HEALTH - When Depression Strikes Teenagers

It can be difficult to imagine that those in the carefree days of youth can be hit by such a somber illness. However, the numbers don't lie; a significant number of young people suffer from depression and this figure is on the rise. Our contributing psychiatrist Dr. Gurdeep Grewal, reveals the facts about teenage depression and how to spot the signs.

AJ is a 15-years-old girl who attends a premier private school. She is a bright and enthusiastic student, and active in various non-academic activities in school as well. However, over a span of six months, she has become increasingly moody and easily irritable, with bouts of tears. She locks herself in her room for hours on end. Her grades have been falling. Of late, she has also been playing truant from school and unknown to her parents, has been sneaking out of the house late at night. She has become argumentative with her parents and friends. Her parents found alcohol and marijuana in her room, for which she was severely reprimanded and punished. She was also not eating and sleeping well and had lost a significant amount of weight. One evening, her parents found her in her room, heavily sedated, with a note stating her intention to take her own life. She was rushed to the Emergency Department and resuscitated.

The case vignette above is a common occurrence in emergency departments on a nearly daily basis. Adolescents and young adults attempting suicide is a silent epidemic, one that is on the rise and needs to be addressed urgently. 2018 theme for World Mental Health Day, which was on October 10, is "Young People and Mental Health in A Changing World". On that note, I figured it would be a good idea to examine how depression manifests in teens and young adults, which I must emphasize, is usually very different from adults and can masquerade in a slew of disguises.

Before we go into signs and symptoms, it would be prudent to examine the prevalence of adolescent depression. Local statistics are not available, to my knowledge, but what we do know from data published overseas is that it is on the rise. In a recent study done in the United States, the lifetime prevalence of major depression among adolescents aged 13-18 years old was 11 percent. Now that's pretty large figure. To put it simply, approximately one in 10 teens are at risk of a depressive illness. The study also found that for a severe depressive episode in this age group, the risk is at 2.3 percent. In general, girls are more prone to depressive disorders and this gender disparity tends to be more prominent during the periods of early adolescence and mid-puberty.

WHO IS AT RISK?

One may ask, why are some kids more resilient than others? Why are some more prone to depression than others? Let's examine who is at risk.
Firstly, there is no singular cause; a depressive episode is usually the end result of the interplay between biological and psychological factors. The role of genetics cannot be downplayed. Studies have confirmed the heritability of depression, children whose parents have a history of depression compared to kids whose parents do not have a history of depression. Another important biological factor is the role of hormonal changes that occur during adolescence, the higher rates of depression in girls are postulated to be attributed to this factors.
Finally, the use and abuse of psychoactive substances such as marijuana, alcohol and methamphetamine, to name a few, will also put teens at increased risk of getting a full-blown depressive episode.

Next are the effects of psycho-social stressors. Children who have been exposed to adverse events while growing up are at increased risk. Examples of adverse childhood events are being physically or sexually abused, being neglected by their parents, a victim of bullying (now we have the problem of cyber-bullying to deal with), personal injury and repeated losses and bereavement. Children who have had to live through chronic adversity such as poverty, being orphaned and put in foster care, family discord (violence between parents and divorce, for example) and such are also more susceptible to developing a depressive episode.

While the above examples appear to be rather extreme forms of adversity, I have come to notice that many teens are getting depressed despite not having had any exposure to major trauma. Many are burned out as a result of overemphasis on getting top marks in school compounded by parental pressures and expectations. There is also a lack of balance in the daily routines of many teens, who seem to keep very hectic schedules shuffling between school, tuition and other classes. Then there are the problems associated with social media and cyber-bullying, peer pressures to fit in and the easy availability of drugs that pile on more pressure on these kids and tip them over into depression.

WHAT TO LOOK OUT FOR

The signs and symptoms of depression in teens can be easily missed and as such, many only come to seek help rather late, commonly when they express suicidal thoughts or have attempted to self-harm. So hopefully this illness and alert parents to get their teens to see a mental health professional early.

Depression in teens may not always manifest with feelings of sadness all the time. Mood variability is very common, and by this I mean they can switch between being in tears and sad to being very irritable and hostile. This may even escalate to bouts of intense anger and rage. Some have intense feelings of apprehension or anxiety as well, and their mood may lift momentarily when something fun or positive happens but then quickly dip again. A normally well-mannered and respectful teen may display uncharacteristic behavior such as shouting and being argumentative with his or her parents and friends. Hence, prolonged periods of low moods, despair and brooding may not be the primary way that depression presents itself. In addition to changes in mood, sleep disturbances are common. Some may have trouble falling and maintaining sleep, while others may sleep excessively.

Teens who are depressed may also be socially withdrawn. They may seem very demotivated and have little interest in their normal hobbies. Their school performance is frequently affected and this deterioration may indeed make them feel worse about themselves. It is also common for depressed teenagers to exhibit delinquent behaviors such as truancy, getting in trouble with the law and using drugs and alcohol. Depressed teens are also at higher risk of engaging in sexual activity, which in turn puts them at risk of sexually transmitted infections and for the girls pregnancy.

Other symptoms to look out for are changes in appetite and weight. Some may feel burdened by excessive and inappropriate feelings of guilt or shame. As the severity of the depression increases, teens may feel increasingly hopeless and may develop ideas about suicide. Self-harm may occur, many teens resort to cutting themselves or taking an overdose of medications. In severe cases, teens may be actively suicidal and this is considered a medical emergency and needs to be attended to immediately.

GETTING HELP

Once there is a suspicion that your teen is depressed, getting an assessment from a professional mental health provider is imperative. A thorough medical and psychological assessment will allow us to make an accurate diagnosis and also rule out potential medical causes that may explain the mood changes (endocrine disorders, for example). Once an assessment has been done, based on the severity of the depression, therapy can be planned and initiated for the patient. When we treat a teen for depression, it is important to involve the family in the management plan. More often than not, there are issues within the family unit that needs to be examined.

For mild depression, usually counselling and other forms of talk therapy will suffice. For moderate to severe depression, a combination of therapy and medications is recommended. Parents are usually (and rightly) concerned about the use of medications, so let's address this issue right now. Selected antidepressants are FDA-approved for use in teenagers (your treating psychiatrists will advise you on the right medications to consider). Parents usual concerns are of dependence and side effects. Selective Serotonin Reuptake Inhibitors (SSRI's) are usually the first line of medications used and these DO NOT cause addiction or dependence. Yes, there are potential side effects such as nausea, vomiting, headaches and weight gain associated with SSRI's but these are usually transient and can be managed. Also, for teens, the dosage of medications used is usually very low and are generally well tolerated.

Another concern (which has received a lot of publicity) is the increased risk of suicide thinking and behaviors among teens that are prescribed the medications. Naturally, parents will look up the use of SSRI's for their kids online and will invariably come across this issue. So, to put this to rest, the studies done showed that while there was a slight increase in suicidal in teens (and this only occurs at the early stage of commencement of the medications), none actually completed any suicide act. The benefits of antidepressant use outweigh the risks, indeed, the risks can be mitigated by close monitoring of the patient. The bottom line is that delay in starting treatment is far more dangerous.

The other question I am frequently asked is, "For how long long does my child need to take the medications?"
Firstly, the positive effects of antidepressants may take 4-6 weeks to manifest. Once the teen is fully recovered, it is recommended to continue the medications for 9-12 months. Once a decision is made to discontinue medications, it will have to be done gradually over a few weeks. Hence parents can be reassured that antidepressants are not to be given indefinitely.

Another important thing to highlight is that the use of sedatives and hypnotics (commonly referred to as sleeping pills) such as alprazolam and diazepam should be avoided in teens. These medications are not definitive treatments for depression or anxiety and carry a risk of dependence. They can also adversely affect the child's cognition and subsequently impair school performance.

TAKING THE HOLISTIC APPROACH

Medications are not a fix-all solution. Combining medications with other forms of therapy is the proper approach. Various forms of psychotherapy are beneficial for teenagers who require a neutral and non-judgmental avenue to express their feelings and an opportunity for them to learn better coping skills. Counseling, cognitive behavior therapy, art therapy and interpersonal therapy may all offer benefits. Frequently, family therapy is also required to fix unhealthy family dynamics and facilitate their recovery. For teens who have been through a traumatic experience such as physical or sexual abuse or bullying, specialized forms of therapy such as Eye Movement Desensitization and Reprocessing (EMDR) may also be used.

In conclusion, depression in teenagers is a serious disorder and is on the rise. Let's be vigilant of the warning signs and seek help early with a qualified mental health professional.