DEPRESSION AFFECTS approximately 5% of today’s teenagers (Shaffer et al., 1996a) and is considered the fourth most important disease in the estimation of disease burden (Murray and Lopez, 1996). The impact of adolescent depression on the individual and society is far reaching, as depression in teenagers has been found to significantly increase the risk of major depression and anxiety disorders, social dysfunction, nicotine dependence, alcohol dependence and abuse, educational underachievement, unemployment, early parenthood, suicide attempts and completed suicide (Fergusson and Woodward 2002 and NHMRC (National Health and Medical Research Council), 1997. Depression in young people: Clinical practice guidelines, Australian Government Publishing Service, Canberra.NHMRC 1997). Suicide, perhaps the most serious potential outcome of depression, was the third leading cause of death in 10 to 20 year olds in the United States from 1999 to 2001 (Centers for Disease Control and Prevention, 2003). Research suggests that as many as 7% of teenagers who develop major depressive disorder may commit suicide as young adults (Weissman, et al., 1999). This relationship between major depression and suicide cannot be overlooked, as research repeatedly shows that between 90% and 98% of teenagers who complete suicide are found to have a psychiatric diagnosis (Brent et al 1999; Marttunen et al 1991 and Shaffer et al 1996b).

Given this strong correlation between depression and suicide, it was our belief that a school-based depression education curriculum would offer effective suicide prevention, while addressing the immense morbidity of major depression. Nurses are well poised to play a collaborative and integral role in developing, implementing and evaluating such a curriculum. As an initial step in developing and testing an adolescent depression education program, it was important to understand students’ baseline knowledge of depression to develop the content around gaps in knowledge. No studies were found that surveyed this group about knowledge of depression. What we know is largely anecdotal or based on individual clinical experiences. The purpose of this article is to report the findings of a survey of 5,645 adolescents, conducted to assess teenagers’ knowledge of depression and bipolar disorder. Description of the education program and reports of the posttest results are presented in a separate publication (Swartz et al., 2004).

Background

The high school population is an optimal target group for depression education because of the aforementioned high rate of suicide in this population coupled with the fact that depressive disorders often start in adolescence, with marked increase in period prevalence estimates from middle to late adolescence (Fergusson and Horwood 2001 and Hankin et al 1998). High schools themselves are excellent venues for health education programs, as schools are recognized as the most universal setting for delivering services to children and consequently are a major focus of the effort to improve children’s mental health services (Weist et al 2001 and Leaf et al 1996). Furthermore, today’s adolescents are accustomed to being taught in school about a myriad of health issues, from eating disorders to smoking to cardiovascular health to sex education (Wade et al 2003; Thomas 2002; Hoelscher et al 2004 and Buston et al 2002).

With regards to depression, however, we have found no publication to date, describing a school-based depression education program, although there are several reports of school based depression prevention programs (Burns and Hickie 2002; Merry et al 2004; Shochet et al 2001 and Oria et al 2001). There are many reports of suicide prevention programs; however, in a large survey of such programs (Garland, Shaffer, & Whittle, 1989), the authors found only 4% of these studies adhered to the theory that suicide is usually a consequence of mental illness. Of these programs, 95% included in the survey espoused the view that youth suicide is most commonly a response to extreme stress or pressure and could happen to anyone. Many of these programs have been criticized for denying the role of mental illness in suicide and normalizing suicidal behavior (Burns & Patton, 2000). Despite the lack of knowledge about the best way to educate teenaged children about suicide, 75.1% of U.S. high schools require that some sort of suicide prevention curriculum be taught (School Health Policies and Programs Study, 2000). Given this combination of inconclusive research on how to best teach suicide prevention, and the large number of schools requiring suicide prevention be taught, it seems imperative that we consider educating our teenagers about the illness of depression as a means to address both the morbidity and mortality of the illness. Furthermore, a collaborative approach to this type of education is fundamental for lessening the burden on our education systems and to strengthen the relationships among the education, mental health and public health systems (Weist et al 2001 and Weist and Christodulu 2000). The Adolescent Depression Awareness Program (ADAP) was developed to address these needs for depression education to be taught in high schools.

Method

ADAP was initiated in 1999 by a team of psychiatrists and psychiatric nurses from the Johns Hopkins University School of Medicine, and the Depression and Related Affective Disorders Association (DRADA), a nonprofit community-based organization and support group. Based on their clinical experiences and knowledge of the field, this team developed ADAP based on the fundamental premise that depression education is a critical means towards suicide prevention in teenagers. The mission of ADAP is to develop a school-based curriculum to educate high school students, teachers and parents about teenage depression. Over the 5 years since its inception, the ADAP team has developed and assessed a 3-hour curriculum which is currently being taught in local high schools by psychiatric nurses and psychiatrists. Thus far, ADAP has trained nine psychiatrists and psychiatric nurses to teach this curriculum. To date, it has been taught to over 5500 students in high schools in three East Coast states and the District of Columbia. ADAP’s development has been further enhanced by a strong collaborative approach, with a team that incorporates the expertise of psychiatric health care professionals, high school teachers and counselors, business professionals and teenagers and families affected by depression and suicide.

The ADAP team designed the program to incorporate rigorous methodology in curriculum development and assessment of students’ learning and attitude changes. Each time the curriculum is taught, the students are given a pretest of their depression knowledge before the program is presented. The same survey is given as a posttest approximately 6 weeks after completion of the curriculum to evaluate changes in students’ knowledge. For the purpose of this article, however, we will focus on the pretest results to provide the important data on the scope of knowledge of teenagers before the intensive intervention. This will fill an important gap in our understanding of the current status of teen knowledge in this area. Data are reported for 5 years of the program.

Setting and participants

The 5,645 students included in the survey were from 29 different public, private, and parochial high schools in three eastern states and the District of Columbia. The protocol received exemption status from the institutional internal review board as no identifying information or personal data were collected from the students. The schools were selected in two ways. In some cases the school contacted DRADA or ADAP staff directly and requested the curriculum be brought to the school. In other cases, the school was part of a large public school district that was already working with the ADAP team to incorporate the curriculum into all of its ninth grade health classes. Although we did not collect demographic data on individual students, the schools are well recognized as economically and ethnically diverse. As well, the students had a broad range of cognitive abilities, from honors students to those receiving special education services