According to the National Mental Health Association (2006), between 2% and 4% of prepubertal children and as many as 12% of adolescents may have depression. A family history of depression is a major risk factor for childhood depression. Other associated factors that may increase the risk of depression in children and adolescents include a history of verbal, physical, or sexual abuse; frequent separation from, or loss of, a loved one; poverty; mental retardation; attention deficit hyperactivity disorder; hyperactivity; and chronic illness. Children may refuse to go to school or pretend to be ill, and adolescents may appear sulky or irritable, common behaviors in this age group making identification of depression a challenge (NIMH, 2009). It should be noted that suicide is the third leading cause of death among persons 15 to 25 years and that the rate of suicide among young males is five times that among young females. Health care providers should recognize the symptoms of depression and refer for treatment as appropriate.

Treatment for depression includes pharmacological therapy, psychotherapy, behavior therapy, electroconvulsive therapy, or a combination of these (APA, 2005; NIMH, 2009). In general, the most effective, first-line treatment is a combination of antidepressant medication and psychotherapy.

Generalized anxiety disorder (GAD) is characterized by chronic, unrealistic, and exaggerated worry and tension about one or more life circumstances lasting 6 months or longer (APA, 2000). Approximately half of cases of GAD begin in childhood or adolescence, and it is more common in women than in men. Symptoms of GAD include trembling, twitching, muscle tension, headaches, irritability, sweating or hot flashes, dyspnea, and nausea. Periods of increasing symptoms are usually associated with life stressors or impending difficulties.

Approximately 6 million American adults have panic disorder (Kessler et al., 2005). Panic disorder can occur at any age, but it most often begins in young adulthood (average age, 17–30 years). Panic attacks consist of a period of intense fear that develops abruptly and unexpectedly. The initial attack may occur suddenly and unexpectedly while the client is performing everyday tasks. Typically, he or she experiences tachycardia; dyspnea; dizziness; chest pain; nausea; numbness or tingling of the hands and feet; trembling or shaking; sweating; choking; or a feeling that he or she is going to die, go crazy, or do something uncontrolled. This can be extremely frightening. A diagnosis of panic disorder is made when attacks occur with some degree of frequency or regularity.

As the disorder evolves, the anxiety attacks become increasingly frequent and severe, and the individual develops anticipatory anxiety (fear of having a panic attack). During this phase, events and circumstances associated with the attack may be selectively avoided, leading to phobic behaviors (e.g., if a woman has an attack while driving, she may become anxious the next time she needs to drive, and she may begin to avoid driving and then refuse to drive altogether). In this phase, the client’s life may become progressively constricted.

As the avoidance behavior intensifies, the client begins to withdraw further to avoid being in places or situations from which escape may be difficult or embarrassing or help may be unavailable in the event of a panic attack (e.g., church, elevators, movie theaters). The fear of being in these situations or places can lead to agoraphobia (literally, fear of the marketplace or open places). Individuals with agoraphobia frequently progress to the point where they cannot leave their homes without experiencing anxiety. Agoraphobia is the most common phobia leading to the use of health services, particularly when accompanied by panic attacks. Rates for co-occurring major depression range from 10% to 65% in persons with panic disorder (APA, 2000). Alcoholism is also common among individuals with panic disorders. Cognitive behavioral treatment and short-course benzodiazepines therapy are used to treat panic disorder.

Social phobia, or social anxiety disorder, is a persistent and intense fear of, and compelling desire to avoid, something that would expose the individual to a situation that might be humiliating and embarrassing (APA, 2000). Its tendency is familial and may be accompanied by depression or alcoholism. The most common social phobia is a fear of public speaking. Other examples include being unable to urinate in a public bathroom and not being able to answer questions in social situations. Most people with social phobias can be treated with cognitive-behavioral therapy and medication.

Simple phobias involve a persistent fear of, and compelling desire to avoid, certain objects or situations. Common objects of phobias are spiders, snakes, dogs, cats, and situations such as flying, heights, and closed-in spaces. The person often recognizes that the fear is unreasonable but avoids the situation or endures it with intense anxiety. Systematic desensitization and normal exposure are the most effective treatments for simple phobias.

Obsessive-compulsive disorder (OCD) is characterized by anxious thoughts and rituals that the individual has difficulty controlling. The person with OCD feels compelled to engage in some ritual to avoid a persistent frightening thought, idea, image, or event. Obsessions are recurrent thoughts, emotions, or impulses that cannot be dismissed. Compulsions are the rituals or behaviors that are repeatedly performed to prevent, neutralize, or dispel the dreaded obsession. When the individual tries to resist the compulsion, anxiety increases. Common compulsions include hand washing, counting, checking, or touching (APA, 2000). Most individuals recognize that what they are doing is senseless but are unable to control the compulsion. About 2% of Americans are afflicted with OCD, which often appears in the teenage years or early adulthood. Depression or other anxiety disorders often accompany OCD. Behavioral therapy and medication aimed at reducing accompanying symptoms have been found to be helpful.

Posttraumatic stress disorder (PTSD) is a debilitating condition that follows a terrifying event. It affects about 3.5% of U.S. adults (Kessler et al., 2005). Individuals with PTSD have recurring, persistent, frightening thoughts and memories of their ordeal. Incidents may include “shell shock” or “battle fatigue” common to war veterans, violent attack, serious accidents, natural disasters, or witnessing mass destruction or injury, such as an airplane crash. Sometimes the individual is unable to recall an important aspect of the traumatic event. Highest incidence of PTSD occurs among combat-experienced military personnel (Smith, Ryan, Wingard et al., 2008). About 19% of Vietnam veterans, for example, have experienced PTSD (Dohrenwend, Turner, Turse et al., 2006).

People with PTSD repeatedly relive the trauma in the form of nightmares or disturbing recollections or flashbacks during the day, resulting in sleep disturbances, depression, and feelings of detachment or emotional numbness, or being easily startled. They may avoid places or situations that bring back memories (e.g., a woman raped in an elevator may refuse to ride in elevators), and anniversaries of the event are often very difficult. PTSD occurs at all ages and may be accompanied by depression, substance abuse, and/or anxiety. It usually begins within 3 months of the trauma, and the course of the disorder varies. Some individuals recover within 6 months; the condition becomes chronic in others. Infrequently, the illness does not manifest until years after the traumatic event. Treatment includes antidepressants and antianxiety medications and psychotherapy. Support from family and friends can be very beneficial.

Bulimia nervosa refers to binge eating, discreetly consuming an abnormally large amount of food, accompanied by maladaptive compensatory methods to prevent weight gain (APA, 2000). For example, a person with bulimia might eat an entire pie, half a cake, or a half gallon of ice cream at one sitting. Snacking throughout the day is not considered bingeing. To lose or maintain weight, the person with bulimia practices purging, which usually involves self-induced vomiting, caused by gagging, using an emetic, or simply mentally willing the action. Laxatives, diuretics, fasting, and excessive exercise may also be employed to control weight.

Bulimia nervosa typically begins in adolescence or during the early 20s, usually in conjunction with a diet. High school and college students, as well as members of certain professions that emphasize weight and/or appearance (e.g., dancers, flight attendants, cheerleaders, athletes, actors, models), are at high risk. The condition may lead to electrolyte imbalance resulting in fatigue, seizures, muscle cramps, arrhythmias, and decreased bone density. Vomiting can damage the esophagus, stomach, teeth, and gums.

Risk factors for eating disorders are perfectionism, low self-esteem, stress, poor coping skills, sexual/physical abuse, poor self-image, dependency on others’ opinions and deference to others’ wishes, and being emotionally reserved (Cochrane, 2005). In response to the severely decreased caloric intake, the body tries to compensate by slowing down body processes. Menstruation ceases; blood pressure, pulse, and respiration rates slow; and thyroid activity diminishes. Electrolyte imbalance can become very severe. Other symptoms include mild anemia, joint swelling, and reduced muscle mass. Anorexia nervosa can be life threatening and has a mortality rate of 5% to 21%.

Treatment for eating disorders includes long-term nutrition counseling, psychotherapy, and behavior modification. Hospitalization may be required for clients with serious complications. Self-help groups and support groups can be very beneficial for both the client and the family.

Nurses need to be aware of the “ProAna” websites, which promote the lifestyle associated with eating disorders. Such knowledge is important, as community health nurses assess the social influences that contribute to the condition. Also, nurses who frequently work with adolescent girls and young women in community settings such as schools and clinics should be aware of the risk factors, signs, and symptoms of anorexia and bulimia and be prepared to intervene.