Counselling and Psychotherapeutic Interventions for Adolescent Depression in Nigeria

Counselling and Psychotherapeutic Interventions for Adolescent Depression in Nigeria

Sabina Nwakaego Obi, PhD

Department of Arts and Social Science Education (Guidance and Counselling Unit), Lead City University, Ibadan, Nigeria

DOI: https://dx.doi.org/10.47772/IJRISS.2023.71047

Received: 30 August 2023; Revised: 12 September 2023; Accepted: 16 September 2023; Published: 20 October 2023

ABSTRACT

The problem of adolescent depression among students in Nigeria is quite disheartening because young people are expected to have a high level of quality of life and mental wellness. Observably, adolescent depression among teenagers in schools co-exists with some factors, and this even makes the bad situation worse. Substance abuse, traumatic childhood experiences, HIV/AIDs and other STIs associated with risky sexual behaviours, internet addiction, marital problems of parents, bad models and health challenges, including disabilities are seen to co-exist with adolescent depression. Consequently, there can be students’ academic failure or poor academic performance, school dropout, health and wellness problems among school students, poor quality of school life, non-suicidal self-injury, suicidal ideation, and suicide. Counselling and psychotherapeutic interventions can assist adolescents to develop high level of subjective wellbeing, overall health and wellness, optimistic life view, re-decision, hope, self-identity and future career aspirations. The psychodynamic theory of depression was used to explain adolescent depression in Nigeria. Findings of some empirical studies were reviewed narratively to search out prevalence of adolescent depression in Nigeria. Finally, the paper highlighted mental health counselling and psychotherapeutic interventions for the reduction of adolescent depression among school students towards their personal and social adjustment in Nigeria.

Keywords: Adolescent depression, wellness, mental health counselling, students in Nigeria

INTRODUCTION

Adolescent depression which is a mental health issue is seen to affect students in schools in Nigeria. The prevalence rate is quite worrisome because typically, adolescents are expected to have a very high level of psychological well-being, happiness, hope and assurance of a bright future. The consequences of mental health challenges are disastrous as many believe there is no permanent cure, but management of the particular mental health problem. The perception of people with mental health condition in a country like Nigeria is even not helping matters. There is the belief in mental health challenges running in the blood line of family members, transferable to others in the environment, incurable, with possible re-occurrence, and attachment to demonic forces. When young people like adolescents in schools are diagnosed of adolescent depression, many thoughts that readily come to mind is, what can cause this? at what age? And so many other questions. Culture seems to play roles in perception, diagnoses and management of adolescent depression in a developing country like Nigeria. The importance of culture has been recently emphasised by Othman et al. (2022), where they submitted that there is a risk that adolescent depression services will not be utilised in low- and middle-income countries (including Nigeria) if initiatives are not culturally compelling. To the authors, culture is so important especially in low- and middle-income countries, where 90% of the world’s adolescents live. To match increased efforts for adolescent depression services in these countries, the socio-cultural environment must be used as a leverage. Similarly, Gibbons and Poelker (2019) identified the role of culture in defining adolescence, hence adolescent mental health services must consider the cultural context of clientele.

Adolescent depression among school students in the present time may not be unconnected with the nature of family life and societal happenings. From clear observations, family life dynamics characterizes the present time. Family time, quality parent-children relations are seen to be declining, with many parenting over focusing on pursuit of means of livelihood to the detriment of spending time with their children. Many young people, especially adolescents may be growing up without socio-emotional support from their parents. Family cohesion has observably waned, as many families are disintegrated, and communication is lacking which could lead to each family member pursuing their own interests. George and Upkong (2013) submitted that many Nigerian families are undeniably troubled, as a lot of families (husbands, wives and children) can best be described as neighbours, living under the same roof, without familial interpersonal interaction. From the foregoing, researchers (Effiong & Usoroh, 2020) have recommended that parents should create a favourable home climate that could trigger openness between them and adolescents to enhance understanding of prevalent needs, challenges and prospects. Further, the researchers recommended that parents should create time for their adolescent children to help attend to their educational, social, emotional and health and psychological needs (Effiong & Usoroh, 2020).

It is a fast-paced world now, with people trying to catch up with the ever changing and dynamic nature of the society. Issues of globalisation, civilisation, modernisation and influx of the western culture continue to influence the traditional Nigerian society, many families seem to be adopting more, the individual pattern of living instead of the communal lifestyle of Nigerians. The individual lifestyle could make each person to face squarely their own life, without trying to look out for another person. Whereas the communal lifestyle features in most cases, care and concern for others and being one’s brother’s keeper. Unfortunately, if people adopt individualistic lifestyle more, the young people in such an environment may be left to cater for themselves and draw from friends and peers for support and care. Regarding adolescents, the focus has always been on their academic performance. There is sadly little attention to adults’ mental health even, and more sadly the issue of mental health of children and adolescents. While there is a growing literature on the mental health literacy of adults, there has not been a parallel interest in the mental health literacy of young people in Nigeria (Aluh et al., 2018). Depression among adolescents has been recognised as a public health problem all over the world (Oderinde et al., 2018). However, there is paucity of researches in the adolescent depression and its peculiarity in the Nigerian society. Alluding to this obvious gap is the submission of Oderinde et al. (2018) which stated that in Nigeria, as in most developing countries, there is a need for more research on the epidemiology of adolescent depression as this will guide prevention, diagnosis and treatment.

Adolescent depression which describes a mood disorder is a form of depression that affects young people between the ages of 10 and 19, transiting into adulthood. Unfortunately, adolescent-onset mood disorders are frequently unrecognised or misdiagnosed and often go untreated (Rockett et al., 2012). This may be due to the known and expected characteristics of young people at the adolescence period of life, including heightened emotionality and seeming irrational search for identity and autonomy. The burden of depression and other mental health conditions is on the rise globally; depression is a leading cause of disability and has been projected to become the 2nd most burdensome disease by the year 2020 (World Health Organisation (WHO), 2017). Untreated mood disorders may result in a variety of negative consequences, the most serious of which is suicide (World Health Organisation (WHO), 2017). Indeed, depression has been found to be the strongest single risk factor for attempted or completed suicides (Beautrais, 2006). Suicide is the second leading cause of death in 15–29-year-olds (World Health Organisation (WHO, 2017) and was the leading cause of injury mortality in 2009 for all age groups combined (Rockett et al., 2012). Oluwole, Fehintola and Oluwole (2018) submitted that during the past decade, suicidality among children and adolescents has received increasing attention due to the confirmed correlation between suicidal ideation and factors like loneliness, trait anxiety, and peer pressure. There is indeed great need for mental health counselling and psychotherapeutic interventions for adolescent depression in Nigeria, especially in the area of prevention as Wahid et al. (2020) rightly submitted that on a global scale, treatment alone is insufficient to address the problem of adolescent depression.

Statement of the Problem

Depression is a serious mental health issue affecting humans of all walks of life, which may have varied implications for physical, mental, social and spiritual wellness. Adolescents who are transiting from childhood to adulthood could have challenges from physical/biological, cognitive, social and emotional domains of development. Adolescents may also have to contend with developmental tasks with the central task being identity formation. With all these issues added to the realities of the present day world, where parents struggle to sustain livelihood, insecurities and economic meltdown, adolescents may be unable to navigate life and develop and or sustain positive emotions. There is need for more studies on wellbeing especially among adolescents as they are the future members of the society who should enjoy all-round health and wellness. As observed, many studies on adolescents in Nigeria have been on academic performance to the neglect of mental wellness of these emerging adults. Despite glaring evidence of adolescents’ health-related vulnerabilities, they have been neglected as a distinct group and overridden by the promotion of family, women, and child health needs (Dehne & Riedne, 2001).

Objectives of the Study

The study was set out to achieve the following objectives:

1. Use the psychodynamics theory of depression to explain adolescent depression especially in the Nigerian socio-cultural context;
2. Search out prevalence of adolescent depression in Nigeria as confirmed by empirical researches; and
3. Highlight mental health counselling and psychotherapeutic interventions for the reduction of adolescent depression among school students in Nigeria.

Adolescent Depression

Depressive disorder as defined by the World Health Organization (WHO) is a mental disorder characterized by an all-encompassing low mood, loss of interest and enjoyment and reduced energy leading to increased fatigability and diminished activity (WHO, 1992). It is the most common form of emotional problem experienced during adolescence and may be accompanied by inappropriate guilt or regret, worthlessness, hopelessness, and confused thinking (Peterson et al, 1993, WHO, 2008). Depression in adolescents is a highly prevalent condition that is often under recognised by families and physicians alike (Saluja et al, 2004). One of the factors that make depression so difficult to diagnose in adolescents is the common behaviour changes that are normally associated with the hormonal changes of the period (Kahn, 1995). The reported one-month prevalence rates of depression among adolescents in developed countries range between 3%-20% with lifetime prevalence rates estimated to range from 15%-35% by late adolescence (Mathet et al., 2003).

Globally, depression is a leading cause of illness and disability among adolescents aged 10–19 years old and, the presence of depression also increases the risk of suicide, which is the third-leading cause of death in this population (Belfer, 2008; Wahid et al., 2020). As the incidence of depression peaks in adolescence, and often remains undiagnosed, the negative consequences of depression persist as a chronic condition throughout the life course (Wahid et al., 2020). The problem of limited efficacy of available interventions along with the limited availability and low-quality of mental health services in many parts of the world persist as significant barriers (Belfer, 2008; Cipriani et al., 2016; Kieling et al., 2019). Therefore, increased identification of depression early in adolescence and administering preventive strategies become highly salient in addressing this global burden (Kieling, et al., 2019). Understanding the biopsychosocial risk factors that can predict the onset of depression, and the protective factors which can inform measures for preventing its manifestation and severity, are important steps towards achieving this goal (Wahid et al., 2020). Consequently, Wahid et al (2020) submitted that major gaps in global research to address prevention and early identification of depression among adolescents must be filled. The authors identified context-specificity in understanding of mental health, adolescent experiences, and risk and protective factors, a lack of feasible and acceptable tools to determine the risk of depression among adolescents before the disorder develops. Also ethical and institutional polices for research involving adolescents vary widely in low-income and middle-income countries (LMICs), including Nigeria (Wahid et al., 2020), and these need urgent attention.

Theoretical Framework- Psychodynamic Theory of Depression

Apparently, there are so many theories to explain depression or adolescent depression, and Bernaras, Jaureguizar and Garaigordobil (2019) submitted that it is likely that no single theory can fully explain the genesis and persistence of depression. Therefore, an eclectic approach must be used if the aetiology, development and sustenance of depression must be wholistically understood, including the spiritual dimension depending on the socio-cultural context involved. There are different categories of theories of depression: from the biological theories/models; cognitive theories; behavioural theories, socio-cultural theories and psychological theories. The psychodynamic theory is in the category of psychological theories of depression. Psychological theories of depression uphold that attachment, fixations (from over or under indulgence), stage crises, personality traits and other personal attributes, including emotions cause depression. For the purpose of this study, the Psychodynamic theory would be the anchor theory.

Psychodynamic Theory of Depression

The Psychodynamic theory which has Sigmund Freud as the pioneer proponent continues to expand its frontiers with several other theorists and sentimentalists upholding its tenets. Freud (1917) is the pioneer theorist who submitted that the state of the mind whether conscious or unconscious has a lot to do with depression. To him, repressed traumatic childhood experiences can later find expression in the form of mood disorder and emotionality. Further, he explained that depression is the exaggerated feeling of guilt and self-blame (Freud, 1917). Sigmund Freud understood depression in terms of inwardly directed anger, introjection of love object/person loss, severe super-ego demands (Freud, 1917), while other psychodynamic theorists posited 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).

Psychodynamic Theory and Adolescent Depression in Nigeria

The Psychodynamic theory can be used to explain adolescent depression in Nigeria to some extent. The different submissions regarding causes or risk factors for depression can be used to explain adolescent depression in the following ways:

Inwardly directed anger–in a typical Nigerian home until recently, children and adolescents are to be seen not heard. In fact, some parents and parent figures still hold the belief that adolescents and all young people must not express any form of emotions or even use verbal language in the presence of adults. This they believe to a large extent, indicates disrespect, lack of self-control and tendency to be overzealous in life. In homes where this kind of belief is still upheld, children can direct emotions (unfortunately negative ones) to themselves and develop pent up emotions and internalised rage which could further lead to mood swing (between being happy and being sad) and adolescent depression.

Introjection of love object/person loss– unconscious internalisation of loss whether of a person or object, privilege, position that was loved could lead to adolescent depression. If children and adolescents are not taught to let go and heal, move on from setback and become resilient, depression could set in. In the present time, adversity quotient has been identified as one of the important quotients in life. Young people must be taught to ‘move on and move up’ else, they stand a risk to develop and sustain depression.

Severe super-ego demands– again, many societies and families are observed to be overly strict without allowing young people to understand reason and logic behind some rules. If adolescents grow up in these kinds of environment, they can develop the trait of maladaptive perfectionism which can lead to depression.

Excessive Narcissistic, oral, and/or anal personality needs– some adolescents in Nigeria may develop excessive sense of self-importance in the guise of confidence and assertiveness. When this happens, young people only live in their heads and think constantly that everything is all about them, and this can affect their moods and intra-personal relationship.

Loss of self-esteem– impaired sense of self-worth and value, and constant negative self-evaluations can lead to adolescent depression among emerging adults in Nigeria, especially if there is continuous negative and unfavourable self-assertions and verbalisations.

Deprivation in the mother-child relationship during the first year– mother-child bond is very critical especially in the early years of a child. If this relationship is absent or faulty in the first year, children may feel disappointed, unloved, neglected, rejected, sad and moody. In Nigeria, family planning and child spacing practices are still coming up especially within regions that are educationally less developed. Some mothers conceive very closely to the youngest baby and focus on the pregnancy or the newer infant as they case may be. This may cause a strain in the mother-child relationship and lead to depression later in life.

Prevalence of Adolescent Depression in Nigeria

According to Alinnor and Okeafor (2023) in Lepine and Briley (2011), depression is projected to become the leading cause of disability as well as the leading contributor to the global burden of disease by 2030. Depression in adolescents is a public health concern as it increases the risk of substance abuse, relationship difficulties, suicide, and poor academic performance (Alinnor & Okeafor, 2023). The school based study aimed to determine the prevalence of depression and its associated risk factors among 1428 adolescents aged 10–19 years in secondary schools in the Port Harcourt metropolis, Rivers State, Nigeria. Sample was selected in the study using the multistage sampling procedure. Data on sociodemographic and family structure were obtained using a self‑administered pretested semi‑structured questionnaire. The presence of depression was determined using the Beck Depression Inventory (BDI). Adolescents with BDI scores of ≥18 were categorized as depressed. Bivariate and multivariate analyses were performed at P < 0.05. Of the 1428 adolescents recruited, 563 (39.4%) were males. The mean age was 14.30 ± 2.04 years. The prevalence of depression was 21.9% (n = 313). Significantly higher odds of depression were reported among females (adjusted odds ratio (AOR): 1.447; 95% confidence interval (CI): 1.107–1.891; P = 0.007), low socioeconomic status (AOR: 1.409; 95% CI: 1.064–1.865; P = 0.017), and family structures that were not monogamous (AOR: 1.586;95% CI: 1.152–2.183; P = 0.005). Depression is not uncommon among in‑school adolescents in Nigeria. In addition to the inclusion of screening for depression in the school health programme, measures to reduce the burden are advocated, especially among female adolescents and adolescents from low socioeconomic backgrounds.

According to Mbanuzuru et al. (2021), depressive disorders are the leading causes of ill-health and disability globally. Depression among adolescents is usually associated with a range of adverse later outcomes which include suicidality, and general poor physical and mental health. To determine and compare the prevalence of depressive disorders among in-school adolescents in urban and rural areas of Anambra State. The study was a cross-sectional analytical study of urban and rural in-school adolescents in Anambra State, Nigeria. A total of 1187 secondary school adolescents in government-owned schools in Anambra State was selected using multi-stage sampling technique. Patient Health Questionnaire-9 (PHQ-9) was the study instrument. The mean age of the participants was 15±2 years. The overall prevalence of depression was 12.5%. The proportion of urban participants identified with depression was significantly higher than that of their rural counterparts (14.5% versus 9.6%). Multiple regression showed that increased odds of developing depression are associated with urban setting (p = 0.001), female gender (p=0.018), and late adolescence (p=0.025). The study found that depressive disorders are prevalent among in-school adolescents in Anambra State, with some of the associated factors being urban setting, female gender and late adolescence. The authors advocated for multi-sectoral intervention programmes to address these identified factors.

Oderinde (2018) carried out a study on prevalence of adolescent depression among secondary school students, aged 10-19 years from the South western part of Nigeria. The one-month prevalence of depression among the study population was 16.3% (using weighting method). Logistic regression analysis showed that death of a mother, being from a polygamous family, low socioeconomic class, having a single parent, having witnessed frequent violence and positive history of sexual abuse were significantly and independently associated with depression in this sample of adolescents.

Chinawa et al (2015) submitted that depression is non-existent before the age of 10 years according to this study. The authors carried out a study on the prevalence of adolescent depression. According to them, depression among adolescents is an uncommon and frequently unrecognized issue in paediatrics. Children and adolescents however suffer from both depression and associated symptoms. The study was carried out among adolescents in secondary schools from two states; Enugu and Ebonyi metropolises within the age range of 9-18 in Enugu metropolis.  The prevalence of moderate depression was lowest (2.3%) at the age of 10 and highest at (6.2%) the age of 13. The prevalence of severe depression was lowest (1.9%) at the age of 11 and highest (7.4%) at the age of 12. Female gender is a risk factor for depression. Children whose parents are separated showed higher incidences of depression in all the spectra studied. Adolescents exhibit different levels of depression with a female preponderance.

Physical inactivity is related to many morbidities but the evidence of its link with depression in adolescents needs further investigation in view of the existing conflicting reports (Adeniyi, Okafor & Adeniyi, 2011). For the study, the data for the cross-sectional study were collected from 1,100 Nigerian adolescents aged 12-17 years. Depressive symptomatology and physical activity were assessed using the Children’s Depression Inventory (CDI) and the Physical Activity Questionnaire-Adolescent version (PAQ-A) respectively. Independent t tests, Pearson’s Moment Correlation and Multi-level logistic regression analyses for individual and school area influences were carried out on the data at p < 0.05. The researchers found that mean age of the participants was 15.20 ± 1.435 years. The prevalence of mild to moderate depression was 23.8%, definite depression was 5.7% and low physical activity was 53.8%. More severe depressive symptoms were linked with lower levels of physical activity and moderate physical activity was linked with reduced risk of depressive symptoms. The odds of having depressive symptoms were higher in older adolescents and in females. Females had a higher risk of low physical activity than male adolescents. Being in Senior Secondary class three was a significant predictor of depressive symptoms and low physical activity. A sizable burden of depression and low physical activity existed among the studied adolescents and these were linked to both individual and school factors. It was suggested that future studies should examine the effects of physical activity among clinical samples of adolescents with depression (Adeniyi et al., 2011).

Omigbodun et al. (2004) reported 12.6% as prevalence of probable depression among adolescents in rural South West Nigeria and found experiencing traumatic events as one of the predictors of depression especially when the event directly affected the youth as in sexual assault or physical abuse.

METHODOLOGY

A narrative literature review was considered the most suitable method to respond to the objectives of this study. The seeks to explain, with the aid of the Psychodynamic theory of depression, some concepts in depression literature in relation to the Nigerian socio-cultural context. Also, the study seeks to narrate the prevalence of adolescent depression in Nigeria as a problem area in dire need of urgent research and policy attention. This is because according to Baumeister and Leary (1997), identifying problems in the empirical literature can serve an invaluable scientific function for actions that are expected to bring sustainable development. Also, the paper seeks to highlight mental health counselling and psychotherapeutic interventions for the reduction of adolescent depression among school students in Nigeria. As the choice of method is justified, the aim of the study therefore, is to educate counselling/clinical psychologists and other mental health care professionals about the state of adolescent depression in Nigeria, and identify where concerted efforts are needed for sustainable development in research and practice.

MENTAL HEALTH COUNSELLING AND PSYCHOTHERAPEUTIC INTERVENTIONS FOR PREVENTING ADOLESCENT DEPRESSION IN NIGERIA

Peer education- Peer education approach can be used to prevent and or reduce adolescent depression in Nigeria. With peer education, some young people will be trained in:

1. health and wellness areas, including sexually transmitted diseases prevention, non-exposure to certain print and electronic media messages promoting social comparison, maladaptive perfectionism, violence and strong language, healthy living and hygiene;
2. life skills education, including negotiation skill, communication (verbal and non-verbal) skill, refusal skill, environmental scanning skill, decision making skill;
3. future planning approaches involving career aspiration, having good role models, mentoring opportunity and volunteering to harness the competencies of young people for positive use.   

When these sets of young people get trained, they become peer educators who will form active clubs in schools and in turn educate their peers and friends in the school. Adolescents form peer relationship during the adolescence period and, they prioritise social engagements that bring them closer to their contemporaries. Thus, peer influence can be strategically used to institute peer education geared towards fostering mental health.

Family therapy- counselling psychologists can organise family conferencing for adolescents and their family members on adolescent depression. Psycho-education strategy can be used to manage adolescent depression thereby fostering mental health of both parents and children. Family therapy can target parenting education where parents are trained to nurture their children and use appropriate styles for different sexes, ages and developmental stages. Family therapy can help in enhancing family cohesion, because separation or divorce of parents could lead to adolescent depression.

Home-school collaboration- counselling psychologists working in schools can advise schools to establish structured pattern of ensuring home-school collaboration, where parents get to be involved in their children’s learning and be more accountable and intentional with enhancing mental health of children. Parents-Teachers Forum, Open Day programmes, Town Hall Meetings can bring both the school and homes together for progress. Schools on the other hand are made to do more by being more effective with school climate that fosters child safety and sense of being accepted and protected.

One-on-one counselling and psychotherapy-counselling psychologists in schools can do more work on individual counselling and psychotherapy. In this way, students seek professional help and enter into formal counselling relationships, where they are encouraged to disclose information and details after being assured of confidentiality. One-on-one counselling and psychotherapy reassures students of commitment towards customised care and treatment as they personalise the experience and develop a sense of belonging.

Substance/Drug prevention programme- For drug prevention programme, a group approach is used by counsellors targeting non-drug users. Drug abuse could lead to depression and other mental health challenges. Thus, adolescents who are not yet active substance users can be assisted not to go into psychoactive substances through periodic and continuous drug prevention programmes.

Interventions for drug users- The menace of substance abuse among adolescents is quite worrisome in the present time. So, active users of psychotropic drugs can be separated from non-users and treated accordingly. Adolescents who are already into drugs must be given continuous counselling and psychotherapy in order to reduce effects of substance abuse which could include depression, anxiety and other mental health conditions. Both group and individual counselling/psychotherapy can be used to professionally address commonalities and different peculiarities among active drug users.

CONCLUSION

Adolescent depression is prevalent in Nigeria, and it has co-existence (co-morbidity) with physical and other mental health problems, and when unattended to, can deteriorate to even more serious psychological illnesses/conditions and adversely affect all aspects of adolescents’ lives. In view of this, evidence-based counselling and psychotherapeutic interventions can be utilised by critical stakeholders in the reduction of adolescent depression in Nigeria.

RECOMMENDATIONS

1. School-based health programmes by counselling psychologists in collaborations with other mental health professionals, including psychiatrists, social workers and medical experts. These kinds of programmes will target improving quality of school life and overall wellness among adolescents.
2. School counsellors’ community advocacy programmes sensitising parents, students, religious bodies, and indeed all members of the society on the importance of lifestyle practices that promote mental health of both young and old people should be carried out. Out-of-school children and adolescents would also benefit from community-based programmes. These advocacy programmes should be facilitated with the use of Information and Communication Technology (ICT) and Digital leadership.
3. Parents should join hands with other stakeholders in ensuring optimal care in terms of social and emotional support for adolescents in schools. Parental care will begin with using balanced parenting styles and nurturing practices, and deliberately creating a good home climate that promotes mental health of children-both boys and girls alike.
4. Schools, school administrators and teachers should work with adolescents and prevent practices that could hamper students’ mental health. These set of stakeholders should also work for the socio-emotional development of students even as they work to improve students’ academic performance. They should be fair in dealing with all students and regard students as humans, and not just deal with students according to their grades or scores in school subjects.

REFERENCES

1. Adeniyi, A. F., Okafor, N. C. & Adeniyi, C. Y. (2011). Depression and physical activity in a sample of Nigerian adolescents: levels, relationships and predictors. Child and Adolescent Psychiatry and Mental Health 2011, 5:16, 1-10.
2. Alinnor, E. A. & Okeafor, C. U. (2023). Depression and associated factors among in-school adolescents in Nigeria. Asian J Soc Health Behav., 6:14-20.
3. Aluh, D. O., Anyachebelu, O. C., Anosike, C., Anizoba, E. L. (2018). Mental health literacy: what do Nigerian adolescents know about depression? Int J Ment Health Syst.,12:8; 1-6.
4. Baumeister, R. F. & Leary, M. R. (1997). Writing Narrative Literature Reviews. Review of General Psychology, 1(3), 311-320.
5. Beautrais, A. L., Joyce, P. R. & Mulder, R.T. (1996). Risk factors for serious suicide attempts among youths aged 13 through 24 years. Acad Child Adolesc Psychiatry, 35, 1174-1182.
6. Belfer, M. L. (2008). Child and adolescent mental disorder: the magnitude of the problem across the globe. Child Psychol Psychiatry, 49, 226-236.
7. Bernaras, E., Jaureguizar, J. & Garaigordobil, M. (2019). Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments. Psychol. 10:543, 1-24.
8. Bibring, E. (1953). The mechanism of depression.
9. Chinawa, J., Manyike, P., Obu, H., Aronu, A. E., Odetunde, O. & Chinawa, A. (2015). Depression among adolescents attending secondary schools in South East, Nigeria. Annals of African Medicine, 14, 46-51.
10. Chodoff, P. (1972). The depressive personality: A critical review. Archives of General Psychiatry, 27(5), 666-673.
11. Cipriani, A., Zhou, X., & Del Giovane, C., et al. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet 388:881–90.
12. Dehne, K. L. & Riedner G. (2001). Adolescence– A dynamic concept. Reprod Health Matters, 9:11‑15.
13. Effiong, N. A. & Usoro, C. (2020). Family Communication Patterns and Cohesion between Adolescents and Parents in Uyo Local Government Area of Akwa Ibom State, Nigeria. Sapientia Foundation Journal of Education, Science and Gender Studies, 2(4), 141-153.
14. Fenichel, O. (1968). Depression and mania. The Meaning of Despair. New York: Science House.
15. Freud, S. (1917). Mourning and melancholia. Standard edition, 14(19), 17.
16. George, I. N. & Poelker, K. E. (2019). Adolescent Development in a Cross-cultural prspective. Cross-cultural Psychology: Contemporary Themes and Perspectives, 190-215.
17. Kahn, J. (1995). Adolescent Depression: An Overview.
18. Kieling, C., Adewuya, A., & Fisher, H. L., et al. (2019). Identifying depression early in adolescence. Lancet Child Adolesc Health 3:211–3.
19. Klein, M. (1934). Psychogenesis of manic-depressive states: contributions to psychoanalysis. London: Hogarth.
20. Lépine, J. P. & Briley, M. (2011). The increasing burden of depression. Neuropsychiatr Dis Treat, 7:3‑7.
21. Mathet, F., Martin-Guehl, C., Maurice, T. S. & Bouvard, M. P. (2003). Prevalence of Depressive Disorders in Children and Adolescents attending Primary Care. A Survey with the Aquitaine Sentinelle Network. Encephale, 29, 391-400.
22. Mbanuzuru, A. V., Uwakwe, R., Adogu, P. O. U., Nnebue, C. C., Udigwe, I. B. & Mbanuzuru, C. M. (2021). Depressive Disorders among In-School Adolescents: How Prevalent in Anambra State, Nigeria. 33,1-2.
23. Oderinde, K., Dada, M., Ogun, O, Awunor, N., Kundi, B., Ahmed, H., Tsuung, A., Tanko, S. & Yusuff, A. (2018). Prevalence and Predictors of Depression among Adolescents in Ido     Ekiti, South West, Nigeria. International Journal of Clinical Medicine, 9, 187-202.
24. Oluwole, D., A., Fehintola, V. A. & Oluwole, A. R. (2018). Appraisal of Perceived Psychological factors on Adolescents’ Suicidal Ideation in Ibadan Metropolis, Oyo State. Nigerian Journal of Applied Psychology, 20, 245-465.
25. Omigbodun, O. O., Esan, O. & Bakare, K. et al., (2004). Depression and Suicidal Symptoms among Adolescents in Rural South Western Nigeria. 16^th World Congress of the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP),      Berlin, 22-26.
26. Ottman, K., Wahid, S. S., Flynn, R., Momodu, O., Fisher, H. L., Kieling, C., Mondelli, V., Adewuya, A. & Kohrt, B. A. (2022). Defining culturally compelling mental health interventions: A qualitative study of perspectives on adolescent depression in Lagos, Nigeria, 2: 1-11. https://doi.org/10.1016/j.ssmmh.2022.100093.
27. Peterson, A. C., Compass, B. E., Brooks-Gunn, J., Stemmlier, M., Ey, S. & Grant, K. E. (1993). Depression in Adolescence. American Journal of Psychology, 48, 155-168.
28. Rockett, I. R. H., Regier, M. D., Kapusta, N. D., Coben, J. H., Miller, T. R. & Hanzlick, R. L., et al. (2012). Leading causes of unintentional and intentional injury mortality: United States, 2000–2009. Am J Public Health, 102: e84–e92. doi:  10.2 105/ AJP H.20 12.300960.
29. Saluja, G., Iachan, R., Scheidt, P., Overpeck, M., Sun, W. & Giedd, J. (2004). Prevalence and Risk Factors for Depressive Symptoms among Young Adolescents. Archive of Paediatric Adolescent Medicine, 158, 760-765.
30. World Health Organisation (WHO) (1992). Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10).
31. World Health Organisation (WHO) Guidelines (2008). Ten facts on Adolescent Health
32. World Health Organization. The global burden #of disease: estimates for 2000-2012. http://www.who.int/ mediacentre/factsheets/fs369/en/. Accessed Aug 2017.