Focus on Primary and Secondary Prevention in Depression - Research Paper Example

Running Head: PREVENTATIVE YOUTH PSYCHIATRY Introduction Depression is a type of mood disorder characterized with symptoms inclusive of sadness, anxiety, sustaining feelings of emptiness and hopelessness, excessive worry or restlessness. Minor depressive symptoms can be short-term, stemming from a traumatic life event or even as a side effect of a medicinal regimen and is usually coped with effectively without psychiatric intervention. Major depressive symptoms, especially in youths, are of more concern to the psychiatric community and include severe symptoms that dramatically interfere with one’s ability to study, sleep, eat and generally enjoy elements of lifestyle. Major depression can even establish a long-term psychiatric problem known as anhedonia, a syndrome in which an individual suffering from depression can no longer sustain any type of gratification or satisfaction from various activities once found enjoyable, inclusive of recreational activities and even social engagement (Cohen, Emmergson, Mann, Forbes & Blanchard, 2010). Major bouts of depression can even include the onset of Persistant Depressive Disorder, in which a depressed mood is long-standing and accompanied by some level of psychosis, inclusive of delusional thinking patterns or even catatonic behaviour (Murray, Buttner & Price, 2012). Prevention of depression in youths is of significant concern to both society and the psychiatric community. Because children are cognitively and emotionally less-developed than adults who maintain better coping skills gleaned through maturity and experience, youths are more prone to self-destructive behaviours and aggression when experiencing major depressive symptoms. Children with major depressive episodes are also more prone to the development of conduct disorder, in which they maintain a recurring and persistent pattern of negative behaviours that fail to respect the rights of other members of society; a type of antisocial attitude. Major depression maintains many implications for parents, educators and even general society. It is estimated that approximately eight percent of all youths and adolescents in society suffer from depressive symptoms (Eapen, 2012). It is further estimated that youths who do experience depression have a 70 percent chance of future recurrence within a five year period. Conduct disorders as a potential outcome of youth depression can serve to limit the capability of parents and educators to instil both cognitive lessons and a sense of moral correctness into the child’s ethical framework which poses risks to society. As a result of the consequences to educators, parents and society associated with youth depression, there is more focus on primary and secondary prevention of child depression. Reddy (2009), however, believes that the definitions of primary prevention in psychiatry are indistinct and that there is limited evidence indicating a higher success rate for certain primary prevention programs that have been tested as reliable and viable tools for prevention. Secondary psychiatric methods appear to be the most practical and feasible strategy for reducing youth depression since proactive diagnoses are difficult to establish, as well as identifying the most at-risk youth population for the onset of depressive symptoms. This paper examines the literature on primary and secondary prevention of child depression, evaluating the strengths and weaknesses of individual studies as well as the field of psychiatry as a whole. Primary Prevention Methods – Self-Reporting Inventories Reddy (2009) provides a vision for primary prevention in psychiatry. First, the establishment of universal prevention is desirable, which is aimed at the entire national or global population. Reddy also provides a framework for selective prevention, which seeks to identify specific subgroups of populations that are potentially at high risk or high-vulnerability. The aim of this approach is to recognize factors which precipitate depression and determine how these factors can be annulled. Reddy (2009) further suggests that prevention methodologies would be viable by seeking to identify those that maintain minimal depressive symptoms that do not necessarily satisfy the specific diagnostic criteria established for diagnosing depression. Hence, the difficulty in primary prevention is segmenting specific populations that maintain higher risk of depression and then creating targeted programs, information or interventions that would be most effective and viable; the vagueness of primary prevention. The U.S. Preventative Services Task Force has identified a rationale that is viable for primary prevention of depression in adolescents between 12 and 18 years of age that has provided some level of proven results for identifying at-risk populations. Recommendations from this organization include the utilization of the Beck Depression Inventory for Primary Care, a type of self-reporting instrument that allows a potential at-risk youth to report on their level of depressive experiences with a scoring system that ranges from zero to five points (USPSTF, 2009). Children who are screened using this instrument who provide a score of four serves as the justification for further psychiatric evaluation associated with depression. Richardson, McCauley & Grossman (2010) suggest that the utilization of the Patient Health Questionnaire 9 is a viable tool for identifying major depressive symptoms with adolescents. This screening instrument was developed by Pfizer, Inc. and is also a self-reporting inventory consisting of multiple choice questions that is recognized as a viable tool for diagnosing mental health disorders, inclusive of not only depression, but also anxiety and somatoform illnesses. A recent study conducted by Moreno, Christakis, Egan, Jelenchick, Cox, Young, Villiard & Becker (2012) evaluated the Patient Health Questionnaire 9 to determine the tool’s viability as a screening tool for youths that openly publicized depressive symptoms on Facebook to uncover whether this clinical scale could be deemed reliable for primary prevention efforts. It was determined by the study conducted by Moreno, et al. (2012) that the tool was only viable as an instrument for evaluating minor depression symptoms with little relevance for major depression identification. One of the main criticisms of using the Patient Health Questionnaire 9 as a primary prevention tool involves the recruitment methodology of perceived at-risk populations. The study conducted by Moreno, et al. (2012) involved scanning Facebook for incidents of language or terminology that involved matches with known depressive symptoms. Upon finding an appropriate sample group, contact was made via telephone with promises of compensation for agreeing to fill out an online survey about depression which was later compared to the Patient Health Questionnaire 9 to make an appropriate diagnosis. In this study, youths were likely seeking social support for the onset of minor depressive symptoms via Facebook as an appropriate social medium and were therefore not experiencing major depressive symptoms. Hence, recruitment efforts in primary prevention methodologies using the Patient Health Questionnaire 9 as an appropriate comparative guide were only identifying a random group of youths that is not representative of a broader national or global population of adolescents. The U.S. Preventative Services Task Force further suggested that primary prevention is effective when utilizing the Beck Depression Inventory for Primary Care. However, as a viable psychiatric tool, there must be an effective recruitment methodology to ensure that these instruments are engaging an appropriate at-risk population. Without the guidance of a pre-existing and diligent psychiatric diagnosis, it is highly subjective to suggest that a viable sample population could be determined by parents or, perhaps, educators that lack the credentials to make such an assessment when determining an appropriate recruited sample. Though these instruments may be valid in that they accurately measure the variables associated with youth depression, determining which population would provide the psychiatric community the most lucrative information for the creation of preventive methods becomes an unreliable venture. Society would then be reliant on the expertise and credentials of experts in the field of psychiatry to determine a recruitment methodology for utilizing these instruments; a dramatic and costly undertaking, especially for researchers unfamiliar with the youth personality and character profiles being recruited. Furthermore, the utilization of a self-reporting instrument must be considerate of a youth’s cognitive development capabilities to ensure accuracy in filling out the instrument reliably. The U.S. Preventative Services Task Force suggests that the Beck Depression Inventory for Primary Care would be viable for recruiting those ranging between 12 and 18. There is a substantial difference in cognitive development between these age ranges (Weiten & Lloyd, 2010), hence impacting the extent to which a child engaged with the aforementioned research instruments can assess the meaning behind these instruments which are often delivered, primarily, to adults with at-risk profiles or known depressive histories. It is logical to assume that an older adolescent with higher reasoning skills at the cognitive level could more easily perjure themselves in a self-reporting instrument, especially when depression maintains a rather negative social stigma in society. Can these instruments, as potential preventative tools, ensure that self-reporting instruments for more mature adolescents can ensure accuracy of self-reporting results? This is a major problem, theoretically, with utilizing such instruments along a recruitment strategy for random samples of adolescents between 12 and 18 years of age. Furthermore, assuming the feasibility of using both aforementioned self-reporting instruments, at what point do these primary prevention methods become viable tools for referring at-risk youths for psychiatric evaluation and/or treatment? Who will make these recommendations? These are practical questions as the problem with youth depression impacts parents, educators and general society. Should society assume that the results of self-reporting instruments, however potentially reliable, should serve as the foundational and justified rationale for referring youths to psychiatric experts? It is likely that educators and parents that have intimate experience and knowledge of youths who are spotlighted for future referrals would have differing evaluations of the youth, related to parent and educator perception of the extent of any potentially recognized depressive symptoms and its impact on their behaviours, socialization skills, and educational prowess. Researchers who applaud these instruments as preventative tools seem to be missing a fundamental aspect of diagnosis and future referrals that involves multiple social actors that will be either resistant to suggestion for psychiatric referral or otherwise combative (especially parents) about their child’s emotional competency. Hence, as a preventative tool, it would seem that the Beck Depression Inventory for Primary Care and the Patient Health Questionnaire 9 are insufficient preventative tools, but do maintain the ability to inform researchers about potential correlations with certain child demographics as a means of potentially identifying at-risk groups. Society must also recognize that some youths are more resilient than others as a result of their tangible intelligence quotients and socialization skills (Buzawa, Buzawa & Stark, 2012). This, too, could complicate identifying an appropriate recruitment sample for preventative evaluation using a randomized sampling approach as this recruitment strategy could not hope to be representative of a less-resilient youth population nationwide or globally who can better cope with the struggles of adolescence, dysfunctional family environments, or any other social factor that might serve as known catalysts for the onset of depressive symptoms. Primary Prevention Methods – Identifying At-Risk Groups One of the main difficulties in primary prevention of youth depression is determining what might potentially serve as a catalyst for the onset of depressive symptoms. Garber, Clarke, Weersing, Beardslee, Brent, Gladstone, et al. (2009) iterate that adolescents who are the children of known depressed parents have a significant risk of the development of a variety of depressive disorders as compared to children of more functional parents. As a tool for primary prevention, the study by Garber, et al. (2009) identified a sample group of parents that had been administered a research instrument known as the Structured Clinical Interview that assesses DSM-IV Axis I disorders that serves to evaluate current mood disorder extent and the volume of previous depressive episodes experienced by the participant. Concurrently, youths were administered the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Epidemiological Version diagnostic tool as a means of diagnosing youth depression and its extent (Garber, et al.). Results of parental diagnoses and youth diagnoses using the aforesaid instruments were evaluated to determine whether more affected parents led to more depressed youths. To gain access to these parents and youths, the study utilized a recruitment method that was inclusive of letters delivered to local physicians within the local community, letters delivered to parents in regional school districts, newspaper advertisements, radio and television promotions, and even an organization involved in health maintenance via their Internet database. The study concluded that better treatment of parents experiencing depression could serve as a mitigation tool for reducing youth depression (Garber, et al.). Though the aforementioned study by Garber, et al. Indicated that a positive preventative tool could involve recruitment of parents with histories or current episodes of depressive mood disorders could identify potential at-risk students, another problem with this approach is also in the recruitment methodology. Not all individuals in a society that experience depression want to be included in a long-term research study, especially those that provide little to no compensation for participation. There is an existing social stigma against those who maintain mental illness, including depression, which was discovered through an extensive research study involving 19,508 participants from 16 different countries (Lees, 2013). Hence, how can recruitment strategies that seek recruitment from a random sample of adults (as a depression-inducing catalyst for youths), ensure that those who show active interest in participation would be representative of those with demographic or personality-based characteristics that find shame, guilt or humiliation as a result of perceived or known social stigmas on depression. As with the preventative approach suggested by the U.S. Preventative Services Task Force and Moreno, et al. (2012), ensuring that a recruited sample is representative of a broader national or global population becomes a significant challenge in the field of psychiatry. Recruitment practices, to ensure relevant and accurate evaluation of at-risk populations, should be considerate of the variables associated with social attitude that could conflict excluding certain groups that might maintain more risk to society who are less apt to be open to research exposure as a result of stigmas or other relevant social concerns. However, there is a strength in recognising that parental depression could serve as a predictor of depressive symptoms in youths. By getting to the heart of potential risk factors of a child’s environment that could serve as a potential onset of depressive symptoms, the field of psychiatry is being responsible in prevention. Ineffectual parenting and neglect, common consequences of parental depression, is quite widely understood as a reason for psychological maladjustment in youths (Dehon & Weems, 2010; Weems & Carrion 2009; Orton, Riggs & Libby, 2009). Prevention, therefore, starts with recognizing and developing effective psychiatric treatment for adults to improve their parenting skills and curb the symptoms of depression that lead to childhood maladjustment or self-esteem development problems. Assuming that the field of psychiatry can develop effective recruitment methods, this could prevent future depressive occurrences with a broader sample of youths impacted by depressed parents in their home environments. Approaching and diagnosing parents who are highly influential in moulding the development of children into healthy and well-adjusted adults is a rather conscientious and theoretically reliable methodology in preventative strategy. Identification and recruitment of other at-risk groups also poses a significant challenge to society today. What necessarily constitutes being at-risk and what organization or expert in the field of psychiatry should be authorized to make such determinations. There could be at-risk groups that are not classified in environments that would provide for appropriate access which would represent only a niche group of the population. It would be a time-consuming and arduous (as well as costly) process to recruit niche group members in society as a means of preventing youth depression. Hence, a more holistic approach to recruitment and the identification of at-risk groups that are relevant to the majority would be a more prudent approach to research in the field of psychiatry and would have the most significant outcomes for society if conducted in this fashion. There is a plethora of potential factors that might serve as predictors or known catalysts for identifying at-risk child populations that could also further complicate identifying how to evaluate, recruit or diagnosis at-risk children that would impose significant burdens on society and psychiatric researchers. Hence, it would appear that establishing a more viable criteria for what constitutes being at-risk would be a paramount goal in primary depression prevention efforts in today’s society. Secondary Prevention Methods – Cognitive Behavioural Therapy Groups It is well-understood in the domain of psychology that youths seek social approval and social belonging as they attempt to establish their own unique sense of personal identity during adolescence (Dumas & Wolfe, 2012; Berger & Rodkin, 2012; McAlister & Cornwell, 2010; Weiten & Lloyd, 2010). This is a fundamental and rather universal aspect of adolescence. In the study conducted by Garber, et al. (2009), youths were exposed to a cognitive behavioural therapy (CBT) group inclusive of between three and 10 different like-aged peers and conducted by independent evaluators holding (at minimum) a Master’s Degree in some field of mental health. The study found that CBT groups, consisting of important peer reference groups, were effective in reducing the prevalence and severity of youth depression. Hence, this study maintains significant implications for potential preventative strategies. Since it is understood that youths seek approval and support from other youths in their social environments during the developmental period of adolescence, Australian society and school districts can potentially be proactive in establishing youth support networks that can facilitate more open discussion about the catalysts and symptoms of youth depression. Sussman, Pokhrel, Ashmore & Brown (2011) iterate that peer group membership with adolescents is a fundamental method of not only building a sense of positive identity, but that voluntary membership in a peer group serves to validate that they actually have achieved a sense of social belonging. Such groups provide a sense of support and provide a direction through conformance to established group norms (Sussman, et al.). Donker, Griffiths, Cuijpers & Christensen (2009) agree that peer group interventions are effective in preventing depression when mediated by a relevant mental health expert. When the group is designed to facilitate psychiatric CBT, the group works co-dependently to facilitate a more positive emotional capacity and attempts to change dysfunctional cognitive thoughts through an approach that involves promoting motivational self-talk and changing cognitions that are largely self-defeating to the individual and/or group (Hoffman, Sawyer & Fang, 2010). What makes cognitive behavioural therapy so effective in a peer group environment is that it provides for cognitive rehearsal where the mediator of the group asks individuals to publicize stressful or challenging situations that have led to depressive symptoms. The patient and the psychiatrist mediating the group teaches the group to rehearse many different positive thinking patterns that reprograms the individual to think more optimistically, thus changing recurring negative thought patterns. One of the most respected and fundamental methods in CBT is having group members adopt the persona of their peer group individuals to engage in role playing. Under this strategy, the patient learns how to adopt more effective and productive social responses when peers begin to serve as social role models within the group dynamic. The psychiatric group mediator then supplements these lessons and peer evaluations with reinforcement strategies, such as providing reward for more effective and productive responses, which serves to reinforce the desired behaviour, a type of operant conditioning. Coupling many different psychiatric strategies, inclusive of operant conditioning, role playing, and allowing group members to gain support and learning from one another would seem to be a rather effective secondary prevention strategy. Though this approach has most often been found effective with those who already maintain recurrent depressive symptoms, the ideology of its foundation would seem to be relevant for preventative services. Schools, parents, and civic organizations (among other potential groups) can adopt a group psychiatry methodology that involves peer reference groups, drawing on the fundamental social needs and motivations of adolescents that strongly seek peer influence and advice to build a sense of self-esteem and social belonging. Drawbacks, however, to this methodology, could be establishing the foundation of over-reliance on support networks in children to justify their social position and establish self-esteem that is critical in some instances to removing depressive symptoms especially when stemming from a perceived or legitimate lack of social belonging. For instance, referencing psychodynamic therapy as a psychiatric tool, it is the goal of the psychiatrist to uncover unconscious drivers that lead to child depression which are not necessarily acknowledged at the cognitive level in the youth. Hence, the depth of discussion in a CBT peer group might not explore historical traumas or other instances that served as catalysts for the onset of depression that are unbeknownst to the youth. Therefore, the peer environment would only be exploratory for conscious drivers or variables related to the fundamental negative evaluations experienced by the child that would be more beneficial through one-on-one interventions with the psychiatrist in a controlled environment. The psychiatrist in this setting is able to explore issues of transference, identify defense mechanisms that complicate effective cognitive self-evaluation of what causes depression, and the utilization of free association to fully explore the dynamics of strong internal conflicts within the child (Cabaniss, Cherry, Douglas & Schwartz, 2011). Peer groups as a secondary prevention method may be insufficient in providing the depth of analysis required of a more focused approach to psychiatry, allowing the individual to become reliant on peer assessments and evaluations rather than exploring inherent conflicts occurring within the child. Secondary Prevention Methods – Bullying and Deliberate Self-Harm Through is a growing prevalence of bullying between peers in the social environment across the world. Bullying is a significant predictor of depression and a study conducted by Garisch & Wilson (2010) identified that deliberate self-harm can occur as a result of depression onset from peer bullying. Children who have been bullied by others in their peer environment have risk factors for self-harm at a rate of three times that of non-bullied youths (U.S. News and World Report, 2012). As previously identified in the essay, children are highly reliant on establishing a sense of social belonging within peer groups and have significant risks for self-esteem destruction as a result of being rejected or bullied by others, hence leading to depression. This is of significant concern as it is recognized that one-in-six children in Australia are bullied every week. Children who bully maintain several recognized characteristics that drive this maladjusted behaviour, inclusive of egocentrism, lack of peer group popularity, an inability to control aggressive impulses, and antisocial behaviours. However, the most alarming statistic is that often bullying occurs in the presence of the victim’s peers, with 87 percent of peers doing absolutely nothing to assist or help the victim. Hence, bullying as a form of catalyst for the onset of depression has significant implications for Australian (and global) society and the prevalence of its social dysfunction is so widespread that it impacts a substantial portion of the child population domestically and around the world. Children who bully others are at a much higher risk for adulthood criminal behaviours and have higher school drop-out rates. Whereas the psychiatric community might believe that victims of bullies would be the only youths maintaining depressive symptoms, research indicates that bullying children are at high risk of maintaining depression as a mental illness (Grohol, 2012). Hence, society should recognize that depression in youths is both a mechanism of depression for bullying children and as a consequence of being bullied in the youth population. With bullying being recognised as a significant cause of depression in youths, coupled with its growing pervasiveness as a social problem in Australia, secondary prevention in the field of psychiatry is rather self-explanatory. There are numerous opportunities for experts in the psychiatric field to educate parents on the familial drivers or other environmental drivers that lead to depression and then subsequently transferring these aggressions onto others in the child’s peer environment. Informative brochures, letters delivered to parents in the home environment illustrating statistics and known drivers of child depression and its relationship to bullying, as well as information publication of known warning signs of mental illness that leads to bullying would assist parents in identifying children that have a history of recurrent depressive symptoms. Such efforts would provide the foundation for increasing referrals for psychiatric evaluation and/or treatment by engaging parents in this diagnosis process, thus improving potential resistance in this process when left solely to experts in the domain of psychiatry. It would be irresponsible not to explore potential secondary prevention methods as it pertains to bullying and depressive symptoms sustained by both the aggressor and the victim. Elledge, Cavell, Ogle & Newgent (2010) found that a school-based mentoring program that occurred during lunch hours between the identified aggressor student and mentors improved social adjustment for the bullying child between the ages of 10 and 12. Such strategies include role modelling conversational skills, suggesting more effective conflict resolution strategies, or strategies to change distorted child views regarding a perceived imbalance of social power in the child’s environment (Elledge, et al.). The difficulty in using mentoring strategies in the school environment is that children of this age group, and in the adolescent group, maintain strong reputational issues as it pertains to their image among peers. Mentoring programs that occur within school operating hours and in a lunch room environment could have potentially negative consequences as it pertains to establishing the appropriate sense of peer belonging. However, educators and administrators in the educational environment are the most familiar with those who maintain risk factors for depression and known bullying instances historically, thus providing an ideal environment for such a mentoring program. The weakness of this approach, however, is that it would require the presence of well-trained experts in the field of psychology to successfully facilitate growth and understanding, as well as emotional adjustment, which are fundamental to providing effective psychiatric treatment. Since the majority of psychiatric approaches require long-term interventions with youths to explore multiple dimensions of unconscious programming as well as changing distorted behavioural tendencies, the short-term interventions for mentoring between student and psychiatric expert might be ineffective in providing a set of holistic treatment outcomes. However, such a program does serve as a foundation for intervening and assisting youths that translate depressive symptoms into bullying against others in an environment where recruitment would be practical, feasible, and realistic for such interventions. As identified, one of the main criticisms of primary prevention is in the recruitment methodology that is often not, theoretically, sufficient for ensuring that adequate representation occurs. Conclusions As illustrated by the research, there are several strategies for primary prevention of depression in children that are inclusive of various self-reporting inventories and even identifying depressed parents and facilitating treatment of this group in order to provide society with better adjusted youths by removing an at-risk factor for many children who live in households with depressed parental figures. The effectiveness of these strategies was supported by many reputable researchers in the domain of psychiatry as well as government organizations that provided some level of evidence that these prevention methods could have positive outcomes if implemented. Secondary prevention, with the recognition that it requires curbing future instances of children that maintain depressive symptoms, would require properly identifying those with high-risk factors for depression or maintain a recurrent history of behaviours and attitudes linked with known factors of depression. The report identified that mentoring programs for bullies that maintain depressive symptoms that facilitate bullying against other peers could be effective as well as including a child in cognitive behavioural therapy groups inclusive of important peer reference groups. The field of psychiatry is considerate of identifying potential catalysts for what drives depressive behaviour in youths, however both primary and secondary prevention methods to this effect have met with vague outcomes and there has been no universal strategy developed that would facilitate a reliable and valid approach to prevention of depression in today’s youths. Perhaps it is due to the complexities of human behaviour, social and cultural factors, household dynamic characteristics, or even the academic environment that makes identifying a set of universal strategies relevant for prevention of depression. This would seem to point, in conclusion, to the need for experts in the psychiatric community to develop a communities of practice methodology that provides more substantial research capabilities and consultation that would provide more solutions and strategies for primary and secondary prevention. Disparate findings that achieve vague results relating to the long-term benefits of various prevention methods make identifying effective and productive strategies rather subjective, founded only on a small handful of research studies that were designed to measure the potential efficacy of various primary and secondary prevention methods. Until there is a form of consensus regarding the most operative and effectual methodologies, child depression is likely to pervade society and remain a significant social issue. References Berger, C. & Rodkin, P. (2012). 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