Adolescent Depression

Research and Recommendation Report

Brenna McAllister
December 15, 2015

Moderate to severe depression affects almost ten percent of American teenagers. About
five percent of American teenagers have symptoms of depressive syndrome and three percent
meet the criteria for depressive disorder (Steinberg, 1993, pg. 426). Despite the many studies
that have been done to better understand depression, it remains prevalent, affecting a large
portion of the human population, especially adolescents. Depression is characterized by
emotional, cognitive, motivational and physical symptoms, including dejection, low self-esteem,
pessimism, hopelessness, apathy, boredom, loss of appetite, difficulty sleeping, and loss of
energy. It is a particularly worrisome problem when studying adolescents, because teenagers are
three times more likely to be affected by depression than children, with late adolescence
presenting the most vulnerable time of the life span for the disorder. Teenage girls are especially
vulnerable, being twice as likely to have depressive disorder (Steinberg, 1993).
There are several prominent theories to explain depression, why it so often strikes during
adolescence, and why it affects girls more often than boys. A well-accepted theory is the
diathesis-stress model, which contends that depression is a result of both an individuals
predisposition to internalizing problems, and chronic or acute stress that sparks the depression.
Three categories of stress are especially likely to cause depression; family conflict, poor peer
relations and chronic or acute stress. Adolescence is a time of increased stress, which also helps
explain why depression is so much more prevalent in teenagers than in children. Although there
are several risk factors and protective influences on how an individual will handle stress (Breton
et al., 2015), for many, their predisposition towards internalization causes the increased stress of
adolescence to result in depressive symptoms. Experts believe that an individuals
predisposition to internalizing problems is partly biological, and is linked to hormonal activity in
the brain and nervous system.

However, this predisposition toward internalization also has to do with an individuals

likelihood to ruminate and have negative cognitive styles (Hamilton, Stange & Abramson, 2015).
Rumination refers to repetitive, passive thinking about ones mood, and negative cognitive styles
refers to incorrectly attributing negative events as global or universal, and drawing inaccurate
conclusions about how those events will affect oneself. In an article entitled Stress and the
development of cognitive vulnerabilities to depression explain sex differences in depressive
symptoms during adolescence published in a journal called Clinical Psychological Science,
Hamilton et al. (2015) studied what they call the mediation hypothesis, which assumes that
following stress, high levels of rumination and negative cognitive styles would predict
depression, especially in females (p. 705). They questioned 382 twelve to thirteen year old
adolescents at four different times, spanning about 2 years. At time one, they questioned
participants about their current depressive symptoms and their rumination and negative cognitive
style patterns, at time two, the questionnaire focused on stressful life events that had happened
since time one, at time three participants again answered questions about their rumination and
cognitive style patterns, and at time four they were questioned on their current depressive
symptoms. The study confirmed the mediation hypothesis. Hamilton et al. also found that these
cognitive vulnerabilities form during middle childhood and early adolescence, and are usually
fully formed by late adolescence. This explains why depression rates peak in late adolescence,
when most individuals have formed these vulnerabilities.
This study also explains the gender bias in depression; girls are more likely than boys to
react to problems with rumination. However, the type of stress seems to impact how adolescents
react. By categorizing stressors first as interpersonal or achievement, and then by further
dividing interpersonal events into dependent or independent, Hamilton et al. (2015) found that

rumination and negative cognitive styles were tied to interpersonal dependent events, but not to
interpersonal independent events or achievement events. In other words, they found that
negative cognitive styles and rumination were both linked to interpersonal events that the
adolescent felt in control of in some way. Furthermore, they found that girls were exposed to
more interpersonal dependent stressors, which contributed to their increased rumination and
negative cognitive styles, which in turn led to increased depressive symptoms.
In a study called A Test of the Vulnerability-Stress Model with Brooding and Reflection to
Explain Depressive Symptoms in Adolescence by P. Paredes and E. Zumalde, published in the
Journal Of Youth & Adolescence, researchers split rumination into two categories brooding and
reflection which they found also explains part of the gender difference. They surveyed a total
of 998 adolescents aged thirteen to seventeen, having them complete three questionnaires meant
to measure rumination, stressors and depressive symptoms, over a period of a year and a half.
They found that while both brooding and reflection affect depression, reflection had either a
positive or negative effect, possibly based on the interpersonal context (Paredes & Zumalde,
2015). This study also helped to explain the gender bias, finding that girls scored higher than
boys on average on both components of rumination. However, Paredes and Zumalde (2015)
found that brooding only predicted depression in girls, partly because girls brood more than
boys, and partly because girls are more vulnerable to the effects of brooding (Paredes &
Zumalde, 2015, p. 866-867).
However, ecological factors predict adolescent depression as well. Smokowski, Evans,
Cotter and Guo (2014) explored correlates of self-esteem and depression in their article entitled
Ecological Correlates of Depression and Self-Esteem in Rural Youth, published in Child
Psychiatry & Human Development. In their survey of 4,321 youth, they found that having a

lower income, having poor relationships with parents and peers, and being female are all risk
factors for high depressive symptoms, and are all correlated with having a low self-esteem.
Contrarily, supportive relationships with parents and peers, high religious orientation, ethnic
identity and school satisfaction were all tied to having a higher self-esteem, and lower depressive
symptoms (p. 500). This supports the diathesis-stress model of adolescent depression. Low
income and poor relationships are causes of stress, and are tied to more depressive symptoms,
while supportive relationships, religious affiliation, strong ethnic identity and school satisfaction
are all sources of support which mediate the effects of stress.
In their article entitled Protective Factors Against Depression and Suicidal Behaviour in
Adolescence, published in the Canadian Journal of Psychiatry, Breton et al. (2015) identified
several other protective factors for depression, as well as risk factors. They surveyed 283
adolescents from a community and 119 adolescents from a mood disorder clinic in Montreal,
Canada, testing the vulnerability-resilience stress model. This model argues that there are
protective factors that can provide resilience to stress, and therefore depression, and that there are
risk factors that increase an individuals vulnerability to stress, which leads to increased
depression.
Their findings supported the vulnerability-resilience stress model. At the .001
significance level, they found focus on solving the problem, work hard and achieve, focus
on positive, physical recreation, family alliance, self acceptance, peer acceptance and
support, future optimism, and self discovery all to be protective factors against depression
for girls. Risk factors for girls at the .001 significance level included hopelessness, worry,
wishful thinking, not coping, tension reduction, self blame, keep to self, and seek to
belong. Less protective factors were found for boys at the .001 significance level; they included

physical recreation, peer acceptance and support, and self discovery. Risk factors for boys
at the .001 significance level were very similar to girls, including hopelessness, worry,
wishful thinking, not coping, tension reduction, keep to self, and seek to belong. It
should be noted that these were the findings from the community only. Although the clinical
sample results did support the vulnerability-resilience stress model as well, the individual
protective and risk factors had slightly different significance levels. However, the message here
should be one of hope. By reducing risk factors in adolescence and increasing protective factors,
the adolescent depression rate may be reduced, or at least adolescents could be more equipped to
handle and cope with their depression.
In an interview with a seventeen-year-old girl who has suffered and still suffers with
depression, she revealed to me how her depression started, what she wished people understood
about depression, the role of peer support in living with depression, and the amazing help her
parents are in handling depression (personal communication, December 5, 2015). To keep her
identity confidential, I will refer to her as Jane. Jane explained to me how her depression first
started, which was entirely in line with the diathesis stress model. Janes father had a heart
attack, and at about the same time her sister became seriously ill and a dear friend of Janes left
[her] in the dust. The following year, a boy at Janes school committed suicide, which sparked
Janes depression. According to her, she realized for the first time that the world was a scary
and dark place. Jane also told me that both of her older sisters had dealt with depression.
According to the diathesis stress model, the vulnerability to depression is partially inherited
which would explain why Jane and both of her sisters had dealt with it. The model also
corresponds with Janes story in that it was the build-up of stressors, especially interpersonal
stressors, which lead to her depression.

Jane expressed to me that she wished people understood that depression was just as real
and crippling as a physical illness, explaining how difficult it was when neighbors or friends
asked why she never left her house. Her statement was completely in line with the thoughts of
Wayne Sears, a licensed clinical mental health counselor whom I interviewed. He expressed that
many people believe depression can be healed by simply getting out, and doing something the
individual enjoys. He emphasized to me that this was not the case, and that depression took
treatment and was harder than most people believed it to be (W. Sears, personal communication,
November 24, 2015).
As Smokowski et al. (2014) and Breton et al. (2015) have shown, depression is largely
affected by the quality of peer relationships. I asked Jane about her friends, and whether they
were supportive of her in fighting her depression. She told me that at first her friends were very
supportive, however some eventually [got] sick with it and [fell] away. She emphasized,
though, that she had a few close friends that stuck with her, and how much it meant to her to
know that there were people who were always there for her, even when she did not feel like
herself.
When asked what was most helpful to her in fighting her depression, Jane said it was her
parents, specifically their unconditional love and support. They took her to see different doctors
and got her different medications until she found one that helped. They lovingly encouraged her
to get out of bed on days that she didnt think she could. She told me how important it was to
her to know that the whole time she fights her depression, she will always have her parents there
doing whatever they can to help. This is consistent with what therapist Wayne Sears said. He
expressed that he always encouraged adolescents to talk to an adult and get help. Whether it is

parents, teachers, counselors or neighbors, social support is an important protective factor in

preventing depression, and plays an essential role in helping adolescents overcome depression.
Depression can be combatted at many levels, including the societal level, the school
level, and the intrapersonal level. At the societal level, people need to understand the nature of
depression, that it is just as real an ailment as cancer or a broken bone, and that individuals
fighting depression need support and love, not judgment. This is the message my campaign for
change portrays. It is a four minute video consisting of clips of my interviews with Jane and
Wayne Sears. It includes both Jane and Mr. Sears describing the very real nature of depression,
its symptoms and onset, and what people can do to help those with depression.
My goal in this campaign for change was to help people who may know someone with
depression, or may be experiencing it themselves, to better understand it, and to remove some of
the negative stigma associated with it. Because it is an audio-visual clip, it would need to be
distributed through either television or the Internet (YouTube). Ideally, my campaign for change
video would reach everyone, since depression is now so prevalent that most people know at least
one person struggling with it. My video is also slightly focused on the parents of adolescents; it
involves recognizing the signs of depression in teenage children and how parents and adults can
help. If an individuals whole community could accept depression as a real and debilitating
ailment, and then offer sympathy instead of judgment, individuals fighting depression would
have more support, which is key in overcoming depression.
Also on the societal level, counseling should be available to any and all adolescents
facing mental health problems. Living with low income is shown to be a risk factor for
depression (Smokowski et al., 2014). In fact, in one study, depressed mood or anxiety was 2.49
times higher in youth with low socioeconomic status than in youth with high socioeconomic

status (Lemstra et al., 2008, p. 125). Unfortunately, because of their lower financial status, these
are the adolescents who have the least access to counselors, and others sources of help. A
potential answer to this problem may be found in the school system.
Middle and High schools could provide teenagers with the adult support they need, if
they have staff members and teachers who are trained. Janes school has a therapist always on
campus, for any students who may need him (personal communication, December 5, 2015). If
all schools gave students free access to a therapist, it could help negate this socioeconomic bias
of depression. Unfortunately, this may be ineffective because of the stigma associated with
depression. Wayne Sears works as a high school counselor, and he stated that the school system
was flexible in working with students with depression and in helping them, but the biggest
problem was that students and parents were unwilling to speak to the counselors and tell them
about their depression (W. Sears, personal communication, November 24, 2015). Depression
continues to be something that individuals are embarrassed or ashamed of.
A possible solution to this could be to dedicate one class period every year of middle and
high school to mental health in adolescence. Perhaps educating students on the prevalence and
reality of depression could lessen that stigma, and create a more accepting environment for those
with mental illness. This de-stigmatization would help teenagers feel more comfortable seeking
help and talking to adults about their depression. Another possible solution would be to train
teachers how to recognize depression, and offer support in an appropriate way. If teachers could
take the role of a pseudo-therapist, and teach individuals with depression different coping skills
to handle it, then students who dont feel comfortable meeting with a counselor or therapist could
still receive some of the benefits of a trained professional.

The last level to combat depression is the intrapersonal level. While access to a mental
health counselor or psychiatrist can help an individual with depression learn coping skills, some
skills can be learned without professional help. According to Wayne Sears, a licensed clinical
mental health counselor, the type of therapy often used to combat depression is cognitive
behavioral therapy (personal communication, December 14, 2015). This type of therapy focuses
on retraining the brain to think correctly, and eliminating the negative cognitive styles discussed
by Hamilton et al. (2015). It is based on the idea that individuals core beliefs shape how they
interpret different situations. What they think about a certain situation determines how they react
(Schuldt, 2014). For example, if someone with healthy core beliefs gets stood up for a date, she
might think, He probably had something come up, Ill call some other friends to hang out with
tonight. Contrastingly, if someone with the unhealthy core belief I am not worthy were to get
stood up for a date, she might think, What is wrong with me? I must be unlovable. Her
reaction would be to spend the night alone, obsessing over why her date stood her up. Therapists
have found that by changing both individuals actions and behaviors, eventually those core
beliefs can be changed as well.
Individuals can focus on changing their unhealthy core beliefs by challenging their
irrational negative thoughts. If an adolescent girl could change her thoughts from whats wrong
with me? to he probably had something come up, she could eventually change her core belief
from one of unworthiness to one of confidence. This is the type of work that therapists do to
combat depression, and although it is easier with professional help, individuals can do this type
of work independently.
Individuals can also fight depression by removing the stressors in ones life. According
to the diathesis-stress model, depression requires both the vulnerability to it (which can be

thought of as the rumination and negative cognitive styles component), treated by cognitive
behavioral therapy, and the stress component (Hamilton et al., 2015). As mentioned earlier, the
three types of stress most likely to cause depression are family conflict, poor peer relations, and
chronic or acute stress. Chronic or acute stress can be managed at the intrapersonal level by
learning stress management skills. Teachers, school counselors, or parents can all help
adolescents to learn these skills, and make resources available for teenagers struggling with
stress management. The schooling system could also be changed, placing less focus on grades
and more on motivation. Changing school from an externally motivated experience to an
internally motivated one could remove a lot of the stress associated with school. However, this
solution may be a bit nave. Certainly there needs to be a way to track student progress and hold
students and teachers accountable for their learning. Perhaps by decreasing the importance of
tests and increasing the importance of participation and engagement, this change in motivation
could occur.
Another type of stress that causes depression is poor peer relations. Adolescence is a
time of many changes, physically, cognitively, and socially, so many peer relationships do
change for the worse during this time. Unfortunately, while high school seems to bring
popularity and approval to some, it also brings rejection and isolation to others. Research shows,
however, that having a fewer number of close friends is more beneficial to healthy adolescent
development than having a large number of acquaintances. Depression could possibly be fought
or prevented by adolescents learning better social skills with peers. This change would need to
happen in childhood, since that seems to be where most antisocial behavior is learned. Perhaps if
cities offered occasional parenting classes, mothers and fathers would have better skills to ensure
pro-social behavior in their children.

Parenting classes would also help alleviate the last source of stress that causes
depression: family conflict. If parents became more aware of adolescent development and
learned successful parenting skills, such as authoritative communication and parenting, there
would likely be less family conflict, and therefore less adolescent depression. Although it is
impossible to entirely de-stress the teenage experience, by removing some of the stressors most
likely to cause depression, the rate among adolescents would decrease.
Decreasing the adolescent depression rate, and giving those with depression coping skills
to handle it, should be a prioritized societal need. Depression affects a substantial amount of the
adolescent population, and it seems to be on the rise. Following the diathesis-stress model of
depression, by decreasing an individuals vulnerability to depression and by decreasing the
stresses in his or her life, depression should be in large part preventable. By lessening the stigma
associated with depression through educating the public, like my campaign for change attempts
to do, teenagers facing depression would have more social support from the adults and peers in
their lives, and would hesitate less in seeking treatment for their depressive symptoms.
Similarly, if parents and teachers were educated in teaching students stress coping and
depression coping skills, perhaps depressive symptoms could be lessened. Finally, by removing
or lessening the stresses known to cause depression, fewer adolescents would be forced to face
this debilitating mental illness.

Annotated Bibliography
Breton, J., Labelle, R., Berthiaume, C., Royer, C., St-Georges, M., Ricard, D., & ... Guil, J.
(2015). Protective Factors Against Depression and Suicidal Behaviour in
Adolescence. Canadian Journal Of Psychiatry, 60S5-S15.
This study examined the vulnerability-resilience stress model, especially specific risk and
protective factors for adolescent depression. Their findings supported the vulnerabilityresilience stress model, and found that different risk or protective factors are more effective for
boys or girls. Specific risk factors tested include: hopelessness and nonproductive coping (worry,
wishful thinking, not coping, tension reduction, ignore the problem, self-blame, keep to self, and
seek to belong). Specific protective factors include: focus on solving problem, work hard and
achieve, focus on positive, relaxing diversions, physical recreation, social support, family
alliance, self-acceptance, peer acceptance and support, future optimism, and self-discovery. This
is a valid source; its from a peer-reviewed journal. I used this source in my report as part of the
literature review and to inform my recommendations.
Hamilton, J. L., Stange, J. P., Abramson, L. Y., & Alloy, L. B. (2015). Stress and the
development of cognitive vulnerabilities to depression explain sex differences in
depressive symptoms during adolescence. Clinical Psychological Science,3(5), 702-714.
doi:10.1177/2167702614545479
This article explores the reason why depression is so much more prevalent in girls than boys.
They cite two cognitive vulnerabilities, negative cognitive style and rumination. Those
vulnerabilities form during middle childhood/early adolescence, end by later adolescence,
making early adolescence a critical period for depression. Stressful life events predict
development of negative cognitive styles and rumination (article details how). There is evidence
that girls are exposed to more interpersonal stressful events, which may explain greater rates of
depression, especially interpersonal stressful events that are dependent (controllable) instead of
independent (fateful/uncontrollable). I used this source in my report as a case in my literature
review, because I like how it explains the theory behind depression, and the gender bias, based
on empirical research.
Lemstra, M., Neudorf, C., D'Arcy, C., Kunst, A., Warren, L., & Bennett, N. (2008). A
Systematic Review of Depressed Mood and Anxiety by SES in Youth Aged 10-15
Years. Canadian Journal of Public Health, 99(2), 125-129.
This source is a literature review of 9 different studies of depression. They found that in youth
aged 10-15 years, depression was more common in youth with low socioeconomic status.
Depressed mood or anxiety was 2.49 times higher in low SES youth than high SES youth. This
article also discusses most common age for onset of depression, and comprehensive list of
symptoms and outcomes of depression. Its from a peer-reviewed journal, so I feel confident its
a valid and academic source. I used the finding that depression is tied to SES in my
recommendations.

Paredes, P. p., & Zumalde, E. e. (2015). A Test of the Vulnerability-Stress Model with Brooding
and Reflection to Explain Depressive Symptoms in Adolescence. Journal Of Youth &
Adolescence, 44(4), 860-869.
This study explored the relationship between rumination and depression. It split rumination into
two categories brooding and reflection. It also tried to explain the gender differences in the
stress-diathesis model. This study found that both components of rumination affect depressive
symptoms. Reflection can have both positive and negative affects on depression, which some
think may depend on the intrapersonal context of the reflection. Girls scored higher than boys on
both ruminative components, especially on reflection. They also found that brooding only
predicts depressive symptoms in girls. So basically, girls brood more than boys, which leads to
depression, and girls are less resilient to the effects of brooding, it has more harmful effects on
girls, which also leads to depression. I used this source in my report to help support the theory
section, and as one of my cases in the literature review.
Schuldt, W. (2014, November 28). Therapy Worksheets, Tools, and Handouts | Therapist Aid.
Retrieved December 15, 2015, from http://www.therapistaid.com/
This source is a website made by licensed therapists for licensed therapists. It includes many
worksheets, handouts, and videos based in different therapeutic techniques. I used a video from
this site to learn about cognitive behavioral therapy, which I used in my report in the
recommendations section.
Smokowski, P., Evans, C., Cotter, K., & Guo, S. (2014). Ecological Correlates of Depression and
Self-Esteem in Rural Youth. Child Psychiatry & Human Development, 45(5), 500-518.
doi:10.1007/s10578-013-0420-8
This study looked at correlates of self-esteem and depression from an ecological perspective.
They found that ethnic identity, religious orientation, and school satisfaction all predicted both
depressive symptoms and self-esteem. Girls were more likely to have depressive symptoms, and
to have a lower self-esteem. They hypothesize that this sex difference is because girls are
socialized to be submissive, which leads to feelings of powerlessness and therefore depression
and low self-esteem. They also found that parent-child conflict is highly predictive of depressive
symptoms and low self-esteem. School characteristics did not significantly impact depressive
symptoms or self-esteem. I used this case in my literature review, to support the stress aspect of
the diathesis-stress model.
Steinberg, L. (1993). Adolescence (9th ed.). New York, New York: McGraw-Hill.
This is the (slightly outdated version of the) course textbook. I used many of the statistics in my
introduction, and I used its explanation of the diathesis-stress model as the heart of my theory
section, which expanded into my literature review.

Wagner, C. C., Alloy, L., & Abramson, L. (2015). Trait Rumination, Depression, and Executive
Functions in Early Adolescence. Journal Of Youth & Adolescence, 44(1), 18-36.
This study examined the relationship between rumination/depression and deficits in executive
functions. Rumination predicted better sustained attention in people who were low on depressive
symptoms, but worse sustained attention in people with high depressive symptoms. Depressive
symptoms were not associated with executive functioning. I did not use this source directly in
my report, however I chose to keep it in my bibliography since it did contribute to my overall
understanding of adolescent depression.