Dr. Carol Glod is Director of Nursing Research at McLean Hospital. She conducts studies of adolescent depression and its possible treatments.
Depression in teens usually goes undiagnosed, and often leads to drug and alcohol abuse or additional behavioral disorders. Furthermore, depression is the leading cause of suicide. In a recent national survey of high school students, nearly 20% of teens thought about attempting suicide, and more than 8% made a suicide attempt.
Teens with depression often look and act differently than adults with depression. For example, teens are usually irritable, rather than sad and depressed. Dr. Glod discusses how many teens develop depression, what signs of depression to look for in teens, how parents and friends can help a depressed teen, treatments for teen depression, and her clinical studies.
How common is depression in teens?
The prevalence of depression is higher in teens than in children. Two and a half percent of children, six to 12 years of age, have depression, while at least eight percent of teens have depression. Some studies suggest that as many as 20% of teenagers have depression.
Is depression more prevalent in teenage girls or boys?
Girls are twice as likely to have depression as boys are. In children younger then twelve years old, depression is about equal in girls and boys. Then, something changes in adolescents.
Why are the numbers of teens who report having suicidal attempts so high?
In the high school surveys, we have found that more than 8% of students had seriously considered suicide to the point of actually making an attempt. These statistics are alarmingly high, because teens have a lot of untreated depression. There is still a lot of stigma associated with having depression, particularly for teenagers. For the majority who feel suicidal, there is an underlying depression that hasn't been identified, hasn't been evaluated, and certainly hasn't been treated.
How do the symptoms of teen depression differ from adult depression?
Depression is a disorder, and it affects teenagers and children just as it affects adults. We diagnose it using the same criteria that we use for adults, but teenagers usually have some symptoms that are more prominent. Teens with depression:
- Tend to complain of feeling irritable or grouchy, while adults are more often sad and depressed. For example, a young woman came to my office who was tearful. I asked her one question, and she walked out and slammed the door. This type of irritable behavior is common among teens.
- Tend to have problems with their sleep. They stay up late, have trouble waking up in the morning, or sleep too much.
- Don't find their usual activities enjoyable. For example, a teen gives up soccer because; "I just didn't like it anymore." Or, a teen may say, "I don't hang around after school with my friends because they don't like me and I don't like them."
- May have physical problems, like stomachaches and headaches that can't be explained.
- May feel suicidal. This is a key symptom that adolescents with depression have. Teens don't always have it, but if they have it, they usually have major depression.
- May have changes in appetite.
- May blame their problems on other people (e.g., "My teacher is giving me a hard time.")
- Show declining school performance (an 'A' student in junior high, all of a sudden is a 'B' and 'C' student).
However, teens with depression don't tend to pull away from their friends, whereas adults tend to withdraw. If you ask most teens with depression if they have friends, and if they are still socializing, they say yes. They may socialize less, or their friends may push them to get out. But they usually don't give up their friendships. If a teen is disconnected from his or her friends, the depression is fairly severe and has been going on a long time.
If a teen ever says that they want to kill themselves, or are thinking about death, this is a serious sign! The person needs to be evaluated immediately. These symptoms are not part of normal adolescence. Some teens are very impulsive, and they tend to confide in their friends, not adults. I had a young girl tell me that she and one of her friends had both been feeling suicidal, and they thought that they might do something together. They had never told anyone before.
Is alcohol and drug abuse a symptom of underlying depression?
Undiagnosed and untreated depression often leads to alcohol and substance abuse and dependence. On average, in teens that develop drug and alcohol problems, the depression precedes the drug and alcohol problems by about five years. Teens may turn to drugs and alcohol in an attempt to self-medicate. They may feel so bad that they want to get high or get drunk to feel numb.
So, it is critical to intervene early. Also, at least 70% of teenagers who have depression will have a recurrence within five years, or at some point in adulthood. Teen depression predicts depression in adulthood. So even if somebody goes through a period of depression, and they get better, it is likely to recur.
How does a parent determine the difference between typical teen rebellious behavior and depression?
Parents typically think that adolescence is a stormy time, with hormonal shifts, so a lot of what gets attributed to normal adolescence can be depression. If you suspect that a teen might have a problem with depression, you need to get a professional evaluation. A teenager may look fine on the outside, but have a lot going on inside. It can be hard for parents to tell. Keep in mind that depression isn't one symptom, it is a group of symptoms, you need to see at least a few signs of depression. Again, if a teen talks of death or suicide, the person needs immediate professional help.
How are teens normally screened for depression in their community and schools?
High schools are starting to give depression-screening surveys, but they are still uncommon. And usually these surveys are anonymous, so no one follows up to get these teens into treatment. Teens also have to self-identify as having a problem. Since most teenagers don't recognize depression, we know that most of them don't get help. Sometimes, they go to their guidance department; a school nurse, a school psychologist, a primary care doctor, or a parent. More likely, they tell their friends.
What should a friend say to someone who is depressed?
It is important to be supportive and to say things like, "I am very concerned about you. You are saying things that I am really worried about, and we need to tell somebody. Let's talk to your parents, or the guidance department or the school nurse." Somehow, they need to let an adult know.
If a depressed teen doesn't want anybody to know, should a friend break his or her confidence?
Yes, definitely. And this is a very hard thing for a teenager to do. Teens don't want to jeopardize a friendship, but on the other hand, people with depression can end up killing themselves. Or, their depression gets worse and worse and worse, and leads to drug and alcohol problems. It is hard to break the code of silence. But is very important to say to the person that if they won't tell their Mom or Dad, then you are going to need to let them know because you are really worried about the person.
What advice do you have for parents or friends trying to help a teen?
The most important thing is to get help. Get an evaluation from a professional who understands depression and the other psychiatric orders. After the evaluation, you can make a decision about what to do.
Do not blame yourself or blame the family. It is a very common notion to think, "I did something wrong," but it is not a result of bad parenting. If the child has diabetes, or mononucleosis, we don't say, "Well the parents weren't there to take care of them," or "The parents did something bad to them." It is the same with depression.
What challenges do you face in treating teens?
The first challenge is getting teenagers to self-identify, plus getting schools, parents, and everybody else to recognize this illness. The second challenge is finding the right treatment that will help. The third challenge is getting teens to stick with treatment long enough to see the benefits. Sometimes treatments, either counseling or medications, take a while to work. Finally, once teens do respond to treatment, we need to decide how long treatment should last. Usually, they need to stay with treatment at least for a few months, sometimes a year, and sometimes longer.
Which is better: talk therapy or medication for teen depression?
It all depends on the case. Generally, if it is a first episode of depression (not too severe -- they are not suicidal) and there is an issue such as divorce in the family, then a course of psychotherapy for six to twelve weeks is recommended. However, we usually see teens that have had depression for months, if not years, have not tried therapy, or have tried therapy that didn't work. At this point, they may have developed other disorders, or are into drugs and alcohol.
Depression is different in each individual and there are varying degrees of severity. Most often we recommend two forms of treatment: psychotherapy individually or in a group setting of teens, along with medication.
What studies are you conducting into teen depression?
We have two main studies. The first is a clinical treatment trial comparing two antidepressants to a placebo (an inactive sugar pill).
The second study looks at the brains of children and teens, ages twelve to nineteen, who have depression, using MRI imaging studies. Ideally, down the road, this will help us predict who will respond to which treatment based on how their brain functions.
What is the benefit to the patient?
One of the benefits is they get a free evaluation. We screen for all of the psychiatric disorders, including bipolar disorder, schizophrenia, attention deficit disorder, anxiety, and alcohol or substance abuse. But the main benefit is for them to help us understand more about the treatment of medications in teenage depression so we can help other teens. Hopefully we can tailor-make treatment down the road. Participants also get paid in both studies.
Can it be dangerous for a teen to participate in a clinical study?
We exclude teens that should not be in a study. If somebody has psychotic symptoms --for instance, they are hallucinating, or they have delusions -- or if they are actively abusing drugs, they can't be in the study. If they are clearly bipolar, with manic and depressive episodes, we exclude them. If they are seriously suicidal or in imminent need of help, we exclude them. We don't want to risk that they might not get a treatment that works for them.
Which types of teens are most interested in participating in studies?
I think that there are two types of people. Some people are interested in science and believe in research. Some really want to help other teens that have depression. They say, "Well I don't know if this is going to help me, but I'll do it if it can help other people." Since September 11, teens are looking for ways that they can help other people.