On March 31, 2017, the show 13 Reasons Why was released by Netflix worldwide. The drama-mystery portrays the trials of high school life, including many of the realities faced today by adolescents and young adults (e.g. feeling isolated, maneuvering relationships, making and losing friendships, heightened emotions, pressure to fit in, bullying, sexual and physical assault, domestic violence, homelessness, depression, anxiety). I, like many others in the mental health profession, was a little late to the “party” and first heard about the show a month ago from my 16-year old sister, who is in the age range of the show’s target audience. While there are many facets of the show which can be dissected, praised, or critiqued, the show never explicitly addresses the issue of depression, which is perhaps the key reason for the main character’s suicide. Many caregivers and families have been notified by their child’s school about the show, but few of these messages actually include any education for consumers about how clinical depression can be assessed. Coincidentally, along with the controversial show, May is Mental Health Awareness month in the U.S. and there is no better time than the present to discuss how you can spot depression in a loved one.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychological Association, 2013), Major Depressive Disorder is diagnosed when a person experiences a minimum of FIVE or more of the following symptoms:
1) Depressed mood most of the day, almost each day
2) Significantly diminished interest or pleasure in previously pleasurable/interesting activities, most of the day, almost every day
3) Significant weight loss or weight gain when one is not trying to lose or gain weight (e.g. a change of 5% body weight in the course of a month)
4) Sleeplessness or excessive sleepiness nearly every day
5) Inability to physically sit still or conversely, physical slowness, almost every day
6) Fatigue or loss of energy almost every day
7) Feelings of worthlessness or inappropriate guilt almost each day
8) Trouble thinking or concentrating almost each day
9) Repeated thoughts of death and dying almost every day, with or without a specific plan to achieve death
The DSM-5 also outlines that the combination of symptoms must cause significant disturbance in an individual’s social and occupational functioning, and the symptoms above cannot be due to another medical condition or the effects of substances.
Critically, there are marked age differences in the prevalence of Major Depressive Disorder (MDD). Individuals in late adolescence or early adulthood, in the 18 to 29-year-old range, experience clinically significant depression at rates that are three times higher than the prevalence of depression in older adults. Also of note, beginning early adolescence (ages 10-14 years), females experience depression at 1.5 to 3-times higher rates than their male counterparts (Kessler et al., 2003). Environmental risk factors for developing MDD include adverse childhood experiences of several types (Chapman et al., 2004) and stressful life events. Risk for non-suicidal self-injury (e.g. cutting one’s wrists, purposely hurting oneself to experience pain without the intent to cause permanent damage) and for lethal suicide exists at ALL times when a person is experiencing a Major Depressive Episode (MDE). Depressive disorders also tend to co-occur in people who are experiencing substance-use disorders, panic disorders, obsessive-compulsive disorders, eating disorders, and borderline personality disorder.
While countless psychometrically valid and reliable measures (e.g. Beck Depression Inventory, Hamilton Depression Rating Scale, Patient Health Questionnaire, Major Depression Inventory) exist which can be used to screen for depression across all ages, one important way to assess for depression is verbally. In the show 13 Reasons Why, when the main character seeks help from the school counselor, the counselor seems to skirt around critical questions put forth by the National Institute of Mental Health such as:
By asking these types of questions, both potential and imminent risks can be identified and appropriate care can be sought before it is too late, as was the case for Hannah Baker in 13 Reasons Why. Many friends, family, and even newer health professionals may be weary to ask these tough questions for fear that they may be "putting ideas into someone's head." However, a review of the research literature (Dazzi et al., 2014) suggests that acknowledging and talking about suicide and depression reduces, rather than increases, suicidal ideation and normalizes the experience of depression, which encourages depressed individuals to seek treatment for their depression rather than to hide it.
*NOTE: If you or a loved one are having thoughts of suicide, please do not hesitate to contact the resources below.
24/7 National Suicide Prevention Lifeline 1-800-273-TALK (8255) En Español: 1-888-628-9454
24/7 Crisis Text Line: Text “HOME” to 741-741
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.
Chapman DP , Whitfield CL , Felitti VJ , et al: Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 82(2):217–225, 2004.
Dazzi, T., Gribble, R., Wessely, S., & Feaar, N. T. (2014). Does asking about suicide and related behaviors induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16). Pp. 3361-3363.
Kessler RC , Berglund P , Demler O , et al: The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 289(23):3095–3105, 2003.
National Institutes of Mental Health, 2017. Ask Suicide-Screening Questions: ASQ.