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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) Its varying types Signs and symptoms Relationship between suicide and depression Treatment (with some practice! ) 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 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 Genetic predisposition to stress Temperament Psychological Factors 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: 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. 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 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 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 Symptoms: Difficulty Concentrating Difficulty Making Decisions Feeling Irritable Trouble with Sleep Behaviors: 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 Most common means of completed suicide: FIREARMS Most often associated with depressive disorder Risk factors: Age, sex, presence of psychiatric illness, family history, isolation from friends, substance abuse More Risk Factors for Suicidal Behavior Adverse life events (Legal/Disciplinary issues) Access to firearms Depression Impulsivity Social isolation Previous suicide attempt Incarceration 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. Of every 100,000 young people in this age group, the following died by suicide: 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. There were also gender differences in suicide among young people, as follows: 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 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 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 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 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 Describe the symptoms and behaviors associated with depression Describe depression as a medical illness that can be treated. 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) Encourage normal participation in activities Can revise performance expectations while depressed 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 Change cognitive distortions 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: 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 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: interpersonal disputes / conflicts interpersonal role transitions complicated grief MH interventions with little or NO evidence of effectiveness for Depression: 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/