# Evidence-based assessment/Vignettes/Hannah Baker

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# Hannah Baker

Hannah Baker is the main fictional character from the 3 season long Netflix TV Series called "Thirteen Reasons Why" based off of a novel also called Thirteen Reasons Why. This page serves as a resource to look at Hannah Baker as if she was a clinical psychologist's patient and they were working hard to diagnose her and get her on the road to better mental health and not her demise like in the show and book. The page What We Wish They Knew: 13 Reasons Why was conceived out of APA Clinical Psychologist's dissatisfaction with the content of the show and the portrayal of sensitive material as well as how they depicted mental health to their young audience. That page serves the purpose of conveying psychological science and helpful insights and resources for coping with each episode and if someone you know or yourself struggles with similar problems covered in the series.

## Clinical description

Hannah Baker is a 17-year-old caucasian female who lives with her mother and father. She moved to the area the summer before her sophomore year. Hannah started working at the Crestmont Movie Theater two months after moving to the area and quit the summer of her junior year. Hannah was also involved in helping with her parent’s pharmacy store. She began her sophomore year at Liberty High School. Hannah used to be an exceptional student who had plans on going to college at NYU or Columbia to become a published writer. However, her grades started slipping in April.
In February, Hannah began showing early signs of depression. She wrote a note to a friend, Zach Dempsey, describing how difficult her life has become. She also wrote a note that was read to her entire class from the class complement bag, which stated: “What if the only way not to feel bad is to stop feeling anything at all, forever?” Hannah used to be involved with the Evergreen Poetry club until a poem she created was published into the school newsletter without her consent. She attended a party with her friend Clay and made comments about wanting her life to end, such as “What’s the point of anything. Do you ever think: I can’t do it anymore? Like, I wanna die. Like, everything's black” while she was sober.
Hannah often feels worthless or guilty for multiple reasons, such as losing her parent’s money, blaming herself for Jeff’s death, and feeling as if she is letting everybody down. Hannah previously had several friends but began to distance herself from them. She is ostracized by her classmates and is often labeled as a slut after a picture of her revealing her underwear was leaked around the school. She was also referenced on a hot or not list, which made her into a target of assault and bullying. In addition to these events, she was stalked by the school photographer, who revealed a photo to the school of her kissing her friend Courtney. Hannah also witnessed her dad cheating on her mother as well as her friend being raped by Bryce Walker. The breaking point for Hannah was when she was raped by Bryce Walker at a party he hosted.

# Assessment findings

In Season 1 Episode 13, Hannah Baker goes to see Mr. Porter, the school counselor, in an appointment she schedules with him a week after being raped by Bryce Walker.. A trained clinical psychologist and a clinical psychology graduate student who has used these depression symptom severity measures as a research assistant evaluated the 13 minutes long scene where Hannah talks with Mr. Porter. The clinical psychologist and graduate student then filled out the Montgomery-Asberg Depression Rating Scale (MADRS) and the Hamilton Depression Scale (HAM-D) about Hannah and what they could observe about her strictly from her meeting with Mr. Porter. If it was not evident from the scene or a problem, then a score of 0 was highlighted. The copy of their combined report with the mean score of their answers for each question is below.
The HAM-D and the MADRS were chosen because they are free, short, simple and validated separately and as complementary. Both measures are practitioner-rated scales on depression that are widely used in adjunct, with higher scores on each measure denoting more severe depression/symptoms.
Click Here to see the questions and answers on the MADRS and HAM-D: MADRS and HAM-D clinician-report on Hannah Baker

### Hamilton Depression Scale Report

Hannah Baker HAM-D Clinician-Report Scores :
| Severity of Depression ||||||
| | Normal/Symptom Absent | Mild | Moderate | Severe | Very Severe |
| HAM-D Cut-Off Scores | 0-7 | 8-13 | 14-18 | 19-22 | >=23 |
| Hannah's Score | | | 16 | | |
The HAM-D assesses the severity of depression with 17 ordinal scale items on mood, guilt, suicide, insomnia, activity, retardation, agitation, anxiety, appetite, fatigue, libido, hypochondriasis, weight, and insight, with overall scores ranging from 0-52.
Hannah's overall HAM-D score was 16 out of a possible maximum score of 52. Her score indicates that she has moderate depression. Items about insomnia/sleep, appetite, anxiety related somatic symptoms, genital symptoms and weight were rated as 0 not because she had none but because based on the scenes of Hannah in Mr.Porter's office, the symptoms did not present themselves. This might be why her HAM-D score is not severe because 8 out of 17 items were not addressed in the "interview". Hypothetically speaking, if Mr. Porter had read over the HAM-D before seeing Hannah he could have conducted a semi-structured interview addressing these areas of well-being in Hannah's life.

### Montgomery-Asberg Depression Rating Scale Report

Hannah Baker MADRS Clinician-Report Scores :
| Severity of Depression |||||
| | Normal/Symptom Absent | Mild | Moderate | Severe |
| MADRS Cut-Off Scores | 0-6 | 7-19 | 20-34 | >34 |
| Hannah's Score | | | 28 | |
The MADRS assesses symptoms of depression to discriminate the level of severity with 10 ordinal scale items on mood, tension, sleep, appetite, concentration, lassitude, anhedonia, pessimism, and suicide with overall scores ranging from 0-60.
Hannah's overall MADRS score was a 28 out of a possible maximum score of 60. Her score indicates that she has moderate symptoms of depression. Items about sleep and appetite were rated as 0 not because she had none but because based on the scenes of Hannah in Mr.Porter's office, the symptoms did not present themselves. These were two simple questions Mr. Porter could have inquired about.

## What can you do to help someone like Hannah?

When someone is struggling with suicidal thoughts, depression, or mental illness it is important to approach the situation a certain way, not like Mr. Porter did with Hannah Baker. Below are some resources to help you get a friend, family member, colleague, acquaintance or partner to a stable point or out of dangers way before getting them connected to professional help.
* Here is an infographic describing 5 mental health first aid steps on how to assess for risks, listen non-judgmentally, encourage professional help and self-help: Helping Someone At RiskHere is an infographic describing common warning signs for people experiencing suicidal ideation: Warning Signs for Suicidal Ideation
* Infographic on what is best to say and what you shouldn't say to a friend experiencing depression: 13 Things To Say & 13 Things Not To Say To A Friend With Depression
* To learn more about symptoms and signs navigate to "What to Look For" section on this page to help you assess for risk.

## Diagnostic interview findings

* CLINICAL PSYCHOLOGICAL INTERVIEW
* Client Information:
* Name: Hannah Baker    Age: 17
* Date of Birth: August 28, 2000
* Gender: ____ Male   _X_ Female
* Race: _X_ Caucasian (NH)  ___ Caucasian (H)
* ___ African American  ___ Asian American
* ___ Other (__________________________)
* Marital Status: _X_ Single  ___ Cohabitate  ___Separated
* ___ Married/Partner  ___ Divorced ___ Widowed
* Living Situation: Lives with both parents
* Overview of Presenting Problems:
* Complete after interview – does not need to be specific diagnoses
* Rank of Importance
* Problem 1: Suicidal
* Onset:   December 2017
* Symptoms:  She has contemplated suicide and feels hopeless. Does not appear to have a specific plan, but still of high concern. Also, she feels sad all the time. Suicidal ideation occurred where she vocalized when high on Molly. (S2, E7)
* Problem 2: Anxiety/Worry
* Onset:   December 2017
* Symptoms: She is constantly worried and concerns herself about what other people think of her. This keeps her from engaging in relationships of any kind and seems to impair her performance in school as well (S1, E8).
* Problem 3: Depression
* Onset:  December 2017
* Symptoms:  She is sad all the time, has lost interest and pleasure in activities, and stays around her home often with little social interaction. She quit her job, she stopped writing and poetry. (S1 E8)
* Additional Conditions:
* Problem 4: Self-image
* Onset due to bullying:  S1 E1 pictures sent after kissing Justin (August 2016),
* Symptoms:  She is highly critical of herself and does not view herself or her feelings as worth the time of others. For instance, feeling undeserving of Clay and of her parents’ attention. Low self-esteem, very guarded and felt like others had alternative motives.
* Problem 5: Sexual Assault/Sexual Exploitation
* Onset: S1 E1 after Justin sent out pictures (August 2016), S1 E3 Bryce sexually assaults Hannah (groping), S1 E4 Tyler is identified as the stalker taking pictures of Hannah, S1 E7 Marcus makes sexual advances on her without consent, S1 E12 Bryce sexually assaults her at his party.
* Symptoms: Hannah has recurring thoughts about death. She has diminished interest in activities she used to be interested in. Hannah feels isolated due to her classmates view of her.
* Family History:
* Q: Where were you born? A: California
* Q: Where did you grow up? A: Small California town
* Q: Who raised you? A: My parents
* Q: How many brothers and/or sisters do you have? A: "0 and 0" Q: Step-siblings? A: "0"
* Q: What was your relationship like with your brothers and sisters? A: Not asked because she has none
* Q: How would you compare yourself with your siblings? A: Not asked because she has none
* Q: Number of times married:    0     1 2 3 ≥4
* Educational History:
* Q: What is the highest grade you completed in school? She is in 10th grade so 9th
* Q: Did you like school? A: No I don’t- people say mean things and spread rumors
* Q: What were your grades like? A: I started out the beginning of the school year well, but her performance has steadily declined.
* Q: Did you ever fail a grade?   Yes / No     Q: If yes, which one? A: Not asked
* Q: Special Education?      Yes / No         Q: If yes, when were you first enrolled in SE? A: Not asked
* Q: What subjects were you enrolled in SE for?       Math Reading All None
* Q: Were you ever in trouble for your behavior at school?   Yes / No     If yes, how often and what type of behavior? Not asked
* Q: Were you ever suspended?  Yes / No      If yes, how frequently? Not asked
* Q: Were you ever expelled?  Yes / No       If yes, how frequently? Not asked
* Additional information?
* She and other girls from her old school participated in bullying at her old school.
* Employment History:
* Q: What was your first job? A: Crestmont Movie Theatre Q: How long did you keep that job? Any other job since that time? A: Job 1: Crestmont Movie Theatre (July 2016 - October 2017), Job 2: Parents' pharmacy (July 2016 - Present) Q: What is the longest you ever had a job? A: 14 months Q: What was your last job? Not asked (answered above) Q: Do you typically respond appropriately to supervisors, coworkers, and work pressures? A: Yes / No Explain: Nobody has ever complained about her work Q: Do you have any friends at work? A: “Yes, a boy named Clay.” Q: Do you hang out outside of work? A: “A couple of time but not really.” Q: Have you ever been fired from a job? A: Yes / No Q: If yes, how many times and why? (not asked)
* Q: Do you currently handle your personal finances? Yes / No Explain: Parents handle money, but there are some family issues. Q: Do you have significant problems handling money? Yes / No Explain: I lost some money from the store one time, but other than that I am responsible with money. Q: What do you mean your family has money issues? A: “My parents’ business is doing poorly.” Q: Can you tell me more about that? A: “A new superstore has opened and is taking away customers from their small business.” Q: Do you do anything to help out financially? A: “No, I save my money for college.” Q: So, you want to go to college after you graduate? A: “Yes, I do”
* Military History: Q: Have you ever served in the armed forces? Yes / No Which branch? Army Navy Marines Air Force National Guard Coast Guard (not asked) Q: How long did you serve? (not asked) Q: Were you ever in active combat? (not asked) What type of discharge did you receive? (not asked)
* Medical History: Q: Are you aware of any complications during your birth? Yes / No Q: Did you crawl, walk, and talk when you were supposed to? Yes No (not asked)
* Q: Have you ever suffered from a head injury or a loss of consciousness? Yes / No Q: Are you currently being treated for any physical illnesses or injuries? Yes / No If so, what are you being treated for? (not asked) Q: What medications (for physical ailments) are you currently taking? A: None Q: Have you suffered from seizures? Yes / No (not asked) Q: Have you suffered from blackouts? Yes / No (not asked)
* Additional Information:
* Abuse History: Q: Have you ever been physically abused? Yes / No Explain: Best friend slapped her in a café because of a misunderstanding about a boy. Q: Are you still friends with her? A: “No I’m not.” Q: Have you ever been sexually abused? Yes / No Explain: Verbally and socially, she was but on an embarrassing list at school which made her feel humiliated. Additionally, another student circulated a picture of her via text messaging which was sexual in nature but unintentionally. Another boy attempted to sexually touch her after seeing this picture and saying she was “easy” (S1 E7). Another student has sexually harassed her and raped her on one occasion. Q: Have you reported this abuse? A: "No" Q: Have you ever been emotionally abused? Yes / No Explain: The same photos, list, and rumors have embarrassed her severely and tarnished her reputation.
* Substance Use History: StartedLast UsedFrequencyAmount per occasionLongest AbstainAlcoholS1 E4S1 E122 times - Only drank with Courtney (S1 E4) or at parties (S1 E11, S1 12)CigarettesMarijuanaCocaineOpiatesHallucinogensS2 E7MDMA/MollyAmphetaminesSedative/HypnoticsOther:Substance RelatedOnly drank with Courtney (S1 E4) or at parties (S1 E11, S1 12)
* Cigarettes
* Marijuana
* Cocaine
* Opiates
* Hallucinogens S2   E7 MDMA/Molly
* Amphetamines
* Sedative/Hypnotics
* Other:
* Substance Related Problems?  None    Legal/DUI    Family/Friends Concern    Acting Out Belligerence  Financial Work Health Blackouts Tolerance    Withdrawal
* Treatment for Substance Abuse:   None
* AA  / NA  / CA
* Legal History:
* Current Charges?    Yes / No          Explain: Not asked
* Past Criminal Record?    Yes / No          Explain: Not asked
* Mental Health History:
* Family History of Mental Illness? Mother’s side of the family has a history of mental illness. When her mom was 12 she was raped by an 18 year old. Her mom was cheated on when her dad started seeing Valerie, her mom didn’t know until a month later. Hannah knew about the affair before her dad confessed.
* Personal Symptom History:
* Q: How would describe your mood generally? A; She says she feels sad continuously because of the situation at school. She does not feel understood. She feels like she has no friends and is helpless and hopeless. Feeling lonely.
* Suicidal Ideation Yes or Gestures No Explain: She says she would like to end her life because it would get rid of her pain and problems. When in a group with friends taking the drug molly, Hannah expresses, "What's the point, right?...No, but, like, really, what's the point of anything? ...Do you ever think, 'I can't do it anymore? Like, I wanna die?'...Like everything's black." She had also expressed this during speech class anonymously and to Mr. Porter. Her plan of suicide was shown after her talk with Mr. Porter. She decides to kill herself by using razor blades that she stole from her parents’ pharmacy. She used the blades to cut her wrists and bled out in a bathtub filled with water.  Although she had a plan and the means to kill herself, they are only apparent when she made all thirteen tapes. Her suicidal thoughts are deemed more passive as they are mostly filled with wishes and desires to die, rather than actively pursuing the plan.
* Q: What leads you to think about suicide? A: “All the bad things people say about me.”
* Q: How long did you start thinking about suicide? A: “A couple of months ago after this all started.”
* Anxiety/Stressed/Worry? She is often worried about what others are saying about her after the list and photo circulated. She worried about having relationships with boys because they might only be interested after hearing that she’s “easy.” After previous friend problems, she worries that all relationships will end in disaster.  She is worried about her parents relationship. Anxious about college plans. Her dream school seems out of reach due to her grades.
* Q: When did you start to worry about this? “After the rumors started going around.”
* Q: Why do you think you care so much what the people at school think? “Because I want to have friends.”
* Q: Irritability? Snapped at a few people, somewhat moody.
* Q: Sleep problems? None
* Q: Delusions? None
* Q: Hallucinations? None
* Q: Other? None
* Q: Previous Diagnoses?  None, never seen a mental health professional
* Q: Previous Psychological Testing? None
* Q: Treatment for Mental Health? None
* Q: Inpatient? No
* Q: Outpatient? No
* Q: What psychiatric medications are you currently taking?   None
* Q: What psychiatric medications have you been on in the past? None
* Daily Activities:
* Q: How do you spend a typical day? A: She goes to school and then to work. Coffee shop, poetry class, spent time at her parents' store, Season 2 she spent a lot of time with Zack.
* Q: Do you ever hang out with any friends outside of school? A: “No not really because I’ve lost a lot of my friends."
* Q: What kinds of things do you do for fun? A: I like to write poetry.
* Q: Have you noticed a deterioration in your personal care? A: Yes / No
* Q: Have you noticed a recent, marked constriction of interest in activities?  A:  Yes   /    No
* Q: “Can you tell me more about that? A: "I don't really enjoy poetry as much as I used to."
* Q: Have you noticed an impaired ability to interact with others?  A:  Yes   /   No
* Q: Can you tell me more about that? A: She feels she can't really trust people.
* Q: Have you noticed an impaired ability to understand, remember, or carry out instructions? A:  Yes / No
* Social History:
* At her previous school, she, along with two other girls bullied a girl named Sarah. This involved Hannah and the other girls sharing a photograph that led to Sarah being bullied. After that occurred, Hannah and her friends were suspended (S2, E10).
* Tell me about your social life- She just moved here before 10th grade so she had few friends before the rumors but now doesn’t really have any at all. She doesn’t do school activities, but occasionally attends parties.
* Describe your friendships/romantic relationships- She had one friend named Kat but she moved away before school started. Otherwise, most of her relationships have deteriorated except a couple. She is interested in her coworker, Clay, romantically but feels he deserves better. Another friend, Tony, is kind to her and does not believe what people say about her.
* Relationship with each person wrote a tape to:
* Tape 1: Justin Foley is the subject of the first tape. Hannah first meets Justin at a party and becomes interested in him. Later, he asks her out, they go on a date and Hannah has her first kiss with Justin. After the date, Justin stays at Hannah’s because of a fight he had with his mom. Justin starts a rumor that they got to “third base” after a picture is spread of the two kissing on a playground.
* Tape 2: Jessica Davis is the subject of the second tape. Jessica and Hannah first meet when the counselor selects them to be friends as they have both recently moved to the area. The two become friends and begin hanging out and getting hot chocolate at Monet’s regularly. They eventually befriend Alex. Later, Alex and Jessica date. When they break up, Alex makes a “hot or not” list which Jessica blames Hannah for.
* Tape 3: Alex Standall is the subject of the third tape. Hannah and Jessica befriended Alex at Monet’s, since he has recently moved to the area. After Alex and Jessica break up, he creates a list and places Hannah on it as having the “best ass” in an attempt to make Jessica jealous. Alex’s list led to Hannah being bullied and to the loss of her friendship with Jessica.
* Tape 4: Tyler Down is the subject of the fourth tape. Tyler serves as their school’s photographer. Hannah  first meets Tyler on the first day of sophomore year when she sees some girls turning him down for him to take pictures. Hannah offers to let him take photos of her. After the Justin incident, he offers to take pictures of Hannah which angers her. He goes to her house to apologize but sees her “sexting” and takes a picture without consent, which begins his stalking of her. One night, Hannah is playing “Truth or Dare” with Courtney Crimsen, and they make out. Tyler takes a picture and leaks it to the school.
* Tape 5: Courtney Crimsen is the subject of the fifth tape. Courtney and Hannah were friends, with Courtney offering to help with Hannah’s stalker. They were having a sleepover at the time the kiss occurred to trap the stalker. Once the photo is leaked that reveals Courtney and Hannah kissing, Courtney begins to spread rumors about Hannah. She contributes to the rumor of Hannah and Justin along with saying Hannah is kissing a lesbian classmate instead of herself.
* Tape 6: Marcus Cole is the subject of the sixth tape. Marcus asked Hannah on a date after participating in the dollar valentine event at their school. Marcus showed up extremely late to the date. When he finally showed up, he sexually assaulted Hannah, to the point where Hannah had to push him out of the booth. He proceeds to say that she thought she was “ easy”.
* Tape 7: Zach Dempsey is the subject of the seventh tape. When Hannah refuses to go on a date with Zach, he gets angry and removed compliments from her box in one of their classes. Zach and Hannah later grow closer as he begins to visit her at her job. Zach and Hannah both lose their virginities to each other and date throughout the summer. It ends right before school starts when Zach is too embarrassed to tell his friends he has been dating her.
* Tape 8: Ryan Shaver is the subject of the eighth tape. Ryan meets Hannah at a Evergreen Poetry Club meeting. Hannah asks him advice on how to write poetry. Without Hannah’s knowledge or consent, Ryan publishes a poem of Hannah’s in the school magazine.
* Tape 9: Justin Foley is the subject of the ninth tape. Justin , as well as Hannah, allows Courtney to be raped at a party. Hannah blames both Justin and herself for the incident.
* Tape 10: Sherri Holland is the subject of the tenth tape. Sherri finds Hannah drunk at the party and proceeds to drive her home. Sherri accidentally knocks down a stop sign while driving. Hannah insists that they contact authorities about the knocked down stop sign, but Sherri disagrees. Sherri ends up leaving Hannah at the stop sign and a car accident occurs the same night. Jeff Atkins dies during the car crash. Sherri tells Hannah that they should stop hanging out. Hannah feels really guilty about the incident.
* Tape 11: Clay Jenson is the subject of the eleventh tape. Although not on the list of reasons, she added him because he plays such an important role in the series of events.
* Tape 12: Bryce Walker is the subject of twelfth tape. Bryce and Hannah first meet at a high school football game. For a period, they hangout and he even tries to kiss her, but she does not let him. At Jessica’s party months later, she witnesses Bryce rape Jessica. At another party later at Bryce’s home, people begin to leave, and Bryce rapes Hannah.
* Tape 13: Mr.Porter is the subject of the thirteenth tape. Hannah meets with Mr.Porter as an attempt to get help. However, the meeting did not go the way Hannah wanted it to go. Mr.Porter blames Hannah for her rape and makes her hesitant to reveal the incident and rape to the authorities. Mr.Porter also tells Hannah to just try to move on if she doesn’t reveal anything.
* How do you handle an argument with your significant other/friend/family member- She avoids the issue? One confrontation, with those who spread rumors about her, was unsuccessful. She would share personal information with her parents, which might lead to arguments, but she holds back because of their financial difficulties.  She does not to talk her parents about issues she is going through.
* Q: Do you think your parents care for you? “Yes.”
* Q: So why don’t you share things anyway, despite their worries? I’m sure they’d love to listen. “Yeah, I just don’t want to burden them.”
* Additional Information/Follow-Up Questions
* Listed in the document above and labeled with “Q:”
* Q: Have you experienced any feelings of depressed mood or hopelessness? If you have, how often do these occur?
* A: There was a week after this incident with a classmate that caused me to feel really depressed for a week. There have also been times when I wonder if the only way to stop feeling bad is to not feeling anything at all (S1, E7).
* Q: Have you experienced lost in interest or pleasure in activities that you previously enjoyed or participated in?
* A:I quit the Evergreen Poetry club. I don’t enjoy attending the club anymore. A poem I made was released without my consent. My privacy felt like it was being invaded. Other people at school made fun of my poem.
* Q: Have you experienced any feeling of extreme guilt?
* A:Yes, I have. I feel guilty about Jeff Atkins death and about Jessica’s rape. I also feel guilty about losing my parent’s money.
* Q:Have you noticed that you have had a time concentrating or making decisions as of recently?
* A:Sort of. Mr.Porter told me my grades have been slipping. I also sometimes zone out or lose focus while talking with other people.
* Q:Have there been times when you have felt that you would be better off dead?
* A:I used to only think like that rarely. After everything has happened, I have started to question this a lot more. “I started thinking how everyone’s lives would be better without me” (S1, E12).

# Prediction Phase
## Shortlist of Probable Hypotheses

Based on Hannah's age and the common clinical issues, here are the possible issues:
* A mood disorder definitely is a leading hypothesis. The suicide attempt also suggests evaluating mood disorder (although not everyone who attempts suicide has a mood disorder). Within the "mood" category, the hypotheses should consider major depression, dysthymia, and bipolar spectrum disorders, as well as other medical issues that could lead to mood symptoms.
* Substance misuse should be another hypothesis, based again on its prevalence in her age group.
* Anxiety disorders would be a third hypothesis.
* Conduct problems would be a fourth -- they are not immediately suggested by the description of the presenting problem, but they are common in the age group, and they also can be a risk factor for self harm.
* Attention problems are worth evaluating based on prevalence, though her prior academic performance does not suggest any additional reason for concern.
* The family conflict is also important to assess.

## Assessing Suicidal Ideation/Suicidality

* The Suicide Behavior Questionnaire-Revised SBQ-R (self-report) is made for 13-18 year olds so it is appropriate for Hannah to take. This is a measure that Mr. Porter or any counselor can give because it is an evidence based assessment that is free and easy to use. For more general information about this measure click here. For more information on how to score and interpret the measure click here. To get a PDF of the measure click here
* The Columbia Suicide Severity Rating Scale (C-SSRS) is made for 12 year olds and older. The Measure | General Information | Scoring Information
* For a free Adult Assessment Battery for the patient/person to take includes these two measures while also assessing ADHD, Depression, Anxiety, PTSD, Bipolar Disorder, and Substance Use. At the end of the survey it will give you the scores, their answers, resources, and more in a PDF.

## The Diagnosis

Based on our HAM-D and MADRS scores as well as diagnostic interview findings, the diagnosis for Hannah is Major Depressive Disorder (MDD).
If you are a clinician and you want to know how to conduct evidence-based assessment in youth, click here.

### Profile/Symptoms

Hannah Baker’s Profile:
A depressive disorder is not the same as experiencing a brief depressive mood. However, if a depressed mood lasts for longer than two weeks, it can be classified as a major depressive disorder. Another indicator of a depressive disorder is if the condition impacts multiple areas of your daily functioning. This can include familial relationships, social interactions, and/or academic performance. Other symptoms include:
Symptoms of Depression:
* An unusually sad mood
* Loss of enjoyment and interest in activities that used to be enjoyable
** Stopped being part of the Evergreen Poetry Club and quit from her job at the Crestmont Movie Theater (S1E8, S1E12)
* Lack of energy and tiredness
* Feeling worthless or feeling guilty though not really at fault
** Felt guilty over Jeff’s death despite not being the direct cause due to being with Sheri who broke the stop sign. (S1E10)
** Feelings of guilt after she kissed Clay but pushed him away due to trauma with boys. Worried that Clay might think she doesn’t like him. (S1E11)
** Felt responsible for parents’ separation (S2E4)
* Thinking often about death or wishing to be dead
** Starts wanting everything to stop because she no longer wants to experience negative emotions and events. (S1E13)
** Writes an anonymous note in the class discussion bag saying "what if the only way not to feel bad is to stop feeling anything at all, forever?" (S1E7)
* Difficulty concentrating or making decisions
** Grades dropping.
* Moving more slowly or sometimes becoming agitated and unable to settle
* Having sleeping difficulties or sometimes sleeping too much
** Has a hard time falling asleep so she takes walks outside.
* Loss of interest in food or sometimes eating too much. Changes in eating habits may lead to either loss of weight or weight gain.
Having one or more of these symptoms doesn't guarantee that an individual has a major depressive disorder. Similarly, there are individuals that could be diagnosed with a major depressive disorder but not show as many symptoms. Despite not being diagnosed as having a major depressive disorder, individuals who possess multiple symptoms can still experience a negative impact on their daily lives.
Symptoms of major depressive disorders can affect an individuals physical and mental states. Some examples of this include:
* Emotions- sadness, guilt, anger, mood swings, lack of emotional responsiveness, feelings of helplessness, hopelessness, irritability
** Hannah’s poem is published against her will. The poem describes feelings of drowning, hopelessness, and loneliness. (S1E8)
* Thoughts- frequent self-criticism, self-blame, worry, pessimism, impaired memory and concentration, indecisiveness and confusion, a tendency to believe others see you in a negative light, thoughts of death and suicide
** Finds out at the college fair that her grades aren’t high enough to get the financial aid she needs (S1E8)
** Writes an anonymous note in the class discussion bag saying "what if the only way not to feel bad is to stop feeling anything at all, forever?" (S1E7)
** Reveals to her school counselor that she believes she doesn’t have any friends and that those that were once close to her now hate her (S1E13)
* Behavior- crying spells, withdrawal from others, neglect of responsibilities, loss of interest in personal appearance, loss of motivation, slowed down, using alcohol or drugs
* Physical- chronic fatigue, lack of energy, sleeping too much or too little, overeating or loss of appetite, constipation, weight loss or gain, headaches, irregular menstrual cycle, loss of sexual desire, unexplained aches and pains

### What to look for

There is no one list of symptoms that applies to all individuals with depression. Every case of depression is different and all individuals have different experiences. Some individuals might choose to hide the symptoms they are experiencing through their depression, while others are showing more visible signs. Changes can occur in behavior, physical appearance or habits, and cognitive functions. Some changes to look for include:
* Sluggish or slow movement, thinking, or speech
* Tendency to be easily aggravated
* Slow, monotone, or seemingly disinterested tone of voice
* Disregard for hygiene and grooming
* Features of sadness (facial expression, body language)
* Anxious or irritable behavior
* Restlessness
* Decreased attention and ability to make decisions
* Changes in dietary or sleep routines and patterns
While some individuals might be able to hide their symptoms from those around them, the severity of their depression could also impact how obvious their symptoms appear. Cases of serious depression are more difficult to hide from friends and family compared to cases of mild depression.

### Causes of Depression

Individuals with depression have a variety of experiences that lead to the development of symptoms. The causes of a depressive disorder can come from childhood events, times of trauma, long term stress, and/or biological conditions. Examples of these causes can include:
* A breakup of a relationship or living in conflict
** Broke up with Zach Dempsey when school started due to Zack being a bystander and not defending her in front of his friends. (S2E6)
** Her family is struggling financially to keep their local drug store in business
** Wrote a poem about a burning house, describing the pain she felt from keeping her father’s affair a secret from her mother (S2E8)
* Long-term poverty
* Loss of job or trouble finding a job
* Long-term disability from an accident
* Bullying or victimization
** A major factor of her depression - she felt isolated because the student body is spreading rumors about her as a slut.
** Ex. Justin Foley secretly taking a picture of her underwear (S1E1)
** Ex: Alex Standall giving her the title as “best ass” on the best/worst list (S1E3)
** Ex: Courtney spreading rumors after pictures of her and Hannah kissing are spread around the school
** Her friends leaving and betraying her
** Ex: Zach Dempsey stealing her notes written with compliments from classmates (S1E7)
* Victim of crime
** Traumatized from her rape by Bryce Walker (S1E12)
** Sexual harassment from Marcus (S1E6)
* Development of a long-term physical illness
* Death of a loved one, such as partner, family member, or friend
* Certain medical conditions such as Huntington’s disease, a brain injury, a stroke, Parkinson’s disease, hypothyroidism, and systemic lupus erythematosus
* Giving birth to a baby
* As a side effect of medications
* Stress as a result of another mental disorder, such as schizophrenia, an anxiety disorder, or an eating disorder
* Intoxication or withdrawal from drugs
* Premenstrual changes in hormone levels
* Lack of bright light exposure during the winter
* Pressures of caring full-time for an individual with a long-term disability
Even though not all individuals with these symptoms experience a depressive disorder, the events that are more likely to cause depression include:
* Previous diagnosis or an episode of depression
* Family members who have experienced periods of depression
** Hannah’s mother reveals during the trial that her family has a history of anxiety (S2E8)
* Tendency to be more sensitive and experience strong emotions
* Difficult experiences during childhood, such as abusive, neglectful, or an overly strict environment
* Gender, females are more prone to depression than males (6 percent and almost 3 percent respectively)

## Risk and Protective Factors and Moderators
### Risk Factors

* Adolescents are at a significant risk for depression. According to the National Institute of Mental Health, an estimated 12.8% of adolescents aged 12-17 experience at least one major depressive episode each year.As Hannah was in this age range, her risk for depression was severely elevated compared to the general public.
* One factor that also may have contributed to Hannah's depression is loneliness. As Hannah was made fun of, she didn't have many friends, so she lacked a support system. This can leave someone feeling lonely and isolated. In a meta analysis conducted in Scandinavia, it was found that bullied children have a much higher risk of suicide. In fact, it was the leading cause next to sexual abuse, with a 2 fold risk of dying by suicide before the age of 20.
* Academic challenges may lower someone's self-esteem, this can be even more impactful for students with a learning disorder. In Hannah's case, her grades started slipping when she started becoming more depressed.
* Adolescents trying to balance the stress of classes, work, family, and other things may be more at risk for depression. Hannah was trying to help her family financially, balance school work, and make friends. This stress could have also put her at risk for depression.
* Stress from lacking monetary security may lead to depression. As Hannah's parents experienced more and more financial trouble, Hannah may have become more stressed and depressed.
* Concerns about the future (college or work) may lead to depression. As Hannah was told that her grades were not good enough to get her into the colleges that she wanted, this disappointment may have led to depression or contributed to it.
* People experiencing romantic relationship problems or unplanned pregnancies may be at a higher risk for depression. We know that Hannah experienced various romantic problems and they could have each been contributors to her depression.
* Inadequate or poor sleep may impair cognitive function and also contribute to depression. We do not really know about Hannah's sleep or lack of sleep.
* Poor health habits such as diet and lack of exercise may increase chances of depression. However, we do not know if this was the case with Hannah.
* Misusing drugs or alcohol may increases the risk of depression. While we know Hannah did use drugs and drank alcohol, we do not know if it was to such a degree that it could be classified as misuse.
* Trauma such as emotional, physical, or sexual abuse may lead to depression. Hannah was sexually assaulted as well as verbally harassed, this could have worsened her depression. According to one meta-analysis, 65% of samples reported a significant correlation between maltreatment in children and later suicide attempts.Those children exposed to this kind of violence have a 10 fold risk of dying by suicide before the age of 20.This maltreatment includes: neglect, physical abuse, emotional abuse, or emotional abuse.
* Other possible factors that may contribute to an adolescent's depression include:
** coming out or struggling with sexual or gender identity
** The emergence of other mental illnesses

### Protective Factors

Potential ways to reduce the likelihood of depression are as follows according to a study conducted by the National Longitudinal Study of Adolescent Health
* Adolescents with high self esteem have a lower risk of depression
* A 2-parent family structure reduces the likelihood of depression.
* Feeling connected to parents, peers, or school may help reduce the likelihood depression in adolescents.

### Moderators

Hannah's gender and age increase the probability of a mood disorder, and may reduce the chances of conduct disorder. Her solid academic performance previously suggests potential resilience.
Hannah's conflict with catching her father cheating and the secrets she keeps from her parents would be considerations before doing family therapy, as they may complicate consent for treatment (Hannah is still a minor).

## Hannah Baker's Timeline of Stressful Events

Suicidal ideation can creep up at any time. There is not an on average length of time between when someone first has thoughts about suicide to when they act on those plans. This is why it is important to recognize the signs and help.

# Prescription Phase
## Treatment Selection

The diagnostic interview suggests major depressive episode. The mood disorder clearly is associated with emotional distress and emotional regulation issues and should be a major focus of treatment.
There are a variety of treatment options for depression. These treatments allow for many diagnosed individuals to recover and live out fulfilling lives. Treatment plans are created for each person, meaning methods can be used individually or combined to be the most effective. Treatment options include:
* Therapy sessions involve actively listening to the patient and giving emotional support when needed. Therapists often help individuals understand what depression is, through psychoeducation, to teach them strategies to deal with it in everyday life.
* Trauma-focused Cognitive Behavioral Therapy would be more applicable for her than just CBT because it was developed to help children/adolescents affected by traumatic events. In Hannah Baker's case, she went through traumatic experiences such as sexual harassment then rape which ultimately led to her dying by suicide. Even though it is more widely used as an effective treatment for PTSD it can be effective in treating other trauma-related disorders as well such as Hannah's increase depressive symptom severity after the sexual assault at Bryan's party. Trauma-focused CBT is often short-term with 6 to 20 sessions with the child and his/her parents present. A trauma-focused CBT session addresses several factors related to the child’s traumatic experiences, including behavioral and cognitive issues, and depression or anxiety symptoms. Hannah Baker's parents had no idea what happened and the extent she was struggling with suicidal ideation before she died by suicide. Trauma-focused CBT helps improve parenting skills and parents’ interactions with their child to help support and cope with their children’s focus of concerns.
* Since Hannah is 17 years old and Cognitive Behavioral Therapy (CBT), as of right now, is the most research supported treatment, especially for adolescents, this selection of therapy would qualify as an evidence-based treatment if it is carried out properly. Psychological therapies such as CBT can be used to treat depression and are often most effective when paired with antidepressant/psychotropic medication if the treatment team thinks it would help with improve the child's treatment process. According to Hannah Baker's MADRS and HAM-D scores, she appears to be suffering from moderate depression which experts suggest antidepressants like SSRIs are helpful for children or adolescents with moderate to severe depression.
** One type is cognitive behavioral therapy that focuses on the effects of our thoughts on our feelings. Depression can cause a variety of negative thoughts ranging from self-hatred to negative feelings about the world. Cognitive behavioral therapy teaches individuals to recognize these negative thoughts as they occur and to make them more realistic to the person’s circumstances. Other aspects of this therapy include scheduling time with enjoyable activities and planning to regulate sleep or deal with stress.
** Interpersonal psychotherapy is a second method for dealing with depression. This focuses on the resolution of conflicts with others, methods to deal with grief or relationship changes, and strategies to better develop relationships.
** Dialectical behavior therapy focuses on dealing with stress, learning to regulate emotions, and to improve personal relationships. This can be particularly beneficial in treating self-harming behavior.
* Antidepressant medications are often helpful for adults with depression.
* Electroconvulsive therapy has been controversial due to cases with negative side effects but have been effective in some causes of severe depression.
* Here is a video on Cognitive-Behavioral Therapy for Adolescent Depression by Brook Maxfield and Kendal Binion: https://www.youtube.com/watch?v=JTcjMPoxUTM .

## Moderating Factors

The double depression is a moderating factor suggesting worse prognosis, along with potential demoralization and early drop out from treatment.

# Process Phase
## Clinically Significant Change
### Reliable Change Index

Pick a treatment target and specify what the RCI would be for it. Discuss how you would explain to Hannah

### Nomothetic Benchmarks

A, B, Cs of Jacobson definitions. General stuff about limitations would go on the main concept page. Here it is focused on the client -- what are the benchmarks they will focus on? How explained to them?

## Minimum Important Difference (MID)

Note that this section is a dangler -- not originally called out in the 12 steps. Medium d as a rule of thumb from Streiner, Norman, & Cairney (2015). Could work from AUC to d to raw units as a way of estimating, since psychology hasn't done research on this yet. Might be able to back into it with studies that had CSQ and outcome data.

## Client Goals & Tracking

These would be personal goals and idiographic measurement -- YTOPS, etc.

## Process Measures

This would be traces such as coming to sessions, doing homework assignments, therapeutic alliance, changes in cognition and practicing coping skills.

## Progress Measures

The Beck Depression Inventory-II (BDI-II) Is a good progress measure to track outcomes of treatment and changes in depression levels over time. There are norms on the BDI-II for different ages so you can compare scores to clinical samples and healthy samples to know if improvement is significantly different. The BDI-II is appropriate measure of depression for ages 13 and up.
YTOPS again and goal setting.

## Termination Planning and Maintenance

Revisit Jacobson benchmarks. Is there much chance of relapse? What things would the client need to pay attention to if they were going to nip that in the bud?

## Resources for Suicide and Depression

If you or a loved one are experiencing depression or having suicidal intentions, here are various resources to help.

### Websites

American Association of Suicidology
The American Association of Suicidology (AAS) is a not-for-profit organization. Their mission statement is "to promote the understanding and prevention of suicide and support those who have been affected by it." They accomplish this through the promotion of research, public education, and training for professionals as well as volunteers. They also serve as the national clearinghouse for information on suicide.
American Foundation for Suicide Prevention
The American Foundation for Suicide Prevention (AFSP) "raises awareness, funds scientific research and provides resources and aid to those affected by suicide." They accomplish this through funding scientific research related to suicide, educating the public about mental health, advocating for new policies regarding mental health, and supporting those affected by suicide.
Mental Health America
Mental Health America is the nation's leading community-based nonprofit intended to help those living with mental illness and promoting the mental health of all Americans. This resource has several mental screening health screening tests (ex: depression, anxiety, work health). They also provide resources on how to find help for yourself or someone you know.
MoodGYM
This scientifically evaluated site teaches new ways of thinking to help prevent depression and gives opportunities to practice skills in order to cope with depression and anxiety. All information you give is anonymous and confidential.
National Alliance on Mental Illness
The National Alliance on Mental Illness (NAMI) seeks to educate families, individuals, and educators on mental illness, advocate for public policy for people with mental illness and their families, and lead public awareness events. They also have a hotline to provide free information and support.
National Institute of Mental Health
The National Institute of Mental Health is a resource from the US government intended to offer information on a variety of mental health issues including suicide and depression. They offer downloadable booklets as well fact sheets.
Suicide Prevention Resource Center
The Suicide Prevention Resource is a federally funded resource that offers fact sheets on suicide by state and by population characteristics. They also offer tools to enhance suicide prevention efforts at many levels (university, hospital, native, and state).
Families for Depression Awareness
Families for Depression Awareness helps those who may be coping with bipolar disorders, depression, and suicidal thoughts by offering education, training, and a close-knit community to rely upon.
Mood Letter
Trustworthy information, hope, and help for those living with mood and anxiety disorders, their families, and the professionals who work with them.

### Books

Feeling Good: The New Mood Therapy by David D. Burns
Control Your Depression by Peter M. Lewinsohn
The above two Cognitive Based Therapy (CBT) based books have been found effective in trials for reducing symptoms of depression.
Ending the Depression Cycle by Martin Antony
Using strategies developed by CBT researchers, this self-help book reveals step-by-step strategies to prevent depression relapse.
Choosing to Live: How to Defeat Suicide Through Cognitive Therapy by Thomas Ellis
This book is the first self-help guide for those considering suicide. The authors speak in a non-judgmental tone providing tools for readers to asses the risk and understand factors that reinforce suicidal ideations. For health care professionals, this book also provides treatment manuals as well as readings and exercises for clients to do at home.
Mind Over Mood: Change How You Feel by Changing the Way You Think by Dennis Greenberger and Christine Padesky
This CBT based book helps people overcome multiple types of emotional issues (anxiety, depression, eating disorders, low self-esteem, etc.). It includes methods on mindfulness, gratitude journals, and worksheets.

### Help Lines

American Psychiatric Association Answer Center
1-888-35-77924
Available from 8:30 am to 6 pm (EST), live operators refer callers to local board-certified psychiatrists.
American Psychological Association Public Education Line
1-800-964-2000
Follow the automated instructions and press number 1. The operator will refer you to local, board-certified psychologists.
National Suicide Prevention Lifeline
1-800-273-8255
Available 24 hours per day, phone calls are transferred to trained counselors in over 130 sites across the nation. All calls are free and confidential. They also have an online chat too: https://suicidepreventionlifeline.org/chat/ .
The Trevor Project
1-866-488-7386
This free confidential, 24 hours per day suicide prevention help line is specifically intended for LGBTQ or questioning teens.

### Support Groups

American Self-Help Group Clearinghouse
This is a searchable database of over 1,000 national, international, model, and online self-help support groups.
National Alliance on Mental Illness
See above for description under websites.
Recovery International
This Chicago-Based self-help mental health organization sponsors weekly group peer-led, telephone, and internet-based meetings. Click "Find a Meeting" to find a meeting in your area.

## Resources for Non-suicidal Self-Injury
### Websites

S.A.F.E. Alternatives (Self-Abuse Finally Ends)
1-800-366-8288
This is a residential treatment program for people who self-injure. They have information about self-injury and starting treatment.

### Books

Bodily Harm: The Breakthrough Healing Program for Self-Injurers by Karen Conterio and Wendy Lader
This book is written by the directors of the S.A.F.E Alternatives program. This book is applicable for people who engage in self-injurious behavior as well as their loved ones. The book includes case studies and diaries of people in recovery, tools for removing barriers in care, and information about treatments for self injury.
Skin Game by Caroline Kettlewell
This book is a memoir on self injury. The author engaged in self-injurious behavior starting in adolescence, for many years.
Cutting: Understanding and Overcoming Self-Mutilation by Steven Levenkron
This book is intended for a range of audiences- people to engage in self-injurious behavior, their loved ones, and health professionals trying to better understand the behavior. It explores the psychological motivations for non-suicidal self-injury, common risk factors, and treatment benefits.