Depression: 'Tis The Season

I am still not used to the fact that it is getting dark outside around 4 o'clock in the afternoon.  There are times when I wonder about having gone into a career where I go to work in the dark, spend almost the entire day in my windowless yet tastefully decorated office, and then leave work just as the sun is beginning to set.  My already pale skin moves from its typical cream with a hint of pink to full-on pasty white.  I could easily be considered for a role as an extra in any one of the plethora of television shows and movies featuring vampires.

Sigh.  Welcome to the dog days of winter.

It has begun--the winter season.  Not only is there less daylight, but it is colder, making people less likely to partake of natural sunlight outdoors even if they could.  The holidays are coming, which means hectic travel schedules and more time with family.  This much togetherness can be positive but also has the potential to aggravate and enhance any already existing conflict or discord.  For those families who are already struggling financially, emotionally, or both, this time of year can be a true challenge.  If you've been in school counseling for a while, you know that these stressors are not confined simply to adults, but that they also can have quite a large impact on our students.

A recent article by Lynne Shallcross in Counseling Today discussed the topic of depression, and a large section of it highlighted the often invisible high-risk group of adolescents, especially adolescent girls.     According to the National Institute of Mental Health, about 11 percent of adolescents have a depressive disorder by the time they are 18 years old, and according to the World Health Organization, depression is the leading cause of disability amongst people ages 15-44.  Additionally, depression can lead to suicide, which is still the third leading cause of death amongst youth ages 10-24 years old.  You may think that this is something that you will not really address as a school-counselor.  After all, we do not provide therapy, and surely if a student is depressed, then they will be taken care of by an outside clinician.  While this may be true, it does not mean that we do not still play a key role in assisting students and families who are working through depression.  More importantly, we are in a position to be able to work towards prevention and education.

First, what is depression?  The DSM-IV-TR defines Major Depressive Disorder as having had the presence of at least one Major Depressive Episode.  A Major Depressive Episode needs to have had at least five or more of the following symptoms present during a two-week period as well as a change from previous functioning, and at least one symptom is either the first or second on the list below:

• Depressed mood most of the day, almost every day.
• Diminished interest or pleasure in typical activities
• Significant weight loss or gain
• Insomnia or hypersomnia
• Observation by others of either psychomotor agitation or excessive slowing down
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive guilt nearly every day
• Diminished ability to think or concentrate nearly every day
• Recurrent thoughts of death, suicide ideation, or suicide attempts (APA, 2000)

The symptoms also need to cause significant distress in their social and/or academic functioning (APA, 2000).  It is important to note that these are the symptoms for adults.  There are some variations among children and adolescents.  First, as is discussed in the Counseling Today article, depression can often be a challenge to diagnose in adolescents because they are already typically undergoing a lot of mood shifts.  We often chalk up extreme sadness in teens to simply been a teenager.  However, if a student's sadness about a situation continues to linger over time about an event that occurred, this may be a warning sign.  Additionally, you may begin to see other areas of concern.  For example, we should also look for changes in attendance, grades, peer groups, and peer relationships, in addition to the mood alterations as well as any physical symptoms like a change in sleeping and eating habits.  Further, in children you may not see so much the diminished interest or depressed mood, but rather instead irritability and defiance.  Also, because of adolescents' quick-to-change moods, strong desire to fit-in, and a need to show a certain "face" in public, students may be depressed and yet also be observed in some situations to appear as if nothing is wrong.  It is not uncommon to have a student who will seem to be outgoing as ever in school, but when they are home by themselves report that they do nothing but cry, sleep excessively, and hide from family and friends.  Thus, often it can take some probing conversations and a careful examination of all the possible symptoms to really get at the heart of the matter.  It is important to note that, as previously stated, girls are at a higher risk of depression than boys, as are children who have suffered trauma or who have conduct or attention disorders.  Additionally, LGBTQIA children are also at a higher-risk for suicide and mental health concerns.  

So, what is your role, as a school counselor, in all of this?  First, we have a real opportunity to do preventative work with regards to depression:

• Build resiliency in all students.  While there is certainly a physical/chemical component to depression, there is often an event of some kind that will trigger an episode.  Students with few coping schools and resources are more likely, in this instance, to slip into depression.  As a high-school counselor, we often talk to our new students and our 9th graders about participating in sports, clubs, community service, and additional extra-curriculars and stress the impact this can have when they fill out college applications.  However, participation in these activities also helps to build connectivity to the school as well as assisting them in forming positive relationships not only with other students but also with the coaches and sponsors.  It is these links to other people, both peers and adults, and the trust between them, that can be invaluable when a stressful life event occurs.  Rather than feeling like he/she is alone, a student will have a network of trusted friends and mentors to go to.  School counselors can help to connect students with these activities through group orientations, through their counseling website/Twitter feed/Facebook page, or through individual meetings with students.  Further, if the activities are related to physical activity, such as club or school sports or dance, these can add another positive coping mechanism and mood-enhancer to the student's life.  Additionally, school-counselors can educate their students on the role of the school counselor as someone who can help them problem solve social/emotional issues in addition to academic and career/college concerns.  If students have a relationship with the school counselor that is based on trust, they will be more likely to come to you if they are struggling with an issue.  The goal is to build a network of support around all students before an episode of depression begins.
• Educate the school community about the signs of depression and suicide.  We do many lessons with our students, most of them focused on academic and career/college skills.  How about throwing in one or two on the warning signs of depression and suicide?  If the students know about the signs--changes in behavior with regards to attendance, grades, extra-curriculars, friends, sleep, diet, talking about harming themselves, saying goodbye to others, and giving away possessions, etc--then they will be more able to clue adults in when they become worried about their friends.  Additionally, let students know what to do if they are worried about their classmates.  They should talk to a parent, teacher, counselor, or other trusted adult about their concerns.  Honor the confidentiality of the student that reports unless there are some extreme circumstances which would make disclosure a necessity.  In this way, students will feel more comfortable with letting staff know if they have a friend about whom they are worried.  Additionally, train the staff on warning signs and develop a procedure for reporting any students of concern to the school-counselors.  This is where strong relationships with your teachers and staff can come into play.  I am always very thankful when a teacher contacts me to ask me about a student who has been missing their class, suddenly not turning in work and failing tests, or who exhibits some other extreme behavior change.  This information allows me to check in with the student to determine what the situation may be and to develop a plan of action to address the presenting issue.

If you do have a student who you are concerned about, what can you do?  In a 2009 article in School Counselor Magazine, Adriean Mancillas, Psy.D gives some excellent tips:

• Do a suicide assessment and monitor the student.  It is important that if you have a student who presents with some of the signs of depression and/or suicide, that you assess them for risk.  If you are at all concerned or are not comfortable with this, please get additional support from another counselor, school psychologist, or school social-worker.  If there is cause to believe that the student may be suicidal, it is important to immediately contact the parent and ask them to take the student to be evaluated by a mental health professional.  Do not leave the student alone for any reason until the parents arrive.  When the student returns to school, make sure to follow-up with the student and family and check on the student frequently.
• If the student presents with some of the signs of depression, contact the family and refer to their physician or recommend mental health providers.  If you have a student whose grades have dropped, who is sleeping 12 hours a day, who has stopped engaging with friends and with activities they used to love, you have cause to be concerned about this student, and you think they might be clinically depressed.  How do you address this with the parents?  Remember: school counselors do not diagnose.  You should not say that their child is suffering from depression.  However, we can tell the parents what behaviors and changes we and other school community members are observing, state that we are very concerned by these observations, and recommend that they please follow up with a visit to a primary care physician or a mental health professional.  They should start with their insurance company, but you should also have on hand a list of local providers, some that will provide services on a sliding scale.  
• Educate and work with the parents.  All parents have dreams for their children, and when a student becomes depressed, it can really interrupt and impact both their academic and social lives.    This can be a challenge sometimes for parents who are worried that this is going to ruin their child's chances to get into a certain college or achieve certain goals.  We have come a long way in this country with regards to acknowledging the legitimacy of mental illness, but there is still a long way to go until we see it in the same framework as physical illness.  People will often wonder why someone cannot simply "snap out of it" when it comes to depression, and it can be our role as school counselors to help educate parents and the community that it is indeed an illness, that it takes time to heal and recover, and that the primary focus for a child who is depressed should be on getting well.  The grades and college plans will come when the child is feeling stronger.  Additionally, some parents may simply need more information about depression in adolescents, and if they have a relationship with you as their child's school counselor, they may be more comfortable seeking answers to their questions from you versus outside providers.
• Help accommodate the student's academic and school needs.  Students who are in the throws of depression and recovery may not be able to keep up with a full-course load, or may need to lessen the rigor of their classes.  They may need reduced work-loads or access to teacher notes.  Additionally, they may need more access to you, the school psychologist, or the school social worker than other students.  You can help to coordinate with the student, the parents, the teachers, and the outside clinicians to develop a plan that will best assist that student.
• Be a support to the student during the school day.  We, as school counselors, do not provide therapy, but we can be supports to our students while they are at school.  Building that relationship early with students can be key before an issue occurs, as it will make the student more comfortable seeking you out and trusting you during their recovery process.  It may be that you will check in with the student once a week, or it may be that the student can come to you if they are feeling overwhelmed during the school day and need a safe space to gather their thoughts before they go back to class.  Either way, you can be an invaluable resource in the building to that student while they are also getting outside assistance. (Adapted from Mancillas, 2009)

As they year goes on, we will see more cases of depression in our students.  As school-counselors, we can take the steps necessary to do some preventative work and education, as well as put supports in place ahead of time to help assist our students and their families who are working through this issue.

The following work was cited within this post:

APA. (2000).  Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., Text Revision.  Arlington, VA: American Psychiatric Association. pg. 356, 375.

The following work was cited within this post and is available to members of the American School Counselor Association:

Mancillas, A. (2009) Supporting Students With Depression.  Retrieved from www.ascaschoolcounselor.org.