Depression is one of the major mental disorders affecting individuals of all ages. Depression falls under mental health conditions associated with an overwhelming feeling of sadness, despair, and isolation. Resultantly, it affects how individual acts, and also their way of thinking. For example, the disorder causes a feeling of sadness or loss of interest in activities that one used to enjoy. If not managed early enough, depression prompts suicidal thoughts. According to the World Health Organization (WHO) (2017), depression is the primary cause of disability, and over 800,000 suicides cases reported yearly result from depression. By 2015, major depression was the third-leading cause of disability, and it is estimated that by 2030, unipolar depression will be the second leading contributor of global burden (Arvind et al., 2019) . The World Health Organization report shows that by 2030, depressed people will have more work and social disability compared to conditions like diabetes, hypertension (WHO, 2017). Over 350 million people globally suffer from depression, with adolescents and women having a higher prevalence. In the US, depression is the most common mental disorder affecting individuals of all ages, races, and socio-economic status. Although depression affects individuals of all ages, depression among young people is becoming a global concern. The paper will focus on diagnosis and associated treatment of depression among adolescents.
Association between Cyberbullying and Depression
Today approximately one in five young people is affected by mental health problems with one of the leading conditions being depression. While depression affects adolescents from all race and status, those from the minority race and low-economic status are at a high level of developing depression disorder. Today, cases of depression among adolescents are linked to advancement in technology. The rise of the internet and social media platforms has exposed many adolescents to cyberbullying, placing them at high risk of depression. Cyberbullying involves posting disparaging comments, posting humiliating images, or threatening someone using social media platforms. A study conducted by Nixon (2014) shows that both victims of bullying and bullies report feeling of depression. Unlike traditional bullying, where the events involved face to face confrontation, cyber victims do not identify their harassers physically e, which makes them feel dehumanized, isolated, and helpless. Cyberbullies are also at high risk of developing depression since they reveal the inability to adapt to stressful situations ( Nixon, 2014 ). Their social life and interactive communication are affected as most prefer to stay lonely or turn to elevated risks like drug and alcohol abuse (Perren et al., 2010). Adolescents who bully others reveal have psychological and physical problems that form a foundation for depression and, thus, suicidal thoughts.
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In the 21 st century, over 90% of young people are active users of social media. Facebook is the most commonly used social media platform used by 54% of teens, 53% uses Instagram, 33% chat room, and 30% used Twitter (“US Department of Education,” 2015). From a study involving 50 participants, 10% revealed to have been victims of cyberbullying, and only 3% admitted to cyberbully. The emotional effect of cyberbullying includes symptoms of depression and social, dissociation, and anger. Victims of cyberbullying who had past emotional episodes like early-traumas, physical, and sexual abuse were likely to develop depression.
In adolescents, depression is characterized by withdrawal from social groups, a drop in academic performance and engagement in risk-taking behaviors. For example, some adolescents also start engaging in drug and alcohol abuse, while others join criminal activities ( Nixon, 2014) . Other symptoms characterized by depression disorder due to depression include persistent sad feelings, anxiety, pessimism, feeling of hopelessness, and guilty, which persist for several weeks ( American Psychiatric Association, 2013 ). Individuals with depression reveal either loss or gain of weight, and if not controlled, many end up becoming obese. Suicidal thoughts are prevalent in individuals suffering from severe depression. Depressed individuals show difficulty in concentration, remembering, and making major life decisions.
The Etiology of Depression Using the Multipath Model
Multipath model is a method used by professionals to analyze a mental illness based on biological, psychological, social, and socio-cultural dimensions. The multipath model provides an organizational framework for understanding depression, its causes, and the complexity of the entire condition. Biological factors include genetics, a chemical in the brain, and the nervous system's functioning, which focuses on genetic polymorphism like a neurotransmitter and stress-related psychological irregularities. According to Durand & Barlow (2012 ), neurotransmitter serotonin has a broad effect on physiological functioning like sleep, emotions, aggression, appetite, sensitivity, and pain. Genetics play a significant role in depression, where the risk of developing the condition is about 2.5 to 3 times for individuals who have a first-degree relative with depression ( England & Sim, 2009) If one family member has depression disorder, there is a high probability that a close relative will develop the disorder. Genetic influences on depression are affected by one's gender and development phase, where the rate is high after the puberty age. Other biological factors include biochemical irregularities that involve neurotransmitters ( Saveanu & Nemeroff, 2012) . The biochemistry aspect of depression entails differences in brain chemicals, which lead to depressive symptoms.
The second dimension is the psychological factors. Behavioral explanation focuses on depressive disorders. However, the emphasis is on reduced reinforcements after the loss of a loved one. A support group is essential for every individual who undergoes stress and depression. Cognitive exegesis of depressive disorder is a significant factor in psychology. An individual's personality is a factor that explains why some individuals are vulnerable to depression than others. People who have low self-esteem and they have low-coping strategies are at high risk of developing depression disorder than their counterparts (Sue at al., 2016). People who have low-self esteem are easily overwhelmed by stress and are likely to develop depression compared to optimistic individuals.
The third dimension is the social environment factor, which focuses on interpersonal stressors, which triggers and increases an individual's vulnerability to depression. Depression is highly constructed on reactions to an adverse environment. According to Saveanu & Nemeroff (2012 ), the early life experiences and traumatizing situations of young people contribute to the development of depression, especially after experiencing a similar cyberbullying situation. Many adolescents who are victims of cyberbullying report a high level of emotional abuse and childhood trauma either through physical, emotional, or sexual abuse. Continuous exposure to chronically stressful situations during their childhood increases vulnerability chances in some people than in others. Over 80% of depression cases are preceded by a significant adverse life event (Sue at al., 2016). The severity of depression depends on both the circumstances of the event and the individual's subjective status. For instance, adolescents who are victims of bullying get depressed following the embarrassing situation, while others develop depression due to low self-esteem.
The socio-cultural aspect is the other dimension of depression that shows how gender differences and sexual orientations contribute to discrimination. Cultures have a different view of depression where, to some, depression is seen as a physical or emotional challenge. Race and ethnicity are associated with depression, especially on the minorities who struggle with discrimination ( Durand & Barlow, 2012 ). Studies show that minority groups, like gays, bisexuals, and people of color, have a high percentage of developing depression than the majority population. Exposure to long-term stressful conditions increases the likelihood of developing depression. Issues like poverty, displacement from home, and unemployment are likely to trigger depression, especially on individuals with low coping capabilities. In adolescents, chronic stress is common among females, especially those from low-socio-economic status. When such individuals get exposed to cyberbullying, they are likely to develop depression, and if not treated on time, they are likely to commit suicide.
DSM-V Diagnostic Criteria
When diagnosing psychiatric illness, clinician relies on the Diagnostic and Statistical Manual of Mental Disorders (DSM). DSM-V provides clear criteria that every clinician must follow when diagnosing depression disorder. However, DSM-V is just a diagnostic tool to guide clinicians, and it does not replace clinical judgment. DSM-V states that at least five symptoms must be evident in two weeks, and at least one symptom needs to be of diminished interest ( American Psychiatric Association, 2013) . The first symptom of depression is low mood. The other symptom is anhedonia or diminished interest or loss of pleasure in most activities and significant weight and appetite change. In adolescents, weight gain or obesity is typical. The victim also reveals insomnia or hypersomnia and do not get adequate sleep. Fatigue or loss of energy and feeling of worthiness is another symptom shown by DSM-V ( American Psychiatric Association, 2013) . Another diagnosis symptom of depression, according to DSM-V, is reduced ability to concentrate and recurrent suicidal thoughts.
A person who reveals five of the above conditions is thus diagnosed with severe depression. However, based on DSM-V criteria, at least one of the symptoms presented should be anhedonia or low mood. The patient must present a change from past functioning and reveal significant clinical impairment in social and occupational functioning ( American Psychiatric Association, 2013) . The symptoms should also not attribute to other medical conditions or physiological effects caused by substance use.
Differential diagnoses
Depression affects patients of all ages, gender, race, and socio-economic background. However, the prevalence is high among patients who have past depressive episodes since it involves frequent relapse. Individuals with chronic medical conditions are at high risk of developing depression. For instance, individuals with hypertension, diabetes, and heart problem are associated with high cases of depression complications. Apart from usual symptoms like insomnia, individuals with severe depression reveal physical symptoms like backache, musculoskeletal complaints, and vagueness (Ng et al., 2016). Before clinicians diagnose an individual, especially adolescents with a significant disorder, there is a need to examine life stressors like peer humiliation, bullying, emotional abuse, and complicated relationship.
When adolescents reveal the above symptoms, it does not explicitly mean they have depression. The clinician needs to differentiate different diagnosis possibilities to determine the actual diagnosis for an appropriate treatment plan. Since there is no lab test to diagnose depression, the clinicians rely on various medical conditions and the symptoms expressed while following the diagnosis criteria presented in DSM-V. Underdiagnosing major depression might delay non-treatment, while over-diagnosing leads to overuse of antidepressants. Therefore, the first step is to ensure an accurate diagnosis. The next differential diagnosis is ruling out drug-related symptoms like those caused by alcohol and cannabis. The clinician also needs to rule out general medical conditions that cause depression (Ng et al., 2016) . Ruling out these symptoms is essential since the patient might require specialized treatment beyond those provided by psychotherapy and antidepressants. Some medical conditions mistaken for depression are diabetes, bipolar disorders, chronic fatigue syndrome, and hypothyroidism (American Psychiatric Association, 2013) . Bipolar disorders are often misdiagnosed as major depression since the patient presents a low mood instead of Hypomania. Different from major depression, Hypomania in bipolar II disorder increases creativity with no functional reduction. Once the clinician identifies the potential cause, there is a need to distinguish specific psychiatric disorders. Lastly, the clinician needs to exclude organic conditions. Patients need to be thyroid testing since changes in thyroid functioning affects moods.
Empirically Supported Treatments
Treatment for depression involves a combination of various therapies and medication. If left untreated, depression can harm the individual's physical, social, and mental well-being, which resultantly increases the economic burden on society ( Halfin, 2007) . Over 90% of patients diagnosed with depression can be effectively treated. However, treatment varies with individuals where some might stay with symptoms for years. While some people only have a single episode of depression, others reveal recurrent depression, which might develop into a chronic disease if left untreated. For young people diagnosed with depression due to cyberbullying, a combination of therapies and treatment is more effective. However, depression remains a highly untreated condition and less managed hence the rising mortality and economic burden. Early diagnosis and treatment of depression improve social function, productivity, and decision making among adolescents.
The first-line treatment for depression is drug therapy and needs to be managed by psychiatric services in tertiary care. When dealing with adolescents, psychotherapy is very crucial. The patients are taken through cognitive-behavioral therapy to help change negative thoughts, especially those associated with suicidal thoughts. Interpersonal therapy is also recommended to help adolescents understand and work through complicated teenage relationship. Lastly, problem-solving therapy is designed to help cyberbullying victims develop realistic solutions to cope with stressful situations. According to Watanabe et al. (2007), these therapies are effective for short-term like six months, hence combining them with antidepressant medications is effective.
Antidepressant therapy seeks to reduce or eliminate acute symptoms of depression and achieve full remission ( Gelenberg et al., 2010 ). The acute phase is meant to achieve a significant response to depressive symptoms through psychotherapy and medication. Some individuals recover during this period, which takes 6 to 12 weeks, while others who fail to return to normal function are modified towards aggressive treatment. Once the mission is achieved, and the emotional function is restored, the patient is taken to the continuation phase. During this phase, the clinician seeks to prevent relapse, and it takes approximately 4 to 6 months. Maintenance is the last phase, which involves long-term management of depressive disorder. Treatment and psychotherapies are continued for at least 12 months to prevent depressive episodes' recurrence.
Various antidepressants are available for the treatment of depression. The choice of antidepressant is based on the unique medical history of the individual. Doctors usually prescribe first-line medications like Selective serotonin reuptake inhibitors (SSRIs) since they are considered safer and have few side effects ( Halfin, 2007) . SSRI comprises of citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and vilazodone. The other recommended antidepressant is Serotonin-norepinephrine reuptake inhibitors (SNRIs). Atypical antidepressants like bupropion, mirtazapine, vortioxetine, and nefazodone are also first-line medicines. Tricyclic antidepressants are issued to treat depression; however, they cause more severe side effects and are only recommended when SSRI fails to heal. Patients with depression are also prescribed monoamine oxidase inhibitors (MAOIs) when other drugs fail, but they require an individual to follow a strict diet.
Conclusion
In summary, major depression is a common disorder among young people. Increased use of social media exposes adolescents to cyberbullying and peer victimization leading to depression. When adolescents present signs and symptoms of depression, the clinician applies the multipath etiology method to understand the psychiatric disorder presented and its causes. The next step is to apply the DSM-V criteria to diagnose the condition depending on the symptoms showed. Before diagnosing the patient with depression, differential diagnosis is performed to ensure accuracy and plan for the most effective treatment.
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