Sándor Kalmár, M.D., Ph.D.

Introduction
In the past decades the acceleration of the changes in our society puts an increasing burden on the mental mechanisms of people and the mental development of the youth. Unfortunately, in spite of the huge advances in neuroscience, the family and school rearing of children, the child psychological and the child psychiatric care system cannot cope with this increased task (Kalmár Patrícia, 2011).

”Mental disorders are on the rise in the EU. Today, almost 50 million citizens (about 11% of the population) are estimated to experience mental disorders, with women and men developing end exhibiting different symptoms. Depression is already the most prevalent health problem in many EU-Member States. The foundation of life-long mental health is laid in the early years. Up to 50% of mental disorders have their oneset during adolescence. Mental health problem can be identified in between 10% and 20% of young people, with higher rates among disadvantaged population groups.” (European Pact for Mental Health and Well-being, 2008).

A quarter century ago the change of the political system in Hungary precipitated a serious value-crisis and caused a lot of harmful effects in nurturing but neither the educational system nor the child psychiatric care system could cope with these difficulties. The present school system is in a crisis, so it cannot ensure to develop the sound personality in every child. The Hungarian educational system produces below-average results with above-average costs while reproduces the above-average inequalities. The large inequalities within the country, the deep poverty, the lack of paramount mental education and nurturing, the lack of essential, consistent eternal values, the inadequate, quantitative and qualitative physical, cultural, mental, and spiritual nutrition are huge obstacles of the development of healthy individual and leads to self-destructive behavior and several, serious physical and mental disorders. (a) The supportive behavior of teachers, (b) appropriate conflict and stress management trainings, (c) required mental health education could be useful factors in the development of personality.

Teachers have a prominent role in the development of the personality and in early recognition of the psychopathological and psychosomatic symptoms (primary prevention) because apart from parents, they spend the most time with the children, and they must be the most sensitive towards emotional, mood and behavioral changes in children. Parents have reason to suppose that when their children are left with qualified teachers, they have knowledge which enables them to deal with the children professionally, and that every teacher

• has expectable essential, consistent eternal values,
• possesses perfect mental health knowledge,
• is familiar with the ”ABC” of mental education,
• is able to increase the mental, cultural and spiritual levels of the children,
• enables the children to cope with current crises,
• can improve conflict solving skills in the children,
• is able to recognize mental and psychosomatic symptoms in children, and know what to do when these appear.

Unfortunately this is not true (Volentics, 2005; Kalmár, 2011).
There are a lot of psychopathological signs and symptoms among adolescents and youths. However, we have two important facts:

1. We can find several psychopathological signs and symptoms without any Psychiatric Disorders among healthy children and young people. A great deal of research has established that psychotic symptoms are far more prevalent in the population than actual psychotic disorder. A meta-analysis of community-based studies in adolescents (aged 13-18 years) demonstrated a median population prevalence of 7.5%. These symptoms may be real psychotic but mostly occur in attenuated form; hallucination, illusion, delusion or overvalued idea but in which reality testing remains intact. The most frequent symptom is the auditory or acoustic hallucination. Otherwise, hearing voices without psychiatric disorders is frequent symptom among the adult population (Keleher et al, 2013).

2. A significantly greater part of young people have psychopathological symptoms and suffer from depressive disorders, but neither the duration nor the intensity of symptoms carry out the criteria for clinical depression. If clinical or subthreshold depressive and other mental disorders remain unrecognized, they would change well-being, future perspectives and the development of the adolescent.

The most important problems:

• According to the “Health behavior of school age children” international study, nearly 30% of Hungarian 7th, 9th and 11th grader boys and 17% of girls reported significant affective symptoms. Only 49.9% of surveyed students showed no depressive symptoms at all. (Örkényi, Kökönyei, Balogh, 2005)
• Mental, cultural and spiritual illiteracy and the number of psychosomatic symptoms and disorders, anxiety and depressive disorders increase already in childhood and adolescence, but the majority of the teachers are not prepared to recognize them. (Volentics, 2005)

Table 1 Some diseases of children aged 15-18 registered at the general practitioners’ and family paediatricians’ service. Number per ten thousand population of corresponding age. Hungary. 2001. 2013. (Yearbook of Health Statistics, 2001, 2013)

HUNGARY	aged 15-18
	year	boy	girl	together
Malignant neoplasms	2001	7.9	6.7	7.9
C00-C97	2013	18.7	12.8	13.2
Diseases of the blood and immune mechanism	2001	153.3	451.0	264.4
D50-D89	2013	398.6	811.1	599.2
Iron deficiency anaemia	2001	127.1	428.6	226.8
D50	2013	275.1	898.0	432.1
Diabetes mellitus	2001	20.8	17.7	21.7
E10-E14	2013	42.3	43.2	42.7
Hypertensive diseases	2001	124.2	72.8	102.4
I10-I15	2013	245.7	125.4	187.2
Asthma	2001	241.9	238.1	209.2
J45	2013	656.4	475.9	568.6

There is a strong connection between iron deficiency anaemia and depressive disorders.

It is important to emphasize that depression is a complex phenomenon with diverse biological, psychological, physical and mental, social, cultural and spiritual roots, which indicates that depression can only be understood taking into account the dynamic interaction between multiple risk factors. If the Depressive Disorders remain unrecognized, they restrict the development and wellbeing of the adolescent. The Depressive Disorders impair school performance, increase days of absence from school, and limit the career opportunities for students. (Makara, 2007) Lifetime prevalence of Depressive Disorders occurring before the age of 18 is 18-20%, the Mental and Adjustment Disorders among children and adolescents in Hungary is 24.8%. (It was 495 480 children in 2013). (Vetró, 1997) but the number of registered cared patients at child and youth psychiatric dispensaries in Hungary was 12 025 (7 543 male and 4 482 female) in 2013. This number is only 2.4% of the children who suffered from Mental Disorders. (Yearbooks of Health Statistics, 2013) Unfortunately a great part of the Mental and Adjustment Disorders among children and adolescents remained unrecognized, and untreated (Pászthy 2005).

Methods
We have examined 932 students (421 boys, 511 girls) in eight different secondary schools in Hungary with testing Child Depression Inventory. In the current study we did not investigate the psychiatric disorders. We used this self-report questionnaire for the assessment of depressive signs and symptoms.

Childhood Depression Inventory. (Kovács Mária, 1981, Hungarian version: Vetró Ágnes) The CDI is used to evaluate depression in children and adolescents examining 27 signs & symptoms and five syndromes. (Symptoms: 1. Depressed mood, 2. Lack of self-confidence 3. Self-respect disturbance, 4. Anhedonia, 5. Behaviour disturbance, 6. Anxiety, Preoccupatio, 7. Self-hate, 8. Self-incrimination, 9. Suicidal thoughts/ intention, 10. Crying, 11. Irritability, 12. Unsociable, 13. Indecisiveness, 14. Feeling of inadequacy, 15. Lack of motivation/interest, 16. Insomnia / Sleep disturbances, 17. Asthenia, 18. Decreased appetite, 19. Hypochondriasis, 20. Isolation, 21. Depressed mood in the school, 22. Loneliness, 23. Learning disturbance, 24. Behaviour disturbance, Inefficiency in behaviour, 25. Lack of love, 26. Adjustment disturbance, 27. Bad tempered. Syndromes: A: Negative mood B: Interpersonal problems C: Ineffectiveness 4: Anhedonia 5: Negative self-esteem.) (Perczel Forintos, Kiss, Ajtay, 2007)

Results
We have found that the 11.64%-54.16% of boys have mild symptoms (1 point) and 2.14%-30.17% have serious symptoms. (2 point) 16.44%-65.17% of girls have mild symptoms (1 point) and0.98%-21.92% have serious symptoms. (2 point)
Ninth item was serious. 25.89% of boys & 34.25% of girls answered: “I think about killing myself but would not do it” and 4.75% of boys & 4.5% of girls answered: “I want to kill myself”. There was one school where 52.38% of girls answered: “I think about killing myself but would not do it” and 14.29% of the girl answered: “I want to kill myself”. It is important because the suicide behavior is high among the adolescents. Suicide is the first cause of death among 15-24 year old children. 21.75% of all mortality was suicide among 15-24 years old youths in 2013 (boys: 24.7%; girls: 13.16%).

The number of suicides was 1,395 between 2000 and 2010. (1 150 male + 245 female) A lot of them had healthy body but temporarily suffered a reversible mental disorder, and frankly speaking we, physicians and health-workers did not do everything for these victims. Most of them died alone without any help, without any hope. They were not allowed to kill themselves. Everybody knows that, nevertheless they committed suicide. I believe we should have done than it was being done to reduce the victims of young suicide in our county.

Table 2 Occurrence of depressive symptoms of 932 Secondary School students by CDI (%)

Symptoms (421boys+511girls)	boy: 1 point	boy: 2 point	girl: 1 point	girl: 2 point
1: Depressed mood	23.99	2.34	45.4	1.57
2: Lack of confidence	45.6	3.8	58.71	6.07
3: Self-respect disturbances	49.17	2.14	65.17	3.52
4: Anhedonia	29.69	2.61	23.68	1.17
5: Behaviour disturbance	26.6	6.41	19.37	3.52
6: Anxiety	32.3	7.36	38.75	5.48
7: Self-hate	18.76	4.04	31.9	4.3
8: Self-accusation	39.19	7.84	37.38	4.5
9: Suicidal thoughts	25.89	4.75	34.25	4.5
10: Crying	11.64	3.56	28.77	2.54
11: Irritability	36.82	9.98	37.38	7.63
12: Unsociable	26.6	3.8	23.48	1.76
13: Indecisiveness	36.34	7.36	54.79	3.33
14: Feeling of inadequacy	33.25	3.8	47.36	11.55
15: Lack of motivation	41.8	30.17	37.57	21.92
16: Insomnia /Sleep disturbances	24.23	7.13	25.64	5.09
17: Asthenia, fatigue	49.64	12.35	57.73	15.26
18: Decreased appetite	17.1	5.46	23.68	4.5
19: Hypochondriasis	21.14	8.79	21.92	6.2
20: Isolation	27.79	4.99	36.2	4.3
21: Depressed mood in the school	28.5	8.55	22.5	2.74
22: Loneliness	27.32	2.61	22.9	1.76
23: Learning disturbance	41.57	14.25	37.57	15.07
24: Inefficiency in behaviour	54.16	11.64	41.88	12.72
25: Lack of love	20.43	6.17	14.68	2.35
26: Adjustment disturbance	37.53	4.27	34.44	2.74
27: Bad tempered	17.1	3.09	16.44	0.98

Table 3 Rate of suicide compared with all mortality. 15-24 year old people (%) Hungary

	2000	2001	2005	2009	2010	2012
male	22.2	24.2	17.8	27.7	23.6	24.7
female	12.8	16.5	9.7	12.8	15.6	13.16
total	19.6	22.2	15.5	23.7	21.4	21.75

Table 4 Depressive syndromes (by CDI) of 932 Secondary School students (%)

CDI (421m+511f)	boy (%)		girl (%)
	mild (1)	serious (2)	mild (1)	serious (2)
A: Negative mood	30.04	6.37	43.05	4.18
B: Interpersonal problems	26.96	4.1	23.92	2.25
C: Ineffectiveness	46.67	14.55	45.55	13.3
D: Anhedonia	29.76	6.6	29.28	5.51
E: Negative self-esteem	28.6	4.51	37.65	5.67
Total	32.09	7.28	35.93	6.18

According to the CDI: 32.09% of boys & 35.93% of girls have mild, and 7.28% of boys & 6.18% of girls have serious depressive syndromes. The worst syndrome is the C: Ineffectiveness. 46.67% of boys & 45.55% of girls have mild and 14.55% of boys & 13.3% of girls have serious syndromes.

Table 5 Depressive syndromes among Secondary School students in different studies according to Children Depression Inventory. (Kalmár, Fischer, 1999; Kalmár Patrícia, 2011; Kalmár, 2013)

Depressive syndromes	Kiskunhalas		Kecskemét		Budapest		Hungary
	1999		1999		2011		2013
	boys	girls	boys	girls	boys	girls	boys	girls
A: Negative mood	27.9	37.8	21.9	37.0	33.16	37.74	36.41	47.23
B: Interpersonal problems	21.2	12.2	16.7	16.9	23.66	12.5	31.06	26.17
C: Ineffectiveness	65.2	69.5	73.0	57.7	62.24	64.71	61.22	58.85
D: Anhedonia	27.5	33.8	21.6	34.7	25.92	29.41	36.36	34.79
E: Negative self-esteem	42.1	56.1	35.0	50.7	30.85	36.47	33.11	43.32

This table shows the results of four studies. The best syndrome is the B: Interpersonal problems, the worst syndromes are the C: Ineffectiveness and the E: Negative self-esteem in every study. These rates show the lack of appropriate mental and health-education in childhood and youth both in the family and the school. The frequency of depressive syndromes becomes significant in adolescence due to the previously accumulating unsuccessful crisis resolutions and the lack of mental, cultural and spiritual education. The negative self-image observable in adult patients develops in childhood and adolescence due to multiple factors, from which the most significant one is the strongly critical attitude of parents and teachers which contributes to reduced self-esteem.

Conclusion
These results are the consequences of the lack of the positive essential, consistent eternal values and the present of negative values in the schools, the lack of perfect mental, cultural, spiritual nurturing and education, and serious mental, cultural, social and spiritual illiteracy of parents and teachers. In spite of the fact that the occurrence of depressive signs and symptoms are frequent among the Hungarian students, the mental education, the mental prevention and psychiatric care service are insufficient in our country.

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