Final Portfolio:

Adolescent Depression in the United States

Emily Reichert

CAS 253

12/13/2011

The following portfolio explores health communication through the scope of adolescent depres-

sion in three important areas: media translation of science, informative health messages, and

health policy.

I am an undergraduate senior studying communication arts and sciences at Penn State University.

I plan to obtain my masters and doctoral degree in health communication in order to pursue a re-

search career studying depression and other mental health related illnesses.

TABLE OF CONTENTS

INTRODUCTION.........................................................................................................................2

PART I............................................................................................................................................5

Scientific Article.......................................................................................................................5

Media Reports..........................................................................................................................6

PART II..........................................................................................................................................9

Principle Analysis........................................................................................................................9

Audience Relevance..................................................................................................................9

Accuracy of Translation.........................................................................................................11

Oversimplification..................................................................................................................13

Vagueness...............................................................................................................................14

Fear and Guilt Appeals..........................................................................................................16

Perceived Control...................................................................................................................19

Narratives...............................................................................................................................22

Associated Myths....................................................................................................................24

Statistical Evidence................................................................................................................24

Metaphors...............................................................................................................................26

Visual Aids..............................................................................................................................28

Layout.....................................................................................................................................29

Recommendations......................................................................................................................30

Teens Health: Depression......................................................................................................30

Web MD: Teen Depression....................................................................................................32

NAMI: Depression in Children and Adolescents Fact Sheet.................................................33

Medline PLUS: Adolescent Depression.................................................................................35

Help Guide.org: Teen Depression..........................................................................................36

PART III.......................................................................................................................................38

Centers for Disease Control and Prevention (CDC)..............................................................38

The National Institutes of Health (NIH).................................................................................39

Food and Drug Administration (FDA)...................................................................................40

REFERENCES............................................................................................................................43

1

INTRODUCTION

Depression is a “prototypical multifactorial disorder” that affects all aspects of an

individual’s well-being including physical, biological, behavioral, and mental functioning

impairment (Hankin 2006 p. 102). It is among the most common of the major psychiatric

disorders and the top causes of morbidity and mortality worldwide (Gladstone et. al. 2011 p. 35).

The disorder commonly begins in adolescence (Hankin 2006 p. 102), is common with an

estimated 20% having depression by the age of 18 and is often persistent (p. 35-6). Depression is

a risk factor for suicide, which is a nationwide epidemic as the third leading cause of death in

adolescents (Gladstone et. al. 2011 p. 36). Despite the fact that depression is among the most

treatable of disorders, the majority of youth do not receive proper treatment for symptoms and

disorders (Gladstone et. al. 2011 p. 36). Research is constantly being done on depression

prevention and treatment in many organizations. However, new and important medical findings

can be rendered useless if they are not communicated effectively to relevant audiences. Therefore

this portfolio samples three key areas of health communication: media translation, informative

messages, and health policy to discuss what makes these different areas meaningful to the public.

In compiling this portfolio I have become familiar and practiced with three important

aspects of health communication. First, media translation of scientific research is crucial in

communicating information to the public, because for many people that is their primary source

for health information. This portfolio asks the questions, how can information be

miscommunicated? How can it be fixed? In what ways can information be harmful, or helpful?

Second, informative health messages are crucial to helping people understand the aspects of

certain illnesses. These combine old and new research to create a summation of the illness for

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effective communication of relevant and important information. Third, public policy has the

ability to shape what research is being done on an illness, how it is studied, and how these

findings are communicated to the public. All three areas are crucial to the field of health

communication, thus they are applied to relevant messages concerning adolescent depression.

Because depression itself is a risk factor for suicide, communicating about it is almost

never exclusive of suicide. Therefore, many ethical dilemmas and questions arise in depression-

related messages. Society has a social responsibility to prevent death, especially that of children

and youth. But personal levels of responsibility also include many aspects of life that cannot be

interrupted or affected by depression, making it difficult to assess when it is appropriate to step

in and take preventative measures for suicide. While it is logical to assume that it is better to be

safe than sorry, treatment for depression can have negative effects on a person’s life along with

the positive.

For example, health care access can greatly affect a person’s ability to effectively deal

with their illness. Questions such as, who receives what treatments?, At what price?, For how

long?, are central to the ethical discussion of mental health treatment. Not everyone has the same

health care program; therefore not everyone has the same coverage for health related issues such

as depression. This can create ethical dilemmas as to how to communicate about depression

treatment and prevention. If everyone cannot afford the same care, then what should be

communicated about treatment? Should messages communicate about what treatment works

best, or just what is affordable? Using either option exclusively could exclude part of the

population and do harm by misinforming that public.

Also related to the ethical issue of treatment is that of stigmas. Even if the best treatment

is available and affordable for an individual, they are still subject to being discriminated against

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because of the stigmatization of mental illnesses. This can result in impaired social relationships,

discrimination at the workplace or future workplaces, and alienation of the individual. Especially

in cases of severe depression where suicide is high risk, checking into a mental health facility in

the hospital may be very helpful to the well-being of the individual, but they will miss work or

school for an amount of time and will have to explain where they were during that time.

Attendance is very important in American culture and not attending could cost the individual

their position. All of these scenarios explore the harmful effects of stigma on an individual, and

these can be instigated by help-seeking behaviors.

Society may have a responsibility to protect its population, but because depression

treatment is complicated and varied, there is always the risk of doing excess harm even with the

best intentions. This portfolio takes these concerns into constant consideration while evaluating

the different forms of health messages.

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PART I

Scientific Article

The prevention related scientific article chosen is “Prevention of Depression in At-Risk

Adolescents: A Randomized Controlled Trial” by Garber, et. al. published in the Journal of the

American Medical Association (JAMA) in June of 2009. JAMA's impact rating is 30 as of 2010.

In the study, 316 participants were selected. Of those, the median age was 14.8, with 58.5%

females, 82.7% whites, 6.3% Latino or Hispanic ethnicity, and 24.5% were siblings (Garber et.

al. 2009 p. 2219). Criteria for inclusion in the study were twofold. Firstly, parent or caregiver

needed to qualify for one or more of the following criteria within the adolescent’s lifetime:

experience a major depressive episode in the past three years, have three or more depressive

episodes, and/or three or more cumulative years in a major depressive or dysthymic episode (p.

2216). Secondly the adolescent needed to be aged 13 to 17 and have at least one or more of the

following: “current subsyndromal depressive symptoms operationalized as an entry score of 20

or higher on the Center for Epidemiological Studies Depression Scale (CES-D), and/or a

previous depressive episode with “complete remission for at least two months” (p. 2216).

Participants were excluded if they had any number of the following criteria: diagnosis of bipolar

I or schizophrenia in either the adolescent or the parent, had a current mood disorder diagnosis,

were on a therapeutic dose of antidepressants, or had previously received more than eight

Cognitive Behavioral therapy for depression (p. 2216). Data was collected from four sources:

Vanderbilt University, University of Pittsburgh, Kaiser Permanente Center for Health Research,

and Judge Baker Children's Center/Children's Hospital (p. 2216). The study reports statistically

significant results with an 11% decline in depressive episodes when compared to usual treatment

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(21.4% vs. 32.7%) (p. 2215, 18, 19, 21). In addition, the study found that those who received CB

Therapy who also had parents with a depressive disorder did not report results much different

from usual treatment (p. 2221, 22). Susceptibility increases if the individuals have a parent

currently suffering from depression (p. 2215, 6). The severity of depression includes relationship

difficulties, impairment in work and school, increased risk for substance abuse, and increased

risk for suicide (p. 2215). These results were consistent with previous research in that cognitive

behavioral therapy is not more effective than alternative interventions when a parent is depressed

at the time of intervention (p. 2222). Cognitive behavioral treatment itself is self-efficacy

because the goal is to identify and change harmful, or negative, cognitive thought processes that

contribute to depressive symptoms. In sum, the effectiveness of the cognitive behavioral

treatment was found to be significantly more effective than conventional treatment alone,

contributing to understanding about response efficacy linked to depressive symptoms.

Media Reports

The three chosen media articles covering the story come from NPR, ABC News, and USA

Today. They range in completeness with the ABC News article being the most complete, USA

Today being somewhat complete, and the NPR article lacking much of the information. All three

include the statistical significance of the results found in the Garber et. al. study, although not all

reports are accurate. This will be covered later. ABC News and USA Today both include

susceptibility (having parents with a depressive disorder) and the health status conditions

required for the study, but ABC News is much more thorough in their health status coverage by

listing parental history, depressive history, exclusion of anyone with bipolar, schizophrenia, those

on antidepressants, and prior Cognitive Behavioral therapy (Mozes 2009 n.p.). USA Today

mentions one needed condition that involved having parents with a history of a depressive

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disorder as being eligible for the study (Szabo 2009 n.p.). Only USA Today covers the sample

size (316) and severity (trouble in school and increased suicide risk) (n.p.), while ABC News is

the only article to cover the participation audience (age) and the sources of data (“four different

medical centers”) (Mozes 2009 n.p.).

Some articles struggle with accuracy and at times the information in the articles is

inconsistent with the findings reported in the Garber et. al. study. Aubrey (NPR) states, “The

study found that cognitive therapy helped reduce the incident of depressive episodes by about 33

percent” (n.p.). Garber et. al. only reports results of Cognitive Behavioral therapy as compared to

usual/alternative to Cognitive Behavioral care, which was found to be 11 percent lower in

depressive episodes (p. 2221). This is inconsistent both with the data reported in the original

study and with the other two parallel media reports. It is especially problematic because this was

the only area of content from the study covered by this article, which oversimplifies the study’s

findings.

Szabo in the USA Today article reports that “the prevention program didn't help at all,

however, for teens whose parents were currently depressed,”(n.p.) but this is not consistent with

the study. Garber et. al. states that “if a parent was currently depressed, the Cognitive Behavioral

prevention program was not more efficacious than usual care in preventing depressive episodes”

and “when a parent is depressed at the initiation of treatment, Cognitive Behavioral therapy is

not more efficacious than alternative interventions” (p. 2221, 22). The study does not report that

there are no results when a parent has a depressive disorder. It states that the effects are not very

different from treatment with alternative interventions, which is still significantly higher than

prevalence while on no treatment at all. This mistake could be harmful for families and

individuals considering different types of therapy, because if additional family members have

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depressive disorder diagnoses, they may be more likely to overlook Cognitive Behavioral

prevention programs because the USA Today article blatantly states that they have no effects

under those circumstances. Aubrey (NPR) provides the best reference with a direct hyperlink to

the original study on the JAMA website. Both Mozes (ABC News) and Szabo (USA Today)

reference the Journal of the American Medical Association and Garber in their articles, but

without a direct link to the study. Overall, all three are competent in referencing the study.

Depression among adolescents is prevalent, harmful, and costly to the American

population. Prevention efforts such as those summarized by Gladstone et. al. and developed and

tested by Garber et. al. significantly contribute to the knowledge surrounding depressive and

related disorders. Unfortunately, without complete and accurate dissemination of the information

to the public, many benefits become lost and distorted and in doing so loses their usefulness.

Alan Mozes from ABC News was the only reporter to both cover a large amount of information,

and do it with accuracy. The other two reports were lacking in completeness and accuracy. This

is not acceptable. Health literacy among reporters is imperative, as evidenced by the examples

provided from NPR and USA Today in this review.

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PART II

The five online health messages chosen for this evaluation were found using a general

Google search for “adolescent depression” and “teen depression.” The pages that were higher in

the result queue that were not scholarly journals were selected. They are, “Depression” (for

teens) on Teens Health, “Teen Depression” on WebMD, “Depression in Children and

Adolescents Fact Sheet” on NAMI, “Adolescent Depression” on Medline Plus, and “Teen

Depression; A Guide for Parents and Teachers” on Help Guide.org,. They all come from different

organizations, but credibility was established if the source met one of the following criteria: cited

often by the media (as was the case for WebMD), was apart of a nonprofit organization (Help

Guide, NAMI, Teens Health), or had credibility by association, such as Medline Plus which is a

service of the National Institutes of Health (NIH). This analysis does not make any judgments

concerning what is correct or incorrect to do and is only analyzing what the messages

communicate. I evaluate the five messages through twelve principles: Audience relevance,

accuracy of translation, oversimplication, vagueness, fear and guilt appeals, perceived control,

use of narratives, associated myths, and use of statistical evidence, metaphors, visual aids, and

layout. Following the analysis of the various concepts will be the recommendations for future

revisions of the messages based on the analysis.

Principle Analysis

Audience Relevance

Audience relevance involves identifying the intended audience, and how well that

intended audience can relate to the message. It is important to consider because messages of who

is susceptible or how severely affected will be tailored to cater to that audience. Sometimes the

intended audience is explicitly stated, other times it is only implied.

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The Teens Health article is listed under the “For Teens” tab as opposed to “For Parents,”

or “For Kids.” The content reflects this intended audience in instances such as the topic on the

sixth page about getting help. In the last paragraph, it gives suggestions for what to say if you

believe that you are depressed and need help. For example, the adolescent is advised to “Ask

your parent to arrange an appointment with a therapist.” Here the audience is clearly someone

who is suffering from depression; while earlier on the page it discusses what to do if you suspect

your friend is suffering from depression. Other times the audience is broad and inclusive. This is

made clear in the second section, “Responses to Depression” where it talks about how anyone

can overlook the symptoms of depression-even those who have it right now. The tone of the

entire article is informational and as inclusive as possible. This matches the susceptibility

statement which reads, “Depression affects people of every color, race, economic status or age;

however, it does seem to affect more girls than guys.” Even the reference to gender is inclusive

because firstly, “more” girls are affected; not girls are the only ones affected. Secondly, it

“seems” that this is the case. This makes it applicable to the reader even if they are a “guy”

wondering if they or their buddy is suffering from a mood disorder. Past that, the severity of the

effects is universal and not specific to any audience.

The WebMD article explicitly states the intended audience for parents of a depressed

adolescent. This is made clear in the first sentence: “Do you ever wonder whether your irritable

or unhappy adolescent might actually be experiencing teen depression?” All information

following that is worded to describe “teens” to parents, and the last section of the article is

entitled, “What can parents do to alleviate teen depression?” It states that teens between the ages

of 18 to 24 are at the highest risk for suicide, and because of the implied severity in suicide, it is

not worth waiting for the symptoms to go away on their own.

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At first glance NAMI’s depression fact sheet does not appear to have an intended

audience. However, after scrolling down the page, the fourth heading reads, “How can you tell if

your child is depressed?” and further down, “What is the right treatment for my depressed

child?” and “How long should my child stay on treatment?” The second section summarizes who

is at risk for depression and includes gender, family history, and environmental stressors. After

that the article includes all adolescents as the audience.

The Medline Plus article does not explicitly refer to the intended audience until the end,

where it is stated in the prevention section, “Talking openly with your teen can help identify

depression early.” For example, under the exams and tests section the article states, “True

depression in teens is often difficult to diagnose, because normal teenagers have up and down

moods.” If this article were aimed at adolescents the language would probably be adjusted to

match that of the Teens Health article and include phrases that aid in identification.

The Help Guide.org article explicitly states in the first section that the intended audience

is anyone who has a relationship with someone who may be at risk for adolescent depression: “as

a concerned parent, teacher, or friend, there are many things you can do to help.” According to

the article all adolescents are equally at risk for developing depression.

Accuracy of Translation

Accuracy of translation refers to how well an article interprets scientific information and

how accurately that interpretation is communicated through the article. Relevant research is

important in aiding current understanding of health related issues, but if they are generalized to

the point that they have no context, it leaves room for misinterpretation and misunderstanding.

The Teens Health and Help Guide.org articles do not reference any scientific material,

despite the fact that all the information in the articles describes scientific findings. This includes

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information pertaining to brain activity in depressed individuals, or the different types of

depression.

WebMD cites a study done by the National Institute of Mental Health (NIMH). This was

the most accurate and thorough summary of all other examples. Details of the study were

bulleted and included such as age of participants, time period, results, and who conducted the

study. There was information missing, but the overall idea of the study was clearly

communicated.

NAMI cites five very recent journal articles with the oldest at 2001 and newest at 2009.

General research studies, such as the “Mood Disorders in Children and Adolescents” article by

Kessler et al., are not cited when referenced in the article. Specific studies include the TADS

team study from 2007 and the Fristad et al. study done in 2009. NAMI loses caveats mentioned

in both articles. For example, the TADS study consisted of 45% males and 74% non-Hispanic

whites. NAMI does not include where or how the research was conducted and the only indication

given of when it was conducted is the year included in the citation. The Fristad et al. (2009)

study was predominately male and white with a median income of $40,000 to $59,000 per

household (p. 1016). Participants were screened through the telephone and interviewed by

various measures (Fristad et al., 2009 p. 1014-5). NAMI only includes the age range of the

participants and the date that the study was published, and in doing so loses many caveats.

The Medline Plus article cites four journal articles and one book. Two involve identifying

depression, one treatment, parental guidelines, and a general overview of “Child and adolescent

psychiatric disorders.” None of these are referenced directly in the article, and it is difficult to

discern what information came from which study. In addition, the first page states, “Adolescent

girls are twice as likely as boys to experience depression. A family history of depression also

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puts teenagers at greater risk.” These statements are stripped of their context and the reader has

no way of knowing how these risk factors were determined, and how it impacts their or their

family’s susceptibility.

Oversimplification

Oversimplifying in a health message involves an attempt to simplify factors such as

disease onset or cause so much so that the true information is misrepresented through an

oversimplified explanation when realistically it is more likely that other factors are involved in

interaction with each other. Oversimplification is something to be avoided in all health messages

because it has the tendency to convey false information about the topic. For example, if an article

attributes depression to only genetics, then readers will be more likely to disregard behavioral or

cognitive factors that also contribute to it. If the risk factors are something out of the reader’s

control, then what is the point of monitoring mental health? This analysis evaluated

oversimplification in relation to risk factors for depression. Help Guide.org does not discuss risk

factors for developing depression, which is an automatic simplification.

The Teens Health Depression article avoids oversimplification in risk factors by including

four factors: genetics, life events, family and social environment, and medical conditions.

Genetics is the first factor listed and three out of the four sentences in the section are devoted to

communicating that genes are not the only cause of depression. They are as follows: “Not

everyone who has the genetic makeup for depression gets depressed, though. And many people

who have no family history of depression have the condition. So although genes are one factor,

they aren't the single cause of depression.” By acknowledging that having a risk factor does not

automatically cause depression, the article acknowledges the complexity of the onset of

depression to the reader.

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The WebMD article on teen depression only lists environmental stress and provides

examples such as grades, social status, sexual orientation, family life, school performance, etc.

Despite the fact that so many are listed, they are all environmental; therefore overall only one

factor is accounted for in risk factors. Because no other factors are listed they are oversimplified.

Self-efficacy oversimplified to only encompass detection which is most clearly evident in the

section entitled, “Can't teen depression go away without medical treatment?” According to

WebMD, the answer is no. This oversimplifies self-efficacy messages because the task is reduced

to one aspect: detection. Keeping yourself enough well informed to be able to tell if someone is

suffering, including yourself. The response efficacy is first and foremost to contact health

professionals, and then they will handle everything from there. This limited approach to

depression treatment can only do more harm than good because it places all of the responsibility

onto the shoulders of the health professionals. What happens to a family's understanding of

adolescent depression when they read this article, are told to trust health professionals

wholeheartedly, only to have their family physician not take the problem seriously, or only

prescribe medication without therapy? The article assumes a default care quality for all “health

professionals” when in reality many different types of qualified physicians have varied

approaches for mental illness detection, treatment, and prevention.

NAMI and Medline Plus both list family history and situational factors as risk factors.

Because there are more risk factors than genetics and environmental factors, both of these

messages oversimplify risk factors.

Vagueness

Vagueness refers to language use that is easily misinterpreted or hard to understand.

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Teens Health Depression makes attempts to avoid vagueness by using simple and commonly

understood words, and using examples for some words, but in some cases this is not enough. An

example on page 3 states “...when adjusting to the loss takes longer than the normally expected

time frame or is more severe than expected and interferes with the person's daily activities.” The

term severe is used and even though an example is given (interferes with person's activities) it is

still unclear as to what a 'normally expected time frame' is, or what 'more severe than expected'

entails. On the other hand, many topics covered in the article are very well defined, such as the

difference between a major depressive disorder and dysthymia, how long it takes for depressive

symptoms to become a depressive disorder, and the difference between feeling sad and having

depression.

WebMD deals with the issue of vagueness by admitting ambiguity where it exists. For

example, on the second page, depression diagnosis is determined by a health professional that

conducts interviews and psychological tests. The severity of the symptoms is also determined by

these same tests, but what constitutes 'severe' is not explained and such knowledge is left only

with medical professionals. This is a poor way to deal with vagueness because who is included in

the “health care professional” category is unclear, and those who are interested in self-diagnosis

are at a loss.

NAMI's fact sheet has many issues with vagueness. The symptoms bullet list includes

“feeling persistently sad or blue.” We know from other sources that the time frame is two weeks

or longer, but this would not be apparent from only reading this article. Again under the

treatment section it is recommended to use exercise and social support in addition to other

treatments but it is mentioned that they “may fail to address more serious symptoms.” What

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these more serious symptoms are, or how exercise and support fails to treat them is not

mentioned.

Medline Plus has few issues with vagueness. Symptoms for depression are clearly capped

at a two-week minimum, factors checked by health care providers are checked, in-depth

descriptions of treatments including talk therapy, hospitalization, medication, etc. The only

aspect that is vague involves the issue of who qualifies as a health professional, which is not

described.

Help Guide.org, like Medline Plus, has few issues with vagueness. Although the two-

week starting point is not mentioned, the article does encourage the reader to consider how long

the symptoms have been present. The section devoted to suicide is extremely clear. There are

very clear examples of suicidal warning signs and tips for talking to a depressed teen. The

treatment section clearly states who constitutes a mental health professional. The family

physician is the initial person the reader is recommended to seek out, but the reader is also

advised to get a recommendation or referral to a mental health professional, specifically a

psychologist or a psychiatrist. Antidepressant information including the risks and effects on the

brain are also gone over in detail even including the FDA time line for how often a teenager

should check in with their doctor.

Fear and Guilt Appeals

Fear and guilt appeals are used more often and strongly in some articles than others. All

of the articles consistently hint, at the very least, to suicide and decreased quality of life. When

explicit fear appeals are used it is always that of suicide. An effort is made, through the use of

severity and susceptibility, to ensure that it is extremely strong and should not be forgotten or put

off for another time. This is done commonly in the articles by stating that it is not good to wait

16

for the person suffering to grow out of it, or get over it. Each article says repeatedly that warning

signs for suicide should not be ignored in any circumstances. Susceptibility is integral to these

kinds of statements because they imply that suicide can happen to anyone, and ruling anyone out

is dangerous. A guilt appeal is implicit in the fear appeal because it frames suicide as a

preventable outcome that can be prevented if you take necessary steps. For example, if someone

read any of these messages and knew someone who had taken their own life, they may feel partly

responsible for the death because they did not take enough action in order to stop it. In all of the

articles the benefits of preventing suicide outweighed all drawbacks to becoming involved in an

adolescents emotional life. Suicide often results in death, and the articles all make the

assumption that preventing death is most important. Whether this is true or not, or if these

drawbacks are even valid is excluded by the assumptions and it is established that these issues

are not covered in any of the articles. In most cases the fear appeals are followed by efficacy

messages that inform the reader how to step in and help to prevent suicide.

Ironically, Teens Health is the only article that does not use a fear appeal, but is the only

one to discuss effectiveness of self-efficacy strategies. Page four is devoted to treatment and the

only messages that hint at a fear appeal communicate that without help depression can get worse,

so it is better to be safe and get help. Suicide is not even mentioned. The strategies include

getting a health checkup, talking to a counselor, finding support through parents, and taking care

of yourself through healthy choices. Each strategy is individually detailed as to how, why, and

how much it is effective. One possible reason this article does not include an explicit fear appeal,

let alone any mention of suicide, may be because of a boomerang effect. A boomerang effect is

when the intent of a message is met with opposing behaviors in the reader. This is the only

message with a teen audience, and discussing suicide to possibly depressed teenagers may only

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increase how much they think about it, and what they know about it, which could result in

increased suicidal ideation. Sometimes informing target populations about subjects that should

be avoided or restricted only backfires.

WebMD introduces suicide at the end of the second page by listing statistics to illustrate

how common and how damaging suicide is. That is followed by warning signs for suicide, then

efficacy strategies to prevent it such as calling suicide hotlines, contacting medical professionals,

and always taking every threat “very, very seriously.” The effectiveness of this strategy of

contacting help is not considered because it is assumed that this is the only option.

Fear appeals are weakly used in the NAMI article, if at all. There are innuendos of

depression taking “a great toll on a young mind” but suicide and depression are only ever linked

during the discussion of antidepressant medication. Even in that section, suicide is weakly used

to arouse fear in the reader.

Medline Plus has a suicide section at the end of the page with information regarding self-

efficacy and suicide. There are warning signs of suicide, suicide hotline numbers, when to call a

medical professional, and in capital letters, “NEVER IGNORE A SUICIDE THREAT OR

ATTEMPT.” Effectiveness of these response options is not discussed at all. They may work as

cure-all's or hardly be effective, but whichever is not relevant because the bottom line is, these

are the only options available.

The Help Guide.org article provides many recommendations for self-efficacy that follow

the fear appeal of suicide. Each strategy has its own section, including recognizing suicidal

behaviors, talking with a depressed teen, and how to seek professional help. Effectiveness in

these sections is only discussed through the idea that different individuals respond differently to

different types of treatment. Therefore, the message is to be persistent and adaptive while

18

pursuing care. In short, effectiveness takes effort. Help Guide.org also includes a guilt appeal in

addition to the fear appeals that states, “Unlike adults, who have the ability to seek assistance on

their own, teenagers usually must rely on parents, teachers, or other caregivers to recognize their

suffering and get them the treatment they need. So if you have an adolescent in your life, it’s

important to learn what teen depression looks like and what to do if you spot the warning signs.”

The appeal states that teenagers are disadvantaged compared to adults when it comes to their

mental health, and therefore it is the responsibility of the adults to look after teens. It is then

followed with a statement that fulfills how to accomplish this responsibility effectively, and

therefore this guilt appeal is judged as successful.

Perceived Control

Perceived control refers to the feeling of certainty that the reader feels by reading

messages intended to communicate effective efficacy measures in order to prevent, treat, or

manage an ailment. Projected control is usually found in sections concerning detection of

depression and prevention of suicide. Higher levels of perceived control in detection of

depression are related to the balance of vagueness and simplification. High levels of perceived

control in suicide prevention are related to clarity of self-efficacy and effectiveness. The purpose

of these messages is to increase the feeling of perceived control in the reader and that they have

control over stopping the progression of depression outcomes.

Teens Health projected somewhat weak feelings of control when discussing the detection

of depression. As mentioned before, the time line for how long symptoms must be present for

depression to be diagnosed is not mentioned. It is simply “weeks or more.” Many symptoms or

manifestations of symptoms are listed, which can create a feeling of ambiguity and loss of

control in the reader. These symptoms range from physical, to cognitive, to behavioral.

19

Qualifications for what symptoms are most important or how many are required for depression to

be diagnosed are not included. This loss of control in the reader feeds in to the next section of

suicide, which in reaction provides a great amount of control to the reader. Teens Health conveys

a strong sense of control in the reader concerning suicide because many options are presented for

self-efficacy, along with information as to how effective each option is. Presenting so many

options could become problematic because it could prompt a feeling of uncertainty in the reader

of which one to choose and so on. Uncertainty is avoided in this article because although there

are so many different options to help depression, each one has the same aim and general goal: to

achieve good mental health usually in realization through talking. Whether it is talking to mental

professional, parents, or to yourself, the goal is to better understand what the depression is, how

it is affecting the individual, and how to stop it from getting worse. By providing many options

for self-efficacy and avoiding uncertainty in those options by keeping a common goal, the Teens

Health article does a very good job of establishing a strong sense of control in the reader.

Therefore, the purpose of detection in Teens Health is not to reassure the reader in their self or

other diagnosis, but to motivate them to take the necessary precautions regardless of if it is

clinical depression or not.

WebMD projects control onto the reader exclusively through response efficacy, or the

treatment options or services available. Perceived control is very low because the article

oversimplifies self-efficacy to detection. Response efficacy applies to both depression detection

and prevention of suicide. In both cases, signs and symptoms are provided but health

professionals uniquely have the ability to diagnose and provide effective treatment. The only

control the reader really has is the control to recognize warning signs and take their child to the

doctor. If the only help a parent or adult can offer is detecting that something is wrong, what are

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they expected to do after they succeed in that? The article goes into detail regarding the response

efficacy that going to the doctor entails, such as medication and psychotherapy, but this creates a

false sense of control based on faith that every health care professional will offer the same

treatment options based on universal standards of effectiveness that simply don’t always exist.

The NAMI article is rated the highest among all five articles for perceived control. This is

because self-efficacy was combined with response-efficacy in the messages instructing the reader

to understand the treatment options, and how to communicate with the health care professionals.

This is the only article that goes into great detail about what information is important for the

doctor to know during the examination. Control in detecting depression is not communicated at

all. It is clearly stated that relying on observed symptoms alone is not an effective way to

diagnose other people, and ignoring them could have disastrous consequences. This fear appeal

is meant to move the reader to take the necessary steps toward prevention and treatment. There is

a very strong amount of control projected onto the reader in the options for treatment. The parent

(the intended audience) is encouraged to not only be aware of all the treatment options available,

but to communicate extensively with the health provider in order to collaborate for a treatment

that is most effective for the child or youth. The NAMI article places a large amount of

responsibility and control onto the reader.

Medline PLUS devotes a lot of text and space to listing factors that contribute to

depression and the symptoms of depression. The time frame of at least two weeks is even

included, but this information is included only to be followed by a statement that observed

symptoms of depression are not a valid way to diagnose adolescents because of their mood

swings. The effect is an empty or false sense of control. A parent may be very educated and

knowledgeable about depression, but no matter how much they research the subject they will

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never have the final say in their child's diagnosis. Concerning suicide, the only responsibility of

the parent is to seek help immediately as soon as symptoms are present, and to keep harmful

medications or weapons locked away. It is only briefly mentioned that parents should talk to their

children because expressing feelings is important. These uneven and contradictory messages

either create a false sense of control, or at the very least a persisting feeling of uncertainty about

what control looks like in this situation.

Help Guide.org most consistently projects control onto the reader through every section,

whether it is knowing the symptoms, finding the right treatment, preventing suicide, or talking

with the child. The bottom line for every section is to empower the parent to effectively care for

their child. This empowerment is done through the use of the guilt appeal that explains adults

are able to take care of themselves and can better acknowledge when they need to go to the

doctor if they feel that something is wrong. It continues that children and teenagers do not have

this option, nor are they as able to tell what is normal or abnormal, and therefore it is the

responsibility of the adults in their lives to stay alert for warning signs in order to help them. By

following this guilt appeal with so much information regarding self and response efficacy, the

feeling of control is clear and informed, because there is a purpose behind the information.

Narratives

Narratives are stories that usually include characters, setting, problem, action, and

resolution. None of the articles include a narrative aside from the Teens Health article, but

narratives are included in this evaluation because it has been shown that their use aids in

understanding and persuasion, especially when they are complete and supplemented with

statistical information.

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The Teens Health depression article includes a narrative in the opening of the article

about Lindsay, a student who is exhibiting symptoms of depression. It goes over how she loses

interest in things she once enjoyed, such as going to the mall with her friend and doing well in

school. She is also gaining weight and having sleep difficulties. Her mom notices, but does not

do anything beyond ask her what is wrong in this narrative. There is no action or resolution, and

statistical evidence follows the narrative. The symptoms are parallel to some of the symptoms

listed on page four of the article: “depressed mood or sadness most of the time (for what may

seem like no reason), lack of energy and feeling tired all the time, inability to enjoy things that

used to bring pleasure, withdrawal from friends, and family, significant weight loss or gain, and

significant change in sleep patterns.” More than half, 7 out of 12, of the symptoms are covered in

the narrative. Page two of the article goes over risk factors for depression, but the narrative does

not include any of these. Lindsay is described as “a really good student,” has friends, and

“nothing particularly bad has happened” to her. Using a fictional character such as Lindsey and

not ascribing any risks to her in the narrative communicates that anyone can be susceptible to

depression, no matter how “healthy” they may seem. Lindsay's case is not of the highest severity

because suicide is not mentioned, but her symptoms are interfering with her daily functioning

and therefore are severe and significant. The narrative as a whole arouses sympathy towards

Lindsay, and a need to know how to help her. It also dodges potential stigmas. Lindsay cannot be

“lazy” or in a “mood” if she is usually an excellent student and has many friends. Therefore

something else must be to blame, i.e. the depression, and the reader is engaged to find out more

to help.

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Associated Myths

Associated myths involve false ideas about depression that the audience may have been

exposed to. Whether or not some of these myths are addressed in the five articles is evaluated.

WebMD, NAMI, and Medline Plus do not cover myths associated with depression. It is included

in this analysis because associated myths are directly relevant to adolescent depression and

should be addressed in health messages concerning it.

Teen Health explicitly talks about the myth that people who have depression are just lazy.

On page one it's stated, “Some people don't really understand about depression. For example,

they may react to a depressed person's low energy with criticism, yelling at the person for acting

lazy or not trying harder. Some mistakenly believe that depression is just an attitude or a mood

that someone can shake off. It's not that easy.” On that same page it states that even people who

suffer from depression may have false beliefs about their condition, such as being weak. On page

seven, it is stated that “depression doesn't mean a person is 'crazy'.”

Help Guide.org discusses many myths associated with depression. In the first sentence it

states, “Teenage depression isn't just bad moods and occasional melancholy.” The second section

discusses how depression is different from the “tough” teen years and that non-depressed teens

“balance the requisite angst with good friendships, success in school or outside activities, and the

development of a strong sense of self.” These phrases distinguish depression from ideas of

weakness or laziness.

Statistical Evidence

Statistical evidence involves the use of numbers or statistics to communicate something,

usually prevalence or susceptibility, about depression. Medline Plus does not include statistical

information in the article.

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Teen Health uses statistical evidence following the conclusion of the narrative in order to

stress the susceptibility of depression in adolescents (“1 in 8 people in their teen years”)

regardless of race, or economic status. It includes that women are more likely to have depression

than men. Efficacy, severity, and violations to code of conduct are not impacted by the included

statistic.

WebMD uses the same statistic to show susceptibility. On page two, suicide statistics are

included to show how many adolescents attempt and succeed in committing suicide. It is called

the third leading cause of death among young people in the US. The statistical evidence

communicates severity along with susceptibility and violates the code of conduct that people are

not getting enough help and are therefore ending their lives.

Statistical evidence is used as the introduction in the NAMI page. It states that 2% of

children and 8% of adolescents meet criteria for major depression, and that one in five teens have

experienced depression. 28% of adolescents experience depression in a primary care setting. In

addition, statistics concerning the prevalence among boys and girls are included in the second

paragraph stating that in childhood depression is equal among boys and girls, but in adolescence

“twice as many girls as boys are diagnosed.” Finally, “over half of depressed adolescents have a

recurrence within seven years.” The 'one in five' statistic is not consistent with the WebMD

article or the Teen Health article, which both cited one in eight as the statistic. These numbers

serve the purpose of communicating the severity, susceptibility, and the response and self-

efficacy involved in adolescent depression. In the antidepressant paragraph, a study done by the

FDA in 2004 is cited and of the 2200 children surveyed, 4% experienced suicidal thoughts,

which was double the expected rate. This statistic serves the purpose of highlighting the risk that

comes with antidepressants especially in children. It was included to inform self-efficacy.

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Help Guide.org states that one in five depressed adolescents receives treatment. This

violates a code of conduct because prior to mentioning those numbers the article states that

depression is very treatable. Because it is treatable, but only 1/5 of those suffering receive help,

there are wasted resources and people who continue to suffer. It also says something about the

response efficacy of depression treatment: that it is effective and can be achieved as long as it is

sought after.

Metaphors

A metaphor is a phrase that compares two separate and distinct things for the purpose of

aiding the understanding of the listener. In health communication this can also include smiles,

analogies, and personifications. They are most effective when used only once, are extended, and

appear in the introduction as compared to the conclusion or body of the message. Teens Health

and Medline Plus does not include metaphors in the articles.

WebMD includes one instance with metaphors. It reads, “It's easy to see why their moods

swing like a pendulum.” This metaphor is used in the first paragraph to describe the moods of a

non-depressed teenager. This metaphor is rated as effective only as long as the reader knows

what a pendulum is. Because it is more likely that they may not, the effectiveness of this

metaphor is low.

NAMI uses three instances of metaphor. The first is in the symptoms section, which is the

fourth down the page. It is the first bullet point and reads, “Feeling persistently sad or blue.” This

is an ineffective metaphor because it is placed in the middle of the article and it is unnecessary.

Sad is a simple concept that does not require the aid of a metaphor. The second reads, “Seeing

every cup as half empty” and is placed in parentheses following a statement about negative

attributional bias. This metaphor, although it is placed later in the article, would be rated as more

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effective because it follows language that may not be understood by audiences other than

medical professionals. It effectively communicates an idea because people know what seeing

every cup as half full means--that is the example usually given when describing pessimism.

However, the idea it communicates may not be entirely accurate. Negative attributional bias is

different from pessimism—it is the tendency to blame the self for negative things that happen,

while positive outcomes are more likely to be attributed to chance. Because the metaphor does

not accurately describe the term, it is not effective and a different metaphor needs to be

considered. “There is no 'one size fits all' in mental health” is the third use of metaphor. It is used

in the end of the article and is referring to treatment options. It is used in the beginning of the

treatment section, is only used once, and is relevant to the point being made so it is also an

effective use of metaphor.

Help Guide.org makes a reference to “growing pains”, and in the same sentence states

that “long-lasting changers in personality, mood, or behavior are red flags or a deeper problem.”

It is used after a bulleted list of symptoms and introduces a section about the difference between

normal sadness and depression, and the difference between teenage and adult depression. These

two metaphors are only used once and appear in the middle of the article. Growing pains are

described as including “the challenges of growing up” but this is also not clearly defined. It is not

addressed in the beginning either, where normal teenage sadness is only said to include

“occasional bad moods or acting out.” It appears that normal teenage sadness is defined in this

article as how it is not depression. This is not helpful, and until these concepts can be defined

metaphors assume an understanding that may not be there to begin with.

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Visual Aids

Visual Aids can be used to complement, substitute, or reinforce a message. They can

include tables, images, etc. NAMI does not include any visual aids.

Teens Health does not include any visual aids aside from the banner used at the top of the

page with two individuals looking at the viewer and text reading, “Depression.” The individual

on the right appears to be female and has dark skin, while the other individual appears to be male

with lighter skin. This is congruent with the claims later on in the article that state depression

affects anyone regardless of age, ethnicity, or economic status. It also includes a male in the

image even though the article states that women are more commonly diagnosed with depression

than men.

WebMD has a link for “A Visual Guide to Understanding Depression” which leads to a

depression overview slide show consisting of photos and descriptions. There are 23 pictures in

all, most of them being photos of white adults. There is an even representation between men and

women. There were two brain images, one of a brain scan and one of a computer generated

image of neurotransmitters. There were two nature shots, one without a person, and five

medication images (two without people). The representation created by the photos does tend to

label the condition. Judging from the photos, depression mostly affects white adults. The set did

not gender depression. This visual aid appears to function as a substitute for other forms of

depression information, although it could be used to reinforce what was read in the WebMD

article. If the audience substituted the visual information for the article and the text that

accompanied each photo it would not be very helpful at all and they would probably go looking

elsewhere, as most of the photos are pictures of “everyday” people or objects.

Medline Plus has a link to an image on the right side of the article. After clicking it the

viewer sees a purple shaded young girl looking out the window. Bubbled text on the left reads,

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“Depression.” Text on the right reads, “Symptoms of depression in children may include apathy,

irritability, and persistent sadness.” This single image labels depression in children as a white

female’s disorder that only has three symptoms. It is most likely used to reinforce the message,

and certainly not as a substitute. If the reader were to only rely on this image they would be

extremely misinformed as much of the information communicated through the image is

misleading due to oversimplification.

Help Guide.org provides a link to a three-minute video for learning “to identify and

express your feelings.” In the video, photos of mostly white adults are shown. Two images of

children appear, two of non-white individuals (one of those also being of a child), and seven teen

photos. Females and males were equally represented with one extra photo of a female being

displayed. The video supplements the article by improving self-efficacy because it provides

messages about where emotions come from and how they impact our daily lives that the article

does not include. If the audience were to substitute the visual information for the text the viewer

would most likely gain knowledge about emotion, but nothing specifically about depression.

Layout

Layout entails the general arrangement of an article that has an effect on the complexity

and readability of the information being communicated. These factors include organization of

information, utilization of headings, bullet points, page length, and text size. All five articles

have inviting layouts, utilization white space, and use of bullets and headings. The articles are

classified as inviting if they are easy to navigate and organized in an effective manner. White

space is used by all articles most commonly be creating spaces in between different paragraphs,

or in some cases between whole pages. All articles use bulleting to list symptoms, effects, and

causes of depression. Headings are also used in all articles to separate sections such as definition,

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symptoms, causes, effects, and treatments. They usually have a larger font of a different color

and bolded. Font size is adjustable in the Teen Health, WebMD, and Health Guide.org articles,

but not in the NAMI and Medline Plus articles. Page length is an important factor in organizing

information and making it readable for the audience. It can impact the sentence length, which

makes reading tedious, or it can impact the heading arrangement, making the important points

lost and thus confusing for the reader. Teen Health and WebMD divide the sections into separate

pages to click through, while the others are one whole page. Dividing the pages up into clickable

sections is most favorable because it makes the material appear more inviting and easy to

navigate.

Recommendations

Teens Health: Depression

The recommendations for the Teens Health article include the areas of accuracy of

translation, vagueness, fear messages, perceived control, narrative use and visual aids.

It was mentioned before that no specific scientific studies were cited in the article at all,

despite all of the information originating from some kind of scientific findings. Therefore a

revision should include specific studies and references where needed in the text as to enable the

reader to trace the information back to the source.

Vagueness is not a huge issue with this article but there are some instances that would

benefit from revision. All references to anything judged as abnormal and normal need to have

definitions included as to what exactly qualifies as abnormal. The perceived control of this article

would also be improved by clarifying vague concepts and terms. One example of this would be

to explicitly state the time line that symptoms need to be present in order for it to qualify.

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Concerning fear and guilt appeals, it has already been established that self-efficacy and

effectiveness are clearly and concisely used, but there is never an explicit statement linking

suicide to depression. Despite the possible increased risk of a boomerang effect and the targeted

audience being teenagers, the revision should still include a statement linking depression to risk

of suicide. Not discussing it carries the risk of not communicating how severe the consequences

of depression can be, and could result in the reader reflecting this message in their understanding

of depression. As long as the strong self-efficacy messages and paired effectiveness of those

strategies are included, and details of how to commit suicide are kept to the bare minimum, a

boomerang effect will be less likely and the benefits of communicating this information will

outweigh the risks.

The narrative should also be expanded to include actions and a resolution to the story.

Considering the layout and overall continuity throughout the different pages, the narrative could

be broken up to introduce or conclude each section. For example, in one story, Lisa's mom could

talk to her to figure out what is going on (determining that they need help), in another, Lisa has

been on medication and going to therapy for three months now and is feeling better (treatment,

self-efficacy, response-efficacy). Simply the inclusion of these two stories would fulfill an action

and resolution in the overall narrative of Lisa and her struggle with adolescent depression.

The article functions fine without the use of visual aids (with the exception of the

banner). Information is clearly organized, and well understood without any graphs or images.

Still, a revision could include some form of visual aid. This could include an image of Lisa, the

protagonist of the narrative, or a table to organize the different causes and symptoms of

depression.

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Web MD: Teen Depression

WebMD would benefit from a revision in oversimplification, fear appeals, perceived

control, narratives, associated myths, visual aids.

The article had issues with oversimplification. As stated previously, it only includes

environmental stress as a risk factor for developing depression. This is incorrect and needs to be

revised to include the additional risk factors that contribute. These can include family history,

poor coping skills, etc.

The fear and guilt appeals used in the article are very strong and should not be changed;

however, information regarding the effectiveness of the strategies for efficacy should be

supplemented along with additional strategies for self-efficacy. These additional strategies can be

borrowed from the Teens Health page to include talking to parents and talking to health

professionals. The section directly under the suicide section talks about what parents can do to

help with depression, but these strategies are provided to “reduce the stress level for your

teenager,” not prevent suicide.

The perceived control needs to be improved in detection of depression. This can be done

by including more information for self-efficacy in criteria for diagnosis. Currently the article

does not offer any information other than the health professional is the one that is able to decide,

and that health professional uses tests that cannot be described. Including information such as

warning signs, a two week minimum for symptoms, and things to expect when going to the

health care professional should be included to increase the self-efficacy and thus the perceived

control of the reader.

Narratives improve identification, so this evaluation makes the recommendation to add

narrative elements. It could provide videos or multiple accounts from real people especially in

the treatment section in order to create a better understanding and identification with the different

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treatment options available. One story could be about George, who tried one brand of

antidepressant medication with counseling with not much luck, but switched to a different

antidepressant and saw results. Raúl may have tried conventional therapy, but then discovered

cognitive behavioral therapy worked better for him.

This article also did not address the associated myths of depression. This needs to be

included, as it is an important aspect to depression prevention and treatment. It could follow the

format provided in the Teens Health article, but other options include integration into already

existing information or it could be used in a visual aid.

There were no visual aids, and the article may benefit from adding them. There were

may instances were items were bulleted when they could have been shown in a table or image.

NAMI: Depression in Children and Adolescents Fact Sheet

Many aspects in the NAMI article will benefit from revision including the use of

accurate translation of the science, oversimplification, fear appeals, perceived control, narratives,

and metaphor use.

Many research articles are cited in an attempt to aid the understanding of the viewer, but

they are not clearly communicated or executed. There are many sources that are not cited in the

text at all, and the ones that are do not cover enough relevant information. They need to include

who the participants were in the studies, where it was conducted, and the methods used.

The article also has issues with oversimplification, mainly concerning risk factors. Only

family history and environmental factors were included. This is too narrow and the other factors

need to be included. Some of the metaphors used in the article are very confusing and

unnecessary.

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The fear and guilt appeals in the article are very weak and would benefit from revision.

Only one small section with two sentences is devoted to communicating the severity, and

susceptibility of suicide. This paragraph should be expanded to include statistical information for

communicating severity. Susceptibility would be better communicated using phrases along the

line of “anyone regardless of age, gender, race, culture can be at risk for suicide.” In addition,

statistics could also be used to convey the susceptibility, such as how many depressed individuals

attempt suicide etc.

The perceived control of the article needs to adopt the level of self-efficacy and apply to

diagnosing depression in adolescents. High levels of self-efficacy for treatment could be

meaningless if there is no perceived control over when it is time to visit the doctor in search of

help.

NAMI devotes a substantial amount of text to the discussion of medication and the risks

and benefits associated with it. This would be an excellent place to fit in a narrative about, for

example, someone who experienced increased thoughts of suicide due to medication because

there is a lot of scientific terminology used in this section, and a narrative would increase

understanding of the concepts through real-life experiences. The article needs to clearly state

who the intended audience is earlier in the article, as the current version does not do so until the

fourth heading down. This could be done by including a statement in the introduction or in the

title.

One of the metaphors used in the article is unnecessary and should be removed. It

compares the feeling of being sad to “being blue,” which should be removed because sadness is a

commonly understood concept that does not require additional metaphorical assistance. The

other instances worked quite well and do not need to be changed or removed in the revision.

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Medline PLUS: Adolescent Depression

Medline PLUS would benefit from revision in audience relevance, accuracy of

translation, oversimplification, perceived control, addition of narratives, associated myths, and

visual aids.

Similar to the NAMI article, Medline Plus needs to specify the audience sooner than at

the end of the article. It does not do so until the end of the article where it has a section about

“talking openly with your teen.” It could be added to the title or subheading of the article, and a

sentence specifying the intended audience should be included. The article also needs to revise the

causes or risk factors of depression to include factors in addition to biological and situational

examples.

As was mentioned previously, this article devotes too much time to listing causes and

symptoms, but not enough time projecting confidence onto the reader for what to do once those

factors are accounted for. A guilt appeal, like the one used in the Help Guide.org article could be

utilized in order to give a purpose to all of that information, even if the parent is unsure about

their child's symptoms. The message, “better safe than sorry” is very effective for this and greatly

improves self-efficacy.

There are many bulleted items concerning causes and symptoms or depression that can

become tedious for the reader, especially when there are so many out of context. A simple

solution to this is to translate some of them into a narrative. For example, one of the symptoms

listed is “feeling upset, restless, and irritable.” A narrative could be included about Lilly, who

cannot stop thinking about how guilty she feels that she embarrassed herself in class the other

day, and how she studies very hard, but she never seems to be as smart as some other people in

her class. These factors are weighing so heavily on her mind that she has a hard time falling

asleep at night and when her dad asks her how her day was, she snaps, “Fine.” Another more

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accurate or real-life account will be most effective, but simply using a narrative is very effective

in illustrating important concepts.

The visual aid needs to be removed or replaced with something else. It is not effective,

and if anything detrimental to the message being communicated in the article.

Help Guide.org: Teen Depression

Help Guide.org would benefit from the addition of the latest scientific research, or

provide information of the sources of the information provided. This was not included and it

would aid in understanding.

The fear appeals and paired self-efficacy strategies are very effective but would benefit

from increased attention to the effectiveness of these strategies. For example, in the

“Encouraging a depressed teen to open up” section, the article states, “Even if you're unsure that

depression is the issue, the troublesome behaviors and emotions you're seeing in your teenager

are signs of a problem.” This sentence is implying that talking helps regardless if depression is

the issue, but how it actually helps is never stated. A simple explanation that describes the

benefits of talking, such as “talking is a way that people understand their feelings to themselves

and to other people. It helps the individual verbalize what they are going through in order to

better identify it for both you and them. That is why talking is a common method used in

therapy.” A statement along these lines would make clear why talking is important regardless of

the presence of a depressive diagnosis.

The addition of narratives would also be beneficial, but the article already communicates

very well without them. The best place would be in the beginning to introduce depression, as

Teens Health does, and follow the narrative with statistical evidence of susceptibility and

severity.

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The Help Guide.org article already utilized visual aids in a great way with a video, and it

could be expanded to include personal accounts of people suffering from or those acquainted

with those who are suffering from depression.

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PART III

Adolescent depression is studied by various research organizations in the United States.

The U.S. Department of Health and Human Services is funded by the United States government

and is responsible for protecting the health of American citizens. The funds represent one fourth

of total expenditures and the department issues more grants than any other agency. These funds

are allocated to the 11 operating divisions, two of which are the Centers for Disease Control and

Prevention (CDC) and the National Institutes of Health (NIH), which both have divisions

devoted to mental health.

Centers for Disease Control and Prevention (CDC)

The CDC is a collaboration of various health specialties united in the mission of health

promotion, prevention, and preparedness. Monitoring, detection, investigation, research, health

policy, prevention, and health promotion is done through ten centers and over 90 departments.

The CDC does work involving mental health through the Prevention Research Centers. The

Mental Health page aims to promote prevention efforts and awareness through scientific

research, translation of research to prevention programs, policies, and systems, and to

communicate those findings and efforts to appropriate audiences. There are several examples of

the type of work supported by CDC. Multiple centers collect information on the national, state,

and local level such as surveillance tracking for health-related quality of life (HRQOL) that

collects and follows trends of U.S. Resident health information. This is done through surveys

such as the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health and

Nutrition Examination Survey (NHANES) that have shown mental distress patterns among

various ethnic, gender, and socioeconomic populations. The CDC also analyzes stigmas

associated with mental illnesses and the relationship of mental illnesses to other health behaviors

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and diseases. One way this is done is through partnering with other federal agencies related to

mental health. Various modules have been developed through the CDC in partnership with other

federal agencies. Some of these include a depression and anxiety module for the Behavioral Risk

Factor Surveillance System (BRFSS), based on criteria from the DSM-IV, which looks at the

extent and occurrence of anxiety and depressive disorders across states. There are two surveys

administered by the CDC and SAMHSA including the Health Styles survey and the Behavioral

Risk Factor Surveillance System Mental Illness and Stigma module, which screens for “serious

psychological distress in response to stigmatization.” The mental health and chronic disease

expert workgroups convene to assist in the development, planning, evaluation of MH/HI

programs in the public health area, research field, and to identify any possible new activities and

priorities. The strategic plan developed by the workgroups includes four goals: 1) monitor

illnesses and related factors, 2) incorporate MH/MI prevention into research and evaluation in all

disease programs, 3) acknowledging cultural, personal, structural barriers to access, 4) distribute

information. CDC also supports evidence-based community interventions on mental health that

focus on interventions to reduce mental illnesses such as depression and promote mental health.

The National Institutes of Health (NIH)

NIH is the United States medical research agency consisting of 27 specific centers

allocated across the country to over 3,000 universities and research institutions. It oversees the

National Institute of Mental Health (NIMH) which studies neural, behavioral, and environmental

factors in a broad range of mental illnesses including anxiety, autism, bipolar, borderline PD,

HIV/AIDS, schizophrenia, eating disorders, and suicide. The four objectives of NIMH include

brain and behavioral science discoveries to inform mental disorder research, tracking occurrence

and severity of mental illnesses in order to know more efficiently when, where, and how to

39

intervene, developing need and circumstance specific interventions, and making the impact of

NIMH-supported research meaningful. One way that the fourth objective is realized is through

community engagement. These outreach and public activities are held by the Office of

Constituency Relations and Public Liaison (OCRPL) and include discussions for research

progress, legislative activities, and outreach with advocates and professionals. The research

division is divided into five programs: the Division of Neuroscience and Basic Behavioral

Science (DNBBS), Division of Adult Translational Research and Treatment Development

(DATR), Division of Developmental Translational Research (DDTR), Division of AIDS

Research (DAR), and Division of Services and Intervention Research (DSIR).

One area of priority studied by the DNBBS, for example, is research related to the interactions of

cognitive, affective, stress, and motivational processes throughout development and the lifespan.

DATR works to bridge the gap between behavioral and neurological advances related to mental

illness. DDTR focuses on mental disorders in childhood and adolescence through

neurobehavioral, biological, risk factor identification, and intervention efficacy. Inside the DAR

division is the Center for Mental Health Research on AIDS (CMHRA) that studies the

consequences of HIV related ailments on mental health and prevention strategies for those who

are affected. DSIR focuses on the efficacy of interventions across domains.

Food and Drug Administration (FDA)

Policy analysis related to mental health, or more specifically adolescent depression, can

include medication information in the form of warning labels and PPI's. Antidepressant

medication must be taken consistently over an extended period of time to be effective and the

ratio of benefits vs. risks varies depending on the age of the patient and how long they have been

taking the medication. Adolescents are at increased risk for suicide while individuals over the

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age of 65 have decreased risk. In addition, the medication poses additional risks if the individual

abruptly stops taking it. Warning labels and patient package inserts (PPI) are two of the efforts

used to communicate these risks to health providers and patients in order to ensure safe and

effective treatment.

A specific example of the influence of policy on adolescent depression is the use of

warning labels. In 2007 The FDA revised antidepressant medication labeling to include

information about risks for suicidal ideation and behavior in adults aged 18 to 24 during the first

one to two months of treatment. Individuals that were currently taking antidepressants, regardless

of age group, were directed to continue taking them. This change applied to all antidepressant

medications. This revision followed up the 2005 labeling changes that warned against suicide

risk in children and adolescents taking medication, but the time period for risk was not yet

known or stated. The black box warning was revised to include this risk of suicidality. The type

of study (short-term), age range (children, adolescents, young adults), specifications (major

depressive disorder, other psychiatric disorders), results (increased risk of suicide), and how the

information applies to all patients is included.

These revisions included new requirements for the package inserts of all antidepressant

medication. PPI were developed in compliance with the Food, Drug and Cosmetic act in order to

include more information than would be able to fit on the product regarding medication with

every prescription or refill. Revisions made in 2007 applied to box warnings included in the

insert (covered in the previous section), the warnings section, and precautions section.

The warnings section states that the risk of suicide is prevalent even without medication

in those with MDD and that the risk does not fully go away until remission occurs, but there is

concern that antidepressants increase this risk in the first stages of treatments. More in-depth

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details of the study are included such as the number of participants, trials, drugs, and results. A

table with age range and counts of suicidality per 1000 patients illustrates the risk according to

different age groups. Limitations to the study, such as long term risk assessment, provide

information in regard to long term treatment. A bolded section states that patients taking

antidepressants, regardless of age, or duration of treatment, should be monitored for changes in

behavior related to worsening condition or suicidality. Symptoms that have been shown to

emerge in patients being treated with antidepressants are listed and it is stated that a link between

these symptoms and suicidality has not been causally established, but there is still worry about

their connection. Information for a specific group of drugs (Lexapro, Paxil, Zoloft, Prozac, etc.)

describes the risk of abruptly stopping treatment and that it should be tapered off. Another bolded

section describes how it is important for caregivers to monitor and report unusual changes in

behavior to health care providers. Information regarding the increased risk of antidepressants in

those with bipolar disorder is discussed and recommended for all patients initially prescribed

antidepressants to be properly screened for bipolar disorders.

The precautions section covers the appropriate measures available for properly informing

patients about their medication. Health care professionals should inform patients and family of

the risks associated with the treatment and instructs them to read the “Antidepressant Medicines,

Depression and other Serious Mental Illness, and Suicidal Thoughts or Actions” medication

guide. It is also recommended that the patients be given an opportunity to discuss the guide in

order to confirm understanding and ask questions. The family, caregivers, and patients should

also be told to monitor communicate with health professionals about any emergence of unusual

behaviors or symptoms especially during any dosage adjustment including initiation and

tapering.

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