Structured clinical interviews show an increased level of aggression, substance use, and suicidal behavior among juvenile offenders with subclinical depression. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | Law and Human Behavior| 2015, Vol. 39, No. 6, 593-601
Aggression, Substance Use Disorder, and Presence of a Prior Suicide Attempt among Juvenile Offenders with Subclinical Depression
Tamara Kang, The University of Texas at El Paso
Jennifer Eno Louden, The University of Texas at El Paso
Elijah P. Ricks, The University of Texas at El Paso
Rachel L. Jones, The University of Texas at El Paso
Juvenile justice agencies often use the presence of a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis as a criterion for offenders’ eligibility for mental health treatment. However, relying on diagnoses to sort offenders into discrete categories ignores subclinical disorders—impairment that falls below the threshold of DSM criteria. The current study used structured clinical interviews with 489 juvenile offenders to examine aggression, presence of a prior suicide attempt, and substance use disorders among juvenile offenders with subclinical depression compared with juvenile offenders with major depression or no mood disorder. Analyses demonstrated that juvenile offenders with subclinical depression reported significantly more aggression, abuse of substances, and the presence of a prior suicide attempt compared to juvenile offenders with no mood disorder, but did not differ significantly on aggression and substance abuse compared with juvenile offenders with major depression. These results have implications for correctional agencies’ policies through which offenders are offered mental health treatment, and provide a first step in identifying early signs of problematic behavior before it worsens. Specifically, the results support the notion that depressive disorders should be viewed along a continuum when determining how to allocate services.
aggression, juvenile offenders, subclinical depression, substance abuse, suicide
Summary of the Research
“In response to growing awareness of the high rates of serious mental disorders (e.g., major depression and bipolar disorder) in criminal justice settings when compared with the general population, many juvenile justice agencies have developed, are considering, or are planning to use specialty services to reduce reoffending among juvenile offenders with severe mental illnesses. Specialty services include mental health courts and specialized probation caseloads, which have demonstrated efficacy at preventing recidivism. However, because access to community treatment providers is often limited, specialized mental health courts for juveniles often have eligibility requirements based on whether the offender has a diagnosable serious mental disorder” (p. 593).
“The current diagnostic system overlooks individuals with subclinical depression—those who experience some symptoms of major depression and have impairment in their daily lives, but the duration, severity, or number of symptoms does not meet the threshold to warrant a formal diagnosis. For example, a juvenile who does not present with five symptoms for most of day nearly everyday for at least two weeks, however severe, would not be diagnosed with major depression according to the DSM–IV–TR or DSM–5” (p. 594).
“Delinquency, a general term for minor crime, misbehavior, disruptive behavior problems, and wrongdoing, appears to interact with major depression among adolescents because of a shared diathesis. The irritability from major depression seems to exacerbate the already high levels of aggression found in many delinquent adolescents in the community, which increases the likelihood of continued delinquency, and violence… Juvenile offenders with subclinical depression likely have many of the same problematic behaviors as juvenile offenders with major depression, but lack the minimum number of symptoms needed for a diagnosis, and are typically ineligible for specialized services. The lack of treatment for subclinical depression may increase the likelihood that the juvenile offender’s delinquency, suicidal ideation, and substance use progress to clinical levels and result in future rearrest” (p.594).
To examine the distinction between delinquent behaviors associated with major clinical depression versus subclinical depression, the present study compared juvenile offenders with a diagnosis of major depression and juvenile offenders with no mood disorder diagnosis.
“Data were derived from routine intake procedures at a juvenile probation agency, where juvenile offenders received a comprehensive semistructured mental health assessment. The semistructured interview yielded diagnoses based on DSM–IV–TR criteria. As described later, the information from these interviews was used to sort juvenile offenders into three categories based on the absence or presence of symptoms and/or the duration and severity of the symptoms of major depression the juveniles endorsed” (p.595). The three groups were: no symptom present, presence of a symptom that did not meet full criteria, and presence of a symptom that met full criteria. Both past and present symptoms were placed into a single category of “lifetime occurrence” (p.595). A total of 489 juvenile offenders from a juvenile probation agency in the Southwestern U.S. were interviewed by master or doctoral students using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) over a 20-month period.
“Juvenile offenders with subclinical depression tended to report behaviors that were similar to juvenile offenders with major depression, and reported higher rates of prior suicide attempts, greater amounts of aggression, and greater rates of substance use disorder than did juvenile offenders with no mood disorder. It appears that juvenile offenders with subclinical depression experience considerable impairment that is similar to that experienced by juvenile offenders with major depression, even without meeting diagnostic criteria for a mental disorder.” (p.597).
“Recidivism risk is complicated to predict, and prior research suggests that the combination of disruptive disorders (e.g., symptoms include initiating physical fights, bullying, aggressively stealing, etc.) and substance use is even more predictive of rearrest than either component alone. Affective disorders on their own do not predict recidivism, but when combined with both disruptive behavior and substance use, the odds of recidivism are more than 2 times more likely than the odds of reoffending for juvenile offenders with no disorder. The present study supports the notion that juvenile offenders with subclinical depression are a special subgroup that may be at a higher risk of reoffending and substance use issues even though they do not have enough symptoms of depression to warrant a diagnosis” (p. 598).
“Juvenile offenders with mental health symptomology, even without meeting criteria for a DSM diagnosis, may be at a disproportionate risk of recidivism and become more deeply embedded in the criminal justice system” (p.598).
Translating Research into Practice
The authors argued against the categorical use of a DSM diagnosis of major depression as the primary determinant for mental health treatment among juvenile offenders. Instead, juvenile offenders should be diverted from the juvenile justice system and assessed for mental health needs.
The use of the Risk-Need-Responsivity (RNR) model for offender populations addresses mental illness under the responsivity model during treatment planning. “When mental illness is addressed during treatment planning, it appears that the offender has a higher likelihood of successfully abstaining from crime, as mental illness is a barrier to effective rehabilitation for criminal behavior” (p.598). If juveniles with subclinical depression are diverted away from the juvenile justice system and receive adequate mental health treatment via the RNR model, they may have a better chance of desisting from future criminal behavior.
“The present study highlights the need for juvenile justice agencies to screen all juveniles for suicidal risk and mental health symptoms…In addition, correctional staff should be educated on the symptoms that overlap and co-occur so that they can better identify the youth who are in need of services, in need of more intensive interventions, or are at a high risk for future delinquency” (p.599).
Juvenile offenders with subclinical depression are a potential high-risk group for delinquent behavior and thus warrant the necessary mental health care, whether or not they have a diagnosis of major depression.
Other Interesting Tidbits for Researchers and Clinicians
Although these findings suggest juveniles with subclinical depression are similar with those diagnosed with major depression in terms of treatment need, “only a small proportion of juveniles with major depression were represented in the sample (8.0% had major depression), whereas juvenile offenders with no mood disorder were overrepresented in the sample” (p.598). Additionally, the study consisted of mainly Latino participants and collapsed past and present symptoms of major depression, aggression, substance use, and suicidality into one single category. Future research may want to address these limitations to both replicate the findings and note any differences in outcomes for other, non-Hispanic ethnicities or when symptom presentation is coded differently.
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