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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.19 no.59 Murcia jul. 2020  Epub 10-Ago-2020

https://dx.doi.org/10.6018/eglobal.402951 

Originals

Depression and suicidal ideation in adolescence: implementation and evaluation of an intervention program

Ana Paula Amaral1  , Josiane Uchoa Sampaio2a  2b  , Fátima Regina Ney Matos3  , Margarida Tenente Santos Pocinho1  , Rafael Fernandes de Mesquita4  , Laelson Rochelle Milanês Sousa5 

1 Escuela Superior de Tecnología de la Salud de Coimbra-IPC. Coimbra. Portugal. amaral.anapm@gmail.com

2a Coimbra Health School, Polytechnic Institute of Coimbra, Portugal

2b Medical Center Cetfama, São Luís, Brasil

3 Instiuto Superior Miguel Torga. Coimbra. Portugal.

4 Instituto Federal de Piauí. Piauí. Brasil.

5 Programa de Posgraduación en Enfermería Fundamental. Escuela de Enfermería de Ribeirão Preto de la Universidad de São Paulo. São Paulo. Brasil.

ABSTRACT:

Objective:

To develop, implement and evaluate a suicide prevention program aimed at adolescents.

Material and Methods:

A quasi-experimental study, before and after, with adolescents from an educational institution in São Luís, Maranhão, Brazil. The study followed the stages of development, implementation and evaluation of a suicide prevention intervention program. Three assessment instruments were administered before and after the intervention: Beck's Suicidal Ideation Scale; Beck's Depression Inventory and Beck's Hopelessness Scale.

Results:

Before the intervention, 102 adolescents participated, 30 (29.4%) had suicidal ideation and depressive symptoms. After the intervention the instruments were applied to the 30 selected adolescents, 12 (40.0%) continued with ideation. Prior to intervention, the average Depression Inventory was 23.83 and then 7.17 (p <0.0001). As for hopelessness, the average obtained before was 7.23 and then 2.17 (p <0.0001); Regarding suicidal ideation, the average obtained before was 10.50 and then 2.57 (p <0.0001).

Conclusion:

There was a decrease in depressive symptoms, hopelessness and suicidal ideation after the implementation of the elaborated intervention program.

Key words: Suicidal Ideation; Depression; Adolescence; Psychoeducational intervention

INTRODUCTION

The adolescence phase characterizes the human being who seeks a new identity. He often accumulates experiences of suffering, loneliness, doubts, anxiety and confusion. Mood swings that range from joy (euphoria) to sadness and depression, mourning in the face of lost childhood, antisocial behaviors, the need for acceptance in groups and opposition to any authority and people representing control are part of this path. Loneliness and isolation are also common among teenagers. Although depression is not a silent disease, it is rarely diagnosed in daily medical practice. It is estimated that only 34% of people with depression seek specialized help and only a third of people with depression find the help they need. Most of the time, people are unable to recognize or name their illness and often have general complaints. The usual practice of medical outpatient clinics is increasingly assumed by professionals from all medical specialties who do not want, or cannot, get to know their client regarding their life history, personal, family, professional, social context, thoughts, feelings and behaviors1.

Depression is one of the risk factors that most reports to suicide. Isolation in people with depression tends to increase the symptoms of the disease. The distancing from friends and closest people, lack of interest in work, leisure and any other day-to-day activity, are striking characteristics. Here, it is important to emphasize the need not to confuse sadness and depression. When talking about depression we refer to a psychiatric illness that requires special care.

Suicidal thoughts are frequent in adolescence, especially in phases of greatest difficulties in the face of an important stressor. Most of the time, they are transient, do not indicate psychopathology or need for intervention. However, when these thoughts are intense and prolonged, the risk of triggering suicidal behavior increases. Adolescents are more prone to immediacy and impulsiveness, and do not yet have full emotional maturity; thus, they find it more difficult to deal with acute stresses, such as, the end of a relationship, situations that cause shame or humiliation, rejection by the social group, school failure and loss of a loved one. These events can act as triggers for suicidal acts 2.

Suicidal ideation is associated with an increased risk of future suicide attempt. Suicide planning implies a high risk of death. The presence of suicidal ideation is, in itself, an important sign of psychological distress and requires extra attention in the clinical evaluation. A psychiatric disorder may be present, requiring prompt recognition and appropriate treatment 2.

Suicidal behavior can be classified into three stages: suicidal ideation (which can range from thoughts of death to structured suicide intention with or without suicidal planning), consummated suicide and the suicide attempt that occurs between ideation and consummated suicide 3.

The effects of family history on suicidal behavior are mediated by both genetic and environmental factors. The higher prevalence of suicide is more associated with the inheritance of impulsive and aggressive traits, than with mental illness. Also important are psychological identification with loved ones and the existence of disturbed dynamics in certain families. One should be alert to domestic violence and to reports of physical or sexual abuse. In adolescence, in addition to the classic disorders associated with suicide, the “attention deficit with hyperactivity” and the “conduct disorder” described in the mental disorders diagnosis and statistics manual (DSM-V) should also be considered, which may occur an exacerbation of other comorbid mental disorders, such as depression, and an increase in impulsiveness and risk behaviors 2.

Given these approaches, it is necessary to develop intervention-type actions to promote the mental health of adolescents in order to identify and reduce possible risks of suicide in this population. This research aims to analyze the results of the development and implementation of a suicide prevention program aimed at adolescents aged between 13 and 17 years.

MATERIAL AND METHODS

Quasi-experimental study, of the type before and after, carried out with adolescents aged between 13 and 17 years old students of a Private Teaching Institution in the city of São Luís, Maranhão, Brazil. The study followed the steps of developing, implementing and evaluating an intervention program aimed at preventing suicide.

Initially, four assessment instruments were administered to 102 adolescents: the sociodemographic form, the Beck Suicide Ideation Scale (SSI), the Beck Depression Inventory (Beck Depression Inventory - BDI) and the Hopelessness Scale Beck (Beck Hopelessness Scale - BHS). The application was collective, with an average duration of 30 minutes.

After application, adolescents with an incidence of depressive symptoms and suicidal ideation were selected based on the results of the questionnaires, and a group of 30 adolescents was constituted.

The 30 participants were part of the implementation of the intervention program, which also took place in the school space. The therapeutic and psychoeducational group interventions consisted of 15 sessions, three times a week. Each session lasted 50 minutes.

At the end of the intervention program, we move on to the second moment of evaluation, in which the participants returned to respond to the instruments administered before the intervention program. The phases corresponding to the evaluation and implementation of the sessions took place over a period of three months, including the months of May, June and July 2017.

Assessment tools

Socio-demographic characterization questionnaire. In order to characterize the sample, a questionnaire consisting of the following data was applied: age, gender, marital status and education.

Beck's Suicidal Ideation Scale. In order to investigate the incidence of suicidal ideation, the Beck Suicide Ideation Scale (Scale for Suicide Ideation - SSI) was chosen, a self-reported version of another clinical instrument, also developed at the CCT of the University of Pennsylvania and used since 1970 to investigate suicidal ideation in psychiatric patients.

In its final form, SSI consists of 21 items, of which 19 have three alternative responses and reflect gradations of the severity of suicidal desires, attitudes and plans. They submit the following contents: 1) Desire to live; 2) Desire to die; 3) Reasons to live or die; 4) Active suicide attempt; 5) passive suicide attempt; 6) Duration of suicide ideas; 7) Frequency of ideation; 8) Attitude towards ideation 9) Control over suicidal acts; 10) Inhibitions for the attempt; 11 Reasons for the attempt; 12) Specificity of planning; 13) Accessibility or timeliness of the method; 14) ability to make the attempt; 15) Probability of actual attempt; 16) Extent of true preparation; 17) Suicide note; 18) Final acts; 19) Secret screening (4). The last two items, not included in the final score, of an informative nature, provide important information regarding the number of previous suicide attempts and the seriousness of the intention to die in the last one (4).

Beck Depression Inventory. The Beck Depression Inventory (BDI) was applied to investigate the presence or absence of depressive symptoms; joint application with SSI is recommended. It is universally recognized as a measure of the intensity of depression and one of the first dimensional features of its kind. It is a self-report scale of 21 items, each with an alternative framework, implying increasing degrees of severity of depression, with a score from 0 to 3.

Beck says he selected the items based on observations and reports of frequent symptoms and attitudes in patients with depression, and were not chosen to reflect any particular theory of depression. BDI items refer to: 1) Sadness; 2) Pessimism; 3) Feeling of failure; 4) dissatisfaction; 5) Guilt; 6) Punishment; 7) Self-loathing; 8) Self-accusations; 9) Suicidal ideas; 10) Crying; 11) Irritability; 12) Social withdrawal; 13) Indecision; 14) change in self-image; 15) Difficulty working; 16) Insomnia; 17) Fatigue; 18) Loss of appetite; 19) Weight loss; 20) Somatic concerns; 21) Loss of libido. In the Portuguese version, the content of the items remains identical. The total score is the result of the sum of the individual scores of the items. The total score allows classification of levels of intensity of depression. The levels described in the Beck and Steer manual, based on CCT patient data, are not identical to those that should be used with psychiatric patients, in the Portuguese version 4.

Beck's Hopelessness Scale. To investigate the presence or absence of hopelessness, we chose the Beck Hopelessness Scale (BHS), originally developed at the CCT, being presented as a measure of the hopelessness dimension. It can be said that the instrument was created as a way to operationalize the hopelessness component of Beck's cognitive model about depression, a component that, according to Beck, will correspond to the definition of hopelessness, presented by Stotland - cognitive schema system, in which the The common denominator is the negative expectation about the near and remote future 4.

According to the authors, hopeless people believe: 1) that nothing will go well for them; 2) that they will never succeed in what they try to do; 3) that your important goals can never be achieved and 4) that your worst problems will never be solved.

The BHS is a dichotomous scale, comprising 20 items, consisting of statements that involve cognitions about hopelessness. By agreeing RIGHT or WRONG with each of them, the subject describes his attitude, allowing it to be possible to assess the extent of negative expectations regarding the immediate and remote future. The total score is the result of the sum of the individual items. It can vary from 0 to 20, which is the estimate of the extent of negative expectations towards the future, which can be classified into levels 4.

Intervention Program

The intervention consisted of 15 sessions, with three weekly sessions. The sessions were group sessions, each lasting approximately one hour. The 30 adolescents were divided into 2 groups of 15 and in each group the 15 sessions were implemented.

At the beginning of each session, we tried to create a happy and relaxed atmosphere through various activities: chatting in a circle, playing recreational games using music, hula hoops, rackets, balls, strings, tambourines and children's guitars. The activities performed in each session are described in the annex to this article.

Data processing

For data analysis, in relation to sociodemographic variables, a descriptive analysis (frequency calculations) was performed. With regard to inferential statistics, Fisher's exact test was used to ascertain the association between depression and suicidal ideation and logistic regression to assess, among the various study variables, which were most associated with suicidal ideation.

The collected data were subject to statistical treatment through the EPI INFO program, a public domain software created by the CDC (Centers for Disease Control and Prevention, in Portuguese Center for Disease Control and Prevention) directed to the health area.

Ethical considerations

This study obtained a favorable opinion from the Ethics Committee of the Higher School of Health Technology of Coimbra, which it considered to be in accordance with the principles established in the Declaration of Helsinki.

RESULTS

The 102 adolescents participating in the study had the following characterization: 72 (70.6%) were female, with a mean age of 15.06 years and the standard deviation of 1.22, 35 (34.3%) were in school. 1st year of high school and 28 (27.4%) the 2nd year. Of the 102 adolescents, 30 (29.4%) had suicidal ideation and 37 mild depression, as shown in Table 1.

Table 1.  Intensity of depression, with and without suicidal ideation (N=102) 

Depression (minimal = 0-11; mild = 12-19; moderate = 20-35; severe = 36-63)

Adolescents with suicidal ideation were selected for participation in the Beck Suicidal Ideation Scale (SSI). Of a total of 30, 25 (83.3%) were female. The ages ranged between 13 and 17 years, with a mean of 15.53 years and a standard deviation (SD) of 1.13. Most attended the 1st (36.7%) and 2nd year (30.0%) of high school.

The results show that after the intervention, regarding depressive symptoms, 22 (73.3%) started to have “minimum” pressure levels, as shown in Table 2.

Table 2.  Adolescents with depression before and after the intervention 

With regard to hopelessness, there was also an increase in the number of adolescents with minimum levels of hopelessness, 27 (90%). Before the intervention, the levels of hopelessness were minimum 8 (26.7%), mild 10 (33.3%), moderate 10 (33.3%) and severe 2 (6.7%). As shown in Table 3.

Table 3.  Adolescents with hopelessness before and after the intervention 

The levels of intensity of depression and hopelessness of the majority of the 30 adolescents who underwent psychoeducational intervention were between the “minimum” and “mild” degrees. The identification of the mere presence of suicidal ideation does not reveal the degree of intentionality, which is why the administration of BDI is recommended to investigate the presence or not of depression and BHS to investigate the presence or not of hopelessness, as the three instruments complement each other .

Table 4.  Adolescents with suicidal ideation before and after the intervention 

When we compare the means of the depression, hopelessness and suicidal ideation indexes obtained in the two moments, we found statistically significant differences (p <0.0001). Before the intervention, the BDI average was 23.83 and after the intervention 7.17 (p <0.0001). As for hopelessness, the average obtained in the BHS before the intervention was 7.23 and after the intervention 2.17 (p <0.0001); With regard to suicidal ideation, the mean obtained in the SSI before the intervention was 10.50 and after the intervention 2.57 (p <0.0001), as shown in Table 5.

Table 5.  Means, standard deviation and alpha of cronbach before and after the intervention 

To check the reliability or the degree of internal consistency between the indicators of the Beck scales, the cronbach's alpha was applied. The BDI Cronbach's alpha coefficient between test and retest varies between 0.76 and 0.83. Regarding BHS between 0.85 and 0.75 and, with regard to SSI between 0.81 and 0.88.

DISCUSSION

Studies have shown that depression, hopelessness and suicidal ideation are important predictors of the risk of suicide 5)(6)(7. In addition, the negative mood was observed as a predictor for suicidal ideation in another study 8. The death wish for adolescents can be interpreted as an alternative for these young people to find meaning in life. However, the adolescent may hide suicidal thoughts for different reasons, such as religious and cultural motivations, among others. The adolescents who participated in the present intervention program had suicidal ideation, depressive symptoms and hopelessness, not hiding their negative thoughts and emotions, nor the desire to end life.

In this study, we developed a set of sessions based on factors relevant to suicide prevention. Authors 5 state that among the main risk factors, depression has a fundamental role in the development of thoughts and behaviors related to death. What was seen in the adolescents who participated in the intervention program, who, in addition to suicidal ideation, also had depressive symptoms.

Knowing the main risk factors associated with suicide and the different ways of manifesting the signs associated with it, can be an important step in planning prevention programs. The factors associated with suicidal ideation in adolescence are multifaceted and include mental disorders, personal and family characteristics, behavioral problems of the adolescent and friends. The authors report that the factors that stand out most are depression, hopelessness, loneliness, sadness, worry, anxiety, low self-esteem, aggression by parents and friends, poor communication with parents, being physically abused at school, substance use, meeting someone who has attempted suicide. Throughout the sessions we implemented, we tried to reflect on risk factors, increasing their awareness and allowing the sharing of ideas / experiences and the development of emotional regulation and problem solving strategies 6.

Suicide prevention is an area that needs greater investment. In this sense, it is important to carry out more research on this topic, which underlies the development of preventive measures, associated with the promotion of the population's health through actions based on scientific evidence 9,10, considering that vulnerability and suicide mortality among Brazilian adolescents has increased significantly in recent years 11)(12.

Of the 102 adolescents initially evaluated, 30 (29.4%) had suicidal ideation, a high number for a non-clinical population, associated with mild (33.3%), moderate (56.7%) or severe depression (10% ). Regarding the 30 adolescents who initially had suicidal ideation, 83.3% were female and the average age was 15.5 years, an age considered of concern for the risk of suicide or for suicidal behavior. Similar results were obtained by another study 9 conducted with 243 adolescents enrolled in private and public schools, of which 34.3% had suicidal ideation or attempted suicide. They also report that, associated with suicidal ideation, mild or moderate depressive symptoms and moderate symptoms of anxiety were identified. Associated with attempted suicide, severe depressive symptoms and anxiety were identified. Corroborating our results, authors 6 also mention that depression, hopelessness, loneliness and sadness are some of the most prominent risk factors for suicidal ideation, as well as being female.

The results of this study suggest that after the intervention program was implemented, the mean values related to depressive symptoms, hopelessness and suicidal ideation decreased significantly in adolescents. The data also point out that after the intervention 73.3% of the adolescents had minimum values of depressive symptoms, 90% of the adolescents had minimum values of hopelessness, and 60% had no suicidal ideation. The 40% who maintained suicidal ideation showed a decrease in the final score. These results are encouraging and allow us to believe that the implementation of therapeutic and psychoeducational group programs have the potential to contribute to the promotion of adolescents' mental health, reducing depressive symptoms, hopelessness and suicidal ideation.

In the literature, we did not find programs similar to the one implemented in order to allow comparisons, however, the importance of interventions that allow transforming part of the suffering arising from disorders into new personal or collective learning is evident 13.

In addition to a decrease in suicidal ideation, the adolescents expressed positive thoughts, expressed their feelings and, throughout the intervention, we had the opportunity to verify that they acquired knowledge and emotional maturity. It is essential to develop protective factors in relation to adolescent suicide, in order to build effective prevention strategies 5, there are reports of successful experiences with prevention programs aimed at the general population 14.

Thus, it is necessary to strengthen the support networks of adolescents, mainly involving the family, peer groups and the school, in promoting more satisfactory relationships and greater well-being, considering that personal and family relationships the perception of support plays an important role in this stage of the life cycle. The activities developed during the sessions aimed to minimize risk factors and strengthen protective factors, in addition to creating a space for sharing and support among peers.

The results of this intervention, in a school context, are in line with that advocated by the Brazilian Association of Psychiatry (15), which argues that suicide prevention is not limited to the health network, but must go beyond it, requiring the existence of measures in various sectors of society, which may collaborate to reduce suicide rates. The articulation of various institutions / organizations in the prevention of suicide would be an important incentive for the development of health promotion initiatives in the community, such as the realization of self-help groups in churches, health education programs in schools, associations and NGOs.

Limitations

The limitation of this study is inherent to the methodological path taken, which used a quasi-experiment, therefore, throughout the intervention, it was not possible to control external variables with potential for interference in reducing the symptoms of depression and suicidal ideation of the research participants.

CONCLUSION

It is concluded that the result of the intervention in the school space was positive, as there was a significant decrease in depressive symptoms, hopelessness and suicidal ideation after the implementation of the elaborated intervention program.

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Received: November 13, 2019; Accepted: February 17, 2020

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