Depression in Youth: Underdiagnosed and Deadly

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Cognitive behavioral therapy, despite its popularity as therapeutic model, is often not well suited to younger patients.
Cognitive behavioral therapy, despite its popularity as therapeutic model, is often not well suited to younger patients.

The onset of depression is the leading cause of morbidity in adolescents, taking an enormous toll on the quality of life in pediatric and young adult populations.1 Most frequently occurring between the age of 10 and 18, the onset frequently heralds chronic, more persistent depression in adulthood.1 Yet depression is significantly underdiagnosed in youth, partially because clinicians are taught to look for symptoms of adult depression, which may present differently in youths.

Identifying Childhood Depression

Because children are expected to have mood swings as they enter their teenage years, both the highs and lows of depression are often explained away as typical teenage behavior. In particular, children who “act out” with aggression or restlessness are rarely evaluated for depression. However, a young person experiencing persistent boredom or disinterest in daily activities because of their depression can become agitated and difficult to manage behaviorally. Unfortunately, because these young people do not always seem “sad,” they are more likely to simply be labeled troublesome by parents and teachers and rarely get treatment for the underlying cause of their behavior.2

Childhood depression can present with traditional symptoms such as blunt affect, lethargy, and hopelessness, but other markers are often more prominent, including:

  • Frequent absences from school or poor performance in school
  • Poor concentration
  • A major change in eating and/or sleeping patterns
  • Low self-esteem and guilt
  • Extreme sensitivity to rejection or failure
  • Increased irritability, anger, or hostility2

Equally worrying are the effects of social stress on depressed youths, reflected in the correlation between childhood depression, bullying, and suicide. Suicide is the third leading cause of death in all American youth, with 8% of young people reporting a suicide attempt in their lifetime. Independent of depressive symptoms, verbal bullying is particularly associated with an increased risk for suicide. However, the presence of depression greatly increases suicide risk in bullied young people. Depressed youths often experience low self-esteem and have a harder time with mood repair, so they are particularly vulnerable to the emotional pain of bullying.3

A vicious cycle can develop: other youths are more likely to view their depressed peers as dangerous and potentially violent, increasing their sense of isolation and thus their depressive symptoms. Additional research indicates that youths who are in treatment for mental health issues are more common targets for teasing and bullying, increasing their risk for suicidality and negatively affecting their participation in mental health treatment.4

Supporting a Younger Patient

Treatment for pediatric and adolescent depression is similar to that in adult depression, utilizing a combination of talk therapy and medication when appropriate. However, the mechanics of therapy look quite different for younger patients, whose experiences with depression vary by age, emotional vocabulary, cognitive development, and experiences with trauma.

Danielle Foote, LICSW, of the National Center for Children and Families in Washington, DC, believes that cognitive behavioral therapy, despite its popularity as a therapeutic model, is not well suited to younger patients. “This model can place undue emphasis on so-called maladaptive behaviors over the complex matrix in which they emerge,” Ms Foote explains. She prefers to utilize psychodynamic approaches that give insight into a young person's inner life and how they understand the world. Rather than positing depression as a dysfunctional response to social interactions, she seeks interventions that focus on how young people make sense of the things that happen to them.

This approach seems particularly appropriate as the field of psychology begins to the grapple with the strong correlation between Adverse Childhood Experiences (ACEs) and long-term mental health problems. ACEs include patterns of abuse (physical, sexual, or emotional), household challenges (such as incarceration of a family member or parental separation or divorce), and neglect (either physical or emotional), all of which are strongly correlated with an increased risk for depression. The number of ACEs a young person experiences has been shown to influence the severity and multiplicity of long-term physical and mental health issues.1

Foote notes that “the interplay between trauma and depression cannot be overstated. Many of the children and youth[s] I've met have survived sexual abuse, domestic violence, removal from primary caregivers, [and] abuse and neglect within systems ostensibly created to protect them. It is not surprising, then, that so many [youths] experienced chronic sadness, lack of motivation, low self-esteem, impulses to harm themselves, withdrawal from friends, poor academic performance, and mistrust in authority figures.” Because trauma is a unifying factor in many adolescent depression diagnoses, it is not surprising to find an anxiety disorder co-occurring in up to 70% of treatment-seeking patients, as both emotional responses are elicited by experiences of violence, instability, or neglect.6

A behavior that seems “maladaptive” to outsiders may have instead helped a young person survive difficult circumstances. Instead of pathologizing a depressed young person for their emotional and behavioral responses, Foote encourages providers to seek a deeper understanding of a young person's experiences with trauma.

Treatment is a Family Affair

While sometimes they are part of the problem, families can also be an essential part of treatment for adolescent depression. Dr Leslie Miller, assistant professor of psychiatry and behavioral sciences and director of the Mood Disorders in Adolescents Clinic at Johns Hopkins Bayview Medical Center in Baltimore, explains, “Treatment is really a collaborative process. Involving the family allows for a much broader perspective of what's actually going on at home.” Family members are encouraged to watch for the warning signs that their child is going through a depressive episode and are taught emotional management skills that they can model and use to support their teen when things get tough. When this isn't possible, because of a lack of supportive relationships at home, Dr Miller helps her young clients develop support systems through other caring adults, such as teachers, religious leaders, and afterschool activity leaders.

Dr Miller notes that if there is conflict between the child and parent that contributes to their depression, ideally she uses therapy as a space to work on improving communication and promoting healthy family dynamics. This is particularly crucial for a young patient's long-term resilience, as warm, accepting, and non-hostile parental relationships are one of the most consistent protective factors against long-term depression.6

Collaborative family treatment also means including caregivers in discussions about medication. “I want to know the teen and parent's thoughts about taking medication before I prescribe anything,” says Dr Miller. If both patient and parents are on board, the next step is making sure a young person is able to take the medication regularly. In older teens, that means creating a plan for how they will remember to take their medicine, like setting alarms or using an app on their phone. “We don't want to create a dynamic where the parents are nagging the kid to take their meds, and the kid doesn't take the meds in order to get back at their parent and it perpetuates an unhealthy cycle,” says Dr. Miller.

Accessing Care

Despite increasing societal awareness about pediatric and adolescent depression, treatment remains elusive for many of the youths that need it. Increasing access to care requires the thoughtful collaboration of mental health professionals and primary care providers.

Because childhood mental health disorders are underdiagnosed by primary care providers, and patients rarely self-refer for psychological services, co-locating psychiatric care within primary care facilities can drastically improve access to mental healthcare for young patients.5 Having an in-house psychiatric nurse practitioner, therapist, or psychiatrist lessens the burden on families seeking care in under-resourced areas who might otherwise have to travel many miles to the nearest treatment facility. Moreover, care coordination and in-house continuing education provides primary care doctors with needed exposure to mental health issues so they can more effectively refer patients to their colleagues.

The patient flow between primary care and psychiatric care can also be inverted. Once a patient is on a stable medication dose for several months, their mental healthcare can be reverted to their primary care physician, freeing up space for the psychiatrist to take on a new patient. 5 

And when co-location is not possible? Never underestimate the power of a warm hand-off between practitioners. Introducing a patient to a new provider in person or over the phone can make a world of difference, ensuring that they don't feel alone or abandoned as they begin the journey of coping with and healing from their mental health issues.

References

  1. Neavin DR, Joyce J, Swintak C. Treatment of major depressive disorder in pediatric populationsDiseases. 2018;6(2):48. doi:10.3390/diseases6020048.
  2. Depression in Children and Teens. Aacap.org. www.aacap.org/aacap/Families_and_Youth/Facts_for_Families/FFF-Guide/The-Depressed-Child-004.aspx. Published 2018. Accessed July 31, 2018
  3. Kodish T, Herres J, Shearer A, Atte T, Fein J, Diamond G. Bullying, depression, and suicide risk in a pediatric primary care sampleCrisis. 2016;37(3):241-246.
  4. Borschuk A, Jones H, Parker K, Crewe S. Delivery of behavioral health services in a pediatric primary care setting: a case illustration with adolescent depressionClin Pract Pediatr Psychol. 2015;3(2):142-153.
  5. Weersing V, Rozenman M, Maher-Bridge M, Campo J. Anxiety, depression, and somatic distress: developing a transdiagnostic internalizing toolbox for pediatric practiceCogn Behav Pract. 2012;19(1):68-82.
  6. Thapar A, Collishaw S, Pine D, Thapar A. Depression in adolescenceThe Lancet. 2012;379(9820):1056-1067.
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