The Teen Mental Health Epidemic: Depression
By Lucille Carr-Kaffashan, Ph.D.
As winter begins, American public health professionals are sounding the alarm about an impending “tridemic”: the simultaneous outbreak of COVID, the flu, and the respiratory illness known as RSV. The rising rates of these viral infections, the latter being especially dangerous for children, are already overwhelming healthcare systems in many communities.
Children’s medical symptoms typically prompt parents and other adults to quickly reach out for help. That is not always the case with mental health symptoms, however, even though we are in the midst of a youth mental health crisis that also can be characterized as an epidemic. Growing numbers of American children are experiencing anxiety and depression, and the increased stressors at this time of year can exacerbate these symptoms.
Some people mistakenly believe that suicide rates are highest during the holiday season. Suicidal thoughts and actions peak in the spring, and are closely related to depression, but it is also important to note that individuals with histories of depression and other mood disorders can experience a worsening of symptoms during the fall and winter months.
Statistics Tell the Story
Many major health organizations, including the U. S. Surgeon General’s office, have released statistics about the youth mental health crisis and have issued calls to action to address it. The CDC’s Youth Risk Behavior Survey for 2009–2019 revealed that 1 in 3 high school students had experienced persistent feelings of sadness or hopelessness in 2019, a 40% increase since 2009. The survey results also indicated that in 2019 approximately 1 in 6 youth had reported making a suicide plan in the past year, a 44% increase since 2009. By 2018, suicide rates for young people ages 10–24 jumped by approximately 60% after having been stable from 2000 to 2007. In 2019, about 19% of high school students reported having seriously considered attempting suicide.
In March 2022, two full years after the COVID-19 pandemic caused widespread school closures, the CDC revealed that in 2021 more than 4 in 10 American teens reported feeling “persistently sad or hopeless”. This increase in depression and suicidality cuts across all demographics, but some students are more at risk than others. For example, a 2021 government survey of almost 8,000 high school students found that the rate of major depressive episodes was higher for adolescent girls (25.2 percent) compared with boys (9.2 percent).
Renee Goodwin, a professor at the City University of New York’s Graduate School of Public Health and Health Policy, has noted that “depression is extremely common in the U.S. and has reached epidemic levels.” As discussed in US News & World Report, according to the 2015–2020 National Survey on Drug Use and Health, since 2015 depression rose fastest among teens and young adults ages 12 and older, while remaining unchanged for individuals who are 35 and older. Of the 3 child/adolescent age ranges reported on by the CDC (ages 3–5, 6–11, 12–17), depression is consistently found to be most common in 12–17–year-olds.
The steady rise in student mental health problems clearly preceded the pandemic. It is also true, however, that the pandemic’s unique set of stressors exacerbated existing issues for many and at the same time created an environment that gave rise to symptoms in previously healthy youth.
Understanding the Crisis
Experts have many hypotheses about the factors that contribute to the teen mental health crisis. For example, it does not appear to be accidental that the rates of anxiety and depression began to rise around the same time that smart phone and social media usage became ubiquitous. It is important to note that this is not an indictment of the digital age. There are, of course, numerous benefits attached to internet and social media usage, and for many youngsters it provided a much-needed lifeline to counterbalance isolation during COVID lockdowns. Like so many other things in life, however, moderation is the key, as well as an awareness of which children are more vulnerable to potential detrimental effects.
For example, girls and young women are particularly vulnerable to societal judgments about weight and appearance, and the tendency to engage in negative self-comparisons and to try to measure up to societal ideals portrayed online can be powerful. Some researchers have noted that smartphone/social media involvement per se may not be damaging to any given youngster, but rather how it interferes with other healthy behaviors. For example, for many young people the constant use of electronics replaces sleep, exercise, and in-person social interactions. Getting appropriate amounts of sleep and exercise is critical to mental wellness, and the ability to be alert and function academically. In-person interactions are necessary to develop communication, conflict resolution, and emotion regulation skills.
Some experts point to the evolution of over-protective parenting styles as part of the problem. Increasingly many parents attempt to clear all potential obstacles in their children’s paths to protect them in an uncertain world. While these behaviors are well-intentioned, taken to an extreme they can interfere with a child’s ability to learn problem solving skills, to tolerate distress, frustration, and failure, and to persistently work toward goals. In other words, modern parenting styles can negatively impact a child’s ability to develop certain skills and a sense of self-efficacy.
A family history of depression and/or anxiety is also relevant, most notably with respect to whether the family acknowledges and pursues treatment for these problems. In families that discount or hide mental health symptoms, or convey a sense of shame, children will be less likely to share their concerns because of fear of shame/stigma or of becoming a disappointment to parents. If ripples of prolonged sadness and hopelessness are hidden, over time depression can build to a tidal wave that feels insurmountable and might even give rise to suicidal impulses. Prolonged, untreated depression changes the brain and contributes to a cycle of maladaptive beliefs and coping behaviors that can be much harder to unravel.
Finally, youth who have been exposed to trauma or other adverse childhood experiences (ACEs) are at risk for depression as well as other mental health diagnoses. The myriad stressors related to the pandemic cannot be ignored, of course, especially as this crisis has exacerbated other troubling aspects of our society. Children are growing up in a world that feels less safe and predictable. Gun violence, climate disasters, economic distress, racial strife, political divisiveness — these all impact the health and well-being of parents and caregivers and inevitably the mental health of American youth.
Depression 101
Occasional feelings of sadness or hopelessness are part of every child’s life. It is the persistence of these feelings that should raise a red flag for parents, educators, and pediatricians, signaling the need to assess a child for possible depression. Unlike anxiety, except in its more extreme and unrelenting forms, depression is not a normal part of life.
As described by the National Institute of Mental Health (NIMH), depression should be suspected if symptoms persist for at least two weeks, and are present mostly every day, for most of the day. Depression can be expressed in different ways, but some common signs include:
- Persistent feelings of sadness, hopelessness, pessimism, guilt, worthlessness, and/or helplessness
- A loss of interest in activities the child previously enjoyed
- Trouble at school, particularly if the child is typically a good student
- Increased irritability, frustration, or restlessness
- New risky or dangerous behaviors
- Decreased energy, fatigue
- Changes in eating or sleeping habits, including sleeping more or sleeping less
- Difficulty concentrating or remembering
- Spending more time alone than usual
- Withdrawing from activities the child once loved
- More frequent medical complaints — aches or pains, headaches, cramps, or digestive problems without a clear physical cause and that do not ease after treatment
- Thoughts/verbalizations about death or suicide, or suicidal behaviors
Depression is a common but serious mood disorder that can affect how a person feels, thinks, and handles daily activities. In its most severe form, an individual might not be able to get out of bed or complete even the most basic self-care activities. But it is important to remember that even youngsters who push through all their academic, social, and extra-curricular activities can be depressed.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) describes a few different types of depression, some of which are related to specific circumstances.
Major depression: symptoms of depression most of the time for at least 2 weeks that typically interfere with one’s ability to work, sleep, study, and eat.
Persistent depressive disorder (also called dysthymia): less severe symptoms of depression that last much longer, typically for at least 2 years.
Perinatal depression: occurs when a woman experiences major depression during pregnancy or after delivery (postpartum depression).
Seasonal affective disorder (SAD): comes and goes with the seasons, typically starting in late fall and early winter and going away during spring and summer.
Depression with symptoms of psychosis: a severe form of depression during which a person experiences psychosis symptoms, such as delusions (disturbing, false fixed beliefs) or hallucinations (hearing or seeing things that others do not see or hear).
Another common mood disturbance is bipolar disorder, which was formerly called manic depression or manic-depressive illness. Individuals with bipolar disorder fluctuate between depressive episodes and periods of elevation (manic or hypomanic) during which they might feel very happy, irritable, or “up,” and when they might exhibit a marked increase in activity level and decreased sleep. Bipolar disorder can appear in younger children but is more common in older teens and adults. Children with mood variability and especially those who are prone to irritability and temper outbursts are more likely to be diagnosed with Disruptive Mood Dysregulation Disorder (DMDD).
Childhood depression frequently co-occurs with anxiety or other mental health disorders. As reported by the CDC in 2016, among children aged 3–17–years, having another mental disorder was most common in children with depression. About 3 in 4 children with depression also had anxiety (73.8%) and almost 1 in 2 had behavior problems (47.2%). The prevalence of child mental health disorders changes with age. ADHD, anxiety, and depression become more common with increased age, while behavior problems are more common among children aged 6–11 years than among either younger or older children.
Finally, it is especially important to consider whether a child is exhibiting signs of Seasonal Affective Disorder (SAD). Exposure to various holiday stressors, combined with a tendency toward seasonal depression, can lead to increased depressive symptoms during the fall and winter months. SAD peaks in the winter months due to shorter days and decreased sunlight. It is related to the disruption in circadian rhythms, decreased levels of serotonin, increased levels of melatonin, and low levels of vitamin D because of decreased exposure to sunlight. In addition to various forms of medication and psychotherapies, lightbox therapy has been shown to be effective for SAD.
There Are Treatments That Help!
Despite the alarming statistics cited here, it is important for parents, pediatricians, and school professionals to remember that there are effective treatments for depression. Monitoring young people for signs of depression can help them access evidence-based treatments that can decrease unnecessary suffering and prevent the tragic loss of a young person to suicide. Psychiatrists and other prescribers have many more medication options than in the past. Cognitive-behavior therapy (CBT), dialectical behavior therapy (DBT), trauma focused therapies, and family and other relationship-oriented therapies can help teens build skills, improve self-esteem, and heal from trauma. Depression is highly treatable but only if we help students and their families access available help.
What Schools Can Do
In October 2021, the American Academy of Pediatrics along with the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in child and adolescent mental health. In December 2021, the U.S. Surgeon General issued an advisory about the youth mental health crisis. These and other organizations called for increased funding across the board for mental health resources and noted that greater integration of mental health care into both school and primary care settings should be prioritized.
Considering the stated priority to offer school-based services, districts can:
1. Strengthen Tier 1 services within their mental health Multi-Tier System of Support (MTSS) by
a. adopting a universal screening tool that is administered to all students at least twice each year to identify students’ mental health needs.
b. infusing mental health education into the curriculum, not just in SEL classes, but in all subjects. For example, science teachers can educate students about the effects of decreased sunlight on mood; physical education teachers can help students prepare for the winter blues by offering suggestions for how to increase physical activity; English teachers can assign journaling exercises that focus on the identification of feelings and other aspects of well-being.
c. providing frequent professional development opportunities for staff about depression and other mental health concerns.
d. offering psychoeducational material for parents on a regular basis, via newsletters, workshops, e-blasts, etc.
2. Nurture a trauma informed school culture that encourages staff to consider what childhood experiences might give rise to poor academic performance and/or problem behaviors. Depressed children or adolescents might not talk about their distress and may not appear sad. For some youngsters depression might manifest as acting out or appearing unmotivated, leading others to incorrectly label the child as a troublemaker or as lazy.
3. Develop collaborative relationships with local mental health providers, organizations, and agencies to strengthen the community safety net and avoid duplication of services.
4. Seek available funding to increase onsite mental health counselors and other resources.
5. Examine referral processes for special services and expedite these where possible. Students struggling with learning disorders, ADHD, or other neuro-cognitive differences are at risk for depression and anxiety.
6. Encourage parents to discuss family mental health history with pediatricians and mental health counselors. Mental health symptoms tend to run in families and to manifest within certain predictable developmental stages (e.g., ADHD often begins to manifest between the ages of 4 and 7; anxiety between 6 and 12; depression in mid-teens).
7. Send frequent reminders to students and families about the new nationwide suicide hotline, available by dialing or texting 988.
8. Review the mental health benefits offered through the district’s employee health plan and do whatever is possible to improve access to care, e.g., by reducing copayments, expanding the list of in-network providers, etc.
And remember — Effective School Solutions is always available to help.
Sources:
https://www.cnn.com/2022/10/11/health/girls-on-the-brink-nakazawa-wellness/index.html
https://www.aarp.org/health/conditions-treatments/info-2022/teens-and-depression.html
https://apps.bostonglobe.com/opinion/graphics/2022/10/teen-social-media-kids-anxiety-depression/
https://www.cnn.com/2022/06/03/health/pandemic-impact-teen-mental-health-wellness/index.html
Anxiety and Depression in Children | CDC
Data and Statistics on Children’s Mental Health | CDC
Youth Risk Behavior Survey Data Summary & Trends Report: 2009–2019 (cdc.gov)
