J. S. S. College of Nursing

J. S. S. COLLEGE OF NURSING

1ST MAIN, SARASWATHIPURAM, MYSORE

SYNOPSIS SUBMISSION

Ms. THUSHARA VASUKUTTAN

1ST YEAR M. Sc NURSING J. S. S. COLLEGE OF NURSING 1ST MAIN, SARASWATHIPURAM MYSORE - 570009

GUIDE:

Dr N V MUNINARAYANAPPA

PROFESSOR AND HOD PSYCHIATRIC NURSING P.G. STUDIES COORDINATOR CUM VICE PRINCIPAL J. S. S. COLLEGE OF NURSING 1ST MAIN, SARASWATHIPURAM MYSORE – 570009

BATCH: 2010 – 2012

1 PROFORMA FOR REGISTRATION OF

SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE Ms. THUSHARA VASUKUTTAN AND ADDRESS 1ST YEAR MSc NURSING (IN BLOCK LETTERS) JSS COLLEGE OF NURSING 1ST MAIN, SARASWATHIPURAM MYSORE-570009. 2. NAME OF THE INSTITUTION JSS COLLEGE OF NURSING MYSORE 3. COURSE OF STUDY AND 1ST YEAR M.Sc NURSING, SUBJECT PSYCHIATRIC NURSING 4. DATE OF ADMISSION TO THE 26.05.2010 COURSE 5. TITLE OF THE TOPIC “ A Descriptive And Comparative Survey Of Depression And Suicide Risk Among Residential And Non Residential Adolescent Girls Of Selected Educational Institutions Of Mysore”

2 6. BRIEF RESUME OF THE INTENDED WORK

6.0 INTRODUCTION

Adolescence is a transition period from childhood to adulthood and is characterized by a spurt in physical, endocrinal, emotional, and mental growth, with a change from complete dependence to relative independence. The period of adolescence for a girl is a period of physical and psychological preparation for safe motherhood. As the direct reproducers of future generations, the health of adolescent girls influences not only their own health, but also the health of the future population. Almost a quarter of India's population comprises of girls below 20 years.1

Numerous factors may predispose adolescent girls to depression. These include the increase in hormones associated with puberty, changes in body shape and emerging sexual identity, family stressors such as divorce and peer pressure. Separation associated with leaving for college is another stressor which may predispose to depression. Adolescents who develop depression often have recurrences in adulthood and a more severe course. Early detection is essential to minimize recurrences and morbidity from the illness.2

Adolescents who have low self esteem are highly self critical, and who feels little sense of control over negative events are particularly at risk to become depressed when they experience stressful events. Adolescent girls are twice as likely as boys to experience depression. In adolescents depressed mood is common because of normal process of maturing, independence conflicts with parents, failure at school, death of a friend or relative, influence of sex hormones, child abuse, any illness, family history of depression etc. There are also associated symptoms like difficult concentration, irritable mood, memory loss, excessive sleeping during day time, fatigue, loss of interest in activities, temper etc.3

School depression is a type of depression that occurs in school going children. Number of students are affected by depression every year and due to the age group that can be affected by depression it is important at the first sign to have the child diagnosed. Following are the symptoms of school depression viz, inability to concentrate while studying, irritation at school without proper reason , poor apetite, sleeping problems which consists of too little sleep or too much sleep, little interest in extracurricular activities, nervousness or hesitation with out any reason, fatigue, negative thoughts and poor self confidence. Some of the causes that may lead to depression in school children are extra pressure of parents and teachers to perform well in examination, too much expectation from parents, book worms, low self confidence, fear of bad performance in studies, no friends, and inferiority complex4.

3 Depression is a common disorder among children (less than 18 years). Approximately 5% of children at any one time may suffer from serious depression. The prevalence of depression increases with age, especially after the onset of puberty. There is no gender related difference in the prevalence of depression among pre-adolescent children. However, onset of puberty is associated with a marked increase in the rate of depression among females, with a female to male ratio of 2:1. It is often during adolescence that depression first manifests itself in girls, and for the first time girls outnumber boys 2:1 in prevalence of the illness. It is estimated that 4.7% of the teenage population suffers from depression. Common symptoms of adolescent depression are irritability, hopelessness, anhedonia, changes in sleep and appetite, academic decline, reduced energy, reduced social interactions, somatic symptoms, and suicidal ideation. Depression in children and adolescents is associated with an increased risk of suicidal behaviours. Depression and suicide can destroy the very essence of a teenager’s personality, causing an overwhelming sense of sadness, despair, or anger.2

Suicide is the act of a human being intentionally causing his or her own death. Suicidal ideation in adolescents is a sign of severe distress and is predictor of poor overall functioning in later life. Suicide is often committed out of despair, or attributed to some underlying mental disorder which includes depression, panic disorder, alcoholism and drug abuse, lack of parent support, negative life events, diminished family cohesion5. Depression is a serious problem that impacts every aspect of a teen’s life. Left untreated, teen depression can lead to problems at home and school, drug abuse, self-loathing—even irreversible tragedy such as homicidal violence or suicide. It comes to no surprise to discover that adolescent depression is strongly linked to teen suicide. An alarming and increasing number of teenagers attempt and succeed at suicide. In depressed teens who also abuse alcohol or drugs, the risk of suicide is even greater. The reasons behind a teen's suicide or attempted suicide can be complex. Although suicide is relatively rare among children, the rate of suicides and suicide attempts increases tremendously during adolescence.6

Parents should be particularly aware of the risk of depression in children who have had long- term or chronic illnesses, who have been abused or neglected, have experience a recent trauma, or lost a loved one. The National Institute of Mental Health also reports that teenage girls are more likely to develop depression than teenage boys (NIMH, 2000).6

Fortunately teenage depression and suicide risk can be treated, and as a concerned parent, nurse teacher or friend. By learning the symptoms of depression and suicide risk and expressing concern when spotting the warning signs. Numerous studies have examined the incidence of suicidal thoughts and suicide attempts by age, race, educational level, family back ground, religion, socio economic status, sexual orientation and other demographic variables.3 The nurses must make it clear to adolescents that suicidal behaviour is not confidential and person must be told. The nurses should

4 explore the following areas like seriousness of attempts, mental status of adolescents; extend of environmental stress and likelihood of repeated suicide attempts.

6.1 NEED FOR THE STUDY

Adolescent girl depression is quite common among the teen years for many females. Although these girls seem to be more common than in boys according to statistics, it may only be the case because girls tend to seek out help more frequently than do boys.6 Depressive disorders are identified by the World Health Organization as priority mental health disorder of adolescence because of its high prevalence, recurrence, ability to cause significant complications and impairment. Across the globe, the lifetime prevalence for major depression in adolescence is 15% to 20% with a recurrence rate of 60–70% often resulting in suicide, school dropout, pregnancy, substance abuse, progressing in to adult depression, functional disability and significant impairment.7

Population studies show that at any one time between 10 and 15 percent of the child and adolescent population has some symptoms of depression. The prevalence of the full-fledged diagnosis of major depression among all children ages 9 to 17 has been estimated at 5 percent. Estimates of 1-year prevalence in children range from 0.4 and 2.5 percent and in adolescents, considerably higher. The prevalence of depression among adolescents among primary-care paediatric care settings in India is 11.2% and recognizing adolescent depression becomes a responsibility of paediatricians. However, up to 50% of depressed adolescents are not diagnosed in primary-care settings.8

A number of epidemiological studies have reported that up to 2.5 percent of children and up to 8.3 percent of adolescents in the U.S. suffer from depression. An NIMH-sponsored study of 9- to 17-year-olds estimates that the prevalence of any depression is more than 6 percent in a 6-month period, with 4.9 percent having major depression. Studies indicate that one in five children have some sort of mental, behavioral, or emotional problem, and that one in ten may have a serious emotional problem. Among adolescents, one in eight may suffer from depression. Of all these children and teens struggling with emotional and behavioral problems.9

A cross-sectional study involving a predominantly adolescent school population was conducted to determine the prevalence and clinical characteristics of depression in adolescents in the city of Mersin, Turkey. The prevalence of depression according to the CBDI (cut-off point: 19) was found to be 12.55% in this study group, with a significantly higher prevalence of depression in girls than in boys.10

5 A cross sectional study of prevalence of depression in adolescent students of a public school in Pune showed that 15.2% of school-going adolescents were found to be having evidence of distress (GHQ-12 score e"14); 18.4% were depressed (BDI score e"12); 5.6% students were detected to have positive scores on both the instruments. Economic difficulty, physical punishment at school, teasing at school and parental fights were significantly associated with higher BDI scores, indicating depression. The study highlights the common but ignored problem of depression in adolescence. The study recommends that teachers and parents be made aware of this problem with the help of school counselors so that the depressed adolescent can be identified and helped rather than suffer silently.11

Depression in children and adolescents is associated with an increased risk of suicidal behaviours. The consequences of untreated depression can be increased incidence of depression in adulthood, involvement in the criminal justice system, or in some cases, suicide. Adolescent suicide is now responsible for more deaths in youths aged 15 to19 than cancer Suicide is the third leading cause of death among young people ages 15 to 24. Even more shocking, it is the sixth leading cause of death among children ages 5-14.5

The age-specific mortality rate from suicide was 1.6 per 100,000 for 10- to 14-year-olds, 9.5 per 100,000 for 15- to 19-year-olds. The age-specific mortality rate from suicide was 1.6 per 100,000 for 10- to 14-year-olds, 9.5 per 100,000 for 15- to 19-year-olds (i.e., about six times higher than in the younger age group.8

The highest suicide rate in the world has been reported among young women in South India by a new study. According to the World Health Organization, as it brings to light Asia's suicide problem. The suicide rate in India is 10.3. In the last three decades, the suicide rate has increased by 43%. The average suicide rate for young women aged between 15 to 19 living around Vellore in Tamil Nadu was 148 per 100,000. This compares to just 2.1 suicides per 100,000 in the same group in the UK. India’s youth suicide rate in 2005 – 2007 was 6.9 per 100,000 between youths aged 15 to 24. Substantially lower than rate of 9.4 in 1995-1997.12

In 2004, an estimated 14.0 percent of adolescents aged 12 to 17 (approximately 3.5 million adolescents) had experienced at least one major depressive episode (MDE) in their lifetime, and an estimated 9.0 percent (2.2 million adolescents) experienced at least one MDE in the past year. Rates of past year MDE varied by age group. Adolescents aged 16 or 17 were more than twice as likely to report past year MDE as those aged 12 or 13 (12.3 vs. 5.4 percent).13

Numerous studies have examined the incidence of suicidal thoughts and suicide attempts by age, race, educational level, family background, religion, socioeconomic level, sexual orientation, and other demographic variables. According to the Surgeon General, a youth commits suicide every 6 two hours in our country. Suicide claims more adolescents than any disease or natural cause. Adolescents now commit suicide at a higher rate than the national average of all ages. Suicide rates for adolescent females have increased between two to three fold. Problem turns out to be depression, it still needs to be addressed, the sooner the better.8

A cross sectional study was conducted on school students to find out stress, psychological health, and presence of suicidal ideas in Chandigarh. Results revealed that the students with academic problems and unsupportive environment at home perceived life as a burden and had higher rate of suicide ideation.14

A longitudinal study was conducted to evaluate the influence of frequent change of residence on risk of attempted and completed suicide among children and adolescents. Researchers found out that frequent change of residence may induce stress among children’s and therefore increase their risk of suicidal behaviour. More research is needed to explore this association.15

Left untreated, teen depression can lead to problems at home and school, drug abuse, self- loathing—even irreversible tragedy such as homicidal violence or suicide. It comes to no surprise to discover that adolescent depression is strongly linked to teen suicide. There are few studies conducted in India comparing residential and non residential adolescent girls and how these girls can be helped. So the researcher finds it relevant from the above described facts and findings to take up the study. Conducting research in this area enriches nurses’ awareness more about depression and suicide risk and their prevention strategies. So the investigator aimed this study to explore depression and suicide risk among residential and non residential adolescent girls in India.

6.2 REVIEW OF LITERATURE

Suicide is the third leading cause of death among adolescents and teenagers. According to the National Institute for Mental Health (NIMH), about 8 out of every 100,000 teenagers committed suicide in 20007. For every teen suicide death, experts estimate there are 10 other teen suicide attempts. In a survey of high school students, the National Youth Violence Prevention Resource Center found that almost 1 in 5 teens had thought about suicide, about 1 in 6 teens had made plans for suicide, and more than 1 in 12 teens had attempted suicide in the last year. As many as 8 out of 10 teens who commit suicide try to ask for help in some way before committing suicide, such as by seeing a doctor shortly before the suicide attempt. In the last three decades, the suicide rate has increased by 43%.16

A pilot study conducted to detect suicide risk in adolescent and adults seeking treatment in an emergency department. An advanced practice nurse verbally administered the RSQ to a convenience

7 sample of 104 patients ages 12 to 82. Psychometric analysis was used. Study showed approximately 30% all patients who participated screened positive for suicide risk. Nurses in all health care settings need to initiate suicide screening and implement nursing interventions directed towards suicide prevention.17

A study done to find out relationships between adolescents' self-reports of perceived parental style, pessimism, and the spectrum of suicidal behavior in a sample of Australian high school students with mean age 15.8. Three hundred and seventy students completed questionnaire. Multiple regression analysis was adopted. This study examined a possible relationship between negative perceptions of parental style and adolescent suicidal behavior being mediated through a sense of hopelessness. Results showed that there was a high level of suicidal behavior reported, with suicidal adolescents perceiving their parents to be significantly more critical, less caring and more overprotective.18

A study investigated the mechanisms underlying peer contagion of depressive symptoms in adolescence. Five annual measurements of data were gathered from a large community-based network of adolescents with mean age of 14.3 years. Results showed that, after controlling for selection and deselection of friends on the basis of depressive symptoms, peers' depressive symptoms predicted increase in adolescents' depressive symptoms over time. Results suggest that peers' depressive symptoms place adolescents at risk of developing depressive symptoms through increasing in failure anticipation.19

A study was conducted to investigate whether yearly prevalence rates of adolescent suicidal episodes follow different patterns by sex. A longitudinal categorical data was used with a sample of 1248 aged between 11 to 19. Multiple-group growth models revealed that peak levels of past-year ideation and plans occurred during mid adolescence for girls, but slowly increased through late adolescence for boys. Results found that prevalence patterns for attempts were very similar for boys and girls, with both increasing through mid adolescence and then declining, although girls' risk declined slightly more rapidly. This information may help alert gatekeepers to developmental periods during which boys and girls are particularly vulnerable to suicide-related experiences, and also may help inform the timing of preventive efforts.20

A longitudinal study was conducted to investigate the association between childhood adversities, interpersonal difficulties during adolescence, and suicide attempts during late adolescence or early adulthood. A community sample of 659 families from Upstate New York was interviewed in 1975, 1983, 1985 to 1986, and 1991 to 1993. During the 1991-1993 interview, the mean age of the offspring was 22 years. Results indicated that maladaptive parenting and childhood maltreatment

8 were associated with an elevated risk for interpersonal difficulties during middle adolescence and for suicide attempts during late adolescence or early adulthood. These interpersonal difficulties may play a pivotal role in the development of suicidal behaviour. Youths who are at an elevated risk for suicide may tend to be in need of mental health services that can help them to cope with an extensive history of profound interpersonal difficulties, beginning in childhood and continuing through adolescence.21

A study done to assess the specific influence of family relationship difficulties, over and above the effect of depression, on the risk of adolescent suicidal behaviour. The study was based on the clinical data summaries, “item sheets,” of children and adolescents who attended the Maudsley Hospital during the 1970s and 1980s.284 cases of suicidal behaviour , defined as suicidal ideas, attempts, opr threats were compared with 3054 non suicidal controls with mean age 13.9, using stepwise logistic regression controlling for age and sex. They concluded the study as although depression is the largest single risk factor for teenage suicidal behaviour, family relationship difficulties make a significant independent contribution to this risk.22

A study was done to examine the relationship between family functioning and adolescent suicidal ideation and suicide attempts. Participating adolescents included psychiatric in patients who had attempted suicide with a sample of 35, high school students reporting suicidal ideation with a sample of 33, non suicidal psychiatric inpatients with a sample of 29, and non suicidal high school students with a sample of 37. Family assessment measure was used to assess adolescents perception of family functioning. Results showed that the suicidal psychiatric inpatients and the suicidal high school students did not differ in their perceptions of family functioning and mother-adolescent relationships. However, both suicide groups reported more distress and family dysfunction than did the no suicidal high school students. Perceived family functioning and mother-adolescent relationships were significantly correlated with levels of depression, hopelessness, and self-esteem. Hence researchers concluded as family functioning is important to consider when assessing and treating adolescents for suicidal behaviour.23

A case control study was designed to examine the environmental, social, and familial characteristics of large representative sample of child and adolescents. Results revealed there was a significant independent impact of the psychosocial factors on increasing suicide risk. The most notable risks were derived from school problems, a family history of suicidal behaviour, poor parent child communication, and stressful life events. Sex, ethnicity and age modified the relationships of

9 few of the psychosocial factors. Results showed socioenvironmental circumstances add significantly to a teenager’s risk of suicide.24

A study was conducted to find relationship between adolescent suicidal behaviour and life events in child hood and adolescence. The researchers compared adolescent suicide attempters with both depressed and non depressed adolescents who never attempted suicide with respect to life events that happened in two periods: childhood and adolescence. Using a semi structured interview, the authors gathered life event data about childhood and adolescence from three groups of adolescents:48 suicide attempters, 66 depressed adolescents who never made suicide attempts and 43 non depressed adolescents who attempted suicide differed from both of the other group. Results indicated that the group of adolescents who attempted suicide differed from both of the other groups in that they had experienced more turmoil in their families, starting in childhood and not stabilizing during adolescence. During adolescence, they were more often sexually abused. During the last year before the attempt, further social instability, such as changes in residence and having to repeat a class, occurred.25

6.3 STATEMENT OF THE PROBLEM

“A descriptive and comparative survey of depression and suicide risk among residential and non residential adolescent girls of selected educational institutions of Mysore.”

6.4 OBJECTIVES

1. To assess and compare the levels of depression among residential and non residential adolescent girls of selected educational institutions.

2. To assess and compare suicidal risk among residential and non residential adolescent girls of selected educational institutions.

3. To find relationship between depression score and suicide risk score among residential and non residential adolescent girls of selected educational institutions.

4. To find association of levels of depression and suicide risk among residential and non residential adolescent girls with their selected personal variables viz, age , religion , parental education, parental occupation , type of family , family monthly income , number of children’s in family , frequent change of residence , number of close friends, free or paid residential school, subjects studying and hobbies .

6.4.1 CONCEPTUAL/THEORETICAL FRAME WORK

Conceptual frame work based on Roy’s Adaptation Model .

6.4.2 OPERATIONAL DEFINITIONS

1. Depression:

Depression is a common mental disorder that presents with depressed mood , loss of interest or pleasure , feeling of guilt or low self worth , disturbed sleep or apetite , poor energy and poor concentration. (WHO definition).26

In this study, depression refers to a state of persistent sadness, loss of selfworth, discouragement and loss of interest in activities , affecting eating and sleep pattern , the way

one feels about oneself and way one thinks about things as expressesed by adolescent girls in response to items in Becks depression inventory and expressed as depression scores.

2. Suicide Risk:

Risk is the possibility that something unpleasant or dangerous might happen.26

In this study, suicide risk is a state where adolescent girls are prone for attempting certain activities intentionally which can lead to their death in response to items in suicide risk assessment scale and expressed as suicide risk scores.

3. Residential Adolescent Girls:

Residential involving living at the place where students are studying.26

11 In this study, it refers to those girls who are in age group of 15 to 18 years studying in various educational institutions and staying in hostels.

4. Non Residential Adolescent Girls:

Non residential involves where students do not live at place where they study.26

In this study, it refers to those girls who are in age group of 15 to 18 years studying in various educational institutions coming from their home.

5. Educational Institutions:

An institution dedicated to education.26

In this study, it refers to the place where residential and non residential adolescent girls are studying for pre university for pursuing their studies.

6.5 HYPOTHESES

The following hypotheses are formulated for the study and will be tested at 0.05 level.

H1: There will be significant difference in the mean score of depression among residential and non residential adolescent girls of selected educational institutions.

H2: There will be significant difference in mean score of suicide risk among residential and non residential adolescent girls of selected educational institutions.

H3: There will be significant relationship between the depression scores and suicide risk scores among residential and non residential adolescent girls of selected educational institutions.

12 H4: There will be significant association of levels of depression and suicidal risk among residential and non residential adolescent girls of selected educational institutions with their selected personal variables viz., age, religion, parental education, parental occupation, type of family, family monthly income, number of children’s in family, frequent change of residence, number of close friends, free or paid residential school, subjects studying and hobbies.

6.6 ASSUMPTIONS

Assumptions of the study are:

1. Adolescent period is a transitional phase in which girls have to cope with many demands like bodily changes, self image, academic performance, peer group acceptance and they can affect psychological health.

2. Adolescent girls who are away from home and studying at residential educational institutions have to deal with separation from loved ones, adjust to new educational environment, meet parental expectations, teachers expectations. These factors may result in stress beyond their coping leading to depression and suicidal risk.

6.7 DELIMITATIONS

The study is delimited to institutions who are not willing to give permission to conduct the study.

7.0 MATERIALS AND METHODS

RESEARCH APPROACH/DESIGN

Exploratory comparative survey will be used.

Schematic Representation of Research Design

Samples Description and Comparison 13 Residential Description and Adolescent comparison of Girls depression among residential and non Depression residential adolescent and Suicide girls Risk Inference

Non Description and Residential comparison of suicide Adolescent risk among residential Girls and non residential adolescent girls

VARIABLES OF STUDY

Study variables: depression and suicide risk among residential and non residential adolescent girls.

Extraneous variables: refers to personal variables viz. age, religion, parental education, parental occupation, type of family, family monthly income, number of children’s in family, frequent change of residence, number of close friends, free or paid residential school, subjects studying and hobbies.

7.1 SOURCES OF DATA

SETTING

The study will be conducted in selected educational institutions of Mysore.

POPULATION

Population of present study comprises of adolescent girls

14 7.2 METHOD OF DATA COLLECTION

(INCLUDING SAMPLING PROCEDURE IF ANY)

SAMPLE

Sample of present study consists of residential and non residential adolescent girls of selected educational institutions.

SAMPLING CRITERIA

A) Inclusion Criteria

Adolescent girls who are:

1. Between age group of 15- 18years 2. Available during the period of data collection 3. Willing to participate in the study 4. Able to comprehend and communicate in either Kannada or English. 5. And Parental consent.

B) Exclusion Criteria

1. The students who are not present at time of data collection. 2. The students who are sick at the time of data collection.

SAMPLING TECHNIQUE

Simple random sampling technique will be adopted to select the sample.

SAMPLE SIZE

. Sample size comprises of 120 adolescent girls (N=120) 15 . 60 residential adolescent girls (n1=60)

. 60 non residential adolescent girls (n2=60)

METHOD OF DATA COLLECTION

. Approval from authority

. Select sample as per criteria and obtain informed consent

. 60 residential and 60 non residential girls will respond to standard scale

. Collect data as per plan

. Becks depression inventory will be used to assess the levels of depression.

. Becks hopelessness scale will be used to assess the suicide risk.

PLAN OF DATA ANALYSIS

A. DESCRIPTIVE STATISTICS

. Frequency and percentage will be used to compute the demographic variables.

. Mean, median, standard deviation will be used to describe and compare depression and suicide risk among residential and non residential adolescent girls.

B. INFERENTIAL STATISTICS:

. Independent ‘t’ test will be used to compare levels of depression and suicide risk among residential and non residential adolescent girls

. Coefficient of correlation will be used to find the relationship between levels of depression and suicide risk among residential and non residential adolescent girls

. Chi-square will be used to find association between levels of depression and suicide risk among residential and non residential adolescent girls with their selected personal variables.

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so, please describe briefly

7.4 Has ethical clearance been obtained from your institutions in case of 7.3

8.0 BIBLIOGRAPHY

1. Anil K Agarwal and Anju Agarwal. A Study of Dysmenorrhea During Menstruation in Adolescent Girls. Indian J Community Med. January2010; 35(1): 159–164.

2. Facts about Depression in Children and Adolescents. university of Michigan depression centre. Available at http://www.med.umich.edu/depression/caph.htm .

3. Teen depression. A guide for parents and teachers. Available at http://www.freeessays.cc/ db/39/pk024.shtml

4. Depression treatment remedies- help yourself to overcome and cure depression. Available at http://www.happymoods.info/school-depression

5. Gail W Stuart. Principles and practice of Psychiatric nursing. 9th Ed. Noida:Mosby publishers. 2009;674-675

6. Statistics - Adolescent Depression. About teen depression. Available at http://www.about- teen-depression.com/depression-statistics.html

7. Depression and Suicide in Children and Adolescents. Mental Health: A report of surgeon general. Available at http://www.surgeongeneral.gov/library/mentalhealth / chapter3/ sec5. html

8. Depression in Children and Adolescents. A Fact Sheet for Physicians. Available at http://www.athealth.com/Consumer/disorders/ChildDepression.html

17 9. Fevziye Toros. N. Gamsiz Bilgin, R. Bugdayci, T. Sasmaz, O. Kurt and H. Camdeviren. Prevalence of depression as measured by the CBDI in a predominantly adolescent school population in Turkey. European Psychiatry. August 2004;19(5):264-271.

10. Vivek Bansal, Sunil Goyal and Kalpana Srivastava. Study of prevalence of depression in adolescent students of a public school. Indian Psychiatry Journal. 2009;18(1):43-46.

11. Vijaya kumar. Indian research on suicide. Indian journal of Psychiatry 2010 September 2010;52(7):291-296. Available at www.indianjpsychiatry.org

12. National survey on drug use and health report. Available at http://oas.samhsa.gov/2k5/youthDepression/youthDepression.htm.

13. B S Chavan and Priti Arun. Stress and suicidal ideas in adolescent students in Chandigarh. Indian journal of medical science July 2009;63(7):281-7. Available at www.indianjmedsci.org

14. Qin P, Mortensen PB, Pedersen CB. Frequent change of residence and risk of attempted and completed suicide among children and adolescents. Archieves of general psychiatry June2009;66(6):628-632. Available at www.nibi.nlm.nih gov/pubmed

15. Epedemiology of suicide. Available at http://en.wikipedia.org/wiki/epidemiology of suicide

16. Victoria N Folse, Katie N Eich, Amy M Hall, Joan B Ruppman. Detecting suicide risk in adolescents and adults in an emergency department. Psychsocial nursing and mental health services March 2006;44(3). Available at www.jpnonline.com

17. Allison S Pearce C, Martin C, Miller K, Long R. Parental influence,pessimism and adolescent suicidality. Archieves of suicidae research March 1995;1(4):229-242,. Available at www.priory.com

18. Zalk MH, Kerr M, Branje SJ, Stattin H, Meeus WH. Peer contagion and adolescent depression:the role of failure anticipation. Journal of child and adolescent psychology November2010;1;39(6):837-848. Available at www.nibi.nlm.nih.gov/pubmedwww.nibi. nlm.nih.gov/pub med

19. Boeninger DK, Masyn KE, Feldman BJ, Conger KD. Sex differences in developmental trends of suicide ideaion, plans and attempts among European American adolescents. Suicide life threatening behaviours October 2010;40(5):451-464. Available at www.pubmed.com

18 20. Jeffery G Johnson, Patricia Cohen et al. Childhood adversities, interpersonal difficulties and risk for suicide attempts during late adolescence and early adulthood. Archieves of general psychiatry August2002;59(8):741-749. Available at http://archpsye ama_assn.org

21. Chris Hollies. Depression, family environment and adolescent suicidal behavior. Journal of American academy of child and adolescent psychiatry May 1996;35(5):622-630. Available at http://www.jacap.com

22. Dalia M Adams MA, James C, Kim L Lenhert. Perceived family functioning and adolescent suicidal behavior. Journal of American academy of child and adolescent psychiatry May 1994;33(4):498-507. Available at http://www.jacap.com

23. Madelyn S Gould, Prudence Fisher, Michal Parides, Michael Flory, David Shaffer. Psychosocial risk factors of child and adolescent completed suicide. Archieves of general psychiatry December 1996;53(12):1155-1162. Available at http://archpsye. ama_assan.org

24. EJ de Welde, I C Keinhoist, RF Diekstra, WH Wolters. The relationship between adolescent suicidal behavior and life events in childhood and adolescence. American journal of psychiatry. January1992;149:45-50. Available at http://ajp.psychitryonline. org

25. Mcmillandictionary.com. Available at http://www.mcmillandictionary.com

26. The free dictionary. Available at http://www.thefreedictionary.com

9.0 SIGNATURE OF THE CANDIDATE 19 10.0 REMARKS OF THE GUIDE

RECOMMENDED AND FORWARDED

11.0 NAME AND DESIGNATION OF GUIDE (in block letters)

Dr. N. V. MUNINARAYANAPPA PROFESSOR AND HOD PSYCHIATRIC NURSING P.G. STUDIES COORDINATOR CUM VICE PRINCIPAL J.S.S COLLEGE OF NURSING, I MAIN, SARASWATHIPURAM, MYSORE.

11.2 SIGNATURE

11.3 HEAD OF THE PSYCHIATRIC NURSING DEPARTMENT

Dr. N. V. MUNINARAYANAPPA PROFESSOR AND HOD PSYCHIATRIC NURSING P.G. STUDIES COORDINATOR CUM VICE PRINCIPAL J.S.S. COLLEGE OF NURSING, I MAIN, SARASWATHIPURAM, MYSORE.

11.4 SIGNATURE

12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL:

RECOMMENDED AND FORWARDED

Dr. BHARTI. M. PROFESSOR AND PRINCIPAL J.S.S COLLEGE OF NURSING, I MAIN, SARASWATHIPURAM, MYSORE.

12.2 SIGNATURE