What are the influencing factors in teenagers with depression?

To identify implications for practice in the care of teenagers suffering from depression a literature
review will be presented to identify factors leading to the illness. By acknowledging a potential
source of depression patients could be offered bespoke care plans to provide holistic patient
centred care. The care planning process is described as central in enabling nurses to plan
interventions with patients (Ballantyne, 2015). Aside from identifying those sources, treating them
individually would be difficult as there are such a wide range of factors contributing to depression.

A broad search will be completed using the EBSCO search tool. From this, a collection of papers
will be selected that best meet the criteria of the search and will be briefly described, identifying
what the study was about and what conclusion it drew. From this, implications for practice within
the field of childrens nursing will be discussed.

Upon completing a search for journals that have reported on the issue of adolescent depression
it was found that there is a complex web of factors that can affect a persons stability. Instead of
exploring several of these factors, papers were chosen out of the search that were linked by a
theme. This will allow for more specific implications for practice to be presented and will show
through several pieces of research what is being contributed to the knowledge base around
depression.

An awareness of this ever-changing knowledge base is crucial to a nurses role in caring for a
patient. As a childrens nurse, not only is care given to the service user but to the family when
taking a holistic approach to care which can benefit patient care, parental satisfaction and has
been linked to reduced cost (Shields et al., 2012). It is therefore vital that nurses are up to date
with a care plan and are aware of how to make that plan work for the entire family.

Nurses may also need to be aware how the family could adversely affect the patients condition.
The factor focused on relates to adolescents who identify as lesbian, gay or bisexual (LGB) and
whether this affects depression. If a patient is cautious of family reactions to their situation it could
aggravate their condition further and trying to engage the family may not help as coming out to
parents is a major psychological decision and hurdle. (Heatherington and Lavner, 2008)

Having an up to date knowledge base is what allows healthcare professionals to carry out
evidence based practice. This means staff are fully aware that research has been carried out to
show that a treatment is effective. By using current best evidence healthcare professionals can
make informed decisions about the care of individual patients. (Greenhalgh, 2010)

Several evidence based practice models have been formed to help facilitate best practice. These
models follow a similar pattern and help identify clinical problems, they then require evidence to
be gathered and evaluated with a view to implementing a change in practice (Gawlinksi and
Rutlegde, 2008). Different models offer different advantages or disadvantages and each model
gives emphasis to various aspects of transforming practice. Hermes et al. (2009) used the Iowa
Model to develop a better suicide risk assessment tool which could be relevant when assessing
depression and suicidal ideation in teenagers.

When performing the search, the CINAHL Complete and MEDLINE databases were used to
provide a large body of results from medical and allied health journals. As the question focuses
on depression results were also included from the PsycARTICLES and PsychINFO databases,
two sources of peer reviewed journals from the American Psychological Association. Finally, the
Child Development & Adolescent Studies database was searched to make sure some results
focused on adolescents as that was also a criterion in the question.

When performing the search, the terms used in the table below were loaded into the search
engine with Boolean operators to account for the varying ways to label the terms.

Depression
OR Adolescent Factors
Mental Illness AND OR AND OR
OR Teenage Causes
Mental Health

To reduce the number of results found the search was refined to only show peer reviewed journals
to which the full text was available and the publication date had to be within the last ten years.
The articles chosen were mostly published in the United States of America (USA) with some being
Australian one being Norwegian and only one performed in the United Kingdom (UK). Whilst this
may affect the implications for practice, the articles all originate in western countries so could be
transferable to practice in the UK.

Thirteen articles were chosen out of the search based on their title, three of these were removed
as the age range was too high to cover adolescents. From this ten, six were chosen that all looked
at the links between sexual orientation and suicide amongst teenagers. The other four articles
discarded either didnt focus on adolescents or covered the broader topics of depression and
hopelessness rather than suicidal tendencies.
AUTHORS YEA JOURNAL AIM TYPE of FINDINGS IMPLICATIONS
R EVIDENCE for PRACTICE
Kitts, Robert Li. 2005 Adolescence To provide Literature That Healthcare
evidence that review physicians professionals
there is an arent need to be
increased risk of adequately more
suicide amongst equipped to understanding
gay adolescents respond to and accepting
and to the issues of gay
encourage brought adolescents
greater suicide about by the and be aware
prevention from psychosocial of support
physicians. issues faced systems
by gay available locally
adolescents. to help their
patients.
Baams, Laura., 2015 Developmental To assess the A No significant The article
Grossman, Psychology mental health of longitudinal link between concluded that
Arnold., LGB youth and a sense of further study
Russel, examining quantitative belonging was needed to
Stephen. stress, study and draw
depression, victimisation implications for
perceived were found practice
burdensomeness but there was
and suicidal a link
ideation. between a
sense of
belonging
and stress
and suicide.
Langhinrichsen 2011 Journal of To explore the An A greater risk Social support
-Rohlin, Homosexuality relationship empirical, of suicidal was shown to
Jennifer., between sexual quantitative ideation was reduce the
Lamis, Dorian., preference and study found in effects of the
Malone, suicidal those stressors
Patrick. behaviour in identifying as associated with
adolescents. bisexual than sexual minority
other sexual youth and the
minorities study stated
that their
findings should
be considered
in all future
work with LGB
youth
Pesola, 2014 Addiction To assess the A That sexual Care providers
Francesca., effects of longitudinal, minority should be
Shelton, depression in quantitative adolescents aware of the
Katherine., sexual minority study were found increased risk
Bree, adolescents. to be at of alcohol use
Marianna. Specifically greater risk and have
relating to of alcohol interventions in
 increased abuse and place for
alcohol use. depression adolescents
Silenzio, 2007 American To examine the Quantitative LGB The report
Vincent., Pena, Journal of links between evidence adolescents suggests the
Juan., Public Health LGB status and reported need for
Duberstein, known markers higher rates further study
Paul., Cerel, of suicide risk of suicide due to the
Julie., Know, and to compare than limitations of
Kerry. them with non heterosexuals their data
LGB people. but problem analysis
drinking and
drug use
were
significant
precursors to
suicide in
sexual
minorities
Wichstrm, 2003 Journal of To find out if Quantitative Those who No direct
Lars., Hegna, Abnormal LGB status evidence had implications
Kristinn. Psychology increase the risk from an experienced were drawn in
of suicide empirical, sexual the study but it
attempt and longitudinal contact with suggested
which aspects of study others of the future research
LGB orientation same sex should explore
affect the risk. were more the various
likely to have aspects of
attempted sexual
suicide than orientation
those who
had only
experienced
sexual
attraction

Kitts (2005) gathered evidence from past studies and experiences to explore the psychosocial
reasons why LGB adolescents are more at risk of suicide. By exploring why issues around
homosexuality are rarely discussed, Kitts (2005) hopes to highlight the significance of the issue
and encourage healthcare professionals to be more proactive in reducing the risk of suicide. The
article aimed to gather evidence of major issues from previous studies. Many looked at the effects
of sexual orientation on adolescent mental health and some looked at ways of integrating the care
of LGB patients with depression into mainstream healthcare. Kitts (2005) highlighted some
alarming statistics about the high rates of suicide amongst LGB teenagers and used his findings
to show that being gay isnt the root cause of issues involving depression. The psychosocial
factors put a large amount of stress onto adolescents both heterosexual and homosexual and a
lack of support, especially for LGB youth, can degrade quality of life and lead to suicidal ideation.
The lack of support stems from a knowledge deficit in physicians who arent aware of local support
groups and who dont acknowledge the seriousness of LGB identification in adolescents. As this
article was published in America in 2005 it is possible that it isnt entirely translatable to the
modern day United Kingdom. The first state to legalise gay marriage had only done so in 2004,
the year before the article, so the stigma associated with discussing sexual orientation may have
declined but not so much that support is easily accessible. In the UK, having healthcare
professionals who feel comfortable broaching the subject of homosexuality will show teenagers
that they can seek out help from people who are able to help. As many of the psychosocial issues
Kitts (2005) identifies revolve around family support and fear of judgement upon coming out,
changing public perceptions of homosexuality is essential to reducing the stressors faced by LGB
adolescents and in turn reducing the rare of suicide.

A 2015 study by Baams et al. (2015) aimed to test two hypotheses they had formed after reviewing
two theories, the minority stress model and the interpersonal-psychological theory of suicide
(IPT). They hypothesised that the stress related to coming out contributed to higher levels of
depression and suicidal ideation and secondly that these stressors are related by perceived
burdensomeness and thwarted belongingness. Grossman et al. (2015) aimed to bring together
the minority stress model and IPT to boost understanding of mental health and high suicide rates
among LGB youth. A longitudinal study was to be performed looking at the risk factors of suicide
among a group of LGB adolescents. Longitudinal studies are useful to expose risk factors due to
the repeated monitoring of participants over extended periods of time. (Coggon et al., 2003)
Participants were asked to rate their coming out stress, perceived burdensomeness, thwarted
belongingness, depression and suicidal ideation. They were also asked about their experience of
victimisation due to their sexual orientation through open ended questions to find out the
frequency of victimisation. To test their hypotheticals, analysis of variance was used to compare
the means of each category and test for statistical significance. The statistical modelling program
Mplus was used to conduct some analysis and test indirect effects. The study found that there
was no significant relation between victimisation and thwarted belongingness but that thwarted
belongingness was significantly related to suicidal ideation. There was also a direct correlation
between coming out stress and suicidal ideation. The mean levels of coming out stress were
found to be worse in gay men and women than in bisexuals and men reported more victimisation
than the females as well as a higher level of coming out stress. The higher levels of victimisation
impacts levels of depression and suicidal ideation and the study attributes this to the participants
feeling like a burden to others. Whilst the study adds to the body of knowledge about the negative
impacts of sexual orientation in LGB youth, it admits more research needs to be done to further
understand how suicide risk is mapped out over the course of adolescence. A wider study could
include preventative factors which would provide better implications for practice however this
study, by combining the minority stress model and IPT, does expose new evidence about LGB
youth and their experiences.

Researchers in a 2011 study aimed to explore the relationship between sexual attraction and
suicidal behaviour, specifically in adolescents who experience same sex attraction.
Langhinrichsen-Rohling et al. (2005) also looked at the role social support plays in mediating the
effects of depression. A large group of adolescents were gathered and questioned about their
experiences of sexual attraction and then split into groups dependent on their answers. The study
then took a history of suicidal behaviour and asked about recent suicidal ideation then used items
from Kazdin's Hopelessness Scale for Children (Kazdin et al., 1986) to assess negative views of
themselves and their future. Symptoms of depression were taken on a scale and the perceived
access to social support. The study found results supported by other studies that bisexual
adolescents are at more risk of depression and therefore suicide and revealed that those with
sexual experiences gave higher reports of suicidal ideation. Langhinrichsen-Rohling et al. (2005)
recommend all future work regarding LGB youth should take these findings into account. Their
findings showed, as they expected, that effective social support could curb the effects of the
stressors associated with sexual minority youth but they did not find a link between support and
the feelings of hopelessness experienced by the group. The study acknowledged its own
limitations including that the participants may have underreported sensitive information or not
given detailed answers to questions regarding suicidal ideation. This was due to the constraints
of the questionnaire created for the participants. Whilst the study may have limitations it still
provides further evidence that being a sexual minority contributes to suicidal ideation and shows
that greater social support is needed to reduce the suicide rate. As a nurse, work in the community
could be used to provide support and healthcare professionals should be aware that sexual
orientation can be a contributing factor to mental health problems that needs to be addressed.

Pesola et al. (2014) had noticed from previous research that LGB adolescents have a higher
chance of participating in alcohol use than their peers. They acknowledge that evidence from
longitudinal studies is limited but due to the higher rates of depression amongst sexual minority
adolescents they aimed to asses to what extent these higher rates of depression affect alcohol
consumption. The study would also aim to explore any gender specific patterns of depression and
alcohol use. The team used participants in the Avon Longitudinal Study of Parents and Children
(ALSPAC) and at aged fifteen the children were questioned about their sexual orientation. All
groups other than 100% heterosexual were grouped together to form the sexual minority group
which came to 12% of the cohort. At aged 16 the participants level of depression was measured
using the Short Mood and Feelings Questionnaire (SMFQ) then at aged 18 the Alcohol Use
Disorders Identification Test (AUDIT) measured alcohol use and tested for alcohol related
problems. These measures found, along with previous studies, that LGB adolescents were at
greater risk of depression and they found that sexual orientation was positively linked to alcohol
use. Pesola et al. (2014) hypothesise that the increased alcohol consumption could be due to
LGB adolescents spending more time in bars and clubs as their social circles exist in such venues.
They also acknowledge that alcohol can be used to elevate moods and reduce dysphoria. This
dissatisfaction with life could be a result of victimisation and coming out fear. As the study was
performed recently in the UK it provides extremely useful data that should be acknowledged by
the healthcare community. Adolescent alcohol use is still a major public health concern with 45%
of young people who drink regularly saying they do so to forget their problems. (Health and Social
Care Information Centre, 2016) An understanding of the reasons why teenagers turn to alcohol
may help in their treatment. If healthcare professionals are willing to question adolescents about
their sexual orientation they may be able to provide access to a support network to reduce their
feelings of hopelessness and in turn reduce their reliance on substances like alcohol.

In 2007, an article by Silenzio et al (2007) explored the risk factors contributing to suicide in LGB
adolescents and hypothesised that the markers indicating suicidal ideation could be different
amongst sexual minority youth than in their heterosexual counterparts. This article used data from
a prospective cohort study, the National Longitudinal Study of Adolescent Health, that was
representative of the national population. This means that its results lie closer to the true values,
or are more accurate. Sexual orientation was measured amongst the cohort and those who did
describe themselves as exclusively or mostly heterosexual were categorised as LGB. Suicidal
ideation was also measured along with depression and alcohol and drug use within the previous
12 months. By using statistical analyses the study examined the relationship between the
stressors, such as alcohol consumption, and the outcomes, namely suicidal ideation. After
controlling factors such as race and gender, the article concludes that LGB adolescents do report
higher rates of suicidal ideation and that problem drinking and depression were associated with
a greater risk of suicidal ideation amongst LGB adolescents. They also report that problem
drinking and depression along with drug use were linked to higher risk of suicidal ideation amongst
heterosexuals. Whilst the report supports evidence that LGB adolescents are more likely to
experience depression and suicidal ideation, it shows that amongst non-LGB teenagers problem
drinking and drug use were greater indicators of future suicidal thoughts. Whilst it is important for
healthcare professionals to tackle alcohol and drug use amongst the adolescent population,
assumptions should not be made about sexual orientation and substance abuse. Further studies
would help to identify indicators of suicidal ideation amongst the LGB community and once they
have been revealed, they can be targeted early to prevent depression.

Wichstrm and Kristinn (2003) performed a longitudinal study to address some of the flaws they
felt were present in other studies. From the literature available they found that there wasnt much
evidence at the time to show exactly why sexual orientation influenced suicidal ideation. They
also found a lack of comparison of risk factors between gay men and lesbians and wished to
explore whether atypical gender roles in LGB adolescents could explain a difference in suicidal
behaviour between genders, if there was a difference at all. The study also aimed to find which
aspects of sexual orientation are important in assessing future risk of suicide. Wichstrm and
Kristinn (2003) found that previous studies often measured suicidal behaviour retrospectively but
assessed risk factors within a short time frame. This poses the question of whether they are risk
factors or consequences of a previous period of depression. Being a longitudinal study, the
participants were first selected in 1992, this means that the results may not be entirely translatable
to modern practice however the study states that there is less prejudice in Norwegian society.
This could reflect the society we have moved towards which is more accepting of sexual minority
citizens. Teenagers sexual orientation was not measured as plainly as other studies, sexual
identity, sexual contact and attraction were all considered when calculating whether participants
fit into the sexual minority group. Whilst the study is slightly older, it more carefully analyses risk
factors leading to suicidal thoughts along a scale of sexual identity and explores potential
explanations. The study found that those who had experienced same sex sexual contact were
more likely to have attempted suicide than those who stated they had no sexual contact but were
attracted to members of the same sex. In an age were sexual interaction is easier to come by as
hook-ups become engrained in popular culture, (Garcia et al., 2013) teenagers experiencing
same sex sexual contact could be higher. If the studys results are relevant to modern practice
this could translate to an increase in suicide attempts amongst LGB adolescents.

The body of evidence available shows that sexual orientation does have a link to depression in
teenagers. There also appears to be a causal link with suicidal ideation however it appears not to
be a persons sexual orientation itself that affects mental health. The social stigma that LGB
adolescents fear they will face seems to have a much greater bearing on their wellbeing. The fear
of rejection from family and the threat of victimisation has been shown to be enough to push
teenagers towards suicide.
Whilst the articles above consider sexual minority adolescents, the fact that they find underlying
issues a larger problem can be mapped onto other conditions. Many illnesses, particularly those
regarding mental health, carry stigma in todays society and lead to an underreporting of
conditions (Greenwood et al., 2016). It is this fear that stops people seeking help or, in the case
of sexual minority adolescents, from coming out. Therefore, the factors that influence depression
amongst teenagers are those things that may be dealt with easily but may be seen to potentially
cause more pain.

Caught in catch 22 situations, teenagers could display warning signs of depression and suicidal
ideation such as substance abuse. When research considers the risk factors and signs leading to
suicide, the factors can again potentially be mapped to other conditions. If the symptoms of
depression are similar then it can be spotted amongst teenagers and then the root cause sought
out to try and resolve the situation.

In practice, it is the common risk factors that researchers have identified that healthcare
practitioners need to be aware of. Whilst it is important they understand the causes of depression
amongst teenagers, it is more essential that they spot it so they can do something about it.

Whilst searching for articles to use in the paper I have gained knowledge not only relating to
depression in adolescents but also in how to use the resources available to me to influence my
practice. Having a knowledge about mental health makes it easier to address, recognise and
respond to so best practice would include taking these skills and applying them to other aspects
of healthcare.

Many of the studies found focused on proving the link between sexual orientation and depression
but not many offered real suggestions on how to then care for those affected by mental illness.
Now the link has been satisfactorily been shown, research should be performed into the best
methods of soothing the symptoms of depression.

Several of the studies were older than ten years. These may not be entirely relevant to practice
today as they could contain outdated information. Whilst they have all added to the knowledge
base regarding adolescent depression, more up to date research could explore if society has
changed within the last ten years and if the risk factors of depression are the same.
References

Baams, L., Grossman, A. and Russell, S. (2015) Minority stress and mechanisms of risk for
depression and suicidal ideation among lesbian, gay and bisexual youth, Developmental
Psychology, 15 (5), pp. 688-696. DOI: http://0-dx.doi.org.lispac.lsbu.ac.uk/10.1037/a0038994

Ballantyne, H. (2015) Developing nursing care plans, Nursing Standard, 30 (26), pp. 51-57.
DOI: 10.7748/ns.30.26.51.s48

Coggon, D., Rose, G. and Barker, D. (2003) Epidemiology for the uninitiated. 5th Ed. London,
BMJ Books.

Garcia, J., Reiber, C., Massey, S. and Merriwether, A. (2013) Sexual hookup culture: a review,
Review of General Psychology, 16 (2) pp. 161-176. DOI: 10.1037/a0027911

Gawlinski, A. and Rutledge, D. (2008) Selecting a model for evidence based practice changes,
Advanced Critical Care, 19 (3), pp. 291-300. Available from:
http://www.kau.edu.sa/Files/0004020/Subjects/EBP%20Changes%20project.pdf [Accessed 15
May 2017)

Greenhalgh, T. (2010) How to read a paper: the basics of evidence based practice. 4th Ed.
Chichester: John Wiley & Sons.

Greenwood, K., Carrol, C., Crowter, L., Jamieson, K., Ferraresi, L., Jones, A. and Brown, R.
(2016) Early intervention for stigma towards mental illness? Promoting positive attitudes
towards severe mental illness in primary school children, Journal of Public Mental Health, 15
(4), pp. 188-199. DOI: http://0-dx.doi.org.lispac.lsbu.ac.uk/10.1108/JPMH-02-2016-0008

Health and Social Care Information Centre (2016) Statistics on alcohol, England 2016.
Available from: https://www.gov.uk/government/statistics/statistics-on-alcohol-england-2016
[Accessed 10 May 2017]

Heatherington, L. and Lavner, J. (2008) Coming to terms with coming out: Review and
recommendations for family systems-focused research, Journal of Family Psychology, 22 (3),
pp. 329-343. DOI: 10.1037/0893-3200.22.3.329

Hermes, B., Deakin, K, Lee, K. and Robinson, S. (2009) Suicide risk assessment: 6 steps to a
better instrument, Journal of Psychosocial Nursing and Mental Health Services, 47 (6), pp. 44-
49. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19585803 [Accessed 15 May 2017]
Kazdin, A., Rodgers, A. and Coblus, D. (1986) The hopelessness scale for children:
psychometric characteristics and concurrent validity, Journal of Consulting And Clinical
Psychology, 54 (2), pp. 241-245. DOI: http://dx.doi.org/10.1037/0022-006X.54.2.241

Kitts, R. (2005) Gay adolescents and suicide: understanding the association, Adolescence, 40
(159), pp. 621-628. Available from: http://0-web.b.ebscohost.com.lispac.lsbu.ac.uk/ehost
[Accessed: 16 March 2017]

Langhinrichsen-Rohling, J., Lamis, D. and Malone, P. (2011) Sexual attraction status and
adolescent suicide proneness: the role of hopelessness, depression and social support, Journal
of Homosexuality, 58 (1), pp. 52-82. DOI: http://0-
dx.doi.org.lispac.lsbu.ac.uk/10.1080/00918369.2011.533628

Pesola, F., Shelton, K. and Bree, M. (2014) Sexual orientation and alcohol problem use among
UK adolescents: an indirect link through depressed mood, Addiction, 109 (7), pp. 1072-1080.
DOI: http://0-dx.doi.org.lispac.lsbu.ac.uk/10.1111/add.12528

Shields, L., Zhou, H., Pratt, J., Taylor, M., Hunter, J. and Pascoe, E. (2012) Family-centred care
for hospitalised children aged 0-12 years. Cochrane Database of Systematic Reviews, Issue 10.
DOI: 10.1002/14651858.CD004811.pub3

Silenzio, V., Pena, J., Duberstein, P., Cerej, J. and Know, K. (2007) Sexual orientation and risk
factors for suicidal ideation and suicide attempts among adolescents and young adults,
American Journal of Public Health, 97 (11), pp. 2017-2019. DOI: http://0-
dx.doi.org.lispac.lsbu.ac.uk/10.2105/AJPH.2006.095943

Wichstrm, L. and Hegna, K. (2003) Sexual orientation and suicide attempt: a longitudinal study
of the general Norwegian adolescent population, Journal of Abnormal Psychology, 112 (1), pp.
144-151. DOI: http://0-dx.doi.org.lispac.lsbu.ac.uk/10.1037/0021-843X.112.1.144
Bibliography

Alvy, L., McKirnan, D., Mansergh, G., Koblin, B., Grant, G., Flores, S. and Hudson, S. (2011)
Depression is associated with secual risk among men who have sex with men but is mediated
by cognitive escape and self efficacy, AIDS and Behaviour, 15 (6), pp. 1171-1179. DOI: http://0-
dx.doi.org.lispac.lsbu.ac.uk/10.1007/s10461-010-9678-z

Bowers, D., House, A. and Owens, D. (2011) Getting started in health research. Oxford, John
Wiley & Sons.

Cronin, P., Coughlan, M. and Smith, V. (2015) Understanding nursing and healthcare research.
London, Sage Publications.

DePoy, E. and Gitlin, L. (2005) Introduction to research: understanding and applying multiple
strategies. 3rd Ed. St. Louis, Mosby.

Jolley, J. (2013) Introducing research and evidence-based practice for nursing and healthcare
professionals. 3rd Ed. New York, Routledge.

McCallum, C. and McLaren, S. (2011) Sense of belonging and depressive symptoms among
GLB adolescents, Journal of Homosexulaity, 58 (1), pp. 83-96. DOI: http://0-
dx.doi.org.lispac.lsbu.ac.uk/10.1080/00918369.2011.533629

McLaren, S. (2015) Gender, age and place of residence as moderators of the internalised
homophobia-depressive symptoms relation among Australian gay men and lesbians, Journal of
Homosexuality, 62 (4), pp. 463-480. DOI: http://0-
dx.doi.org.lispac.lsbu.ac.uk/10.1080/00918369.2014.983376

Poteat, P., Scheer, J., DiGiovanni, C. and Mereish, E. (2014) Short-term prospective effects of
homophobia victimisation on the mental health of heterosexual adolescents, Journal of Youth
and Adolescence, 43 (8), pp. 1240-1251. DOI: http://0-
dx.doi.org.lispac.lsbu.ac.uk/10.1007/s10964-013-0078-3