social hypothesis of depression

Psychological Theories of Depression

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

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Depression is a mood disorder that prevents individuals from leading a normal life at work, socially, or within their family. Seligman (1973) referred to depression as the ‘common cold’ of psychiatry because of its frequency of diagnosis.

Depending on how data are gathered and how diagnoses are made, as many as 27% of some population groups may be suffering from depression at any one time (NIMH, 2001; data for older adults).

Behaviorist Theory

Behaviorism emphasizes the importance of the environment in shaping behavior. The focus is on observable behavior and the conditions through which individuals” learn behavior, namely classical conditioning, operant conditioning, and social learning theory.

Therefore, depression is the result of a person’s interaction with their environment.

For example, classical conditioning proposes depression is learned through associating certain stimuli with negative emotional states. Social learning theory states behavior is learned through observation, imitation, and reinforcement.

Operant Conditioning

Operant conditioning states that depression is caused by the removal of positive reinforcement from the environment (Lewinsohn, 1974). Certain events, such as losing your job, induce depression because they reduce positive reinforcement from others (e.g., being around people who like you).

Depressed people usually become much less socially active. In addition, depression can also be caused by inadvertent reinforcement of depressed behavior by others.

For example, when a loved one is lost, an important source of positive reinforcement has lost as well. This leads to inactivity. The main source of reinforcement is now the sympathy and attention of friends and relatives.

However, this tends to reinforce maladaptive behavior, i.e., weeping, complaining, and talking of suicide. This eventually alienates even close friends leading to even less reinforcement and increasing social isolation and unhappiness. In other words, depression is a vicious cycle in which the person is driven further and further down.

Also, if the person lacks social skills or has a very rigid personality structure, they may find it difficult to make the adjustments needed to look for new and alternative sources of reinforcement (Lewinsohn, 1974). So they get locked into a negative downward spiral.

Critical Evaluation

Behavioral/learning theories make sense in terms of reactive depression, where there is a clearly identifiable cause of depression. However, one of the biggest problems for the theory is that of endogenous depression. This is depression that has no apparent cause (i.e., nothing bad has happened to the person).

An additional problem of the behaviorist approach is that it fails to consider cognitions (thoughts) influence on mood.

Psychodynamic Theory

During the 1960s, psychodynamic theories dominated psychology and psychiatry. Depression was understood in terms of the following:

• inwardly directed anger (Freud, 1917),
• introjection of love object loss,
• severe super-ego demands (Freud, 1917),
• excessive narcissistic , oral, and/or anal personality needs (Chodoff, 1972),
• loss of self-esteem (Bibring, 1953; Fenichel, 1968), and
• deprivation in the mother-child relationship during the first year (Kleine, 1934).

Freud’s psychoanalytic theory is an example of the psychodynamic approach . Freud (1917) proposed that many cases of depression were due to biological factors.

However, Freud also argued that some cases of depression could be linked to loss or rejection by a parent. Depression is like grief in that it often occurs as a reaction to the loss of an important relationship.

However, there is an important difference because depressed people regard themselves as worthless. What happens is that the individual identifies with the lost person so that repressed anger towards the lost person is directed inwards towards the self. The inner-directed anger reduces the individual’s self-esteem  and makes him/her vulnerable to experiencing depression in the future.

Freud distinguished between actual losses (e.g., the death of a loved one) and symbolic losses (e.g., the loss of a job). Both kinds of losses can produce depression by causing the individual to re-experience childhood episodes when they experience loss of affection from some significant person (e.g., a parent).

Later, Freud modified his theory stating that the tendency to internalize lost objects is normal and that depression is simply due to an excessively severe super-ego. Thus, the depressive phase occurs when the individual’s super-ego or conscience is dominant. In contrast, the manic phase occurs when the individual’s ego or rational mind asserts itself, and s/he feels control.

In order to avoid loss turning into depression, the individual needs to engage in a period of mourning work, during which s/he recalls memories of the lost one.

This allows the individual to separate himself/herself from the lost person and reduce inner-directed anger. However, individuals very dependent on others for their sense of self-esteem may be unable to do this and so remain extremely depressed.

Psychoanalytic theories of depression have had a profound impact on contemporary theories of depression.

For example, Beck’s (1983) model of depression was influenced by psychoanalytic ideas such as the loss of self-esteem (re: Beck’s negative view of self), object loss (re: the importance of loss events), external narcissistic deprivation (re: hypersensitivity to loss of social resources) and oral personality (re: sociotropic personality).

However, although highly influential, psychoanalytic theories are difficult to test scientifically. For example, its central features cannot be operationally defined with sufficient precision to allow empirical investigation. Mendelson (1990) concluded his review of psychoanalytic theories of depression by stating:

“A striking feature of the impressionistic pictures of depression painted by many writers is that they have the flavor of art rather than of science and may well represent profound personal intuitions as much as they depict they raw clinical data” (p. 31).

Another criticism concerns the psychanalytic emphasis on the unconscious, intrapsychic processes, and early childhood experience as being limiting in that they cause clinicians to overlook additional aspects of depression. For example, conscious negative self-verbalization (Beck, 1967) or ongoing distressing life events (Brown & Harris, 1978).

Cognitive Explanation of Depression

This approach focuses on people’s beliefs rather than their behavior. Depression results from systematic negative bias in thinking processes.

Emotional, behavioral (and possibly physical) symptoms result from cognitive abnormality. This means that depressed patients think differently from clinically normal people. The cognitive approach also assumes changes in thinking precede (i.e., come before) the onset of a depressed mood.

Beck’s (1967) Theory

One major cognitive theorist is Aaron Beck. He studied people suffering from depression and found that they appraised events in a negative way.

Beck (1967) identified three mechanisms that he thought were responsible for depression:

The cognitive triad (of negative automatic thinking) Negative self schemas Errors in Logic (i.e. faulty information processing)

The cognitive triad is three forms of negative (i.e., helpless and critical) thinking that are typical of individuals with depression: namely, negative thoughts about the self, the world, and the future. These thoughts tended to be automatic in depressed people as they occurred spontaneously.

For example, depressed individuals tend to view themselves as helpless, worthless, and inadequate. They interpret events in the world in an unrealistically negative and defeatist way, and they see the world as posing obstacles that can’t be handled.

Finally, they see the future as totally hopeless because their worthlessness will prevent their situation from improving.

As these three components interact, they interfere with normal cognitive processing, leading to impairments in perception, memory, and problem-solving, with the person becoming obsessed with negative thoughts.

Beck believed that depression-prone individuals develop a negative self-schema . They possess a set of beliefs and expectations about themselves that are essentially negative and pessimistic. Beck claimed that negative schemas might be acquired in childhood as a result of a traumatic event. Experiences that might contribute to negative schemas include:

• Death of a parent or sibling.
• Parental rejection, criticism, overprotection, neglect, or abuse.
• Bullying at school or exclusion from a peer group.

However, a negative self-schema predisposes the individual to depression, and therefore someone who has acquired a cognitive triad will not necessarily develop depression.

Some kind of stressful life event is required to activate this negative schema later in life. Once the negative schema is activated, a number of illogical thoughts or cognitive biases seem to dominate thinking .

People with negative self-schemas become prone to making logical errors in their thinking, and they tend to focus selectively on certain aspects of a situation while ignoring equally relevant information.

Beck (1967) identified a number of systematic negative biases in information processing known as logical errors or faulty thinking. These illogical thought patterns are self-defeating and can cause great anxiety or depression for the individual. For example:

• Arbitrary Inference:  Drawing a negative conclusion in the absence of supporting data.
• Selective Abstraction:  Focusing on the worst aspects of any situation.
• Magnification and Minimisation: If they have a problem, they make it appear bigger than it is. If they have a solution they make it smaller.
• Personalization:  Negative events are interpreted as their fault.
• Dichotomous Thinking:  Everything is seen as black and white. There is no in between.

Such thoughts exacerbate and are exacerbated by the cognitive triad. Beck believed these thoughts or this way of thinking become automatic.

When a person’s stream of automatic thoughts is very negative, you would expect a person to become depressed. Quite often these negative thoughts will persist even in the face of contrary evidence.

Alloy et al. (1999) followed the thinking styles of young Americans in their early 20s for six years. Their thinking style was tested, and they were placed in either the ‘positive thinking group’ or ‘negative thinking group’.

After six years, the researchers found that only 1% of the positive group developed depression compared to 17% of the ‘negative’ group. These results indicate there may be a link between cognitive style and the development of depression.

However, such a study may suffer from demand characteristics. The results are also correlational. It is important to remember that the precise role of cognitive processes is yet to be determined. The maladaptive cognitions seen in depressed people may be a consequence rather than a cause of depression.

Learned Helplessness

Martin Seligman (1974) proposed a cognitive explanation of depression called learned helplessness .

According to Seligman’s learned helplessness theory, depression occurs when a person learns that their attempts to escape negative situations make no difference.

Consequently, they become passive and will endure aversive stimuli or environments even when escape is possible.

Seligman based his theory on research using dogs.

A dog put into a partitioned cage learns to escape when the floor is electrified. If the dog is restrained whilst being shocked, it eventually stops trying to escape.

Dogs subjected to inescapable electric shocks later failed to escape from shocks even when it was possible to do so. Moreover, they exhibited some of the symptoms of depression found in humans (lethargy, sluggishness, passive in the face of stress, and appetite loss).

This led Seligman (1974) to explain depression in humans in terms of learned helplessness , whereby the individual gives up trying to influence their environment because they have learned that they are helpless as a consequence of having no control over what happens to them.

Although Seligman’s account may explain depression to a certain extent, it fails to take into account cognitions (thoughts). Abramson, Seligman, and Teasdale (1978) consequently introduced a cognitive version of the theory by reformulating learned helplessness in terms of attributional processes (i.e., how people explain the cause of an event).

The depression attributional style is based on three dimensions, namely locus (whether the cause is internal – to do with a person themselves, or external – to do with some aspect of the situation), stability (whether the cause is stable and permanent or unstable and transient) and global or specific (whether the cause relates to the “whole” person or just some particular feature characteristic).

In this new version of the theory, the mere presence of a negative event was not considered sufficient to produce a helpless or depressive state. Instead, Abramson et al. argued that people who attribute failure to internal, stable, and global causes are more likely to become depressed than those who attribute failure to external, unstable, and specific causes.

This is because the former attributional style leads people to the conclusion that they are unable to change things for the better.

Gotlib and Colby (1987) found that people who were formerly depressed are actually no different from people who have never been depressed in terms of their tendencies to view negative events with an attitude of helpless resignation.

This suggests that helplessness could be a symptom rather than a cause of depression. Moreover, it may be that negative thinking generally is also an effect rather than a cause of depression.

Humanist Approach

Humanists believe that there are needs that are unique to the human species. According to Maslow (1962), the most important of these is the need for self-actualization (achieving our potential). The self-actualizing human being has a meaningful life. Anything that blocks our striving to fulfill this need can be a cause of depression. What could cause this?

• Parents impose conditions of worth on their children. I.e., rather than accepting the child for who s/he is and giving unconditional love , parents make love conditional on good behavior. E.g., a child may be blamed for not doing well at school, develop a negative self-image and feel depressed because of a failure to live up to parentally imposed standards.
• Some children may seek to avoid this by denying their true selves and projecting an image of the kind of person they want to be. This façade or false self is an effort to please others. However, the splitting off of the real self from the person you are pretending to cause hatred of the self. The person then comes to despise themselves for living a lie.
• As adults, self-actualization can be undermined by unhappy relationships and unfulfilling jobs. An empty shell marriage means the person is unable to give and receive love from their partner. An alienating job means the person is denied the opportunity to be creative at work.

Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). Learned helplessness in humans: critique and reformulation . Journal of abnormal psychology, 87(1) , 49.

Alloy, L. B., Abramson, L. Y., Whitehouse, W. G., Hogan, M. E., Tashman, N. A., Steinberg, D. L., … & Donovan, P. (1999). Depressogenic cognitive styles : Predictive validity, information processing and personality characteristics, and developmental origins. behavior research and therapy, 37(6) , 503-531.

Beck, A. T. (1967). Depression: Causes and treatment . Philadelphia: University of Pennsylvania Press.

Beck, A. T., Epstein, N., & Harrison, R. (1983). Cognitions, attitudes and personality dimensions in depression. British Journal of Cognitive Psychotherapy .

Bibring, E. (1953). The mechanism of depression .

Brown, G. W., & Harris, T. (1978). Social origins of depression: a reply. Psychological Medicine, 8(04) , 577-588.

Chodoff, P. (1972). The depressive personality: A critical review. Archives of General Psychiatry, 27(5) , 666-673.

Fenichel, O. (1968). Depression and mania. The Meaning of Despair . New York: Science House.

Freud, S. (1917). Mourning and melancholia. Standard edition, 14(19) , 17.

Gotlib, I. H., & Colby, C. A. (1987). Treatment of depression: An interpersonal systems approach. Pergamon Press.

Klein, M. (1934). Psychogenesis of manic-depressive states: contributions to psychoanalysis . London: Hogarth.

Lewinsohn, P. M. (1974). A behavioral approach to depression .

Maslow, A. H. (1962). Towards a psychology of being . Princeton: D. Van Nostrand Company.

National Institute of Mental Health. (2001). Depression research at the National Institute of Mental Health http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml.

Seligman, M. E. (1973). Fall into helplessness. Psychology today, 7(1) , 43-48.

Seligman, M. E. (1974). Depression and learned helplessness . John Wiley & Sons.

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Social and cognitive approaches to depression: towards a new synthesis

Affiliation.

• 1 Department of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, UK.
• PMID: 8563657
• DOI: 10.1111/j.2044-8260.1995.tb01484.x

A description of a social-cognitive theory of depression is presented which combines the concepts of mental models, personal goals and social roles. An analysis is made of how a number of proposals about the onset of depression can be summarized as the loss of a valued goal or social role in an individual who has few other sources of self-worth. In subsequent sections, limitations of the theory are outlined, and the relationship between the present theory and other theories of depression is briefly considered.

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Depression as a Social Disease

A consideration of johann hari's book "lost connections.".

Posted February 28, 2018 | Reviewed by Hara Estroff Marano

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What causes depression and anxiety ? I have been a practicing psychologist and psychoanalyst for almost 40 years and have seen hundreds of patients suffering from both. In my experience, some factors are obvious. People who suffer from depression and anxiety have experienced stresses and traumas in their development that predispose them to mood disorders. Garden-variety psychodynamic theory teaches us that issues involving loss, neglect, guilt , and rejection usually figure prominently in the backgrounds of people who present with significant symptoms of depression and anxiety.

In addition, over 50 years of research into the neurobiology of mood disorders strongly suggests that genetic and biological factors usually accompany, if not underlie, these painful affective states. As a result of these assumptions, the treatment of depression today usually relies heavily on pharmacology, and drug companies have spent billions making sure that this explanation is widely accepted. Someone in five US adults is taking at least one drug for a psychiatric problem; nearly one in four middle-aged women in the United States is taking antidepressants at any given time, and around one in 10 boys at American high schools are being given powerful stimulants to make them focus.

Since it's well known that psychological events produce biological changes, it remains debatable whether or not disorders of our biochemistry are causes or effects. What we do know is that untold amounts of money have been spent by the pharmaceutical industry to finance research and public relations designed to enshrine biochemistry and pharmacology as primary in the diagnosis and treatment of depression and anxiety.

However, what of the social, cultural, and even political contexts that contribute to emotional suffering? We owe writer and journalist, Johann Hari, a great debt for illuminating these broader contextual factors in his new book, Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions. Hari first debunks the "received wisdom " that assumes that the jury is in regarding the neurochemical basis of depression and the efficacy of antidepressants. He points to research based on the unpublished studies done by pharmaceutical companies on the efficacy of antidepressants, that almost unintentionally reveal a profound placebo effect underlying the clinical improvements reported. When depressed people who are being studied feel cared for by psychiatric researchers, they improve at astoundingly high rates (sometimes by as much as 40%). Thus, the pure biochemical antidepressant effect of these medications is much smaller than has commonly been assumed. In addition, when patients do get better, a commonly seen phenomenon, within a year, at least half of them are again clinically depressed.

We have to acknowledge that some real people get better in real ways on antidepressants. However, it is also true that these benefits are less than advertised and results often diminish over time. Locating the cause of depression entirely in the brain and advocating a primarily pharmacological approach to its treatment is a paradigm with limited efficacy.

Hari argues that depression and anxiety should be considered two sides of the same coin. He asserts that everything that causes an increase in depression also causes an increase in anxiety and the other way around. He points out that these two types of distress "rise and fall together." Again, this aligns with my own experience treating patients with depression and anxiety. In my clinical experience, it's rare to see one without the other.

Most of Lost Connections presents the author’s account of the research done on the social and cultural causes of depression. For example, in the 1970s, British researchers George Brown and Tirril Harris and their team extensively interviewed 115 women living in a working-class suburb of London who were diagnosed with depression and compared their responses to a second group of 344 so-called "normal,” that is, non–depressed, women from the same income group. Their findings were stunning at that time: The depressed women were three times more likely to have experienced certain major life stressors in the year prior to their diagnosis than the non-depressed women. The depressed women had more stressors, more trauma, and fewer factors thought to provide psychological resilience , such as close friends and supportive extended family.

The notion that trauma and stressful life experience cause depression and anxiety is really no longer controversial. For example, in the mid-1990s, Dr. Vincent Felitti of Kaiser Hospital in San Diego conducted an extraordinary and simple study, called the Adverse Childhood Experiences Study—or ACE Study. He sent out a questionnaire to 17,000 people who were seeking healthcare from Kaiser, a questionnaire asking people to check off which of 10 different categories of childhood trauma they had experienced. These traumas included most of the terrible things that can happen to you when you're a child, including various types of sexual , physical or emotional abuse . In addition, respondents filled out a detailed medical questionnaire testing for all sorts of things that could be problematic, such as obesity, addiction , or depression. The results stunned even Dr. Felitti: For every category of traumatic experience that someone went through as a child, that person was radically more likely to become depressed as an adult. The correlation was almost perfect—the greater the trauma, the greater the risk for depression, anxiety, or suicide . For example, if you had six categories of traumatic events in your childhood, you were five times more likely to become depressed as an adult than someone who didn't have any. If you had seven types of traumatic events as a child, you were 3100% more likely to attempt to commit suicide as an adult.

The notion that depression isn't a disease but, instead, a normal response to abnormal life experiences wouldn't surprise most of us, except for the fact that we live in a culture which pathologizes psychic suffering as a disorder within individuals, rather than as suffering that makes sense given a pathological environment. The cost of such victim blaming is high. If you believe that depression is solely a result of disordered brain chemistry, you don't have to think about your life and about what other people may have done to you. It's painful to think along these lines, which may be one of the reasons why a biological explanation is often easier. As Hari says, quoting Dr. Robert Anda who worked on the ACE study, "when people have these kinds of problems, it's time to stop asking what's wrong with them, and time to start asking what happened to them."

Hari believes that the social and cultural causes of depression all involve some form of "disconnection." For example, he argues that people in our culture are disconnected from meaningful work and cites as evidence a huge Gallup poll about work conducted in 2011 and 2012 that included millions of workers across 142 countries. Gallup found that only 13% of people described themselves as "engaged" in their jobs—meaning that they were enthusiastic about and committed to their work and pleased with their contribution to their organization. Sixty-three percent reported themselves "not engaged" and 24% described themselves as "actively not engaged"—which, in this survey, meant that they acted out their unhappiness, undermining their coworkers, and even seeking to damage the companies for which they work. Nearly twice as many people hate their jobs as love their jobs. The prevalence of deadening, routinized, and alienated work leads people to feel unappreciated, unrecognized, and frustrated, with little or no sense of contributing to something bigger and better than themselves. Disempowerment and indifferent hierarchies at work cause depression.

Hari explores another form of disconnection that is more obvious, namely being disconnected from other people. Social isolation and loneliness have been shown to have a wide range of negative physical/health consequences. Feeling lonely, for example, causes our cortisol levels to soar, a hormonal outcome that causes wide-ranging damage to the body and mind. In fact, acute loneliness is seen as every bit as stressful as being physically attacked. Human beings are wired to be in groups, and, when we aren’t for too long, we feel alienated and insecure. Loneliness and social isolation is increasingly a public health epidemic in America. As sociologist Robert Putnam has shown, the percentage of Americans actively involved in community organizations has radically declined. From 1985 to 95—only one decade—active involvement in community organizations decreased almost 50%. We seem to have stopped banding together and have found ourselves increasingly shut away in our own homes. We do things together less than any generation that came before us. And, finally, we know that being alone changes our brains and that curing that loneliness changes our brains, so if we're not looking at social as well as biological factors, we can't understand what's really going on with depression today.

Hari then goes on to talk about another form of disconnection--being disconnected from "meaningful values." In this section, he offers a critique of our consumer culture clearly dominated by an addiction to material possessions, money, and status. He points out that advertising experts have admitted since the 1920s that their job is to make people feel inadequate and to then offer their products as the solution to the very inadequacy they have created. A capitalist economy and culture that tells us that there is never enough and that we are never enough, provides us with what Hari calls "junk values." Materialism has never been associated with health and happiness . In fact, when people are asked to reflect on what really matters to them they usually admit to such deep values as meaningful work, community, family, or being a loving person in service to others. When we are estranged from ourselves, we suffer.

Hari also reviews some of the usual suspects that come up in any discussion about emotional well-being, including being disconnected from status, respect, and social approval by virtue of the gross and radical imbalances of income and wealth in our society, as well as being disconnected from the natural world in a society in which most people live in cities and conduct most of their life indoors. There is powerful scientific evidence that suggests that societies with greater equality have less psychiatric illness and that being out in nature reduces depression and anxiety.

Hari wants to be clear that he is not saying that genetics and neurobiology have no effect on depression. What he is saying is that the brain and even our genes respond to signals from the world. For example, London cab drivers who have to memorize the entire map of London have brains that, when scanned, reveal that the part responsible for spatial awareness is bigger than it is in the brains of the rest of us. Experience changes the brain. Clearly, once changes in the brain have occurred, they gain a momentum of their own and contribute to, or reduce, emotional distress. Genes can significantly increase our sensitivity to environmental stress, but that's a far cry from saying that they are a primary cause depression. Hari points out that historically depression and anxiety were regarded as moral failures, and, as a result, the notion that depression is primarily biological can be seen as a defense against blame and judgment. However much such a defense may help some people fend off social disapproval and private shame , the question of causation isn't answered.

The importance of understanding the social and cultural conditions that seem to produce depression and anxiety is that it points the way towards interventions and social changes that could yield tremendous psychological benefits on a mass scale. Obviously, I'm a believer in psychotherapy and I've also repeatedly seen the short- and medium-term benefits of medications. However, to truly deal with the epidemic of depression and anxious suffering in the world we need to consider making more radical social and political changes. Reducing inequality, for example, is not merely in the interest of justice, but would likely produce a significant decrease in depression and anxiety. Further, experiments in cooperative, more democratic and egalitarian work arrangements have shown that such innovations, by reducing the alienation and estrangement people feel at work, can significantly decrease stress while not sacrificing success in the marketplace. Hari says that we need to ask depressed people not “what's the matter with you,” but, instead, “what matters to you?”

Such "solutions" involve making radical changes in social life . However, I think that our movement acquires a greater degree of urgency and validity if we understand how much emotional suffering can potentially be remediated. Such understanding can even inform political proposals like those that call for a Universal Basic Income, or UBI, in which people are given a fixed amount of money every year, completely without conditions, to do with whatever they wish –-something that has been tried experimentally many times the world over. Such projects not only directly address the problem of poverty and income inequality but emotional health and welfare as well. The UBI gives people the freedom to live and work in ways aligned with their deeper non-materialistic, non-“junk” values. They can hold out for work that is less alienated and more safely connect with their families and communities. The research into these experiments has shown that they greatly enhance the overall levels of emotional as well as physical well-being.

When we privilege explanations of depression and anxiety that emphasize our internal biology, we let society off the hook. We privatize psychological pain even as the role that our culture contributes to that pain goes unchallenged. Johan Hari’s new book helps us tell a different story. As Hari points out, it is even a story endorsed by the World Health Organization—the leading medical body in the world—that summarized the evidence in 2011 in this way: "Mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as if individual, solutions.” In its official statement for World Health Day in 2017, the United Nations explained that "the dominant biomedical narrative of depression" is based on "biased and selective use of research outcomes" that "cause more harm than good, undermine the right to health, and must be abandoned."

Hari eloquently states this case in his last chapter when he says: "You aren't a machine with broken parts. You are an animal whose needs are not being met. You need to have a community. You need to have meaningful values, not the junk values you've been pumped full of all your life, telling you happiness comes through money and buying objects. You need to have meaningful work. You need the natural world. You need to feel you are respected. You need a secure future. You need connections to all these things. You need to release any shame you might feel for having been mistreated.”

I think it's fair to say that in order to achieve these things, we need a revolution.

Michael Bader, D.M.H., is a psychologist and psychoanalyst in San Francisco. He is the author of Male Sexuality: Why Women Don't Understand It—and Men Don't Either .

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The Morning

Americans’ struggle with mental health.

We explore why rates of anxiety and depression are higher than they were before the pandemic.

By Ellen Barry

I cover mental health.

It is no mystery why rates of anxiety and depression in the United States climbed in 2020, at the height of the pandemic. But then life began a slow return to normal. Why haven’t rates of distress returned to normal, too?

Self-reported anxiety and depression have declined from the peak they reached in November 2020, when 42.6 percent of adults said they had symptoms, according to the Household Pulse Survey, a Census Bureau tool that measures well-being. Since then, that figure has declined to 20.7 percent. That’s still double the 11 percent of Americans who said the same thing before the pandemic.

In today’s newsletter, I’ll explain why. Researchers say a big reason for this stubbornly elevated distress is young people, whose low mood was not linked to the pandemic.

A youth epidemic

The share of young adults reporting anxiety and depression had been rising for about a decade before Covid struck. That continued throughout the pandemic — and did not ease as quickly when vaccines became available.

This is likely because their symptoms were tied to problems other than the virus, like economic precarity, the housing crisis, social isolation and political turmoil, said Emma Adam, a psychologist at Northwestern. “There’s so many things affecting adolescents and young adults that are about uncertainty with their future,” Adam said. “And that hasn’t changed.”

Age, of course, tracks with income. Adam’s team found that people between the ages of 18 and 39 were half as likely to live in their own home as their counterparts over 40. That means they were especially vulnerable to inflation, rent increases and job loss — just as they faced big decisions like whether to have children or own a home.

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College of Social Science

Msu study finds placebos reduce stress, anxiety and depression.

August 15, 2024 - Shelly DeJong

Even when participants knew they had placebos, their COVID anxiety reduced

A study out of Michigan State University found that non-deceptive placebos, or placebos given with people fully knowing they are placebos, effectively manage stress — even when the placebos are administered remotely. 

Researchers recruited participants experiencing prolonged stress from the COVID-19 pandemic for a two-week randomized controlled trial. Half of the participants were randomly assigned to a non-deceptive placebo group and the other half to the control group that took no pills. The participants interacted with a researcher online through four virtual sessions on Zoom. Those in the non-deceptive placebo group received information on the placebo effect and were sent placebo pills in the mail along with instructions on taking the pills. 

The study,   published in Applied Psychology : Health and Well-Being, found that the non-deceptive group showed a significant decrease in stress, anxiety and depression in just two weeks compared to the no-treatment control group. Participants also reported that the non-deceptive placebos were easy to use, not burdensome and appropriate for the situation.

"Exposure to long-term stress can impair a person’s ability to manage emotions and cause significant mental health problems, so we’re excited to see that an intervention that takes minimal effort can still lead to significant benefits,” said  Jason Moser , co-author of the study and professor in MSU’s Department of Psychology. “This minimal burden makes non-deceptive placebos an attractive intervention for those with significant stress, anxiety and depression.”

The researchers are particularly hopeful in the ability to remotely administer the non-deceptive placebos by health care providers.

“This ability to administer non-deceptive placebos remotely increases scalability potential dramatically,” said Darwin Guevarra, co-author of the study and postdoctoral scholar at the University of California, San Francisco, “Remotely administered non-deceptive placebos have the potential to help individuals struggling with mental health concerns who otherwise would not have access to traditional mental health services.”

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162 lies and distortions in a news conference. NPR fact-checks former President Trump

Domenico Montanaro

Former President Donald Trump, the Republican presidential nominee, speaks during a news conference at his Mar-a-Lago estate in Florida on Aug. 8. Joe Raedle/Getty Images hide caption

There were a host of false things that Donald Trump said during his hour-long news conference Thursday that have gotten attention.

A glaring example is his helicopter emergency landing story, which has not stood up to scrutiny .

But there was so much more. A team of NPR reporters and editors reviewed the transcript of his news conference and found at least 162 misstatements, exaggerations and outright lies in 64 minutes. That’s more than two a minute. It’s a stunning number for anyone – and even more problematic for a person running to lead the free world.

Politicians spin. They fib. They misspeak. They make honest mistakes like the rest of us. And, yes, they even sometimes exaggerate their biographies .

The expectation, though, is that they will treat the truth as something important and correct any errors.

But what former President Trump did this past Thursday went well beyond the bounds of what most politicians would do.

Here’s what we found, going chronologically from the beginning of Trump’s remarks to the end:

1. “I think our country right now is in the most dangerous position it’s ever been in from an economic standpoint…” 

The U.S. economy has rebounded from the pandemic downturn more rapidly than most other countries around the world. Growth has slowed in recent months, but gross domestic product still grew at a relatively healthy annual clip of 2.8% in April, May and June – which is faster than the pace in three of the four years when Trump was president. — Scott Horsley, NPR chief economics correspondent

2. “…from a safety standpoint, both gangs on the street…”

We don’t have great, up-to-date data on gang activity in the U.S., but violent crime trends offer a good glimpse into safety in the country. Nationally, violent crime – that includes murder, rape, robbery and aggravated assault – has been trending way down after a surge in 2020, according to the most recent data from the FBI . That data is preliminary and incomplete, covering around three-quarters of the country, but other crime analysts have found similar trends. Crime levels, of course, vary locally : murders are down in Philadelphia, for instance, but up in Charlotte, N.C. — Meg Anderson, NPR National Desk reporter covering criminal justice

3. “...and frankly, gangs outside of our country in the form of other countries that are, frankly, very powerful. They’re very powerful countries.”

The U.S. is not in the “most dangerous position” from a foreign-policy standpoint than ever before. Biden pulled troops out of Afghanistan in his first year in office — though the withdrawal itself was chaotic and a target of much criticism — and since then, U.S. troops have not been actively engaged in a war for the first time in 20 years. The U.S. is supporting Ukraine and Israel, of course, and has troops in Iraq and Syria, but they’re not fighting on any regular basis.

What’s more, however, FBI Director Christopher Wray has said the greatest threat to the country is domestic extremism . And beyond organized groups the very definition of extremism is changing, as fringe ideologies move into the mainstream, and radicalization takes hold amongst parts of the populace. Consider: the Jan. 6 riot at the U.S. Capitol and the assassination attempt on Trump’s life, even with a motive that remains murky at best. Regardless, the call is coming from inside the house, domestic extremism experts warn. Many polls show a sobering degree of support for political violence to drive change. — Andrew Sussman, NPR supervising editor for national security

4-5. “ We have a lot of bad things coming up. You could end up in a Depression of the 1929 variety, which would be a devastating thing, took many years– took many decades to recover from it, and we’re very close to that.”

There is nothing to suggest that a 1930s style Depression is on the horizon for the United States. And the Depression did not take “many decades to recover from.” It ended during World War Two , in 1941. — Scott Horsley

6. “And we’re very close to a world war. In my opinion, we’re very close to a world war.”

No serious person thinks that the U.S., Russia and China are about to start a world war. Right now, Russia appears to be having a hard time defending Russia, given Ukraine’s recent incursions. While there are concerns about things like the potential for regional conflagrations in the Middle East, only Trump is talking about world war. — Andrew Sussman

7. “ Kamala's record is horrible. She's a radical left person at a level that nobody's seen.” 

It’s debatable how liberal Harris is. Some in California didn’t like her record on criminal justice and thought she was not progressive enough. She’s clearly liked by progressives and her voting scores as a senator are on the liberal end of the spectrum, but is she “radical left” and “at a level that nobody’s seen”? There are plenty of people alive and in history who would be considered far more liberal and more radical.

8. “She picked a radical left man.”

Few, if any, reasonable people would say Walz is a “radical left man.” He had a progressive record as governor with a Democratic legislature, but the things passed are hardly radical – free school lunch, protecting abortion rights, legalizing marijuana, restricting access to certain types of guns. All of these things have majority support from voters. What’s more, that “progressive” record ignores Walz’s first term as governor when he worked with Republicans because Democrats didn’t control the legislature. And it ignores Walz’s time as a congressman when he was considered a more moderate member given that he was from a district that had been previously held by a Republican.

9. “He's going for things that nobody's ever even heard of. Heavy into the transgender world.” 

Last year, Walz championed and signed a bill that prevented state courts of officials from complying with child-removal requests, extraditions, arrests or subpoenas related to gender-affirming health care that a person receives or provides in Minnesota. “Heavy into the transgender world” is vague and misleading.

10. “He doesn't want to have borders. He doesn't want to have walls.”

Walz has never called for having no borders. He has voiced opposition to a wall because he doesn't think it will stop illegal immigration. He told Anderson Cooper on CNN , for example, that a wall "is not how you stop" illegal immigration He called for more border-control agents, electronics and more legal ways to immigrate.

11. “He doesn't want to have any form of safety for our country.”

Trump himself praised Walz’s handling of the aftermath of the George Floyd murder at the hands of a police officer. And it’s certainly hyperbole to say he “doesn’t want any form of safety for our country.” Walz served in the U.S. National Guard for 24 years, so clearly, he’s interested in the country having national security. And domestically, he’s never been a “defund the police” advocate. Walz opposed a ballot measure that would have gotten rid of minimum police staffing levels, for example. That angered advocates. He signed police reforms into law , but that does not prove wanting no safety.

12. “He doesn't mind people coming in from prisons.”

Walz has not said he wants people coming in from prisons. Trump is trying to tie his claim that other countries are sending prisoners to the United States to Democrats’ immigration policies.

13. “And neither does she, I guess. Because she's not, she couldn't care less.”

Harris has said a lot to the contrary of not caring about the levels of migrants coming across the border, let alone people coming in from prisons. In fact, when in Guatemala, she said her message for people thinking of immigrating to the United States was: " Do not come. Do not come ."

14. “She's the border czar. By the way, she was the border czar, 100%. And all of a sudden, for the last few weeks, she's not the border czar anymore, like nobody ever said it.”

Harris was never appointed “border czar.” That’s a phrase that was used incorrectly by some media outlets. Biden tasked Harris with leading the “ diplomatic effort ” with leaders in Central American countries, where many migrants are coming from.

Biden said he wants Harris “to lead our efforts with Mexico and the Northern Triangle and the countries that help — are going to need help in stemming the movement of so many folks, stemming the migration to our southern border.” He added that Harris “agreed to lead our diplomatic effort and work with those nations to accept — the returnees, and enhance migration enforcement at their borders — at their borders.”

Harris herself that day spoke of “the need to address root causes for the migration that we’ve been seeing.”

15. “We have a very, very sick country right now. You saw the other day with the stock market crashing. That was just the beginning. That was just the beginning.”

The stock market did not “crash.” The stock market fell sharply at the end of last week as investors fretted about a softening job market. This was amplified on Monday when Japan’s stock market tumbled 12%, sparking a selloff around the world. Stocks in Japan and elsewhere have since regained much of this ground, however. The Dow Jones Industrial Average jumped 683 points on the day of Trump’s news conference. — Scott Horsley

16. “Fortunately, we've had some very good polls over the last fairly short period of time.”

Most good polls have shown Harris gaining not just nationally, but also in the swing states, though these same polls show a very close race.

17. “Rasmussen came out today. We're substantially leading.” 

Trump is not substantially leading, and Rasmussen is viewed as one of the least credible pollsters in the country.

18. “And others came out today that we're leading, and in some cases, substantially, I guess, MSNBC came out, or CNBC came out also, with a poll that was, you know, has us leading.” 

Polls have not shown substantial leads. CNBC had Trump leading by 2, unchanged from his 2-point lead in July.

19. “And leading fairly big in swing states. In some polls, I'm leading very big in swing states… .”

Again, polls in swing states have shown a tightened race.

20. “But as a border czar, she's been the worst border czar in history, in the world history.”

Vice President Harris was never asked to lead immigration policy. That’s the job of Homeland Security Secretary Alejandro Mayorkas. Again, the term “border czar” was used inaccurately by some media outlets, and it’s a term conservatives have been using to attack her, in part, because she has only visited the Southern U.S. border a few times since 2021. But in reality, Harris was tapped by President Biden to address the root causes of migration . Her approach has focused on deterrence. She’s told migrants to not come to the U.S., and she has been able to secure more than $5 billion in commitments from private companies to help boost the economy in Central American countries. — Sergio Martínez-Beltrán, NPR immigration correspondent based in Texas 

21. “I think the number is 20 million, but whether it's 15 or 20, it's numbers that nobody's ever heard before. 20 million people came over the border in the last– during the Biden-Harris administration. Twenty-million people. And it could be very much higher than that. Nobody really knows what the number is.”

It’s unclear where Trump is getting this number from. According to U.S. Customs and Border Protection , since 2021 agents have had more than 7.3 million encounters nationwide with migrants trying to cross into the country illegally. Under Biden, unlawful crossings hit an all-time high last year, but that number has decreased significantly, in part, due to Biden’s asylum restrictions at the Southern U.S. border. An April report from the Office of Homeland Security Statistics found there’s nearly 11 million unauthorized migrants in the country. — Sergio Martínez-Beltrán

22. “Just like far more people were killed in the Ukraine-Russia war than you have reported.”

Neither Russia nor Ukraine is revealing its own casualty figures, so there are only very broad estimates. — Andrew Sussman 

23. “A lot of great things would have happened, but now you have millions and millions of dead people. And you have people dying financially, because they can't buy bacon; they can't buy food; they can't buy groceries; they can't do anything. And they're living horribly in our country right now.”

Grocery prices actually jumped sharply during Trump’s last year in office, as pandemic lockdowns disrupted the food supply chain and Americans were suddenly forced to eat more of their meals at home. Grocery inflation in June 2020 hit 5.6%. This was masked, however, by a plunge in other prices, as the global economy fell into pandemic recession.

As the economy rebounded, prices did, too. Inflation began to rise in 2021, and spiked in 2022 after Russia’s invasion of Ukraine sent food and energy prices soaring. Inflation has since moderated, falling from a peak of 9.1% in June 2022 to 3% in June 2024 . (July’s inflation figures will be released next week.) Grocery prices have largely leveled off in the last year, although they remain higher than they were before the pandemic – a potent reminder of the rising cost of living.

Economists have warned that Trump’s proposed import tariffs and immigration restrictions could result in higher inflation in the years to come. Researchers from the Peterson Institute for International Economics estimate the tariffs alone would cost the typical family about $1,700 a year . — Scott Horsley

24. “We've agreed with NBC, fairly full agreement, subject to them, on Sept. 10th.”

This is ABC, not NBC.

25. “She can't do an interview. She's barely competent and she can't do an interview.” 

Harris hasn’t done interviews since getting into the campaign, but she has done them in the past, so saying “she can’t do” one or that she is “barely competent” are just insults. Trump tends to revert to questioning the intelligence of Black women who challenge him. In fact, Trump did it nine times in this news conference, saying either Harris is not that “smart” (five times) "incompetent” (three times) or “barely competent,” as he did here.

26-27. “Why is it that millions of people were allowed to come into our country from prisons, from jails, from mental institutions, insane asylums, even insane asylums, that's a– it's a mental institution on steroids. That's what it is.”

Immigration experts have said they have not been able to find any evidence of this. Adam Isacson, director for defense oversight at the Washington Office on Latin America, told FactCheck.org : “It’s hard to prove a negative — nobody’s writing a report saying, ‘Ecuador is not opening its mental institutions’ — but what I can say is that I work full-time on migration, am on many coalition mailing lists, correspond constantly with partners in the region, and scan 300+ RSS feeds and Twitter lists of press outlets and activists region wide, and I have not seen a single report indicating that this is happening. … As far as I can tell, it’s a total fabrication.”

Notably, a version of this did happen in 1980 during the Mariel boatlift from Cuba . The Washington Post noted three years later: “Back in 1980, it seemed to be a humanitarian and patriotic gesture to accept provisionally, without papers or visas, all those fleeing from the port of Mariel. More than 125,000 came. Most were true refugees, many had families here, and the great majority has settled into American communities without mishap. But the Cuban dictator played a cruel joke. He opened his jails and mental hospitals and put their inmates on the boats too.”

Without a question, some migrants who have come into the U.S. have committed crimes, but the data show the vast majority do not. According to Northwestern University , immigrants are less likely to commit a crime than U.S.-born people and certainly at no higher rates that the population writ large. (Trump goes on to repeat this claim minutes later in the news conference as well, so it is included in our count here.)

28. “We have a president that's the worst president in the history of our country.”

Trump may have this opinion, but he says it as if it’s fact, and a 2022 survey of historians ranked Biden in the top half of presidents. Trump, on the other hand, was No. 43. The two below Trump were James Buchanan, who did little to stop the impending U.S. Civil War, and the impeached and nearly convicted Andrew Johnson.

29. “We have a vice president who is the least admired, least respected, and the worst vice president in the history of our country.” 

A recent rating of vice presidents did not show this. Harris was in the bottom half of vice presidents, but Spiro Agnew, Dan Quayle, Henry A. Wallace and were toward the bottom of the list.

30. “The most unpopular vice president.”

This might have been true about a year ago or so, but not anymore. An NBC poll then showed Harris had the lowest favorability rating of any modern VP they’d tested. But her numbers have turned around. The NPR poll had Harris with a 46%/48% favorable to unfavorable rating, which was higher than Trump’s and his running mate, JD Vance, who is among the least popular running mates in recent history .

31. “Don't forget, she was the first one defeated. As I remember it, because I watched it very closely, but she was the first one.”

Harris was not “defeated,” because she dropped out of the Democratic presidential race before Iowa. But even if one considers her dropping out on Dec. 3, 2019, a defeat, she was not the first of the Democratic candidates in that primary campaign to do so. At least 10 others dropped out sooner .

32-34. “And I'm no Biden fan, but I'll tell you what, from a constitutional standpoint, from any standpoint you're looking at, they took the presidency away. … And they took it away.” 

There’s nothing in the U.S. Constitution about picking presidential candidates. This is a party process, and everything has been done within party rules. And, again, the presidency wasn’t taken away: Biden is still president.

35. “They said they're going to use the 25th Amendment.”

This was never floated as a possibility to get Biden to withdraw from the race. Biden’s Cabinet members are all people he appointed and who are loyal to him. In addition, the 25th Amendment outlines a procedure for removing a sitting president from office, not from running for a second term.

36-39. "They're going to hit you hard. ‘Either we can do it the nice way. I heard, I know exactly, because I know a lot of people on the other side, believe it or not. And, they said, ‘We'll do it the nice way, or we'll do it the hard way.’ And he said, ‘All right.”

This was not said; he did not hear; no Democrats in the know are talking to Trump; and this dialogue is made up.

40. “We're leading, we're leading.”

The race is statistically tied in national polls and in the states. In some national polls, Harris leads. In some, Trump does.

41-42. “I'm saying it's a–, for a country with a Constitution that we cherish, we cherish this Constitution to have done it this way is pretty severe, pretty horrible. … But to just take it away from him, like he was a child.”

Again, this is Trump talking about how Biden stepped aside, and there’s nothing in the Constitution about how the political parties should pick candidates. And nothing was taken away.

43-46. “And he's a very angry man right now, I can tell you that. He's not happy with Obama, and he's not happy with Nancy Pelosi. Crazy Nancy, she is crazy, too. She's not happy with any of the people that told him that you've gotta leave. He's very unhappy, very angry, and I think he, He also blames her. He's trying to put up a good face, but it's a very bad thing in terms of a country when you do that. I'm not a fan of his, as you probably have noticed, and he had a rough debate, but that doesn't mean that you just take it away like that.” 

Trump can’t speak to Biden’s state of mind; all evidence is that Nancy Pelosi is perfectly sane – see her recent multiple rounds of interviews about her book, including with NPR ; again, Trump doesn’t know Biden’s state of mind; and again, nobody took it away.

47-51. “She's trying to say she had nothing to do with the border. She had everything. She was appointed to head the border. And then they said border czar. Oh, she loved that name. She loved that name. But she never went there. She went to a location once along the border, but that was a location that you would love to go and have dinner with your husband or whoever. That was a location that was not part of the problem. That was not really going to the border. So I– essentially she never went to the border.”

(1) As previously noted, she was not put in charge of the border and certainly did not have “everything” to do with it; (2) she was not appointed to head the border; (3) if “they” is the White House, then “they” did not call her “border czar”; (4) Trump doesn’t know what Harris might have thought about the term; (5) Harris did not go to a place at the border “you would love to go and have dinner with your husband or whoever.”

In 2021, Harris toured border patrol facilities in El Paso, Texas, visited an area where asylum seekers were screened, and met with migrants. Republicans criticized her at the time for not going to the Rio Grande Valley.

52. “Now we have the worst border in the history of the world.” 

World history is filled with cases where one country has crossed a border and invaded a neighboring country.

53. “She destroyed San Francisco. She destroyed California as the A.G. But as the D.A. She destroyed it. She– San Francisco. … She destroyed– no cash bail, weak on crime, uh, she's terrible.”

As San Francisco’s district attorney from 2004 to 2011, and then California’s attorney general until 2017, it’s true that Kamala Harris was deeply connected to how crime was prosecuted during that particular period. However, no single person is responsible for destroying any city or state, not to mention that both are not destroyed.

There are just too many factors that contribute to why crime rises and falls. What’s more, according to the FBI , both violent and property crime rates in California more or less mirrored national trends during her tenures. As a prosecutor, Harris was largely seen as aligning more with law-and-order tendencies, though she has supported some progressive reforms, like offering certain criminal defendants drug treatment instead of going to trial. She also tweeted support for a Minnesota bail fund after the 2020 protests of George Floyd’s murder. — Meg Anderson

During her campaign for the 2020 nomination, she rolled out a plan that would have phased out cash bail , and she pledged to eliminate it as president because “no one should have to sit in jail for days or even years because they don’t have the money to pay bail.” But in the same campaign, during a debate, former Hawaii Rep. Tulsi Gabbard criticized Harris for keeping cash bail in place as district attorney.

54. “And yet they weaponized the system against me.” 

The justice system was not weaponized against Trump. Biden went through pains to not show any interference with the Justice Department. And Trump was found guilty by a jury of his peers in New York in a state case.

55-58. “I won the big case in Florida. I won the big case. … Nobody even wrote about it. The big case.” 

(1) Trump did not “win” the classified documents case against him in Florida; (2) this was not “the big case” against him; (3) there was plenty of coverage of it; and (4) he goes on to repeat that he won the case later.

For context: the judge in the case controversially dismissed it, claiming the special counsel was unconstitutionally appointed despite Supreme Court decisions upholding independent counsels. The Justice Department has signaled it will appeal by the end of August but by the time the decision comes back, the election will be over.

Trump had four criminal cases against him including the classified documents case – the fraudulent business practices case in New York, for which he was convicted on 34 felony counts; an election interference case in Georgia; and the other federal case dealing with Jan. 6. If there was a biggest case, it was the last one.

59. “The judge was a brilliant judge, and all they do is they play the ref with the judges. But this judge was a fair but brilliant judge.”

There has been lots of criticism of the judge in the case, Aileen Cannon, who Trump appointed. She had very little experience as a trial judge, made several decisions that were questioned by legal experts and early in this case, had a ruling, in which she called for a special master to review classified documents first, overturned by the 11th Circuit.

60. “Now Biden lost it because he didn't have presidential immunity. He didn't have the Presidential Records Act. He lost it.”

This was not “Biden’s case.” It was to be tried by special counsel Jack Smith, who was appointed by Attorney General Merrick Garland. The Biden White House has made efforts to keep an arms-length distance from the investigation. Biden often declined to comment on the Justice Department’s and state investigations into Trump when it would likely have been politically advantageous for him to talk about it on the campaign trail.

61. “But the– I call it prosecutors, special counsel, special prosecutor to me. He–, appointed by him and appointed by Garland. He said the man's incompetent. He can't stand trial, but he can run for president.” 

This appears to be a misrepresentation of what special counsel Robert Hur said of Biden in a report he released investigating the president’s handling of classified documents. Hur said he wouldn’t be charging Biden, called the president “an elderly man with a poor memory" and said a jury might find sympathy with him because of it. He did not say Biden was incompetent and could not stand trial.

62. “She couldn't pass her bar exam.”

This is false. Harris passed her bar exam on the second try . She failed on first attempt, which is not unusual for California’s bar exam given its difficulty.

63. “I was doing very well with Black voters, and I still am. I seem to be doing very well with Black males. This is according to polls, as you know. 

Trump was not doing “very well” with Black voters. Biden was not doing as well with Black voters as he did in 2020, according to most surveys, but that didn’t mean Black voters were moving heavily toward Trump. Many seemed more likely not to vote. There were signs that Trump was doing better with Black men, but there wasn’t much good evidence to support this in polling, considering most national polls have such high margins of error with voter groups. A typical national survey might have 1,000 voters and 100 or so Black voters, give or take. That’s typically a margin of error upward of +/- 10 percentage points, meaning results could be a whopping 10 points higher or lower.

64. “Extremely well with Hispanic.”

Like with Black voters, it’s difficult to tell in most national surveys exactly how well a candidate is doing with Latino voters because of high margins of error. “Extremely well” depends on how it’s defined, but this is an exaggeration.

65. “Jewish voters, way up.”

Jewish voters traditionally vote roughly 2-to-1 for Democrats in presidential elections, so this seems more like a hope than reality.

66. “White males, way up. White males have gone through the roof. White males, way up.” 

It’s just not the case that Trump is “way up.” NPR polling finds that while Trump is doing as well as ever with white men without college degrees, Harris – and Biden before her – is actually leading with white men with college degrees, a group Trump won in 2020, according to exit polls .

67. “It could be that I'll be affected somewhat with Black females. Well, we're doing pretty well. And I think ultimately they'll like me better, because I'm gonna give them security, safety and jobs.”

Trump is not doing well with Black females. Black women are a key pillar Democratic voting group, and Black voters have moved more in Harris’ favor since she’s gotten in.

69. “We have a very bad economy right now. We could, we could literally be on the throes of a depression. Not recession, a Depression. And they can't have that. They can't have that.”

This is not the case. See earlier fact check. (He repeats this again later in the press conference, so it is included here in the count.)

70. “I know Josh Shapiro. He's a terrible guy. And he's not very popular with anybody.” 

A Fox News poll last month showed Pennsylvania Gov. Josh Shapiro, a finalist to be Harris’ running mate, had a 61% approval rating in the state. Other polls also found him with a net-positive rating, though, not quite as high.

71. “Listen, I had 107,000 people in New Jersey. You didn't report it.”

It was reported that the numbers come from faulty information about the size of a crowd at Trump’s rally. More accurate estimates appear to be anywhere from 30,000 to 60,000 . Still, a very large crowd, but Trump is exaggerating here.

72-77. “What did she have yesterday? 2,000 people? If I ever had 2,000 people, you'd say my campaign is finished. It's so dishonest, the press. … When she gets 1,500 people, and I saw it yesterday on ABC, which they said, ‘Oh, the crowd was so big.’ … I have 10 times, 20 times, 30 times the crowd size. And no, they never say the crowd was big. … I think it's so terrible when you say, ‘Well she has 1,500 people, 1,000 people,’ and they talk about, oh, the enthusiasm.” 

(1-3) Trump gave at least three incorrect estimates here, downplaying Harris’ crowd sizes (2,000, 1,500 and 1,000); (4) He also far overestimated how big his crowd sizes are compared to Harris’; (5-6) He twice said the press is dishonest about her crowd size and about his.

For context, the Harris campaign’s estimate was 10,000 or more at each rally. What the exact number is might be unclear — as is often the case with crowd-size estimates — but they were bigger than 2,000 and 1,500. Reporters have often commented on the size of Trump’s crowds. Frequently, they are very large, certainly larger than ones that Hillary Clinton drew in 2016 or Joe Biden this year, but Trump also regularly exaggerates their sizes.

78. “If I were president, you wouldn't have Russia and Ukraine, where it never happened. Zero chance. You wouldn't have had Oct. 7th of Israel.”

This is speculation, and that there is simply no way to know what would have happened in either case if he'd been reelected.

79. “You wouldn't have had inflation. You wouldn't have had any inflation because inflation was caused by their bad energy problems.” 

Again, this is speculative. Energy and food prices jumped sharply around the world following Russia’s invasion of Ukraine and the resulting sanctions on Russian energy. Gasoline prices in the U.S. hit a record high topping $5 a gallon. But domestic energy production has not suffered during the Biden administration. In fact, U.S. oil and natural gas production hit record highs last year. AAA reports the average price of gasoline today is $3.45/gallon. — Scott Horsley

80. "I don't know if you know, they're drilling now because they had to go back because gasoline was going up to $7, $8, $9 a barrel."

Oil and gas production has largely been determined by energy companies. They were disciplined about not expanding production when prices were low but have become more aggressive as prices climbed. While Kamala Harris opposed “fracking” for oil and gas during her 2019 presidential campaign, she now says she would not try to outlaw the practice – which is important in battleground states such as Pennsylvania. — Scott Horsley

81. “Everybody's going to be forced to buy an electric car, which they're not going to do because they don't want that. It's got a great market. It's got a market. It's really a sub market.”

The Biden administration has set a goal of having 50% of new vehicle sales be electric by 2030 . It has primarily tried to achieve this through carrots rather than sticks, offering incentives to make electric cars more affordable, encouraging the development of electric charging stations and using the federal government’s own purchasing power to create demand. — Scott Horsley

82. “We don't have enough electricity. We couldn't make enough electricity for that.”

A shift to electric vehicles will require a rapid updating and expansion of the U.S. power grid, according to the Electric Power Research Institute . However, as EVs become more efficient, the increased demand could be reduced by as much as 50% per mile traveled over the next three decades. — Scott Horsley

83. “The weight of a car, the weight of a truck, they want all trucks to be electric. Little things that a lot of people don't talk about. The weight of a truck is two-and-a-half times, two-and-a- half times heavier.” 

Electric vehicles are typically heavier than gasoline-powered vehicles, because of the batteries. But the weight difference is about 30% , not 250% as Trump said. What’s more, American vehicles have been getting heavier for decades, long before the move to EVs, thanks to the popularity of pickup trucks and SUVs.

84. “You would have to rebuild every bridge in this country, if you were going to do this ridiculous policy.”

While many bridges and other transportation infrastructure need improvement , the additional weight of EVs is just one of many factors that will need to be considered. Another challenge is that bridges and highways are typically funded through gasoline taxes. The shift to EVs, which don’t use gasoline, will require an alternate source of highway funding.

85-90. “So, but on crowd size in history, for any country, nobody's had crowds like I have, and you know that. And when she gets 1,000 people and everybody starts jumping, you know that if I had a thousand people would say, people would say, that's the end of his campaign. I have hundreds of thousands of people in, uh, South Carolina. I had 88,000 people in Alabama. I had 68,000 people. Nobody says about crowd size with me, but she has 1,000 people or 1,500 people, and they say, oh, the enthusiasm's back.”

There were at least six different misstatements here – (1) Trump has had large crowds, but “in history,” there certainly there have been people with larger crowds, from Barack Obama and others; (2, 3) her crowds have been larger than 1,000, which he repeats twice; (4) no serious analysts have said this is the end of Trump’s campaign. This race is very close; (5) there’s no evidence for crowds of the size Trump notes in South Carolina and Alabama; (6) people do talk about Trump’s crowd sizes.

91. “They wanna stop people from pouring into our country, from places unknown and from countries unknown from countries that nobody ever heard of.”

Someone has likely heard of whatever the unnamed country is.

92-93. “We're leading in Georgia by a lot. We're leading in Pennsylvania by a lot.”

The races in Georgia and Pennsylvania are within the margin of error, according to an average of the polls.

94. “So I won Alabama by a record. Nobody's ever gotten that many votes. I won South Carolina by a record. You don't win Alabama and South Carolina by records and lose Georgia. It doesn't happen.”

It does, and here’s why. Demographically, Georgia has become very different from South Carolina and Alabama. Georgia’s population is now majority-minority, according to the U.S. Census Bureau. Alabama and South Carolina are 64% and 63% white, respectively.

Georgia’s Black population is also significant politically — 33% of the state’s population is Black. By comparison, Alabama is 27% Black, South Carolina 26%. Latinos also make up 11% of Georgia’s population and Asian Americans are 5%, both of which are higher than Alabama and South Carolina. And Georgia’s population is marginally younger — 15% of Georgia’s population is older than 65% compared to 18% in Alabama and 19% in South Carolina.

95. “If we have honest elections in Georgia, if we have honest elections in Pennsylvania, We're gonna win them by a lot.”

Winning them by a lot is highly unlikely, considering how close the states have been in recent elections, but perhaps more pressing is Trump’s insinuation that there were voting problems in the two states, which there were not. That’s why Trump is upset with Republican Georgia Gov. Brian Kemp, for example, because he upheld the valid 2020 election results even in the face of pressure from Trump.

96. “Of course there'll be a peaceful transfer. And there was last time.”

This wholly ignores the Jan. 6 siege on the Capitol, which took place because of Trump’s election lies.

97. “Because I'm leading by a lot.”

Again, this is a very close race.

98. “We have commercials that are at a level I don't think that anybody's ever done before.”

This is false. Since Super Tuesday, Democrats have outspent Trump’s campaign and outside groups supporting him by more than double, according to data provided by AdImpact and analyzed by NPR — $373.5 million to $150.6 million.

99. “She's not smart enough to do a news conference.”

There is plenty of evidence that Harris is “smart enough to do a news conference,” as she has done in the past.

100. "We're in great danger of being in World War III. That could happen." 

Again, no serious analyst believes this.

101. “I think those people were treated very harshly, when you compare them to other things that took place in this country where a lot of people were killed.”

The Justice Department investigation into the events of Jan. 6, 2021, is the largest and most complex federal criminal probe in U.S. history, the attorney general has said. More than 140 law enforcement officers were injured that day, in what U.S. Attorney Matthew Graves has described as the biggest mass casualty event involving police. It’s hard to find any comparable event in recent American history.

As of Aug. 6, 2024, according to Graves’s office, prosecutors have charged more than 160 people with using a deadly or dangerous weapon or causing serious bodily injury to an officer. Prosecutors have also secured convictions on the rarely-deployed charge of seditious conspiracy, or attempting to overthrow the government by use of force, against top leaders of the Oath Keepers and the Proud Boys.

Even so, only a small number of Jan. 6 defendants have been held in federal custody while they await trial. Mostly, these are the rioters who allegedly used the most violence on that day more than three years ago. Republican members of Congress have toured the jail facilities and decried conditions there, expressions of support that defendants facing ordinary charges in D.C. have not received. — Carrie Johnson, NPR national justice correspondent

102. “Nobody was killed on Jan. 6th.” 

Conservatives were upset at the time that one of the rioters, Ashli Babbitt, was killed when she was shot by police, as she was trying to force her way into the Speaker’s Lobby of the Capitol, which leads to the House chamber, with a crowd of others. Many officers were injured that day; one died of a stroke as a result of Jan. 6; and others later died by suicide that their families say was also a result of Jan. 6.

103-105. “And, you know, it's very interesting, the biggest crowd I've ever spoken to. … The biggest crowd I've ever spoken before was that day. … The biggest crowd I've ever spoken. … I've spoken to the biggest crowds. Nobody's spoken to crowds bigger than me.” 

It was not the biggest crowd he’s ever spoken to. His inauguration would have topped that. And others have had bigger crowds, as noted earlier.

106. “I said peacefully and patriotically.”

While Trump did utter those words, it is misleading. Trump also said the word “fight” multiple times , and he told the already angry crowd because of the election lies he fed them: “We fight like Hell and if you don’t fight like Hell, you’re not going to have a country anymore.” Trump aides testified that he “refused” to tweet the word “peaceful” in the days leading up to the rally because he thought it might discourage people from being there, and he was concerned about his crowd size.

107-108. “If you look at Martin Luther King, when he did his speech, his great speech, and you look at ours, same real estate, same, everything, same number of people. If not, we had more. …You look at the picture of his crowd, my crowd, uh, we actually had more people.”

First, the speeches did not take place at the “same real estate.” Trump spoke from a position just south of the Ellipse. Martin Luther King Jr. spoke from the steps of the Lincoln Memorial

Second, the crowds were not the same size and Trump’s was certainly not larger. It is an extraordinary claim and shows just how much Trump cares about crowd size.

109. “We have a Constitution. It's a very important document, and we live by it. She has no votes.” 

Again, there’s nothing in the Constitution about how parties should pick their presidents.

110-111. “They said, ‘You're not going to win, you can't win, you're out.’ And at first they said it nicely, and he wasn't leaving, and then you, you know, the, you know it better than anybody. … At first, they were going to go out to another vote, they were going to go through a primary system, a quick primary system, which it would have to be. And then it all disappeared, and they just picked a person.”

As explained earlier, this is not how Biden wound up stepping aside. The story is yet another Trump invention. He also lies here in saying that “they were going to go through a primary system” and “it would have to be” a quick primary system.” There’s no requirement that a primary is held. In fact, for many years, candidates’ selection as party nominees had nothing to do with primaries, and they were not as prevalent as today.

112-113. “That was the first out. She was the first loser, OK? So, we call her the first loser. She was the first loser when– during the primary system, during the Democrat primary system, she was the first one to quit. And she quit.”

As explained earlier, Harris was not the first one out in the 2020 Democratic primary race. And “first loser” appears to be a name Trump made up at this news conference, as Harris has not been referred to that way as a result of her run for the 2020 nomination.

114. “She did, obviously, a bad job. She never made it to Iowa. Then for some reason, and I'm, I know he regrets it, you do too, uh, he picked her, and she turned on him too. She was working with the people that wanted him out."

Once again, this is a false conspiracy invented by Trump.

115. “She was the first one out.” 

Trump repeats this false line again.

116. “I think the abortion issue is written very much tempered down, and I've answered I think very well in the debate, and it seems to be much less of an issue, especially for those where they have the exceptions.”

Abortion rights as a political and social issue has certainly not “tempered down.” There are millions of women, especially across the South, who do not have access to abortion and women who have experienced pregnancy losses with the inability to access medications for those necessary procedures.

117. “As you know, and I think it's when I look for 52 years, they wanted to bring abortion back to the states. They wanted to get rid of Roe v. Wade and that's Democrats, Republicans, and Independents, and everybody. Liberals, conservatives, everybody wanted it back in the states. And I did that.”

Everybody absolutely did not want that. It was actually quite unpopular for the Supreme Court to overturn Roe . And he again repeats that it has become less of an issue.

118-119. “I think that abortion has become much less of an issue. It's a very small.” 

“I think it's actually going to be a very small issue. What I've done is I've done what every Democrat and every Every Republican wanted to have done.” 

“I think the abortion issue has been taken down many notches. I don't think it's of– I don't think it's a big factor anymore, really.”

Minutes apart from each other, he repeats these three false claims. Abortion rights is not a “very small” issue for millions of voters. Democrats are organizing around it, and it has been seminal to Biden and Harris’ campaigns.

120. “Previous to [Virginia Gov.] Glenn [Youngkin], the governor, he said the baby will be born, we will put the baby aside, and we will decide with the mother what we're going to do. In other words, whether or not we're going to kill the baby.”

This is a distortion Republicans continue to push about what former Virginia Gov. Ralph Northam said. This has been fact-checked by others multiple times .

121-122. “I think the abortion issue has been, uh, taken down many notches. I don't think it's of, uh, I don't think it's a big factor anymore, really.”

“Everybody wanted it in the states.”

“But that issue has is very much subdued.”

He once again returns to the issue of abortions, which remains a “factor,” not everybody wanted it in the states, the issue is not “very much subdued.”

123-124. “ She wants to take away everyone's gun.” 

Harris has not proposed taking away all guns. She has proposed banning assault-style weapons, something that was in place for a decade. Some surveys had shown majority support for this. Others show a split. (Trump makes this case later, as well, so that is also included in the count.)

125. “Some countries have actually gone the opposite way. They had very strong gun laws and now they have gone the opposite way, where they allowed people to have guns, where in one case they encouraged people to go out and get guns, and crime is down 29%.”

It’s difficult to compare gun violence and gun laws in the United States to other countries, simply because of the staggering amount of guns we have here. Although the U.S. has less than 5% of the world’s population, it holds almost 40% or more of the world’s civilian-owned guns. And it has “the highest homicide-by-firearm rate of the world’s most developed nations,” per the Council on Foreign Relations . Norway, Canada and Australia all tightened their gun restrictions after shootings. — Meg Anderson

126. “On July 4th, 117 people were shot and 17 died. The toughest gun laws in the United States are in the city of Chicago. You know that. They had 117 people shot. Afghanistan does not have that.” 

Though Trump didn’t get the numbers exactly right, Chicago did have an incredibly violent July 4th holiday weekend this year. According to Mayor Brandon Johnson, more than 100 people were shot and 19 of those people died. Chicago does have strict gun laws, in part because its state does: Everytown For Gun Safety, a nonprofit that advocates for gun control, ranks Illinois third in the nation for the strength of its gun-control laws. However, no state or city exists within a bubble, and Illinois is surrounded by states with much weaker laws, including Indiana, which is just a short drive from Chicago. — Meg Anderson

127. “For 18 months, not one American soldier was shot at or killed, but not even shot at.” 

This is, to put it charitably, misleading. It appears that he’s actually referencing the period when the Trump administration signed the deal with the Taliban, in advance of U.S. troops leaving. The deal said the U.S. would be out in 14 months, and in exchange the Taliban wouldn’t harbor terrorists and would stop attacking U.S. service members. Needless to say, the deal didn’t hold. But as the AP notes , “There was an 18-month stretch that saw no combat, or ‘hostile,’ deaths in Afghanistan: from early February 2020 to August 2021.” – Andrew Sussman

128. “Kamala is in favor of not giving Israel weapons. That's what I hear.”

Harris does not support an Israel weapons embargo. A Biden administration official posted on social media that Harris "has been clear: she will always ensure Israel is able to defend itself against Iran and Iran-backed terrorist groups.” A leader of the uncommitted movement said Harris “expressed an openness” to a meeting about an embargo, but the Biden administration official said Harris "will continue to work to protect civilians in Gaza and to uphold international humanitarian law,” not that she would support an embargo.

129. “She's been very, very bad to Israel, and she's been very bad and disrespectful to Jewish people.”

Harris’ husband, Doug Emhoff, is Jewish. The couple has hosted Passover Seders.

130. “Well, I know Willie Brown very well. In fact, I went down in a helicopter with him. We thought maybe this is the end. We were in a helicopter going to a certain location together and there was an emergency landing.”

This claim has not held up to scrutiny. Politico reported that Trump did have to make an emergency landing in a helicopter with a Black California politician decades ago, but it wasn’t Willie Brown, the former San Francisco mayor and state assembly speaker. It was Nate Holden, a former Los Angeles city councilman and state senator.

131-132. “This was not a pleasant landing, and Willie was— he was a little concerned. So I know him. I know him pretty well. I mean, I haven't seen him in years. But he told me terrible things about her.”

“He was not a fan of hers very much at that point.”

This is something Trump repeated twice, minutes apart from each other. Brown strongly denies having been on a helicopter with Trump or telling Trump negative things about Harris, whom he dated in the mid-1990s and supports now for president. The relationship ended in 1995.

133. “Our tax cuts, which are the biggest in history… .”

The 2017 tax cuts were not the biggest in history. As a share of the economy, they barely make the top 10 . They were big enough, however, to blow a big hole in the federal budget, which is why Trump was overseeing a nearly $1 trillion dollar annual deficit before the pandemic. — Scott Horsley

134. “It'll destroy the economy.”

This is what Trump said will happen if his tax cuts are not renewed. But The 2017 tax cut did not deliver the economic boom that its supporters promised, and there’s no reason to think reversing a portion of the cut would cause economic destruction. — Scott Horsley

135. “I've never seen people get elected by saying, 'We're going to give you a tax increase.'”

Vice President Harris has echoed President Biden’s pledge not to raise taxes on anyone making less than $400,000. However, Biden has called for raising taxes on wealthy individuals and raising the corporate tax rate from 21% to 28% – halfway back to where it was before the 2017 cut. — Scott Horsley

136. “These guys get up, think of it. ‘We're going to give you no security.’ …”

No Democratic presidential candidate has advocated “no security.”

137. “We're going to give you a weak military… .’ ”

An analysis by the American Enterprise Institute, a conservative think tank, showed a “review of historical defense budget trends shows there is more at play in determining overall investments in defense than just which party is in the White House.” Indeed, since the year 2000, U.S.-led wars overseas have resulted in a surge of spending by both Democratic and Republican administrations.

138-139. “…We're going to give you no walls, no borders, no anything.”

Harris, Walz and the Democratic Party have never said they want “no borders.” They certainly oppose Trump’s wall/fence along the entire U.S.-Mexico border, citing the exorbitant cost and its relative ineffectiveness, they say, compared to using other methods. (Trump later says that Harris wants “open borders,” so that’s included in the count here.)

140. “...We're going to give you a tax increase.”

Again, this is misleading and suggests Harris wants to increase taxes across the board when they have consistently talked about increasing taxes only on the wealthy. In Harris’ view, those making more than $400,000 a year .

141. “They're gonna destroy Social Security.”

Democrats have consistently advocated for keeping Social Security and making it solvent.

142. “They've weaponized government against me. Look at the Florida case. It was a totally weaponized case. All of these cases, by the way, the New York cases are totally controlled out of the Department of Justice. They sent their top person to the various places. They went to the A.G.'s office, got that one going, then he went to the D.A.'s office, got that one going, ran through it. No, no, this is all politics, and it's a disgrace.”

In congressional testimony this year, Attorney General Merrick Garland told lawmakers that President Biden had never called him to discuss any of the cases against Trump. Garland also had aides review Justice Department leaders’ email for any correspondence with Manhattan District Attorney Alvin Bragg. In a letter to Congress in June 2024, the Justice Department said it had found no such contacts.

In that same letter, Justice Department legislative affairs chief Carlos Uriarte said the department did not “dispatch” former acting Associate Attorney General Matthew Colangelo to New York to join Bragg’s team prosecuting Trump. “Department leadership was unaware of his work on the investigation and prosecution involving the former president until it was reported in the news,” Uriarte wrote. — Carrie Johnson

143. “Any time you have mail-in ballots, you're gonna have problems. ... We should have one-day voting; we should have paper ballots; we should have voter ID; and we should have proof of citizenship.” 

Trump continues to spread baseless claims about mail ballots. There’s no proof of widespread fraud with the voting method. When it comes to paper ballots, they're standard. One estimate found that in the 2024 general election, "nearly 99% of all registered voters will live in jurisdictions where they can cast a ballot with a paper record of the vote."

The proof of citizenship comment echoes a Republican push on the issue , though studies have shown voting by non-U.S. citizens in federal elections to be exceedingly rare. The GOP-led House has passed a bill to require such documentary proof, but it’s likely to go no further in a Senate led by Democrats who are opposed to adding new voting restrictions. — Ben Swasey, voting editor

144. “The polls have suggested, there are some polls that say we're going to win in a landslide.” 

There are no polls that suggest Trump will win in a landslide. By all accounts, this is a very close race.

145. “...they're paying 50, 60, 70 percent more for food than they did just a couple of years ago.”

The rise in grocery prices is a common complaint , but Trump exaggerates the scale of the increase. According to the Consumer Price Index, grocery prices have risen 25% since before the pandemic and 21% since President Biden took office. (At the same time, average wages have risen 23% since before the pandemic and 17% since President Biden took office.)

146-149. The Strategic National Reserve is “virtually empty now. We've never had it this low.”

“He's sucked all of the oil out.”

“Essentially the gasoline to keep the, to keep the price down a little bit. … But you know what? We have no strategic national reserves now. He's emptied it. It's almost empty. It's never been this low.”

“They've just, for the sake of getting some votes, for the sake of having gasoline–. You know, that's meant for wars. It's meant for, like, tragedy. It's not meant to keep a gasoline price down, so that somebody can vote for Biden or, in this case, Kamala.” 

The strategic oil reserve is actually up in the past year . Biden has since repurchased about 32 million barrels of oil for the Strategic Petroleum Reserve. As of this month, the reserve held about 376 million barrels of oil. The reserve was lower when Trump left office than when he got in.

150. “I see it right now, I see her going way down on the polls now.”

The opposite is true. Harris has continued her momentum since getting into the race.

151-152. “...now that people are finding out that she destroyed San Francisco, she destroyed the state of California.” 

As addressed earlier, Harris is not entirely responsible for San Francisco or the state of California. Crime trends there were similar to national crime trends during her time as district attorney in San Francisco and as the state’s attorney general. What’s more, preliminary data for this year indicates that many cities in California, including San Francisco, are seeing murder rates falling. (Trump repeats the claim one more time later in the news conference, so it is included in the count here.) — Meg Anderson

153. “She was early, I mean, she was the first of the prosecutors, really, you know, now you see Philadelphia, you see Los Angeles, you see New York, you see various people that are very bad, but she was the first of the bad prosecutors, she was early.”

Although Harris did refer to herself in her 2019 memoir as a “progressive prosecutor,” her legacy has largely been seen as tougher on crime. She has supported some progressive reforms, such as pretrial diversion, which offers certain criminal defendants things like drug treatment instead of going to trial. — Meg Anderson

154. “You know, with Hillary Clinton, I could have done things to her that would have made your head spin. I thought it was a very bad thing – take the wife of a president of the United States, and put her in jail. And then I see the way they treat me. That's the way it goes. But I was very protective of her. Nobody would understand that. But I was. I think my people understand it. They used to say, lock her up, lock her up. And I'd say, just relax, please.”

Trump called for Clinton’s imprisonment multiple times , including going along with crowd chants of “lock her up.”

155. “Don't forget, she got a subpoena from the United States Congress, and then after getting the subpoena, she destroyed everything that she was supposed to get. 

Clinton aides requested emails be deleted months before the subpoena, and the FBI said there’s no evidence the messages were deleted with a subpoena in mind. — Carrie Johnson

156. “I thought it was so bad to take her, and put her in jail, the wife of a president of the United States. And then, when it's my turn, nobody thinks that way.”

The Justice Department closed an investigation into Hillary Clinton’s use of a private email server to conduct some State Department business in 2016. Then-FBI Director Jim Comey gave a press conference to explain his reasoning in July of that election year. Comey said, “We did not find clear evidence that Secretary Clinton or her colleagues intended to violate laws governing the handling of classified information,” but he criticized Clinton and her aides for being “extremely careless in their handling of very sensitive, highly classified information” that flowed through the server.

By contrast, prosecutors in the Florida case against former President Donald Trump said Trump had flouted requests from the FBI and a subpoena for highly classified materials he stored in unsecure spaces like a ballroom and a bathroom at his Mar-a-Lago resort. The indictment in that case accuses Trump of unlawfully retaining government secrets and of intentionally obstructing justice with the help of an aide who moved boxes of materials and otherwise allegedly thwarted the FBI probe. Trump and his co-defendants pleaded not guilty. The Justice Department says it is appealing the district court’s decision to toss the case on constitutional grounds. — Carrie Johnson

157. “A lot of the MAGA, as they call them, but the base. And I think the base is, I think the base is 75% of the country, far beyond the Republican Party.”

Rounding up, Trump won 46% of the vote in 2016 and 47% of the vote in 2020. He has a high floor, but a low ceiling politically. Majorities continue to say they have an unfavorable rating of Trump, which has been consistent for years. No American presidential candidate has ever gotten 75% of the vote in this country, dating back to 1824 since data was kept for popular votes. Lyndon B. Johnson got 61% in 1964, Richard Nixon slightly less than 61% in 1972, Ronald Reagan 59% in 1984. Since then, Barack Obama got nearly 53% in 2008 and 51% in 2012, the first candidate since Eisenhower to win at least 51% of the vote twice.

158. “My sons are members, and I guess indirectly I'm a member, too.”

Trump here is talking about membership in the National Rifle Association. Another family member being an NRA member does not make someone else an NRA member “indirectly.”

159. “She served 24 years for being on a phone call having to do with drugs. You know who I'm talking about. She was great. And she had another 24 years to go. And it was largely about marijuana, which in many cases is now legalized, OK?”

Presumably, Trump is talking about Alice Marie Johnson, who had been convicted on cocaine conspiracy and money laundering charges . Kim Kardashian advocated for Johnson and won a pardon for her from Trump.

160. “They're either really stupid, and I don't believe they're stupid, because anybody that can cheat in elections like they cheat is not stupid.”

More than 60 court cases proved there was not widespread fraud or cheating that would have made any difference in any state.

161. “Lately I've seen where they're trying to sign these people up to vote. And they have to stop. They cannot let illegal immigrants vote in this upcoming election.”

This is a conspiracy not based in fact. Immigrants in the country illegally cannot vote in presidential elections, and there’s no evidence there is an intentional effort to sign them up in mass numbers to sway elections.

162. “If you go to California, and you ask the people of California, do they like the idea of sanctuary cities? They don't like it.”

The subject of sanctuary cities actually mostly splits Californians. Slim majorities have actually said that they favor the sanctuary-state law and are against their cities opting out of the law. Of course, this breaks down along party lines, and since California is heavily Democratic, those results might not be surprising. But it’s more divided than Trump suggests.

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New study links gut microbiome to depression and anxiety

Ariel university researchers find gut bacteria composition affects social behavior and mental health; hyaluronic acid shows improved social interactions and reduced depression-like symptoms in mice, offering potential new treatments for humans.

The goal: Developing new treatments for depression and anxiety

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The indirect effect of future anxiety on the relationship between self-efficacy and depression in a convenience sample of adults: revisiting social cognitive theory.

1. Introduction

1.1. depression in emerging adults, 1.2. association between future anxiety and depression, 1.3. the relationship between depression, future anxiety, and self-efficacy, 1.4. the current study.

• There are age (emerging and middle adulthood) and gender (women, men) differences in symptoms of depression, future anxiety, and self-efficacy (H1).
• Self-efficacy is related negatively to symptoms of depression and future anxiety (H2).
• The higher the level of future anxiety, the higher the level of depression symptoms (H3).
• Low self-efficacy contributes to higher depression directly and indirectly through increased levels of future anxiety (H4).

2. Materials and Methods

2.1. study design and procedure, 2.2. participant characteristics, 2.3. measures, 2.3.1. depression, 2.3.2. future anxiety, 2.3.3. self-efficacy, 2.3.4. demographic survey, 2.4. statistical analysis, 3.1. a preliminary statistical analysis, 3.2. gender and age differences in depression symptoms, future anxiety, and self-efficacy, 3.3. associations between depression, future anxiety, and self-efficacy, 3.4. analysis of mediation, 4. discussion, 4.1. age and gender differences in depression, future anxiety, and self-efficacy, 4.2. the relationships between depression, future anxiety, and self-efficacy, 4.3. mediating effect of future anxiety on the relationships between self-efficacy and depression, 4.4. limitation of the study, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Szota, M.; Rogowska, A.M.; Kwaśnicka, A.; Chilicka-Hebel, K. The Indirect Effect of Future Anxiety on the Relationship between Self-Efficacy and Depression in a Convenience Sample of Adults: Revisiting Social Cognitive Theory. J. Clin. Med. 2024 , 13 , 4897. https://doi.org/10.3390/jcm13164897

Szota M, Rogowska AM, Kwaśnicka A, Chilicka-Hebel K. The Indirect Effect of Future Anxiety on the Relationship between Self-Efficacy and Depression in a Convenience Sample of Adults: Revisiting Social Cognitive Theory. Journal of Clinical Medicine . 2024; 13(16):4897. https://doi.org/10.3390/jcm13164897

Szota, Marta, Aleksandra M. Rogowska, Aleksandra Kwaśnicka, and Karolina Chilicka-Hebel. 2024. "The Indirect Effect of Future Anxiety on the Relationship between Self-Efficacy and Depression in a Convenience Sample of Adults: Revisiting Social Cognitive Theory" Journal of Clinical Medicine 13, no. 16: 4897. https://doi.org/10.3390/jcm13164897

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• Published: 17 August 2024

The associations of social isolation with depression and anxiety among adults aged 65 years and older in Ningbo, China

• Lian Li 1 , 2 ,
• Kaijie Pan 1 , 2 ,
• Jincheng Li 1 , 2 ,
• Meiqin Jiang 3 ,
• Yan Gao 4 ,
• Hongying Yang 1 , 2 &
• Guolin Bian 1 , 2  

Scientific Reports volume  14 , Article number:  19072 ( 2024 ) Cite this article

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• Risk factors

Social isolation was associated with emotional problems (depression and anxiety) among older adults, however, little is known in China. Thus, we conducted a cross-sectional study including 6,664 ≥ 65 years older adults in Ningbo, China. We collected data on social isolation, depression, and anxiety by specific scales. The relationship between social isolation and emotional problems was estimated by multivariate-adjusted logistic regression models. The population–attributable risk percentage (PAR%) was used to explore the contribution of social isolation to emotional problems. Overall, the percentage of participants who had experienced social isolation, depression, and anxiety was 12.67%, 4.83%, and 2.63%. Compared with the elderly without social isolation, the adjusted odds ratios (95% confidence interval) of depression and anxiety with social isolation were 1.77 (1.25–2.51) and 1.66 (1.05–2.63), respectively. The PAR analysis showed that 10.66% of depression and 9.03% of anxiety could be attributable to social isolation. In the gender subgroup, ORs and PAR% were only significantly observed in female participants. In Chinese older adults, social isolation has been linked to depression and anxiety, suggesting the importance of taking effective and feasible interventions to reduce social isolation and emotional problems, especially among females.

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Introduction.

Depression and anxiety are the most frequent emotional problems experienced by older adults worldwide 1 . In China, nearly 3.8% and 4.7% of older adults (over 65 years) were reported to suffer from depressive and anxiety disorders, respectively 2 , resulting in a high burden of disease in this population. Depression and anxiety are generated both by biological factors (e.g., sex, somatic illness, functional disability) and psychosocial factors (e.g., low contact frequency, a childless or unmarried status) 3 . Changes in some psychosocial factors may reduce emotional problems in older adults 3 .

Social isolation refers to a poor living condition involving a lack of social contact and participation or inadequate social interactions with friends, relatives, and others 4 . Social isolation can be measured by the following variables: whether one lives alone, the frequency of conversations with relatives and friends, and the frequency of participation in social activities 5 . A study conducted in the United States found that approximately 24.0% of community-dwelling adults older than 65 years old were socially isolated 6 . Two studies conducted in China showed that the prevalence of social isolation was 29.7% among community-dwelling older adults in Qingdao 7 and 28.9% among their counterparts in Shanghai 8 .

Studies generally have recognized the profound negative effect of social isolation on physical and mental health 9 , 10 . The longitudinal Aging Social Survey found that social isolation independently determined the probability of depression in both China 11 and the Netherlands 12 . A study in Ireland 13 found that objective social isolation independently affected the process of depression or anxiety. However, no study has explored the proportion of cases of depression and anxiety that might be prevented by alleviating social isolation among older adults. Previous research has indicated that various factors are linked to depression and anxiety among older individuals. Age has been consistently identified as a primary contributing factor to the heightened risk of mental health 14 , 15 . Additionally, social and demographic variables, including education status 15 , marital status 16 , and household income 17 have been shown to correlate with increased prevalence of mental health concerns in older adults. Furthermore, substance use 18 , lifestyle behaviors 18 , 19 , and sleep behaviors 20 have been found to have significant associations with mental health outcomes in this population. Self-rated health 21 and chronic disease 16 have also been identified as relevant factors linked to mental health.

Thus, in our study, we aimed to determine the current prevalence of social isolation, depression, and anxiety symptoms among community-dwelling older adults in Ningbo, China, and to investigate the relationships between these variables, including (1) the adjusted associations of social isolation with depression and anxiety, (2) the adjusted population attributable risk percentage (PAR%) for social isolation among cases of depression and anxiety, (3) the adjusted associations and PAR% in the gender subgroup.

Study design and population

Ningbo, situated in the Yangtze River Delta region of China, is a prominent city with six districts and four counties. As of 2022, its population reached approximately 9.6 million, with 1.4 million individuals aged 65 and older. A cross-sectional study of older adults (aged 65 years and older) in Ningbo, China was conducted from June to August 2022. Two community units in each district and county in Ningbo were randomly selected by computer generation and included all participants in each unit who met the inclusion criteria in our study. The inclusion criteria were (1) residence in the selected communities for more than one year, (2) an age of 65 years or older, and (3) the ability to understand our questionnaires, with no serious mental illness. The exclusion criteria were the absence of key variables in participants. All of the questionnaires were completed by the participants during face-to-face sessions with community workers. For participants who could not complete the paper questionnaire without assistance, the community workers verbally read the questions and completed the questionnaires according to the participants’ answers. Ethical approval for this study was obtained from the Ethics Committee of Ningbo Kangning Hospital, and written informed consent was obtained from all participants.

Defining depression and anxiety

Depression and anxiety were assessed using a validated 9-item Patient Health Questionnaire (PHQ-9) and a 7-item validated Generalized Anxiety Disorder (GAD-7) scale; these measures were based on the participants’ experiences over the previous 2 weeks, and each item was rated on a 4-point scale: “not at all” = 0, “several days” = 1, “more than half of the days” = 2, and “nearly every day” = 3. The total scores of the PHQ-9 and GAD-7 ranged from 0 to 27 and from 0 to 21, respectively. The Chinese versions of the PHQ-9 and GAD-7 have both been shown to have good reliability and validity for screening anxiety 22 and depression 23 . As previously recommended 24 , 25 , we used the screening cutoff score of 10 for both scales, and a score ≥ 10 corresponded to at least a moderate level of depression or anxiety. A PHQ-9 score 10 had a sensitivity (the probability of a positive test given that the elderly has the disease) of 88% and a specificity (the probability of a negative test given that the elderly is well) of 88% for major depression 26 , A GAD-7 score 10 had a sensitivity of 89% and a specificity of 82% for generalized anxiety disorder 25 .

Defining social isolation

Social isolation was assessed using three questions that addressed whether the participant lived alone (yes = 1, no = 0), had social contact (contacted less than once per month = 1, other = 0), and participated in social activities (participated less than once per week = 1, other = 0); these questions have been described elsewhere 5 , 27 . We then summed the scores of the responses to these questions, and a score of 2 or 3 was considered to indicate social isolation 27 .

All of the covariates were based on baseline data. The sociodemographic characteristics included age (continuous), gender (male, female), residence location (urban, rural), education (< 6 or ≥ 6 years), marital status (married or widowed/divorced/never married), and pension income (< 2000, 2000–5000, or > 5000 CNY/month). Additional covariates included the participants’ self-rated health (good, intermediate, or poor) and number of chronic non-communicable diseases (0, 1, 2, ≥ 3).

Substance use included two aspects: alcohol consumption (never, former, or current) and smoking (never, former, or current). Lifestyle behaviors included three aspects: sedentary time per day (< 3, 3–5, or > 5 h/day), physical activity performance per week (< 3 or ≥ 3 times/week), and a self-reported healthy diet (yes or no). Sleep behaviors included two aspects: sleep disturbance (difficulty falling asleep or waking up after falling asleep) over the past week (0, 1–2, 3–4, or 5–7 times/week) and sleep duration over the past week (< 6, 6–8, > 8 h/day).

Statistical analysis

The participants’ baseline characteristics were compared using the t -test for continuous variables and the chi-squared test for categorical variables. We estimated the proportions of participants with social isolation, depression, and anxiety in all population and gender subgroup. The links between social isolation and depression and anxiety were computed using a multivariate-adjusted logistic regression model and are reported as adjusted odds ratios (AORs). Population attributable risk percentages (PAR%) 28 were calculated to assess the proportions of cases of depression and anxiety that could potentially be prevented if social isolation were mitigated among older adults. The calculation was based on the formula reported by Bruzzi et al. 28 : PAR% = 1 −  \(\sum_{j}\frac{{P}_{j}}{\begin{array}{c}\sim \\ {R}_{j}\end{array}}\) , where j is 1, 2, 3, … level; P j is the ratio of the number of cases to the total number of cases at the j level; and \({\begin{array}{c}\sim \\ R\end{array}}_{j}\) is the relative risk of the exposure factor level adjusted for other factors at the j level. In the statistical analysis, P values < 0.05 were considered statistically significant. All the statistical analyses were completed by SAS version 9.4 (SAS Institute, Cary, NC, USA) .

Ethics statement

This work was conducted in accordance with the principles of the Declaration of Helsinki and ethics approval (NBKNYY-2023-LC-29) was obtained from the Ethics Committee of Ningbo Kangning Hospital, and written informed consent was obtained from all participants.

In total, 6,664 community-dwelling older adults were recruited for this study (response rate was 84.9%), of whom 45.50% were men. In Table 1 , the men were significantly older than the women (72.89 ± 6.25 vs. 72.40 ± 6.05 years, P  = 0.001). The percentages of participants who were current alcohol drinkers and smokers were higher among men than among women (Table 1 ). The percentage of participants who participated in physical activity more than 3 times/week was lower among men than among women (Table 1 ). Compared with women, men had better sleep disturbance and sleep duration status ( P  < 0.001 for both) (Table 1 ).

Overall, 12.67% of the participants reported that they had experienced social isolation, and the rate of social isolation was significantly higher among women than among men (15.66% vs. 9.10%, P  < 0.05, Fig.  1 ). The prevalence of depression and anxiety among the participants was 4.83% and 2.63%, respectively. Univariate logistic regression analysis showed that age, sedentary, sleep disturbance, social isolation, and more diseases were significantly positively linked with depression and anxiety. Meanwhile, higher pension income, being in marital status, physical activity, longer sleep duration, healthy diet, and self-rated health were significantly negatively linked with depression and anxiety (Fig.  2 ).

The percentage of isolation ( A ), anxiety and depression ( B ) in the gender group among over 65 years old Chinese.

The association factors of anxiety and depression by univariate logistic regression analysis.

Multivariate logistic regression analysis showed that older adults who had experienced social isolation were 1.77 times more likely to have depression than those who were not socially isolated (AOR = 1.77, 95% confidence interval [CI]: 1.25–2.51, P  < 0.001, Table 2 ). Social isolation also was significantly associated with an increased likelihood of anxiety in older adults (AOR = 1.66, 95% CI: 1.05–2.63, P  = 0.029, Table 2 ) after controlling for multiple variables. However, no significant associations of social isolation with depression and anxiety were observed in male participants [AOR (95% CI) = 1.42 (0.77–2.58) and 0.98 (0.42–2.26), respectively; P  > 0.05 for both]. In contrast, female participants who had experienced social isolation were 1.99 and 1.92 times more likely to have depression and anxiety, respectively, than those who had not experienced social isolation, and these results were significant ( P  < 0.05 for both, Table 2 ).

The results regarding the adjusted PAR% for social isolation are shown in Table 3 . Among our participants, the PAR% related to social isolation was as high as 10.66% and 9.03% for depression and anxiety, respectively. Besides, the adjusted PAR% related to social isolation were as high as 15.12% and 12.84% for depression and anxiety in women. The adjusted PAR% of social isolation were no statistical significance for depression and anxiety in men (Table 4 ).

This study investigated the prevalence of social isolation, depression, and anxiety in a sample of community-dwelling older adults in Ningbo, China. Overall, 12.67% of the participating older adults reported having experienced social isolation, and the prevalence of depression and anxiety in this population was 4.83% and 2.63%, respectively. The participants who had experienced social isolation were more likely to have depression and anxiety than those who were not socially isolated. Furthermore, our results shed light on some key intermediate factors that affected the relationship between social isolation and increased risks of depression and anxiety.

The participants who had experienced social isolation had 1.77 and 1.66 times greater odds of having depression and anxiety than those who were not socially isolated, which was congruent with the findings of earlier studies. For example, in a study of Irish older adults, the lowest level of social isolation was associated with a 43% and 52% probability of depression or anxiety 13 . Furthermore, social disconnectedness could predict an increase in subsequent depression and anxiety symptoms due to an increase in perceived isolation among older adults in the United States 29 . Moreover, social isolation at baseline predicted higher depression and anxiety scores at follow-up (incidence rate ratio = 1.35 and 1.32, respectively) in a study of older adults in Shanghai 8 . As we have seen, it does seem depressive symptoms are understudied in the elderly in social isolation studies in China, but this does not seem to be true for other East Asia generally. In the results of their studies, social isolation has been actively linked to depressive symptoms in the elderly in Japan 30 , 31 and South Korea 32 , 33 , 34 . Depression and anxiety share a biological mechanism of activation via the hypothalamic–pituitary–adrenal (HPA) axis, which may explain their associations with social isolation 35 . The HPA axis is a major stress response system in humans. Studies have suggested that social isolation increases the activation of the HPA axis in humans 36 . Research findings also have confirmed the possibility of excess HPA axis activity in people with both depression and anxiety 37 . Thus, social isolation may make older adults more vulnerable to depression and anxiety via activation of the HPA axis 35 .

In our study, we first found that the PAR% of social isolation was 10.66% and 9.03% for depression and anxiety, respectively, suggesting that eliminating social isolation could reduce depression and anxiety in older adults by almost 10%. In this regard, sufficient attention should be paid to social isolation among older adults, who should be motivated to change their situation and seek relevant help. Moreover, measures to reduce social isolation are needed. Potential interventions for eliminating social isolation among older adults include (1) improving their interpersonal communication skills through lectures and training, (2) increasing regular contact with or the provision of companionship or care for them, (3) offering opportunities for them to engage in social interaction (e.g., community activities), and (4) changing their cognition about social isolation and social support 38 , 39 . Social isolation is the objective absence of social relations, meanwhile, loneliness is the subjective experience of the lack of social relations 35 . Although social isolation and loneliness are not exactly equivalent, potential interventions for eliminating social isolation among older adults might partly mitigate their loneliness, and further alleviate mental unhealth 40 .

It is evident that elderly women are more likely to experience social isolation. In 2019, the average life expectancy in China was 77.7 years, with a gender disparity of 6.2 years favoring women. This gap is projected to widen to 7.0 years by 2035 41 . Consequently, elderly women are more likely to experience widowhood and live alone, thereby heightening their risk of social isolation. Furthermore, the association and PAR% of social isolation with depression and anxiety were found to be significant exclusively among elderly women. Gender differences in response to social isolation may be partially attributable to sexually dimorphic reactions. In male mice subjected to social isolation, increased dopamine release was observed during subsequent social interactions, leading to enhanced pleasurable sensations. This, in turn, fostered a heightened desire for social engagement 42 . The phenomenon was not observed in female mice. Consequently, this can explain the reason for the impact of social isolation appeared to be mitigated in males.

Strengths and limitations

The strengths of the current study include a large sample size and the use of validated scales to measure social isolation, depression, and anxiety. In addition, the PAR% of social isolation in depression and anxiety was first explored. However, this study has several limitations. First, all of the participants were recruited from communities in Ningbo, and therefore the conclusions may not be generalizable to other regions in China. Second, this was a cross-sectional study, and therefore causal associations cannot be assumed. Longitudinal studies of the relationships of social isolation with depression and anxiety will be needed to infer causality. In addition. although we adjusted for as many confounders as possible, this was an observational study, and therefore we cannot rule out the possibility of residual confounders. Third, all of the data included in the analyses were based on self-reports, suggesting the possibility of reporting bias. The scales for depression and anxiety were based on self-reports rather than clinical assessments and diagnoses, which may also contribute to different results. Fourth, some of the participants had poor health status (such as having difficulty in reading or writing) and required assistance from the interviewers to complete their questionnaires, which may have increased the risk of social desirability bias.

Conclusions

In conclusion, this study highlights the associations of social isolation with increased risks of depression and anxiety among older adults, especially among females. The findings from this study suggest the importance of identifying older adults who are at risk of social isolation, especially among females. Effective and feasible interventions are needed to eliminate social isolation and pay attention to mental health in this population.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Affiliated Kangning Hospital of Ningbo University.

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Acknowledgements

The authors express their gratitude to the doctors from the office of Mental health and the community health service center who were involved in the data collection.

This work was supported by the Ningbo Medical & Health Leading Academic Discipline Project (2022-F28), Ningbo Top Medical and Health Research Program (2022030410) and Ningbo Medical and Health Brand Discipline (PPXK2018-08).

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Department of Psychiatry, Affiliated Kangning Hospital of Ningbo University, Ningbo, 315201, Zhejiang, China

Lian Li, Kaijie Pan, Jincheng Li, Hongying Yang & Guolin Bian

Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, 315201, Zhejiang, China

Fenghua District Center for Disease Control and Prevention, Ningbo, 315500, China

Meiqin Jiang

Third People’s Hospital of Xiangshan, Xiangshan Hospital of Traditional Chinese Medicine Group, Ningbo, 315725, China

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L.L. conceived and designed the study, performed the statistical analysis, and drafted the article. K.P., J.L., M.J., and Y.G. collected the data. Hongying Yang and Guolin Bian contributed to the study design and the article’s critical revision. All authors revised the article and approved the final version.

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Li, L., Pan, K., Li, J. et al. The associations of social isolation with depression and anxiety among adults aged 65 years and older in Ningbo, China. Sci Rep 14 , 19072 (2024). https://doi.org/10.1038/s41598-024-69936-w

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• Pain Management
• Cannabidiol (CBD)

CBD for Depression and Anxiety

The market for products containing cannabidiol, or CBD, has exploded in recent years. Surveys show 14%-33% of U.S. adults have used CBD at some point. People take it for all kinds of health issues, including pain and insomnia, without much hard science to show whether it works.

Scientists are studying it as a potential treatment for diseases including Parkinson’s and multiple sclerosis, and mental health conditions including schizophrenia, posttraumatic stress disorder (PTSD), anxiety, and depression. There’s evidence that CBD can offer some help to people who have anxiety or depression. But very little research has been done, and there’s plenty of reason to proceed with caution. 

What Is CBD?

Cannabidiol is a chemical compound found in the Cannabis sativa plant, a species that includes both hemp and marijuana. It’s different from the other main compound in cannabis, THC, in the way that it binds to certain receptors in your brain. It doesn’t make you feel “high.” 

In the U.S., it can be legally manufactured from the hemp plant, and it is sold in many different forms. You can take it by mouth as an oil, a capsule, or a spray, or spread it on your skin as a lotion or oil. It’s added to food, drinks, pet products, and personal items like cosmetics, and it’s even infused into fabric. Depending on your state laws, you can buy it online, in specialty stores, or in your neighborhood grocery or drugstore.

What’s the Evidence for CBD in Anxiety and Depression Treatment?

You may have heard from a friend or read online about people who swear CBD helped with their mental health issues. But there have been very few scientific studies comparing the effects of CBD to the effects of another medicine or a fake medicine called a placebo.

Anxiety . More than a dozen studies have been done on lab animals over the past 3 decades that showed that depending on the dose, CBD could reduce behavior similar to anxiety in people. A handful of studies have been done with people that had similar results.

• Two studies from 1974 and 1982 found that CBD lowered anxiety caused by taking THC.
• A 1993 study found less anxiety in people who took CBD and then performed a public speaking test.
• People in a small study published in 2003 reported feeling less anxious after taking CBD than those who took a placebo. 
• Two studies published in 2011 found CBD reduced symptoms in people diagnosed with social anxiety disorder. 
• A study published in 2019 showed CBD worked better than a placebo for teenagers with social anxiety. 
• Young people whose regular anxiety medicine wasn’t working well showed improvement after adding CBD in a study published in 2022. 
• Results from the first phase of an ongoing trial using CBD and other cannabis compounds published in 2022 found the medication could ease symptoms over 4 weeks. 

The Drug Enforcement Administration changed its rules about CBD in 2015, making it easier to use it for research. More than a dozen studies are going on now or are being set up to test the effect of CBD on anxiety. Some involve people diagnosed with anxiety disorders. Others are looking at anxiety in people with cancer or other diseases. 

Depression.  Anxiety and depression are often treated using the same drugs, showing they may be influenced by the same brain processes. So it makes sense that if CBD works for anxiety, it might also work for depression. But there have been even fewer studies focusing on depression specifically. Almost 2 dozen animal studies found CBD can have an antidepressant effect. Also:

• A study of people with cancer and chronic pain published in 2012 found an improvement in symptoms of depression. The drug tested contained CBD and THC. 
• Two studies published in 2018 found CBD reversed depression symptoms brought on by marijuana use.
• In a survey of more than 2,000 people, more than 1 in 6 reported using CBD to manage depression. Almost two-thirds of them said it worked very well or moderately well. 
• The study published in 2022 on young people that showed a benefit for anxiety symptoms also found significant improvement in depression symptoms.

In addition to one study planning to test CBD for treating anxiety and depression in people with bipolar disorder, another study on CBD for chronic pain is measuring whether it also improves depression symptoms. 

Doctors aren’t exactly sure how CBD might improve anxiety and depression symptoms. It acts on more than 65 receptors in your brain, some of which affect your levels of serotonin. That’s a brain chemical that helps control your mood. Several drugs already used to treat anxiety and depression focus on boosting your levels of serotonin. But other receptors and brain pathways may also be involved. 

Is CBD Safe for Treating Anxiety and Depression?

Right now, CBD is only approved to treat certain seizure disorders. A report by the World Health Organization found it to be generally safe and not likely to be abused. 

But other than the anti-seizure medications, CBD products aren’t regulated by the FDA. That means the government can’t guarantee whether any given CBD product is safe, or even if it actually contains what the manufacturer says it does. 

Companies aren’t allowed to market them as medicines, dietary supplements, or food additives, although they do.

Here are some things to consider before you try CBD for anxiety or depression: 

• The amount of CBD in the product could be more or less than what the label says.
• The product might have ingredients that aren’t listed, including the intoxicating ingredient in marijuana, THC. 
• Without government oversight of the manufacturing process, the product could be contaminated. 
• Doctors don’t know how much of the CBD you eat, inhale, or rub on your skin actually gets into your system. 
• Studies have tested CBD in different doses, but scientists don’t yet know how much you’d need to take for it to help you, or how often or for how long you’d need to be treated. 

The FDA is working with lawmakers to come up with a system to evaluate and approve CBD products. 

What Are the Possible Side Effects of CBD?

Clinical studies on CBD in people and animals have identified several possible side effects. They include:

• Decreased appetite
• Crankiness and other mood changes
• Liver damage
• Male infertility

CBD can interact with certain other drugs, or change the way those drugs work in your body, which can lead to dangerous side effects. They include certain antibiotics, antidepressants, cholesterol medicines, and blood thinners. 

Should You Try CBD for Anxiety and Depression?

That’s very much a question to discuss with your doctor. You shouldn’t stop taking any medication you’ve been prescribed without talking with them first. You may need to slowly reduce your dose of certain anxiety and depression medications to avoid side effects. 

If you do use CBD, or marijuana, to manage depression or anxiety, it’s important to be honest with your doctor about it. A recent survey found that many people take CBD but don’t tell their doctors. That makes it hard to know whether your medical treatment or therapy is helping. And taking CBD with other prescription medicines can change the way they work. 

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Substance Abuse and Mental Health Services Administration: “Cannabidiol (CBD) – Potential Harms, Side Effects, And Unknowns.”

Mayo Clinic: “What are the benefits of CBD – and is it safe to use?” “Antidepressant withdrawal: Is there such a thing?”

Biomolecules : “Cannabidiol: A Potential New Alternative for the Treatment of Anxiety, Depression, and Psychotic Disorders.”

Frontiers in Immunology : “Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age.”

Neuropsychopharmacology : “Effects of Cannabidiol (CBD) on Regional Cerebral Blood Flow.”

Frontiers in Psychology : “Anxiolytic Effects of Repeated Cannabidiol Treatment in Teenagers With Social Anxiety Disorders.”

Journal of Clinical Psychiatry : “Cannabidiol for Treatment-Resistant Anxiety Disorders in Young People: An Open-Label Trial.”

Communications Medicine : “Clinical and cognitive improvement following full-spectrum, high-cannabidiol treatment for anxiety: open-label data from a two-stage, phase 2 clinical trial.”

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Cannabis and Cannabinoid Research : “A Cross-Sectional Study of Cannabidiol Users.”

World Health Organization: “Cannabidiol (CBD) Critical Review Report.”

Harvard Health Publishing: “Cannabidiol (CBD): What we know and what we don't.”

CDC: “CBD: What You Need to Know.”

News release, FDA.

FDA: “What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD.”

Frontiers in Psychiatry : “Cannabidiol (CBD) in the Self-Treatment of Depression-Exploratory Study and a New Phenomenon of Concern for Psychiatrists.”

Journal of General Internal Medicine : “Cannabidiol Interactions with Medications, Illicit Substances, and Alcohol: a Comprehensive Review.”

Using CBD for PTSD

PTSD can cause debilitating symptoms like flashbacks and insomnia and lead to self-destructive behavior. Can CBD help? Learn what the science has to say.

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Looking for information on CBD side effects? Read on to learn about CBD's safety profile and how to minimize any possible side effects.

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Cannabidiol (CBD) can change the way your body breaks down medicines you take. It can intensify side effects of others. Find out what NOT to take with CBD.

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Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments

Elena bernaras.

1 Developmental and Educational Department, University of the Basque Country, Donostia/San Sebastián, Spain

Joana Jaureguizar

2 Developmental and Educational Psychology Department, University of the Basque Country, Lejona, Spain

Maite Garaigordobil

3 Personality, Evaluation and Psychological Treatments Department, University of the Basque Country, Donostia/San Sebastián, Spain

Depression is the principal cause of illness and disability in the world. Studies charting the prevalence of depression among children and adolescents report high percentages of youngsters in both groups with depressive symptoms. This review analyzes the construct and explanatory theories of depression and offers a succinct overview of the main evaluation instruments used to measure this disorder in children and adolescents, as well as the prevention programs developed for the school environment and the different types of clinical treatment provided. The analysis reveals that in mental classifications, the child depression construct is no different from the adult one, and that multiple explanatory theories must be taken into account in order to arrive at a full understanding of depression. Consequently, both treatment and prevention should also be multifactorial in nature. Although universal programs may be more appropriate due to their broad scope of application, the results are inconclusive and fail to demonstrate any solid long-term efficacy. In conclusion, we can state that: (1) There are biological factors (such as tryptophan—a building block for serotonin-depletion, for example) which strongly influence the appearance of depressive disorders; (2) Currently, negative interpersonal relations and relations with one's environment, coupled with social-cultural changes, may explain the increase observed in the prevalence of depression; (3) Many instruments can be used to evaluate depression, but it is necessary to continue to adapt tests for diagnosing the condition at an early age; (4) Prevention programs should be developed for and implemented at an early age; and (5) The majority of treatments are becoming increasingly rigorous and effective. Given that initial manifestations of depression may occur from a very early age, further and more in-depth research is required into the biological, psychological and social factors that, in an interrelated manner, may explain the appearance, development, and treatment of depression.

Introduction

Depression is the principal cause of illness and disability in the world. The World Health Organization (WHO) has been issuing warnings about this pathology for years, given that it affects over 300 million people all over the world and is characterized by a high risk of suicide (the second most common cause of death in those aged between 15 and 29) [World Health Organization (WHO), 2017 ]. Studies on the child population which use self-reports to evaluate severe symptoms of depression, specifically the Children's Depression Inventory (CDI, Kovacs, 1992 ) and the Children's Depression Scale (CDS, Lang and Tisher, 1978 ), have observed prevalence rates of, for example, 4% in Spain (Demir et al., 2011 ; Bernaras et al., 2013 ), 6% in Finland (Puura et al., 1997 ), 8% in Greece (Kleftaras and Didaskalou, 2006 ), 10% in Australia (McCabe et al., 2011 ), and 25% in Colombia (Vinaccia et al., 2006 ). The main classifications of mental disorders are the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (American Psychiatric Association, 2014 ), published by the American Psychiatric Association, which has become a key reference in clinical practice, and version 10 of the International Classification of Diseases (ICD-10, 1992), published by the WHO, which classifies and codifies all diseases, although initially its aim was to chart mortality rates. The new ICD-11 classification will be presented for approval to Member States at the World Health Assembly in May 2019, and is expected to come into effect on January 1, 2022 [World Health Organization (WHO), 2018 ]. The two classifications offer different categorizations of depressive disorders, although certain similarities do exist, and it should be borne in mind also that both have been criticized for hardly distinguishing at all between child and adult depression.

Throughout history, there have been many different explanatory theories of depression. Biological and psychological theories are the ones which have mainly tried to explain the origin of this mental disorder. Biological theories have, from a variety of different perspectives, postulated that depression may occur due to noradrenalin deficits (e.g., Schildkraut, 1965 ; Narbona, 2014 ), endocrine disorders (e.g. Birmaher et al., 1996 ), sleep-related disorders (e.g., Sivertsen et al., 2014 ; Pariante, 2017 ), alterations in brain structure (Whittle et al., 2014 ), or the influence of genetics (Scourfield et al., 2003 ). Psychological theories have attempted to explain depression on the basis of psychoanalysis and, more specifically, in terms of attachment theories (e.g., Bowlby, 1976 ; Ainsworth et al., 1978 ; Blatt, 2004 ; Bigelow et al., 2018 ), behavioral models (e.g., Skinner, 1953 ; Ferster, 1966 ; Lewinsohn, 1975 ), cognitive models (e.g., Seligman, 1975 ; Abramson et al., 1978 ; Beck, 1987 ), the self-control model (e.g., Rehm, 1977 ; Rehm et al., 1979 ), interpersonal theory (e.g., Markowitz and Weissman, 1995 ; Milrod et al., 2014 ), stressful life events (e.g., Reinherz et al., 1993 ; Frank et al., 1994 ), and sociocultural models (e.g., Lorenzo-Blanco et al., 2012 ; Chang et al., 2013 ; Reeves et al., 2014 ).

Evaluating depression accurately has been another concern upon which psychology has focused, with attention being centered specifically around diagnosing this pathology in childhood and adolescence. Although many diagnostic instruments have been developed and validated, mainly for the adolescent and adult stages of life, it is still difficult to find diagnostic tests for evaluating depression in children. Preventing depression is another aspect to which much importance is attached by the World Health Organization (WHO) ( 2017 ), which argues that school programs, interventions aimed at parents and specific exercises for the elderly population help reduce the prevalence of this pathology. Depression prevention programs do exist, but they are mainly targeted at adolescents and very few focus on children under the age of 10.

The treatment of depression is another aspect that should not be overlooked. In 2016, the WHO and the World Bank announced that investing in the treatment of depression and anxiety leads to four-fold returns, since these pathologies cost the global economy one trillion US dollars each year. Furthermore, they claimed that humanitarian emergencies and conflicts highlight a pressing need to broaden current therapeutic options. In this sense, the multiple different explanatory theories of depression have given rise to a plethora of different treatments (psychotherapeutic, behavioral, cognitive-behavioral, interpersonal, etc.) which are currently being analyzed with a high degree of precision and scientific rigor.

In light of the different aspects related to depression outlined above, the present study has the following aims: (1) To analyze the construct of depression offered by the two main mental disorder classifications (DSM-5 and ICD-10); (2) To provide an overview of the main explanatory theories of depression; (3) To outline the child and adolescent depression evaluation instruments most commonly used in scientific literature; (4) To provide a brief overview of child and adolescent depression prevention programs in the school environment; and (5) To describe the most scientifically rigorous and effective clinical treatments for this mental disorder.

The databases used for carrying out the searches were PubMed, PsycINFO, Web of Science, Scopus, Science Direct and Google Scholar, along with a range of different manuscripts. With the constant key word being depression, the search for information cross-referenced a series of other key words also, namely: childhood, adolescence, explanatory theories, etiology, evaluation instruments, prevention programs, and treatment. Searches were conducted for information published between 1970 and 2017.

Thus, first we describe the construct of depression and summarize the main explanatory theories. Next, we present the main evaluation instruments used to measure child and adolescent depression and report the results of a bibliographical review of prevention programs in school settings. Finally, we outline the main clinical treatments used nowadays to treat child and adolescent depression.

The Construct of Depression: DSM-5 and ICD-10

Depression features in both of the two most important global classifications: the DSM-5 and the ICD-10. As stated earlier in the introduction, the new ICD-11 classification will be presented for approval to Member States at the World Health Assembly in May 2019, and is expected to come into effect on January 1, 2022. The presentation of the new classification in 2019 will enable countries to plan for its implementation, prepare the necessary translations and train professionals accordingly [World Health Organization (WHO), 2018 ]. In texts published by WHO collaborators (Luciano, 2017 ), it has been suggested that the ICD-11 will include mood disorders within the mental and behavioral disorder category. However, until the final version is published, this information cannot be fully verified.

The two classifications (DSM-5 e IDC-10) offer different categorizations of depressive disorders, as shown in Table 1 . The WHO includes depressive disorders in the mood disorders category, although this review only focuses on Sections F32, F33, F34, and F38, which include the most frequent depressive disorders and which, in turn, contain subsections that will be further specified later on.

Depressive disorders according to the DSM-5 and the ICD-10.

According to the DSM-5, depressive disorders all have one common feature, namely the presence of sad, empty or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function (DSM-5). They may become a serious health problem if allowed to persist for long periods of time and occur with a moderate-to-severe degree of intensity. One important consequence of depression is the risk of suicide, which is, according the World Health Organization (WHO) ( 2017 ), the second most common cause of death among young people aged between 15 and 29.

The main novelty offered by the DSM-5 in its section on depressive disorders is the introduction to Disruptive mood dysregulation disorder (which should not be diagnosed before the age of 6 or after the age of 18). This disorder is characterized by severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property). These outbursts often occur as the result of frustration and in order to be considered a diagnostic criterion must be inconsistent with the individual's developmental level, occur three or more times per week for at least a year in a number of different settings (at home, at school, etc.) and be severe in at least one of these. This disorder was added to the DSM-5 due to doubts arising in relation to how to classify and treat children presenting with chronic persistent irritability as opposed to other related disorders, specifically pediatric bipolar disorder. The prevalence of this disorder has been estimated at between 2 and 5%, with male children and teenage boys being more likely to suffer from it than their female counterparts.

Major Depressive Disorder

Major depressive disorder is characterized by a depressed mood most of the day, nearly every day, although in children and adolescents this mood may be irritable rather than depressed. The disorder causes a markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, or excessive or inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the United States, the 12-month prevalence is ~7%, although it is three times higher among those aged between 18 and 29 than among those aged 60 or over. Moreover, the prevalence rates for women are ~1.5–3 times higher than for men.

Persistent Depressive Disorder (Dysthymia)

Persistent depressive disorder (dysthymia) is a consolidation of DSM-5-defined chronic major depressive disorder and dysthymic disorder, and is characterized by a depressed mood for most of the day, for more days than not, for at least 2 years. In children and adolescents, mood can be irritable and duration must be at least 1 year. The DSM-5 specifies that patients presenting symptoms that comply with the diagnostic criteria for major depressive disorder for 2 years should also be diagnosed with persistent depressive disorder. When the individual in question is experiencing a depressive mood episode, they must also present at least two of the following symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, or difficulty making decisions and feelings of hopelessness. The prevalence of this disorder in the United States is 0.5%.

Premenstrual Dysphoric Disorder

The diagnostic criterion for premenstrual dysphoric disorder states that, in the majority of menstrual cycles, at least five symptoms must be present during the last week before the start of menstruation, and individuals should start to feel better a few days later, with all symptoms disappearing completely or almost completely during the week after menstruation. The most important characteristics of this disorder are affective lability, intense irritability or anger, or increased interpersonal conflicts, markedly depressed mood and/or over-excitation, and symptoms of anxiety which may be accompanied by behavioral and somatic symptoms. Symptoms must be present during most menstrual cycles during the past year and must negatively affect occupational and social functioning. The most rigorous estimations of the prevalence of this disorder claim that 1.8% of women comply with the criterion but have no functional impairment, while 1.3% comply with the criterion and suffer functional impairment and other concomitant symptoms of another mental disorder.

Substance/Medication-Induced Depressive Disorder

Substance/medication-induced depressive disorder is characterized by the presence of the symptoms of a depressive disorder, such as major depressive disorder, induced by the consumption, inhalation or injection of a substance, with said symptoms persisting after the physiological effects or the effects of intoxication or withdrawal have disappeared. Some medication may generate depressive symptoms, which is why it is important to determine whether the symptoms were actually induced by the taking of the drug or whether the depressive disorder simply appeared during the period in which the medication was being taken. The prevalence of this disorder in the United States is 0.26%.

Depressive Disorder Due to Another Medical Condition

Depressive disorder due to another medical condition is characterized by the appearance of a depressed mood and a markedly diminished interest or pleasure in all activities within the context of another medical condition. The DSM-5 offers no information about the prevalence of this disorder.

The category Other specified depressive disorder is used when the symptoms characteristic of a depressive disorder appear and cause significant distress or impairment in social, occupational or other areas of functioning but do not comply with all the criteria of any depressive disorder, and the clinician opts to communicate the specific reason for this. In the Other unspecified depressive disorder category , on the other hand, the difference is that the clinician prefers not to specify the reason why the presentation fails to comply with all the criteria of a specific disorder and includes presentations about which there is insufficient information for giving a more specific diagnosis.

In the ICD-10, depressive disorders are included within the mood disorders category. The following disorders are analyzed below: single depressive episode, recurrent depressive disorder, and persistent mood (affective) disorders.

Single Depressive Episode

The classification Single depressive episode distinguishes between depressive episodes of varying severity: mild, moderate, and severe without psychotic symptoms. Characteristics common to all of them include lowering of mood, reduction of energy, and decrease in daily activity. There is a loss of interest in formerly pleasurable pursuits, a decrease in the capacity for concentration, and an increase in tiredness, even during activities requiring minimum effort. Changes occur in appetite, sleep is disturbed, self-esteem and self-confidence drop, ideas of guilt or worthlessness are present and the symptoms vary little from day to day. In its mildest form, two or three of the symptoms described above may be present, and the patient is able to continue with most of their daily activities. When the episode is moderate, four or more of the symptoms are usually present and the patient is likely to have difficulty continuing with ordinary activities. In its most severe form, several of the symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of somatic symptoms are usually present. If the depressive episode is with psychotic symptoms, it is characterized by the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation.

Recurrent Depressive Disorder

Recurrent depressive disorder is characterized by repeated episodes of depression similar to those described above for single depressive episodes without mania. There may be brief episodes of mild mood elevation and over activity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment. The more severe forms of this disorder are very similar to manic-depressive depression, melancholia, vital depression, and endogenous depression. The first episode may occur at any age, from childhood to old age. The onset may be either acute or insidious and can last from a few weeks to many months. Recurrent depressive disorder can be mild or moderate, but in neither of these is there any history of mania. This section also includes recurrent depressive disorder currently in remission, in which the patient may have had two or more depressive episodes in the past, but has been free from depressive symptoms for several months.

Persistent Mood [Affective] Disorders

Persistent mood [affective] disorders are persistent and usually fluctuating disorders in which the majority of episodes are not sufficiently severe to warrant being diagnosed as hypomanic or mild depressive episodes. Since they last for many years and affect the patient's normal life, they involve considerable distress and disability. This section also includes cyclothymia and dysthymia. Cyclothymia is a persistent instability of mood involving numerous periods of depression and mild elation, none of which are sufficiently prolonged to justify a diagnosis of bipolar affective disorder or recurrent depressive disorder. This disorder is frequently found among the relatives of patients with bipolar affective disorder and some patients with cyclothymia eventually develop bipolar affective disorder. For its part, dysthymia is a chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of mild, moderate, or severe recurrent depressive disorder.

Other Mood (Affective) Disorders

Finally, other mood (affective) disorders include any mood disorders that do not fall into the categories described above because they are not of sufficient severity or duration. They may be single, recurrent (brief), or specified episodes.

The manifestations and symptoms of depression vary in accordance with age and level of development. However, it is clear that the DSM-5 and the ICD-10 do not distinguish between adult and child depression, although by including disruptive mood dysregulation disorder, the DSM-5 does take into account the fact that children and young people aged between 7 and 18 may express their distress in other ways, through chronic, severe, and recurrent irritability manifested verbally and/or behaviorally. Similarly, major depressive disorder specifies that in children the mood may be irritable rather than depressed. However, no distinctions of this kind are found in the ICD-10, an absence which may lead to the faulty inference that the characteristics of child and adolescent depression are similar to those of adult depression.

Explanatory Theories of Depression

Depressive disorders cannot be explained by any single theory, since many different variables are involved in their onset and persistence. The principal biological and psychological theories were therefore taken as the main references for this section. Subsequently, the contributions made by each of these theories regarding depression were studied by conducting searches in PubMed, Web of Science, Science direct, and Google Scholar. With the constant key words being depression, child depression and adolescent depression, the search for information cross-referenced a series of other key words also in accordance with the specific theory in question. Due to the importance of some seminal works in relation to the development of psychological theories of depression, certain authors have remained key references for decades. A total of 64 bibliographical references were used. The following is a summary of the various explanations for the onset of depression, according to the different theoretical frameworks.

Biological Theories

If a mood disorder cannot be explained by family history or stressful life events, then it may be that the child or adolescent in question is suffering from a neurological disease. In such a case, depressive symptoms may manifest early in children and adolescents as epileptic syndromes, sleep disorders, chronic recurrent cephalalgias, several neurometabolic diseases, and intracranial tumors (Narbona, 2014 ).

Noradrenalin Deficit

Serotonin is a monoamine linked to adrenaline, norepinephrine, and dopamine which plays a key role, particularly in the brain, since it is involved in important life regulation functions (appetite, sleep, memory, learning, temperature regulation, and social behaviors, etc.), as well as many psychiatric pathologies (Nique et al., 2014 ). Serotonin modulates neuroplasticity, particularly during the early years of life, and dysfunctions in both systems contribute to the physiopathology of depression (Kraus et al., 2017 ). MRI tests in animals have revealed that a reduction in neuron density and size, as well as a reduction in hippocampal volume among depressive patients may be due to serotonergic neuroplasticity changes. Branchi ( 2011 ), however, argues that improving serotonin levels may increase the likelihood of both developing and recovering from the psychopathology, and underscores the role played by the social environment in this process. In this sense, Curley et al. ( 2011 ) point out that the quality of the social environment may influence the development and activity of neural systems, which in turn have an impact on behavioral, physiological, and emotional responses.

Endocrine Alterations

Age-related changes and the presence of biological risk factors, including endocrine, inflammatory or immune, cardiovascular and neuroanatomical factors, make people more vulnerable to depression (Clarke and Currie, 2009 ). Indeed, some studies suggest that depression may be linked to endocrine alterations: nocturnal cortisol secretions (Birmaher et al., 1996 ), nocturnal growth hormone secretion (Ryan et al., 1994 ), thyroid stimulating hormone secretion (Puig-Antich, 1987 ), melatonin and prolactin secretions (Waterman et al., 1994 ), high cortisol levels (Herane-Vives et al., 2018 ), or decreased growth hormone production (Dahl et al., 2000 ). Puberty and the accompanying hormonal and physical changes require special attention because it has been proposed that they could be associated with an increased incidence of depression (Reinecke and Simons, 2005 ).

Sleep Disorders

Sleep problems are often associated with situations of social deprivation, unemployment, or stressful life events (divorce, bad life habits, or poor working conditions) (Garbarino et al., 2016 ). It also seems, however, that sleep disorders are linked to the development of depression. This relationship occurs as a result of how insufficient sleep affects the hippocampus, heightening neural sensitivity to excitotoxic insult and vulnerability to neurotoxic challenges, resulting in a net decrease in gray matter in the hippocampus in the left orbitofrontal cortex (Novati et al., 2012 ).

For their part, Franzen and Buysse ( 2008 ) state that bidirectional associations between sleep disturbances (particularly insomnia) and depression make it more difficult to distinguish cause-effect relations between them. It is therefore unclear whether depression causes sleep disturbances or whether chronic sleep disturbances lead to the appearance of depression. What does seem clear, however, is that treating sleep disturbances (both insomnia and hypersomnia) may help reduce the severity of depression and accelerate recovery (Franzen and Buysse, 2008 ).

Longitudinal studies have identified insomnia as a risk factor for the onset or recurrence of depression in young people and adults (Sivertsen et al., 2014 ). In comparison with the non-clinical population, depressed children and adolescents report both trouble sleeping and longer sleep duration (Accardo et al., 2012 ).

For their part, Foley and Weinraub ( 2017 ) observed that, among preadolescent girls, early and later sleep problems directly or indirectly predicted a wide variety of social and emotional adjustment disorders (depressive symptoms, low school competence, poor emotion regulation, and risk-taking behaviors).

Altered Neurotransmission

Studies conducted over the past 20 years have shown that increased inflammation and hyperactivity of the hypothalamic–pituitary–adrenal (HPA) axis may explain major depression (Pariante, 2017 ). Some of the pathophysiological mechanisms of depression include altered neurotransmission, HPA axis abnormalities involved in chronic stress, inflammation, reduced neuroplasticity, and network dysfunction (Dean and Keshavan, 2017 ). Other studies report alterations in the brain structure: smaller hippocampus, amygdala, and frontal lobe (Whittle et al., 2014 ). Nevertheless, the underlying molecular and clinical mechanisms have yet to be discovered (Pariante, 2017 ). Major depressive disorder in children and adolescents has been associated with increased intracortical facilitation, a direct neurophysiological result of excessive glutamatergic neurotransmission. However, contrary to the findings in adults with depression, no deficits in cortical inhibition were found in children and adolescents with major depressive disorder (Croarkin et al., 2013 ).

Genetic Factors

Other studies have highlighted the importance of genetics in the onset of depression (40%) (Scourfield et al., 2003 ). It is important to recognize that a genetic predisposition to an excessive amygdala response to stress, or a hyperactive HPA axis (moderate hyperphenylalaninemia) due to stress during early childhood may trigger an excessive effect or alter an otherwise healthy psychological system (Dean and Keshavan, 2017 ). Kaufman et al. ( 2018 ) support a potential role for genes related to the homeobox 2 gene of Orthodenticle (OTX2) and to the OTX2-related gene in the physiopathology of stress-related depressive disorders in children. Furthermore, genetic anomalies in serotonergic transmission have been linked to depression. The serotonin-linked polymorphic region (5-HTTLPR) is a degenerate repeat in the gene which codes for the serotonin transporter (SLC6A4). The s/s genotype of this region is associated with a reduction serotonin expression, in turn linked to greater vulnerability to depression (Caspi et al., 2010 ).

For their part, Oken et al. ( 2015 ) claim that psychological disturbances may trigger changes in physiological parameters, such as DNA transcription, or may result in epigenetic modifications which alter the sensitivity of the neurotransmitter receptor.

Psychological Theories

This section outlines the different psychological theories which have attempted to explain the phenomenon of depression. Depression is a highly complex disorder influenced by multiple factors, and it is clear that no single theory can fully explain its etiology and persistence. It is likely that a more eclectic outlook must be adopted if we are to make any progress in determining the origin, development, and maintenance of this pathology.

Attachment-Informed Theories

Attachment theory was the term used by Bowlby ( 1976 ) to refer to a specific conceptualization of human beings' propensity to establish strong and long-lasting affective ties with other people. Bowlby ( 1969 , 1973 ) proposes that consistency, nurturance, protectiveness, and responsiveness in early interactions with caregivers contribute to the development of schemas or mental representations about the relationships of oneself with others, and that these schemas serve as models for later relationships. Bowlby's ethological model of attachment postulates that vulnerability to depression stems from early experiences which failed to satisfy the child's need for security, care and comfort, as well as from the current state of their intimate relations (Bowlby, 1969 , 1973 , 1988 ). Adverse early experiences can contribute to disturbances in early attachments, which may be associated with vulnerability for depression (Cummings and Cicchetti, 1990 ; Joiner and Coyne, 1999 ). Associations between insecure attachment among children and negative self-concept, sensitivity to loss, and an increased risk of depression in childhood and adolescence have been reported (Armsden et al., 1990 ; Koback et al., 1991 ; Kenny et al., 1993 ; Roelofs et al., 2006 ; Allen et al., 2007 ; Chorot et al., 2017 ). Relationships between secure attachment and depression seem also to be mediated by the development of maladaptive beliefs or schemas (Roberts et al., 1996 ; Reinecke and Rogers, 2001 ).

Thus, attachment theory has become a useful construct for conceptualizing many different disorders and provides valuable information for the treatment of depression (Reinecke and Simons, 2005 ).

Ainsworth described three attachment styles, in accordance with the child's response to the presence, absence, and return of the mother (or main caregiver): secure, anxious-avoidant, and anxious-resistant (Ainsworth et al., 1978 ). The least secure attachment styles may give rise to traumatic experiences during childhood, which in turn may result in the appearance of depressive symptoms.

Similarly, Hesse and Main ( 2000 ) argued that the central mechanism regulating infant emotional survival was proximity to attachment figures, i.e., those figures who help the child cope with frightening situations. Using Ainsworth's strange situation procedure, Main ( 1996 ) found that abused children engaged in more disorganized, disruptive, aggressive, and dissociative behaviors during both childhood and adolescence. Main ( 1996 ) also found that many people with clinical disorders have insecure attachment and that psychological-disoriented and disorganized children are more vulnerable.

For his part, Blatt ( 2004 ) explored the nature of depression and the life experiences which contribute to its appearance in more depth, identifying two types of depression which, despite a common set of symptoms, nevertheless have very different roots: (1) anaclitic depression, which arises from feelings of loneliness and abandonment; and (2) introjective depression, which stems from feelings of failure and worthlessness. This distinction is consistent with psychoanalytical formulations, since it considers defenselessness/dependency and desperation/negative feelings about oneself to be two key issues in depression.

Brazelton et al. ( 1975 ) found that at age 3 weeks, babies demonstrate a series of interactive behaviors during face-to-face mother-infant interactions. These behaviors were not found to be present in more disturbed interactions, which may trigger infant anxiety.

In a longitudinal study focusing on the relationship between risk of maternal depression and infant attachment behavior, Bigelow et al. ( 2018 ) analyzed babies at age 6 weeks, 4 and 12 months, finding that mothers at risk of depression soon after the birth of their child may have difficulty responding appropriately to their infant's attachment needs, giving rise to disorganized attachment, with all the psychological consequences that this may involve. Similarly, Beeghly et al. ( 2017 ) found that among infants aged between 2 and 18 months, greater maternal social support was linked to decreasing levels of maternal depressive symptoms over time, and that boys were more vulnerable than girls to early caregiving risks such as maternal depression, with negative consequences for mother-child attachment security during toddlerhood.

Authors such as Shedler and Westen ( 2004 ) have attempted to find solutions to the problems arising in relation to the DSM diagnostic categories, developing the Shedler Westen Assessment Procedure (SWAP-200) to capture the wealth and complexity of clinical personality descriptions and to identify possible diagnostic criteria which may better define personality disorders.

For their part, Ju and Lee ( 2018 ) argue that peer attachment reduces depression levels in at-risk children, and also highlight the curative aspect of attachment between adolescent peers.

Behavioral Models

The first explanations proposed by this model argued that depression occurs due to the lack of reinforcement of previously reinforced behaviors (Skinner, 1953 ; Ferster, 1966 ; Lewinsohn, 1975 ), an excess of avoidance behaviors and the lack of positive reinforcement (Ferster, 1966 ) or the loss of efficiency of positive reinforcements (Costello, 1972 ). A child with depression initially receives a lot of attention from his social environment (family, friends…), and behaviors such as crying, complaints or expressions of guilt are reinforced. When these depressive behaviors increase, the relationship with the child becomes aversive, and the people who used to accompany the child avoid being with him, which contributes to aggravating his depression (Lewinsohn, 1974 ). Low reinforcement rates can be explained by maternal rejection and lower parental support (Simons and Miller, 1987 ), by a lower rate of reinforcement offered to their children by mothers of depressed children (Cole and Rehm, 1986 ), or by low social competence (Shah and Morgan, 1996 ).

Depression is mainly a learned phenomenon, related to negative interactions between the individual and his or her environment (e.g., low rate of reinforcement or unsatisfactory social relations). These interactions are influenced by cognitions, behaviors and emotions (Antonuccio et al., 1989 ).

Cognitive Models

The attributional reformulation of the learned helplessness model (Abramson et al., 1978 ) and Beck's cognitive theory (Beck et al., 1979 ) are the two most widely-accepted cognitive theories among contemporary cognitive models of depression (Vázquez et al., 2000 ).

Learned helplessness is related to cognitive attributions, which can be specific/global, internal/external, and stable/unstable (Hiroto and Seligman, 1975 ; Abramson et al., 1978 ). Global attribution implies the conviction that the negative event is contextually consistent rather than specific to a particular circumstance. Internal attribution is related to the belief that the aversive situation occurs due to individual conditions rather than to external circumstances. Stable attribution is the belief that the aversive situation is unchanging over time (Miller and Seligman, 1975 ). People prone to depression attribute negative events to internal, stable and global factors and make external, unstable, and specific attributions for success (Abramson et al., 1978 ; Peterson et al., 1993 ), a cognitive style also present in children and adolescents with depression (Gladstone and Kaslow, 1995 ).

The Information Processing model (Beck, 1967 ; Beck et al., 1979 ) postulates that depression is caused by particular stresses that evoke the activation of a schema that screens and codes the depressed individual's experience in a negative fashion (Ingram, 1984 , p. 443). Beck suggests that this distortion of reality is expressed in three areas, which he calls the “cognitive triad”: negative views about oneself, the world and the future as a result of their learning history (Beck et al., 1983 ). These beliefs are triggered by life events which hold special meaning for the subject (Beck and Alford, 2009 ).

Self-Control Model

This theory assumes that depression is due to deficits in the self-control process, which consists of three phases: self-monitoring, self-evaluation, and self-administration of consequences (Rehm, 1977 ; Rehm et al., 1979 ). In the self-monitoring phase, individuals attend only to negative events and tend to recognize only immediate, short-term consequences. In the self-evaluation phase, depressed individuals establish unrealistic evaluation criteria and inaccurately attribute their successes and failures. If self-evaluation is negative, in the self-administration of consequences phase the individual tends to engage very little in self-reinforcement and very frequently in self-punishment.

Both Rehm's self-control model (Rehm, 1977 ) and Bandura's conception of child depression (Bandura, 1977 ) assume that children internalize external control guidelines. These guidelines are related to family interaction patterns and both may contribute to the etiology or persistence of depression in children.

In a study conducted with children aged between 8 and 12 years, Kaslow et al. ( 1988 ) found that depressed children had a more depressive attributional style and more self-control problems.

Interpersonal Theory

This model, which is closely linked to attachment theories, aims to identify and find solutions for an individual's problems with depression in their interpersonal functioning. It suggests that the difficulties experienced are linked to unresolved grief, interpersonal disputes, transition roles and interpersonal deficits (Markowitz and Weissman, 1995 ).

Milrod et al. ( 2014 ) argue that pathological attachment during early childhood has serious consequences for adults' ability to experience and internalize positive relationships.

Similarly, various different studies have highlighted the fact that one of the variables that best predicts depression in children is peer relations (Bernaras et al., 2013 ; Garaigordobil et al., 2017 ).

Stressful Life Events

Studies focusing on the adult population have reported that between 60 and 70% of depressed adults experienced one or more stressful events during the year prior to the onset of major depression (Frank et al., 1994 ). In children and adolescents, modest associations have been found between stressful life events and depression (Williamson et al., 1995 ). For their part, Shapero et al. ( 2013 ) found that people who had suffered severe emotional abuse during childhood experienced higher levels of depressive symptoms when faced with current stressors. Sokratous et al. ( 2013 ) argue that the onset of depression is not only triggered by major stressful events, but rather, minor life events (dropping out of school, your father losing his job, financial difficulties in the family, losing friends, or the illness of a family member) may also influence the appearance of depressive symptoms.

Events such as the loss of loved ones, divorce of parents, mourning or exposure to suicide (either individually or collectively) have all been associated with the onset of depression in childhood (Reinherz et al., 1993 ). Factors such as a history of additional interpersonal losses, added stress factors, a history of psychiatric problems in the family and prior psychopathology (including depression) increase the risk of depression in adolescents (Brent et al., 1993 ). Birmaher et al. ( 1996 ) found that prior research into stressful life events in relation to early-onset depression had been based on data obtained from self-reports, making it difficult to determine the causal relationship, since events may be both the cause and consequence of depression.

However, not everyone exposed to this kind of traumatic experience becomes depressed. Personality and the moment at which events occur are both involved in the relationship between depression and stressful life events, although biological factors such as serotonergic functioning (Caspi et al., 2010 ) also exert an influence.

Sociocultural Models

These models postulate that cultural variables are responsible for the appearance of depressive symptoms. These variables are mainly acculturation and enculturation. In acculturation, structural changes are observed (economic, political, and demographic), along with changes in people's psychological behavior (Casullo, 2001 ). Some studies link increased suicide rates with economic recession (Chang et al., 2013 ; Reeves et al., 2014 ). Enculturation occurs when the older generation invites, induces or forces the younger generation to adopt traditional mindsets and behaviors.

In an attempt to better understand the influence of culture and family on depressive symptoms, Lorenzo-Blanco et al. ( 2012 ) tested an acculturation, cultural values and family functioning model with Hispanic students born in the United States. The results revealed that both family conflict and family cohesion were related to depressive symptoms.

Another study carried out with girls aged 7–10 years (Evans et al., 2013 ) observed that internalizing an unrealistically thin ideal body predicted disordered eating attitudes through body dissatisfaction, dietary restraint and depression.

Finally, the importance of family interactions in the onset of depressive symptoms cannot be overlooked. Parenting style has been identified as a key factor in children's and adolescents' psychosocial adjustment (Lengua and Kovacs, 2005 ). Parental behavior has been studied from two different perspectives: warmth and control. Warmth is linked to aspects such as engagement and expression of affection, respect, and positive concern by parents and/or principal caregivers (Rohner and Khaleque, 2003 ). In this sense, prior studies have identified a significant association between parental warmth and positive adjustment among adolescents (Barber et al., 2005 ; Heider et al., 2006 ). Rohner and Khaleque ( 2003 ) argue that children's psychological adjustment is closely linked to their perception of being accepted or rejected by their principal caregivers, and other studies have found that weaker support from parents is associated with higher levels of depression and anxiety among adolescents (Yap et al., 2014 ).

Similarly, Jaureguizar et al. ( 2018 ) found that a low level of perceived parental warmth was linked to high levels of clinical and school maladjustment, and that the weaker the parental control, the greater the clinical maladjustment. These authors also found that young people with negligent mothers and authoritarian fathers had higher levels of clinical maladjustment.

In short, according to the different theories, depression may be due to (1) biological reasons; (2) insecure attachment; (3) lack of reinforcement of previously-reinforced behaviors; (4) negative interpersonal relations and relations with one's environment and the resulting negative consequences; (5) attributions made by individuals about themselves, the world and their future; and (6) sociocultural changes. It is likely that no single theory can fully explain the genesis and persistence of depression, although currently, negative interpersonal relations and relations with one's environment and sociocultural changes (economic, political, and demographic) may explain the observed increase in the prevalence of depression.

Evaluation Instruments

Many different evaluation instruments can be used to measure child and adolescent depression. Tables 2 , ​ ,3 3 outline the ones most commonly used in scientific literature. Table 2 summarizes the main self-administered tests that specifically measure child and adolescent depression, while Table 3 presents tests that measure child and adolescent depression among other aspects (i.e., broader or more general tests). Finally, Table 4 summarizes the main hetero-administered psychometric tests for assessing this pathology.

Self-administered psychometric tests designed specifically for evaluating child and adolescent depression.

KR-20, Kuder-Richardson coefficient (formula 20); κ, Cohen's kappa reliability co-efficient; PPV, Positive predictive value; NPV, Negative predictive value; AUC, Area under the Receiver Operating Characteristic Curve (AUC) .

Self-administered general psychometric tests which, among other variables, also assess child and adolescent depression.

Hetero-administered psychometric tests for assessing child and adolescent depression.

As shown in the tables above, there are several self-administered instruments that can be used with children from age 6 to 7 onwards, although their duration should be taken into consideration in order to avoid overtiring subjects. While it is clear that an effort has been made to design shorter measures (compare, for example, the 66 items of the CDS with the 16 items of the longest version of the KADS), the duration of the test should not be the only aspect taken into account when selecting an evaluation instrument.

One of the most widely used instruments to measure child depression in the scientific literature is the Children's Depression Inventory-CDI (Kovacs, 1985 ), which is based on the Beck Depression Inventory-BDI (Beck and Beamesderfer, 1974 ). Thus, it is based on Beck's cognitive theory of depression. Following this same theoretical line, the Children's Depression Scale-CDS (Lang and Tisher, 1978 ) was designed, but in this case, this instrument was not created based on another instrument previously designed for adult population (as in the case of the CDI), but instead from its beginnings, it was conceived exclusively to assess child depression. Chorpita et al. ( 2005 ) explain that the CDI measures a broader construct of negative affectivity rather than depression as a separate construct, and that it may be useful for screening for trait dimensions or personality features, whereas other instruments, such as the Revised Child Anxiety and Depression Scale-RCADS (Chorpita et al., 2000 ), measure a specific clinical syndrome.

Table 2 describes many other instruments that are very useful as screening tests for depression and depressive disorder, such as the Center for Epidemiological Studies Depression Scale for Children-CES-DC (Weissman et al., 1980 ) (based on the Center for Epidemiological Studies Depression Scale for Adults, CES-D; Radloff, 1977 ), the Mood and Feelings Questionnaire-MFQ (Angold et al., 1995 ), or the Depression Self-Rating Scale for Children-DSRS (Birleson, 1981 ). This last one, for example, is useful to measure moderate to severe depression in childhood and is based on the operational definition of depressive disorder, that is, a specific affective-behavior pattern that implies an impairment of a child's or adolescent's ability to function effectively in his/her environment (Birleson, 1981 ).

The cognitive and affective component of depression is the one that is most present in the instruments described in Table 2 . In fact, for example, the Short Mood and Feelings Questionnaire (SMFQ) includes the cognitive and affective items from the original MFQ item pool, in addition to some items related to tiredness, restlessness, and poor concentration (Angold et al., 1995 ). In the SMFQ, more than half of the items from the MFQ were removed, and even so, high correlations between the MFQ and the SMFQ were found (Angold and Costello, 1995 ), which may be indicating that the really important items were the cognitive and affective items that were maintained. Reynolds et al. ( 1985 ) defended that children could accurately report their cognitive and affective characteristics, so “ if one wishes to know how a child feels, ask the child” (Reynolds et al., 1985 , p. 524).

Depending on the specific aim of the evaluation or research study, a broader diagnostic measure, such as those outlined in Table 3 , may also provide valuable information. Finally, it is worth noting that only two hetero-administered instruments were found for teachers, with all others being clearly oriented toward the clinical field. In this sense, special emphasis should be placed on the need to develop valid and reliable instruments for teachers, since they may be key agents for detecting symptoms among their students. While it is important to train teachers in this sense, it is also important to provide them with instruments to help them assess their students. The instruments that are currently available have produced very different results as regards their correlation with students' self-reported symptoms, although in general, teachers tend to underestimate their students' depressive symptoms (Jaureguizar et al., 2017 ).

Child and Adolescent Depression Prevention Programs in the School Environment

Extant scientific literature was reviewed in order to summarize the main depression prevention programs for children and adolescents in school settings. The databases used for conducting the searches were PubMed, PsycINFO, Web of Science, Scopus, Science Direct, and Google Scholar, along with a range of different manuscripts. With the constant key word being depression, the search for information cross-referenced a series of other key words also, namely: “child * OR adolescent * ,” “prevent * program,” and “school OR school-based.” Searches were conducted for information published between January 1, 1970 and December 31, 2017.

First, articles were screened (i.e., their titles and abstracts were read and a decision was made regarding their possible interest for the review study). The inclusion criteria were that the study analyzed all the research subjects of the review study (depression, childhood, or adolescence and prevention programs in school settings), that study participants were aged between 6 and 18, that the study was published in a peer-reviewed journal and that it was written in either English or Spanish. Review studies and their references were also analyzed. Studies focusing mainly on psychiatric disorders other than depression were excluded.

Finally, 39 studies were selected for the review, which explored 8 prevention programs that are outlined in Table 5 . In general terms, child depression prevention programs are divided into two main categories: universal programs for the general population, and targeted programs aimed at either the at-risk population or those with a clear diagnosis. Although scientific literature reports that targeted programs obtain better outcomes than universal ones, the latter type nevertheless offer certain advantages, since they reach a larger number of people without the social stigma attached to having been specially selected (Roberts et al., 2003 ; Huggins et al., 2008 ). Thus, the ideal context for instigating universal child depression prevention programs is the school environment.

School-based child and adolescent depression prevention programs.

Type: T, targeted; U, universal .

Table 5 outlines the most important child depression prevention programs carried out in the school context. They are all cognitive-behavioral programs implemented either by psychologists or teachers with specialist training, consisting of between 8 and 15 sessions. Only a few universal programs designed to prevent the symptoms of depression focus on younger children, since most are targeted mainly at the adolescent population (Gillham et al., 1995 ; Barrett and Turner, 2001 ; Farrell and Barrett, 2007 ; Essau et al., 2012 ; Gallegos et al., 2013 ; Rooney et al., 2013 ). Indeed, in the present review, only four universal child depression prevention programs were found that were aimed at a younger age group (between 8 and 12): the Penn Resiliency Program, FRIENDS, the Aussie Optimism Program, and FORTIUS (see Table 5 ).

As shown in the table, the results of the various programs outlined are not particularly positive, since on many occasions the effects (if there are any) are not sustained over time or are limited in scope (being dependent on who applies the program or on the sex of the participant, etc.). Nor is the distinction between universal and targeted programs particularly clear as regards their effects, since although targeted programs may initially appear to be more effective, their impact is not found to be sustained in the long term.

Greenberg et al. ( 2001 ) argue that researchers should explain whether their prevention programs focus on one or various microsystems (basically family and school), mesosystems or exosystems, etc. (following the model described by Bronfenbrenner, 1979 ), or are centered exclusively on the individual and his or her environment, since this will influence the results reported. These same authors conclude that programs focused exclusively on children and adolescents themselves are less effective than those which aim to “educate” subjects and bring about positive changes in their family and school environments.

As Calear and Christensen ( 2010 ) point out in their review, some authors suggest that the fact that some targeted programs are aimed at people with high levels of depressive symptoms entails a broader range of possibilities for change; however, this does not help us understand why these changes are not sustained over time. Thus, further research is required in this field in order to identify what specific components of those programs observed to be effective actually have a positive impact on the level of depressive symptoms, how these programs are developed, who implements them and whether or not their effects are sustained in the short, medium, and long term.

Clinical Treatments for Depression

In order to draft this section, a search was conducted for the most commonly-used therapies with proven efficacy for treating depression. The databases used were PubMed, Web of Science, Science direct, and Google Scholar. The key words used in the search were treatment, depression, child depression, and adolescent depression. A total of 30 bibliographic references were used in the drafting of this summary, including the major contribution made by The American Psychological Association's Society of Clinical Psychology (American Psychological Association, Society of Clinical Psychology (APA), 2017 ) regarding the most effective psychological methods for treating depression.

Although the World Health Organization (WHO) ( 2017 ) claims that prevention programs reduce the risk of suffering from depression, it has yet to be ascertained what type of programs and what contents are the most effective. The WHO also states that there are effective treatments for moderate and severe depression, such as psychological treatments (behavioral activation, cognitive behavioral therapy, and interpersonal psychotherapy) and antidepressant drugs (although it also warns of adverse effects), as well as psychosocial treatments for cases of mild depression. Moreover, a study conducted with adolescents by Foster and Mohler-Kuo ( 2018 ) found that the combination of cognitive-behavioral therapy and fluoxetine (antidepressant drug) was more effective than drug therapy alone.

The efficacy of treatment with antidepressants has been called into question for some years now. Iruela et al. ( 2009 ) claim that tricyclic antidepressants (imipramine, clomipramine, amitriptyline) are not recommended in childhood and adolescence since no benefits other than the placebo effect have been proven and furthermore, they generate major side effects due to their cardiotoxicity. They are therefore particularly dangerous in cases of attempted suicide. These same authors also advise against the use of monoamine oxidase inhibitors (MAOIs) due to dietary restrictions, interactions with other medication and the lack of clinical trials with sufficiently large groups which guarantee their efficacy. SSRIs or serotonergic antidepressants are the ones that have been most extensively studied in this population. The most effective is fluoxetine, the use of which is recommended in association with cognitive psychotherapy for cases of moderate and severe child depression.

On another hand, Wagner and Ambrosini ( 2001 ) analyzed the efficacy of pharmacological treatment in children and adolescents and stated that, at best, antidepressant therapy for depressed youth was moderately effective. Peiró et al. ( 2005 ) indicate that there is a great debate about the safety of selective serotonin reuptake inhibitors (SSRIs) in childhood. SSRIs, except for fluoxetine in the United States, have never been authorized by any agency for use in children or adolescents, mainly because of the risk of suicide to which they are associated. In 1991, the Food and Drugs Administration (FDA) claimed that there was insufficient evidence to confirm a causal association between SSRIs and suicide. Vitiello and Ordoñez ( 2016 ) conducted a systematic review of the topic and found more than 30 controlled clinical trials in adolescents and a few studies with children. Most studies found no differences between studies that administered drugs and those that used placebo, but they did find fluoxetine to be effective. They noted that antidepressants increased the risk of suicide (suicidal ideation and behaviors) compared to studies that had used placebos. The authors recommend using antidepressants with caution in young people and limiting them to patients with moderate to severe depression, especially when psychosocial interventions are not effective or are not feasible.

As regards the effectiveness of psychodynamic treatments, Luyten and Blatt ( 2012 ) advocate the inclusion of psychoanalytic therapy in the treatment of child, adolescent and adult depression. After conducting a review of both the theoretical assumptions of psychodynamic treatments of depression and the evidence supporting the efficacy of these interventions, these authors concluded that brief psychoanalytic therapy (BPT) is as effective in treating depression as other active psychotherapeutic treatments or pharmacotherapy, and its effects tend to be maintained in the longer term. They also observed that the combination of BPT and medication obtained better results than medication alone. Longer-term psychoanalytic treatment (LTPT) was found to be effective for patients suffering from chronic depression and co-morbid personality problems. Together, the authors argue, these findings justify the inclusion of psychoanalytic therapy as a first-line treatment in adult, child, and adolescent depression.

In a qualitative study carried out by Brown ( 2018 ) on parents' expectations regarding the recovery of their depressed children, a direct relationship was observed between said expectations and type of attachment. Parents who remained more passive and expected expert helpers to fix their child experienced reduced hope months after finishing the program. However, when parents changed their interactions with their child and adopted more positive expectations regarding their cure, they felt a more sustained sense of hope. Moreover, when parents themselves participated in therapy sessions, as part of their child's treatment, they felt greater hope and effectiveness in contributing to their child's recovery.

The American Psychological Association's Society of Clinical Psychology [American Psychological Association, Society of Clinical Psychology (APA), 2017 ] has published a list of psychological treatments that have been tested with the most scientific rigor and which, moreover, have been found to be most effective in treating depression. These treatments are as follows:

• – Self-Management/Self-Control Therapy (Kanfer, 1970 ). Depression is due to selective attention to negative events and immediate consequences of events, inaccurate attributions of responsibility for events, insufficient self-reinforcement, and excessive self-punishment. During therapy, the patient is provided with information about depression and taught skills they can use in their everyday life. This 10-session program can be delivered either in group or individual formats, at any age.
• – Cognitive Therapy (Beck, 1987 ). Individuals suffering from depression are taught cognitive and behavioral skills to help them develop more positive beliefs about themselves, others, and the world. Méndez ( 1998 ) argues that therapists working with depressed children should pursue three changes: (1) Learn to value their own feelings; (2) Replace behaviors which generate negative feelings with more appropriate behaviors; and (3) Modify distorted thoughts and inaccurate reasoning. The number of sessions varies between 8 and 16 in patients with mild symptoms. Those with more severe symptoms show improvement after 16 sessions.
• – Interpersonal Therapy (Klerman et al., 1984 ). García and Palazón ( 2010 ) identified four typical focal points for tension in depression, related to loss (complicated mourning), conflicts (interpersonal disputes), change (life transitions), and deficits in relations with others (interpersonal deficits), which generate and maintain a depressive state. It uses certain behavioral strategies such as problem solving and social skills training and lasts between 12 and 16 sessions in the most severe cases, and between 3 and 8 sessions in milder cases.
• – Cognitive Behavioral Analysis System of Psychotherapy (McCullough, 2000 ). This therapy combines components of cognitive, behavioral, interpersonal, and psychodynamic therapies. According to McCullough ( 2003 ), it is the only therapy developed specifically to treat chronic depression. Patients undergoing this therapy generate more empathic behaviors and identify, change and heal interpersonal patterns related to depression. Patients are recommended to combine the therapy with a regime of antidepressant medication.
• – Behavior Therapy/Behavioral Activation (BA) (Martell et al., 2013 ). Depression prompts sufferers to disengage from their routines and become increasingly isolated. Over time, this isolation exacerbates their depressive symptoms. Depressed individuals lose opportunities to be positively reinforced through pleasant experiences or social activities. The therapy aims to increase patients' chances of being positively reinforced by increasing their activity levels and improving their social relations. The therapy usually lasts between 20 and 24 sessions, with the brief version consisting of between 8 and 15 sessions.
• – Problem-Solving Therapy (Nezu et al., 2013 ). The aim is to enhance patients' personal adjustment to their problems and stress using affective, cognitive, and behavioral strategies. The therapy usually comprises around 12 sessions, although substantial changes are generally observed from the fourth session onwards. This therapy is widely used in primary care. It is an adaptation that is easy to apply in general medicine by personnel working in those contexts, and can be completed in around 6 weeks (Areán, 2000 ).

The treatments that, according to the American Psychological Association, Society of Clinical Psychology (APA) ( 2017 ), have modest research support and could be used with children are as follows:

• – Rational Emotive Behavioral Therapy (Ellis, 1994 ). This short-term, present-focused therapy works on changing the thinking which contributes to emotional and behavioral problems using an active-directive, philosophical and empirical intervention model. Using the A-B-C model (A: events observed by the individual; B: Individual's interpretation of the observed event; C: Emotional consequences of the interpretations made), the aim is to bring about the cognitive restructuring of erroneous thoughts, so as to replace them with more rational ones. The most commonly used techniques are cognitive, behavioral, and emotional.
• – Self-System Therapy (Higgins, 1997 ). Depression occurs as the result of the individual's chronic failure to achieve their established goals. During therapy, patients review their situation, analyze their beliefs and, on the basis of the results, alter their regulation style and move toward a new vision of themselves. Therapy generally consists of between 20 and 25 sessions.
• – Short-Term Psychodynamic Therapy (Hilsenroth et al., 2003 ). The aim of this therapy is to help patients understand that past experiences influence current functioning, and to analyze affect and the expression of emotion. The therapy focuses on the therapeutic relationship, the facilitation of insight, the avoidance of uncomfortable topics and the identification of core conflictual relationship themes. It is usually combined with pharmacological treatment to alleviate depressive episodes.
• – Emotion-Focused Therapy (emotion regulation therapy or Greenberg's experiential therapy) (Greenberg, 2004 ). According to Greenberg et al. ( 2015 ), this therapy combines elements of client-based practices (Rogers, 1961 ), Gestalt therapy (Perls et al., 1951 ), the theory of emotions and a dialectic-constructivist meta-theory. The aim is to create a safe environment in which the individual's anxiety is reduced, thereby enabling them to confront difficult emotions, raising their awareness of said emotions, exploring their emotional experiences in more depth and identifying maladaptive emotional responses. The therapy is delivered in 8–20 sessions.
• – Acceptance and Commitment Therapy (Hayes, 2005 ). This theory has become increasingly popular over recent years and is the contextual or third-generation therapy that is supported by the largest body of empirical evidence. It is based on a realization of the importance of human language in experience and behavior and aims to change the relationship individuals have with depression and their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Strategies are used to teach patients to decrease avoidance and negative cognitions, and to increase focus on the present. The aim is not to modify the content of the patient's thoughts, but rather to teach them how to change the way they analyze them, since any attempt to correct thoughts may, paradoxically, only serve to intensify them (Hayes, 2005 ).

Ferdon and Kaslow ( 2008 ), for their part, in a theoretical review of the treatment of depression in children and adolescents, concluded that the cognitive-behavioral-therapy-based specific programs of the Penn Prevention program meet the criteria to conduct effective interventions in children with depression. In adolescent depression, the cognitive-behavioral therapy and the Interpersonal Therapy–Adolescent seem to have a well-established efficacy. Weersing et al. ( 2017 ), in this same line, state that, although the efficacy of treatments in children is rather weak, cognitive-behavioral therapy is probably the most effective therapy. They also confirm that, in depressed adolescents, cognitive behavioral therapy, and interpersonal psychotherapy are appropriate interventions.

There are other studies also which focus on treatments for depression in childhood. For example, Crowe and McKay ( 2017 ) carried out a meta-analysis of the effects of Cognitive Behavioral Therapy (CBT) on children suffering from anxiety and depression, concluding that CBT can be considered an effective treatment for child depression. According to these authors, the majority of protocols for children have been adapted from protocols for adults, and the most common techniques are psychoeducation, self-monitoring, identification of emotions, problem solving, coping skills, and reward plans. Similarly, cognitive strategies include the identification of cognitive errors, also known as cognitive restructuring. In another meta-analysis conducted to analyze the efficacy and acceptability of CBT in cases of child depression, Yang et al. ( 2017 ) observed that, in comparison with the control groups that did not receive treatment, the experimental groups showed significant improvement, although they also pointed out that the relevance of this finding was limited due to the small size of the trial groups.

Another study carried out in Saudi Arabia concluded that student counseling in schools may help combat and directly reduce anxiety and depression levels among Saudi children and adolescents (Alotaibi, 2015 ).

Family-based treatment may also be effective in treating the interpersonal problems and symptoms observed among depressed children. The data indicate that the characteristics of the family environment predict recovery from persistent depression among depressed children (Tompson et al., 2016 ). In this sense, Tompson et al. ( 2017 ) compared the effects of a family-focused treatment for child depression (TCF-DI) with those of individual supportive psychotherapy among children aged 7–14 with depressive disorders. The results revealed that incorporating the family into the therapy resulted in a significant improvement in depressive symptoms, global response, functioning, and social adjustment.

To conclude this section, it can be stated that treatment for depression should be multifactorial and should bear in mind the personal characteristics of the patient, their coping strategy for problems, the type of relationship they have with themselves and the type of relationship they establish with their environment (friends, school, family, etc.). Thus, in order for the individual to attain the highest possible level of psychological wellbeing, attention should focus on both these and other related aspects.

Conclusions

The present review aims to shed some light on the complex and broad-ranging field of child and adolescent depression, starting with a review of the construct itself and its explanatory theories, before continuing on to analyze existing evaluation instruments, the main prevention programs currently being implemented and the various treatments currently being applied. All these aspects are intrinsically linked: how the concept is defined depends on the explanatory variables upon which said definition is based, and this in turn influences how we measure it and the variables we define as being key elements for its prevention and treatment.

It is interesting to note the low level of specificity of both the construct itself and the explanatory theories offered by child and adolescent psychology, which suggest that child depression can be understood on the basis of the adult version of the pathology. This may well be a basic error in our approach to depression among younger age groups. The fact that universal prevention programs specifically designed for children are obtaining only modest results may indicate that we have perhaps failed to correctly identify the key variables involved in the genesis and maintenance of child and adolescent depression.

The review of current child and adolescent depression prevention programs revealed that the vast majority coincide in adopting a cognitive-behavioral approach, with contents including social skills and problem solving training, emotional education, cognitive restructuring, and strategies for coping with anxiety. These contents are probably included because they are important elements in the treatment of depression, as shown in this review. But if their inclusion is important and effective in the treatment of depression, why do they not seem to be so effective in preventing this pathology? There are probably many factors linked to prevention programs which, in one way or another, influence their efficacy: who implements the program and what prior training they receive; the characteristics of the target group; group dynamics; how sessions are run; how the program is evaluated; and if the proposed goals are really attained (e.g., training in social skills may be key, but perhaps we are not training students correctly). Moreover, in universal prevention programs carried out in schools, the intervention focuses on students themselves rather than adopting a more holistic approach, as recommended by certain authors such as Greenberg et al. ( 2001 ). But, if we accept that depression is multifactorial and that risk and protection factors may be found not only in the school environment but also in the family and social contexts, should prevention not also be multifactorial?

There is therefore still much work to be done in order to fully understand child and adolescent depression and its causes, and so design more effective evaluation instruments and prevention and treatment programs. Given the important social and health implications of this disorder, we need to make a concerted effort to further our research in this field.

Author Contributions

MG designed the study and wrote the protocol. EB and JJ conducted literature review and provided summaries of previous research studies, and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. The Research Project was sponsored by the Alicia Koplowitz Foundation, with grant number FP15/62.

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