The teenage years are full of ups and downs. Every day presents a new challenge. Teens are learning who they are, finding their place within the social structure of their friends and classmates, adjusting to physical changes, figuring out how to be good at something, do well in school and be liked by others.
Add to all this the possibility that a teen may not yet have the self understanding to label their negative feelings or identify what triggers those feelings. They may not be used to talking about how they feel. So they may not ask for help when they need it.
It’s no surprise they might get moody or angry for seemingly little or no reason. That can be normal teenage turbulence.
But how do you know when the stresses and challenges of being a teen have triggered clinical depression?
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Especially these days. Depression rates have increased in teens over the last 10 years, affecting as many as 11% to 20% of teens. An estimated 30-50% of these teens are not being recognized or treated.
That’s why my fellow pediatricians and I screen all our teen patients for depression with a short questionnaire. We get positive screens pretty frequently. Often parents are surprised. Sometimes we get push back from parents who assume they are fine and want us to assume that they are fine too. When the screen is positive, we dig deeper.
Two red flags mark out what is normal teenage turbulence with its ups and downs, and what is clinical depression. The first big red flag is if your teen is spending more time down than up. Depressed teens have a feeling of either depressed or irritable mood more days than not. The second flag is whether they are having impairment in their day to day activities- i.e. they are not functioning as their usual selves.
In addition to these two red flags, we look for teens to have at least 4 of the other 8 symptoms of depression which are discussed below. We use the mnemonic SIGECAPS to represent the other symptoms of depression – Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psycho-motor disturbance, Suicidal ideation. These are explained below.
Depressed or Irritable Mood
Adults are more reliably able to verbalize feeling down, depressed, sad, or hopeless, but many teens may just seem irritable, easily annoyed, on edge, touchy, or angry. They may not realize or admit they feel sad. Family members and friends have to “walk on egg shells” all the time around them. They may lash out with little provocation. This can also be normal behavior for teens: what teen isn’t ornery sometimes- who doesn’t have some down days? The key here is that the irritable or depressed mood is there most of the time, more days than not, over at least two consecutive weeks.
This can be either sleeping too much or sleeping too little- or an erratic sleep pattern. They may complain of having a hard time sleeping at night even if they are not laying awake thinking about their problems. They may sleep excessively during the day. A normal teen needs 9 hours of sleep per night, and with all the homework, practices, work shifts, rehearsals etc that kids have these days, teens are unfortunately often sleep deprived and tired, and have to catch-up on sleep on the weekends. Depressed kids, however, never seem to be able to catch up, or the normal amount of rest just doesn’t cut it for them.
Diminished interest or pleasure
Depressed teens may lose enjoyment they used to get from their preferred activities. They just don’t want to draw anymore, they don’t get any enjoyment from playing football like they used to, or don’t enjoy playing an instrument like they did. Everything seems hopeless and purposeless. Relationships with friends or loved ones just aren’t important anymore and they may withdraw from social interaction. Another way this can manifest is lack of motivation- they may feel unmotivated to do their homework, go to school or do anything.
Feelings of worthlessness or guilt
Depressed teens often tell me they feel stupid, or like a failure, or say other self-deprecating things. They may excessively internalize things going on around them and blame themselves unnecessarily. They may appear extremely sensitive and interpret events or things people say or do as evidence of their inferiority or incompetence. They may be excessively self critical or struggle to identify positive self attributes, or be preoccupied with letting others down, or jump to negative premature conclusions about others’ intentions or about their own failings.
Fatigue or loss of energy
Depressed adolescents often complain of not having any energy or feeling tired all the time. Sometimes they say they feel physically weighed down, like their arms and legs are heavy.
Poor concentration or impaired decision-making
Depressed teens often have a harder time focusing compared to their baseline. They may say they have a harder time getting their homework done or it may take them longer. They may have a harder time thinking through a decision and become more indecisive. They may lose their train of thought easily or have a hard time being present in the moment. This can lead to decline in their school, extracurricular or job performance.
Appetite or weight changes
Depressed teens often tell me they just don’t feel like eating. Or sometimes they find themselves eating way more than usual. Whereas an adult might have weight loss, a teen may not be gaining enough weight. Depression may or may not be occurring together with an eating disorder like anorexia (refusing to maintain a normal body weight by restricting intake).
Psychomotor agitation (restlessness or hyperactivity) or retardation (sluggishness)
This is less common for teens in my experience, but they may admit to feeling sluggish in their movements or speech. Sometimes the teen doesn’t realize it, but parents notice they take longer to answer questions or form thoughts or sentences, or aren’t as active as usual. Sometimes kids become more restless, fidgety, and jumpy.
Suicidal ideation refers to thoughts about suicide. Kids often don’t want to volunteer that they have these thoughts because they are afraid of upsetting their parents, so it’s essential for parents ask boldly, directly, and in a way that does not project shame. Control your fear. It doesn’t help to get angry. You will not make your child become suicidal by asking about it. For coaching videos on how to talk about suicide, click here.
Suicidal thoughts can range through the spectrum of suicidal thought: first, a teen may just feel like they don’t want to live anymore, or think that their family or friends would be better off without them; next they may be thinking about what they could do to end their life; then develop the intention to follow through with those thoughts; and finally, actually make a plan to carry those thoughts out. It’s critical to know where a teen is on that continuum.
Any sign of suicidal ideation must be taken seriously and evaluated promptly. Under-reacting is at least as dangerous as over-reacting. A teen’s decision to take their own life can be impulsive and occur without much warning. If your child tells you they are even thinking about suicide, make contact with their doctor or another professional immediately, or call the National Suicide Prevention Lifeline at 1-800-273-8255 or take your child to the Emergency Room to talk with a crisis worker. If they have thought of a specific means they would use to commit suicide or have attempted suicide, they may need to be temporarily admitted to a hospital to keep them safe. Additional resources on suicide prevention are available at uofuhealth.org/safeut,
Treatment of Depression
There is an unfortunate unconscious stigma placed by society on treating mental health problems. It shouldn’t be that way. There is no shame in taking your child to a Pulmonologist to treat their asthma or a Neurologist to treat their seizures. Likewise, there should be no shame in seeing a “shrink” or “therapist”. And it doesn’t mean you are “crazy” if you get mental health treatment. You need to read it your child of this.
The mainstay of treatment of depression in teens is counseling, which can help with many typical teenage problems as well. Through counseling, teens learn coping strategies, self-management skills, and self-awareness. Therapy can be hard work, but it leads to true healing when there is a good therapeutic relationship.
When teens are having a lot of impairment from their symptoms, medication is a safe and effective treatment used to help get teens better faster along with counseling. We can’t rely on medication to solve all problems, but it can be very important for some kids in order to start turning around. I think of antidepressant medication like a cast for a fracture. It helps to stabilize the damage, decrease pain, and allow the healing to begin, which happens through the real work of therapy, leading to changes in patterns of thinking, lifestyle changes, interpersonal connection, and addressing past trauma.
If you have concerns about your teens’ mental health, please don’t hesitate to make an appointment with your child’s doctor. As pediatricians, we are just as much teen doctors as we are baby doctors. We seek to care for the whole child- that means mental and emotional as well as physical health. We also encourage parents to care for their own mental health, as it is closely connected with the mental health of their children.
For further information, please see the following resources. And share with family and friends.