Targeting Teenage Depression
By Karen Swartz, M.D.
Baltimore, MD, USA
How does a Johns Hopkins psychiatrist find herself in countless high school auditoriums and classrooms around the country? With over 2 million youths experiencing major depression each year and suicide being the third leading cause of death among adolescents and young adults, the facts support the need for programs that target suicide and depression among adolescents. For me, however, this was a more personal mission.
In 1998, there were three deaths from suicide in Baltimore, all high school students. I was asked to speak to parents at one of the schools. I was distressed by how little the average parent knew about depression even within a well-educated community. In response to these tragedies, the community asked for a collaboration between Johns Hopkins and local schools to develop a program for the high school students. As a clinician, my message was simple – depression is a treatable medical condition. From that conviction the Adolescent Depression Awareness Program (ADAP) evolved.
While the message was clear, the best way to reach students, teachers and parents was not straightforward. A team from Johns Hopkins worked with local teachers to outline the key elements of a depression education program for high school students: 1) all students, not just those felt to be at risk for depression, should be taught the curriculum; 2) it should occur during health class to reinforce that depression is like other medical illnesses; and, 3) the curriculum should be interactive and follow the format of a high school health class, not a medical school lecture. Since the program was being developed by a group of psychiatrists and psychiatric nurses at Johns Hopkins, input on the curriculum from the students and high school health teachers was critical in developing our interactive program with a high level of student participation.
Today, ADAP is a 3-hour depression education program designed to be taught to all high school students, typically during health class. The curriculum involves a wide variety of activities including group discussions, interactive activities, group projects, and videos with teens describing their experiences with depression and bipolar disorder. The key messages include that depression, like other medical illnesses, has a group of symptoms that can be recognized; depression is treatable, usually with a combination of medication and talk therapy; and, without treatment the consequences of depression can be very serious, the greatest of these placing people at risk for suicide.
For the first five years of the program, all the classroom teaching was done by the Hopkins team. This allowed us to critically review and revise the program and to incorporate the suggestions of the students and teachers quickly. This experience also helped us to better understand what typical high school students knew about depression and address their most common questions. It also made all of us better teachers and appreciative of the types of group projects and activities that capture and hold the attention of students in this media age.
With the curriculum refined, the next challenge was to develop a training program so that high school health teachers and counselors could effectively teach the curriculum. In the process of developing this training program for high school professionals, we realized that they wanted and needed advanced training about mood disorders rather than our thoughts about teaching. We designed the ADAP curriculum to encourage class discussion and questions, and make sure the teachers had an excellent knowledge base about depression, bipolar disorder and suicide in order to field the students' questions. We also learned that some needed this training to believe themselves that depression is a treatable medical illness.
From the first year, we surveyed the students' knowledge about depression and bipolar disorder and their attitudes about seeking help or encouraging friends to seek help both before and after they were taught the ADAP curriculum. We did not want to be another program that "felt good" but could not show that we were changing the way students thought about depression or intended to act if they were experiencing a problem with their mood. We now have data collected over 15 years on over 50,000 students that shows that ADAP improves knowledge and changes attitudes about getting help. For example, following the program, a significantly larger number of students would "tell someone" if a friend shared that they had depression but asked them to keep it a secret. For privacy reasons, we did not track the number of students who sought formal treatment, but we know from families and school counselors who chose to contact us that students definitely self-identify as having depression or bipolar disorder after receiving the ADAP curriculum, and as a result they are getting help.
Our training efforts began in the Baltimore-Washington area and have now expanded to other areas of the country. The current training model involves a one day, in-person training for high school teachers, counselors, social workers, psychologists and administrators at a local school or training center. As the person who has conducted all of the trainings to date, I made sure that those full-day trainings are both active and interactive. The focus is on education about mood disorders and includes videos of individuals with mood disorders and their family members share their experience and perspective. It is reassuring that the same pre-test and post-test surveys given to students taught by their local teachers and counselors also shows clear improvements in knowledge and positive changes in attitudes about help seeking. We now know that ADAP can be effectively taught by the school-based professionals when properly trained.
We have been funded primarily by memorial foundations of families who have lost a child to depression or bipolar disorder and want to "do something" to help others with these challenging illnesses. The families often forge relationships with local schools and take on the challenging job of convincing school administrators to include ADAP in the health curriculum. Collaborations with multiple foundations have now taken ADAP to many states including Delaware, Texas, Illinois, Oklahoma, and Florida. The limitations for further expansion are, of course, time and funding.
Knowing that we had developed a curriculum that effectively educates high school students about depression and the importance of getting treatment, we began exploring how we could use technology to reach a greater number of educators and students. We have developed and are now piloting a web-based training program and data collection system. The web-based program presents the same material as the in-person training program with a series of recorded modules. We have recently received a small grant to study whether the web-based training is as effective as the in-person training; the changes in knowledge and attitudes in students taught by educators trained in these two ways will be compared. There is tremendous potential for the web-based training to allow ADAP to reach a much greater number of schools and students.
Mood disorders interrupt and limit lives. The majority of teens with a mood disorder will not seek help when first ill and will suffer unnecessarily. Improving knowledge and encouraging treatment through education has the potential to changes the lives of adolescents suffering with depression and bipolar disorder. ADAP's mission has not changed over 16 years – all teenagers, teachers and parents need to understand that depression is a treatable medical illness and know what steps to take to facilitate getting help for someone suffering.