WCW Blog

The Women Change Worlds blog of the Wellesley Centers for Women (WCW) encourages WCW scholars and colleagues to respond to current news and events; disseminate research findings, expertise, and commentary; and both pose and answer questions about issues that put women's perspectives and concerns at the center of the discussion.

13 Reasons Why and the Need for Correct Messages About Teen Depression and Suicide

13 Reasons Why Character Poster Clay Jensen13 Reasons Why and the Need for Correct Messages About Teen Depression and Suicide

By now, parents and professionals have reacted to the new Netflix series, 13 Reasons Why. Mental health advocates and school administrators have highlighted the risks of depicting suicide as a means of revenge, of dramatizing teen suicide, and of showing school counselors as uncaring and ineffective. I would be remiss if I did not add my voice to others' by expressing my dismay that this program exposes teens to such unhealthy messages about such an important topic, and that teen depression is presented as a malady that can only be addressed through suicide.

Rather than repeating the many critiques of this series, my purpose here is to share correct messages about adolescent depression and suicide that we, as professionals and parents, should know and should be sharing with our children. Of course this is a difficult topic to broach with adolescents, but given that so many teens have watched this series already, we must embrace this opportunity to teach our children, and ourselves, about youth depression and suicide. This conversation is particularly important now, in the midst of Mental Health Awareness Month.

In fact, suicide is the third leading cause of death among adolescents, and rates of suicidal thinking and behavior are particularly high among Lesbian, Gay, and Bisexual youth. While youth depression and youth suicide are distinct concerns, approximately half of all teens that die by suicide have a mood disorder, such as depression, at the time. Adolescent depression is quite common, with approximately 11 percent of all teens experiencing depression during adolescence. Although youth depression is prevalent and impairing, we now have available numerous depression prevention and treatment protocols that work. Thus, most teens who struggle with depression go on to lead healthy and productive lives.

How do we know if a teen might be experiencing depression or considering suicide? Among other symptoms, signs of youth depression include low mood or irritability, lack of interest in activities, a change to sleep or eating patterns, reduced concentration, fatigue, low self-esteem, and thoughts of death or suicide. Of course all teens experience such symptoms now and then. We worry about teens that experience a cluster of these symptoms, and when these symptoms persist over a period of at least two weeks.

tracy thirteenreasons quoteLikewise, we worry about teens that exhibit signs of suicide. Sometimes these signs are subtle, such as giving away prized possessions, withdrawing from friends, or exhibiting significant behavioral changes, such as intense fights with family and friends. Teens thinking about suicide may also provide verbal cues, such as, “I wish I were dead” and “It’s not worth it anymore.” Also, many people who contemplate suicide do so because they believe they are a burden to others, and that they will be doing others a favor if they are no longer here. Thus, if you hear a teen say, “My family would be better off without me,” it is important to take action. Remember that 50-70 percent of people who make a suicide attempt communicate their intent prior to acting, mostly through such actions or verbal cues. Thus, if you recognize any of these signs, it is important to ASK. Although many of us find it scary to ask about suicide, or worry that asking about suicide will give someone the idea to attempt suicide, we know from numerous studies that talking about suicide will not lead to suicidal behavior.

How do you ask a teen if s/he might be thinking about suicide? Ask the question directly. It is okay to ask a teen if s/he has ever felt like it would be better if they were dead, or if, when very upset, they have experienced suicidal thoughts. If a teen acknowledges suicidal thoughts, s/he should be provided reassurance that help is available, and should be brought for an evaluation and treatment immediately. It’s important to remember that most people who talk about suicide do not really want to die. In fact, most suicides are not impulsive acts, and most people who contemplate suicide give many cues of their intentions, making suicide a largely preventable form of death in the United States.

The primary danger of 13 Reasons Why is that it reinforces damaging myths about youth depression and suicide. Now that this series has been released, and knowing that our teens may well have watched it, our best course of action is to counter those damaging myths by sharing important truths about teen depression and suicide.

Tracy Gladstone, Ph.D. is an associate director and senior research scientist at the Wellesley Centers for Women at Wellesley College, as well as the director of the Robert S. and Grace W. Stone Primary Prevention Initiatives, which focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

References:

Avenevoli, S., Swendsen, J., He, J., Burstein, M., & Merikangas, K. R. (2015). Major depression in the national comorbidity survey–adolescent supplement: Prevalence, correlates, and treatment. Journal of The American Academy Of Child & Adolescent Psychiatry, 54(1), 37-44. doi:10.1016/j.jaac.2014.10.010
Berkowitz, Larry (2017). Suicide Assessment and Intervention Training for Mental Health Professionals [PowerPoint slides]. NEAS, 2400 Post Road, Warwick, RI.
Burton, C. M., Marshal, M. P., Chisolm, D. J., Sucato, G. S., & Friedman, M. S. (2013). Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: A longitudinal analysis. Journal of youth and adolescence, 42(3), 394-402.
Gould, M.S., Marrocco, F.A., Kleinman, M., Thomas, J.G., Mosstkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: A randomized controlled trial. JAMA, 293(13), 1635-43.
Joiner, T. (2009). The interpersonal-psychological theory of suicidal behavior: Current empirical status. Psychological Science Agenda, 23(6).
Kann, L., Kinchen, S., Shanklin, S. L., Flint, K. H., Hawkins, J., Harris, W. A., ... & Whittle, L. (2014). Youth Risk Behavior Surveillance--United States, 2013. Morbidity and Mortality Weekly Report (MMWR). Surveillance Summaries. Volume 63, Number SS-4. Centers for Disease Control and Prevention.
Nadworny, E. (2016). Middle School Suicides Reach an All-Time High. www.NPR.org
Nock, M.K., Green, J.G., Hwang, I., McLaughlin, K.A., Sampson, N.A., Zaslavsky, A.M., & Kessler, R.C. (2013). Prevalence, correlates, and treatment of lifetime suicide behavior among adolescents: results from the Nation Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70(3), 300-10.
QPR Institute. QPR Online Gatekeeper Training for ORGANIZATIONS [Training modules]. Retrieved from https://www.qprinstitute.com/organization-training
Robins, E., Gassner, S., Kayes, J., Wilkinson Jr, R. H., & Murphy, G. E. (1959). The communication of suicidal intent: a study of 134 consecutive cases of successful (completed) suicide. American Journal of Psychiatry, 115(8), 724-733.
The JED Foundation. (2017). 13 Reasons Why: Talking Points [Leaflet]. Retrieved from https://www.jedfoundation.org/13-reasons-why-talking-points/
World Health Orgranization. (2004, September 8). Suicide huge but preventable public health problem, says WHO [Online forum post]. Retrieved from WHO Media centre website: http://www.who.int/mediacentre/news/releases/2004/pr61/en/

 

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Suicide Prevention: The Depression Link

depressedteenSuicide Prevention: The Depression Link

This is a repost from an article originally published on this blog September 6, 2013.

National Suicide Prevention Week (September 8-14) is a time to both raise awareness of suicide as a national public health issue, and to think critically about how suicide can be prevented. In the United States, suicide is the second leading cause of death among adolescents (Hoyert & Xu, 2012), and, in 2011, nearly 16 percent of adolescents in the United States reported seriously considering suicide. When thinking about preventing adolescent suicide, it is important to consider factors that increase the risk of suicidal thoughts and behaviors, such as depression. Suicidal thinking is a symptom of depression, and over half of the adolescents who completed suicide had a mood disorder at the time (Bridge, Goldstein & Brent, 2006; Nock et al., 2013). Fortunately, a number of researchers have developed empirically-supported interventions to prevent the onset of depression in teens, and prevention efforts that target adolescents at risk for depression may ultimately prove helpful in preventing suicidal behaviors as well. During this national week of suicide prevention awareness, it is important to recognize the link between depressive illness and suicide in youth, and the promising role of depression prevention in potentially preventing suicidal behavior.

Most of us bring our children to see their doctors annually, because prevention-focused well-child care is a cornerstone of pediatric practice. Unfortunately, prevention is generally not part of the equation when it comes to youth mental health. With limited health care dollars and limited mental health resources available, clinicians and policymakers tend to focus on alleviating mental health concerns once they arise. Yet research suggests that many young people do NOT get treatment for mental health concerns once they arise, and mental health concerns, such as depression, are associated not only with suicide risk, but also with long-term adverse impacts on educational attainment, relationship functioning, risk of substance abuse, and future depressive episodes, even among those who receive treatment. Moreover, of those teens who DO receive treatment for depression, only about half fully recover and, among those who do recover, relapse is quite common.

blogpullquoteDepressionLinkTreating youth depression once it emerges may be much more distressing, and much less effective, than identifying early symptoms of illness and treating them before they develop into a full-blown disorder. Prevention approaches have the potential to reach a large number of adolescents, and may be more acceptable than treatment because services can be rendered in non-clinical settings (e.g., schools, primary care settings), and do not require adolescents to identify themselves as ill.

So how can adolescent depression be prevented? The core of many depression prevention programs is resilience. Not all adolescents with risk factors for depression develop the disorder; the ones who do not develop depression are resilient, which means they have the emotional skills and/or the social supports to “bounce back” from adversity. Many programs to prevent adolescent depression are designed to teach coping and emotional regulation skills, and/or to strengthen supportive relationships, in order to provide youth at elevated risk with the tools they need to be resilient.

Research on the prevention of youth depression is quite encouraging! For example, in our longitudinal, multi-site study of adolescents at risk for depression, we found that teens who participated in a group cognitive-behavioral prevention program were less likely to experience a depressive disorder at nine- (Garber et al., 2009) and 32- (Beardslee et al., in press) months follow-up, relative to at-risk teens who were assigned to a treatment-as-usual control group. Likewise, our colleagues working on the Penn Resiliency Project have found that children and adolescents who participate in their school-based cognitive-behavioral program are less likely to experience depressive symptoms than are children and adolescents assigned to control conditions. Similarly, in a study of Interpersonal Psychotherapy approaches to preventing youth depression, Young and colleagues found that teens who participated in a skills-based intervention targeting interpersonal role disputes, role transitions and interpersonal deficits reported fewer depressive symptoms at six-months follow-up than teens who were assigned to a school counseling control group.

Here at WCW, we are currently studying the efficacy of a primary-care, Internet-based depression-prevention program for adolescents who are at risk for the development of depression, based on a past history of depression and/or current symptoms of depressive disorder. While many of these youth depression prevention programs are still being evaluated in randomized controlled research trials, early results suggest that prevention programs may work. It seems we can indeed provide teens with strategies that they can use over time, as they encounter stress and challenging life events, so that they are able to stay healthy and avoid the onset of significant mental health concerns.

What are the risks for depression in adolescents? When should you be worried about your teen? When we talk about risks for depression, we often think in terms of specific factors (i.e., factors identified through empirical research to be associated specifically with increased risk for youth depression) and nonspecific factors (i.e., factors that are associated with increased risk for a range of disorders, including depression). Specific risk factors for adolescent depression include having low self-esteem, being female, developing a negative body image, low social support, a negative cognitive style, and ineffective coping. The strongest specific risk factor for the development of depression, above and beyond these other factors, is having a parent with depressive illness. In fact, offspring of depressed parents are at about a two- to four-fold increased risk of developing depressive disorders, relative to children of parents without depression. Nonspecific risk factors that also increase risk of youth depression include poverty, exposure to violence, social isolation, child maltreatment, and family breakup.

Although the presence of these risk factors is associated with an increased risk for youth depression, as noted above, many at-risk children are resilient and never develop a depressive disorder. Having supportive adults present, strong family relationships, strong peer relationships, coping skills, and skills in emotion regulation all can contribute to resiliency. Even depressed parents can promote resilience in their teens by encouraging teens to engage in outside activities, maintain supportive relationships, and recognize themselves as separate from issues and concerns that are affecting other family members.

How can you recognize signs and symptoms of depression in your child, and how can you help? Depressed teens are often sad or irritable, and may exhibit a range of additional symptoms, such as withdrawal from friends and usual activities, sleep difficulties (i.e., difficulty sleeping or sleeping all the time), somatic complaints (i.e., headaches, stomach aches), poor school performance, self-critical talk, changes in eating patterns, difficulty sitting still, and may start writing or thinking about death. If you are concerned about your teen, then express your concern openly and honestly. Tell your child that you care, and that you want to help. Don’t be afraid to ask your child if he is experiencing suicidal thoughts – asking will NOT make him contemplate suicide or take his own life. Reach out to your child’s pediatrician for assistance and referrals. Let your child know that treatments are available, and that you are going to work together to get your child the help she needs.

National Suicide Prevention Week is an opportune time to consider the many ways that suicidal thoughts and actions can be combated, including preventing the onset of depression in adolescents, and getting teens help if they are depressed already.

Tracy Gladstone, Ph.D. is a Senior Research Scientist and Director of the Robert S. and Grace W. Stone Primary Prevention Initiatives at the Wellesley Centers for Women at Wellesley College. The Stone Primary Prevention Initiatives focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

References:

Beardslee, W.R., Brent, D.A., Weersing, V.R., Clarke, G.N., Porta, G., Hollon, S.D., Gladstone, T.R.G., Gallop, R., Lynch, F.L., Iyengar, S., DeBar, L., & Garber, J. (in press). Prevention of depression in at-risk adolescents: Longer-term effects. Journal of the American Medical Association Psychiatry.

Bridge, J. A., Goldstein, T. R., & Brent, D. A. (2006). Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry, 47(3‐4), 372-394.

Centers for Disease Control and Prevention. (2012). Youth Risk Behavior Surveillance- United States 2011. Morbidity and Mortality Weekly Report, 61(4), 1-168.

Garber, J., Clarke, G.N., Weersing, V.R., Beardslee, W.R., Brent, D.A., Gladstone, T.R.G., DeBar, L.L., Lynch, F.L., D’Angelo, E., Hollon, S.D., Shamseddeen, W., & Iyengar, S. (2009). Prevention of depression in at-risk adolescents: A randomized controlled trial. Journal of the American Medical Association, 301, 2215-2224.

Hoyert, D. L., & Xu, J. (2012). Deaths: preliminary data for 2011. National Vital Statistics Report, 61(6), 1-65.

Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA: The Journal of the American Medical Association Psychiatry, 70(3), 300-310.  

 

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Suicide Prevention: The Depression Link

depressedteenSuicide Prevention: The Depression Link

National Suicide Prevention Week (September 8-14) is a time to both raise awareness of suicide as a national public health issue, and to think critically about how suicide can be prevented. In the United States, suicide is the second leading cause of death among adolescents (Hoyert & Xu, 2012), and, in 2011, nearly 16 percent of adolescents in the United States reported seriously considering suicide. When thinking about preventing adolescent suicide, it is important to consider factors that increase the risk of suicidal thoughts and behaviors, such as depression. Suicidal thinking is a symptom of depression, and over half of the adolescents who completed suicide had a mood disorder at the time (Bridge, Goldstein & Brent, 2006; Nock et al., 2013). Fortunately, a number of researchers have developed empirically-supported interventions to prevent the onset of depression in teens, and prevention efforts that target adolescents at risk for depression may ultimately prove helpful in preventing suicidal behaviors as well. During this national week of suicide prevention awareness, it is important to recognize the link between depressive illness and suicide in youth, and the promising role of depression prevention in potentially preventing suicidal behavior.

Most of us bring our children to see their doctors annually, because prevention-focused well-child care is a cornerstone of pediatric practice. Unfortunately, prevention is generally not part of the equation when it comes to youth mental health. With limited health care dollars and limited mental health resources available, clinicians and policymakers tend to focus on alleviating mental health concerns once they arise. Yet research suggests that many young people do NOT get treatment for mental health concerns once they arise, and mental health concerns, such as depression, are associated not only with suicide risk, but also with long-term adverse impacts on educational attainment, relationship functioning, risk of substance abuse, and future depressive episodes, even among those who receive treatment. Moreover, of those teens who DO receive treatment for depression, only about half fully recover and, among those who do recover, relapse is quite common.

blogpullquoteDepressionLinkTreating youth depression once it emerges may be much more distressing, and much less effective, than identifying early symptoms of illness and treating them before they develop into a full-blown disorder. Prevention approaches have the potential to reach a large number of adolescents, and may be more acceptable than treatment because services can be rendered in non-clinical settings (e.g., schools, primary care settings), and do not require adolescents to identify themselves as ill.

So how can adolescent depression be prevented? The core of many depression prevention programs is resilience. Not all adolescents with risk factors for depression develop the disorder; the ones who do not develop depression are resilient, which means they have the emotional skills and/or the social supports to “bounce back” from adversity. Many programs to prevent adolescent depression are designed to teach coping and emotional regulation skills, and/or to strengthen supportive relationships, in order to provide youth at elevated risk with the tools they need to be resilient.

Research on the prevention of youth depression is quite encouraging! For example, in our longitudinal, multi-site study of adolescents at risk for depression, we found that teens who participated in a group cognitive-behavioral prevention program were less likely to experience a depressive disorder at nine- (Garber et al., 2009) and 32- (Beardslee et al., in press) months follow-up, relative to at-risk teens who were assigned to a treatment-as-usual control group. Likewise, our colleagues working on the Penn Resiliency Project have found that children and adolescents who participate in their school-based cognitive-behavioral program are less likely to experience depressive symptoms than are children and adolescents assigned to control conditions. Similarly, in a study of Interpersonal Psychotherapy approaches to preventing youth depression, Young and colleagues found that teens who participated in a skills-based intervention targeting interpersonal role disputes, role transitions and interpersonal deficits reported fewer depressive symptoms at six-months follow-up than teens who were assigned to a school counseling control group.

Here at WCW, we are currently studying the efficacy of a primary-care, Internet-based depression-prevention program for adolescents who are at risk for the development of depression, based on a past history of depression and/or current symptoms of depressive disorder. While many of these youth depression prevention programs are still being evaluated in randomized controlled research trials, early results suggest that prevention programs may work. It seems we can indeed provide teens with strategies that they can use over time, as they encounter stress and challenging life events, so that they are able to stay healthy and avoid the onset of significant mental health concerns.

What are the risks for depression in adolescents? When should you be worried about your teen? When we talk about risks for depression, we often think in terms of specific factors (i.e., factors identified through empirical research to be associated specifically with increased risk for youth depression) and nonspecific factors (i.e., factors that are associated with increased risk for a range of disorders, including depression). Specific risk factors for adolescent depression include having low self-esteem, being female, developing a negative body image, low social support, a negative cognitive style, and ineffective coping. The strongest specific risk factor for the development of depression, above and beyond these other factors, is having a parent with depressive illness. In fact, offspring of depressed parents are at about a two- to four-fold increased risk of developing depressive disorders, relative to children of parents without depression. Nonspecific risk factors that also increase risk of youth depression include poverty, exposure to violence, social isolation, child maltreatment, and family breakup.

Although the presence of these risk factors is associated with an increased risk for youth depression, as noted above, many at-risk children are resilient and never develop a depressive disorder. Having supportive adults present, strong family relationships, strong peer relationships, coping skills, and skills in emotion regulation all can contribute to resiliency. Even depressed parents can promote resilience in their teens by encouraging teens to engage in outside activities, maintain supportive relationships, and recognize themselves as separate from issues and concerns that are affecting other family members.

How can you recognize signs and symptoms of depression in your child, and how can you help? Depressed teens are often sad or irritable, and may exhibit a range of additional symptoms, such as withdrawal from friends and usual activities, sleep difficulties (i.e., difficulty sleeping or sleeping all the time), somatic complaints (i.e., headaches, stomach aches), poor school performance, self-critical talk, changes in eating patterns, difficulty sitting still, and may start writing or thinking about death. If you are concerned about your teen, then express your concern openly and honestly. Tell your child that you care, and that you want to help. Don’t be afraid to ask your child if he is experiencing suicidal thoughts – asking will NOT make him contemplate suicide or take his own life. Reach out to your child’s pediatrician for assistance and referrals. Let your child know that treatments are available, and that you are going to work together to get your child the help she needs.

National Suicide Prevention Week is an opportune time to consider the many ways that suicidal thoughts and actions can be combated, including preventing the onset of depression in adolescents, and getting teens help if they are depressed already.

Tracy Gladstone, Ph.D. is a Senior Research Scientist and Director of the Robert S. and Grace W. Stone Primary Prevention Initiatives at the Wellesley Centers for Women at Wellesley College. The Stone Primary Prevention Initiatives focus on research and evaluation designed to prevent the onset of mental health concerns in children and adolescents.

References:

Beardslee, W.R., Brent, D.A., Weersing, V.R., Clarke, G.N., Porta, G., Hollon, S.D., Gladstone, T.R.G., Gallop, R., Lynch, F.L., Iyengar, S., DeBar, L., & Garber, J. (in press). Prevention of depression in at-risk adolescents: Longer-term effects. Journal of the American Medical Association Psychiatry.

Bridge, J. A., Goldstein, T. R., & Brent, D. A. (2006). Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry, 47(3‐4), 372-394.

Centers for Disease Control and Prevention. (2012). Youth Risk Behavior Surveillance- United States 2011. Morbidity and Mortality Weekly Report, 61(4), 1-168.

Garber, J., Clarke, G.N., Weersing, V.R., Beardslee, W.R., Brent, D.A., Gladstone, T.R.G., DeBar, L.L., Lynch, F.L., D’Angelo, E., Hollon, S.D., Shamseddeen, W., & Iyengar, S. (2009). Prevention of depression in at-risk adolescents: A randomized controlled trial. Journal of the American Medical Association, 301, 2215-2224.

Hoyert, D. L., & Xu, J. (2012). Deaths: preliminary data for 2011. National Vital Statistics Report, 61(6), 1-65.

Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA: The Journal of the American Medical Association Psychiatry, 70(3), 300-310.  

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