the association between depression and suicide in adolescence

Running head: DEPRESSION AND SUICIDE 1

The association between Depression and Suicide in adolescence

Student: Euridiki Damoulianou

Instructor: Barbara Kondilis

Psy230: Developmental Psychology II

Hellenic America University

Spring 2011


Abstract

This paper contains a complete analysis of depression in adolescence, such as its

symptoms, causes and treatment and its link to suicide ideation. In addition, this paper

includes the full description of a study which was conducted on 20 May 2011 in

Greece. In this research four subjects (Greek, Whites, and ages 27 - 48) were

interviewed. Two of the participants were diagnosed with depression since

adolescence and the other two were relatives of two individuals, who committed

suicide due to major depression. Each interview lasted for two hours and within two

days all the interviews were conducted. It was concluded that individuals who have

low-self esteem, suffer from depression and have experienced a traumatic life-event,

present high risk levels of committing suicide. In the discussion section, several

limitations of the study are mentioned and suggestions are proposed for further

research.


The Association between Depression and Suicide in Adolescence

Depression, which according to Greek Ministry of Health affects 850,00 men and

1,1000 women in Greece annually, it is a serious mental disease which disrupts

relationships and daily lives. There are several types of depression, such as: major

depressive disorder ,which prohibits an individual’s day to day functions such as

sleeping, studying and eating, dysthymic disorder which is characterized by periodic

long-term depression, psychotic depression which is associated with a degree of a

psychosis, such as a break of reality and creation of illusions, postpartum depression

which it occurs when a woman develops a depressive episode after one or two moths

the birth of her child and seasonal affective disorder which occurs when an

individual develops a depressive episode during a seasonal period such as the winter

months or during summer )(www.nimh.nih.gov) .

Adolescence is considered to be a crucial developmental stage for understanding the

causes, treatment and course of depression. According to the U.S. National Institute

for Health (www.nimh.nih.gov), almost 20% of the teenage population experience

depression. In the past, adolescent’s problems were not treated, because people

believed that the teenager would overcome them after they would finish adolescence

(Petersen, 1993). However, according to recent studies, the psychosocial cognitive

and physical changes that the adolescent experiences during puberty, can fill him/her

with emotional turmoil and make him /her vulnerable towards depression and other

mental health illness(Petersen, 1993). Thus, it is essential that depression during

adolescence is diagnosed and treated at its early stages before developing into serious

psychiatric disorder during adulthood (Petersen, 1993).


Depression in adolescence is usually measured through adolescent’s self-reports of

their emotions, through interviews -with the adolescents who suffer from depression

or with their parents-, or through items included in checklists of depressive symptoms

(Meares, 2003). Depressed adolescences are likely to experience a set of negative

emotions such as sadness, guilt, fear, anger, disgust, contempt and anxiety and to

display low performance or attendance at school, social withdraw and sleep

disturbances (Meares, 2003). Furthermore, depressed adolescent boys tend to display

aggressive patterns of behavior within their school and home premises, to engage into

delinquent and anti-social behaviors and substance use as well as present higher rates

of anger, while depressed girls tend to develop negative body images, eating disorders

and low self-esteem (Meares, 2003). Moreover, according to the National Institute of

Mental Health, girls, Native Americans and homosexual teens have an increased risk

of depression. There are a set of theories which explain the causes of depression

during adolescence. Firstly, according to the developmental theory, adolescents while

they try to become autonomous and to gain self-control through their transition to

maturity, they experience a set of stressful situations which sometimes are difficult to

resolve (Meares, 2003).Every adolescent who tries to cope with a stressful event

initially denies that there is a threat but if the threat continues, it develops into anxiety

and anger (Petersen, 1993). Although anger may help an adolescent to mobilize

resources to cope with the stressful situation, sometimes it cannot help him/her to

cope with it (Petersen, 1993). As a result, the individual becomes depressed (Petersen,

1993).

According to Erikson’s psychoanalytic theory, the main developmental task that an

adolescent has to achieve is to resolve their identity crisis and to form an identity.

Highland (1979) states that if a teenager cannot resolve his/her identity crisis or


he/she is faced with a role change for which he/she is not ready, and then he/she has

high possibilities to experience depression.

Cognitive- behavioral theory implies that, depression experienced during adolescence

is associated with low-self esteem, negative self-evaluation, and negative view of the

future and a negative interpretation of one’s experiences (Meares, 2003). The

adolescent with a destructive cognitive triad, becomes helpless and eventually

depressed. According to the social role theory, an environment which does not

provide adolescents with opportunities to think and act independently can make them

helpless (Meares, 2003).

In addition, according to the family theory, the parental styles, the degree of

attachment that an adolescent has with his parents and the family-environment that

he/she grows, play an important role whether he/she will display depressive

symptoms (Meares, 2003). According to studies, certain traits were commonly found

among the families with depressive teenagers including negative parental feelings

projected onto the adolescent, lack of generational boundaries, inflexible family

systems and frequent conflicts among the parents (Meares, 2003). Moreover,

adolescents with depressed parents have high possibilities to display serious

cognitive, behavioral, school and social problems and consequently depression. This

happens due to heredity factors, emotional unavailability from the parents and

dysfunctional parent-child relationship (Petersen, 1993). Furthermore, traumatic

events inside the family environment like- parental divorce, abusive behavior against

the teenager or neglect- increase dramatically the possibilities for the adolescent to

develop depressive symptoms (Petersen, 1993).


Furthermore, according to the biological theory, genetic factors are implicated with

depression. According to studies, depressed adolescents tend to secrete less cortisol in

comparison with the non-depressed teens (Meares, 2003).According to Lewis (1985)

some adolescents have a genetic predisposition towards depression and experience an

altered biochemical state which causes depression. However, because during

adolescence occur a lot of developmental changes in the cognitive, behavioral and

neurochemical functioning, it is difficult to examine adequately the biological factors

which are associated with depression in the adolescents (Petersen, 1993).

Moreover, during adolescence low peer popularity, poor relationships and less contact

with friends and a lot of experiences of rejection can contribute to depression, because

adolescents value a lot popularity and intimacy among friends and if a teenager has

not developed closed and supportive relationships with his peers , he/she is at a great

risk of becoming depressive(Petersen, 1993). Especially, if an adolescent has weak

relationships with his parents, his/her peers can provide him/her with affection, secure

and emotional support (Petersen, 1993).

Environmental stressors during adolescence such as the loss of a loved one,

responsibilities at home, arguments with peers, the transition from the elementary to

the high school and the end of an important romantic relationship, are associated to

some degree with depression (Colman, 2010). External factors such as stressful life

events increase the risk of depression both to adolescents with low or high genetic risk

(Colman, 2010). However, stressful events do not directly cause depression but the

adolescents who have suffered from a stressful event, before the onset of depression,

present higher severity of depression overall (Colman, 2010). In addition, although it

seems that the symptoms of depression appear immediately after an unpleasant event,


some events -especially the events that occur during early or middle- childhood-, can

increase the possibility of depression during adolescence-for example parental divorce

(Colman, 2010).

Adolescents- particularly females- who are dissatisfied with their body are more

likely to display symptoms of depression than other adolescents who are satisfied with

their body image (Lamis & Malone, 2010). Rierdan and Koff (1997) proved through

their research that adolescence’s negative perceptions about his/her body, might

contribute to the onset of depressive symptoms. The association between body

dissatisfaction and depression can exist with-out the existence of an eating disorder

such as bulimia and those who do not exhibit an eating disorder but perceive

themselves as less attractive may also be recognized as being depressed (Keel

&Davis, 2000). Keel & Davis further provide evidence that suggests there is a link

between eating disorders/body image and those who also show depressive symptoms.

Finally, according to a set of studies by Lamis & Malone (2010) indicate that heavy

alcohol use and alcohol dependence are associated with high risks of depressive

emotions during adolescence, and that a heavy episode of drinking and alcohol

dependence has more possibilities to occur among adolescents who experience

depression .Similarly these researchers found out that -among adolescents who suffer

from depression - consumption of alcohol is often related to their attempt of easing

their depressive emotions or symptoms.

As far as the treatment of depression during adolescence is concerned, it usually has

two parts (1) drug therapy –psychotropic medications which change temporally or

permanently the biochemical state of depressed adolescents- and (2) psychological

and cognitive therapy – which helps the depressed adolescences to cope with threats


more effectively and to find more flexible patterns of behavior (Highland, 1979).

Also, cognitive therapy can help a depressed adolescence to work successfully

through developmental crises, to formulate an identity, to be in position to form

intimate relationships and to provide him/her with problem-solving skills (Highland,

1979).

In some cases, an adolescent can overcome his depressive symptoms with-out any

kind of treatment as he gains maturity through his transition from adolescence to early

adulthood (Boyd, 2003). However, sometimes depression, (even if the case that the

adolescent receives treatment), remains incurable and a set of depressive symptoms in

adolescence repeat and become more intense during early-adulthood (Boyd, 2003).

Suicide is a complex phenomenon where several environmental, social and economic

factors contribute to it. According to the National Institute for Mental Health, suicide

is the third leading cause of death among adolescents. In a survey of high school

students it was found out that one out five teens had thought about suicide, one out six

teens had made plans for suicide and one out of twelve teens had attempted suicide

during the past year and though there are more attempts at suicide by female

adolescents as a whole, the male adolescents are more successful at dying

(www.teendepression.org). This is likely due to the choice of method for suicide

attempt.

According to studies, adolescents with depressive disorders present a significantly

greater risk of committing suicide than those who are psychological healthy and that a

great number of adolescents who have suicidal thoughts or have attempted suicide,

suffer from depression (Liu, 2006). In fact, 2% to 7% of the patients who are

diagnosed with depression actually die from suicide (Zivin, 2007). It is also


interesting the fact that about 7% percent of male adolescents diagnosed with

depression die by suicide, meanwhile the respective percentage for female adolescents

is 1% (Zivin, 2007).

Thus, there is a link between depression and suicide. Depression distorts an

adolescent‘s point of view to such a degree that he /she perceives even small every-

day problems as major ones, which are impossible for one to solve, so that these

pessimistic negative thoughts added to the loss of pleasure and energy and low-self

esteem that an adolescent diagnosed with depression feels, makes one feel that death

is the only solution to escape from emotional pain (Zivin, 2007).

The purpose of this study is to assess the link between depression in adolescence and

suicide. Thus, my hypothesis, based on previous studies, literature and common

sense, is that adolescents who suffer for major-depression , combined with low-self

esteem and a stressful event (for example parental divorce) are at risk of developing

suicidal thoughts and committing or try to commit suicide during adolescence or

young adulthood.

Method

Participants

The cases of the study were four adults, two of them were diagnosed with

major depression during adolescence and the other two committed suicide due to


major depression (two of their relatives were interviewed). There were one male and

three females, aged 22 - 35 years old, Greeks and from different social, educational

and financial backgrounds. The participants of this study were selected from the

researcher’s social environment.

Procedure

The interviews were conducted in the participant’s homes. To start with,

within two days met with two of the participants separately with interviews in the

participant’s homes, after an arranged appointment which lasted for approximately

two hours. Before the onset of the interviews, the subjects were given an informed

consent form, where the purpose of the study was explained (to figure out the link

between depression during adolescence and suicide). Afterwards, the participants had

to reply to a set of questions .Furthermore, all the answers were written done to a note

book. If a subject felt uncomfortable with a particular question, they had the right not

to answer it. In addition, each participant was asked different questions .For example,

the relatives of those who had committed suicide due to major depression, were asked

different questions from the subjects who were diagnosed with major depression.

Finally, at the end of each interview, the subjects were thanked for their participation

in this study.

Results

The results for each participant varied, due to the uniqueness of each case.

However, some results were same for all of them. More specifically, case#1, #case2

and #case 4 were diagnosed with moderate depression in late-adolescence (17 to

18years old), while the case# 3was diagnosed with moderate depression in middle-


adolescence (14years old). Although, all the participants received treatment, their

condition deteriorated during their transition to young-adulthood .The subjects in

adolescence, were diagnosed with moderate depression, whereas in young-adulthood

they were diagnosed with major depression .The case#1, who committed successfully

suicide at the age of 35, during childhood he experienced both his parents ’suicide.

His father at the age of 35, after suffering years from depression, hung himself and

died. His mother at the age of 30, two months after her husband’s death, committed

suicide as well (received more than 20 psychotic pills). In addition, case#4, hung

himself at exactly the same age like his father.

The case#3, who committed suicide after swallowing more than 10

psychotropic drugs, she did not have any case of suicide within her family. However,

her mother was diagnosed with mild-depression. The case#4 two months before his

suicide, he had plans for the future and high levels of energy. Moreover, he did not

display any warning-signs, such as desperation and uncontrollable anxiety. On the

contrary, the case#3, two months before her suicide, she had extremely low-mood and

no future-plans. Furthermore, (according to her mother), she expressed frequently to

her family her wish to commit suicide and she avoided any social contacts outside her

family.

Both the case#3 and case4# before their death, they wrote an analytical letter

to their families, where the causes of their decision to commit suicide, were explained.

In addition, all the cases, apart from the case#2, were hospitalized into a public

institution.

Moreover, case#2, since adolescence she displayed high levels of sensation –

seeking and many times she engaged into risky behaviors, such as the use of illegal


substances and unprotected sex with strangers. The case#1 has suicidal thoughts and

she tried 5 times unsuccessfully to commit suicide via pills consumption and self-

hurting.

On the contrary, the case#2 neither attempted to commit suicide nor she had

any suicidal thoughts. Furthermore, all the cases experienced a set of stressful events

during adolescence and young adulthood. For example, the case#1, when she was 20

years old broke up with her boyfriend after an important long-term relationship .Also;

case#3 experienced her parents’ divorce at the age of 14.

All the cases displayed low levels of self-esteem and self-respect. For

example, the case#3 frequently told her mother that she felt incompetent and

worthless. In addition, the case#1 is weight-conscious. Also, all the cases suffered

from sleep-disturbances, persistent headaches and low-levels of energy.

The case#2 never received affection and support from her family. Case#1,

case#3 and case#4 had secure attachment with their family members. Although,

case#4 lost his parents during childhood, he had a close, loving relationship with his

wife and children. The case#1 and case #3 did not have any social contacts, while the

case#4 was very sociable.

Finally, the case#1 gets easily anxious and aggressive while she interacts with

other individuals. The other cases displayed low levels of anger and aggressiveness

during their interactions with other individuals.

Discussion

Obviously, the causes, symptoms and ways an individual confronts major

depression and suicide in adolescence and later in young-adulthood, depend on their


personality traits, socio-economic and educational background, gender and family of

origin. However, the results of this study show that individuals, who experience major

depression, share some common traits.

Depression has more possibilities to occur in late than the early adolescence (3

out of the 4 subjects were diagnosed with depression in late-adolescence). This might

occur, because older adolescents are obligated to take more responsibilities in

comparison to younger ones, such as some future choices. These responsibilities

contribute to higher levels of anxiety and consequently to depressive symptoms.

In addition, depression or suicide, inside the family, are two significant

factors, which can make an individual vulnerable to depression or suicide, as the

examples of case#3 and case#4. This study also proves, that some individuals imitate

their parent’s behavior, like the case#4, who committed suicide the same way and at

the same age, like his father. Thus, there is evidence that depression and suicide

ideation have a genetic basis and are hereditary.

As far as the external stressors are concerned, they can lead to the

deterioration of depression. Initially, all the cases were diagnosed with moderate

depression, but after the experience of a traumatic event, their depression escalated.

However, it has to be emphasized that depression is not only caused by an

unpleasant external event, but in combination with an individual’s biological

predisposition to display depressive symptoms (the participants of the study had

already depression before a stressful event occurred).

Furthermore, individuals who plan to commit suicide follow different

behavioral patterns and display different signs .For example, case #3, two months


before her suicide, had a very low mood and no ambitions. On the contrary, case#4

two months before his suicide, seemed very calm and presented high levels of

optimism and energy. He might behaved this way because he felt that via suicide, had

formulated his plan to find a way to escape from emotional pain.

Furthermore, gender is another factor which has impact on how an individual

deals with suicidal thoughts and attempts. Women and men use different methods to

commit suicide. For example, the case#4 (male) chose to hung himself, while the

case#3(female) swallowed psychotic pills.

Also, drug use added with high-rates of sensation seeking, is quite common

among persons who experience depression .For example , like case#2 ,who is drug

addict and frequently engages into risky behaviors.

This might happens, because while an individual tries to alleviate emotional

pain, engages into risky behaviors and habits without evaluating first their negative

long- term effects. However, illegal substance use and risky behavior can

simultaneously be the consequence and cause of depression. For example, an

individual might use drugs to become less depressed or drug use can lead him/her to

depression.

Moreover, low-self esteem is a common trait among patients of depression.

Although it is debatable whether it is the cause or the consequence of depression, all

the cases in this study felt worthless. Thus, low-self esteem is associated with

depression. A very low-self esteem, combined with negative external events,

increases dramatically not only the possibilities of depression but of suicide as well.


Thus, the initial hypothesis, that the combination of major-depression, low-self

esteem and experience of a traumatic or more traumatic events increases significantly

the possibilities of suicide ideation, was proven for the case#1,case#3 and case#4. The

case#2 displayed these particular traits (low self-esteem and the experience of a

negative life event), but until now, she neither attempted to commit suicide nor she

had suicidal thoughts. However, because this person is mentally altered, due to drug

use, is difficult to identify whether she has or not suicidal ideation, based only on her

responses during the interview.

This research displays some limitations though. Firstly, although interviews

present facts (what happens in the real world and not only in labs), they lack scientific

evidence and do not define the cause and effect. In fact, they are mainly descriptive

and have low- internal validity. Also, some participants in interviews might lie about

their condition, because they try to adjust their answers to what the researcher would

probably wish to hear .In addition, this study has low- external validity, because it

was based only on 4 cases, and thus its results cannot be generalized.

Suggestions for future studies on depressive individuals include the

investigation of a larger sample of subjects and from various cultures. Also,

interviews should be combined with additional tests for a deeper assessment of the

cases, because the subjects during the interviews might exaggerate or hide some facts.


References

Colman, PHD (2010). Life Course Perspectives on the Epidemiology of Depression. The Canadian Journal of Psychiatry, 55(100), 622-632.

Meares (1987). Depression in Childhood and Adolescence. National association of social workers.

Highland, a (1979). Depression in Adolescence. A developmental view. Child Welfare, 58, 557-585.

Keel, PK &Davis, TL (2000). Relationship between Depression and body dissatisfaction in women diagnosed with bulimia nervosa. The international Journal of Eating Disorders, 30(1), 48-56.

Lamis, A & Malone, S (2010). Body Investment, Depression and Alcohol Use as Risk Factors for Suicide Proneness in College Students. Hogrefe Publishing, 31(3), 118-127.

Petersen, C (1993).Depression in Adolescence. American Psychologist, 48(2), 155-168.

Teen depression, Statistics, Facts on Teenage Depression. (2011). Teen suicide statistics. Retrieved May 26, 2011 from http://www.teendepression.org/related/teen-suicide-statistics/

U.S. National Institute of Mental Health. (2011). Depression. Retrieved May 3, 2011 from http://www.nihm.nih.gov/health/publications/depression/index.shtml.

Zivin, K (2007).Suicide Mortality among Individuals Receiving Treatment for Depression in the Veterans Affairs Health System: Associations with Patient and Treatment Setting Characteristics. America Journal of Public Health, 97(12).

http://www.teendepression.org/related/teen-suicide-statistics/


Appendix A

Interview questions

1. At what age were you (or your family member) diagnosed with depression and which degree (mild, moderate, major)? How long have you (or your family member) been suffering from depression?

2. Have you ever thought or tried to commit suicide? Why? Why not?

3. What emotions did you experience (for example anger, desperation or worthless) that made you to ask for medical help?

4. How do you perceive yourself? Do you think that you are a person who can accomplish your goals?

5. Before his/her suicide, did he/she display any warning signs? Did his/her behavior change? Did he/she leave a letter? If yes, what did he/she say about her decision?

6. Do you feel energetic? Do you want to try a new activity, such as a new sport?

7. Do you have secure attachment with your family? Does your family give you adequate support? Is a history of depression or suicide within your family?

8. Does the consumption of illegal substances make you feel positive? What kind of emotions do you develop when you consume drugs? Does emotional pain deteriorate, if you do not receive them for some days?

9. Do you have trouble sleeping or nightmares?

10. Have you ever experienced a traumatic life event?

11. Have you ever stayed in an institution? If yes, for how long?

12. What is your educational and socio-economic background?

13. Have you attended a therapy or received medication?


Appendix B

Informed consent form

You are invited to take part in a study which main goal is to examine the link

between depression in adolescence and suicide. The present study’s research project is

being organized by a Hellenic American University student, Euridiki Damoulianou,

under the supervision of Professor Barbara Kondilis. You will answer verbally to a set

of questions which will be written down in a note book. Your identity will be kept

confidential to the extent provided by law. Your decision whether or not to take a part

in this research study is completely voluntary. If you decide to participate you are free

to withdraw without any penalties.

Euridiki Damoulianou Date

........................

Signature

....................................

Print name


Appendix C

The key points of the interviews

Case#1: single, female, aged 29, no children, attended a technical school.

a) Diagnosed with moderate depression in late-adolescence but after a traumatic external event (the end of an important long term relationship), diagnosed with major depression.

b) 5 suicide attempts via the consumption of psychotropic pills and suicidal thoughts.

c) No case of depression or suicide within family history and adequate support from parents.

d) Feelings of worthlessness, incompetence and low –levels of energy.

e) Sleeping disturbances, headaches and stomach aches.

f) Weight-conscious.

g) Hospitalized in an institution for depression, at one point of her life.

Case#2: single, female, aged 27, no children, dropped –out school.

a) Consumption of illegal drugs, high-levels of sensation seeking and risky behaviors such as unprotected sex.

b) No communication with parents and inadequate affection and support from family.

c) No suicidal thoughts or suicide attempts.

d) Low-self esteem and self-respect.

e) No case of suicide or depression within family.

f) Sleeping disturbances, headaches and stomach aches.

Case #3: single, female, aged 22, no children, college undergraduate.

a) Committed suicide at the age of 22(via consumption of psychotic pills).

b) No case of suicide within family. One parent (mother) diagnosed with mild-depression.

c) Adequate support and affection from family.


d) Sleeping disturbances, headaches and stomach aches.

e) Social withdraw and few social contacts.

f) Low-self esteem and self-respect.

g) Diagnosed with moderate depression at the age of 14 and diagnosed with major depression in early-adulthood.

h) Hospitalized in an institution for depression, at one point of her life.

Case#4: married, male, aged 35, two children, college undergraduate.

a) Committed suicide at the age of 35 (hung himself).

b) History of suicide within family. Both parents committed suicide during his childhood. The father hung himself and the mother consumed psychotic pills.

c) Two months before the suicide high levels of energy, optimism and calmness.

d) Hospitalized in an institution for depression, at one point of his life.

e) Diagnosed with moderate depression in late-adolescence and diagnosed with major depression in young-adulthood.

f) Low levels of self-esteem and self-respect.

the association between depression and suicide in adolescence

Health & Medicine

causes of depression

major depression

postpartum depression

psychotic depression

course of depression

types of depression

increased risk of depression

periodiclongterm depression