1. Depression: Who, What and Treatment
Nicole Gawer, LMSW, LCSW
PACES of Wyandot County; School Based Therapist

2. Introduction What will you get out of this presentation?
An introduction to depression and suicide symptoms, warning signs, and treatment options.
This is the most brief introduction to depression, please seek a professional mental health provider for individual needs.
DISCLAIMER: Tough topics will be discussed that may be triggering/upsetting to you… We encourage you to take a break if you need to.

3. Overview Depression: Helpful ways to think about depression
The What and the Who
Professional treatment
Suicide:
Early Intervention and professional treatment
Who is at risk and warning signs
Immediate action steps and suicide facts
Thoughts for at home:
Affecting the daily environment
The Brain and Adverse Childhood Experiences

4. Helpful ways to think about depression
You are not a therapist, forgive yourself for what you didn’t do, what you didn’t think of, what you didn’t know, forgive yourself for your own imperfections. Not only will you feel better if you forgive yourself, you are modeling self forgiveness, which is invaluable for a person with depression. You are perfectly imperfectly you. Not a perfect parent, not a perfect teacher, not a perfect human being. Forgive.

5. Helpful ways to think about depression
Depression is a disorder, not a decision or a choice. If someone has cancer, we don’t blame them for their cancer. We also don’t blame them if their cancer doesn’t get better or, if it does get better, but comes out of remission. We don’t tell them to “Try harder” to get rid of their cancer.
A person with depression is not a depressed person, they are a person first and their depression is just a part of them.

6. Helpful ways to think about depression
We are all doing the best that we can, and we can do better 
Your child is doing the best that she can and she can do better 
You are doing the best that you can and you can do better.

7. Helpful ways to think about depression
Think about what works and what is helpful, not what is good or bad.
Take out the judgement, the judgment doesn’t help. And when you do judge, because you will judge, forgive yourself.
Notice the way you think about it…
“She just needs to get over it”  “Nobody wants to be miserable, I will help to hold the hope while she feels hopeless.”
Feelings are always valid and cannot be changed. Accept each human being for who he is.

8. Organic Depression
Brain chemicals such as serotonin , norepinephrine, and dopamine are different in the depressed brain
Depression is not a choice, it is an imbalance of certain particular chemicals in the brain.
We do not blame person for getting cancer nor do we blame them if the cancer treatment doesn’t work. Mental health is no different except in our societal norms.
There are reports that depression has increased significantly in the past 50 years. The reasons for this are not definitively known
1) decreased social stigma leading to increased reporting may be partially
2) brain chemicals can be generational. Example: “love chemicals” released during breast feeding have been found to release at the same level as the woman’s mother had released them for her as a baby

9. What: Clinical Depression Definition
DSM definition or more of the following:
depressed mood most of the day, nearly every day, in children and adolescents can be irritable mood
markedly diminished interest or pleasure in (almost) all activities most the day, nearly every day
significant weight loss when not dieting
insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue or loss of energy almost every day
Feelings of worthlessness or excessive or inappropriate guilt, almost every day
Diminished ability to think or concentrate
Recurrent thoughts of death, recurrent suicidal ideation (with or without plan, or suicide attempt)
Mild, moderate, severe. Single episode or recurrent episode.
With anxiety, with psychosis, with melancholic features, Post partum, peripartum, seasonal pattern, due to other medical condition, dystehmia.

10. What: Mood Symptoms Sad/depressed mood – or- irritable mood
Anhedonia (lack of interest in pleasurable activities)
Decrease or increase in appetite, resulting in weight loss or gain
Intense feelings of worthlessness, hopelessness, or guilt
Recurring suicidal ideation
**Symptoms are present almost every day for 2+weeks

11. What: Depression Manifestations
Sleep disturbance
Continued agitation
Decline in school achievement
Deterioration in personal hygiene/habits
Inability to concentrate
Sluggishness or fatigue
**Symptoms are present almost every day for 2+weeks

12. What: Depression Behaviors
Substance use (medications not prescribed to him, street drugs, alchohol)
Decline in relationships
Increase of poor decision making
Starting to bully when one was once bullied
Other significant behavioral changes
Spending time in room or isolated from family or peers
Restricting food or overeating
Withdrawing from activities which were previously enjoyed
**Symptoms are present almost every day for 2+weeks

13. What: Depression Feelings
Hating yourself for hating yourself. Feeling sad because you feel sad. Constantly judging yourself. Wanting to feel happy but crying instead. Can go to work or go to school and seem fine, perhaps even a model student.
Watch for statements of “I can’t every do anything right.. Nobody likes me.”
Also, anger. Anger is an adaptive coping mechanism as anger is much more tolerated in society than sadness is. Covers up the real problem.
Irritability: You say, “I am concerned that your math grade is falling” and he feels like you just said, “You are so stupid, you must not be trying. You are never going to pass math and are a failure.”

14. The What: Depression Feelings

15. The What: Depression Feelings

16. Who: Depression
Anxiety and depression have been on the rise since 2012.
Girls are at higher risk than boys.
Family history of depression increases the chances that a child will have depression by 11%
In 2015 about 3 million teens age 12 – 17 had had at least one major depressive episode in the past year.
Statistics likely on low end because there is such social stigma that people do not report or seek help.

17. Who: Depression
All people are at risk; age, gender, socio-economic level, educational level do not matter, no one is immune
Family history increases risk
Negative or traumatic current and past life experiences increase risk
Hormonal changes increase risk
Poor physical health or medical conditions increase risk
Lack of sunlight, healthy eating and exercise increases risk

18. Who: Depression
“The first time Faith-Ann Bishop cut herself, she was in 8th grade. It as 2 in the morning…she sliced into the soft skin near her ribs… there was sense of deep relief. “it make the world very quiet for a few seconds… for a while I didn’t want to stop, because it was my only coping mechanism. I hadn’t learned any other way… She hid the marks on her torso and arms, and hid the sadness she couldn’t explain and didn’t feel was justified. On paper, she had a good life. She loved her parents and new they would be supportive if she asked for help. She just couldn’t bear seeing the worry on their faces.” Time. September 7, by Susanna Schrobsdorff.
“We are the first generation that cannot escape our problems at all” Faith-Ann Bishop, 20.

19. Who: Prominent people with depression
Kristin Bell Lady Gaga Cara Delevingne Dwayne “The Rock” Johnson Sarah Silverman Jon Hamm Demi Lovato Owen Wilson Wayne Brady Kerry Washington Sheryl Crow J.K. Rowling Trevor Noah Neal Brennan Ashley Judd Heath Ledger Robin Williams David Arquette Catherine Zeta-Jones Andre Waters Gwenyth Paltrow Amanda Beard Jeret Peterson Princess Diana Tipper Gore Andrew Koenig Brooke Shields Paige Hemmis Winona Ryder Nicki Manaj Ellen Degeneres Kanye West Miley Cyrus Jim Carey Brad Pitt Angelina Jolie Halle Berry Mandy Moore Drew Carey Carrie Fisher Roseanne Barr Buzz Aldren Terry Bradshaw Doug Duncan
Jeret Peterson (committed suicide), Andrew Koenig (committed suicide), Owen Wilson (had a suicide attempt),
Other leaders or prominent people? Make this pretty (columns)

20. Why Seek Professional Help?
Get the correct diagnosis; PTSD, anxiety, long term ADHD, drugs and alcohol can all look similar to depression
Get evidenced based treatments
Learn more about mental health and diagnosis
Learn and practice coping skills
Learn what helps and what doesn’t
“Helpers” can provide validation to child and parent
Prevent further escalation of mental health symptoms
Open up communication
Seeking help is a life skill to model for children

21. Treatment: Professional
Get Professional Guidance - diagnosis, treatment and medication options
Cognitive Behavioral Therapy or other evidence based therapy for depression; grief and loss therapy if needed
Therapy providers - Social Worker, Professional Counselor, Marriage and Family Therapist or Psychologist

22. Treatment: Professional
Medication is an option, particularly if symptoms persist and risk is elevated
Medication providers - psychiatrist or primary care doctor
Just because a medication worked doesn’t mean it will always work, continue to see provider as recommended and do not stop taking medication without doctor oversight.

23. Treatment: Professional
Community Mental Health Centers
Private Providers
Beyond therapy: case management, crisis hotline and clinic, parent support groups, wrap around services, school modifications etc.

24. Depression and Suicide
Take a breathe… talking about suicide is one of the most difficult but also preventative things we can do. I encourage you to take a break if you need to.

25. When depression becomes a safety concern:
Depression is miserable, it takes your energy and feels as though it takes your ability to make choices in life.
Depression does not mean someone will consider or attempt suicide, but it can.
I have talked to an adult that remembers sitting under her porch at age 4 thinking about how she might kill herself, she said it would have made all the difference to have been able to share her “secret.”

26. Early Prevention Steps:
Open the door to talking about Suicide and Self-harm to help raise awareness. Help youths normalize talking about it. Many statistics identify that youths feel more comfortable talking to peers about suicidal feelings rather than adults. If you normalize these suicidal thoughts it could change. (If you see warning signs talk to the youth or the youth’s friends.)
Educate youths on where they can go for help for themselves or for a friend.
National Suicide Prevention Hotline:

27. Early Prevention Steps:
Lock Firearms
Lock medications
Ensure medication compliance
Implement “safety checks” of personal areas
Create a “safety plan”

28. Early Prevention Steps:
DO NOT:
Tell the person they shouldn’t talk about such things
Tell him he should be happy, he has everything he needs
Tell him he “shouldn’t” feel that way
Problem solve as a first step
Hover over him, smothering or constant focus on negative is not helpful and doesn’t allow for recovery
Take away coping items such as music, gymnastics class, etc.
Problem solve example: coming up with a plan for passing an upcoming exam invalidates the emotion of feeling like a failure

29. Treatment: Professional
Psychiatric hospitalization - threat to self, others or psychotic
If you are concerned your loved one might be suicidal:
Call 911
Local hospital for a psychiatric screen
Local mental health hospital
Crisis / suicide hotline
Let a clinician decide risk level!

30. Who: Increased Risk for Suicide
Individuals who are depressed and exhibit the following symptoms are at particular risk for suicide:
Extreme hopelessness
Heightened anxiety or panic attacks
Insomnia
Talk about dying or have a prior history of attempts
Extreme agitation

31. Who: Increased Risk for Suicide
Long standing history of emotional or behavioral problems
Period of escalation of problems
Isolation and lack of connection to family and friends (no one to talk to)
Disintegration of traditional support systems
Personal history of suicidal thinking or attempts
Personal history of self harm behaviors
Be faced with a situation of humiliation or failure (recent or long term; social media or event)
Terminal or chronic health conditions
Family history of suicide
History of Trauma (community violence, DV, Rape, sexual or physical abuse, bullying)
Pressure to succeed – rigidly adhering to very high standards for self
Pressure cooker or volcano.
Can be impulsive

32. Who: Increased Risk for Suicide
A recent death or suicide of a friend or family member
A recent break-up with a boyfriend or girlfriend, or conflict with parents
A recent divorce in the family
Significant adjustment (move, new family dynamics, new school, change in family finances)
News reports of other suicides by young people in the same school or community
Recent series of events (breakdown of social supports, peers, friends, family)
Recent criminal charge or situation where the youth feels there is no hope for redemption
Impulsive

33. Who: Special Populations
Youth involved in the juvenile justice and child welfare systems have a high prevalence of many risk factors for mental, emotional, and behavioral disorders associated with suicide. Juveniles in confinement and foster care have life histories that put them at higher suicide risk. (HHS, 2012). Suicide among youth in contact with the juvenile justice system occurs at a rate about four times greater than the rate among youth in the general population. (HHS, 2012). In one study, children in foster care were almost three times more likely to have considered suicide and almost four times more likely to have attempted suicide than those who had never been in foster care. (Pilowsky & Wu).
(HHS, 2012; Pilowsky & Wu, 2006; SPRC, 2008)

34. Who: Special Populations
LGBTQ Youth:
Higher rates of major depression, anxiety disorder, conduct disorder, and substance use disorder
Teens unsure of their sexual orientation are more than 3x more likely to attempt suicide
30% of transgender individuals surveyed reported having attempted suicide compared to 4.6% of US adults and young adults in the US
Many LBGT youth do not disclose, as a result, sexual orientation and gender identity do not show up in autopsy interviews
LGBT youth who experienced severe family rejection were more than 8x more likely to attempt suicide

35. Behavior Warning Signs
Talk about suicide, death and/or no reason to live
Be preoccupied with death and dying
Withdraw from friends and/or social activities.
Have a recent sever loss (esp. relationship) or threat of a significant loss.
Experience drastic changes in behavior
Lose interest in hobbies, work, school, etc.
Prepare for death by making out a will (unexpectedly) and final arrangements
Give away prized possessions

36. Behavior Warning Signs
Take unnecessary risks; be reckless, and/or impulsive
Lose interest in their personal appearance
Increase their use of alcohol or drugs
Express a sense of hopelessness
Have a history of violence or hostility
Have been unwilling to “connect” with potential helpers
Post statements via social media about death or “not being here”

37. Immediate Action Steps:
Seek immediate professional help, this is not an all inclusive list
Call: crisis line, 911, hospital, provider
Follow previously established safety plan
Maintain structure
If someone states feeling suicidal, believe him
Support skill use and stay with the person (not hovering though)
Remove unsafe items including razors, knives, belts etc.
Ensure all medications, alcohol etc are locked
Ensure all firearms are locked

38. Suicide Facts:
2/3 of people who commit suicide were depressed at their time of death
2010 – Suicide was the 10th leading cause of death in the US claiming 38,357 lives
Suicide rates among youth (ages 15-24) have increased more than 200% in the last 50 years
4x more men than women commit suicide
3x more women than men attempt suicide
People with multiple episodes of depression are at greater risk for suicide
Dependence on alcohol or drugs greatly increase suicide risk

39. Suicide Facts:
Suicide is the SECOND leading cause of death for ages (2013 CDC WISQARS).
More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease, COMBINED.
Each day in our nation there are an average of over 5,400 attempts by young people grades 7-12.
Four out of Five teens who attempt suicide have given clear warning signs.

40. Suicide Facts: Impulsivity of Youth
A study by Swahn and Potter (2011) reported that of the 153 youths who had a medically severe suicide attempt 25 % of the survivors made the decision within 5 mins. and 71% of the survivors made the decision within 1 hour of the thought.
Dr. Bill Geis’ (Zero Suicide Initiative) statistics report that that 33 % of youths age 0-17 made the decision to attempt suicide (any kind of suicide attempt – not just medically lethal) the same day.

41. Suicide Facts: Influences of Media and Social Media
Research continues to demonstrate that vulnerable youth are susceptible to the influence of reports and portrayals of suicide in the mass media.
Reported instances of teens “copying” the method of a reported suicide in the media.
Shows, movies, and even reality t.v. have glamorized family chaos and dysfunction, being “crazy”, and drug/alcohol use
“Screen time” has drastically increased for youth over the past 5-10 years. The average 14 year old spends 4-10 hours a day on their phone, tablet, or computer
Gwenn Schurgin O'Keeffe, MD, Kathleen Clarke-Pearson, MD

42. Suicide Facts: How People Reach Out
New research shows that teens and young adults are frequently using social networking sites and mobile technology to express suicidal thoughts and intentions as well as to reach out for help
Ohio State University Study:
Of 2 million downloaded comments, the researchers narrowed it down to 1,083 that contained suggestions of suicidality, and eventually arrived at 64 posts that were clear discussions of suicide.
Final results of this survey showed that respondents first chose talking to a friend or family member when they were depressed, followed by sending texts, talking on the phone, using instant messaging and posting to a social networking site.
Just song lyrics or really wanting to die?

43. Providing a safe, predictable environment: Good for everyone!
Thoughts for at home:
Providing a safe, predictable environment: Good for everyone!

44. Affecting the Daily Environment
Daily mindfulness
Fun activities
Opposite to Emotion
“Helper” activities like volunteering or otherwise participating in a community in a positive manner
Eat right / Good sleep hygiene
Exercise
Emotional awareness and regulation skills
Family support

45. Mindfulness
Be aware. Notice what is going on in your body and what thoughts are going through your mind.
If your body is tense, take a deep breathe.
If you are having lots of negative thoughts that are not helpful, notice them. Noticing is the first step. Then make a choice if you want to change them to be more in line with your values. (example “Johnny is acting a fool again”  “I am going to take a breathe and ask Johnny if he wants a hug or if he needs to put on his headphones for a few minutes.”)
Take 3 minutes at lunch to do what you need to do; listen to favorite song? Put on favorite lotion? Watch a video of your baby nephew?

46. Affecting the Daily Environment
Know your child’s friends
A child is more likely to talk to a friend than an adult, this is congruent with their developmental stage.
Talk to your child about depression and suicide, make sure he knows you can come to him with his own problems or those of a friend
Have a relationship with your child; put down your phone, stop working, listen
Model healthy behaviors
Provide consistency
Normalize all feelings as well as thoughts of suicide, thinking about suicide is a lot more common than anyone will ever know
Ask specific questions; what made you sad today? What made you happy today?
Be your child’s “Facebook Friend”, don’t censor, be curious

47. Affecting the Daily Environment - Managing Stress
Breathing
Notice very beginnings of starting to feel overwhelmed and coach on what to do.
“Connect now or correct later”, build consistent and caring relationship.
Teach and model self care.
Teach that emotions are ok, it is behavior is what is not ok. If their emotions aren’t ok, then that means that they aren’t ok as human beings and that affects self esteem which only creates more problems.
Patterned, rhythmic activities like walking, dancing, singing and meditative breathing allow a return to a calmer cognitive stated where problem solving and higher-order thinking can occur.
Take breaks
Allow for downtime

48. Affecting the Daily Environment
Work on changing behaviors, not emotions. Emotions are central to our sense of self.
Validate and attune to the emotion -

52. Affecting the Daily Environment - Connect
Sometimes listening to a sad song is just what the person needs.
Attunement - Notice, name, validate and respond.
Notice what is going on.
Name the emotion you think the person is experiencing.
Validate – the emotion is real and valid (even if it seems out of proportion or bizarre to you), the behavior is what is not ok.
Respond - Let the child know what you are going to do or what choices they have to respond.
“I statements” - “I feel ______ when _____________”

53. Affecting the Daily Environment - Connect
Find something to be involved in, feeling connected is one of the most protective things we can do.

54. Attunement and Validation in the movies
file:///C:/watch?v=CN0YORDRNVk&index=9&list=PLip0-Ftvi-pIwt_adxV0JoIhJvvAoEDIZ
Movie: Inside Out provides a very accurate depiction of how the brain works and how minor trauma’s add up to big emotions often exhibiting itself as anger. When does Riley come home and feel better? When she allows her self to feel the really vulnerable emotion of sadness.

55. Affecting the Daily Environment – Building Resiliency
“The roots of resilience… are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other.”
Diana Fosha (Vanderkolk, pg 105)

56. Affecting the Daily Environment – Building Resiliency
Learning how to ask for help.
Developing self esteem.
Develop problem solving skills/model problem solving.
Establishing clear and consistent consequences.
Help them see they have value but giving back to community.
Giving choices
Mastering a skill
Assigning chores and giving responsibility.
A lot of these are about increasing sense of self identity and knowing/feeling that they are important.
Experiencing success.
Learning how to identify and express feelings.
For more go to:
A sense of belonging.
Modeling appropriate behavior.
Learning to accept help.

57. The Environment: The Brain and ACES
Violence and chronic exposure to toxic stress disrupt the process of normal child development. These experiences alter the architecture of the brain in ways that threaten their ability to achieve academic and social competence.
Not just a behavioral or emotional problem, also an academic problem. “… (there is) a relationship between exposure to violence and deficits in children’s language development, memory, attention and locus of control.”

58. The brain

59. “ACES”
Adverse Childhood Experiences - study conducted by Kaiser Permanante in San Diego in the mid-1990’s with Dr. Vincent Felitti heading the study.
Trauma overwhelms a person’s ability to cope
Truama is any incident occurring to a person that is perceived by them to be traumatic

60. Adverse Childhood Experiences Are Common
Abuse:
Psychological 11%
Household dysfunction:
Physical 28%
Substance abuse 27%
Sexual 21%
Parental separation/divorce 23%
Mental illness 17%
Neglect:
Battered mother 13%
Emotional 15%
Criminal behavior 6%
Physical 10%

63. Early intervention & treatment can help!

64. References:
Suicidal Teens Reach Out Through Social Media, Not Suicide Hotlines By Traci Pedersen Associate News Editor Reviewed by John M. Grohol, Psy.D. on July 27, 2013
CyberSafe: Protecting and Empowering Kids in the Digital World of Texting, Gaming and Social Media by Gwenn O’Keeffe, M.D., FAAP
AAP Internet safety resources site,
Suicidal Behavior Among LGBT Youth Fact Sheet: Based on 2010 Data, American Association of Suicidology
Hispanic Suicide Fact Sheet: Based on 2010 Data, American Association of Suicidology
Parent Plus: “Teach children to beware of bullies in the cyber-schoolyard,” March AAP News,
Clinical Report The Impact of Social Media on Children, Adolescents, and Families: Gwenn Schurgin O'Keeffe, MD, Kathleen Clarke-Pearson, MD, Council on Communications and Media

65. References
Bailey, B. (2015). Conscious Discipline: An Online Learning Course. Retrieved from
Brendtro, L. K., Ness, A., & Mitchell, M. (2001). No Disposable Kids. Longmont, CO: Sopris West.
Craig, S. E. (2016). Trauma-Sensitive Schools: Learning Communities Transforming Children’s Lives, K – 5. New York: Teachers College Press.
Holden, M. (2010). Children and Residential Experiences: Creating Conditions for Change. Washington, DC: CWLA Press.
The National Childhood Stress Network. (2005). Trauma-Focused Cognitive Behavior Therapy: An Online Learning Course. Retrieved from
Module 1 and 2 Enhanced Suicide Care: Suicide Screening and Assessment (Youth), Bill Geis, Ph.D
National Child Traumatic Stress Network Children Sexual Abuse Committee (2009). Caring for Kids: What Parents Need to Know About Sexual Abuse. Los Angeles, CA and Durham, NC: National Center for Child Traumatic Stress.
Siegel, D. J. & Bryson, T. P. (2011). The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Mind. New York: Random House.
Souers, K. & Hall, P. (2016). Fostering Resilient Learners: Strategies for Creating a Trauma-Sensitive Classroom. Alexandria, VA: ASCD.
Szalavitz, M. & Perry, B. D. (2010). Born for Love. New York: William Morrow.
Van Der Kolk, B. A. (2014). The Body Keeps Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking.
Wesselmann, D., Schweitzer, C. & Armstrong, S. (2014). Integrative Parenting: Strategies for Raising Children Affected by Attachment Trauma. New York: Norton Professional.