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Down Time: Teens and Depression

Thousands of tweens and teens suffer from undiagnosed depression. But as one family learned, facing the problem openly and squarely can change everyone's outlook.

By Clay P. Burns

It was early spring. Alone in the upstairs bathroom, my 12-year-old daughter, Marie*, carefully counted out 15 tablets of acetaminophen. She swallowed the pills, a few at a time, then crept back to her room and slipped under the covers, expecting to fall asleep and not wake up. My wife and I knew her mood had been low, but it never occurred to us that anything this serious could be happening.

Marie had been spotted kissing the boyfriend of one of the "popular" girls. They retaliated by spreading stories that she'd slept with every boy in sixth grade, that she was a slut and that anyone seen with her would come under similar attack. Even her closest friends began to desert her. She didn't confide in her mother or me or anyone else who might have been able to help her.

Luckily, all that happened was she spent the night throwing up. Since she seemed better the next day, we remained unaware, assuming she'd had a minor stomach flu. It wasn't until two weeks later, when my wife stumbled on Marie's diary open in her room, that the full story began to reveal itself.

Not Just a Case of Teen Blues

Marie's suicide attempt, I learned, was not an unusual event. According to the Centers for Disease Control and Prevention (CDC), 15% of high schoolers have seriously considered killing themselves, and 7% say they've tried. Suicide is the third leading cause of death for children 11 to 18.

In most cases, the underlying cause is depression. While all teens will occasionally be sad, angry and gloomy, most survive adolescence without serious harm. But about 11% of kids 13 to 18 grapple with clinical depression, reports the National Institute of Mental Health (NIMH). Boys and girls are at equal risk until puberty, when the rate for girls doubles, for reasons that are not clear.

According to the CDC, only 21% of kids who need mental health evaluations receive them, often because their families don't have health insurance or access to providers, they fear being stigmatized or adults—like Marie's mother and me—fail to recognize the warning signs.

And today's teens are grappling with more worries than ever. UCLA's Higher Education Research Institute recently surveyed kids entering college and discovered that their emotional health level had dropped to record lows, triggered by recession-related money worries and the increased pressure to excel in school.

For vulnerable kids, the normal social complexities of adolescence can provoke a serious episode. That's what happened with Marie. Being bullied was bad enough, but it was depression (diagnosed after she took the acetaminophen) that caused the urge to self-destruct. "At its worst," says Harold Koplewicz, M.D., an adolescent psychiatrist and president of the Child Mind Institute in New York City, "teen depression can seem like adolescent moodiness on steroids."

That makes it hard for parents to distinguish between ordinary angst and a true disorder. Among the symptoms to watch out for, says Judy Garber, Ph.D., a clinical psychologist and researcher at Vanderbilt University in Nashville, are talk of suicide, inability to concentrate, excessive fatigue, slowed movement and a decrease or increase in appetite. The difference between a passing phase and a serious disease is severity and longevity: Exhaustion during exam week isn't cause for concern. Being terribly tired for two weeks or longer might be.

If you suspect depression, schedule an evaluation with a psychologist or psychiatrist specializing in adolescents right away, says Glenn Hirsch, M.D., medical director of the Child Study Center at New York University. "You wouldn't wait for a tiny infection to become raging pneumonia," he says. "Mental illness is no different." Untreated kids are at risk for academic failure and substance abuse—with consequences that may follow them, along with the depression, into adulthood. And put aside any fears that the assessment itself could put suicidal thoughts into a tween's or teen's mind. "There's nothing dangerous about getting your child checked out," says Dr. Hirsch.

The day my wife found Marie's diary we rushed her to a psychiatrist. He recommended hospitalization (the insurance company would authorize only a one-week stay), regular talk therapy sessions and medication. But in one way, at least, I did exactly what Dr. Hirsch warns against. Desperate to keep Marie's disorder private, I closed up, telling no one what our family was going through. What would happen, I worried, if neighbors, friends at school and other parents began to think of Marie as a kid with emotional problems? Would she lose all her friends? Would teachers somehow treat her differently?

In the end, there was no keeping my daughter's situation secret—Marie was missing school and was clearly not herself. But I shouldn't have worried, because openness turned out to be the best possible thing for her and our family. Other parents didn't tell their kids to stay away from Marie, as I feared they would. On the contrary, many were understanding—and a surprising number admitted that their children were grappling with similar problems.

Hopeless but Not Helpless

In fact, because there are so many kids with untreated mental illness, many experts suggest all teens should undergo a mental health screening, either at school or during yearly physicals. The current method favored by professionals, TeenScreen, was developed by David Shaffer, professor of psychiatry at Columbia University in New York. The simple questionnaire, which takes kids about five minutes to fill out, doesn't result in a diagnosis but does identify teens who require further evaluation. (Go to teenscreen.org for more information.)

For children who need help, the most effective treatment is a combination of talk therapy and medication. A major study by the NIMH found that teens given a combination of Prozac and cognitive behavior therapy (CBT) recovered faster than those receiving therapy alone. "The idea is to teach kids they can change their moods by changing their thoughts," says Dr. Koplewicz. "They learn to give more positive interpretations of situations and relationships." He gives an example: A depressed tween or teen who sees someone frowning, immediately concludes, "He's angry at me," and she feels bad. CBT helps her explain the situation to herself differently, to think instead, "He's probably just having a bad day," and not take the scowl personally.

The use of antidepressants in teens does raise concerns. The NIMH study found that 15% of the teens taking Prozac alone had suicidal thoughts, versus 6% of the teens not on medication. But the use of CBT with antidepressants provides safeguards against the risk of suicide, the study suggests. The research has unfortunately been misinterpreted, with some concluding that antidepressants shouldn't be used at all for kids, says Lia Gaggino, M.D., mental health chair of the Michigan chapter of the American Academy of Pediatrics. "You have to realize the study didn't measure what would have happened with no treatment at all," she says. "When doctors and parents got scared and stopped using the medication, suicide rates actually went up slightly." The NIMH research also found that continuing treatment is the linchpin of long-term recovery from depression, though it remains unclear exactly how long active intervention should go on.

My daughter's teen years were marked by more ups and downs, including a period when she decided to go off her medication. She had been forewarned by her doctors that this could cause serious withdrawal symptoms and should be done only under medical supervision, but she went ahead anyway, without anyone's knowledge. Six months later she came to me feeling emotionally rocky and asked to start taking antidepressants again.

Now a college student, Marie hasn't had an episode of depression for several years. She seemed to grow stronger as she got older, which is fairly common. I've been told by other parents that their children also improved as they made the transition from adolescence to adulthood. Families should not assume kids will automatically outgrow depression, however. "You have to catch mental illness early and treat it correctly," says Dr. Hirsch. "The point is to address the current symptoms and give kids the skills they need to better handle their lives going forward."

Marie will always be at risk, yet she is doing so much better now that I no longer wake in a panic about where she is and what she's doing. People sometimes want to know what her mother and I did to pull her through. I tell them Marie deserves all the credit. She's the one who bravely hung in there, facing her demons and making the good choices that give us all hope of a bright future for her.

Depression Warning Signs

A child who shows any of these symptoms consistently for two weeks or more should see a mental health professional specializing in adolescents as soon as possible.

Facebook Depression

When the journal Pediatrics reported last spring that there might be a connection between intense Internet use and teen mental disorders, the term "Facebook depression" went viral. But is it real? "I don't think so," says Sharon Chirban, Ph.D., a child psychologist at Children's Hospital in Boston. "Facebook is just another type of social interaction that highlights something already there." She does advise unplugging your child for a few days if social networking seems to trigger negative emotions. "Time away from the computer lets her follow interests and nurture in-person relationships," she says, "and that will help her feel better about herself."

Originally published in the September 2011 issue of Family Circle magazine.

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