Understanding the experience of adolescent depression : qualitative studies with adolescents from Porto Alegre, Brazil

Adolescence is a time of physical and psychosocial change, as well as a period of intense growth, learning, adaptation, and development. Nonetheless, the current conceptualization of depression in adolescence pays limited attention to important differences that might occur in terms of the manifestation of the disorder in this specific developmental stage. In this sense, the idea of understanding how adolescents experience depression arises as part of a broader scope to understand psychopathology, highlighting the need for exploring the complexities and subtleties of mental health disorders. Therefore, this dissertation has as main objective to contribute to the understanding of the experience of adolescent depression using qualitative methods. Two studies are here presented. The first aimed to understand adolescents’ and other stakeholders’ conceptualizations of depression, focusing on their accounts of how depression changed the lives of adolescents. This approach had as a goal to include different voices and points of view, aiming to gather a comprehensive understanding of the contextual factors of the environments of adolescents who suffered from depression. The second study explores adolescents’ initial reactions after receiving a clinical diagnosis of Major Depressive Disorder. In this sense, we queried adolescents to explore the subjective experience of receiving the diagnosis, but also how this affects the contextualization of past experiences in light of this new diagnosis. Overarchingly, these studies present the vital role of interpersonal relationships in adolescent depression, recognizing the importance of impaired social functioning in depression. Finally, this dissertation contributes to addressing gaps in the contemporary literature about adolescent depression. It presents information on an understudied sample - Brazilian adolescents - and adds to a modest body of literature that uses qualitative methodologies as a powerful tool for building in-depth interpretations regarding how one interprets, understands, and shares their experiences.A adolescência é um período de mudança física e psicossocial, além de um período de intenso crescimento, aprendizado e desenvolvimento. Entretanto, a conceitualização atual de depressão na adolescência dá pouca atenção às diferenças importantes que podem ocorrer em termos da manifestação do transtorno nesse estágio específico do desenvolvimento. Nesse sentido, a ideia de compreender como os adolescentes vivenciam a depressão surge como parte de um escopo mais amplo de compreensão da psicopatologia, destacando a necessidade de explorar as complexidades e sutilezas da vivência dos transtornos mentais. Portanto, esta dissertação tem como objetivo principal contribuir para a compreensão da vivência da depressão em adolescentes por meio de métodos qualitativos. Dois estudos são aqui apresentados. O primeiro teve como objetivo compreender as conceitualizações de depressão de adolescentes e outras partes interessadas, com foco em seus relatos de como a depressão mudou a vida dos adolescentes. Essa abordagem teve como objetivo incluir diferentes vozes e pontos de vista, visando reunir uma compreensão abrangente dos fatores contextuais dos ambientes de adolescentes com depressão. O segundo estudo explora as reações iniciais dos adolescentes após receberem um diagnóstico clínico de Transtorno Depressivo Maior. Nesse sentido, buscamos explorar a experiência subjetiva de receber o diagnóstico, mas também como isso afeta a contextualização de experiências passadas à luz desse novo diagnóstico. De maneira geral, esses estudos apresentam o papel vital das relações interpessoais na depressão na adolescência, reconhecendo a importância de prejuízos no funcionamento social na depressão. Por fim, esta dissertação aborda lacunas na literatura contemporânea sobre depressão na adolescência, apresentando informações sobre uma amostra pouco estudada - adolescentes brasileiros. Dessa forma, soma-se a um modesto corpo de literatura que utiliza metodologias qualitativas como ferramenta para construir interpretações aprofundadas sobre como adolescentes interpretam, compreendem e compartilham suas experiências

PEGA LEVE – SANTÉ MENTALE DES ÉTUDIANTS UNIVERSITAIRES

La salud mental en el entorno universitario involucra una variedad de factores personales, institucionales y ambientales en una etapa de transición en el ciclo de vida de los estudiantes, que pueden hacerlos más vulnerables al inicio, agravamiento o perpetuación de trastornos mentales comunes. Además, la búsqueda de ayuda y tratamiento adecuado en esta población es insuficiente, principalmente debido a las barreras de actitud, como el estigma y las estrategias de afrontamiento disfuncionales, que proporcionan peores resultados. Así, el proyecto de extensión “Pega Leve - salud mental de estudiantes universitarios”, una intervención basada en la capacitación de gatekeepers entre los propios estudiantes, se presenta como una herramienta potencial para la promoción y prevención de la salud mental en esta población, permitiendo la creación de redes de apoyo, identificación temprana de casos de riesgo y derivación adecuada a servicios de salud mental. Durante 2018 y 2019, más de setecientas personas se vieron afectadas por las acciones promovidas por Pega Leve y tres grupos de gatekeepers fueron formados de acuerdo con el protocolo sin precedentes desarrollado para el proyecto, lo que resultó subjetivamente en una mayor percepción de compromiso y apoyo social y ubica al estudiante como agente activo de promoción de la salud mental en los diversos microambientes forman la Universidad.Mental health in the university setting involves a variety of personal, institutional, and environmental factors at a transitional stage in the students' life cycle, which may make them more vulnerable to the onset, aggravation, or perpetuation of common mental disorders. In addition, the search for help and adequate treatment in this population is insufficient, mainly due to attitudinal barriers such as stigma and dysfunctional coping strategies, which provides worse outcomes. Thus, the extension project “Pega Leve - college students’ mental health”, an intervention based on gatekeeper training among peers, presents itself as a potential tool for the promotion and prevention of mental health in this population, allowing the creation of  support networks, early identification of risk cases and appropriate referral to mental health services. During 2018 and 2019, more than seven hundred people were affected by the actions promoted by Pega Leve and three gatekeeper groups were formed according to the unprecedented protocol developed for the project, subjectively resulting in a greater perception of engagement and social support and placing the student as an active mental health promotion agent in the various microenvironments comprised by the University.La santé mentale en milieu universitaire implique une variété de facteurs personnels, institutionnels et environnementaux à un stade transitoire du cycle de vie des étudiants, ce qui peut les rendre plus vulnérables au début, à l'aggravation ou à la perpétuation de troubles mentaux courants. En outre, la recherche d'aide et de traitement adéquat dans cette population est insuffisante, principalement en raison d'obstacles comportementaux tels que la stigmatisation et des stratégies d'adaptation dysfonctionnelles, qui produisent des résultats pires. Ainsi, le projet d'extension "Pega Leve - Santé mentale des étudiants universitaires", une intervention basée sur la formation de gatekeepers parmi les étudiants eux-mêmes, se présente comme un outil potentiel pour la promotion et la prévention de la santé mentale dans cette population, permettant la création de réseaux de soutien, l'identification précoce des cas à risque et l'orientation appropriée vers les services de santé mentale. En 2018 et 2019, plus de sept cent personnes ont été touchées par les actions promues par Pega Leve et trois groupes de gatekeepers formés selon le protocole sans précédent mis au point pour le projet, ce qui a abouti subjectivement à une meilleure perception de l'engagement et du soutien social, en plaçant l'étudiant en tant qu’agent actif de promotion de la santé mentale dans les divers micro-environnements compris par l’Université.A saúde mental no ambiente universitário envolve diversos fatores pessoais, institucionais e ambientais em uma etapa de transição do ciclo vital dos estudantes, o que pode torná-los mais vulneráveis ao início, agravamento ou perpetuação de transtornos mentais comuns. Somado a isso, as buscas por ajuda e tratamento adequado nessa população são insuficientes, principalmente devido às barreiras atitudinais como o estigma e estratégias de coping disfuncionais, o que propicia desfechos piores. Dessa forma, o projeto de extensão “Pega Leve – saúde mental do estudante universitário”, intervenção baseada em treinamento de gatekeepers entre os próprios estudantes se apresenta como uma potencial ferramenta de promoção e prevenção em saúde mental nessa população, permitindo a criação de redes de apoio, identificação precoce dos casos de risco e encaminhamento adequado para serviço de saúde mental. Durante os anos de 2018 e 2019, foram mais de setecentas pessoas atingidas pelas ações promovidas pelo Pega Leve e três turmas de gatekeepers formadas segundo o protocolo inédito desenvolvido para o projeto, resultando subjetivamente em uma maior percepção de engajamento e apoio social e colocando o estudante como agente ativo de promoção de saúde mental nos diversos microambientes compreendidos pela Universidade

Pega Leve - saúde mental do estudante universitário : um relato de experiência

A saúde mental no ambiente universitário envolve diversos fatores pessoais, institucionais e ambientais em uma etapa de transição do ciclo vital dos estudantes, o que pode torná-los mais vulneráveis ao início, agravamento ou perpetuação de transtornos mentais comuns. Somado a isso, as buscas por ajuda e tratamento adequado nessa população são insuficientes, principalmente devido às barreiras atitudinais como o estigma e estratégias de coping disfuncionais, o que propicia desfechos piores. Dessa forma, o projeto de extensão “Pega Leve – saúde mental do estudante universitário”, intervenção baseada em treinamento de gatekeepers entre os próprios estudantes se apresenta como uma potencial ferramenta de promoção e prevenção em saúde mental nessa população, permitindo a criação de redes de apoio, identificação precoce dos casos de risco e encaminhamento adequado para serviço de saúde mental. Durante os anos de 2018 e 2019, foram mais de setecentas pessoas atingidas pelas ações promovidas pelo Pega Leve e três turmas de gatekeepers formadas segundo o protocolo inédito desenvolvido para o projeto, resultando subjetivamente em uma maior percepção de engajamento e apoio social e colocando o estudante como agente ativo de promoção de saúde mental nos diversos microambientes compreendidos pela Universidade.Mental health in the university setting involves a variety of personal, institutional, and environmental factors at a transitional stage in the students' life cycle, which may make them more vulnerable to the onset, aggravation, or perpetuation of common mental disorders. In addition, the search for help and adequate treatment in this populationis insufficient, mainly due to attitudinal barriers such as stigma and dysfunctional coping strategies, which provides worse outcomes. Thus, the extension project “Pega Leve -college students’ mental health”, an intervention based onpsychoeducation andgatekeeper training among peers, presents itself as a potential tool for the promotion and prevention of mental health in this population, allowing the creation of support networks, early identification of risk cases and appropriate referral to mental health services. During 2018 and 2019, more than seven hundred people were affected by thepsychoeducationsactions promoted by Pega Leve, subjectively resulting in a greater perception of engagement and social support and placing the student as an active mental health promotion agent in the various microenvironments comprised by the University.La santé mentale en milieu universitaire implique une variété de facteurs personnels, institutionnels et environnementaux à un stade transitoire du cycle de vie des étudiants, ce qui peut les rendre plus vulnérables au début, à l'aggravation ou à la perpétuation de troubles mentaux courants. En outre, la recherche d'aide et de traitement adéquat dans cette population est insuffisante, principalement en raison d'obstacles comportementaux tels que la stigmatisation et des stratégies d'adaptation dysfonctionnelles, qui produisent des résultats pires. Ainsi, le projet d'extension"Pega Leve -Santé mentale des étudiants universitaires", une intervention basée sur lapsychoéducation et laformation de gatekeepersparmi les étudiants eux-mêmes, se présente comme un outil potentiel pour la promotion et la prévention de la santé mentale dans cette population, permettant la création de réseaux de soutien, l'identification précoce des cas à risque et l'orientation appropriée vers les services de santé mentale. En 2018 et 2019, plus de sept cent personnes ont été touchées par les actions promues par Pega Leve, ce qui a abouti subjectivement à une meilleure perception de l'engagement et du soutien social, en plaçant l'étudiant en tant qu’agent actif de promotion de la santé mentale dans les divers micro-environnements compris par l’Université.La salud mental en el entorno universitario involucra una variedad de factores personales, institucionales y ambientales en una etapa de transición enel ciclo de vida de los estudiantes, que pueden hacerlos más vulnerables al inicio, agravamiento o perpetuación de trastornos mentales comunes. Además, la búsqueda de ayuda y tratamiento adecuado en esta población es insuficiente, principalmente debido a las barreras de actitud, como el estigma y las estrategias de copingdisfuncionales, que proporcionan peores resultados. Así, el proyecto de extensión “Pega Leve -salud mental de estudiantes universitarios”, una intervención basada em lapsicoeducación y la capacitación de gatekeepersentre los propios estudiantes, se presenta como una herramienta potencial para la promoción y prevención de la salud mental en esta población, permitiendo la creación de redes de apoyo, identificación temprana de casos de riesgo y derivación adecuada a servicios de salud mental. Durante 2018 y 2019, más de setecientas personas se vieron afectadas por las accionespsicoeducativaspromovidas por Pega Leve, lo que resultó subjetivamente en una mayor percepción de compromiso yapoyo social y poniendoal estudiante como agente activo de promoción de la salud mental en los diversos microambientes que componenla Universidad

Mind the brain gap: the worldwide distribution of neuroimaging research on adolescent depression

Adolescents comprise one fourth of the world’s population, with about 90% of them living in low- and middleincome countries (LMICs). The incidence of depression markedly increases during adolescence, making the disorder a leading cause of disease-related disability in this age group. However, most research on adolescent depression has been performed in high-income countries (HICs). To ascertain the extent to which this disparity operates in neuroimaging research, a systematic review of the literature was performed. A total of 148 studies were identified, with neuroimaging data available for 4,729 adolescents with depression. When stratified by income group, 122 (82%) studies originated from HICs, while 26 (18%) were conducted in LMICs, for a total of 3,705 and 1,024 adolescents with depression respectively. A positive Spearman rank correlation was observed between country per capita income and sample size (rs=0.673, p = 0.023). Our results support the previous reports showing a large disparity between the number of studies and the adolescent population per world region. Future research comparing neuroimaging findings across populations from HICs and LMICs may provide unique insights to enhance our understanding of the neurobiological processes underlying the development of depression

Neuroimaging adolescents with depression in a middle-income country : feasibility of an fMRI protocol and preliminary results

Objective: To test the feasibility and to present preliminary results of a neuroimaging protocol to evaluate adolescent depression in a middle-income setting. Methods: We assessed psychotropic medication-free adolescents (age range 14-16 years) with a diagnosis of major depressive disorder (MDD). Participants underwent a comprehensive clinical evaluation and both structural and functional magnetic resonance imaging (fMRI). In this pilot study, a preliminary single-group analysis of resting-state fMRI (rs-fMRI) data was performed, with a focus on the default mode network (DMN), cognitive control network (CCN), and salience network (SN). Results: The sample included 29 adolescents with MDD (mean age 16.01, SD 0.78) who completed the protocol. Only two participants were excluded due to MRI quality issues (head movement), and were not included in the analyses. The scans showed significant connectivity between the medial prefrontal cortex and posterior cingulate cortex (DMN), the ACC and anterior insula (SN), and the lateral prefrontal cortex and dorsal parietal cortex (CCN). Conclusion: We demonstrated the feasibility of implementing a complex neuroimaging protocol in a middle-income country. Further, our preliminary rs-fMRI data revealed patterns of resting-state connectivity consistent with prior research performed in adolescents from high-income countries

Reward - and threat - related neural function associated with risk and presence of depression in adolescents : a study using a composite risk score in Brazil

Background: Neuroimaging studies on adolescents at risk for depression have relied on a single risk factor and focused on adolescents in high-income countries. Using a composite risk score, this study aims to examine neural activity and connectivity associated with risk and presence of depression in adolescents in Brazil. Methods: Depression risk was defined with the Identifying Depression Early in Adolescence Risk Score (IDEA-RS), calculated using a prognostic model that included 11 socio-demographic risk factors. Adolescents recruited from schools in Porto Alegre were classified into a low-risk (i.e., low IDEA-RS and no lifetime depression), high-risk (i.e., high IDEARS and no lifetime depression), or clinically depressed group (i.e., high IDEA-RS and depression diagnosis). One hundred fifty adolescents underwent a functional MRI scan while completing a reward-related gambling and a threatrelated face-matching task. We compared group differences in activity and connectivity of the ventral striatum (VS) and amygdala during the gambling and face-matching tasks, respectively, and group differences in whole-brain neural activity. Results: Although there was no group difference in reward-related VS or threat-related amygdala activity, the depressed group showed elevated VS activity to punishment relative to high-risk adolescents. The wholebrain analysis found reduced reward-related activity in the lateral prefrontal cortex of patients and high-risk adolescents compared with low-risk adolescents. Compared with low-risk adolescents, high-risk and depressed adolescents showed reduced threat-related left amygdala connectivity with thalamus, superior temporal gyrus, inferior parietal gyrus, precentral gyrus, and supplementary motor area. Conclusions: We identified neural correlates associated with risk and presence of depression in a well-characterized sample of adolescents. These findings enhance knowledge of the neurobiological underpinnings of risk and presence of depression in Brazil. Future longitudinal studies are needed to examine whether the observed neural patterns of high-risk adolescents predict the development of depression

Frontolimbic network topology associated with risk and presence of depression in adolescents : a study using a composite risk score in Brazil

BACKGROUND: There have been significant challenges in understanding functional brain connectivity associated with adolescent depression, including the need for a more comprehensive approach to defining risk, the lack of representation of participants from low- and middle-income countries, and the need for network-based approaches to model connectivity. The current study aimed to address these challenges by examining resting-state functional connectivity of frontolimbic circuitry associated with the risk and presence of depression in adolescents in Brazil. METHODS: Adolescents in Brazil ages 14 to 16 years were classified into low-risk, high-risk, and depressed groups using a clinical assessment and composite risk score that integrates 11 sociodemographic risk variables. After excluding participants with excessive head movement, resting-state functional magnetic resonance imaging data of 126 adolescents were analyzed. We compared group differences in frontolimbic network connectivity using region of interest–to–region of interest, graph theory, and seed-based connectivity analyses. Associations between self-reported depressive symptoms and brain connectivity were also explored. RESULTS: Adolescents with depression showed greater dorsal anterior cingulate cortex (ACC) connectivity with the orbitofrontal cortex compared with the 2 risk groups and greater dorsal ACC global efficiency than the low-risk group. Adolescents with depression also showed reduced local efficiency and a lower clustering coefficient of the subgenual ACC compared with the 2 risk groups. The high-risk group also showed a lower subgenual ACC clustering coefficient relative to the low-risk group. CONCLUSIONS: These findings highlight altered connectivity and topology of the ACC within frontolimbic circuitry as potential neural correlates and risk factors of developing depression in adolescents in Brazil. This study broadens our understanding of the neural connectivity associated with adolescent depression in a global context