Teenagers and Depression: Heartbreak, Hope, and How to Help
Teenagers today are in crisis. Here’s what’s behind their struggle and—if you are sick with worry, wondering if your struggling adolescent will be okay—some hope, too. New, faster-acting treatments are on the horizon.
Pain. Persistent, confounding, invisible emotional pain. Our teenagers are overwhelmed by too many demands and too many expectations. And being constantly bombarded with images of inauthentic beauty and unobtainable lives on social media only makes a bad situation worse.
On top of that, many are grappling with existential worries. You know, all that stuff we can’t control—gun violence, climate change, the war in Ukraine, and a global pandemic to name a few.
Understanding Why Teenagers Get Depressed
It used to be that drinking and driving is what killed teenagers. Today, the biggest threat to their health just may be themselves.
In the past decade, the teen suicide rate has surged by 60% and 1 in 5 high school students report that they have considered taking their life. (Meanwhile, rates of teen pregnancy, smoking, and drunk driving have declined.) What’s behind these terrible statistics? Experts say untreated depression is the likely culprit.
Research is still emerging, but pandemic-related isolation has exacerbated the problem. In October 2021—in an effort to bring attention to this difficult issue—the American Academy of Pediatrics together with the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national state of emergency in children’s mental health.
In June 2021, the Centers for Disease Control and Prevention (CDC) reported that emergency department visits for suspected suicide attempts among adolescents jumped 31% in 2020, compared with 2019. That data was even worse for girls. In the 12-17 age bracket, suspected suicide attempts were 51% higher.
California-based licensed marriage and family therapist Linnea Butler, LMFT says in-person connection is especially important for teenagers, and during the pandemic, those opportunities largely ceased to exist. “The lack of peer groups and activities that validate their identity and increase their self-confidence has taken a huge toll on this vulnerable population,” she explains.
The Teenage Brain: A Work in Progress
Physiological factors also contribute to depression in teenagers. The underdeveloped teenage brain lacks the coping skills needed to handle difficult feelings. Puberty arriving earlier in both boys and girls (factors like childhood obesity and endocrine disruptors in the environment are possible culprits, researchers say) adds another layer of complexity. Childlike minds simply aren’t well suited to navigate surging hormones and rapidly-changing bodies, experts say.²
Important brain development occurs during sleep, so the importance of getting enough sleep consistently cannot be overstated. Sleep is essential for normal brain development, and this generation simply doesn't get enough of it. Many teens admit to playing video games and watching TikTok reels well into the night. Many public high school hours start very early—especially factoring in time for bus rides—which contributes to sleep deprivation in this age group. Studies on adolescents show that lack of sleep is linked to depression.
Unhealthy Forms of Distraction
Looking to escape the pain—and not knowing what else to do—kids do what they have done for generations and reach for drugs or alcohol.
Recreational marijuana, which is legal and easily accessible in several states, is the go-to. But recent studies show that it, too, heightens depression in the teenage population. Data from the National Survey on Drug Use and Health (conducted from 2012 to 2017) show a link between the frequency of cannabis use and the development of the major depressive disorder (MDD) in adolescents. The study’s results: “Adolescents with any history of cannabis use had significantly higher rates of lifetime MDD, MDD with severe role impairment, and past year suicide attempt.”
There is also a growing body of evidence that cannabis in teens with a genetic predisposition to psychotic disorders can worsen the risk due to their developing brains’ susceptibility to its effects.
While those substances may offer temporary relief and distraction, they elevate anxious and depressive thoughts. Sexual promiscuity—sometimes used to avoid complicated and difficult feelings—often leaves teens with feelings of self-loathing.
Barriers to Treating Adolescent Depression
The good news is that the brain can be taught to become more resilient. Working with a therapist can help. Teens are prone to rumination and interpreting information that reinforces a negative outlook. Psychotherapy like cognitive-behavioral therapy (CBT) can help change their focus and teach teens how to form rewarding relationships.
Antidepressant medication, especially when combined with behavioral therapy, has been proven effective for treating depression in some teens. But access to mental health care continues to be a problem in the US, especially in low-income and rural communities.
And the access problem is not just related to cost or lack of health insurance.
The American Academy of Paediatrics recently found that more than half of our nation’s kids with a treatable mental health disorder do not receive treatment due to a concerning shortage of child psychiatrists.⁴ (Note: Child and adolescent psychiatry is a specialized field that requires two additional years of training beyond regular psychiatry.)
Given the dearth of child psychiatrists, paediatricians desperate to help sometimes prescribe antidepressants, although they aren’t sufficiently schooled in psychiatric medication management. There are a variety of medications that can help with depression, but they aren't always effective. Plus, it’s difficult to predict which medicine will relieve symptoms, so time-consuming medication trials are often necessary.
The most commonly prescribed medications for depression are selective serotonin reuptake inhibitors (SSRIs)⁵. They don’t work for everyone (an estimated 30% to 50% of people with depression don't respond to antidepressants) and they don’t act quickly. It typically takes 3 to 6 weeks for benefits to be realized—not ideal if your child is in acute distress.⁶ Plus, many have not been studied for long-term effects.
Unfortunately, some antidepressants have been shown to increase the risk of suicide in the adolescent population, particularly when the drug is being initiated (the first 2-4 weeks). In 2004, the FDA issued a black box warning indicating an increased risk of suicidal thinking and behaviour in young people, in nine antidepressants: citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor), mirtazapine (Remeron), nefazodone (Serzone), and bupropion (Wellbutrin).
What Is Treatment-Resistant Depression?
Sometimes, even with treatment, the symptoms of depression do not improve. Clinicians call this predicament treatment-resistant depression or TRD.
Butler, who is also certified in dialectical behavior therapy says TRD is defined by depression that has been unresponsive to at least two or more treatments. “Often this refers to trying at least two antidepressants, most commonly a selective serotonin reuptake inhibitor (SSRI) or a serotonin–norepinephrine reuptake inhibitor (SNRI), and not seeing improvement,” she explains.
Trying several medications but stopping due to side effects, does not qualify as TRD, says Tracey Marks, MD, a general and forensic psychiatrist in Atlanta.
TRD becomes a legitimate concern when a patient has no response at all from prescribed medications or they do not experience significant symptom improvement from prescribed medications. According to Dr. Marks, “When a person only gets partially better … and the part that’s left over still makes them pretty dysfunctional, that’s TRD.”
David Brent, MD, endowed chair in suicide studies and professor of psychiatry at the University of Pittsburgh School of Medicine, pointed out in a report, Treatment-Resistant Depression in Adolescents, that parental depression, family discord, and a history of abuse all have been shown to predict poor response to treatment for depression. Something else worth noting is that “alcohol and substance abuse may mimic or complicate a depressive picture, as well as confer treatment resistance.”
When symptoms of depression persist, having the wrong diagnosis should also be considered. Other mental health conditions can mimic or co-exist with depression. Butler explains, “Depression, including TRD, can be secondary to a different and more core diagnosis. Without treating that core problem, the depression will be [unmanageable].”
Bipolar depression is not commonly mistaken for TRD; however, post-traumatic stress disorder (PTSD), borderline personality disorder (BPD), and bipolar depression that exists with attention-deficit hyperactivity disorder (ADHD) can be difficult to differentiate.
If you are concerned about the diagnosis, seek a second opinion. Input from other parents struggling similarly can be valuable. Local families dealing with the challenges of teenagers with depression can be excellent sources of information about mental health care providers in your area. The National Alliance on Mental Illness (NAMI) has over 600 state and local affiliates across the country. Many of the affiliates have free support and education groups for families.
Three Promising Treatments for Depression and TRD
The most promising treatments for persistent depression may not involve medication. Treatments like transcranial magnetic stimulation (TMS), SAINT, and ketamine-assisted treatment (KAT) or psychotherapy (KAP) have not been fully vetted for adolescents by the FDA (because it’s difficult to conduct clinical trials in teenagers) but can be considered in that population, under the right conditions.
Because these are not FDA approved, use is considered off-label and not covered by insurance or practice guidelines, which some clinicians may avoid to prevent legal trouble. Clinical trial participation or careful benefit-risk discussion with a provider willing to administer it off-label are the only ways to access these treatments in a pediatric population currently.
Here’s what else you need to know:
#1. Transcranial Magnetic Stimulation (TMS)
Transcranial magnetic stimulation, or TMS, is a non-invasive form of brain stimulation that is generally well tolerated and doesn’t require anesthesia.
“I have referred quite a few adult clients to TMS for treatment-resistant depression,” says Butler. “In my experience, TMS is either beneficial or neutral. It takes a long time to see the effects, sometimes as many as 80 sessions, so it is possible that the people with minimal or no effect did not do it long enough. There are rare reports of adverse reactions to TMS but I haven't seen anything conclusive.”
Treatment times vary, but typically last under an hour each day. And a typical course of treatment involves five times a week for four to six weeks.
Butler says TMS is available in many areas, but most clinics focus on adult treatment (TMS is not approved for people under the age of 18). “If you’re interested in exploring TMS for your teens, you should know that it may take some additional leg work to find a clinic that works with teens.”⁹
#2. Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT)
A more specialized form of TMS that teaches the brain to properly respond to depressive thoughts is SAINT, an acronym for the Stanford Accelerated Intelligent Neuromodulation Therapy.
In a small study, Stanford researchers recently found that SAINT resolved depression symptoms for 90% of people in their study. The American Journal of Psychiatry (AJP) published the results and found that the treatment, which was administered over the course of five days (10 sessions, 10-minutes each session) was well-tolerated, safe, and effective.
To learn more, visit the Brain Stimulation Lab patient website. This emerging treatment is also recruiting participants for ongoing clinical trials.
#3. Ketamine-Involved Treatment
KAT or KAP involves the drug ketamine, which was once used mainly as an anaesthetic on battlefields and in operating rooms. The drug which has psychoactive properties induces a feeling of calm and relaxation.⁷˒⁸
The American Journal of Psychiatry seemingly endorsed ketamine as an effective treatment for young people at imminent risk of suicide. An editorial published in April 2021 stressed the urgency of advancing the research agenda and stated, “We must think broadly about improving access to mental health care for youths across the continuum of care [and] prioritizing innovative treatments like rapid-onset antidepressant medications to reduce acute suicide risk should be at the top of the national mental health agenda.”
Mental health struggles including depression aren’t always obvious in teenagers. They can’t be diagnosed with a simple blood test or an X-ray. And it’s all too easy to chalk up moodiness or anger to “normal” teenage angst but these kids need us now more than ever.
Resources for Parents and Adolescents
#1. Society for Adolescent Health and Medicine has resources specifically geared to adolescents and young adults and their parents.
#2. American Academy of Child and Adolescent Psychiatry provides concise, up-to-date information on issues that impact children, teens, and their parents.
#3. Yale Center for Clinical Investigation. Ketamine for Adolescent Suicidality. Clinical trial information and other resources for families.
#4. notOK is a free digital panic button that connects you with immediate support via text, phone call, or GPS location.
#5. Teen Line is staffed with professionally trained youth counsellors who provide support, resources, and hope to young people who feel lost to mental health challenges.
#6. IMAlive is a live online network that uses instant messaging to respond to people in crisis.
#7. National Suicide Prevention Lifeline offers help to anyone in need of support who is experiencing thoughts of suicide.
#8. Speaking of Suicide is a site for immediate help with suicidal thoughts for suicidal individuals and their loved ones, survivors, mental health professionals and others who care.
#9. Boys Town National Hotline 800-448-3000 (serves the youth of all genders). This free service is staffed by specially trained counsellors and is available 24 hours a day, 365 days a year. Find help with a range of issues including abuse, anger, depression, school issues, and bullying.
#10. Samaritans 24-Hour Crisis Hotline (212) 673-3000 offers non-religious and confidential 24-hour emotional support for those in crisis, depressed, or feeling overwhelmed.
www.psycom.net/depression/depression-treatment/treatment-resistant-depression/teens
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