A national survey published in June of over 1,500 teenagers found that 70% are struggling with mental health issues. Even before COVID-19, the mental health of our teens was an issue. According to the National Institute of Mental Health (NIMH), 13.3% of U.S. kids ages 12 to 17 had at least one major depressive episode during the previous year and one-third had an anxiety disorder in their lifetime.
Once upon a time, depression in teenagers was thought to be something they would outgrow. Not so! Teens can have different types of depression:
Major depressive disorder (MDD): an intense episode of depression lasting longer than two weeks.
Chronic depression (dysthymia): a milder depression lasting for at least two years.
Adjustment disorder: depression developing after an upsetting event.
Seasonal affective disorder: depression developing during winter when hours of daylight are shorter.
Bipolar disorder: experiencing episodes of major depression and episodes of mania (emotional highs).
Disruptive mood dysregulation disorder: having intense, frequent outbursts of aggression and anger for more than a year.
Teens can also have different anxiety disorders:
Generalized anxiety disorder (GAD): excessive worrying about many things and may have physical symptoms, such as chest pain, headache, abdominal pain, or vomiting.
Obsessive compulsive disorder (OCD): having obsessive thoughts and compulsions (actions that try to relieve anxiety).
Phobia: intense fear of a specific thing, such as heights, leading to avoidance behavior.
Social anxiety: intense anxiety triggered by social situations.
Sometimes finding treatment is more difficult than making a diagnosis. Parents are often met with the same refrains when trying to seek treatment for their children: “No appointments until January… not accepting new patients… they don’t take our insurance… they don’t take care of teenagers….”
Unfortunately, there is a serious shortage of mental health providers in the U.S. By 2025, we may be facing a shortage of up to 15,600 psychiatrists.
Treatment usually involves therapy and medication. Evidence has shown that the combination provides better outcomes than either alone. Therapy can be provided by psychologists, social workers, and counselors. Types of therapy that are helpful for teenagers include cognitive behavioral therapy which addresses negative patterns of thinking and behaving, and interpersonal therapy which focuses on developing healthier relationships. Medications for depression or anxiety need to be managed by a prescribing provider such as a psychiatrist, doctor or nurse practitioner.
So where can teens get medication in a timely manner? From their primary care provider (PCP).
Medications correct imbalances of neurotransmitters in the brain that are involved with mood and emotion. Selective serotonin reuptake inhibitors (SSRIs) are the most widely used; they increase the levels of serotonin in the brain. Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase the levels of both serotonin and norepinephrine.
Start low and go slow: a medication for depression or anxiety in teens is started at low doses and the dose is increased slowly to reduce side effects. Frequent office visits are needed for the first month. It can take up to eight weeks to feel the benefit of the medication. Teens should be treated for at least six to 12 months to prevent relapse. When it is time to stop, it is important to taper slowly. Abruptly stopping may result in discontinuation syndrome which is mild but can cause headaches, nausea, and flu-like symptoms.
Although SSRIs and SNRIs are usually well tolerated, side effects may include abdominal pain, nausea, and headaches. Sometimes, a PCP may still need to refer a teen to a psychiatrist such as when a teen has agitation, suicidal or homicidal thoughts or behaviors, psychosis, bipolar depression, or treatment-resistant depression.
What about the “black box” warning? Since 2004, the US Food and Drug Administration has required all antidepressants to carry a warning stating that children and adolescents who take these medications are at increased risk for suicidal thinking or behavior especially in the first few weeks after starting or when the dose is changed. This is rare and should prompt a conversation with your child’s PCP to be weighed against the potential long-term benefit of reducing suicide risk by improving mood.
For teens in crisis, help is available 24/7 from the National Suicide Prevention Lifeline: 1-800-273-TALK (8255). In an emergency, call 911 or go to the nearest hospital emergency room.
Rima Himelstein is a pediatrician and adolescent-medicine specialist at Nemours/Alfred I. duPont Hospital for Children. Christine DiPaolo is a doctorate of nurse practitioners who specializes in pediatrics and adolescent medicine at Nemours.