To respond to the many requests we have received for Group Therapy services, Thrive Boston Counseling now offers Therapy groups for a variety of life issues, including:

• Women’s Issues Boston Therapy Group (and Cambridge Therapy Group)
• Men’s Issues Boston Therapy Group (and Cambridge Therapy Group)
• Sexual / Pornography Addiction Boston Therapy Group (and Cambridge Therapy Group)
• Substance Abuse Boston Therapy Group (and Cambridge Therapy Group)
• Parenting Skills Boston Therapy Group (and Cambridge Therapy Group)

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During these difficult financial times, many persons are experiencing higher levels or stress, worry, and anxiety. The following five (5) anxiety reducing tips could help you overcoming stress and live a better life, even if your financial budget is in “crisis.”

1)     STAY CONNECTED. We often withdraw when we become stressed or depressed. Instead, turn to your social support – Be around friends and family – Don’t isolate. Let those close to you help you through the hard times.

2)     GET OUT OF YOUR MIND. It is good to Be concerned about finances, but worrying all the time is not helpful. Schedule a specific time to worry–20 minutes a day. If you find yourself worrying outside that designated time, tell yourself “I’ve scheduled a time for this.” Then, immediately refocus on something else. The human mind is bad at focusing on more than one thing at a time, so focus on something good.

3)     DON’T LIE TO YOURSELF. When we experience an upsetting event, such as losing a job, we can (and often do) make things worse by telling ourselves destructive lies. For example,

a.       -I’m not valuable *

b.      -no one will ever hire me again*

c.       -my life is going down the toilet*

The truth to the situation is rarely so negative, and can even be positive. True statements may be:

d.      -I will find another job*

e.      -I have friends and family that care about me*

f.        -my value is not based solely on their work*

4)      BEST FRIEND TEST. We are often harder on ourselves than we are with anyone else. Sometimes I have my clients ask themselves “if my best friend was in the same situation, would I want them to feel this way? What advice would I give to my best friend?” Then I have them take that advice.

5)     EXERCISE. Tried and true, exercise is a great stress reducer.

6)     TAKE CONTROL. Anxiety often shows up when we feel helpless. Show yourself you’re not helpless by doing things that will help. For example, write a budget, go to a job fair, cancel your magazine subscription, organize your files, CHANGE SPENDING HABITS, update your resume. Even if times are still tough, you can tell yourself “I am doing the things within my control to better the situation.”

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Dear Reader,

This is Dr. Anthony Centore, with Thrive Boston Counseling. I was just asked to write a couple short ideas on how to create / promote happiness in life, for potential publication somewhere (I don’t even know where). Anyway, as I send the quotes out into the ether of the publication world, I thought I would also share them with you here. I hope they are helpful! 

Be Well,

Anthony

Happiness Quote 1:

Many persons trade immediate happiness for future pain (example:  charging something you can’t afford to a credit card). Other people are professionals at delaying gratification, trading current pain at the hope of future happiness (example: working 50-plus hours a week). One key to happiness is to discover things that make you happy now, and will also promote happiness later.

Happiness Quote 2:

Happiness is often about having perspective. When something is not going well in life, the happy person will say, “I lost my job. However, I still have my heath, my family, the ability to live a full life, and I will find a new job.”

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How are parents to react to this? Is laughter good therapy? Or is this a serious oversight by the school district. 

According to sources, toll free numbers are often bought in bulk, and advertisements containing “adult content” are not uncommon. Hence, an expired toll free number could easily become connected to a service that provides “adult content.”

News article: http://www1.whdh.com/news/articles/local/BO101807/

**

Anthony Centore Ph.D. is Founder of, and Therapist at, Thrive Counseling LLC

Boston Counseling

Seattle Counseling

Philadelphia Counseling

Atlanta Counseling 

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Many research studies, including the June 14 issue of The Archives of Internal Medicine, indicate that elderly persons are at a higher suicide risk than other age groups.

Suicide currently ranks the 11th leading cause of death.

A link to the recent news article is here: http://www.msnbc.msn.com/id/28704127/

**

Anthony Centore Ph.D. is Founder of eCounseling.com and Thrive Counseling LLC

Boston Counseling

Seattle Counseling

Philadelphia Counseling

Atlanta Counseling
 

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PORTRAITS

Nicole got extremely drunk at a party and made a fool of herself in front of her entire high school.  She left the party, humiliated, and began thinking about each of the other stupid things she had done lately.  When she saw the glow of headlights coming up behind her, she decided to run out into the middle of the road.

Tony had severe diabetes and his only hope was to have his leg amputated.  The day before the surgery, he wrote a note to his family and overdosed on his pain medications.

Carly drove off of a bridge two days before her college graduation.  Not long after, her parents found out that she had failed all of her classes and was told that she would not be able to graduate.

DEFINITIONS & KEY THOUGHTS

Suicide is the tragic and fatal culmination of a psychological process caused by unresolved events that lead to hopelessness and depression.

An individual who is considering suicide in unable to see any hope that their future will be any better than their painful past of present.

The risk of suicide is highest within a year after a failed attempt.

One the norm, males are prone to utilizing more violent means for suicide than females, and are often more successful.  Females, on the other hand, seem to attempt suicide more often, but are less successful than males because they tend to utilize less lethal means. 

It has been found that suicide often goes hand in hand with substance abuse seeing as substances are connected to twenty to fifty percent of all suicides.

Those who are more at risk for suicide include those who have recently begun taking antidepressants, and those with subsiding depression. 

Suicidal individuals often do not see any option other than death.  They do not see the big picture and wholeheartedly believe that suicide is a reasonable thing to do.

Note: Any threat of suicide should always be taken seriously.

ACTION STEPS

1. Get help immediately. Protecting the life of a suicidal individual is the most important priority.  One should not worry about embarrassing the individual by calling for help from the police or paramedics if that individual has a plan or the means to commit suicide.  Do not attempt to transport a suicidal individual to the hospital on your own- it is far too dangerous.  If the suicidal individual is under the influence of alcohol or drugs, arrange for them to be under constant supervision while they are detoxing or sobering up.  If the individual is no longer suicidal once sober, they should be encouraged to seek substance abuse treatment. 
2. Follow up.  Check-in with the suicidal individual often after their attempt.  If their thoughts are not improving, encourage them to seek further help.

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• Forgiveness is giving up your right to hurt someone who has hurt you.

• Forgiveness does not diminish the wrong done against you.

• Forgiveness is not a denial of what happened.

• Forgiveness does not take away the consequences the other person will face because of his or her actions.

• Forgiveness is an act and a process. Even when a person decides to forgive another person, feelings of relief or healing are usually not immediate. Forgiving someone can be difficult and uncomfortable.

• Forgiveness is not weakness. It is the most powerful thing you can do. It breaks the hold that has been put on your life. Refusing to forgive allows the person or thing that was hurtful to you continue to hurt you.

• Forgiveness does not mean forgetting. Forgiveness does not require you to become a “doormat.”

• Forgiveness does not require you to open yourself up to the offender to be hurt again.

• Forgiveness does not wait for the offender to apologize or earn forgiveness in some way.

ACTION STEPS TO FORGIVENESS

1. Acknowledge the Hurt

• Don’t minimize it or deny the wrong that was done against you.
• Don’t make excuses for the offender.
• Write it down. Journaling is a great way to work through anger and hurt. It organizes your thoughts and helps you acknowledge the truth as you see it in black and white. Sometimes writing a letter to the offender is helpful (this letter is usually not to be sent, but is for working through your own thoughts and feelings).

2. Identify Your Emotions

• When someone does something to hurt you, you might experience regret and anger. These emotions are not wrong, but are a normal response to an offense.
• It is important to identify how the offense made you feel and then to express it. After writing down the offense, write down how you felt when the offense happened and how you have felt since then.

3. Cancel the Debt

• Write a “blank check” of forgiveness.
• You may want to write down the offenses they have done and then write “Canceled” or “Paid in Full” over them. You may want to burn the letter you wrote expressing your grief and hurt.

4. Set Boundaries

• Decide what you need to do to protect yourself from letting this person hurt you again. For instance, if someone is offensive to you verbally, you can choose not to associate with them, or tell them that if they begin to insult you that you will not talk to them until they are willing to speak kindly.
• Don’t continue to look for approval from a person who has hurt you.

5. Make a Commitment to Forgive

• Make a personal or (if possible) public commitment to forgive the person for what they have done.
• Commit to not using the thing they have done against you as a weapon against them.
• When you have doubts about whether you “really” forgave the person, remember the commitment you made to forgive. Remember that forgiveness is a choice, not a feeling.

If you are struggling to forgive an offense that was done against you, you are not alone. Forgiving can be an extremely difficult process. The thing about unforgiveness, it will hurt you more than it hurt the person who has wronged you. Some persons have found counseling to be helpful in the process of forgiving and moving on with one’s life. Thrive Boston Counseling and Psychotherapy has Licensed Professional Counselors, Doctoral-Level expert therapists, who can help you find forgiveness, and move on with your life in a healthy, and positive way. Thrive Boston Counseling – 617-513-5433

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I don’t think Bill Cosby is necessarily a lonely guy, but I remember a scene from the Cosby Show where he tells Trudy (his youngest daughter) he wants to be alone.

“But won’t you be lonely?” Trudy asks.

Not likely. The 30 minutes of alone time Bill wanted (and never got) would not have brought him to a place of loneliness, but looking around it seems many people today have asked for alone time—if not by our words by choices—too often. And the result is a feeling of darkness that’s hard to describe with words alone (no pun intended).

Loneliness involves a deep sense of isolation and disconnection from others, and it occurs when persons feel that they have no one with whom to share the joys and hardships of life. Some have stated that their loneliness feels less like sadness and more like an imprisonment that leaves them despondent toward life (I suppose that is why solitary confinement is such a severe punishment).

Statistics to prove my point

While everyone can benefit from some amount of alone time, a healthy and fulfilling life needs close interpersonal relationships. Unfortunately, people today feel more isolated that ever. The average family unit is severely fractured, the divorce rate is at almost 50%, and more people live alone today than ever before in American history.

In my counseling practice (thriveboston.com), more than half of the clients who solicit therapy—no matter what their presenting problem (depression, addiction, anxiety, sexual issues)—are also presenting a severe lack of interpersonal relationships. In direct response to their loneliness, many feel cynical and depressed; they lack confidence, feel rejected, feel alienated, and feel inadequate to build meaningful relationships.

Some time ago I began asking myself, “why are the majority of my clients—many who are young, attractive, intelligent, even well-to-do—profoundly disconnected from others?” I have identified several reasons, and in doing so have identified a number of strategies for overcoming isolation and building those important relationships, that I have found helpful. My clients and I refer to the process as “refilling the inner circle,” and we have specific criteria (identified at the end of this article) a relationship must meet to be considered part of one’s inner circle.

Let’s begin by looking at why persons today are so isolated.

Our society is Primed for Isolation

It is easy, even in vogue, to blame society for our problems. And while I am going to go ahead and say that society is a major part of the loneliness problem, I would also like to remind everyone (including myself) that society is not some tyrannous robotic that operates our lives. Our society is each one of us. We are the society we blame.

So how is our society (meaning all of us) affecting the number of relationship-starved clients pouring into Thrive Boston Counseling? Harvard professor Daniel Gilbert points out that people today have to answer three major life-questions that their parents, grandparents, and great grandparents didn’t answer. Those questions are: 1) Where to live, 2) What to do, and, 3) Who to do it with.[i]

Less than a century ago most people were born, raised, lived, and died in one community. They did the job their parents did. They would build friendships in grade school and at church, and then keep those friends for the duration of their lives. They wed early, and had several children in their early 20s. Making new friends and families was not an issue. They lived and died surrounded by their kith and kin.

However, today it is the norm to leave one’s family and friends behind as we pursue our educational and vocational goals. First we leave for college, where we usually build new friendships. However, those don’t last either, because when undergrad ends we move again—a series of times in our 20s and 30s. Each time we travel alone, leaving old relationships behind (physically). We need to reconnect and establish new relationships at every juncture. All the while, we are more focused on our education or career than we are personal relationships, so the task of making friends is always at the bottom of the to-do-list. And nothing at the bottom of the to-do-list ever gets done.

The result:Many of us have no close friends, we are unmarried, and we live lives that feel (to our unfortunate surprise) empty and bleak.

Community is a Dirty Word

Community and Family are becoming foreign (even dirty) words. We place a low value on “community” because we don’t really understand what community is anymore. Many of us, when we think about community, envision a small town with cantankerous old couples walking down the street, sheriffs with big hats, corner stores that close at 6pm (and all day Sunday), and one-dimensional suburban nuclear families. This image of community has little that interests us, and even less to offer. It makes us feel all the more disconnected. Thankfully it is a lie.

Strategy One: Redefine Community.

Community is what you want it to be. Community means joining a kickball team. Community means being surrounded by friends who love you, who you respect, and who you want to share your life with. For many of us, an acceptable community looks more like “dorm life” than a Norman Rockwell painting. Community is having three friends who show up at your place at 8 in the morning, with coffee. Community is having those same friends knock on your door as 5pm on a Thursday to pull you away from the computer. The corner store in your community is open 24 hours a day, even on Christmas.

Strategy 2: Kill Your TV (It is mocking you)

Here is a short list of hit shows: Grey’s Anatomy, Scrubs, Friends (ok Friends is a bit old), Lost, Laguna Beach, and The OC.

Why are these shows so popular? Or, better put, what do all these shows have in common? Answer: Every hit show on this list displays profoundly close relationships that most of us don’t have in our lives. The Grey’s Anatomy cast lives together, the Lost cast is lost together, and do you remember that episode of Scrubs where three of Dr. Cox’s patients died?—his colleagues took shifts sitting with him in his apartment, as he drank himself silly.

I am willing to bet that more than the lavish lifestyle, the beach, the adventure, or the interesting job, what draws us to these shows are the close relationships between the characters. The TV mocks us, because we miss this truth all the time. We watch Grey’s and think we want to be a doctor. All we really want is to live in a big old house with six close friends.

Kill your TV. Move into a house with six close friends. You will miss two seasons of your favorite show and not even notice.

Strategy 3: Things are the red herring.

In the video game “The Sims” the players controls the actions of an average person (a “sim”), living a normal life. You start with a basic house, and help your sim to get a job, build friendships, and buy stuff. Buying stuff is a lot of fun. There are hundreds of items from work out centers to flat screen TVs to modern art you can buy for your sim, that can make his/her life more enjoyable.

The creator of the video game “The Sims” was once interviewed, and questioned about the materialism about the game. The items are a “Red Herring,” he explained. The way to win the game—to have a happy sim—is has nothing to do with the items. A happy sim has strong relationships with the other characters in the game.[ii]

The same mistake players of the Sims make we make in our real lives. We work 50-plus hour a week to buy things we think we want, or to live in lavish spaces we can hardly afford. All the while we would be happier sitting on milk crates with a group of close friends. A house full of nice things but without friends is hell.

Here is the secret to personal success: People, not stuff. Community, not career.

Step 4: Explore people, not places

Not long ago I was listening to a lecture by a Stanford Professor who spoke about a research study that investigated people’s priorities. Here’s how the study worked: Participants of different ages were shown two different marketing campaigns. One of the campaigns appealed to the person’s desire for learning and adventure; the title read something to the tune of “Explore and learn from far off places.” The second campaign appealed to the person’s desire for relationships. The title read something similar to “Build relationships with those you care about.” Which marketing campaign do you think people preferred? It depended on age.

The younger participants chose adventure, and the older participants chose relationships. The older people are wiser, right? Maybe not. When the older participants were first asked to imagine that a drug had hit the market that was guaranteed to extend their life by several decades, they also chose adventure and learning.

I found this interesting, and then saddening. Not because I don’t like exploration —but because adventure and learning without relationships is hell. The participants were continually prioritizing something that would ultimately make them less happy (Interestingly, it was only the idea of death that led them to prioritize what was of real value).

A client of mine, let’s call him Doug, is profoundly unhappy (and lonely). His solution is to leave the ivory tower of Harvard and move to Florida. There he would buy a jet ski, and a satellite dish. He would build computers and fix four wheelers. “Not bad!” I tell him, “Close your eyes and imagine being there. Imagine being there for two days alone. How happy are you?” As we explore the idea he begins to see, after only an hour on the Jet Ski he would be bored, wanting to talk to someone.

The idea of the lonely traveler seems romantic. But when you are that traveler, you don’t care so much about the museums after a few days. You watch people on the street. Friends laughing, and lovers holding hands. Soon you are on your cell phone, making oversees calls to connect to the people you thought you didn’t need.

Here is the secret to personal success: People, not places.

Strategy 5: Pay the Price

Every choice we make costs a price. The choice to build a support system is no different. It takes an investment of time and resources. You are going to need to put some margin into your schedule if you are going to be successful in building relationship. You might need to work as hard for relationships as you do at your career. Warning: this could slow your business, career, and even your money making potential. It can also increase your life satisfaction exponentially.So consider—what are relationships worth? How much money would it take for you to live a life of solitude (I am hoping there is no sum high enough)?

I know someone who recently left a lucrative position to be with friends in another state. Society might scoff at this, but she if happier now than she has been in years.

Strategy 6: More confidence, more skills

This strategy could be a book.

One reason persons remain in solitude is that they have been alone for so long they begin to think that others will not understand them, others will reject them, or they think they are not able to build and maintain close relationships.

First, I communicate to my clients at ThriveBoston is that they have nothing to lose, and the world to gain, when they try to build relationships. I also remind them that other people—when it comes to building relationships—might feel as disconnected and worried as they do. I counter the idea that no one will understand them by telling them the truth that I talk to people all day that are feeling and saying the same exact thing they are!

If they say they are not “a person who can just go up to someone and talk to them,” I remind them that there is no such thing as talent[iii] and that practice and experience is the only way to become “a person who can just go up to someone and talk to them.”

Strategy 7: Make sure they are in the inner circle

Earlier in this article I wrote that my clients and I have specific criteria for whether a person is in their inner circle. There are three criteria any relationship must meet.

1)You must interact with the person outside of the venue in which you met them. For example, if you meet someone at the gym/coffee shop/a friend’s house, the person cannot be considered part of your inner circle unless you arrange to meet the person somewhere else.

2)You must have spent time with the person for the sole purpose of spending time together. Having friends who you play basketball with does not count as having “inner circle” friends—the focus is on having a good game of basketball, not on building relationship. I ask my clients, “Have you gotten together with the person to just ‘hang out?’ Have you gone to get coffee or a meal with this person? Have you gotten together just to ‘Catch up?’”

3)You must meet with this person one-on-one, and be willing to share both the joys and hardships of life with the person. Does the person go to you with his/her triumphs and problems? Do you do go to him/her with your triumphs and problems? Do you trust the person to keep a confidence? Does he/she trust you to keep confidence?

The Isolation Epidemic is real. It is treatable, but only with significant lifestyle changes. For many, the cure is not easy, but it is always worthwhile. All the strategies I wrote here can be summarized with this sentence: Put more effort into interpersonal connections than you do anything else in your life. This is a radical idea, but it is an idea that can change your life for the better.

Anthony Centore Ph.D. is a counselor, psychotherapist, and life coach serving Cambridge, MA and the greater Boston area. For clients at a distance, Anthony also provides services by telephone and email. Visit thriveboston.com to learn more, call 617-513-5433 to schedule a session, or email thriveboston@gmail.com.

This article may be reprinted if it is unaltered, and the author’s contact information remains included.

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Abstract
Depression is very common in adolescence and if not treated properly it can produce long-term negative consequences, such as alcohol and drug abuse, criminal behavior, and even suicide.  It is imperative that parents, educators, mental health workers, and the entire society better understand the signs, symptoms, risk factors, and behavior problems associated with depression in adolescence.  This paper attempts to provide society with a better understanding of adolescent depression by reviewing the current literature on adolescent depression. This paper defines depression and reviews its symptoms, as well as the genetic, environmental, and social influences of adolescent depression. It also examines gender and racial differences among adolescents with depression and examines treatment options available to depressed adolescents.

Introduction
Everyone has most likely experienced a sad mood at one time or another in their lives.  A short period of sadness is not uncommon as humans struggle with the pressures of every day life, such as financial, marital, and job difficulties.  Raising children and taking care of aging parents add to the increase in people’s sometimes sad moods.  However, it is depression that is of significant concern in our society, today.  Many adults experience depression which can result in significant health consequences and even death from suicide.  Furthermore, depression is one of the most common disorders that occur among adolescents. Depression affects 5 to 8 percent of adolescents (Son, 2000).  Depression can have devastating effects on adolescents.  Research indicates that depressed adolescents are at risk for increased illness, low academic performance, difficult family and peer relations, substance abuse, and delinquent behavior (Allen-Meares, Colarossi, Oyserman, & DeRoos, 2003).  Also, depression is often associated with suicide among adolescents and suicide is the third leading cause of death for youth ages 15-24 (McCarthy, Downes, & Sherman, 2008).  The dangers associated with adolescent depression are evidence that recognizing, understanding, and treating adolescent depression are extremely important.  However, while adolescent depression is common it is difficult to recognize.  It is imperative that society, especially parents, educators, and mental health professionals understand what adolescent depression is, recognize its symptoms and its causes, as well as recognize the effects depression has on adolescents and the options available in treating adolescent depression.

What is Adolescent Depression?
Depression is an emotional state that involves feelings of great sadness, worthlessness, and guilt. The Diagnostic and Statistical Manual of Mental Health Disorders (4th ed., text revised) (DSM-IV-TR) requires that five out of nine symptoms must be present for at least two
weeks for a diagnosis of depression to be given.  These nine symptoms include a sad, depressed mood most of the day, for most days, loss of interest and pleasure in regular activities, difficulties sleeping, lethargy or agitation, loss or increase in weight and appetite, loss of energy, negative self-concept and feelings of worthless and guilt, difficulty concentrating, and recurrent thoughts of death or suicide.  The symptoms of either depressed mood, or loss of interest and pleasure must be one of the five symptoms for a depression diagnosis to be made.  Other symptoms include low self-esteem, and somatic complaints.  Depression is a recurrent disorder and has increased steadily over the last fifty years, especially among adolescents (Davison & Neale, 2001).  Within two years, 40% of individuals will experience another depressive episode and within five years 72% will have a recurrent episode. While the DSM-IV-TR diagnosis does not differentiate between adolescents and adults, the symptoms are the same for adolescents for the most part.  The requirement of depressed mood most of the day does specifically mention that this mood can appear as an irritable mood among the adolescent population.  Adolescents experience more symptoms of somatic complaints, social withdrawal, and irritability rather than a sad mood.  Symptoms of depression can also be different for adolescents of different ages.  Younger adolescents may have symptoms of anxiety manifested in clinging behaviors, fearfulness, and physical complaints.  Furthermore, research indicates that 89% of depressed
adolescents usually show signs of sleep difficulty while 79.5% show appetite and weight disturbances (McCarthy, Downes, & Sherman, 2008).

Risk Factors of Adolescent Depression
It is just as important to understand the risk factors of adolescent depression as it is to recognize the symptoms of it.  Young people can become depressed for many reasons.  Biomedical risk factors are associated with adolescent depression.  This includes a genetic
predisposition to depression.  Parental depression or a family history of depression increases the risk that adolescents will also develop depression.  Adolescents with chronic illnesses such as diabetes, asthma, or heart disease are also at risk for depression.  Another biomedical risk factor is puberty.  The hormonal changes during puberty can bring about a depressive episode.  Furthermore, girls are twice as likely to experience depression as boys.  Using certain drugs such as birth control pills and Acutane for acne has been found to cause adolescent depression, also (Bhatia & Bhatia, 2007).
There are also psychosocial factors that put adolescents at risk for getting depression.  Childhood neglect or abuse is one such psychosocial factor.  Adolescents who experience physical, emotional, or sexual abuse are at a higher risk for developing depression (Bhatia & Bhatia, 2007).  For example, one study by Buzi, Wienman, and Smith reveals that sexual abuse is a significant factor is predicting depression.  In this study, adolescents were recruited from teen clinics in the Southwest part of the United States that provide free family planning and reproductive health services to adolescents. Each participant was given a questionnaire that combined several measures from other adolescent risk-behavior surveys.  The Reynolds Adolescent Depression Scale (RADS) was used to measure depression symptoms. Two hundred seventy-nine females participated in the study.  Forty of the adolescents reported a history of sexual abuse.  Forty of the participants scored at or above a raw score of 77 on the RADS which indicates that these adolescents should be evaluated further for depression. This study suggests that sexual abuse is a significant factor is predicting depression (Busi, Weinman, & Smith, 2007).  Other psychosocial factors that influence adolescent depression include stressors such as peer pressure, low academic performance, and poverty.  Adolescents who experience the loss of a loved one, or have difficult parental or romantic relationships are also at greater risk for depression (Bhatia & Bhatia, 2007).  In addition, depressed parents can influence depression in adolescents.  Furthermore, adolescents with parents who abuse alcohol or controlled substances are at a higher risk for developing depression (Feldman, 2008).  Parental attachment during childhood and adolescence may also play a role in adolescent depression.  A study by Maria Cristina Richaud De Minzi examines this notion.  Richaud De Minzi examined whether there are differences in the influence of attachment and parent-child relationships on depression, along with other areas.   The study examined 1,019 children in elementary schools in Buenos Aires.  Each child was tested using the Argentine Scale of Perception of the Relationships with Parents, the Kern’s Security Scale, the Self-Perception Profile for Children, the Dimensions of Depression Profile for Children and Adolescents, and the Louvian Loneliness Scale for Children and Adolescents.  Results indicated that parents’ acceptance promotes secure attachment and positive outcomes in children and helps protect them from depression (Richaud De Minzi, 2006). Other psychosocial factors that influence adolescent depression include adolescents who feel unpopular, have few close friends, experience rejection, have to move to another place to live, and change to a new school.(Son, 2000).

Cognitive factors also influence adolescent depression.  Negative thinking and low self-esteem can contribute to depression in adolescents.  Depressed individuals see themselves as worthless, and undesirable.  They also tend to view all of their experiences in negative ways.  Adolescents who view themselves, others, and their future negatively tend to be depressed. Charoensuk conducted a study of 812 Thailand students.  Charoesnuk administered several questionnaires to test parental bonding, everyday stressors, depressive symptoms, negative thinking, and self-esteem.  Negative thinking was assessed using the Crandell Cognitions Inventory and self-esteem was measured using the Rosenburg Self-Esteem Scale. 

The results
concluded that among all factors tested, negative thinking was the strongest predictor of depressive symptoms.  Self-esteem was also a predictor of depressive symptoms, but this was only the case when negative thinking was a strong factor.  Thus, without negative thinking, self-esteem would not be much of an issue in influencing depression (Charoensuk, 2007).
Other factors have been shown to increase the risk of depression.  Adolescents who have a history of depression, or smoke are more likely to experience depressive symptoms.  In addition, some psychological disorders such as Anxiety Disorder and Attention-Deficit Hyperactivity Disorder, or conduct and learning disorders influence adolescent depression as well (Bhatia & Bhatia, 2007).
Effects of Depression on Adolescents
It is difficult if not impossible to prevent adolescent depression resulting from heredity, or environmental influences like physical or sexual abuse.  However, knowledge of the harmful behaviors that result from adolescent behavior may allow parents, educators, and mental health professionals to find preventions for these behaviors among depressed adolescents.  Depression has been found to occur along side harmful disorders, such as eating disorders which include obesity, anorexia, and bulimia.  Obsessive-compulsive behaviors, anxiety disorders, and conduct, and oppositional-defiant disorders also have been found to be present along with depression.  Further, adolescents tend to engage in harmful behaviors, such as smoking cigarettes, alcohol and drug abuse, criminal behavior, and even suicide (Allen-Meares, Colarossi, Oyserman, & DeRoos, 2003).  However, it is not clear which comes first, the depression or the harmful behaviors, or vice versa.  Many mental health professionals counsel depressed adolescents assuming that depression occurs first followed by harmful behaviors because there is much research indicating this.  However, some studies suggest otherwise.  For example, a study by Silberg, Rutter, D’Onofrio, and Eaves on the genetic and environmental factors in adolescent substance use revealed that harmful behaviors occurred first, then depression.  Their study revealed that their was a greater effect of substance abuse leading to depression than the other way around (Silberg, Rutter, D’Onofrio, & Eaves, 2003).  Another study conducted by Teresa Otsuki revealed a different picture.  Otsuki studied a sample of Asian Pacific Islander and Non-API American high school students in California. The sample included 13,374 ninth – and twelfth-grade students among 34 high schools in California. Questionnaires were administered in the classrooms of these students.  The questionnaire used was the Multiethnic Drug and Alcohol Survey.  Self-esteem and depression were measured.  Results indicated that both self-esteem and depression were significantly related to substance use (Otsuki, 2003).
Depression has been closely associated with delinquent behavior among adolescents.  Many adolescents engage in illegal use of illicit drugs, petty theft, group assault, and truancy.  Adolescents who are depressed engage in violent and non-violent crimes, as well as promiscuous

sexual behavior.  One study conducted by Ritakallio, Kaltiala-Heino, Kivivouri, Luukaala, and Rimpela investigated patterns of criminal behavior according to depression among repeatedly delinquent adolescents.  This study was conducted on 53,524 students aged 14 to 16 years who took part in the Finnish School Health Promotion Study.  The study investigated several issues among adolescent depression and delinquent behavior.  Specifically, the study examined whether any differences existed in criminal activities between depressed and non-depressed delinquent adolescents.  These differences were assessed by comparing the frequency of self-reported delinquent behavior among both groups.  Results indicated that depression was associated with repeated delinquency, and both depressed boys and girls repeated delinquent behaviors more frequently than non-depressed boys and girls.  Depression was also associated with a variety of delinquent behaviors.  Depressed adolescents tended to engage in more types of delinquent behaviors as well as more violent crimes than did non-depressed adolescents (Ritakallio, Kaltiala-Heino, Kivivuori, Luukkaala, & Rimpela, 2006).
Probably the most serious consequence of adolescent depression is suicide.  Suicide is the leading cause of death in adolescents ages 15 to 19 and the third leading cause of death among all adolescents, just falling behind accidents and homicides.  White males are at the highest risk of suicide, but African Americans are not following far behind.  While suicide occurs at higher rates for boys, girls attempt suicide more often.  Suicide attempts by boys usually cause automatic death because of the methods used to commit suicide, such as using guns.  Girls usually attempt suicide using less violent methods, such as a drug overdose.  While there are many reasons for such a high rate of suicide among adolescents, such as peer pressures, and stress, depression is a major factor as well.  With such a high risk of suicide among adolescents it is important that society recognizes the risk factors and warning signs of suicide, as well as depression.  Risk factors for suicide include having attempted suicide before, depression that includes strong feelings of helplessness and hopelessness, additional psychiatric problems such as conduct disorder, alcohol and substance abuse, stressful life events such as family difficulty or divorce, and access to firearms.   There are several warning signs that are important to recognize regarding adolescent suicide.  These warning signs include adolescents who talk about suicide, or dying, difficulty with school such as poor academic performance, or low attendance, making arrangements such as giving away personal belongings, writing a will, loss of appetite or over eating, depression, sleep difficulties that include not being able to sleep, or sleeping all the time, extreme changes in behavior, and a preoccupation with death in music, art, and literature (Feldman, 2008).

The prevention of suicide is of great importance.  Parents, educators, doctors, and mental health professionals can do a lot in preventing adolescent suicide.  Feldman offers several suggestions.  One important suggestion is to talk and listen to the person that is contemplating suicide.  Just listening in a non-judgmental way can help adolescents talk through their issues.  Also, it can be helpful to talk specifically about suicide with a suicidal person.  Getting specific information such as how the person plans to commit suicide, whether they have a gun or pills, and where they keep them can be important information in keeping the adolescent from committing suicide. Evaluating the seriousness of the adolescent’s claims and behaviors is important as well.  If the person is in serious danger, do not leave them alone.  Being supportive also helps.  Just letting the person know you are there for them and care about them, and attempting to break down that person’s isolation feelings is important. Seek professional help for this person.  Remove all dangerous objects out of reach of this person, such as guns, razors, scissors, and medication.  Call for help immediately, do not keep it secret.  Do not try to call the suicidal person’s bluff by daring them to attempt suicide to make them aware of the wrong thinking because this sometimes can cause the person to actually do it.  Contracting with the suicidal personal that he or she promises not to attempt suicide until talking with someone can help. It is important to not be fooled by a suicidal person’s sudden improvement.  It is still imperative to seek professional help for them because the issues are probably still there (Feldman, 2008).
Gender, Ethnic, and Racial Differences
There are many gender, ethnic, and racial differences among adolescents with depression.  On average, more girls than boys are depressed.  African Americans, and Native Americans  have been found to have higher rates of depression than whites.  However, whites and Asians are more likely to be depressed when under stress than African Americans or Hispanics.  Factors that lead to higher depression in girls may be the drop in their self-esteem during middle school due to peer and media pressure to be more attractive, thin, and to value relationships over academic or career achievements.  Ethnic and racial differences in adolescent depression may occur due to the fact that minorities experience significant stressors such as poverty and discrimination.  Furthermore, due to lack of financial and social resources, African Americans, Hispanics, and Native Americans have difficulty keeping healthy.  They may have more illness such as colds, and are at more risk for developing chronic illnesses, such as diabetes and heart disease.  These illnesses contribute to depression (Feldman, 2008). Brown, Elder, and Meadows conducted a study on race-ethnic inequality and psychological distress in adolescents.  The study examined

adolescents in grades 7 through 12 from across the United States.  The sample included 10, 718 females (52% White, 24% African American, 17% Hispanic, 7% Asian) and 9,948 males (52% White, 22% African American, 18% Hispanic, 8% Asian).  Depression was measured in these adolescents using a variation of the Center for Epidemiological Studies Depression Scale.  Stressful life events, coping and problem solving skills, mother’s social support, and age was also measured. Results indicated that depressive symptoms varied dramatically across race and ethnic groups.  Whites scored the lowest depressive symptoms while Hispanics and Asians scored the highest levels.  African Americans scored levels in between whites, Hispanics and Asians.  In addition, this study revealed higher scores of depressive symptoms in females than males (Brown, Elder, & Meadows, 2007).
Prevention and Treatment for Adolescent Depression
There are three factors that provide protection and help adolescents cope with depression and the struggle of the transition period of adolescence itself.  First, positive relationships with parents and friends provide adolescents with a good support system to help them cope with stress.  As stated earlier, parents are significant in producing positive outcomes and high self-esteem in their children.  In addition, adolescents who have close friends tend to not be depressed like those who have few close friends.  Second, adolescents who find a particular area of competence or expertise cope with stress and depression better.  Participating in sports, music, art, and other activities provide adolescents with friends and boost their self-confidence if they do well, and can create a sense of belonging if the identify with a team or group. Participating in these positive activities and others, such as shopping, going out with friends, watching television, or taking up a hobby such as collecting coins, or scrap booking can relieve stress and keep
adolescents from participating in harmful behaviors, such as smoking, drinking, or stealing.  Lastly, adolescents who feel needed and take on a responsibility role for others such as responsibility to a younger sibling or to a team cope better with stress which may prevent depression (Craig & Baucum, 2002). McCarthy, Downs, and Sherman conducted a study to identify many factors, specifically persons’ sources of assistance, and helpful and unhelpful factors of treatment. The study included a sample of students ages 20 to 23 that had been diagnosed with adolescent depression at ages 15 to 18.  These students were administered a questionnaire that reflected the DSM-IV-TR criteria for major depression.  They also were administered the Beck Depression Inventory-II which assessed the level of depression of the students. The data was analyzed mostly through a five step analytic process outlined by McLeod.  Other guidance came from the work of Strauss, Polkinghouse, and suggestions form the Journal of Counseling and Development.   McCarthy, Downs, and Sherman reported that five themes emerged from their data. They found that the participants found talking to someone to be helpful, such as talking to a counselor.  The participants felt that just being able to sit down and discuss their depression without having to have a reason for the depression was helpful.  A second theme was the relief and respect that occurred.  The participants attributed their decrease in depressive symptoms to the therapy with the counselor rather than just the medication.  Another theme that emerged had to do with parental an adult partnerships.  Most of the participants depended on the parents to help them rather than rejecting them.  Participants said the parental support of their parents being involved with therapy just by driving them to an appointment, for example was helpful.  Helpful friends were important to the participants as well.  Finally, participants seemed to possess a realistic optimism.  The participants knew that the depression would reoccur, but
they were not negative about it.  They were realistic about the return of the depression being a real possibility, but were optimistic about how to handle it (McCarthy, Downes, & Sherman, 2008).
However, the above factors will not always protect adolescents from depression.  Therefore, one must look to all the treatment options available to adolescents once they have become depressed. Psychotherapy, pharmocycotherapy, and education for the parents and family are significant.
Cognitive-Behavioral Therapy, and interpersonal therapy can help adolescents cope with depression.  Cognitive-Behavioral therapy is considered first before using drugs to treat depression in adolescents.  Cognitive-Behavioral Therapy helps patients recognize distortions in thoughts about themselves and the way others see them.  Cognitive-Behavioral Therapy is seen as better than other methods in the treatment of adolescent depression.  However, interpersonal psychotherapy is used in the treatment of adolescent depression as well.  It involves helping adolescents focus on areas of difficulty in their lives, such as grief, arguments with others, and transitions.  Children and adolescents ages 10 to 14 with mild depressive symptoms responded well to therapeutic intervention.  Other studies reveal that adolescents ages 13 to 17 do well with Cognitive Behavioral Therapy, but children younger than 9 years of age may not benefit from this therapy due to their verbal and cognitive limitations.  Other therapies are helpful in treating adolescent depression including play therapy, family therapy, and group therapy (Dopheide, 2006).
Treatment of adolescent depression with antidepressant medications is another option.  Selective serotonin reuptake inhibitors (SSRIs) have been approved by the Food and Drug
Administration (FDA) for treating adolescent depression.  Fluoxetine is one antidepressant approved by the FDA in treating depression in children 8 years or older. In the study, Treatment of Adolescents with Depression Study, the combination of Cognitive-Behavioral Therapy and fluoxetine was shown to be better at reducing depressive symptoms among adolescents ages 12 to 17 during a 12 week study than Cognitive-Behavioral Therapy or fluoxetine alone. Sertaline is another antidepressant medication commonly used to treat adolescent depression.  However, it is used less commonly since the FDA issued warnings about increased suicidal risks associated with antidepressants.  The FDA approved its use for the treatment of obsessive-compulsive disorder in children ages six years and older.  Sertaline has lower risks of drug interactions than fluoxetine, but its effectiveness in treating depression lags behind fluoxetine.  Paroxetine was the drug most commonly used to treat adolescent depression in 2002.  However, the FDA found that adolescents taking paroxetine were at a higher risk of developing suicidal behavior, so the FDA issued a warning in June 2003 that paroxetine should not be used to treat pediatric depression. Citalopram is being studied as an option for treating adolescent depression because it has a low risk of drug interactions compared with the other drugs, but its use is still being investigated.  Fluvoxamine has been approved by the FDA for treatment of obsessive-compulsive disorder in children 8 years of age and older.  It has been effective in decreasing depressive symptoms as well as binging, purging, and anxiety (Dopheide, 2006).  However, parents and pediatricians may be somewhat reluctant to use antidepressants in adolescents due to adverse reactions and side effects.  SSRI side effects include mild stomach upset, or adolescents may become sedated.  Frontal lobe symptoms such as disinhibition, apathy, and indifference can occur if too much medication is given.  Serotonin Syndrome which can be deadly is of concern as well. There are
many other drugs that have been studied for their effectiveness in treating adolescent depression and some are and are not approved by the FDA (Son, 2000).
Trycyclic drugs were the first drugs available in treating adolescent depression. These drugs have been effective in treating attention-deficit hyperactivity disorder and obsessive-compulsive disorder.  However, clinical trials showed no significant difference in using these drugs versus using a placebo in the treatment of depression. The potential cardio toxicity side effects and anticholingeric concern has led to trycyclic drugs being used second to SSRIs in treating depression. Another harmful side effect of trycyclic drugs is weight gain. Sudden death has occurred in some children as well (Son, 2000).
Due to the numerous side effects and dangers in using psychotropic drugs, it is important that families and caregivers exercise caution and are aware of warning signs of the dangers in persons taking these drugs.  A medication guide should come with all medications and should provide danger signs to look.  These include looking for suicidal thoughts or behaviors, behavioral changes or increase in suicidal thoughts, depression, anxiety, panic attacks, or agitation.  It is also important to be aware of signs of restlessness, aggression, anger, violence, impulsive behavior, and moodiness.  Furthermore, careful monitoring from a clinician is beneficial in preventing suicidal behavior in adolescents on antidepressants (Dopheide, 2006).
Patient and family education is another important treatment option for adolescents with depression. Education providing a better understanding of depression and its risks provides several benefits.  For example, patients may be more willing to comply with therapy if they know all the facts and seriousness of their disorder.  Also, it may relieve guilt in parents who feel that their child’s depression is their fault and it may also help parents be more aware of
depressive and suicidal symptoms.  This education would benefit the adolescent’s entire social support network, including teachers, pediatricians, pastors, coaches, and the like (Son, 2000).
Conclusion
A majority of adolescents have and cope with depression every day.  Adolescent depression can be difficult to recognize and treat, but it does not have to be a death sentence for them.  Suicide rates are high among adolescents and depression is a major factor that increases the risk of suicide.  However, parents, educators, coaches, mental health professional as well as all of an adolescent’s support system who is armed with the knowledge and understanding of depression, its symptoms, causes, risks, and treatment options can help defend adolescents against this serious disorder.

References
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Feldman, Robert S. (2008). Development Across the Life Span (5th ed.,  pp. 71-72). Upper Saddle                       River, NJ: Pearson Prentice Hall.
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