Teen Depression

Teens who develop depression are also more prone to having other biological challenges, like low birth weight, trouble sleeping, and having a mother younger than 18 years old at the time of their birth.

Depression that rises to the level of meeting criteria for a diagnosis can be broadly understood as depression that is severe enough that it interferes with the person's ability to function in some way. It is quite common in every age group, affecting more than 16% of the population in the United States at some point in their lifetime. Depression occurs at a rate of about 2% during childhood and from 4%-7% during adolescence. This mental illness is a leading cause of health impairment (morbidity) and death (mortality).

Depression is common during the teenage years, affecting about 20% of adolescents by the time they reach adulthood. Other statistics about teen depression include that more than 8% of adolescents suffer from depression that lasts a year or more.

As with most mental health disorders, depression in teens does not have one single definitive cause. Rather, people with this illness tend to have a number of biological, psychological, and environmental risk factors that contribute to its development.

• Neurotransmitters: Biologically, depression is associated with a reduced level of the neurotransmitter serotonin in the brain and with an imbalance of the neurotransmitter norepinephrine.
• Brain factors: This emotional illness is associated with a decrease in the size of some areas of the brain, as well as increased activity in other areas of the brain.
• Gender: Females are more likely to get depression than males, but that is thought to be the result of, among other things, a combination of biological differences based on gender, as well as the differences in how girls and women are encouraged to interpret their environment and respond to it and how they express themselves compared to men and boys.
• Genetics: There is thought to be at least a partially genetic contribution to the development of depression because children and adolescents with a depressed parent are up to four times more likely to develop the illness themselves.
• Biological challenges: Teens who develop depression are also more prone to having other biological challenges, like low birth weight, trouble sleeping, and having a mother younger than 18 years old at the time of their birth.
• Psychological risk factors: These include low self-esteem, poor body image, a tendency to be highly self-critical, and feeling helpless when dealing with negative events.
• Body changes: Teen depression and other mood disorders are somewhat associated with the stress of body changes, including the fluctuating hormones of puberty, as well as teen ambivalence toward increased independence, and with changes in their relationships with parents, peers, and others.
• Other disorders: Teenagers who suffer from conduct disorder, attention deficit hyperactivity disorder (ADHD), clinical anxiety, or who have cognitive and learning problems, as well as trouble relating to others are at higher risk of also developing depression.
• Environmental stressors: Depression may be a reaction to environmental stresses, including trauma like verbal, physical, or sexual abuse, the death of a loved one, school problems, or being the victim of bullying or peer pressure. Gay, bisexual, and transgender teens are at higher risk for depression, thought to be because of the bullying by peers and potential rejection by family members. Teens in military families have been found to be at risk for experiencing depression, as well.

The aforementioned environmental risk factors tend to specifically predispose individuals to depression. Other risk factors tend to predispose people to depression as well as putting them at risk for other problems. Such nonspecific risk factors for depression include poverty, exposure to violence, having an antisocial peer group or being socially isolated, abuse victimization, parental conflict, and family dissolution. Teens who have low physical activity, poor academic performance, or lose a relationship are at higher risk for depression. Research is increasingly showing that exposure to pollution or other environmental toxins is also thought to negatively influence mood.

Clinical depression, also called major depression, is more than sadness that lasts for a day or two before feeling better. In true depressive illnesses, the symptoms last weeks, months, or sometimes years if no treatment is received. Depression often results in the sufferer being unable to perform daily activities, like getting out of bed or getting dressed, much less working, doing errands, or socializing.

According to the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), which is the accepted resource for diagnosing mental disorders, general symptoms of a major depressive episode, regardless of age, include having a depressed or irritable mood for at least two weeks and having at least five of the following clinical signs and symptoms:

• Feeling sad or blue
• Crying frequently
• Loss of interest or pleasure in usual activities
• Significant increase or decrease in appetite
• Significant weight loss, failing to gain weight appropriately, or gaining excessive weight
• Change in sleep pattern: inability to sleep or excessive sleeping
• Agitation, irritability, or anger
• Fatigue or loss of energy
• A tendency to isolate from friends and family
• Trouble concentrating
• Feelings of worthlessness or excessive guilt
• Thoughts of death or thoughts, plans, or attempts at completing suicide

Depressed teenagers may also experience the classic symptoms but may exhibit other symptoms as well, including

• poor school performance,
• persistent boredom,
• frequent complaints of physical symptoms, such as headaches and stomachaches,
• engaging in self-harm that is not intended to cause death (for example, cutting or burning oneself),
• more risk-taking behaviors, and/or showing less concern for their own safety.

Examples of risk-taking behaviors include driving recklessly or at excessive speed, socializing with strangers or otherwise without sufficient regard for their own safety, engaging in promiscuous or unprotected sex, or becoming intoxicated with alcohol or other drugs, especially in situations in which they are driving or may be in the presence of others who engage in risky behaviors. The use of alcohol or other drugs that occurs in depressed teens and other age groups is often thought to be the individual's attempt (risky and ultimately ineffective as it may be) to make themselves feel better (self-medicating).

Parents of teens with depression often report noticing the following behavior changes in the adolescent:

• Crying more often or more easily
• More irritability or hostility than usual
• Eating changes, changes in sleeping patterns, or weight change significantly or the teen fails to gain weight appropriately for their age
• Unexplained physical complaints (for example, headaches or abdominal pain)
• Spending more time alone, withdrawal from friends and family
• Becoming more "clingy" and more dependent on certain relationships (This is less common than social withdrawal.)
• Overly pessimistic or exhibits excessive guilt or feelings of worthlessness
• Expresses thoughts about hurting him or herself or exhibits reckless or other harmful behavior

About 3,000 youth die by suicide each year in the United States, making it the third leading cause of death in youth ages 10-24. Latino and African-American teenage girls are thought to attempt suicide more often than their age peers who are male or of other ethnic backgrounds. Native-American teens tend to complete suicide nearly twice as often as the national average, and gay, lesbian, bisexual, and transgender teens complete suicide four times more than their heterosexual age peers.

10 warning signs for teen suicide can include the following:

1. A sudden change in behavior
2. Lack of motivation
3. Social withdrawal/isolation
4. A change in eating patterns
5. Preoccupation with death or dying
6. Giving away valued personal possessions
7. Symptom or signs of depression
8. Increased moodiness
9. Hopelessness
10. What appears to be a sudden improvement in mood (due to resolving to die by suicide)

Many providers of health care may help make the diagnosis of clinical depression in teens, including licensed mental health therapists, pediatricians or other primary care providers, specialists whom you see for a medical condition, emergency physicians, psychiatrists, psychiatric physician's assistants, psychologists, psychiatric nurses, nurse practitioners, and social workers. Since the symptoms of depression can mimic those of other mental health disorders and depression can co-occur with other mental health disorders, the professional will ask about many other emotional problems to make that distinction.

One of these professionals described above also will likely conduct or refer for an extensive medical interview and physical examination as part of establishing the diagnosis. Depression may be associated with a number of other medical conditions or can be a side effect of various medications. For this reason, routine laboratory tests are often performed during the initial evaluation to rule out other causes of symptoms. Occasionally, an X-ray, CT or MRI scan, or other imaging study may be needed. As part of this examination, the sufferer may be asked a series of questions from a standardized questionnaire or self-test to help assess the risk of depression and suicide.

If the symptoms indicate that a teen is suffering from clinical depression, the health care provider will likely strongly recommend treatment. Treatment may include addressing any medical conditions that cause or worsen depression. For example, an individual who is found to have low levels of thyroid hormone might receive hormone replacement with levothyroxine (Synthroid). Other components of treatment may be supportive therapy, such as changes in lifestyle and behavior, psychotherapy, and complementary therapies. Treatment may include medication for moderate to severe depression. If symptoms are severe enough to warrant treatment with medication, symptoms tend to improve faster and for longer when medication treatment is combined with psychotherapy.

Most practitioners will continue treatment of major depression for at least six months to a year after symptoms have stabilized. Treatment for teens with depression can have a significantly positive effect on how well the adolescent functions with peers, family, and at school. Without treatment, symptoms tend to last much longer and may never get better. In fact, they may get worse. With treatment, chances of recovery are improved.

Psychotherapy

Psychotherapy ("talk therapy") is a form of mental health counseling that involves working with a trained therapist to figure out ways to solve problems and cope with depression. It can be a powerful intervention, even producing positive biochemical changes in the brain. In addition to individual psychotherapy, group therapies have been found to be beneficial forms of treatment based on the normal developmental tendencies for adolescents to value their peer relationships. Two major approaches are commonly used to treat teen depression: interpersonal therapy and cognitive behavioral therapy. In general, these therapies take weeks to months to complete. Each has a goal of alleviating the symptoms. More intense psychotherapy may be needed for longer when treating very severe depression or for depression with other psychiatric symptoms.

• Interpersonal therapy (IPT): This form of psychotherapy helps to alleviate depressive symptoms and helps the sufferer develop more effective skills for coping with social and interpersonal relationships. IPT employs two strategies to achieve these goals:
  • The first is education about the nature of depression. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment.
  • The second strategy is defining problems (such as abnormal grief or interpersonal conflicts). After the problems are defined, the therapist is able to help set realistic goals for solving these problems and work with the depressed teen using various treatment techniques to reach these goals.
• Cognitive behavioral therapy (CBT): This type of psychotherapy has been found to be effective as part of treatment for even severe adolescent depression. This approach helps to alleviate depression and reduce the likelihood it will come back by helping the teen change his or her way of thinking about certain issues. In CBT, the therapist uses three techniques to accomplish these goals.
  • Didactic component: This phase helps to set up positive expectations for therapy and promote the youth's cooperation with the treatment process.
  • Cognitive component: This aspect of CBT helps to identify the thoughts and assumptions and ways of thinking that influence the teen's behaviors, particularly those that may predispose the sufferer to being depressed.
  • Behavioral component: This employs behavior-modification techniques to teach the teenager more effective strategies for dealing with problems.

Medications

The major types of antidepressant medications prescribed for adults are the selective serotonin reuptake inhibitors (SSRIs), the tricyclic antidepressants (TCAs), and the atypical antidepressants. TCAs are sometimes prescribed in adults in severe cases of depression or when SSRI medications don't work but have been determined not to be largely effective in treating teen depression. The monoamine oxidase inhibitors (MAOIs) have fallen out of favor as antidepressants, particularly in adolescents, because of the negative interactions this group of medications can have with numerous foods and medications.

SSRI medications affect levels of serotonin in the brain. For many prescribing doctors, these medications are the first choice because of the high level of effectiveness and general safety of this group of medicines. Examples of these medications are listed here. The generic name is first, with the brand name in parentheses.

• Fluoxetine 
• Sertraline 
• Paroxetine 
• Fluvoxamine 
• Citalopram 
• Escitalopram 
• Vortioxetine 
• Vilazodone 

Only fluoxetine and escitalopram are approved by the U.S. Food and Drug Administration (FDA) for the treatment of teen depression. Any other medications used to treat this illness in teens are therefore considered to be being used "off label."

Although FDA approved for use in teens with just bipolar disorder in the case of lurasidone and schizophrenia as well as bipolar disorder rather than for the treatment of depression in the case of other atypical neuroleptic medications like aripiprazole, risperidone, olanzapine, paliperidone, and quetiapine, these medications are also sometimes prescribed in addition to an antidepressant in adolescents with severe depression who fail to improve after receiving trials of different antidepressants. They may also be prescribed in addition to, or instead of, an antidepressant in teens who suffer from bipolar disorder.

Non-neuroleptic mood-stabilizer medications are also sometimes used with an antidepressant to treat teens with unipolar depression who do not improve after receiving trials of different antidepressants. These medications might also be considered in addition to or instead of an antidepressant in adolescents who suffer from bipolar disorder. Examples of non-neuroleptic mood stabilizers that are used for this purpose include divalproex sodium, carbamazepine, and lamotrigine. Of the non-neuroleptic mood stabilizers, lamotrigine seems to be unique in its ability to also treat unipolar depression effectively by itself as well as in addition to an antidepressant. It is only used in people older than 16 years of age or older due to rare but potentially serious side effects.

Atypical antidepressant medications work differently than the commonly used SSRIs. The following medications might be prescribed when SSRIs have not worked: bupropion, venlafaxine, duloxetine, desvenlafaxine, or levomilnacipran.

About one-half of teens who take antidepressant medications get better. It may take anywhere from one to six weeks of taking medication at its effective dose to start feeling better. The prescribing mental health professional (for example, psychiatrist or other physician, nurse practitioner, physician assistant) will likely assess the depressed teen that is receiving the medication soon after it is started to see if the medication is being well tolerated and if symptoms have begun to improve. If not, the doctor may adjust the dose of the medication or prescribe a different one.

After symptoms begin to improve, the prescribing doctor will likely encourage the depressed teen to continue taking the medication for six months to a year since stopping the medication too soon may cause symptoms to return or to get worse. Some people need to take the medication for longer periods of time to keep the depression from returning. Stopping abruptly may cause the depression to return or for serious withdrawal effects to occur, depending on the medication that is being taken.

The side effects of antidepressant medications vary considerably from drug to drug and from person to person.

• Common side effects include dry mouth, sexual dysfunction, nausea, tremor, insomnia, blurred vision, constipation, and dizziness.
• In very rare cases, some people of all ages have been thought to have become acutely more depressed once on the medication, even attempting or completing suicide or homicide. Children and teenagers are thought to be particularly vulnerable to this rare possibility. However, when considering this risk, it is important to also consider the risk of the potential serious outcomes that can result from untreated depression.

Alternative treatments

Several nonprescription herbal and dietary supplements are used by some people to treat depression. Little is known about the safety, effectiveness, or appropriate dosage of these remedies, although they are taken by thousands of people around the world.

• A few of the best-known alternative remedies continue to be studied scientifically to see how well they work, but to date, there is little evidence that herbal remedies effectively treat moderate to severe clinical depression.
• Medical professionals usually are hesitant to recommend herbs or dietary supplements, particularly in teens, because they are not regulated by the U.S. Food and Drug Administration (FDA), as prescription drugs are, to ensure their purity, quality, and safety.

Depression can be quite chronic, in that 85% of people who have one episode of the illness will have another one within 15 years of the first episode. A bit over 50% of teens who are part of research studies on depression treatment significantly improve. About 12% will relapse in the first year, and about 60% of teens who suffer from clinical depression will suffer with a recurrence of it during adulthood. Clinical depression is the leading cause of disability in the United States in people over 5 years of age.

Adolescent depression is associated with a number of potentially negative outcomes, including problems at school, work, in their relationships, and with drugs. Certainly the worst potential outcome of depression, suicide is the third leading cause of death in teens.

Teen depression is a risk factor for developing a number of other mental health symptoms and disorders. Teens with depression are more likely to engage in self-mutilation. That the number of teens who engage in that behavior is increasing is thought to be partially due to its being promoted by trends in music and media, including social media that features self-mutilating behaviors. Adolescents with depression are also at risk of having poor school performance, early pregnancy, and engaging in alcohol and other drug abuse. As adults, people who suffered from depression during adolescence are at risk for job disruptions, as well as family and other social upheaval during adulthood.

Attempts at prevention of teen depression tends to address both specific and nonspecific risk factors, strengthen protective factors, and use an approach that is appropriate for the teen's developmental level. Such programs often use cognitive behavioral and/or interpersonal approaches, as well as family based prevention strategies because research shows that these interventions are the most helpful to teens' well-being.

The inverse of most risk factors, protective factors for teen depression include having the involvement of supportive adults, strong family and peer relationships, healthy coping skills, and skills in emotion regulation. Children and adolescents of a depressed parent tend to be more resilient when the teen is more able to focus on age-appropriate tasks in their lives and on their relationships, as well as being able to understand their parents' illness. For depressed parents, their children seem to be more protected from developing the illness when the parent is able to demonstrate a commitment to parenting and to relationships. Youth of depressed parents have also been found to benefit from being part of a support group that uses cognitive therapy as the management approach.

Family members and friends are advised to seek and encourage the depressed teen to receive mental health evaluation and treatment. Family members may consult with the teen's primary care doctor or seek mental health services by contacting one of the resources identified below. Friends of the depression sufferer sometimes think that they would be betraying their friend's confidence by notifying the depressed teen's parents, teachers, school counselor, or other school personnel about their friend's troubles. The potential risk of their friend's sadness worsening and leading to their becoming suicidal or homicidal far outweighs the risk of the depressed teen feeling betrayed.

Once the depressed youth is in treatment, family members can help encourage good mental health by gently encouraging him or her to adopt a healthy lifestyle. Examples of that include encouraging the teen to drink plenty of water, maintain a healthy diet, get adequate sleep, participate in regular exercise, and engage in appropriate stress-management activities. Friends can encourage the depressed peer to remain socially active rather than becoming isolated. Both family and friends can be helpful to the depressed teen by discouraging their loved one from using alcohol or other drugs or otherwise engaging in risky behaviors.

American Association of Suicidology
http://www.suicidology.org
202-237-2280

American Foundation for Suicide Prevention
http://www.afsp.org

Jason Foundation
http://www.jasonfoundation.com

National Alliance for the Mentally Ill
2101 Wilson Boulevard Suite 302
Arlington, VA 22201
HelpLine: 800-950-NAMI [6264]
http://www.nami.org/

National Institute of Mental Health
http://www.nimh.nih.gov

National Suicide Prevention Hotline
800-SUICIDE (784-2433)
http://www.suicide.org

National Suicide Prevention Lifeline
800-273-TALK (8255)

National Youth Crisis Hotline
800-448-4663

National Youth Violence Prevention Resource Center
866-SAFEYOUTH (1-866-723-3968)
Hours: Monday through Friday, 8 a.m.-6 p.m. Eastern time

Parental Stress Hotline (support for parents)
800-632-8188

Substance Abuse and Mental Health Services Administration (SAMHSA)
http://www.samhsa.gov

Suicide and Depression Hotline -- Covenant House
800-999-9999

Suicide Prevention Advocacy Network (Span)
http://www.spanusa.org

Yellow Ribbon Suicide Prevention Program
http://www.yellowribbon.org/