case study of depression

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression, a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

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Antidepressants: A Research Update and a Case Example

What experiences do people have if they take antidepressants.

Posted December 20, 2018

• Find a therapist to overcome depression or anxiety

This post briefly reviews what researchers have been finding about the effectiveness and also the downsides of antidepressant medications — Zoloft, Prozac, and the like. The post then adds a fascinating case example, a self-description submitted to me by a reader who has experienced both the ups and the downs of antidepressant drugs. First, though, a word about my personal bias : Antidepressant pills definitely do help some people. At the same time, I regard them as vastly over-prescribed for mild to moderate depression and also for anxiety . Other treatment strategies for these situations can be equally or more effective, and without the downsides. In my TEDx talk on lifting depression , for instance, I demonstrate an antidepressant visualization exercise that I have used effectively in my clinical practice for decades. See also the techniques here .

What does the latest research suggest about whether you should take antidepressant medications?

For a particularly comprehensive review of the established medical risks of antidepressants , this article from Harvard Medical School is especially informative. You can find many similar articles with a web search of antidepressant risks.

In addition, a recent comprehensive review article of 522 trials and more than 116,000 patients — a meta-analysis combining the findings of all the available studies — reported on findings regarding 21 antidepressant drugs. This review was described as the most comprehensive analysis of the evidence ever undertaken. The Lancet Psychiatry , which reported the study, also then published a further analysis by the study’s authors. Here are their conclusions:

• Antidepressants can be, on average, an effective treatment for adults with moderate-to-severe major depression in the acute phase of illness.
• Effective as defined in this study means that there was a 50 percent or more reduction of depressive symptoms over an eight-week period. “Effective” did not imply complete remission (removal) of the depression.
• Some patients experienced great benefit from the medication ; others gained little or no benefit. In general, the more severe the depression, the more benefits from the antidepressant.
• The average response to a placebo (a sugar pill disguised as medication) was 35 percent. The average response to antidepressants ranged between 42 percent (reboxetine) and 53 percent (amitriptyline).
• For between 47 and 58 percent of subjects, depending on the specific drug, the medication was not effective. That is, they did not experience at least a 50 percent reduction in their depression symptoms.

Note that the depressed clients who did receive relief from taking an antidepressant medication definitely felt better — and yet not necessarily fully healed. Again, "effective" is defined as a 50 percent improvement in symptoms. This definition raises a number of questions:

• What about the remaining effects of depression, if only 50 percent of the symptoms have been relieved by the medication?
• Are antidepressant drugs appropriate to prescribe for milder depression? Or are non-medication therapy techniques just as or more effective? The research deals with only moderate to severe depression. Yet most prescriptions for antidepressants are given for milder to moderate depressive reactions.
• Earlier studies have concluded that the combination of both drugs and psychotherapy has the highest response rate. Both show about equal effectiveness on their own, except that psychotherapy has longer-lasting positive impacts, because it teaches skills and understandings that have long-term benefits. And what about the European research which has found that after people have taken an antidepressant, they become more likely to have subsequent depressive episodes?
• Because of the addictive potential of anti-anxiety drugs, like Xanax and Librium (xxx), antidepressants with sedating side-effect profiles now are prescribed to keep anxiety at bay. What are the effectiveness rates of antidepressants for treating anxiety?
• What about the negative side effects of antidepressants? The Lancet Psychiatry summary article says nothing about these, the most significant of which is drug dependency. Drug dependency means that once people have taken an antidepressant over a significant time period, their body begins to depend on it. The result is that when they try to discontinue taking the medication, their body has a rebound reaction of depression. That depression does not mean that they needed the antidepressant all along. It just means that the drug has caused their body to no longer produce the chemistry of well-being on its own.

A Medications Case Example: Despair, Delight, Disaster, and More

Many thanks to LC, for sharing her antidepressant experiences.

LC: It all started one late afternoon. I was in my car with my toddler-aged son, driving home through typical late afternoon traffic.

Suddenly I smelled the distinct scent of burning. Ahead of me, just five cars away, a plume of neon orange fire was climbing higher and higher. It was so out of place and so sudden that I didn't feel panicked or scared, I just stared for a few seconds, mouth wide open, my brain calibrating a fire on the highway.

Then I saw the people starting to run. And the panic set in. People all around me were jumping out of their cars and running down the highway, away from the gas truck that was literally on fire in front of us. The truck was still mostly intact, and it dawned on me all at once that a larger explosion might be imminent.

I jumped out of the car, pried open the car-seat straps, and then, flinging my son over my shoulder, ran to get as far away from the gasoline truck as possible. There was a BOOM sound, but I didn't look back. I just kept running and saying, "It's OK. We just need to move away from the fire," both to my son, and to myself.

The sirens started. Police and fire-trucks and ambulances somehow made their way through the maze of stopped cars.

A tragic gas leak had killed the driver of the truck. I texted my husband. I called and apologized profusely to my one-year-old's sitter for being so late.

Three hours later, I was on my way home. I had to run to the grocery store, pick up my 4-year-old from preschool, and make dinner. With three young children, I didn't have time to panic, process, or recover. I had to just keep going.

It was only later that night, after 11:00 p.m., that I felt the effects of that experience. My husband tried to calm me down. I was inconsolable. I wanted to scream or cry or run, but I was paralyzed and terrified.

The next day, I couldn't do anything. My anxiety was telling me that I was in danger. I wasn't, but the panic was still there. I was dreading trying to sleep again.

My sister told me to go immediately to a psychiatrist. I did. The psychiatrist talked to me for about 1 minute and then handed me a Xanax (an anti-anxiety pill) and a cup of water: "You are having a panic attack, and you've been in it for almost 24 hours. We need to get you calmed down."

Having a doctor hand me something I could swallow immediately soothed me. I was able finally to speak enough to tell the psychiatrist that I had seen a terrifying accident, and that I had never really suffered from anxiety or panic attacks before. I begged her to please make the anxiety stop.

The psychiatrist prescribed Xanax for a couple of weeks and then Cipralex, a commonly-used SSRI antidepressant that treats both depression and anxiety, to take long-term. She also said that it was imperative that I find a therapist and explore what was going on in my mind. I guess she assumed the trigger was deeper than just seeing a gasoline truck in flames.

Dr. Heitler: Traumatic events can trigger intense panic either during or at some point after the dangerous event has concluded. Eventually, especially with a chance to talk about what happened, the anxiety calms down. In LC’s case however, the parasympathetic nervous system , whose job it is to calm feelings of fear , was not functioning.

Fortunately, the anti-anxiety pill, Xanax, is fast-acting and effective.

Fortunately also, the psychiatrist had suggested that Lia speak with a talk therapist. Talking about the thoughts that were barraging her would enable Lia to digest her thoughts and feelings, both from the recent trauma and from prior events that had troubled her for some time.

Unfortunately, the psychiatrist did not offer non-pill options to calm the intense anxiety reaction. As the saying goes, to a man with a hammer, the world is a nail.

In this case, the hammer was in fact effective. Xanax brought Lia immediate relief. There are, however, non-pill options that can produce the same immediate calming effect. Both acupoint tapping and a visualization called the spinning technique would probably have done the job equally well. In addition, Lia easily could learn to do these techniques on her own at home should the anxiety return.

LC: The thing is . . . I knew that I needed therapy. It had been a long time coming. An unspoken trauma from the past was finding its way out, visiting me in dreams , and violating random moments in my life. I had been doing my best to silence it, shushing it desperately, hoping that it would just go away. So I started therapy. And I started the antidepressant drugs. And I was able to breathe. For a while.

Therapy opened my mind to myself. I had closed it years before. Re-opening it was as if a door had been kicked down. The halls and rooms of my mind were inviting me to explore, to wander, and to get reacquainted with my inner-world.

The SSRI seemed to be working too. I was more calm. I was more at ease. I wasn't barking at my husband about crumbs on the counter or scrubbing toys with bleach every night. I was laughing a little more, yelling a little less, more balanced.

What was from therapy, and what was from the SSRI? I didn’t care. I was just relieved to be breathing normally.

Dr. Heitler: Multiple studies of the treatment of serious emotional distress conclude that the combination of medication and psychotherapy is more potent than either alone. Lia’s case exemplifies this principle. Pills and talk therapy can potentiate each other, that is, cause each other to be more effective than either treatment alone could be.

At the same time, newer therapy techniques, such as the Body Code and Emotion Code, enable a therapist to radically shorten the time and intensity of talk therapy. Within one session or several, an Emotion Code therapist can pinpoint the earlier problem and immediately release trapped negative emotions so that they cease to have impact. With the underground spring that had been feeding anxious, angry and/or depressed feelings turned off, the feelings of vitality and well-being that we call mental health can emerge.

Marriage therapy also might well have helped Lia. My policy is when anyone who is married seeks therapy with me, I encourage them to bring their spouse. In almost all cases, underlying marital issues have been fanning the flames of negative emotions.

The spouse also can have a significant role in fostering a return to mental health. For instance, an anxious or depressed person may have an impulse to spend his evenings isolating and ruminating, saying troubling thoughts over and over to himself. Rumination exacerbates anxiety and depression. If husband and wife enjoy activities together in the evening, they are likely to be able to replace the rumination with pleasant interactions.

LC: I don't regret starting the antidepressant, the Cipralex. I truly feel like that drug saved my mind. It also probably held my marriage together for several more years. But by a year later, I knew that something was off. I knew that it was the medication.

Dr. Heitler: An antidepressant, especially in combination with good talk therapy, can work miracles in enabling people to get back to functioning in a normal emotional zone. The difficulties tend to come with the duration of use.

By prescribing an antidepressant medication and then keeping her on it for more than an initial several months, LC’s psychiatrist had inadvertently invited increasingly negative side effects. The negative side effects which had begun while Lia was taking the pills became even worse when she tried to get off the pills.

LC: At about a year, I started feeling fuzzy, num­­b, and detached. I would have several-minute episodes of not knowing what I was doing or how I got there. Then the confusion would dissipate, and I would be left thinking that I was just imagining it. But it would happen again. Fleeting, but tangible. Almost leaving a taste in my mouth.

I shared this with my husband, but he was worried about the anxiety returning if I messed with my medication. I waited.

Dr. Heitler: LC’s husband’s concerns had some genuine validity. The difficulty is that after a year of taking antidepressants, anyone who attempts to stop taking them must end their use very slowly. Otherwise, removal of the drugs can precipitate serious depression and/or anxiety.

It’s not that these emotions had been lurking there all along. Rather, antidepressants create drug dependency. The body forgets how to produce the chemicals that sustain well-being when they are being provided artificially by pills.

LC: The side effects worsened. I had no sex drive. I stopped feeling motivated to hang out with friends. I stopped caring about how I looked or what I was wearing. I was sinking. I had been saved from anxiety, and was now slipping into depression.

I made a unilateral decision to go off my meds. It wasn't a wise one. Looking back, I see that it was very much a desperate stand against the many factors in my life that I wasn't in control of — my devastation over my marriage that was quietly but quickly ending, my loss of focus on my passions and hobbies, my overweight and exhausted body, too strict in my religious life . . . the list goes on.

To simply argue that the SSRIs were ruining my life would be short-sighted and most likely wrong. I was ruining my life. But I was absolutely clear that the drug I was putting into my body every day was dragging me down and making it much harder to move forward. I felt very much alone — and for the first time in a while, very clear in my mission.

Dr. Heitler: In addition to creating drug dependency when used for more than several months at a stretch, antidepressants can produce a number of further negative side effects. Weight gain, loss of sexual feelings, emotional numbness, and "brain zapping" are among the most common. LC experienced these, and more.

LC: Going off SSRIs cold-turkey is nothing short of a ride through hell. The physical and emotional effects of suddenly depriving your brain of serotonin is horrific.

I was tormented by anxiety. I experienced electric pulses starting in my head and traveling down my entire body. I found myself in tears over everything. I had so much guilt over the decision. But I couldn't put that pill back in my mouth.

I pushed. It was raw without the drug. My husband and I separated. I said goodbye to God on a park bench and said hello to myself. I sabotaged a friendship — not something I'm proud of. I lost 35 pounds. I started singing out loud. I started running.

I told the psychiatrist what I had done. Even though so many things were better, I was on the verge of another breakdown, and I didn't know what to do.

The psychiatrist prescribed a different drug, this time an SNRI (two chemicals for the brain's "happy" place instead of one). She explained that since I was in the middle of a divorce — a major life-crisis for anyone — it probably wasn't the best time to go off psychiatric drugs.

That night I sat with the new pill in my hand. It took a serious pep talk to swallow it, but I did. I felt like I needed all the help I could get. I had three young children depending on me to keep it together, and I couldn't afford to let emotions destroy me. I had delved extensively into my past and had finally put to rest the lurking earlier trauma. I told myself I would take the drug, and when life settled down, I would get off.

Fast-forward a year and a half. A very similar cycle ensued. At first the SNRI filled me with renewed calm. It was like a rosy tint on life was just a pill away. And then . . . the fog set in. Again, about a year in, I felt that familiar detachment. I stopped caring about the little things. I started to feel like I was being numbed. Like I was underwater. Watching the world from below, too slow to stay actively involved in my own life. My sex drive started dying, and with it, my drive for life deteriorated.

With this new and more powerful drug, I again started feeling physical side effects. If I took the pill a few hours later than usual, I would get extremely nauseous. But if I took it in the morning, I would also get nausea and throw up. On the drug, I was more prone to migraines , I fainted several times that year, and I started gaining weight quite rapidly — despite my strictly healthy lifestyle.

This time around, I was determined to get off the drug safely. I checked in with a doctor. I started by taking off just one-quarter of the dose and did so every four weeks, allowing my brain to adapt each time.

Nonetheless, again it was hard, even painful. Each time I weaned down a dose, I had a week of horrible brain zaps. Even worse, I was much more reactive and impatient with my children. The weaning process took four months.

At the same time, I truly feel like this time around I experienced a beautiful and inspiring rebirth of myself. My senses feel heightened. My experiences are fully my own again.

Dr. Heitler: Paradoxically, ending her use of antidepressants turned out for LC to be the ultimate cure. With the pills no longer compromising her body’s chemistry, LC’s natural vitality eventually returned. So did her sexual feelings, ability to lose weight, eventual loss of the brain zapping, and a return of her former good-humored self.

LC’s conclusions: I'm still forming an objective opinion on the use of SSRIs. The power of these drugs, for better and for worse, is something that shouldn't be taken lightly. Off them now though, for me, heading away from antidepressants is heading in the right direction.

Dr. Heitler’s conclusions: Again, as I said at the outset, for a severe or suicidal depressive episode, antidepressant medications can relieve the intensity of dark thoughts and desperate feelings.

At the same time, Lia’s case illustrates well that antidepressants may:

• Have limited or no effectiveness for almost half of users
• Help somewhat, while many aspects of the depression remain
• Produce problematic side effects, like weight gain, decreased sexual feelings, brain zapping, nausea, clouded thinking, and numbing of feelings of joy as well as of negative emotions
• Create drug dependence when used for longer than a few months, and therefore difficult withdrawal symptoms, including withdrawal-induced depression
• Be prescribed for usages for which they are not intended (i.e., mild depressive reactions and anxiety) and for which non-drug options may be equally effective
• Be prescribed at length, for years rather than months, increasing the difficulties of eventual withdrawal

Susan Heitler, Ph.D ., is the author of many books, including From Conflict to Resolution and The Power of Two . She is a graduate of Harvard University and New York University.

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An Exploratory Study of Students with Depression in Undergraduate Research Experiences

• Katelyn M. Cooper
• Logan E. Gin
• M. Elizabeth Barnes
• Sara E. Brownell

*Address correspondence to: Katelyn M. Cooper ( E-mail Address: [email protected] ).

Department of Biology, University of Central Florida, Orlando, FL, 32816

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Biology Education Research Lab, Research for Inclusive STEM Education Center, School of Life Sciences, Arizona State University, Tempe, AZ 85281

Depression is a top mental health concern among undergraduates and has been shown to disproportionately affect individuals who are underserved and underrepresented in science. As we aim to create a more inclusive scientific community, we argue that we need to examine the relationship between depression and scientific research. While studies have identified aspects of research that affect graduate student depression, we know of no studies that have explored the relationship between depression and undergraduate research. In this study, we sought to understand how undergraduates’ symptoms of depression affect their research experiences and how research affects undergraduates’ feelings of depression. We interviewed 35 undergraduate researchers majoring in the life sciences from 12 research-intensive public universities across the United States who identify with having depression. Using inductive and deductive coding, we identified that students’ depression affected their motivation and productivity, creativity and risk-taking, engagement and concentration, and self-perception and socializing in undergraduate research experiences. We found that students’ social connections, experiencing failure in research, getting help, receiving feedback, and the demands of research affected students’ depression. Based on this work, we articulate an initial set of evidence-based recommendations for research mentors to consider in promoting an inclusive research experience for students with depression.

INTRODUCTION

Depression is described as a common and serious mood disorder that results in persistent feelings of sadness and hopelessness, as well as a loss of interest in activities that one once enjoyed ( American Psychiatric Association [APA], 2013 ). Additional symptoms of depression include weight changes, difficulty sleeping, loss of energy, difficulty thinking or concentrating, feelings of worthlessness or excessive guilt, and suicidality ( APA, 2013 ). While depression results from a complex interaction of psychological, social, and biological factors ( World Health Organization, 2018 ), studies have shown that increased stress caused by college can be a significant contributor to student depression ( Dyson and Renk, 2006 ).

Depression is one of the top undergraduate mental health concerns, and the rate of depression among undergraduates continues to rise ( Center for Collegiate Mental Health, 2017 ). While we cannot discern whether these increasing rates of depression are due to increased awareness or increased incidence, it is clear that is a serious problem on college campuses. The percent of U.S. college students who self-reported a diagnosis with depression was recently estimated to be about 25% ( American College Health Association, 2019 ). However, higher rates have been reported, with one study estimating that up to 84% of undergraduates experience some level of depression ( Garlow et al. , 2008 ). Depression rates are typically higher among university students compared with the general population, despite being a more socially privileged group ( Ibrahim et al. , 2013 ). Prior studies have found that depression is negatively correlated with overall undergraduate academic performance ( Hysenbegasi et al. , 2005 ; Deroma et al. , 2009 ; American College Health Association, 2019 ). Specifically, diagnosed depression is associated with half a letter grade decrease in students’ grade point average ( Hysenbegasi et al. , 2005 ), and 21.6% of undergraduates reported that depression negatively affected their academic performance within the last year ( American College Health Association, 2019 ). Provided with a list of academic factors that may be affected by depression, students reported that depression contributed to lower exam grades, lower course grades, and not completing or dropping a course.

Students in the natural sciences may be particularly at risk for depression, given that such majors are noted to be particularly stressful due to their competitive nature and course work that is often perceived to “weed students out”( Everson et al. , 1993 ; Strenta et al. , 1994 ; American College Health Association, 2019 ; Seymour and Hunter, 2019 ). Science course instruction has also been described to be boring, repetitive, difficult, and math-intensive; these factors can create an environment that can trigger depression ( Seymour and Hewitt, 1997 ; Osborne and Collins, 2001 ; Armbruster et al ., 2009 ; Ceci and Williams, 2010 ). What also distinguishes science degree programs from other degree programs is that, increasingly, undergraduate research experiences are being proposed as an essential element of a science degree ( American Association for the Advancement of Science, 2011 ; President’s Council of Advisors on Science and Technology, 2012 ; National Academies of Sciences, Engineering, and Medicine [NASEM], 2017 ). However, there is some evidence that undergraduate research experiences can add to the stress of college for some students ( Cooper et al. , 2019c ). Students can garner multiple benefits from undergraduate research, including enhanced abilities to think critically ( Ishiyama, 2002 ; Bauer and Bennett, 2003 ; Brownell et al. , 2015 ), improved student learning ( Rauckhorst et al. , 2001 ; Brownell et al. , 2015 ), and increased student persistence in undergraduate science degree programs ( Jones et al. , 2010 ; Hernandez et al. , 2018 ). Notably, undergraduate research experiences are increasingly becoming a prerequisite for entry into medical and graduate programs in science, particularly elite programs ( Cooper et al. , 2019d ). Although some research experiences are embedded into formal lab courses as course-based undergraduate research experiences (CUREs; Auchincloss et al. , 2014 ; Brownell and Kloser, 2015 ), the majority likely entail working with faculty in their research labs. These undergraduate research experiences in faculty labs are often added on top of a student’s normal course work, so they essentially become an extracurricular activity that they have to juggle with course work, working, and/or personal obligations ( Cooper et al. , 2019c ). While the majority of the literature surrounding undergraduate research highlights undergraduate research as a positive experience ( NASEM, 2017 ), studies have demonstrated that undergraduate research experiences can be academically and emotionally challenging for students ( Mabrouk and Peters, 2000 ; Seymour et al. , 2004 ; Cooper et al. , 2019c ; Limeri et al. , 2019 ). In fact, 50% of students sampled nationally from public R1 institutions consider leaving their undergraduate research experience prematurely, and about half of those students, or 25% of all students, ultimately leave their undergraduate research experience ( Cooper et al. , 2019c ). Notably, 33.8% of these individuals cited a negative lab environment and 33.3% cited negative relationships with their mentors as factors that influenced their decision about whether to leave ( Cooper et al. , 2019c ). Therefore, students’ depression may be exacerbated in challenging undergraduate research experiences, because studies have shown that depression is positively correlated with student stress ( Hish et al. , 2019 ).

While depression has not been explored in the context of undergraduate research experiences, depression has become a prominent concern surrounding graduate students conducting scientific research. A recent study that examined the “graduate student mental health crisis” ( Flaherty, 2018 ) found that work–life balance and graduate students’ relationships with their research advisors may be contributing to their depression ( Evans et al. , 2018 ). Specifically, this survey of 2279 PhD and master’s students from diverse fields of study, including the biological/physical sciences, showed that 39% of graduate students have experienced moderate to severe depression. Fifty-five percent of the graduate students with depression who were surveyed disagreed with the statement “I have good work life balance,” compared to only 21% of students with depression who agreed. Additionally, the study highlighted that more students with depression disagreed than agreed with the following statements: their advisors provided “real” mentorship, their advisors provided ample support, their advisors positively impacted their emotional or mental well-being, their advisors were assets to their careers, and they felt valued by their mentors. Another recent study identified that depression severity in biomedical doctoral students was significantly associated with graduate program climate, a perceived lack of employment opportunities, and the quality of students’ research training environment ( Nagy et al. , 2019 ). Environmental stress, academic stress, and family and monetary stress have also been shown to be predictive of depression severity in biomedical doctoral students ( Hish et al. , 2019 ). Further, one study found that self-esteem is negatively correlated and stress is positively correlated with graduate student depression; presumably research environments that challenge students’ self-esteem and induce stress are likely contributing to depressive symptoms among graduate students ( Kreger, 1995 ). While these studies have focused on graduate students, and there are certainly notable distinctions between graduate and undergraduate research, the research-related factors that affect graduate student depression, including work–life balance, relationships with mentors, research environment, stress, and self-esteem, may also be relevant to depression among undergraduates conducting research. Importantly, undergraduates in the United States have reported identical levels of depression as graduate students but are often less likely to seek mental health care services ( Wyatt and Oswalt, 2013 ), which is concerning if undergraduate research experiences exacerbate depression.

Based on the literature on the stressors of undergraduate research experiences and the literature identifying some potential causes of graduate student depression, we identified three aspects of undergraduate research that may exacerbate undergraduates’ depression. Mentoring: Mentors can be an integral part of a students’ research experience, bolstering their connections with others in the science community, scholarly productivity, and science identity, as well as providing many other benefits ( Thiry and Laursen, 2011 ; Prunuske et al. , 2013 ; Byars-Winston et al. , 2015 ; Aikens et al. , 2016 , 2017 ; Thompson et al. , 2016 ; Estrada et al. , 2018 ). However, recent literature has highlighted that poor mentoring can negatively affect undergraduate researchers ( Cooper et al. , 2019c ; Limeri et al. , 2019 ). Specifically, one study of 33 undergraduate researchers who had conducted research at 10 institutions identified seven major ways that they experienced negative mentoring, which included absenteeism, abuse of power, interpersonal mismatch, lack of career support, lack of psychosocial support, misaligned expectations, and unequal treatment ( Limeri et al. , 2019 ). We hypothesize negative mentoring experiences may be particularly harmful for students with depression, because support, particularly social support, has been shown to be important for helping individuals with depression cope with difficult circumstances ( Aneshensel and Stone, 1982 ; Grav et al. , 2012 ). Failure: Experiencing failure has been hypothesized to be an important aspect of undergraduate research experiences that may help students develop some the most distinguishing abilities of outstanding scientists, such as coping with failure, navigating challenges, and persevering ( Laursen et al. , 2010 ; Gin et al. , 2018 ; Henry et al. , 2019 ). However, experiencing failure and the stress and fatigue that often accompany it may be particularly tough for students with depression ( Aldwin and Greenberger, 1987 ; Mongrain and Blackburn, 2005 ). Lab environment: Fairness, inclusion/exclusion, and social support within one’s organizational environment have been shown to be key factors that cause people to either want to remain in the work place and be productive or to want to leave ( Barak et al. , 2006 ; Cooper et al. , 2019c ). We hypothesize that dealing with exclusion or a lack of social support may exacerbate depression for some students; patients with clinical depression react to social exclusion with more pronounced negative emotions than do individuals without clinical depression ( Jobst et al. , 2015 ). While there are likely other aspects of undergraduate research that affect student depression, we hypothesize that these factors have the potential to exacerbate negative research experiences for students with depression.

Depression has been shown to disproportionately affect many populations that are underrepresented or underserved within the scientific community, including females ( American College Health Association, 2018 ; Evans et al. , 2018 ), first-generation college students ( Jenkins et al. , 2013 ), individuals from low socioeconomic backgrounds ( Eisenberg et al. , 2007 ), members of the LGBTQ+ community ( Eisenberg et al. , 2007 ; Evans et al. , 2018 ), and people with disabilities ( Turner and Noh, 1988 ). Therefore, as the science community strives to be more diverse and inclusive ( Intemann, 2009 ), it is important that we understand more about the relationship between depression and scientific research, because negative experiences with depression in scientific research may be contributing to the underrepresentation of these groups. Specifically, more information is needed about how the research process and environment of research experiences may affect depression.

Given the high rate of depression among undergraduates, the links between depression and graduate research, the potentially challenging environment of undergraduate research, and how depression could disproportionately impact students from underserved communities, it is imperative to begin to explore the relationship between scientific research and depression among undergraduates to create research experiences that could maximize student success. In this exploratory interview study, we aimed to 1) describe how undergraduates’ symptoms of depression affect their research experiences, 2) understand how undergraduate research affects students’ feelings of depression, and 3) identify recommendations based on the literature and undergraduates’ reported experiences to promote a positive research experience for students with depression.

This study was done with an approved Arizona State University Institutional Review Board protocol #7247.

In Fall 2018, we surveyed undergraduate researchers majoring in the life sciences across 25 research-intensive (R1) public institutions across the United States (specific details about the recruitment of the students who completed the survey can be found in Cooper et al. (2019c) ). The survey asked students for their opinions about their undergraduate research experiences and their demographic information and whether they would be interested in participating in a follow-up interview related to their research experiences. For the purpose of this study, we exclusively interviewed students about their undergraduate research experiences in faculty member labs; we did not consider students’ experiences in CUREs. Of the 768 undergraduate researchers who completed the survey, 65% ( n = 496) indicated that they would be interested in participating in a follow-up interview. In Spring 2019, we emailed the 496 students, explaining that we were interested in interviewing students with depression about their experiences in undergraduate research. Our specific prompt was: “If you identify as having depression, we would be interested in hearing about your experience in undergraduate research in a 30–60 minute online interview.” We did not define depression in our email recruitment because we conducted think-aloud interviews with four undergraduates who all correctly interpreted what we meant by depression ( APA, 2013 ). We had 35 students agree to participate in the interview study. The interview participants represented 12 of the 25 R1 public institutions that were represented in the initial survey.

Student Interviews

We developed an interview script to explore our research questions. Specifically, we were interested in how students’ symptoms of depression affect their research experiences, how undergraduate research negatively affects student depression, and how undergraduate research positively affects student depression.

We recognized that mental health, and specifically depression, can be a sensitive topic to discuss with undergraduates, and therefore we tried to minimize any discomfort that the interviewees might experience during the interview. Specifically, we conducted think-aloud interviews with three graduate students who self-identified with having depression at the time of the interview. We asked them to note whether any interview questions made them uncomfortable. We also sought their feedback on questions given their experiences as persons with depression who had once engaged in undergraduate research. We revised the interview protocol after each think-aloud interview. Next, we conducted four additional think-aloud interviews with undergraduates conducting basic science or biology education research who identified with having depression to establish cognitive validity of the questions and to elicit additional feedback about any questions that might make someone uncomfortable. The questions were revised after each think-aloud interview until no question was unclear or misinterpreted by the students and we were confident that the questions minimized students’ potential discomfort ( Trenor et al. , 2011 ). A copy of the final interview script can be found in the Supplemental Material.

All interviews were individually conducted by one of two researchers (K.M.C. and L.E.G.) who conducted the think-aloud interviews together to ensure that their interviewing practices were as similar as possible. The interviews were approximately an hour long, and students received a $15 gift card for their participation.

Personal, Research, and Depression Demographics

All student demographics and information about students’ research experiences were collected using the survey distributed to students in Fall 2018. We collected personal demographics, including the participants’ gender, race/ethnicity, college generation status, transfer status, financial stability, year in college, major, and age. We also collected information about the students’ research experiences, including the length of their first research experiences, the average number of hours they spend in research per week, how they were compensated for research, who their primary mentors were, and the focus areas of their research.

In the United States, mental healthcare is disproportionately unavailable to Black and Latinx individuals, as well as those who come from low socioeconomic backgrounds ( Kataoka et al. , 2002 ; Howell and McFeeters, 2008 ; Santiago et al. , 2013 ). Therefore, to minimize a biased sample, we invited anyone who identified with having depression to participate in our study; we did not require students to be diagnosed with depression or to be treated for depression in order to participate. However, we did collect information about whether students had been formally diagnosed with depression and whether they had been treated for depression. After the interview, all participants were sent a link to a short survey that asked them if they had ever been diagnosed with depression and how, if at all, they had ever been treated for depression. A copy of these survey questions can be found in the Supplemental Material. The combined demographic information of the participants is in Table 1 . The demographics for each individual student can be found in the Supplemental Material.

a Students reported the time they had spent in research 6 months before being interviewed and only reported on the length of time of their first research experiences.

b Students were invited to report multiple ways in which they were treated for their depression; other treatments included lifestyle changes and meditation.

c Students were invited to report multiple means of compensation for their research if they had been compensated for their time in different ways.

d Students were asked whether they felt financially stable, particularly during the undergraduate research experience.

e Students reported who they work/worked with most closely during their research experiences.

f Staff members included lab coordinators or lab managers.

g Other focus areas of research included sociology, linguistics, psychology, and public health.

Interview Analysis

The initial interview analysis aimed to explore each idea that a participant expressed ( Charmaz, 2006 ) and to identify reoccurring ideas throughout the interviews. First, three authors (K.M.C., L.E.G., and S.E.B.) individually reviewed a different set of 10 interviews and took detailed analytic notes ( Birks and Mills, 2015 ). Afterward, the authors compared their notes and identified reoccurring themes throughout the interviews using open coding methods ( Saldaña, 2015 ).

Once an initial set of themes was established, two researchers (K.M.C. and L.E.G.) individually reviewed the same set of 15 randomly selected interviews to validate the themes identified in the initial analysis and to screen for any additional themes that the initial analysis may have missed. Each researcher took detailed analytic notes throughout the review of an interview, which they discussed after reviewing each interview. The researchers compared what quotes from each interview they categorized into each theme. Using constant comparison methods, they assigned quotes to each theme and constantly compared the quotes to ensure that each quote fit within the description of the theme ( Glesne and Peshkin, 1992 ). In cases in which quotes were too different from other quotes, a new theme was created. This approach allowed for multiple revisions of the themes and allowed the authors to define a final set of codes; the researchers created a final codebook with refined definitions of emergent themes (the final coding rubric can be found in the Supplemental Material). Once the final codebook was established, the researchers (K.M.C. and L.E.G.) individually coded seven additional interviews (20% of all interviews) using the coding rubric. The researchers compared their codes, and their Cohen’s κ interrater score for these seven interviews was at an acceptable level (κ  =  0.88; Landis and Koch, 1977 ). One researcher (L.E.G.) coded the remaining 28 out of 35 interviews. The researchers determined that data saturation had been reached with the current sample and no further recruitment was needed ( Guest et al. , 2006 ). We report on themes that were mentioned by at least 20% of students in the interview study. In the Supplemental Material, we provide the final coding rubric with the number of participants whose interview reflected each theme ( Hannah and Lautsch, 2011 ). Reporting the number of individuals who reported themes within qualitative data can lead to inaccurate conclusions about the generalizability of the results to a broader population. These qualitative data are meant to characterize a landscape of experiences that students with depression have in undergraduate research rather than to make claims about the prevalence of these experiences ( Glesne and Peshkin, 1992 ). Because inferences about the importance of these themes cannot be drawn from these counts, they are not included in the results of the paper ( Maxwell, 2010 ). Further, the limited number of interviewees made it not possible to examine whether there were trends based on students’ demographics or characteristics of their research experiences (e.g., their specific area of study). Quotes were lightly edited for clarity by inserting clarification brackets and using ellipses to indicate excluded text. Pseudonyms were given to all students to protect their privacy.

The Effect of Depressive Symptoms on Undergraduate Research

We asked students to describe the symptoms associated with their depression. Students described experiencing anxiety that is associated with their depression; this could be anxiety that precedes their depression or anxiety that results from a depressive episode or a period of time when an individual has depression symptoms. Further, students described difficulty getting out of bed or leaving the house, feeling tired, a lack of motivation, being overly self-critical, feeling apathetic, and having difficulty concentrating. We were particularly interested in how students’ symptoms of depression affected their experiences in undergraduate research. During the think-aloud interviews that were conducted before the interview study, graduate and undergraduate students consistently described that their depression affected their motivation in research, their creativity in research, and their productivity in research. Therefore, we explicitly asked undergraduate researchers how, if at all, their depression affected these three factors. We also asked students to describe any additional ways in which their depression affected their research experiences. Undergraduate researchers commonly described five additional ways in which their depression affected their research; for a detailed description of each way students’ research was affected and for example quotes, see Table 2 . Students described that their depression negatively affected their productivity in the lab. Commonly, students described that their productivity was directly affected by a lack of motivation or because they felt less creative, which hindered the research process. Additionally, students highlighted that they were sometimes less productive because their depression sometimes caused them to struggle to engage intellectually with their research or caused them to have difficulty remembering or concentrating; students described that they could do mundane or routine tasks when they felt depressed, but that they had difficulty with more complex and intellectually demanding tasks. However, students sometimes described that even mundane tasks could be difficult when they were required to remember specific steps; for example, some students struggled recalling a protocol from memory when their depression was particularly severe. Additionally, students noted that their depression made them more self-conscious, which sometimes held them back from sharing research ideas with their mentors or from taking risks such as applying to competitive programs. In addition to being self-conscious, students highlighted that their depression caused them to be overly self-critical, and some described experiencing imposter phenomenon ( Clance and Imes, 1978 ) or feeling like they were not talented enough to be in research and were accepted into a lab by a fluke or through luck. Finally, students described that depression often made them feel less social, and they struggled to socially engage with other members of the lab when they were feeling down.

The Effect of Undergraduate Research Experiences on Student Depression

We also wanted to explore how research impacted students’ feelings of depression. Undergraduates described how research both positively and negatively affected their depression. In the following sections, we present aspects of undergraduate research and examine how each positively and/or negatively affected students’ depression using embedded student quotes to highlight the relationships between related ideas.

Lab Environment: Relationships with Others in the Lab.

Some aspects of the lab environment, which we define as students’ physical, social, or psychological research space, could be particularly beneficial for students with depression.

Specifically, undergraduate researchers perceived that comfortable and positive social interactions with others in the lab helped their depression. Students acknowledged how beneficial their relationships with graduate students and postdocs could be.

Marta: “I think always checking in on undergrads is important. It’s really easy [for us] to go a whole day without talking to anybody in the lab. But our grad students are like ‘Hey, what’s up? How’s school? What’s going on?’ (…) What helps me the most is having that strong support system. Sometimes just talking makes you feel better, but also having people that believe in you can really help you get out of that negative spiral. I think that can really help with depression.”

Kelley: “I know that anytime I need to talk to [my postdoc mentors] about something they’re always there for me. Over time we’ve developed a relationship where I know that outside of work and outside of the lab if I did want to talk to them about something I could talk to them. Even just talking to someone about hobbies and having that relationship alone is really helpful [for depression].”

In addition to highlighting the importance of developing relationships with graduate students or postdocs in the lab, students described that forming relationships with other undergraduates in the lab also helped their depression. Particularly, students described that other undergraduate researchers often validated their feelings about research, which in turn helped them realize that what they are thinking or feeling is normal, which tended to alleviate their negative thoughts. Interestingly, other undergraduates experiencing the same issues could sometimes help buffer them from perceiving that a mentor did not like them or that they were uniquely bad at research. In this article, we use the term “mentor” to refer to anyone who students referred to in the interviews as being their mentors or managing their research experiences; this includes graduate students, postdoctoral scholars, lab managers, and primary investigators (PIs).

Abby: “One of my best friends is in the lab with me.  A lot of that friendship just comes from complaining about our stress with the lab and our annoyance with people in the lab. Like when we both agree like, ‘Yeah, the grad students were really off today, it wasn’t us,’ that helps. ‘It wasn’t me, it wasn’t my fault that we were having a rough day in lab; it was the grad students.’ Just being able to realize, ‘Hey, this isn’t all caused by us,’ you know? (…) We understand the stresses in the lab. We understand the details of what each other are doing in the lab, so when something doesn’t work out, we understand that it took them like eight hours to do that and it didn’t work. We provide empathy on a different level.”

Meleana: “It’s great to have solidarity in being confused about something, and it’s just that is a form of validation for me too. When we leave a lab meeting and I look at [another undergrad] I’m like, ‘Did you understand anything that they were just saying?’ And they’re like, ‘Oh, no.’ (…) It’s just really validating to hear from the other undergrads that we all seem to be struggling with the same things.”

Developing positive relationships with faculty mentors or PIs also helped alleviate some students’ depressive feelings, particularly when PIs shared their own struggles with students. This also seemed to normalize students’ concerns about their own experiences.

Alexandra: “[Talking with my PI] is helpful because he would talk about his struggles, and what he faced. A lot of it was very similar to my struggles.  For example, he would say, ‘Oh, yeah, I failed this exam that I studied so hard for. I failed the GRE and I paid so much money to prepare for it.’ It just makes [my depression] better, like okay, this is normal for students to go through this. It’s not an out of this world thing where if you fail, you’re a failure and you can’t move on from it.”

Students’ relationships with others in the lab did not always positively impact their depression. Students described instances when the negative moods of the graduate students and PIs would often set the tone of the lab, which in turn worsened the mood of the undergraduate researchers.

Abby: “Sometimes [the grad students] are not in a good mood. The entire vibe of the lab is just off, and if you make a joke and it hits somebody wrong, they get all mad. It really depends on the grad students and the leadership and the mood that they’re in.”

Interviewer: “How does it affect your depression when the grad students are in a bad mood?”

Abby: “It definitely makes me feel worse. It feels like, again, that I really shouldn’t go ask them for help because they’re just not in the mood to help out. It makes me have more pressure on myself, and I have deadlines I need to meet, but I have a question for them, but they’re in a bad mood so I can’t ask. That’s another day wasted for me and it just puts more stress, which just adds to the depression.”

Additionally, some students described even more concerning behavior from research mentors, which negatively affected their depression.

Julie: “I had a primary investigator who is notorious in the department for screaming at people, being emotionally abusive, unreasonable, et cetera. (…) [He was] kind of harassing people, demeaning them, lying to them, et cetera, et cetera. (…) Being yelled at and constantly demeaned and harassed at all hours of the day and night, that was probably pretty bad for me.”

While the relationships between undergraduates and graduate, postdoc, and faculty mentors seemed to either alleviate or worsen students’ depressive symptoms, depending on the quality of the relationship, students in this study exclusively described their relationships with other undergraduates as positive for their depression. However, students did note that undergraduate research puts some of the best and brightest undergraduates in the same environment, which can result in students comparing themselves with their peers. Students described that this comparison would often lead them to feel badly about themselves, even though they would describe their personal relationship with a person to be good.

Meleana: “In just the research field in general, just feeling like I don’t really measure up to the people around me [can affect my depression]. A lot of the times it’s the beginning of a little spiral, mental spiral. There are some past undergrads that are talked about as they’re on this pedestal of being the ideal undergrads and that they were just so smart and contributed so much to the lab. I can never stop myself from wondering like, ‘Oh, I wonder if I’m having a contribution to the lab that’s similar or if I’m just another one of the undergrads that does the bare minimum and passes through and is just there.’”

Natasha: “But, on the other hand, [having another undergrad in the lab] also reminded me constantly that some people are invested in this and meant to do this and it’s not me. And that some people know a lot more than I do and will go further in this than I will.”

While students primarily expressed that their relationships with others in the lab affected their depression, some students explained that they struggled most with depression when the lab was empty; they described that they did not like being alone in the lab, because a lack of stimulation allowed their minds to be filled with negative thoughts.

Mia: “Those late nights definitely didn’t help [my depression]. I am alone, in the entire building.  I’m left alone to think about my thoughts more, so not distracted by talking to people or interacting with people. I think more about how I’m feeling and the lack of progress I’m making, and the hopelessness I’m feeling. That kind of dragged things on, and I guess deepened my depression.”

Freddy: “Often times when I go to my office in the evening, that is when I would [ sic ] be prone to be more depressed. It’s being alone. I think about myself or mistakes or trying to correct mistakes or whatever’s going on in my life at the time. I become very introspective. I think I’m way too self-evaluating, way too self-deprecating and it’s when I’m alone when those things are really, really triggered. When I’m talking with somebody else, I forget about those things.”

In sum, students with depression highlighted that a lab environment full of positive and encouraging individuals was helpful for their depression, whereas isolating or competitive environments and negative interactions with others often resulted in more depressive feelings.

Doing Science: Experiencing Failure in Research, Getting Help, Receiving Feedback, Time Demands, and Important Contributions.

In addition to the lab environment, students also described that the process of doing science could affect their depression. Specifically, students explained that a large contributor to their depression was experiencing failure in research.

Interviewer: “Considering your experience in undergraduate research, what tends to trigger your feelings of depression?”

Heather: “Probably just not getting things right. Having to do an experiment over and over again. You don’t get the results you want. (…) The work is pretty meticulous and it’s frustrating when I do all this work, I do a whole experiment, and then I don’t get any results that I can use. That can be really frustrating. It adds to the stress. (…) It’s hard because you did all this other stuff before so you can plan for the research, and then something happens and all the stuff you did was worthless basically.”

Julie: “I felt very negatively about myself [when a project failed] and pretty panicked whenever something didn’t work because I felt like it was a direct reflection on my effort and/or intelligence, and then it was a big glaring personal failure.”

Students explained that their depression related to failing in research was exacerbated if they felt as though they could not seek help from their research mentors. Perceived insufficient mentor guidance has been shown to be a factor influencing student intention to leave undergraduate research ( Cooper et al. , 2019c ). Sometimes students talked about their research mentors being unavailable or unapproachable.

Michelle: “It just feels like [the graduate students] are not approachable. I feel like I can’t approach them to ask for their understanding in a certain situation. It makes [my depression] worse because I feel like I’m stuck, and that I’m being limited, and like there’s nothing I can do. So then I kind of feel like it’s my fault that I can’t do anything.”

Other times, students described that they did not seek help in fear that they would be negatively evaluated in research, which is a fear of being judged by others ( Watson and Friend, 1969 ; Weeks et al. , 2005 ; Cooper et al. , 2018 ). That is, students fear that their mentor would think negatively about them or judge them if they were to ask questions that their mentor thought they should know the answer to.

Meleana: “I would say [my depression] tends to come out more in being more reserved in asking questions because I think that comes more like a fear-based thing where I’m like, ‘Oh, I don’t feel like I’m good enough and so I don’t want to ask these questions because then my mentors will, I don’t know, think that I’m dumb or something.’”

Conversely, students described that mentors who were willing to help them alleviated their depressive feelings.

Crystal: “Yeah [my grad student] is always like, ‘Hey, I can check in on things in the lab because you’re allowed to ask me for that, you’re not totally alone in this,’ because he knows that I tend to take on all this responsibility and I don’t always know how to ask for help. He’s like, ‘You know, this is my lab too and I am here to help you as well,’ and just reminds me that I’m not shouldering this burden by myself.”

Ashlyn: “The graduate student who I work with is very kind and has a lot of patience and he really understands a lot of things and provides simple explanations. He does remind me about things and he will keep on me about certain tasks that I need to do in an understanding way, and it’s just because he’s patient and he listens.”

In addition to experiencing failure in science, students described that making mistakes when doing science also negatively affected their depression.

Abby: “I guess not making mistakes on experiments [is important in avoiding my depression]. Not necessarily that your experiment didn’t turn out to produce the data that you wanted, but just adding the wrong enzyme or messing something up like that. It’s like, ‘Oh, man,’ you know? You can get really down on yourself about that because it can be embarrassing.”

Commonly, students described that the potential for making mistakes increased their stress and anxiety regarding research; however, they explained that how other people responded to a potential mistake was what ultimately affected their depression.

Briana: “Sometimes if I made a mistake in correctly identifying an eye color [of a fly], [my PI] would just ridicule me in front of the other students. He corrected me but his method of correcting was very discouraging because it was a ridicule. It made the others laugh and I didn’t like that.”

Julie: “[My PI] explicitly [asked] if I had the dedication for science. A lot of times he said I had terrible judgment. A lot of times he said I couldn’t be trusted. Once I went to a conference with him, and, unfortunately, in front of another professor, he called me a klutz several times and there was another comment about how I never learn from my mistakes.”

When students did do things correctly, they described how important it could be for them to receive praise from their mentors. They explained that hearing praise and validation can be particularly helpful for students with depression, because their thoughts are often very negative and/or because they have low self-esteem.

Crystal: “[Something that helps my depression is] I have text messages from [my graduate student mentor] thanking me [and another undergraduate researcher] for all of the work that we’ve put in, that he would not be able to be as on track to finish as he is if he didn’t have our help.”

Interviewer: “Why is hearing praise from your mentor helpful?”

Crystal: “Because a lot of my depression focuses on everybody secretly hates you, nobody likes you, you’re going to die alone. So having that validation [from my graduate mentor] is important, because it flies in the face of what my depression tells me.”

Brian: “It reminds you that you exist outside of this negative world that you’ve created for yourself, and people don’t see you how you see yourself sometimes.”

Students also highlighted how research could be overwhelming, which negatively affected their depression. Particularly, students described that research demanded a lot of their time and that their mentors did not always seem to be aware that they were juggling school and other commitments in addition to their research. This stress exacerbated their depression.

Rose: “I feel like sometimes [my grad mentors] are not very understanding because grad students don’t take as many classes as [undergrads] do. I think sometimes they don’t understand when I say I can’t come in at all this week because I have finals and they’re like, ‘Why though?’”

Abby: “I just think being more understanding of student life would be great. We have classes as well as the lab, and classes are the priority. They forget what it’s like to be a student. You feel like they don’t understand and they could never understand when you say like, ‘I have three exams this week,’ and they’re like, ‘I don’t care. You need to finish this.’”

Conversely, some students reported that their research labs were very understanding of students’ schedules. Interestingly, these students talked most about how helpful it was to be able to take a mental health day and not do research on days when they felt down or depressed.

Marta: “My lab tech is very open, so she’ll tell us, ‘I can’t come in today. I have to take a mental health day.’ So she’s a really big advocate for that. And I think I won’t personally tell her that I’m taking a mental health day, but I’ll say, ‘I can’t come in today, but I’ll come in Friday and do those extra hours.’ And she’s like, ‘OK great, I’ll see you then.’  And it makes me feel good, because it helps me take care of myself first and then I can take care of everything else I need to do, which is amazing.”

Meleana: “Knowing that [my mentors] would be flexible if I told them that I’m crazy busy and can’t come into work nearly as much this week [helps my depression]. There is flexibility in allowing me to then care for myself.”

Interviewer: “Why is the flexibility helpful given the depression?”

Meleana: “Because sometimes for me things just take a little bit longer when I’m feeling down. I’m just less efficient to be honest, and so it’s helpful if I feel like I can only go into work for 10 hours in a week. It declutters my brain a little bit to not have to worry about all the things I have to do in work in addition the things that I need to do for school or clubs, or family or whatever.”

Despite the demanding nature of research, a subset of students highlighted that their research and research lab provided a sense of stability or familiarity that distracted them from their depression.

Freddy: “I’ll [do research] to run away from those [depressive] feelings or whatever. (…) I find sadly, I hate to admit it, but I do kind of run to [my lab]. I throw myself into work to distract myself from the feelings of depression and sadness.”

Rose: “When you’re sad or when you’re stressed you want to go to things you’re familiar with. So because lab has always been in my life, it’s this thing where it’s going to be there for me I guess. It’s like a good book that you always go back to and it’s familiar and it makes you feel good. So that’s how lab is. It’s not like the greatest thing in the world but it’s something that I’m used to, which is what I feel like a lot of people need when they’re sad and life is not going well.”

Many students also explained that research positively affects their depression because they perceive their research contribution to be important.

Ashlyn: “I feel like I’m dedicating myself to something that’s worthy and something that I believe in. It’s really important because it contextualizes those times when I am feeling depressed. It’s like, no, I do have these better things that I’m working on. Even when I don’t like myself and I don’t like who I am, which is again, depression brain, I can at least say, ‘Well, I have all these other people relying on me in research and in this area and that’s super important.’”

Jessica: “I mean, it just felt like the work that I was doing had meaning and when I feel like what I’m doing is actually going to contribute to the world, that usually really helps with [depression] because it’s like not every day you can feel like you’re doing something impactful.”

In sum, students highlighted that experiencing failure in research and making mistakes negatively contributed to depression, especially when help was unavailable or research mentors had a negative reaction. Additionally, students acknowledged that the research could be time-consuming, but that research mentors who were flexible helped assuage depressive feelings that were associated with feeling overwhelmed. Finally, research helped some students’ depression, because it felt familiar, provided a distraction from depression, and reminded students that they were contributing to a greater cause.

We believe that creating more inclusive research environments for students with depression is an important step toward broadening participation in science, not only to ensure that we are not discouraging students with depression from persisting in science, but also because depression has been shown to disproportionately affect underserved and underrepresented groups in science ( Turner and Noh, 1988 ; Eisenberg et al. , 2007 ; Jenkins et al. , 2013 ; American College Health Association, 2018 ). We initially hypothesized that three features of undergraduate research—research mentors, the lab environment, and failure—may have the potential to exacerbate student depression. We found this to be true; students highlighted that their relationships with their mentors as well as the overall lab environment could negatively affect their depression, but could also positively affect their research experiences. Students also noted that they struggled with failure, which is likely true of most students, but is known to be particularly difficult for students with depression ( Elliott et al. , 1997 ). We expand upon our findings by integrating literature on depression with the information that students provided in the interviews about how research mentors can best support students. We provide a set of evidence-based recommendations focused on mentoring, the lab environment, and failure for research mentors wanting to create more inclusive research environments for students with depression. Notably, only the first recommendation is specific to students with depression; the others reflect recommendations that have previously been described as “best practices” for research mentors ( NASEM, 2017 , 2019 ; Sorkness et al. , 2017 ) and likely would benefit most students. However, we examine how these recommendations may be particularly important for students with depression. As we hypothesized, these recommendations directly address three aspects of research: mentors, lab environment, and failure. A caveat of these recommendations is that more research needs to be done to explore the experiences of students with depression and how these practices actually impact students with depression, but our national sample of undergraduate researchers with depression can provide an initial starting point for a discussion about how to improve research experiences for these students.

Recommendations to Make Undergraduate Research Experiences More Inclusive for Students with Depression

Recognize student depression as a valid illness..

Allow students with depression to take time off of research by simply saying that they are sick and provide appropriate time for students to recover from depressive episodes. Also, make an effort to destigmatize mental health issues.

Undergraduate researchers described both psychological and physical symptoms that manifested as a result of their depression and highlighted how such symptoms prevented them from performing to their full potential in undergraduate research. For example, students described how their depression would cause them to feel unmotivated, which would often negatively affect their research productivity. In cases in which students were motivated enough to come in and do their research, they described having difficulty concentrating or engaging in the work. Further, when doing research, students felt less creative and less willing to take risks, which may alter the quality of their work. Students also sometimes struggled to socialize in the lab. They described feeling less social and feeling overly self-critical. In sum, students described that, when they experienced a depressive episode, they were not able to perform to the best of their ability, and it sometimes took a toll on them to try to act like nothing was wrong, when they were internally struggling with depression. We recommend that research mentors treat depression like any other physical illness; allowing students the chance to recover when they are experiencing a depressive episode can be extremely important to students and can allow them to maximize their productivity upon returning to research ( Judd et al. , 2000 ). Students explained that if they are not able to take the time to focus on recovering during a depressive episode, then they typically continue to struggle with depression, which negatively affects their research. This sentiment is echoed by researchers in psychiatry who have found that patients who do not fully recover from a depressive episode are more likely to relapse and to experience chronic depression ( Judd et al. , 2000 ). Students described not doing tasks or not showing up to research because of their depression but struggling with how to share that information with their research mentors. Often, students would not say anything, which caused them anxiety because they were worried about what others in the lab would say to them when they returned. Admittedly, many students understood why this behavior would cause their research mentors to be angry or frustrated, but they weighed the consequences of their research mentors’ displeasure against the consequences of revealing their depression and decided it was not worth admitting to being depressed. This aligns with literature that suggests that when individuals have concealable stigmatized identities, or identities that can be hidden and that carry negative stereotypes, such as depression, they will often keep them concealed to avoid negative judgment or criticism ( Link and Phelan, 2001 ; Quinn and Earnshaw, 2011 ; Jones and King, 2014 ; Cooper and Brownell, 2016 ; Cooper et al. , 2019b ; Cooper et al ., unpublished data ). Therefore, it is important for research mentors to be explicit with students that 1) they recognize mental illness as a valid sickness and 2) that students with mental illness can simply explain that they are sick if they need to take time off. This may be useful to overtly state on a research website or in a research syllabus, contract, or agreement if mentors use such documents when mentoring undergraduates in their lab. Further, research mentors can purposefully work to destigmatize mental health issues by explicitly stating that struggling with mental health issues, such as depression and anxiety, is common. While we do not recommend that mentors ask students directly about depression, because this can force students to share when they are not comfortable sharing, we do recommend providing opportunities for students to reveal their depression ( Chaudoir and Fisher, 2010 ). Mentors can regularly check in with students about how they’re doing, and talk openly about the importance of mental health, which may increase the chance that students may feel comfortable revealing their depression ( Chaudoir and Quinn, 2010 ; Cooper et al ., unpublished data ).

Foster a Positive Lab Environment.

Encourage positivity in the research lab, promote working in shared spaces to enhance social support among lab members, and alleviate competition among undergraduates.

Students in this study highlighted that the “leadership” of the lab, meaning graduate students, postdocs, lab managers, and PIs, were often responsible for establishing the tone of the lab; that is, if they were in a bad mood it would trickle down and negatively affect the moods of the undergraduates. Explicitly reminding lab leadership that their moods can both positively and negatively affect undergraduates may be important in establishing a positive lab environment. Further, students highlighted how they were most likely to experience negative thoughts when they were alone in the lab. Therefore, it may be helpful to encourage all lab members to work in a shared space to enhance social interactions among students and to maximize the likelihood that undergraduates have access to help when needed. A review of 51 studies in psychiatry supported our undergraduate researchers’ perceptions that social relationships positively impacted their depression; the study found that perceived emotional support (e.g., someone available to listen or give advice), perceived instrumental support (e.g., someone available to help with tasks), and large diverse social networks (e.g., being socially connected to a large number of people) were significantly protective against depression ( Santini et al. , 2015 ). Additionally, despite forming positive relationships with other undergraduates in the lab, many undergraduate researchers admitted to constantly comparing themselves with other undergraduates, which led them to feel inferior, negatively affecting their depression. Some students talked about mentors favoring current undergraduates or talking positively about past undergraduates, which further exacerbated their feelings of inferiority. A recent study of students in undergraduate research experiences highlighted that inequitable distribution of praise to undergraduates can create negative perceptions of lab environments for students (Cooper et al. , 2019). Further, the psychology literature has demonstrated that when people feel insecure in their social environments, it can cause them to focus on a hierarchical view of themselves and others, which can foster feelings of inferiority and increase their vulnerability to depression ( Gilbert et al. , 2009 ). Thus, we recommend that mentors be conscious of their behaviors so that they do not unintentionally promote competition among undergraduates or express favoritism toward current or past undergraduates. Praise is likely best used without comparison with others and not done in a public way, although more research on the impact of praise on undergraduate researchers needs to be done. While significant research has been done on mentoring and mentoring relationships in the context of undergraduate research ( Byars-Winston et al. , 2015 ; Aikens et al. , 2017 ; Estrada et al. , 2018 ; Limeri et al. , 2019 ; NASEM, 2019 ), much less has been done on the influence of the lab environment broadly and how people in nonmentoring roles can influence one another. Yet, this study indicates the potential influence of many different members of the lab, not only their mentors, on students with depression.

Develop More Personal Relationships with Undergraduate Researchers and Provide Sufficient Guidance.

Make an effort to establish more personal relationships with undergraduates and ensure that they perceive that they have access to sufficient help and guidance with regard to their research.

When we asked students explicitly how research mentors could help create more inclusive environments for undergraduate researchers with depression, students overwhelmingly said that building mentor–student relationships would be extremely helpful. Students suggested that mentors could get to know students on a more personal level by asking about their career interests or interests outside of academia. Students also remarked that establishing a more personal relationship could help build the trust needed in order for undergraduates to confide in their research mentors about their depression, which they perceived would strengthen their relationships further because they could be honest about when they were not feeling well or their mentors might even “check in” with them in times where they were acting differently than normal. This aligns with studies showing that undergraduates are most likely to reveal a stigmatized identity, such as depression, when they form a close relationship with someone ( Chaudoir and Quinn, 2010 ). Many were intimidated to ask for research-related help from their mentors and expressed that they wished they had established a better relationship so that they would feel more comfortable. Therefore, we recommend that research mentors try to establish relationships with their undergraduates and explicitly invite them to ask questions or seek help when needed. These recommendations are supported by national recommendations for mentoring ( NASEM, 2019 ) and by literature that demonstrates that both social support (listening and talking with students) and instrumental support (providing students with help) have been shown to be protective against depression ( Santini et al. , 2015 ).

Treat Undergraduates with Respect and Remember to Praise Them.

Avoid providing harsh criticism and remember to praise undergraduates. Students with depression often have low self-esteem and are especially self-critical. Therefore, praise can help calibrate their overly negative self-perceptions.

Students in this study described that receiving criticism from others, especially harsh criticism, was particularly difficult for them given their depression. Multiple studies have demonstrated that people with depression can have an abnormal or maladaptive response to negative feedback; scientists hypothesize that perceived failure on a particular task can trigger failure-related thoughts that interfere with subsequent performance ( Eshel and Roiser, 2010 ). Thus, it is important for research mentors to remember to make sure to avoid unnecessarily harsh criticisms that make students feel like they have failed (more about failure is described in the next recommendation). Further, students with depression often have low self-esteem or low “personal judgment of the worthiness that is expressed in the attitudes the individual holds towards oneself” ( Heatherton et al. , 2003 , p. 220; Sowislo and Orth, 2013 ). Specifically, a meta-analysis of longitudinal studies found that low self-esteem is predictive of depression ( Sowislo and Orth, 2013 ), and depression has also been shown to be highly related to self-criticism ( Luyten et al. , 2007 ). Indeed, nearly all of the students in our study described thinking that they are “not good enough,” “worthless,” or “inadequate,” which is consistent with literature showing that people with depression are self-critical ( Blatt et al. , 1982 ; Gilbert et al. , 2006 ) and can be less optimistic of their performance on future tasks and rate their overall performance on tasks less favorably than their peers without depression ( Cane and Gotlib, 1985 ). When we asked students what aspects of undergraduate research helped their depression, students described that praise from their mentors was especially impactful, because they thought so poorly of themselves and they needed to hear something positive from someone else in order to believe it could be true. Praise has been highlighted as an important aspect of mentoring in research for many years ( Ashford, 1996 ; Gelso and Lent, 2000 ; Brown et al. , 2009 ) and may be particularly important for students with depression. In fact, praise has been shown to enhance individuals’ motivation and subsequent productivity ( Hancock, 2002 ; Henderlong and Lepper, 2002 ), factors highlighted by students as negatively affecting their depression. However, something to keep in mind is that a student with depression and a student without depression may process praise differently. For a student with depression, a small comment that praises the student’s work may not be sufficient for the student to process that comment as praise. People with depression are hyposensitive to reward or have reward-processing deficits ( Eshel and Roiser, 2010 ); therefore, praise may affect students without depression more positively than it would affect students with depression. Research mentors should be mindful that students with depression often have a negative view of themselves, and while students report that praise is extremely important, they may have trouble processing such positive feedback.

Normalize Failure and Be Explicit about the Importance of Research Contributions.

Explicitly remind students that experiencing failure is expected in research. Also explain to students how their individual work relates to the overall project so that they can understand how their contributions are important. It can also be helpful to explain to students why the research project as a whole is important in the context of the greater scientific community.

Experiencing failure has been thought to be a potentially important aspect of undergraduate research, because it may provide students with the potential to develop integral scientific skills such as the ability to navigate challenges and persevere ( Laursen et al. , 2010 ; Gin et al. , 2018 ; Henry et al. , 2019 ). However, in the interviews, students described that when their science experiments failed, it was particularly tough for their depression. Students’ negative reaction to experiencing failure in research is unsurprising, given recent literature that has predicted that students may be inadequately prepared to approach failure in science ( Henry et al. , 2019 ). However, the literature suggests that students with depression may find experiencing failure in research to be especially difficult ( Elliott et al. , 1997 ; Mongrain and Blackburn, 2005 ; Jones et al. , 2009 ). One potential hypothesis is that students with depression may be more likely to have fixed mindsets or more likely to believe that their intelligence and capacity for specific abilities are unchangeable traits ( Schleider and Weisz, 2018 ); students with a fixed mindset have been hypothesized to have particularly negative responses to experiencing failure in research, because they are prone to quitting easily in the face of challenges and becoming defensive when criticized ( Forsythe and Johnson, 2017 ; Dweck, 2008 ). A study of life sciences undergraduates enrolled in CUREs identified three strategies of students who adopted adaptive coping mechanisms, or mechanisms that help an individual maintain well-being and/or move beyond the stressor when faced with failure in undergraduate research: 1) problem solving or engaging in strategic planning and decision making, 2) support seeking or finding comfort and help with research, and 3) cognitive restructuring or reframing a problem from negative to positive and engaging in self encouragement ( Gin et al. , 2018 ). We recommend that, when undergraduates experience failure in science, their mentors be proactive in helping them problem solve, providing help and support, and encouraging them. Students also explained that mentors sharing their own struggles as undergraduate and graduate students was helpful, because it normalized failure. Sharing personal failures in research has been recommended as an important way to provide students with psychosocial support during research ( NASEM, 2019 ). We also suggest that research mentors take time to explain to students why their tasks in the lab, no matter how small, contribute to the greater research project ( Cooper et al. , 2019a ). Additionally, it is important to make sure that students can explain how the research project as a whole is contributing to the scientific community ( Gin et al. , 2018 ). Students highlighted that contributing to something important was really helpful for their depression, which is unsurprising, given that studies have shown that meaning in life or people’s comprehension of their life experiences along with a sense of overarching purpose one is working toward has been shown to be inversely related to depression ( Steger, 2013 ).

Limitations and Future Directions

This work was a qualitative interview study intended to document a previously unstudied phenomenon: depression in the context of undergraduate research experiences. We chose to conduct semistructured interviews rather than a survey because of the need for initial exploration of this area, given the paucity of prior research. A strength of this study is the sampling approach. We recruited a national sample of 35 undergraduates engaged in undergraduate research at 12 different public R1 institutions. Despite our representative sample from R1 institutions, these findings may not be generalizable to students at other types of institutions; lab environments, mentoring structures, and interactions between faculty and undergraduate researchers may be different at other institution types (e.g., private R1 institutions, R2 institutions, master’s-granting institutions, primarily undergraduate institutions, and community colleges), so we caution against making generalizations about this work to all undergraduate research experiences. Future work could assess whether students with depression at other types of institutions have similar experiences to students at research-intensive institutions. Additionally, we intentionally did not explore the experiences of students with specific identities owing to our sample size and the small number of students in any particular group (e.g., students of a particular race, students with a graduate mentor as the primary mentor). We intend to conduct future quantitative studies to further explore how students’ identities and aspects of their research affect their experiences with depression in undergraduate research.

The students who participated in the study volunteered to be interviewed about their depression; therefore, it is possible that depression is a more salient part of these students’ identities and/or that they are more comfortable talking about their depression than the average population of students with depression. It is also important to acknowledge the personal nature of the topic and that some students may not have fully shared their experiences ( Krumpal, 2013 ), particularly those experiences that may be emotional or traumatizing ( Kahn and Garrison, 2009 ). Additionally, our sample was skewed toward females (77%). While females do make up approximately 60% of students in biology programs on average ( Eddy et al. , 2014 ), they are also more likely to report experiencing depression ( American College Health Association, 2018 ; Evans et al. , 2018 ). However, this could be because women have higher rates of depression or because males are less likely to report having depression; clinical bias, or practitioners’ subconscious tendencies to overlook male distress, may underestimate depression rates in men ( Smith et al. , 2018 ). Further, females are also more likely to volunteer to participate in studies ( Porter and Whitcomb, 2005 ); therefore, many interview studies have disproportionately more females in the data set (e.g., Cooper et al. , 2017 ). If we had been able to interview more male students, we might have identified different findings. Additionally, we limited our sample to life sciences students engaged in undergraduate research at public R1 institutions. It is possible that students in other majors may have different challenges and opportunities for students with depression, as well as different disciplinary stigmas associated with mental health.

In this exploratory interview study, we identified a variety of ways in which depression in undergraduates negatively affected their undergraduate research experiences. Specifically, we found that depression interfered with students’ motivation and productivity, creativity and risk-taking, engagement and concentration, and self-perception and socializing. We also identified that research can negatively affect depression in undergraduates. Experiencing failure in research can exacerbate student depression, especially when students do not have access to adequate guidance. Additionally, being alone or having negative interactions with others in the lab worsened students’ depression. However, we also found that undergraduate research can positively affect students’ depression. Research can provide a familiar space where students can feel as though they are contributing to something meaningful. Additionally, students reported that having access to adequate guidance and a social support network within the research lab also positively affected their depression. We hope that this work can spark conversations about how to make undergraduate research experiences more inclusive of students with depression and that it can stimulate additional research that more broadly explores the experiences of undergraduate researchers with depression.

Important note

If you or a student experience symptoms of depression and want help, there are resources available to you. Many campuses provide counseling centers equipped to provide students, staff, and faculty with treatment for depression, as well as university-dedicated crisis hotlines. Additionally, there are free 24/7 services such as Crisis Text Line, which allows you to text a trained live crisis counselor (Text “CONNECT” to 741741; Text Depression Hotline , 2019 ), and phone hotlines such as the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can also learn more about depression and where to find help near you through the Anxiety and Depression Association of American website: https://adaa.org ( Anxiety and Depression Association of America, 2019 ) and the Depression and Biopolar Support Alliance: http://dbsalliance.org ( Depression and Biopolar Support Alliance, 2019 ).

ACKNOWLEDGMENTS

We are extremely grateful to the undergraduate researchers who shared their thoughts and experiences about depression with us. We acknowledge the ASU LEAP Scholars for helping us create the original survey and Rachel Scott for her helpful feedback on earlier drafts of this article. L.E.G. was supported by a National Science Foundation (NSF) Graduate Fellowship (DGE-1311230) and K.M.C. was partially supported by a Howard Hughes Medical Institute (HHMI) Inclusive Excellence grant (no. 11046) and an NSF grant (no. 1644236). Any opinions, findings, conclusions, or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the NSF or HHMI.

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Submitted: 4 November 2019 Revised: 24 February 2020 Accepted: 6 March 2020

© 2020 K. M. Cooper, L. E. Gin, et al. CBE—Life Sciences Education © 2020 The American Society for Cell Biology. This article is distributed by The American Society for Cell Biology under license from the author(s). It is available to the public under an Attribution–Noncommercial–Share Alike 3.0 Unported Creative Commons License (http://creativecommons.org/licenses/by-nc-sa/3.0).

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Study to probe whether outdoor swimming can reduce symptoms of depression

There is emerging evidence that open water swimming can have a positive impact on mental health, according to experts..

Researchers are seeking hundreds of people to take part in the first large study into whether outdoor swimming can reduce symptoms of depression.

Open water bathing has been praised as a way to improve wellbeing in the last few years, with emerging evidence that it can have a positive impact on mental health, experts said.

The number of adults experiencing moderate to severe depression in the UK doubled to nearly one in five between March and June 2020 during the Covid-19 pandemic, compared to one in 10 before the crisis.

The research call comes after the first clinical trial into its benefits for adults with depression was completed last year.

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Experts from the University of Portsmouth and Sussex Partnership NHS Foundation Trust worked with 87 people with mental health difficulties to see if they would sign up for the project and remain engaged until the end of the programme.

Dr Heather Massey, who is co-leading the new study, said the initial trial results were “really promising”.

The University of Portsmouth senior lecturer said: “We reported reductions in symptoms of depression and anxiety in the outdoor swimming group compared with the control group, and there was a lower number of them seeking depression-specific therapy post-treatment and at follow-up.

“The use of antidepressants and sleeping tablets, on average, also reduced more.

“Our next task is to see if a full-scale randomised control trial produces similar results. If we can demonstrate outdoor swimming is a viable and cost-effective treatment for depression, it has the potential to be rolled out across the UK.”

The further study called Outside will be rolled out across 15 sites in England in a two-and-a-half year study aiming to explore if people with mild to moderate depression benefit from an outdoor swimming course.

Researchers will monitor whether the activity leads to a reduction in depressive symptoms and anxiety for up to 38 weeks following the trial.

They will also see if it improves mindfulness and is a safe and cost-effective treatment to run.

Richard Williams, from Worcestershire, was among those to take part in the first study at the Lenches lakes in Evesham. He suffered from depression and anxiety for years and in 2022 tried to take his own life.

“I was at a real low point in my life, and felt completely alone,” the 41-year-old said.

“After hitting rock bottom I decided to reach out to the Samaritans charity and eventually felt ready to go home and work on myself. I began therapy, and that’s how I found out about the cold water immersion study.”

He added: “It has completely changed my life. I’m swimming twice a week, in a cold tub every day and even signed up to an Ironman.

“So I’ve gone from a recovering alcoholic and recluse into firing on all cylinders now, and wanting to help others and spread the word.”

The research project will host swimming sessions across the country including Brighton, Maidstone, Sunderland, Windermere, Nottingham, Bristol, Manchester and Penzance.

The settings will be a mix of sea swimming, lakes and semi-heated outdoor pools.

Clara Strauss, research deputy director at Sussex Partnership, said: “This is the first large trial of its kind that will tell us if outdoor swimming is helpful for people living with depression.

“If it is, this could increase the range of options available to people as they find their path to recovery.”

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• v.172(3); 2000 Mar

Evidence-Based Case Review

Identifying and treating adolescent depression, martha c tompson.

1 Department of Psychology Boston University 64 Cummington St Boston, MA 02215-2407

Fawn M McNeil

Margaret m rea.

2 Department of Psychiatry and Biobehavioral Sciences University of California Los Angeles, CA 90095

Joan R Asarnow

• Understand the importance of diagnosing and treating depression in adolescents
• Identify the symptoms of depression in adolescents and the difference between depression and normal adolescent moods
• Identify suicidal risk in a depressed adolescent
• Understand when a specialty consultation is needed
• Understand what effective treatments are available

By age 18, about 20% of our nation's youth will have had depressive episodes, 1 , 2 with girls at substantially higher risk. 2 Major depressive episodes in adolescence last an average of 6 to 9 months, 2 , 3 6% to 10% of depressed adolescents have protracted episodes, and the probability of recurrence within 5 years is about 70%. 3 Given that depressed people are as likely to seek help in primary care settings as in mental health establishments, 4 primary care physicians may be the first to be aware of this problem in their adolescent patients.

Case history

Wanda S, aged 16 years, comes for her checkup accompanied by her mother. She is in good health and has had no notable illnesses in the past year. However, Wanda complains of difficulty sleeping in the past few months and of frequently being tired. Her mother asks for a few minutes alone to discuss her concerns about her daughter. She states that “Wanda has been much more irritable than her usual self” and that “her teachers have been complaining that she doesn't seem to attend to her work lately and her grades are slipping.” Wanda's mother remembers being an unhappy adolescent herself and asks your advice on how to help her daughter.

When directly questioned, Wanda admits to “feeling pretty bad for the last few months, since school began.” She concedes that she feels sad and blue most days of the week and believes that she is “a loser.” She's been spending more time alone and, despite complaining of chronic boredom, has little energy or desire to engage in recreational activities.

Our conclusions are based on literature searches using both MEDLINE and PsychLIT databases, and most are derived from empiric findings and clinical trials. Because of the relatively modest literature, particularly on treatment, some suggestions are based on published opinions of experts. We have noted when expert opinion is our source.

What does depression look like in adolescents?

According to the Diagnostic and statistical manual of mental disorders , fourth edition, 5 an adolescent must have five out of nine characteristic symptoms most of the time for at least 2 weeks for a diagnosis of major depressive disorder. At least one of these symptoms must be either depressed or irritable mood or a pervasive loss of pleasure or interest in events that were once enjoyed. Many seriously depressed adolescents experience both. For example, a depressed adolescent may feel sad most of the day, act crabby, stop hanging out with friends, and seem to lose her love of soccer.

Summary points

• Adolescent depression is common, and primary care physicians are often in a position to first identify the symptoms
• Depression includes changes in moods, thoughts, behaviors, and physical functioning. Among adolescents, depression may include irritable as well as sad moods
• Unlike normal adolescent moods, depression is severe and enduring and interrupts the adolescent's ability to perform in school, to relate to peers, and to engage in age-appropriate activities
• In assessing the risk of suicide, ask straightforward questions about the adolescent's intent, plan, and means
• Antidepressant medication and psychotherapy may be effective treatments; a combination of these is frequently optimal
• Education about depression with both the adolescent and parents provides a rationale for treatment, may alleviate family misunderstandings, and facilitates recovery

Although all adolescents occasionally become sad, and adolescent angst may be normal and common, symptoms of major depression are more severe in intensity, interfere with social, academic, and recreational activities, and last for months at a time, 2 instead of fluctuating like more typical adolescent ups and downs. 6 Depression occurs as a cluster of signs and symptoms, including emotional, physical, and mental changes that usually signify an alteration from the adolescent's normal personality. 3

Some adolescents present with depressive symptoms but do not meet the full criteria for having major depression. Dysthymic disorder is characterized by milder but more persistent symptoms than major depression. In dysthymic disorder, symptoms are present much of the time for at least one year in adolescents (2 years in adults).

Wanda's physician prescribes a low dose of fluoxetine hydrochloride (Prozac), a selective serotonin reuptake inhibitor. In addition, the physician refers Wanda for interpersonal therapy to help her cope with the losses and disappointments of the past year, develop new peer relationships, and reintegrate herself into high school activities.

This multifaceted approach will address the physical and psychological symptoms Wanda has been experiencing and provide her with skills she can use to combat future depressive symptoms and interpersonal problems.

What contributes to adolescent depression?

The vulnerability-stress model is useful for understanding depression. According to this model, adolescent depression results from a predisposition for depression, which is then triggered or complicated by environmental stress. The exact nature of the predisposition may include biologic and cognitive factors. This interplay between life's stresses and cognitive and biologic vulnerabilities is important in conceptualizing depression in an adolescent.

An accumulation of adverse life circumstances and events can trigger depression. Family adversity, 7 academic difficulties, 3 chronic medical conditions, 8 and loss in the adolescent's life may increase risk. As Wanda's history illustrates, losses such as her breakup with a boyfriend and failure to make the track team may serve as triggers. Illnesses such as asthma, sickle cell anemia, irritable bowel syndrome, recurrent abdominal pain, and diabetes mellitus may put an adolescent at particular risk. 8

Cognitive models of depression suggest that it is not stressful events and circumstances but rather the tendency toward negative interpretations about these situations that initiates and maintains depression. 9 , 10 When an adverse event occurs, the depressed adolescent often understands the cause of the event as something stable, internal, and global. For example, Wanda fails to make the track team and attributes this failure to being a “loser.” This cause is stable (unlikely to change), internal (her own fault), and global (affecting everything she does).

Vulnerability to depression may result from biologic or genetic factors and lead to numerous biologic changes. First, studies of family history show that offspring of depressed parents are at high risk for depression 11 and that depressed adolescents have high rates of depression among their family members. 12 Wanda's mother may have been depressed during adolescence. Second, as depressions become more severe, biologic changes may occur, including dysregulation of growth hormone and changes in sleep architecture. 6

How do you assess adolescent depression?

The diagnosis of depression is made clinically. Physicians need to ask about changes in an adolescent's moods, feelings, and thoughts; behaviors; daily functioning; and any impairment in that functioning, as well as physical symptoms. Furthermore, a medical explanation (for example, thyroid disease or adrenal dysfunction) or substance misuse needs to be ruled out as possible causes. The best methods of assessment supplement the adolescent's selfreport with reports from parents or guardians and other outside sources. 2 Whereas youths tend to be better reporters of their internal experiences, such as their mood and thoughts, parents tend to be better reporters of overt behaviors, such as disruptive behavior in the classroom and defiance. 13 As in all primary care evaluations, ethnic and cultural factors must also be considered. For example, in some cultures, making eye contact with an authority figure may not be considered proper etiquette, and the failure to do so may not reflect a depressed mood. 3 In recent years, several screening tools for depression have been adapted for use in primary care settings. 14 , 15 The use of these screening techniques can improve the quality of assessments of depression while reducing the time needed for questioning during routine examinations.

How do you assess and intervene when an adolescent is suicidal?

Depression is associated with a markedly increased risk of suicide and attempted suicide. 16 , 17 , 18 About 41% of depressed youths have suicidal ideation, and 21% report a past attempt at suicide. 2 Although many people are concerned that asking directly about suicide may suggest the idea, most depressed youths have suicidal thoughts and are relieved at the opportunity to share them. Unfortunately, adolescents may not volunteer this information unless directly questioned. Often depressed youths have thoughts of death, a desire to die, or a more overt suicidal intention. Asking straightforward, unambiguous questions to assess the risk of suicide is the best strategy. Questions may include “Have you thought that life was not worth living?” “Have you wished you were dead?” “Have you thought about killing yourself?” “What have you thought about doing?” “Have you ever tried to hurt yourself?” or “Have you ever actually tried to kill yourself?” If there is evidence of suicidal thoughts or attempts, it is then critical to establish if the adolescent has the intent, plan, and means to attempt suicide. Questions to ask may include “Are you going to try?” “How would you do it?” and “Do you have a gun (knife, pills)?”

When is a specialty consultation needed?

Depression in adolescents is frequently complicated by other mental health and life problems. Because these additional problems affect management strategies, it is important to screen for comorbid disorders and problems with psychosocial functioning and life stress. If at any point the primary care physician feels uncertain about the diagnosis and/or management strategy, specialty mental health consultation is recommended. Primary care physicians should obtain a consultation with a specialist if any of the following are present: current or past mania, two previous episodes of depression, chronic depression, substance dependence or abuse, eating disorder, a history of being admitted to a hospital for psychiatric problems, or a history of suicide attempts or concerns regarding the risk for suicide.

TREATMENTS EFFECTIVE FOR ADOLESCENT DEPRESSION

Although research on the treatment of adolescent depression is limited, recent clinical trials have identified promising interventions, both pharmacologic and psychotherapeutic. The physician also needs to help the family to understand the adolescent's symptoms.

Although research has clearly documented the use of antidepressant medication for adults with depression, 19 far fewer studies have examined the use of these agents in adolescents. Selective serotonin reuptake inhibitors are the first choice in medication for depressed adolescents because of their relatively benign side effects, their safety in overdose, and because they only need to be taken once daily. 3 Both tricyclic antidepressants and monoamine oxidase inhibitors are less efficacious in adolescents, are more lethal in overdose, 20 and are not recommended at this time. 3

Cognitive behavior therapies are effective in treating adolescent depression. 21 , 22 They assume that developing more adaptive ways of thinking, understanding events, and interacting with the environment will reduce depressive symptoms and improve a youth's ability to function. The cognitive component of the treatment focuses on helping adolescents identify and interrupt negative or pessimistic thoughts, assumptions, beliefs, and interpretations of events and to develop new, more positive or optimistic ways of thinking. The behavioral component focuses on increasing constructive interactions with others to improve the likelihood of receiving positive feedback.

Interpersonal therapy emphasizes improving relationships. The therapy is brief and focuses on the problems that precipitated the current depressive episode. It helps the adolescent to reduce and cope with stress. Two studies 23 , 24 have shown its effectiveness in reducing depression.

No definitive guidelines have been published for deciding when to begin with medication, psychotherapy, or a combination of medication plus psychotherapy. We have, however, suggested several considerations based on common sense to help clinicians make this decision. 25 , 26 , 27 For example, medication should be considered if an adolescent does not seem interested in thinking about problems, has limited cognitive abilities, is severely depressed with vegetative symptoms, has had two or more episodes of depression, has not responded to 8 to 12 weeks of psychotherapy, or cannot regularly get to therapy sessions. Conversely, psychotherapy should be considered as the first alternative for adolescents who fear medication or do not like taking pills, prefer talking about problems, have complex life stressors that need sorting out, have contraindications to medication (such as pregnancy or breast-feeding), or have not responded to an adequate trial of medication. For some adolescents who have combinations of severe depression, limited cognitive skills, and complex life stressors, it may be best to begin with both medication and psychotherapy.

Parents may have little understanding of the adolescent's symptoms and sometimes interpret falling grades and lack of interest as willful behavior. By giving parents information about the symptoms, causes, and treatments of depression, the physician can help them to help their child to recover, to monitor symptoms, and to facilitate ongoing care. 3 Families differ in their willingness to consider the possibility that their child may have a psychological or psychiatric problem. For personal and/or cultural reasons, some families may be more receptive to a medical model, which identifies the depressive symptoms as part of an illness, and so they are more comfortable with a pharmacologic intervention. Other families may find a cognitive explanation more acceptable and see psychotherapy as a more palatable option. Further, primary care physicians may note that on finding out about their adolescent's depression, parents may feel guilty or feel they are being blamed and thus be resistant to suggestions for interventions. Appropriate education about depression and possible causes may help allay these concerns.

Symptoms of major depressive disorder in adolescents

• Depressed or irritable mood
• Loss of pleasure or interest in activities that were once enjoyed
• Significant weight loss or gain when not dieting, or an increase or decrease in appetite
• Insomnia or hypersomnia
• Observable slowing of movements and speech or increased agitation
• Feelings of worthlessness or excessive and/or inappropriate guilt
• Difficulty concentrating and/or making decisions
• Recurrent thoughts of death or suicide or a suicide attempt
• For a diagnosis, an adolescent must have at least 5 symptoms, which must include at least one of either of the first 2 symptoms, for at least 2 weeks.

When assessing adolescents for depression who already have chronic illnesses, it is important to look at the symptoms that are less likely to overlap with the physical illness, such as feelings of guilt, worthlessness, and hopelessness. It may be difficult to decipher whether changes in sleep patterns, appetite, and increased fatigue are due to the illness or to depression. 3

Symptoms of dysthymic disorder in adolescents

Depressed or irritable mood must be present for most of the day, more days than not, for at least 1 year. In addition, 2 of the following 6 symptoms must be present:

• Poor appetite or overeating
• Low energy of fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

During this time, the adolescent has never been without the depressive symptoms for more than 2 months at a time but does not meet criteria for a major depressive episode.

Having assessed thoughts of death, the intention to die, plans for an attempt, the means to commit suicide, and the availability of support, the physician must estimate the degree of risk and make choices for managing the patient's risk of suicide. 3 First, although thoughts of death or thinking of suicide in vague terms suggests a low risk, such symptoms indicate a need for both immediate intervention and close monitoring (because suicidal risk can increase). Second, when the adolescent acknowledges having a plan or means but no intent, emergency care may not be needed if safety can be ensured through involving parents and other support systems. Parents need to be in close proximity and to remove potential means such as firearms, and the adolescent needs to be referred for psychotherapy. However, if the adolescent does not have a supportive family, has access to lethal means, or has other risk factors (for example, a past suicide attempt, family history of suicide, recent exposure to suicide, substance abuse, bipolar illness, mixed state, or severe stress), more intensive interventions are needed, and the adolescent needs to see a mental health specialist. Finally, when the adolescent has intent, plan, and means, the risk for suicide is high. Such adolescents need help immediately, and psychiatric emergency care may be needed. 3 Regardless of risk, follow-up care is essential to tackle the concerns that contributed to the adolescent's suicidal feelings.

Empirically supported treatment options

Selective serotonin reuptake inhibitors Alters dysfunctional neurotransmitter systems

Cognitive behavioral therapy Monitors and changes dysfunctional ways of thinking

Interpersonal therapy Improves interpersonal skills and problem-solving abilities

Funding: National Institutes of Health, Agency for Health Care Policy and Research