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Section 6
Teen Developmental Issues or Depressive Symptoms?

Question 6 | Test | Table of Contents

Diagnosis of depression in adolescents can be difficult due to problems differentiating between the normal, transient difficulties and developmental issues that occur in this age group and depressive symptoms. However accurate and timely diagnosis is critical because of the far reaching effects of depressive disorder on the functioning and adjustment of the adolescent. Depressive disorders may lead to serious consequences, including increased risk for illness, interpersonal and psychosocial difficulties, substance abuse, and suicide. This article reviews the adolescent depression and suicide research literature and discusses risk factors, unique symptom presentation, and effective treatment strategies. It also examines gender differences in the expression of symptoms and recommends gender-specific assessment and treatment strategies.

The accurate and early diagnosis and treatment of depression in adolescents is essential. The incidence of depression among youth age 9-17 has been estimated at 5% and only a minority are treated (Shaffer et al., 1996). Studies suggest that the 1-year prevalence in adolescents is as high as 8.3% (U.S. Department of Health & Human Services [HHS], 1999). Depression persists, or only partially remits, in more than half of them (Oldehinkel, Wittchen, & Schuster, 1999).

Depression in adolescents may lead to serious consequences including suicidal behaviors. The Center for Disease Control (CDC, 2000) reports that from 1980 to 1997, the rate of suicide among 15- to 19-year-old adolescents increased by 11% and among those aged 10 to 14 by 109%. Suicide is responsible for more deaths in youths age 15 to 19 than any disease. In 1996, suicide was the third leading cause of death (behind unintentional injury and homicide) in 15 to 24 year olds and the fourth leading cause of death in 10 to 14 year olds.

There are gender and racial differences in the suicide rates. Boys are four times more likely to complete suicide than girls while girls are twice as likely to attempt suicide (HHS, 1999). The risk for suicide is highest among young white males, but suicide rates have increased most rapidly for young black males (CDC, 2000). Hispanic high school students are more likely than any other student to attempt suicide (HHS, 1999). The highest rate of completed suicide in the United States is among Native American male adolescents and young adults (HHS, 1999).

The presence of adolescent depression predicts continued risk for recurrences and persistence of depressive episodes, negative consequences, and suicidal risk into adulthood (Rao et al., 1995; Weissman et al., 1999). Successful treatment in adolescence is crucial, because adults with psychiatric illnesses are 20 times more likely to die from accidents or suicide than those without a mental disorder (Murphy, Monson, & Olivier, 1987). Depressed adolescents are more likely to experience stressful life events as young adults (Lewinsohn & Clarke, 1999). They are at higher risk for developing substance abuse and becoming an unwed parent. They are also less likely to complete college and earn as much money as those who were not depressed as adolescents (Lewinsohn & Clarke, 1999). These negative consequences during adolescence and young adulthood make early recognition and treatment essential.

Symptoms of Depression
The diagnosis of a major depressive episode in the Diagnostic and Statistical Manual of Mental Disorders, (4th ed.), (American Psychiatric Association, 1994) requires the presence of five or more of the following symptoms for a period of 2 weeks: (a) depressed mood, (b) loss of interest or pleasure, (c) significant weight or appetite change, (d) insomnia or hypersomnia, (e) psychomotor agitation or retardation, (f) fatigue/loss of energy, (g) feelings of worthlessness or inappropriate guilt, (h) diminished ability to think or concentrate, and/or (i) recurrent thoughts of death or suicidal ideation/plan/attempts. Depressed mood or loss of interest or pleasure must be one of the five presenting symptoms.

The requirement for a diagnosis of depressive disorder in adolescents is the same as for adults, but adolescents present symptoms in a different manner (Blackman; 1995). Wearing black clothing, writing morbid poetry, or a preoccupation with music with nihilistic themes may suggest pervasive sadness. The: adolescent may stay up all night watching television or have difficulty in getting up for school or sleep during the day. An adolescent who once performed adequately in school may lack motivation and miss classes and have a drop in grades due to loss of concentration and slowed thinking. Expressing boredom may be a synonym for depression. Loss of appetite may manifest itself as an eating disorder. Adolescent depression may also present primarily as conduct disorder, substance or alcohol abuse, family turmoil, or rebellion with no typical symptoms of depression.

The experienced counselor must be alert to this different symptom presentation and be able to differentiate it from normal adolescent development and experimentation. Preferences for black clothing or the fact that an adolescent expresses boredom does not necessarily indicate depression. However the counselor must examine the behavior in light of known risk factors for depression and suicide. In addition to information from the clinical interview, the counselor should communicate with significant others in the adolescent's life, including parents and teachers. Assessment of the adolescent's premorbid personality as well as any other stress or trauma that might have preceded the symptoms is indicated (Blackman, 1995). Formal psychological testing may also be helpful in distinguishing depressive disorder from developmental issues. Results from assessment instruments including the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Reasons for Living Inventory for Adolescents (RFL-A), Beck Depression Inventory for Primary Care (BDI-PC), Children's Depression Inventory (CDI), or the Center for Epidemiologic Studies Depression Scale (CES-D) may assist the counselor in screening for depression (Osman et al., 1998; Winter, Steer, Jones-Hicks, & Beck, 1999; National Institute of Mental Health, 2000). In addition to all of the above, knowledge of the risk factors for depression and suicide can greatly enhance diagnostic accuracy.

Risk Factors for Depression and Suicide
Research suggests that persistent or escalating stressful events (e.g., disagreements with parents) increase the risk for development of adolescent depression or anxiety (Rueter, Scaramella, Wallace, & Conger, 1999). Stoelb and Chiriboga (1998) cite broken homes, a family history of psychiatric illness and/or suicidal behavior, and childhood abuse/neglect as common factors in adolescent suicide. However family functioning rather than structure appear to be more important in assessing risk (Wannan & Fombonne, 1998). A lack of a sense of belonging has been shown to be a good predictor of depression, so assessing the nature of the adolescent's family relationships as well as relationships with peers and social networks is essential (Hagerty & Williams, 1999). Social support, peer relationships, and sense of group membership seem to offer some protective factor that mediates the effects of depression and concomitant risk of suicide (Morano, Cisler, & Lemerond, 1993).

Problems most frequently reported by adolescents with suicidal ideation were specifically in the areas of family, friends, boy/girlfriends, and school problems (McLaughlin, Miller, & Warwick, 1996). Issues like disciplinary action, rejection, humiliation, or ending a relationship, that at worst might be embarrassing to an adult, may seem catastrophic to the adolescent who lacks problem-solving skills (Stoelb & Chiriboga, 1998). These problem-solving deficits are related to the development of hopelessness and suicidal symptoms (Joiner & Rudd, 1995).

The most robust and consistent of predictors and correlates of suicidality across all age groups is hopelessness (Joiner & Rudd, 1996). McLaughlin et al. (1996) found that adolescents engaging in acts of deliberate self-harm are more likely to report feelings of hopelessness about their future even after depression is taken into account. Lewinsohn, Rohde, and Seeley (1994) documented the association between hopelessness and suicidal ideation in a large sample of community adolescents. A study of both clinical and nonclinical adolescents found that the best predictors of suicidality were hopelessness and negative personal experiences, particularly rejection by the family (Cotton & Range, 1996). There were no gender differences demonstrated in the role of hopelessness for adolescents (Langhinrichsen-Rohling, Lewinsohn, Rohde, & Seely, 1998)

The presence of other psychiatric disorders in the adolescent also increases the risk factor for the development of depression and associated suicidal risk. In adolescents, major depressive episodes are frequently associated with Disruptive Behavior Disorders, Attention-Deficit Disorders, Anxiety Disorders, Substance-Related Disorders, and Eating Disorders (DSM-IV, 1994). Adolescents diagnosed with a personality disorder are 10 times more likely to commit suicide than those who are not (Blumenthal, 1990). A personality disorder diagnosis is predictive of suicidal behavior, especially in combination with substance abuse and depression (Blumenthal, 1990).

The presence of a mental disorder increases risk in both males and females. However, there are gender-related differences in morbidity and symptom expression. Disruptive Behavior Disorders (attention deficit disorder, conduct disorder, and oppositional defiant disorder) are more frequently diagnosed in males and have been associated with suicidal behavior. In a study by Brent et al. (1993), more than 80% of suicide Victims could have been diagnosed with conduct disorder. Males with conduct disorder also exhibit more risk-taking and health-compromising behaviors than females (Langhinrichsen-Rohling et al., 1998).

Violence appears to be a risk factor for the development of hostility and depressive symptoms. Research studies demonstrate a correlation between exposure to violence and depression (DuRant, Cadenhead, Pendergrast, Slavens, & Linder, 1995; Martinez & Richters, 1993). Adolescents who were victims of violence or witnessed violence against persons familiar to them had a significant incidence of depressive symptoms. In particular; intrafamilial violence was highly correlated with adolescent depression, hopelessness, and lack of purpose in life (DuRant et al., 1995). Suicide rates among Violent and aggressive adolescents were much higher than those in the general population (Moses, 1999). Aggression affects suicidality in young males while depression and/or post-traumatic stress disorder affects suicidality in young women (Prigerson & Slimack, 1999). Males are more likely to be exposed to violence, suffer subsequent depression, and exhibit violent behavior. They are also more likely to deny affect and therefore admit to less psychological distress (Moses, 1999).

Gender differences in the expression of affect tend to make it more difficult to diagnose depression in adolescent males than in females. Adolescent females report more typical affective symptoms of depression than adolescent males (Langhinrichsen-Rohling et al., 1998). Using only an assessment instrument for depression may identify depressed females but not depressed males. The tendency of males to deny affect and display aggressive behaviors may result in the misdiagnosis of depression in adolescent males as disruptive behavior disorder. Also the tendency of males to engage in more risk-taking and injury-producing behaviors increases the risk for suicide in males not properly diagnosed and treated.

Homosexuality may also be a risk factor for adolescents (Stoelb & Chiriboga, 1998). The pressure of identifying as homosexual in a homophobic culture is particularly confusing for the adolescent struggling with issues of acceptance. Lesbians tend to identify as homosexual later in life, age 20-23, while gay males tend to do so by age 15 (Lewinsohn & Clarke, 1999). This identification of sexual orientation at an earlier stage of development creates an increased risk factor for gay males. Rotheram-Borus, Rosario, Reid, Van Rossem and Roy (1995) found that 30% of gay adolescent males had attempted suicide at least once and more than 50% of attempters had multiple attempts. A study by Remafedi, French, Story, Resnick, and Blum (1998) that examined the relationship between suicide risk and sexual orientation found that suicidal intent and attempts were associated with bisexual and homosexual orientation in adolescent males, but not adolescent females.

Suicide of prominent figures or individuals personally known by the adolescent as well as fictional accounts of adolescent suicide are risk factors for adolescent suicide (Rubenstein, Heeren, Housman, Rubin, & Stechler, 1989). Exposure to the suicide or suicidal behavior of others influences the adolescent to attempt or commit suicide. Particularly nonfictional newspaper and television coverage of suicide has been associated with a statistically significant increase in suicide among adolescents (CDC, 1994).

Assessment of Suicide Risk
A preponderance of evidence shows that more than 90% of children and adolescents who commit suicide have a mental disorder (Shaffer & Craft, 1999)--21% of those who completed suicide saw a mental health professional within 3 months of their death (Shaffer et al., 1996). The most common diagnosis in suicidal adolescents is a mood disorder with or without a substance abuse disorder and/or anxiety disorder (Shaffer et al., 1996). The presence of major depressive disorder increases the risk of suicide in adolescent females 12 fold, and a previous suicide attempt increases the risk factor 3 fold (HHS, 1999). For adolescent males a previous suicide attempt is the most significant predictor followed by depression, disruptive behavior, and substance abuse (HHS, 1999).
Behavioral Assessment

An assessment of suicidal risk in adolescents must include a behavioral assessment of: (a) classroom behavior, skipping classes, poor concentration, disruptive behavior, decline in performance, death or suicidal themes in work, loss of pleasure, or inability to tolerate praise or rewards; (b) interpersonal behavior, withdrawing from friends, giving away prized possessions, sudden changes in relationships, or not wanting to be touched by others; (c) personal behaviors, apathy, risk taking, self-mutilation, impulsive tendencies, and (d) verbal behaviors, expression of suicidal intent or depression (America's Continuing Education Network, 1996). Additionally episodic and chronic life stressors must be assessed. These include trouble with school authorities or the law, recent losses, major disappointments or humiliation, family dysfunction, chronic mental illness in parent, abuse, exposure to suicide or violence. These episodic and chronic stressors may lead to a significant acute crisis in the adolescent's life (Blackman, 1995).
-Stanard, Rebecca Powell, Journal of Mental Health Counseling, Jul2000, Vol. 22, Issue 3

Personal Reflection Exercise #6
The preceding section contained information about assessment and treatment of adolescent depression and suicidality.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview—Revised: Development, reliability, and validity. Psychological Assessment, 32(7), 677–689.

Madjar, N., Sarel-Mahlev, E., & Brunstein Klomek, A. (2020). Depression symptoms as mediator between adolescents' sense of loneliness at school and nonsuicidal self-injury behaviors. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication.

Till, B., Wild, T. A., Arendt, F., Scherr, S., & Niederkrotenthaler, T. (2018). Associations of tabloid newspaper use with endorsement of suicide myths, suicide-related knowledge, and stigmatizing attitudes toward suicidal individuals. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 428–437.

What factors regarding depression in adolescents make it difficult to diagnose?
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Section 7
Table of Contents