Using the topic you selected for the Week 1 discussion (depression in youth and teens), go to the Ashford University Library and find three scholarly/peer-reviewed journal articles about the topic. Do

. . . . . 8 In future issues Using emotions to negotiate Copy number variation:

The new genetic frontier S ince the 1990s, schools have imple- ment ed a number of different pro- grams aimed at preventing suicide and violence in children and teens. Th e stakes are high. Homicide is the second leading cause of death, and suicide the third leading cause of death, in Americans ages 10 to 24. Th ese tragic deaths attest to underlying problems that occur far more frequently: depression, substance abuse, and aggression.

Two large-scale studies, for example, have estimated that more than 20% of young peo- ple will develop major depression by age 18.

In a survey of a large, nationally representa- tive sample of students, 22% of 12th graders said that they had used an illegal drug, and 44% reported drinking alcohol, in the pre- vious month. Other studies have reported that 13% of high school students said they had been in a physical \b ght on school property at least once in the previous year, 7% of students ages 12 to 18 said they had been bullied in the previous six months, and 8% of high school students said they had been threat- ened or injured by a weapon in school. Left unaddressed, these issues create a volatile mix. The combination of depres- sion and drugs or alcohol is especially dan- gerous: one analysis found that two-thirds of adolescents who attempted suicide had both a psychiatric disorder and a history of substance abuse. In the past few years, new information has emerged about how eff ective school- based programs are at preventing depression and violence, and what challenges remain.

Detecting depression Although depression can occur at any age, it aff ects adolescents and teens more oft en than younger children. A marked increase in depressive symptoms starts appearing around age 13, but the peak ages for onset are between 16 and 24. Yet depression can be diffi cult to diagnose in young people, mainly because symptoms seldom involve mood alone, and usually appear in con- junction with symptoms of a co-occurring disorder. An analysis of symptoms experienced by 423 patients ages 12 to 17 enrolled in the Treatment for Adolescents with Depression Study, for example, concluded that only 20% of them suff ered mainly from depres- sive symptoms. More oft en, these adoles- cents and teens developed a mix of mood and behavioral problems that did not, at \b rst glance, suggest depression: symptoms such as agitation, anxiety, attention diffi cul- ties, distraction, or de\b ant and oppositional behaviors. Symptoms of depression also tend to vary according to age and sex. In adoles- cents (ages 10 to 14), depression is likely to manifest as anxiety, refusal to go to school, or physical problems such as headaches or stomachaches. In older teens (ages 14 to 18), mood and thinking are more likely to be aff ected. Th ey may show a loss of inter- est or pleasure in normal activities or nega- tive thinking. In boys, depression may cause anger, acting out, risk-taking behaviors, or obsession with school work. In girls, it tends to cause tearfulness, apathy, social isolation, or weight gain or loss. A variety of school-based depression screening programs exist. Signs of Suicide (SOS), for example, uses a video, a brief ques- tionnaire, and classroom discussion to edu- cate students about depression and suicide and help identify those at risk. TeenScreen uses a short screening questionnaire to identify students with symptoms suggesting School-based safety interventions Identifying children and teens at risk for depression or violence. New Special Health Report from Harvard Medical School Viruses and Infectious Diseases: Protecting yourself from the invisible enemy To order, call 877-649-9457 (toll-free) or visit www.health.

harv ard.edu . For customer service harvardMH @ strategicfulfi llment.com Write us at mental _ letter @hms.harvard.edu Visit us online at www.health.harvard.edu ❷ HARVARD MENTAL HEALTH LETTER www.health.harvard.edu SEPTEMBER 2008 Editor in Chief Michael Craig Miller, MD Editor Ann MacDonald Founding Editor Lester Grinspoon, MD Editorial Board Mary Anne Badaracco, MD Jonathan F. Borus, MD Christopher B. Daly Sandra Dejong, MD Frank W. Drislane, MD Anne K. Fishel, PhD Donald C. Goff, MD Stuart Goldman, MD Alan I. Green, MD William E. Greenberg, MD Shelly Greenfield, MD, MPH Thomas G. Gutheil, MD Michael Hirsch, MD Kimberlyn Leary, PhD, ABPP Robert W. McCarley, MD Michael J. Mufson, MD Andrew A. Nierenberg, MD Scott L. Rauch, MD, PhD Nadja Lopez Reilly, PhD Hester H. Schnipper, LICSW, BCD Janna M. Smith, LICSW, BCD Caroline L. Watts, EdD Barbara Wolfe, PhD, RN Editorial Board members are associated with Harvard Medical School and affi liated institutions.

Th ey review all published articles.

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CIRCULATION DEPT., 1415 JANETTE AVENUE, WINDSOR, ON N8X 1Z1 • E-mail: [email protected] School programs continued depression, who then undergo a one- on-one interview with a mental health professional. Parents are noti\b ed if their children are deemed at risk, and off ered a referral for mental health services. School-based screenings used on their own, however, are controversial. Th e U. S.

Preventive Services Task Force, for exam- ple, concluded in 2002 that the evidence was not suffi cient to recommend for or against routine screening of children and adolescents for depression. Th e agency is currently conducting a review of the latest evidence.

Prevention and treatment To move beyond one-time screenings, many schools have implemented various types of ongoing depression-prevention efforts. Although specific approaches vary, these programs generally educate staff and students about depression and suicide, provide advice and practice in challenging negative thinking, and seek to build resilience and problem-solving skills. Some are universal prevention ef- forts, off ered to all students, while others are targeted to students most at risk. Several reviews have concluded that interventions to fend off depression may be modestly eff ective, at least in the short term. In studies conducted six months to three years aft er such interventions, however, it’s not clear that they have any lasting eff ect. As one reviewer put it, a depression-prevention program is not like an inoculation that confers immu- nity; instead, the most eff ective programs are those that incorporate some type of booster sessions and ongoing follow-up.

In an eff ort to provide school offi cials with the information and training to off er eff ective programs, clinicians in the psy- chiatry department of Children’s Hospital Boston have developed a depression- prevention effort that grew out of a broader adolescent wellness program de- veloped in conjunction with colleagues at McLean Hospital. Th e Swensrud Depres- sion Prevention Initiative (named for the family foundation that funds it) provides training and an ongoing curriculum so that participants can incorporate what they’ve learned about depression into a system for monitoring and intervention.

Workshops typically involve a range of people—teachers, school administra- tors, nurses, community leaders, parents, and students—in order to create a safety infra structure that will remain in place aft er the training ends. Th e program is currently being off ered only in Massachusetts, but it may be launched nationally in the future, in con- junction with a documentary featuring teens with depression talking about their experiences. In the meantime, materials are available online (see “Resources”). A common question asked by school offi cials and parents is how to distinguish normal teenage mood swings and rebelli- ons from actual symptoms of depression.

Dr. Nadja N. Reilly, director of the Swens- rud Depression Prevention Initiative (and a member of the editorial board of the Harvard Mental Health Letter ), recom- mends evaluating three key areas. Severity. Symptoms of teen depres- sion encompass changes in mood (anger, sadness, irritability), behaviors (sleeping or eating more or less than usual, tak- ing drugs or alcohol, acting out), feel- ings (loneliness, insecurity, apathy), thoughts (hopelessnes s, worthlessness), and perceptual disturbances (pain, hal- lucinations). The more pronounced these symptoms, the more likely that the problem is depression and not a passing mood. Duration. Any notable deterioration in behavior or mood that lasts two weeks or longer, without a break, may indicate depression. Domains. Problems noticed in sev- eral areas of a teen’s functioning—at home, in school, and in interactions with friends—may indicate depression rather than a bad mood related to a particular situation.

Violence prevention programs In an eff ort to reduce violence and ag- gression in schools, about 90% of schools now offer programs that teach anger SEPTEMBER 2008 www.health.har vard.edu HARVARD MENTAL HEALTH LETTER ❸ management, discourage bullying, or teach mediation and social skills. In- struction about dating violence and sexual assault is offered in 52% of middle schools and about 80% of high schools. Two analyses published in 2007 concluded that such school-based interventions are eff ective at reducing aggression and violence. Th e larger of the two looked at 249 studies of intervention programs and concluded that both universal and tar- geted approaches were eff ective. Both types of programs rely on cognitive in- terventions, although the targeted pro- grams (designed for children and teens with conduct disorders) may also incor- porate behavioral interventions, social skills instruction, and counseling. Th e researchers estimate these programs may result in 25% to 33% reductions in the number of students involved in aggressive or disruptive behavior, such as school \b ghts, use of off ensive words, or bullying. Regardless of design, all of the vio- lence prevention programs examined were about equally effective as long as they were given on a regular basis.

So the real task for school offi cials is to find a program they can reliably implement. Th e worst kind of violence—a school shooting or other type of attack that leads to injuries and death—is for- tunately rare. Even so, since the 1999 shootings at Columbine High School in Colorado, schools have been seeking advice about how to prevent such at- tacks. A recent report by researchers at McLean Hospital, the U. S. Secret Ser- vice, and the U. S. Department of Edu- cation provides new information. Th e report is a follow-up to an earli er study, the Safe School Initiative, which found that—prior to the 37 school at- tacks analyzed—many attackers had felt bullied, 61% had a history of feel- ing depressed or desperate, and 78% had attempted suicide or had suicidal thoughts. In 30 of the incidents (four out of \b ve), at least one other person knew in advance that some type of attack was planned, while in 22 inci- dents (three out of five), more than one person knew ahead of time. Yet in most cases, these bystanders—usually friends, schoolmates, or siblings—did not alert authorities. Dr. William S. Pollack, director of the Center for Men and Young Men at McLean Hospital and lead author on the new study, said the interviews with bystanders revealed that a key determi- nant of whether someone came forward with information was whether he or she felt an emotional connection to an adult at the school—a teacher, admin- istrator, or school safety offi cer. School staff and teachers can promote such connections through seemingly small acts that help build relationships—such as greeting students regularly, address- ing them by name, and talking to them about life outside of school. Th e study also encourages schools to develop policies and provide spe- ci\b c methods for reporting threats, in- cluding anonymously; to specify who at the school is responsible for investi- gating the threat; and to ensure that the informant will be treated with respect and the information provided will be closely guarded.

It all comes down to thinking about making connections, Dr. Pollack says.

He suggests that schools weave the type of safety net—among students, school faculty, administrators, and staff —that will help to prevent a violent attack.

Th ose same connections, forged as part of on going violence and depression- prevention eff orts, can prevent other types of less dramatic, but pervasive, suff ering as well.

Hahn R, et al. “Eff ectiveness of Universal School-Based Programs to Prevent Violent and Aggressive Behavior: A Systematic Review,” American Journal of Preventive Medicine (Aug.

200\f): Vol. 33, Suppl. No. 2, pp. S114–29.

Herman KC, et al. “Empirically Derived Sub- types of Adolescent Depression: Latent Pro\b le Analysis of Co-Occurring Symptoms in the Treatment for Adolescents with Depression Study (TADS),” Journal of Consulting and Clinical Psychology (Oct. 200\f): Vol. \f5, No. 5, pp. \f16–28.

Pollack WS, et al. Prior Knowledge of Potential School-Based Violence (Washington, D.C.:

U. S. Secret Service and U. S. Department of Education, May 2008).

Sutton JM. “Prevention of Depression in Youth: A Qualitative Review and Future Sug- gestions,” Clinical Psychology Review (June 200\f): Vol. 2\f, No. 5, pp. 552–\f1.

Wilson SJ, et al. “School-Based Interventions for Aggressive and Disruptive Behavior:

Update of a Meta-Analysis,” American Journal of Preventive Medicine (Aug. 200\f): Vol. 33, Suppl. No. 2, pp. S130–43.

For more references and PDFs of some of the resources mentioned, please see www.health.harvard.edu/mentalextra . Adolescent Wellness, Inc.

Children’s Hospital Boston and McLean Hospital Provides information about two curricula:

one to promote overall mental health, and the other for preventing depression.

www.adolescentwellness.org Center for Men and Young Men McLean Hospital Offers comprehensive ser vices for male adults and adolescents to cope with stress and emotional challenges.

www.mclean.harvard.edu/patient /adult / cfmym.php School Psychiatry Program Massachusetts General Hospital Provides online links to a variety of screening tools and advice about a range of psychiatric problems.

www.massgeneral.org/schoolpsychiatry Signs of Suicide (SOS) Screening for Mental Health, Inc.

Offers a class discussion program about depression and suicide for middle and high school students.

www.mentalhealthscreening.org TeenScreen Program Columbia University Offers a two-part screening program for depression and a referral for further evaluation when necessary.

www.teenscreen.org Resources