The hardest questions pediatricians must routinely ask teenagers at checkups are those about depression and suicide. But they aren’t optional; we have to ask them, every time.
From 2005 to 2014, the prevalence of depression — that is, the chance of having a major depressive episode over the course of a year — increased significantly among 12- to 17-year-olds in the United States. These data come from an annual survey, the National Surveys on Drug Use and Health, in which the same structured questions are asked every year. The trend toward more depression was steeper in girls than it was in boys. Furthermore, when 18- to 25-year-olds were surveyed, there was again a significant increase in the prevalence of depression, but only among those 18 to 20. So it appears to be increasing in the population from 12 to 20.
Dr. Ramin Mojtabai, a psychiatrist who is a professor in the department of mental health at the Bloomberg School of Public Health at Johns Hopkins and the first author on the study, said that there was no real increase from 2005 to 2011, but then the rise began, and got more pronounced in 2012 and 2013.
Why was the prevalence of depression increasing, and why was it more intense among girls? Were adolescents actually suffering more from depression, or was it possible they were just more willing to talk about it? Dr. Mojtabai said that over the past couple of decades, teenagers have generally been more open about depression, but the researchers didn’t think that could account for the pattern they were seeing.
They adjusted for the prevalence of substance abuse, and still the trend was there; it wasn’t explained away by drug use or drinking. Neither could it be accounted for by looking at household composition (two parents versus one parent versus no parents).
Suicide is the second leading cause of death in adolescents 15 to 19, second only to accidents, but that rate, as opposed to the incidence of depression, has actually been decreasing since the 1990s. But the Centers for Disease Control and Prevention announced last November that the suicide rate for younger children from 10 to 14 had increased to the point where the risk of dying by suicide was as high as the risk of dying in a traffic accident; they were looking at 2014 data, the most recent available.
Dr. Benjamin Shain, the head of the division of child and adolescent psychology at NorthShore University Health System, was the lead author on the American Academy of Pediatrics’ clinical report last summer on suicide and suicide attempts by adolescents. “When it comes to your child, in a sense statistics don’t matter, what matters is your particular child,” he said. “Pay attention to worry signs.”
Too often, he said, the parental impulse is to give advice or even step in and try to fix the problem. “What parents should do is mostly listen, that should be 90 percent of the conversation,” he said. The other 10 percent of the time, parents should not attempt to offer a solution, “but help the child problem solve.” He raised concerns, in particular, about the impact of electronic media on adolescents.
Dr. Mojtabai pointed out that the study was missing some information about factors like child abuse and neglect and about screens and digital devices, which some reports have associated with depressive symptoms.
“There’s certainly evidence that cyberbullying may be connected to an increase in depression particularly among girls, maybe an increase in suicide,” Dr. Shain said. And this is an area, he said, where many parents feel at a loss about how to guide their children; the parental impulse may be to take away the cellphone, which may make things worse for some adolescents.
“They tend to find parent restriction of social media actually more traumatic than whatever the event was,” he said. “That’s how they connect to their peer group, that’s how they get their support, that’s how they have a conversation with their group; you take this away and then you have a very isolated child.”
Over all, Dr. Mojtabai said, we need more information about whether there really is a trend here, and much more information about the teenagers’ lives. Still, it’s important for parents to be aware of the risks, both for children who are already struggling with mental health issues, and for those who may not yet have given their feelings a name.
“A lot of children and adolescents have psychiatric problems that are not recognized by parents and they go untreated as a result,” he said.
The signs of teenage depression include mood changes, like persistent sadness or irritability, and changes in level of functioning, such as school failure. They also include withdrawal from friends and family, a loss of interest in activities that had been important, and changes in eating and sleeping patterns, as well as some pretty nonspecific signs like lack of energy, trouble concentrating and unexplained aches and pains.
Any parent of an adolescent has to wonder, of course, what’s the difference between “regular” adolescent mood swings and teenage behaviors and these warning signs. Parents need to ask themselves how severe the symptoms seem, and how persistent. When a child really seems to have changed, you can’t just write it off as adolescence.
Dr. Shain pointed out that many of the warning signs are relatively nonspecific; there could be many reasons adolescents might be hiding in their rooms, or bringing home significantly worse grades.
“It could be depression, could be drugs, could be simply that their schoolwork is too hard,” he said. “The first step is sit and have a conversation with your child — what’s going on — the next step could be talk with teachers or bring your child to a counselor or psychiatrist.”
And though this increase in the prevalence of depression was not explained by substance abuse, it’s important to remember that substance abuse and depression have always gone together in adolescents; those who report depression are more likely to have used drugs or alcohol.
Identifying depression, of course, doesn’t solve the problem, and this is not an issue that lends itself to quick fixes, even with caring and supportive families. As the A.A.P. clinical report says: “Suicide risk can only be reduced, not eliminated, and risk factors provide no more than guidance.”
This can be a long and hard journey for teenagers and their families, but the message to parents, and to pediatricians, is that we have to keep asking the right questions.