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A physical illness calls the need for medical attention, and our first instincts tell us to seek professional help. On the other hand, mental illness invites a lot of skepticism in looking out for psychiatric help (Thornicroft, 2007). Partly due to a lack of awareness and literacy in society (Thompson et al., 2004), and partly due to the inadequacy of treatment services. Additionally, mental illness carries with it a certain stigma (Barney et al., 2006; Cooper-Patrick et al., 1997; McNair et al., 2002) in that almost always, mental illnesses are stereotyped. This makes it harder for people to talk about their illness, in anticipation of harsh judgments (Henderson, Evans-Lacko, & Thornicroft, 2013). There are different kinds of stigma associated with mental illness and the majority of these originate from mental health professionals and our social community (Crowe & Averett, 2015). For instance, help-seeking stigma is the stigma experienced when looking out for help because of a mental illness (Tucker et al., 2013). Another stigma often related to psychological illness is self-stigma (Corrigan, 2004), which emphasizes the fact that low self-esteem commonly generates negative thoughts leading to depression. Associative stigma and anticipated stigma are also generally involved with mental illness.

Research suggests that stigma revolving around mental health is not the only reason for reluctance to seek psychiatric care. The general belief that depression resolves by itself, even without treatment, has proven to be another potential barrier to professional help-seeking (Ortega & Alegria., 2002; Prins et al., 2002; Sareen et al., 2007; Wells et al., 1994). A direct outcome of these stigmatizing behaviors is that patients rely heavily on the idea that symptoms will curtail over time.

The concept of depression holds multiple psychological, biological, and social factors that are responsible for the outset of the condition as well as its recurrence (Beck, A.T., & Bredemeier, K., 2016). Numerous studies have been conducted on adults explaining their general beliefs about the causes of depression. Research points out that young adults, aged 18 to 22 years generally believe depression could be due to psychological, biological, or social factors (Goldstein, B., & Rosellie, F., 2003) whereas, with an increase in age, the view that depression is a biological illness becomes more common. (Cook, T.M., & Wang, J., 2011). Studies also elaborate on the fact that those who generally attribute depression to a biological basis, tend to be more positive regarding the outcome of the overall illness as opposed to those who believe that the condition is psychologically related (Goldstein, B., & Rosselli, F., 2003; Cook, T.M., & Wang, J., 2011).

The diagnostic norm to identify and define major depressive disorder is essentially the same when used for children, adolescents, and adults. DSM IV and 5 present with a single exception to this. While adult symptoms include depressed, sad mood as the benchmark sign for depression, children/ adolescents often portray irritability as a primary symptom (APA, 2000, 2013). Broadly, depressive symptoms exhibited by adolescents are categorized into vegetative and somatic. Vegetative symptoms in adolescence manifest as a loss of interest in daily activities and a decrease in school performance. These signs are generally highlighted by a contentious attitude, making social relations difficult. More commonly observed in depressed adolescents, are appetite changes leading to weight fluctuations, along with fatigue and sleep disturbances such as insomnia (Goodyear and Cooper, 1993; Nardi et al., 2013; Roberts et al., 1995; Ryan et al., 1987). Somatic symptoms are generally the ones that refer to any physical complaints like headaches and musculoskeletal pains (McCauley et al., 1991; Nardi et al., 2013; Ryan et al., 1987). Chronic stress or anxiety, which is one of the main factors that initiate mental disorders (including depression), often precipitates physical symptoms that require medical care (O’Neill, M., 2015). The unique mind-brain-body interaction emphasizes that an illness in the mind might negatively influence the physiology of the brain and body (Glannon, W., 2002).

Glennon (2002) suggests that chronic depression may be attributed to a psycho-neuro-immunologic cause, inclusive of one psychological and three physiological aspects. These are psychological, neurological, immunological, and endocrinal facets. Normally, a threatening situation in our environment stimulates several parts of our brain, including the hypothalamus-pituitary-adrenal (HPA) axis, the Sympathetic Nervous System (SNS), and our endocrine system. When this anxiety-producing situation regresses, the body generates a feedback mechanism that shuts down all machinery active in a state of panic. The amygdala present in our limbic system regulates emotions. In the event of a stressor, the activated amygdala further stimulates the SNS and the hypothalamus. Our SNS prepares the body for a fight or flight response. Simultaneously, when the hypothalamus is triggered, cortisol secretion is promoted from the adrenal glands. This is the hypothalamic-pituitary-adrenal (HPA) axis. Now the body is said to be prepared for a complete physiologic stress response (Conlan, 1999, McEwen, 1999; Sternberg, 1999, 2000; LeDoux, 1996, 1999). Once the stressor recedes, the counteractive Parasympathetic Nervous System (PNS) gets activated, which negates the actions of the SNS. This calms the body down. These body responses are said to be adaptive to the situation, that aid the survival of the being.

Biologically speaking, adolescent depression is believed to be caused due to a disturbance in the hypothalamus-pituitary-adrenal (HPA) axis, and abnormal amounts of serotonin and growth hormones (Goodyer, 1999; Goodyer et al., 1996). More specifically, a decrease in serotonin production is considered the primary etiology for the development of depression in pediatric patients (Goodyer, 1999; Goodyer, Herbert, Tamplin & Altham, 2000). The fourth facet of the depression model Glennon (2002) talks about, is mind, which is the only aspect that deals with the real world. As a sensory processing system, our mind is shown to apply constraints on the three organ systems, thus controlling the adaptive stress response. When this regulation is lost, bodily response to stress remains active, and an increase in negative thoughts and emotions is experienced, which is considered to be the key symptom of depression. This highlights the role of the psychological condition of the patient and the crucial part played by it in the development of depression in adolescents.

The DSM-5 describes a unified category for Dysthymic disorder and chronic major depression, called Persistent Depressive Disorder. Dysthymic disorder is generally considered a mild form of chronic depression, but studies have pointed out that a lot of patients suffering from the condition do experience episodes of chronic major depression (Keller, M.B., et al, 2000). Depression is often considered a debilitating and chronic disorder, that presents early in life, usually initiating in childhood or adolescence (Stevanovic, D., Jancic, J. & Lakic, A., 2011). Mental disorders are considered one of the leading causes of disability worldwide (Baxter et al., 2014), and adolescent age, especially, is considered a high-risk category for the establishment of major depressive disorder. Generally, depression is often associated with detrimental future health effects and adverse consequences (Naicker et al., 2013). In addition to social withdrawal and a generally foul mood, children who experience an episode of severe depression in their early years are usually at an increased risk of developing suicidal tendencies (Windfuhr, K. et al, 2008; Hawton, K., & van Heeringen, K., 2009). According to Weissman, Wolk & Goldstein (1999), the risk of a suicide attempt increases five times for a depressed adolescent, while the possibility of recurrence increases twofold. Evidence also hints at the fact that there is an elevated risk for the development of depression in somebody who has experienced a similar episode by 19 years of age (Lweinsohn, P.M., Rhode, P., Klein, D.N., & Seeley, J.R., 1999).

While depression in adults is a reason for concern, it is evident that often, the illness is an outcome of a similar experience in the early years of life. Research also suggests that chronic depression is one of the most common psychological disorders in adolescents (Baxter et al., 2014). This alarming fact makes it clear why it is essential to study and investigate its reasons as well as determine the most efficient way to treat the condition.

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The most common treatment modalities studied by multiple randomized control trials are psychotherapy (“control behavior therapy”- CBT and interpersonal therapy) and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) (Bridge, J.A. et al, 2007; Weisz, J.R., McCarthy, C.A., Valeri, S.M., 2006).

Several SSRIs are available for the treatment of depression in adolescents but, Fluoxetine has been found to be the most effective in treating depression (TADS Team, 2004; Emslie, G.J., Rush, A.J., Weinberg, W.A., Kowatch, R.A., Hughes, C.W., Carmody, T., Rintelmann, J. 1997; Emslie, G.J. et al, 2002). It is the only US Food and Drug Administration-approved medication used for the treatment of depression in adolescents. In addition to SSRIs, several other drug categories are employed for the treatment of depression including tricyclic antidepressants (TCAs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase (MAOA) inhibitors. However, due to their increased side effects and limited research on the efficacy of the drugs, they are not used as the primary tools for the treatment of depression in adolescents.

According to Brock, K., Nguyen, B., Liu, N., Watkins, M., and Reutzel, T. (2005), the treatment of depression includes a multi-specialty approach. Mild cases of depression, which are mostly caused by stressful life experiences can be successfully treated by CBT. More severe cases of depression require the intervention of drugs. The rationale behind this is that depression often involves a decrease in the neurotransmitter serotonin in the brain. Selective serotonin reuptake inhibitors (SSRIs) thus aid in an increase in the amount of serotonin in the body and are considered the first line of treatment for severe depression. Fluoxetine shows high efficacy and fewer side effects, presenting this category of the drug to be the choice of treatment for depression (DeVane & Sallee, 1996; Kutcher, 1997; Leonard et al., 1997; Preskorn, 1994).

Although SSRIs are considered the first-line treatment for depression, there have not been enough studies to prove their superiority to psychotherapy. Debate on the effectiveness of medications has been going on for a while now and although the use of SSRIs has recently increased for the treatment of depression, the risk associated with it has also been highlighted significantly. An increased risk of suicide attempts has led regulation authorities to broadcast safety instructions and dangers associated with the consumption of SSRIs. A few countries, like the United Kingdom, have exercised a law that labels SSRIs “contraindicated” for pediatric patients. A recent meta-analysis has also highlighted the increased risk of side effects associated with drug therapy (Le Noury et al., 2015). The most common side effect that generates concern is tolerance. Other adverse effects include gastrointestinal distress (appetite fluctuations, stomach aches, nausea, etc.) and nervous system disturbances such as headaches, tremors, agitation, restlessness, etc. SSRIs have also been found to trigger manic episodes in children aged 10-14 years (Martin et al., 2004; Shaffer et al., 2002). Studies have shown that SSRIs may sometimes cause allergic reactions and hyponatremia (Cheung et al., 2005; Kandil, Aksu & Ozyavuz, 2004; Ryan, 2005; Shaffer et al., 2002) in patients as well. Furthermore, meta-analyses have now indicated that the effect size as observed when treating an individual using pharmacotherapy decreases with increasing severity (Weersing, V.R., Jeffreys, M., Do, M.C.T., Schwartz, K.T.G., Baleno, C., 2017). This difference in treatment effects could possibly be due to varying methodological factors like sample size or responses in the control group etc. (Bridge, et al., 2007).

This data has shifted the attention of researchers toward finding better psychotherapy modalities for the treatment of depression. In lieu of that, three meta-analyses have been published, that bring forth surprising facts about psychotherapy in depression. The first one was conducted by Reinecke, Ryan, and DuBois (1998a). This study examined six adolescent patients, all undergoing CBT. The beneficial effects of the treatment were recorded and an effect size of 1.02 was generated which is interpreted to be significant. The second meta-analysis, also focused on the effects of CBT in depressed adolescents, generating an effect size of 1.27 (Lewinsohn & Clarke, 1999). This study was based on twelve comparison studies. Another meta-analysis conducted by Micheal and Crowley (2002) studied the overall effects of psychotherapy in depressed adolescents. This study placed no restriction on the kind of psychotherapy used and produced an effect size of 0.72, with a sample of fourteen controlled trials. The high effect sizes across these three meta-analyses hints that psychotherapy is a superior treatment choice as opposed to drug therapy. Another major modality of treatment employed for depression in adolescents is cognitive behavior therapy (CBT). As stated by Weersing & Gonzalez, the most favored treatment option used for youth depression is CBT, with evidence pointing it to be the most successfully researched modality available. Broadly, the treatment plan for an adult does not vary greatly as compared to that of an adolescent. The major difference is that a more collective, engaging, and interactive plan of treatment is followed for an adolescent patient.

According to Corcoran, J., & Hanvey-Phillips, J., (2008), psychotherapy intervention focuses on two major aspects of treatment: The behavioral model and the Cognitive model. The behavioral model involves practicing reinforcement strategies and motivating coping behaviors in youth while the cognitive model aids in modifying negative or distorted behaviors that are the key features of depression. The combination of these models gives way to a Cognitive-Behavioral Model that is inclusive of treatment plans utilized in each individual model. For instance, the combined intervention model trains adolescents on how to effectively communicate socially along with daily activities that are intended to improve their mood. These activities, in the long run, aid in the reorganization of negative thoughts into more productive ones.

The meta-analysis conducted by Weisz, J.R., McCarty, C.C., and Valeri, S.M. (2006) suggests that depression in adolescents has become a critical health concern, and it interferes with operational social, family, and school life. Additionally, depressive symptoms in adolescents also give way to the development of further medical illness in the later years of their lives including, but not restricted to, psychiatric disorders. Research points out that recurrence of depression is very common in individuals who have experienced at least one major depressive episode during their adolescence (Klein, Dougherty, & Olino, 2005). This calls for the need for further research in using psychotherapy for depression in adolescents. The fact that pharmacotherapy generally presents with side effects, the studies suggest that the treatment of depression could be efficient by using CBT alone. This involves behavior modification and daily positive reinforcing activities. Additionally, early intervention in cases of depression could indeed be helpful in avoidance of the condition in adulthood.

Adolescent depression is also known to increase the risk of suicide attempts and completed suicides. (Cottrell et al., 2002; Waslick, Kandel, & Kakouros, 2002). One way to tackle this growing problem of depression is adequate training for school social workers, parents, and school staff to successfully identify signs of depression in teenagers and to provide appropriate counseling and referrals (Corcoran, J., & Hanvey-Phillips, J., 2008)

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