15 (from 5.1 to
15.2%)
• About one third of girls aged 12 to 14
with MDE received treatment in the past
year compared with about two fifths of
those aged 15 to 17.
• Need to target our efforts toward middle
school girls
Source: National Survey on Drug Use and Health, 2008 to 2010 (revised March 2012). This is an
annual survey sponsored by SAMHSA. The survey collects data by administering questionnaire s to
a representative sample of the population through face-to-face interviews at their places of
residence.
Biopsychosocial Diathesis

Biological Factors
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Genetic predisposition
to stress
Temperament
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Psychological
Factors

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Early Life Experiences
Attachment Style
Social Factors

Current Significant Relationships

Current Social Support
Untreated Adolescent Depression:
Significant Public Health Implications

Risk factor for school dropout, teenage pregnancy, suicide,
and substance abuse/use (Mufson, et al., 2004)

Urban environment with associated stressors may be
particularly problematic for increasing depression among
youth (USDHHS, 2001)

Few youth with a depression receive care; treatment
underutilization for depression highest among Black (AA)
youth (USDHHS, 2001; Wu, et al., 2001; Garland, et al.,
2005).

Half of all lifetime adult mental health disorders start during
childhood (Kessler et al., 2005). A significant contributor to
the 12-month prevalence rate is the recurrence of mental
health problems (Kessler et al., 2012).
Depression and Community Violence
(Gaylord-Harden et al., 2011)

Regardless of SES, ethnic minority youth
experience more violence than their White
counterparts.

Expressions of sadness or low self-esteem
may increase victimization

Desensitization or “numbing effect” for
depression.
Depressive Disorders

Major Depressive
Disorder

Dysthymic Disorder

Depressive Disorder
Not Otherwise
Specified (NOS)
Depression
Modifications in DSM- IV for children:
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irritable mood (vs. depressive mood)
observed apathy and pervasive boredom (vs. anhedonia*)
failure to make expected weight gains (rather than
significant weight loss)
somatic complaints
social withdrawal
declining school performance
*Anhedonia: An inability to experience pleasure from normally pleasurable life
events such as eating, exercise, and social or sexual interaction.
Major Depressive Disorder
Major Depressive Episode:
Five (or more) of the following symptoms have been present during the
same two-week period and represent a change from previous
functioning. At least one symptom is either (1) depressed mood or (2)
loss of interest or pleasure.
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Depressed mood most of the day, nearly every day, as indicated by subjective
report or based on the observations of others. In children and adolescents,
this is often presented as irritability.
Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day
Significant weight loss when not dieting or weight gain (change of more than
5% of body weight in a month), or decrease or increase in appetite nearly
every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (observable by others)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or inappropriate guilt nearly every day
Diminished ability to think, concentrate, make a decision nearly every day
Recurrent thoughts of death, recurrent suicidal ideation with or without a
specific plan, or an actual suicide attempt
Major Depressive Disorder

Symptoms cause clinically significant distress or
impairment in social or academic functioning

Symptoms are not due to the direct physiological
effects of a substance (drugs or medication) or a
general medical condition

Although there is a different diagnostic category
for individuals who suffer from bereavement,
many of the symptoms are the same and
counseling techniques may overlap.
Dysthymic Disorder

Major difference between a diagnosis of Major
Depressive Disorder and Dysthymia is the
intensity of the feelings of depression and the
duration of symptoms.

Dysthymia is an overarching feeling of
depression most of the day, more days than not,
that does not meet criteria for a Major
Depressive Episode.

Impairs functioning and lasts for at least one
year in children and adolescents, two in adults.
Depressive Disorder NOS

Disorders with depressive symptoms BUT do not meet
criteria for: Major Depressive Disorder, Dysthymic
Disorder, Adjustment Disorder with Depressed Mood, or
Adjustment Disorder with Mixed Anxiety and Depressed
Mood

Examples: premenstrual dysphoric disorder, minor
depressive disorder (at least 2 weeks, but < 5
symptoms)

Also used in situations in which clinician has concluded
that a depressive disorder is present, but is unable to
determine whether it is primary, due to medical
condition, or substance induced
What type of depression??
Mario comes for a follow-up appointment to the
SBHC. His risk assessment showed that he has
felt sad or blue for at least two weeks. Upon
further inquiry, Mario reports that he generally
feels sad, and finds little enjoyment in activities.
He reports having felt this way for several years.
In fact, he can’t recall a time when he didn’t feel
mostly down. He denies suicidal ideation, and is
doing pretty well in school. He is not very social,
but does have a few friends.
What type of depression??
Tonya has come for an initial appointment to the
SBHC. During the risk assessment, Tonya reports a
number of depressive symptoms, including suicidal
ideation. Tonya seems to display a lot of negative
thinking and cognitive distortions. For example, she
believes that “nobody” likes her and that she will
“never” be successful in school. Her math teacher
often compliments her work, but Tonya dismisses the
teacher’s comments as him “just trying to be nice.”
Tonya has good grades in all classes except for one,
yet she only acknowledges her below average
Chemistry grade. Tonya has felt extremely sad for
about three weeks, which is a contrast from her
usually happy disposition.
Depression Versus
Normal Adolescent
Development
Adolescent Development
Adolescent Development

Periods of transient milder problems with
low self-esteem, anxiety, depressive feelings
are quite common.

Needs to be differentiated from clinical
depression!
Signs of Adolescent Depression
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Unhappiness
Gradual withdrawal into
helplessness and apathy
Isolated behavior
Drop in school performance
Loss of interest in activities
that formerly were sources of
enjoyment
Feelings of worthlessness,
hopelessness, helplessness
Fatigue or lack of energy or
motivation
Change in sleep habits
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Change in eating habits
Self-neglect
Preoccupation with sad
thoughts or death
Loss of concentration
Increase in physical
complaints
Sudden outbursts of temper
Reckless or dangerous
behavior
Increased drug or alcohol
abuse
Irritability; restlessness
Source: http://www.focusas.com/Suicide.html
Symptoms and Behaviors
Shared by Depression and Other
Mental Disorders
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Symptoms:
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Difficulty Concentrating
Difficulty Making Decisions
Feeling Irritable
Trouble with Sleep
Behaviors:
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Acting-out
Criminal Behavior
Irresponsible Behavior
Poor School Performance
Pulling Away from Family and Friends
Use of Alcohol or Other Illegal Substances to Cope
Depression and Suicide
Suicide

Attempts- 3:1/F:M, Completions- 4:1/M:F
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Most common means of completed suicide:
FIREARMS
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Most often associated with depressive disorder
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Risk factors: Age, sex, presence of psychiatric
illness, family history, isolation from friends,
substance abuse
More Risk Factors for
Suicidal Behavior
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Adverse life events
(Legal/Disciplinary
issues)
Access to firearms
Depression
Impulsivity
Social isolation
Previous suicide
attempt
Incarceration
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Helplessness
Poor self-esteem
Witness/experience
family violence or
abuse
Exposure to other’s
suicide behaviors
Rigid cognitive patterns
of thinking
Pregnancy
Adolescents and Suicide

In 2007, suicide was 3rd leading cause of death for young people ages
15 to 24.
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Of every 100,000 young people in this age group, the following died by
suicide:
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Children ages 10 to 14 — 0.9 per 100,000
Adolescents ages 15 to 19 — 6.9 per 100,000
Young adults ages 20 to 24 — 12.7 per 100,000

More likely to use firearms, suffocation, and poisoning than other
methods of suicide, overall. Children more likely to use suffocation.
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There were also gender differences in suicide among young people, as
follows:
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Nearly five times as many males as females ages 15 to 19 died by suicide.
Just under six times as many males as females ages 20 to 24 died by
suicide.
Source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics
Query and Reporting System (WISQARS): www.cdc.gov/ncipc/wisqars
Screening for Depression

The Clinical Interview
The Adolescent: Know the criteria but ask the questions without jargon
Key Informants:
Teachers: Honor their practice wisdom
Parents: May focus on certain symptoms. Get the whole picture
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Semi-structured Interview – you may not conduct one, you are likely to interpret one
K-SADS - http://www.wpic.pitt.edu/ksads/default.htm
Standardized measures
 Child Behavior Checklist http://www.aseba.org/forms.html
 State-Trait Anxiety http://www.mindgarden.com/products/staisch.htm
 Child Depression Inventory (CDI) - Distinguishes depression
typehttp://www.pearsonassessments.com/HAIWEB/Cultures/enus/Productdetail.htm?
Pid=015-8044-762
 Beck Depression Inventory
http://www.pearsonassessments.com/haiweb/cultures/enus/productdetail.htm?pid=015-8018-370
 Hamilton Depression Rating Scale – Gold Standard?
http://ajp.psychiatryonline.org/cgi/content/full/161/12/2163
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DSM –IV R but DSM V coming – may integrate depression and anxiety for adolescents!
Challenges to Treating Depression: The NO-SHOW
Project
“No-Show” Project – Detroit, MI (PI: Sean Joe)
Challenges in Treating Adolescents
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Feel stigmatized
Feel parents are the problem
Miss appointments or lateness
Early termination
Reluctance to talk – confidentiality
concerns
Therapist relationship with parent
Parent psychiatric illness
Lack of parent support for treatment
Quote Regarding Negative
Perception of Providers
“I don’t know. I don’t trust them [referring
to mental health therapists]…they get paid
to listen to you…I couldn’t do that [go to
therapy].”
-16 year-old Black male with depression
How could you address some
of these challenges?
 Stigma?
 Missed
appointments?
 Reluctance
to talk?
What is the Common Elements
approach?

“Clinicians ‘borrow’ strategies and techniques from known
treatments, using their judgment and clinical theory to adapt
the strategies to fit new contexts and problems” (Chorpita, Becker &
Daleiden, 2007, 648-649)

An alternate to using treatment manuals to guide practice

Using elements that are found across several evidencesupported, effective interventions

Actual practice elements become unit of analysis rather than
the treatment manual

Practice elements are selected to match particular client
characteristics
Depression: Practice Components
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Psychoeducation
Cognitive/Coping
Problem Solving
Activity Scheduling
Skill-building/Behavioral Rehearsal
Social Skills Training
Depression: Practice
Components
86
Child Psychoeducation
Cognitive/Coping
71
Problem Solving
71
% of EBP w/
Practice
Component
68
Activity Scheduling
64
Skill-building/Behavioral
Rehearsal
57
Social Skills Training
0
20
40
60
80
100
Psychoeducation
Clinicians should devote considerable time to
explaining the causes, symptoms and treatment
methods for depression to the student.
Most effective if clinician devotes more than one
session to psychoeducation for the student.
Providing Psychoeducation
about Depression
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Describe the symptoms and behaviors
associated with depression
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Describe depression as a medical illness that
can be treated.
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Decreases the stigma that can be associated with
depression
Takes the blame off of the adolescent for causing the
depression
Provides an optimistic prognosis for the depression
improving with treatment
Describe the interpersonal context of depression
Limited Sick Role

Give the student the notion that having depression is like
having any other illness

It affects they way they function in their day to day life
(e.g., drop in grades, less interest in after school
activities)
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Encourage normal participation in activities
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Can revise performance expectations while depressed
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Encourage parents to be less critical of performance and
more supportive of participation
Psychoeducation
In using psychoeducation for students,
clinicians should review:
• how depression develops
• how depression effects student’s life
• how you, as a clinician, intend to help them
(i.e. your treatment approach)
Psychoeducation
Review symptoms of depression in terms
the student can understand:
thinking – “I can’t, I won’t”
 Social withdrawal
 Irritability
 Poor school performance (not just grades)
 Lack of interest in peer activities
 Muscle aches or lack of energy
 Negative
Psychoeducation
Help the student identify ways in which
depression effects their life:
•
•
•
•
•
Feeling helpless a lot of the time.
Lowering their confidence-level about
intelligence, friends, future, body, etc.
Missing out on a lot of fun.
Getting into trouble because of boredom.
Not trying out for sports teams or drama club.
Psychoeducation
Emphasize the student’s role in the
treatment process.
•
•
•
Explain to students the importance of their emotions.
Describe benefits of your treatment method.
Establish an incentive for participation in the
treatment process.
•
•
Identify low-cost or free rewards and activities.
Contact parents to discuss and define incentive system.
Let’s Practice Psychoeducation
with a Depressed Client
Scenario:
Cassie is a 14-year-old female diagnosed with Dysthymic
disorder. Cassie indicated that she has not considered
receiving services for her mood disorder. In fact she
stated, “I do not need services, my family and I are very
close, so I talk to them about my problems.” Cassie
further mentioned that her family encourages her to talk
whenever she is feeling sad or depressed. Cassie
indicates that she has struggles with her mood, but she
does not feel the need to address her issues outside of
her cohesive family network.
Let’s Practice Psychoeducation
with a Depressed Client
Scenario:
Terry is 16-year-old male diagnosed with Major Depression Disorder.
He indicated that he struggles with forming peer relationships and is
contemplating sharing with friends that he is gay. In the last month,
Terry’s grades have gone from mostly Bs to Ds. His parents and
teachers noticed that Terry also has not been his usual happy self.
Terry was referred to his school mental health counselor to receive
treatment for his consistent depressive symptoms. He is pondering
treatment, but has not yet made a decision to attend therapy. He is
fearful that his peers would ridicule him for being in therapy and this
would exacerbate the tension he already has with them. He
recognizes, however, a need for treatment regarding his depressive
symptoms and decides to attend one session, although he feels
some ambivalence about treatment.
Cognitive/Coping
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Change cognitive
distortions
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Increase positive self talk

Normally there will be some
type of event that will
trigger the irrational
thought.
Cognitive Distortions

Black or white - Viewing situations, people, or
self as entirely bad or entirely good-nothing in
between.

Exaggerating - Making self-critical or other
critical statements that include terms like never,
nothing, everything or always.

Filtering - Ignoring positive things that occur to
and around self but focusing on and inflating the
negative.

Labeling - Calling self or others a bad name
when displeased with a behavior
Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health Curriculum - A Training
Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of Nursing, printed by the University of
Colorado School of Nursing.
Cognitive Distortions

Discounting - Rejecting positive experiences as
not important or meaningful.

Catastrophizing - Blowing expected
consequences out of proportion in a negative
direction.

Judging - Being critical or self or others with a
heavy emphasis on the use of "should have, ought to,
must, have to, and should not have.“

Self-blaming - Holding self responsible for an
outcome that was not completely under one's control.
Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health Curriculum - A Training
Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of Nursing, printed by the University of Colorado
School of Nursing.
Cognitive Distortions

Jumping to conclusions:
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Fortune Telling: You constantly anticipate and predict
future situations will turn out badly, often despite the
absence of facts.
Mind Reading: You assume that you know why and what
others are thinking, feeling and doing, without proof.
Emotional Reasoning: You reach conclusions
based on your feelings, “I feel this way so it must be”,
“it feels terrible, so it must be terrible”, “I’ll wait until I
feel like doing this.”
Source: Ten Days to Self Esteem by David D. Burns, M.D., © 1993, Harper Collins Publishers, Inc.
Revisiting the Scenarios
 Cognitive
Distortions in the case
of Cassie
 What
about Terry?
Problem Solving

Assist students in generating
solutions to problems

Focus on one problem at a
time
Problem Solving
Central goals of problem solving:

Improve how to confront interpersonal problems

Increase the number of pro-social solutions

Impart skills for how to approach and solve future
problems
Problem Solving
Explain the basis of problem solving:
•
•
Think about a problem to be solved.
Inspect the situation to be resolved.
Five Steps to Problem-Solving
1.
2.
3.
4.
5.
Say what the problem is
Think of solutions
Examine each one (What good and bad
things would happen if s/he tried the
solution?)
Pick one and try it out
See if it worked. If so, great! If not, go
back to the list of solutions and try
another one.
Helpful Hints: Problem Solving

Walk adolescent through hypothetical
problem one step at a time.

It is okay for the therapist to contribute a
few solutions.

After evaluating the plan:
You may need to go back to Step 1 or 2
 It may be helpful to establish consequences

Helpful Hints: Problem Solving

Teach students how to apply problem solving to different
daily situations:

Rehearse how to generate solutions.

Include coping statements in their problem solving strategy to
prolong positive emotions.

Confront unpleasant emotions by using coping strategies –
Catch the positive, let the negative go, etc.

Recognize that they have the ability to make the situation better
(self-efficacy).
Let’s Problem Solve with Cassie
1.
2.
3.
4.
5.
What is Cassie’s main concern?
What are some solutions?
What are some good or bad things
associated with each solution?
(Decisional Balance)
Which one should we try first?
What happens if it works? What happens
if it does not work?
SUSTAINABILITY
Activity Scheduling

Scheduling enjoyable
and goal-directed
activities into the child’s
day

Assists withdrawn
students with reengaging
in pleasurable activities
Activity Scheduling

Provides the child with the opportunity to
feel more effective as he or she completes
tasks such as school projects

Child needs to be educated about the
relationship between involvement in an
activity and improvement in mood.
Activity Scheduling with Tyler
Tyler, a 17-year-old senior, self referred himself to the school
mental health clinician. He has always done well in school,
but reports that he has lost interest in school and all his
activities in the past year. He has gone from an “A” student to
a “D” student. He reports that he has been feeling sad for a
year and doesn’t really know why. He has lost significant
weight from his lack of appetite and reports problems
concentrating and sleeping. He is confused by why he is so
sad, but feels he just can’t “snap out of it” and wants help. He
blames himself for not being able to handle senior year as
well as his other friends. He stated to you that “I’m the only
one who is going through problems and it is my fault that I
can’t handle it better.”
MH interventions shown to be
EFFECTIVE for depressive or
withdrawn behavior problems…
“Of the available services
reviewed, Cognitive Behavioral
Therapy remains the intervention
of choice… Interpersonal Therapy
appears to be a reasonable
alternative to CBT”
What is Cognitive Behavior Therapy (CBT)?

Relatively short-term, focused
psychotherapy

Focus:
How you are thinking (your cognitions)
 How you are behaving and communicating

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Emphasis on present rather than past

Learn coping skills
What is Interpersonal Therapy (IPT)?

Short term, usually involves up to 12 sessions

Focuses on 1-2 key interpersonal issues most
closely related to the depression.

Interpersonal events include:
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interpersonal disputes / conflicts
interpersonal role transitions
complicated grief
MH interventions with little or NO
evidence of effectiveness for
Depression:
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Family Therapy*
Relaxation
Self-Control Training
Self-Modeling
Non-directive Supportive Therapy
* Note: Family Engagement in CBT and IPT,
however, has been shown to be important!
Strategies for Family
Engagement
 Cassie:
How could you engage
Cassie’s family in treatment?
 Tyler:
How could you engage
Tyler’s family in treatment?
 Best
practices?
Review: Major Points

Signs of Adolescent Depression
 Depression vs. Normal Development

Biopsychosocial factors for depression
 Risk factors for suicide

Depression: Practice Components

CBT vs. IPT

Importance of Family Engagement
Resources

Family Guide: What Families Should Know
about Adolescent Depression and Treatment
Options, NAMI: www.nami.org
(Search for “depression” and PDF for family guide
depression will come up)

SAMHSA, Major Depression in Children &
Adolescents:
http://store.samhsa.gov/product/Depressionamong-Adolescents/SR110
Resources

Mental Health America: Depression and
Mood Disorder Fact Sheets:
http://www.nmha.org/index.cfm?objectid=C7DF9
50F-1372-4D20-C8B5BD8DFDD94CF1
Acknowledgements

Kerri Chambers


Crystal Williams


Research Coordinator, SOM, UMB
PhD Student, SSW, UMB
Drs. Nancy Lever and Sharon Stephan

Co-Directors, Center for School Mental Health
Michael’s contact:
 Email: [email protected]
 Website: http://www.ssw.umaryland.edu/faculty_and_research/bios/lindsey/