Introduction
Anxiety and depression may not manifest as the common symptoms people are used to
seeing. Depression can present as pessimism, guilt, fatigue, problems concentrating, difficulty
sleeping, diet changes, and suicidal ideation (Williams, Pg. 104, 2019). Anxiety can manifest as
a general discomfort, suicidal ideation, or psychosomatic symptoms such as upset stomach, hair
pulling, and nail biting (Morris & March, Pg. 71, 2004; L. Niino, personal communication, Oct
3, 2020). An important factor is the oversights that may occur because of the common co-
occurrences of anxiety and depression. Due to similar symptoms, it is possible that risk factors
and symptoms mask one condition or the other when both conditions are present. For example, a
genetic influence for anxiety could go unnoticed in an individual who has anxiety and depression
(Morris & March, Pg. 82, 2004; Saluja et al., 2004). There is a significant stigma regarding
individuals with mental health illnesses however, in 2001 approximately 25% of the global
population reported having some mental health concern in their lifetimes, making up
approximately 12% of the global health burden (Corrigan et al., 2014). In the United States,
mental health illnesses affect nearly 57 million adults, with less than 40% obtaining consistent
and effective treatment (Corrigan et al, 2014). With a global prevalence such as this, what
groups are most affected?
PRECEDE-PROCEED Phase 1 (Social Assessment)
Anxiety and depression are increasingly common conditions that affect older adolescents
due to the unpredictable mood swings that typically accompany puberty years (L. Niino,
personal communication, Oct 3, 2020). Anxiety is an emotional state that is accompanied by a
feeling of tension and nervousness (Speilberger, 2010). Depression, on the other hand, is
associated with an emotional state of viewing yourself as helpless or unable to live up to
perceived expectations (Bibring, 1953). The symptoms associated with anxiety and depression
are already life altering despite the tumultuous transition into adulthood (L. Niino, personal
communication, Oct 3, 2020). Often presenting as a sad or complacent mood, teens may lose
interest in their regular hobbies and begin to sequester themselves from friends and family.
Their schoolwork is likely to suffer as they may have problems focusing during classes or with
completing homework assignments (Williams, Pg. 104, 2019). Changes in sleep patterns can
also affect academic function as they may be regularly tardy if unable to wake up on time or
perform poorly academically if they are not getting enough sleep. Occasionally, anxiety and
depression manifest as psychosomatic symptoms, such as significant weight changes (L. Niino,
personal communication, Oct 3, 2020). These symptoms can increase risk factors for, or result
in, secondary conditions such as anorexia nervosa or bulimia (Williams, Pg. 104, 2019).
Although these conditions are not biased and can occur across all areas of life regardless of
ethnicity, gender, or socioeconomic status, it is seen at varying rates (L. Niino, personal
communication, Oct 3, 2020). Due to the stigma associated with anxiety and depression,
adolescents may feel the need to hide their problems or symptoms instead of seeking help
(Williams, Pg. 106, 2019; L. Niino, personal communication, Oct 3, 2020). With health
communication and educational efforts provided to the students at Shasta High School in
Redding, Ca, students can gather sufficient knowledge on depression and anxiety as well as learn
coping mechanisms for dealing with either condition.
PRECEDE-PROCEED Phase 2 (Epidemiological Assessment)
Epidemiology of Depression & Anxiety
Depression and anxiety affect 1 in 6 adolescents in the United States with greater
incidence in females. Anxiety is an increasingly common disorder in adolescents affecting every
child in some way or form however, only 10% are considered to have an anxiety related illness
(Morris & March, Pg. 71, 2004). Depression related diseases are accountable for higher rates of
mortality, morbidity, and a greater fiscal demand than all other mental illnesses (Saluja et al.,
2004). Depression is reported in 18% of adolescents with 25% occurring in females as opposed
to 10% in males. The rate of occurrence increases significantly with age for both genders.
Ethnicity is also linked to a higher prevalence of depression and anxiety. Despite treatment
options available, once depression occurs it is likely to cause a lifelong struggle, with earlier
onset indicating more severe cases as they get older (Saluja et al., 2004). It is estimated that of
those diagnosed with depression and anxiety, no more than 40% receive proper treatment from
one year to another for various reasons such as lack of access to or not seeking treatment
(Corrigan et al, 2014).
Genetic risk factors
Genetic risk factors are perhaps the most trying as they are unchangeable factors we are
born with that increase or decrease our chances of developing certain conditions. Gender,
ethnicity, and family history are factors that have been linked to increased rates of depression
and anxiety. If one, or both, parents has anxiety or depression, the children are more at risk of
developing the same condition. Parental behavior, while living with anxiety, can also influence
it in their offspring. They are likely to show poor coping skills and behavior choices leading to,
or exacerbating, the illness which their children may mirror (Morris & March, Pg. 62, 2004).
Studies have shown that before high school years, males and females show similar risks
of developing depression symptoms however, upon entering high school, approximately ages 13-
15, the prevalence begins to change. While both genders experience a heightened risk of
developing depression in high school, females show significantly higher rates than their male
counterparts. In fact, the prevalence of depression doubles for males by the time they become
sophomores in high school while tripling for females (Saluja et al., 2004).
Ethnicity is also an indicator of increased risk factors with the highest rate of prevalence,
29%, reported in American Indian adolescents and the lowest, 15%, reported in African
American adolescents (Saluja et al., 2004). American Indians report the highest prevalence
followed by Hispanics and Caucasians with African Americans and Asian Americans having the
lowest. Female adolescents across all ethnicities maintain a higher prevalence of depression over
males (Saluja et al., 2004).
Behavioral risk factors
Health behaviors have a vast impact on an adolescent’s risk of developing depression
and/or anxiety. These risk factors are changeable allowing the adolescent to control how great or
small their risk level is. Higher rates of teen anxiety have been linked to varying parenting styles
which include limited displays of affections and being overly protective or controlling. Multiple
studies have shown that controlling mothers have daughters with higher anxiety levels (Morris &
March, Pg. 61, 2004). While this is not an individual behavior choice, parenting styles can
greatly alter the way an adolescent functions and handles various situations.
Substance abuse is linked to significantly higher rates of depression and anxiety in both
males and females then adolescents who do not abuse drugs or alcohol (Saluja et al., 2004).
Abusing substances can be learned or a cry for help. If exposed to high risk behaviors, like
smoking or drinking, adolescents may indulge earlier in life because it is normal to them. It can
also be a cry for help if they are not receiving attention at home from parents or guardians.
Bullying is also linked to an increased prevalence of depression in adolescents for both
the victim and the bully. Of those being bullied, 37% of females showed symptoms of
depression compared to 18% in males. Of those doing the bullying, 46% of females reported
depression while 15% of males reported symptoms (Saluja et al., 2004). Students who bullied or
were bullied more often had twice the chance of developing depression (Saluja et al., 2004).
Environmental risk factors
The environment in which adolescents are exposed to can have a large impact on their
risk of depression and anxiety. Mistreatment in childhood, such as sexual or physical abuse, is
linked to significant mental health repercussions. Increases in the prevalence of depression and
anxiety has been linked to abuse during adolescence and younger years. Not all teens who are
abused develop one of these conditions however, they are considered high risk thereafter (Harpur
et al., 2015). It is estimated that approximately 7% of adolescent males and 18% of females in
the United States are victims of sexual abuse while 22% of males and 36% of females report
physical or emotional abuse (Harpur et al., 2015). Approximately 37% of reported cases of
depression, and 26% of anxiety, are linked to various forms of mistreatment. In a recent study,
52% of mistreated adolescents showed signs of anxiety and depression compared to 40% in the
control group with no form of mistreatment (Harpur et al., 2015). Despite the significant genetic
influence that can result in a cooccurrence of depression and anxiety, research findings indicate
that the adolescent’s environment may be the determining factor of if they will develop one,
both, or neither condition(s) (Morris & March, Pg. 84, 2004).
PRECEDE-PROCEED Phase 3 (Educational & Ecological Assessment)
The predisposing factor linked to depression and anxiety is the stigma associated with
mental health illnesses. It is predicted this stigma is the greatest barrier to receiving proper and
effective treatment as affected teens do not seek treatment to avoid being labeled as mentally ill.
Anxiety and depression are increasingly overlooked in the adolescent age range warranting
intervention be put in place. It is estimated that 8% of all older adolescents within the United
States has depression symptoms but is viewed as normal stress levels for the age group. In some
cases, these symptoms are even misdiagnosed as attention or substance abuse disorders (Saluja et
al., 2004). Understanding must be established to acknowledge the prevalence of anxiety and
depression and its presentation in high school students. Depression and anxiety are highly
treatable conditions however, the low rates of awareness and acknowledgment result in lower
rates of diagnosis.
Enabling factors are linked to access to effective and affordable resources. The enabling
factor of individuals with anxiety and depression seeking treatment is linked to a lack of
education, socioeconomic status, and distribution of resources. If students are not educated on
the symptoms of anxiety and depression, they are unaware that anything is wrong and requires
professional intervention (Corrigan et al., 2014). The affordable alternatives are commonly not
used despite the largest affected population being adolescents and low-income individuals
(Saraceno, 2004). The services offered are often expensive and may not be covered by health
insurance. It is common for government funding to be dispersed ineffectively, reserving the
majority for inpatient mental health facilities. When seeking outpatient treatment for diagnoses,
individuals go without or receive poor quality care (Saraceno, 2004).
The most effective reinforcing factors occur through support systems. Resisting anxiety
and depression after incidents of abuse have been linked to the individuals support system
(Harpur et al., 2015). To provide effective support systems to adolescents, individuals must offer
support, patience, and encouragement when needed. Comments about dying or suicide should
always be taken seriously and reported to someone who can help if they cannot themselves.
Including the adolescent with depression of anxiety in group events can help disperse depression
symptoms and distract them from anxious or sad feelings. It is also important to help them
follow their treatment plans and ensure they take their medications properly (Williams, Pg. 107,
2017).
Program Focus
The Teen COPE program, which stands for Creating Opportunities for Personal
Empowerment, will be implemented at Shasta High School located in Redding, Ca. beginning in
March and continue through the end of April. During this two-month program, all students will
attend educational seminars, that include presentations, public speakers, and interactive health
education activities, to increase knowledge. These interventions will educate students on anxiety
and depression, as well as teach students coping mechanisms to better handle stressors of the
average adolescent life.
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