“Searching for

Happily Ever After”

An Overview of Depression

Dr. Brian L. Bethel Child and Family Therapist

Independent Trainer and ConsultantLPCC-S, LCDC III, RPT-S

www.brianlbethel.com

INTERPLAY

COUNSELING & CONSULTING

COPYRIGHT

• Copyright © 2017 by Brian L. Bethel, PhD, LPCC-S,

LCDC III, RPT-S Searching for Happily Ever After,

An Overview of Depression. This presentation or

contents from this presentation may not be sold,

reprinted or redistributed without prior written

permission from the author. Direct questions about

permissions to:

• Brian L. Bethel: interplaycounseling@gmail.com

www.brianbethel.com

Imagine that a category five hurricane has

just been predicted for your area.

Who or what are you going to need to

survive the hurricane?

HURRICANE WARNING

THE STORM

THE STORM

What comes to your mind when you

hear the term Depressive Disorder ?

DEPRESSIVE DISORDER

MOOD DISORDERS

Mood disorders represent a category of mental

disorders in which the underlying problem

primarily affects a person’s persistent

emotional state (their mood).

DEPRESSIVE DISORDERS

Are mental illnesses characterized by a

profound and persistent feeling of sadness or

despair and/or a loss of interest in things that

were once pleasurable.

BIPOLAR DEFINED

Bipolar disorder is a serious mental illness in which

common emotions become intensely and often

unpredictably magnified. Individuals with bipolar

disorder can quickly swing from extremes of

happiness, energy and clarity to sadness, fatigue

and confusion.

American Psychological Association

HAPPY

SAD

MYTHS

Myth: Teens who claim to be depressed

are weak and moody and just need to pull

themselves together.

FACT: Depression is not a weakness, but a

serious health disorder. Both young people and

adults who are depressed need professional

treatment.

MYTHS

Myth: There is nothing anyone can do to help people who

are depressed – they just need to work

FACT: A trained therapist or counselor can help them

learn more positive ways to think about themselves,

change behavior, cope with problems or handle

relationships. Also, a physician can prescribe

medications to help relieve the symptoms of depression.

For many people, a combination of psychological therapy

and medication is beneficial.

MYTHS

Myth: Only adults can get truly depressed.

FACT: Depression is epidemic among teens

today. Up to 20% of young people will

experience clinical depression during their

teenage years. That’s one out of every five

teenagers.

MYTHS

Myth: People who are depressed mostly feel

sad.

FACT: Other symptoms of depression can be

irritability, lack of energy, change in appetite,

substance abuse, restlessness, racing thoughts,

reckless behavior, too much or too little sleep,

or otherwise unexplained physical ailments.

MYTHS

Myth: Telling someone to cheer up usually

helps.

Trying to cheer someone up might make them

feel even more misunderstood and ashamed of

their thoughts and feelings. It is important to

listen well and take them seriously.

MYTHS

Myth: Most people with depression cannot be

helped.

FACT: Depression can be effectively treated in

90 percent of cases with a combination of

medication and therapy. Unfortunately, only 1 in

3 people with depression will get help.

MYTHS

Myth: Depression does not run in families.

FACT: Children with depression are more likely

to have a family history of depression.

MYTHS

Myth: Once depression is treated, it goes away.

FACT: Almost 75% of teenagers who experience

an episode of clinical depression will experience

another one in their lifetime.

MYTHS

Myth: Teens who talk about suicide don’t kill

themselves.

FACT: Teens who are thinking about suicide

usually find some way of communicating their pain

to others – often by speaking indirectly about their

intentions. Most suicidal people will admit to their

feelings if questioned directly.

MYTHS

• Myth: Anyone who self-injures is crazy and

should be locked up.

• Fact: For most who practice self-injury, it is

used as a coping mechanism.

Caicedo & Whitlock, (2009)

Cornell University (2016)

PREVALENCE

PREVALENCE

Depression occurs in 1-2% of children

before puberty.

NIMH

PREVALENCE

After puberty rates of depression increase

significantly to about 3-8%.

NIMH

PREVALENCE

About 20% of adolescents will experience

meaningful symptoms of depression by the

time they enter adulthood.

University of Michigan

PREVALENCE

Years between 15-24 represent the most

common time for the onset of a depressive

disorder.

University of Michigan

PREVALENCE

One in twenty children and adolescents

experience a potentially disabling

depression before the age of 19

University of Michigan

PREVALENCE

Higher rates of depression in females than

males.

NIMH

PREVALENCE

Children and adolescents with depression

are 8-20 times more likely to complete

suicide compared to children without

depression.

NIMH

PREVALENCE

The number of young people aged 15-16

with depression nearly doubled between

the 1980’s and 2000’s

NIMH

PREVALENCE

Approximately 20% of adults with bipolar

disorder had symptoms beginning in

adolescence.

NIMH

PREVALENCE

Some 20% of adolescents with major

depression develop bipolar disorder within five

years of the onset of depression.

Birmaher, B.

PREVALENCE

• Estimated that 1/3 of all children in the US that are diagnosed with ADHD are actually Bipolar.

NIMH

PREVALENCE

• 3.4 million children & adolescents with depression in the US may actually be experiencing the early onset of bipolar disorder.

NIMH

PREVALENCE

• Approximately fourteen percent

of the teen population self-injure.

14%

86%Mental Health America, 2016

Riaz & Agha, 2012

PREVALENCE

• 17-35% of the college population

self-injure.

17%

83%Mental Health America, 2016

Riaz & Agha, 2012

TYPES OF DEPRESSIVE

DISORDERS

Major Depressive Disorder

Dysthymia

Seasonal Affective Disorder

Postpartum Depression

Bipolar Disorder

MAJOR DEPRESSION

A condition characterized by a long-lasting

depressed mood or marked loss of interest or

pleasure (anhedonia) in all or nearly all

activities.

Five or more of the following in a one year

period.

MAJOR DEPRESSION

Depressed mood

Reduced level of interest or pleasure

Loss or gain of weight

Disturbances in sleep

Behavior that is agitated or slowed down

Feeling fatigued

MAJOR DEPRESSION

Thoughts of worthlessness

Reduced ability to think/concentrate

Thoughts of death or suicide

BIPOLAR I

Bipolar I Disorder: defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible.

APA, 2013

BIPOLAR II

Bipolar II Disorder: defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes described above.

APA, 2013

CYCLOTHYMIC DISORDER

Cyclothymic Disorder: defined by numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

APA, 2013

UNSPECIFIED BIPOLAR

Unspecified Bipolar and Related Disorders— defined by bipolar disorder symptoms that do not match the three categories listed above.

APA, 2013

BIPOLAR I

One or more Manic Episode or Mixed Manic

Episode Minor or Major Depressive Episodes

often present

May have psychotic symptoms

APA, 2013

BIPOLAR I

Specifiers: anxious distress, mixed features, rapid

cycling, melancholic features, atypical features,

mood-congruent psychotic features, mood

incongruent psychotic features, catatonia,

peripartium onset, seasonal pattern

Severity Ratings: Mild, Moderate, Severe (DSM-5, p.

154)

APA, 2013

BIPOLAR II

One or more Major Depressive Episode

One or more Hypomanic Episode

No full Manic or Mixed Manic Episodes

APA, 2013

BIPOLAR II

Specifiers: anxious distress, mixed features,

rapid cycling, melancholic features, atypical

features, mood-congruent psychotic features,

mood incongruent psychotic features,

catatonia, peripartium onset, seasonal patter

Severity Ratings: Mild, Moderate, Severe

APA, 2013

CYCLOTHYMIC

For at least 2 years (1 in children and

adolescents), numerous periods with

hypomanic symptoms that do not meet the

criteria for hypomanic

APA, 2013

CYCLOTHYMIC

Present at least ½ the time and not without

for longer than 2 months

Criteria for major depressive, manic, or

hypomanic episode have never been met

APA, 2013

MANIC EPISODE

A distinct period of abnormally and

persistently elevated, expansive, or irritable

mood. Lasting at least 1 week.

APA, 2013

MANIC EPISODE

Three or more (four if the mood is only irritable) of the

following symptoms:

Inflated self-esteem or grandiosity

Decreased need for sleep

Pressured speech or more talkative than usual

Flight of ideas or racing thoughts

Distractibility

Psychomotor agitation or increase in goal-directed

activity

Hedonistic interestsAPA, 2013

MANIC EPISODE

Causes marked impairment in occupational functioning in usual social activities or relationships, orNecessitates hospitalization to prevent harm to self or others, orHas psychotic featuresNot due to substance use or abuse (e.g., drug abuse, medication, other treatment), or a general medial condition (e.g., hyperthyroidism).

HYPOMANIC

Similarities with Manic Episode

Same symptoms

Differences from Manic Episode

Length of time

Impairment not as severe

May not be viewed by the individual as

pathological

However, others may be troubled by erratic

behavior

DEPRESSIVE EPISODE

A period of depressed mood or loss of interest

or pleasure in nearly all activities

In children and adolescents, the mood may be

irritable rather than sad.

Lasting consistently for at least 2

weeks.

Represents a significant change from

previous functioning.

DEPRESSIVE EPISODE

Five or more of the following symptoms (at least one of which is either (1) or (2):

Depressed moodDiminished interest in activitiesSignificant weight loss or gainInsomnia or hypersomniaPsychomotor agitation or retardationFatigue/loss of energyFeelings of worthlessness/inappropriate guiltDiminished ability to think or concentrateindecisivenessSuicidal ideation or suicide attempt

RAPID CYCLING

Rapid-Cycling Specifier

Can be applied to Bipolar I or II

Four or more mood episodes (i.e., Major Depressive, Manic,

Mixed, or Hypomanic) per 12 months

May occur in any order or combination

Must be demarcated by …

a period of full remission, or

a switch to an episode of the opposite polarity

Manic, Hypomanic, and Mixed are on the same pole

TREATMENT

TREATMENTEDUCATION

COUNSELING MEDICATION

PROGNOSIS

At least 70% - 80% of kids with depression can be effectively treated

– Without treatment, 40% will have 2nd episode within 2 years– 20% - 40% may go on to develop bipolar disorder

PROGNOSIS

Treatment methods may include

– Individual psychotherapy– Family therapy – Medication, e.g. TCA’s, SSRI’s

• Combined treatment with pharmacotherapy and psychotherapy is recommended

CAUSES

Biological

Genetics (family history)

Neurochemical

Environmental/Psychological

Life Stress

GENETIC FACTORS

Children with depressed parent 3x likely to

have lifetime episode of MDD (lifetime risk 15%-

60%)

Prevalence of MDD in first-degree relative of

children with MDD is 30%-50% (parents of MDD

children also have anxiety, substance abuse,

personality disorders)

MEDICATION

Most children are given many different combinations of drugs

Some drugs are mood-stabilizing drugs that adults take

A large amount of these drugs have not been tested on children

MEDICATION

Most of these drugs can have life threatening effects:

DiabetesSignificant weight gainHormonal problems that can lead to infertilityFatal blood disorders

MEDICATION

Some side affects of the drugs found in children:

Hair lossDrooling One side of child’s face drooped

MEDICATION

• Mood StabilizersLithiumAnticonvulsantsDepakote Tegretol TryleptalLamictalNeurontin Topamax

MEDICATION

New antipsychoticsRisperdal, Zyprexa, Seroquel, Geodon, Abilify etc.AntidepressantsSelective Serotonin Reuptake InhibitorsEffexor, Wellbutrim, etc.Others: benzodiazepines etc.

PSYCHOTHERAPY

Cognitive therapy - to increase

compliance with medication

Psychotherapy - if patient interested, can

increase compliance

Family therapy to support the family

structure

Group therapy

PSYCHOTHERAPY

Clinician should have knowledge in treating illness.

Isn’t convinced he/she knows all the answers.

Communicates with family and other providers.

Listens well.

Is aggressive towards treatment.

PSYCHOTHERAPY

Wants to work with family

Understands the possible trauma of hospitalization.

Willing to challenge managed care.

Values parental input

PSYCHO-EDUCATION

Help child & family make sense of the illness

Understand the role of medications

Help parents eliminate their own unhelpful cognitions

Enhance child & family’s skills & coping strategies for dealing with the illness

THE COGNITIVE TRIANGLE

THOUGHTS

FEELINGSBEHAVIORS

THOUGHTS FEELINGS

BEHAVIORSCONSEQUENCES

THE COGNITIVE SQUARE

FAMILY REACTIONS

Denial and Fear

Shame

Stress of Unpredictability

Judge and Jury

Grieving Process

Re-defining parenting

FAMILY TREATMENT

Focus on day-to-day mood fluctuations and

changes in functioning rather than discrete

episodes.

Help adolescent and parents distinguish age-appropriate moodiness from bipolar disorder.

Use developmentally appropriate terminology.

Miklowitz, D. & George, E. (2000)

FAMILY TREATMENT

Empathize with the adolescent’s discomfort

with diagnosis.

Use visually stimulating handouts and homework sheets

Miklowitz, D. & George, E. (2000)

Questions