In 2011, suicide outranked homicides as the second leading cause of death of 15- to 19-year-olds for the first time ever in United States history, and this continues to be the case today.
The Centers for Disease Control monitors teen suicide rates over time and trends indicate a peak in the 1990s, particularly among male adolescents. Since 2010, both male and female teen suicide rates have increased. The most dramatic rise in suicide occurred in females 15 to 19 years of age, although males still have overall higher rates of suicide completion.
Depression symptoms are pervasive issues in teens and young adults leading to impaired functioning and engagement. The 2009-2012 National Health and Nutrition Examination survey found that 5.7% of 12- to 17-year-olds had moderate or severe depressive symptoms in the two weeks prior to the questionnaire. Females in the same survey demonstrated higher rates of depression and suicidal ideation compared to males in every age group.
What could lead to these increasing rates of teen depression and suicide? Common factors include family stressors such as finances, which affect youth often as much as their parents. Increased access to lethal means and exposure to domestic and community violence are also associated with the increase. Adolescents can experience trauma personally (e.g. bullying, child abuse, dating/sexual violence), but also through social media, TV and movies. Increasing awareness of these issues can be life-saving if family and friends know depression signs. As healthcare providers, we should also acknowledge that exposure to social media of this nature is very often triggering for individuals suffering from depression and suicidal thoughts.
Teen angst vs. depression
Sadness and depression often look a lot alike and telling the difference is difficult. Sadness is normal for everyone, temporary and not always felt by people who are depressed. Regular mood changes, including feelings of sadness, are short-lived and usually resolve within several days. Depression, however, involves feelings of hopelessness, anger or frustration that last for much longer and get in the way of normal daily activities.
Adolescence is a transitional phase from childhood to adulthood and by nature can be very complex. This development involves not only biological and physiologic changes, but social and conceptual modifications, as well. Neurodevelopment of the amygdala and prefrontal cortex are implicated in the development of adolescent depression. It is normal for adolescents to seek autonomy and independence. In contrast, withdrawing from fun activities, dropping grades with no apparent cause, isolating from peers and making statements of self-harm are not normal. Providers should work to differentiate between the signs of depression in teens and normal teenage development.
Signs of depression in teens
- Prolonged anger, frustration or tearfulness
- Withdrawal from activities of previous enjoyment
- Loss of relationships or lack of interest in them (i.e. friendships, romantic relationships)
- Change in appetite (i.e. not eating or eating too much, which may affect weight)
- Trouble sleeping or sleeping excessively
- Moving or speaking slowly or too quickly if expressing signs of mania
- Difficulty concentrating or remembering information (can include a drop in academic performance)
- Increased thoughts or references to death or suicide including self-harm behaviors
Discussing suicide prevention
Adolescents and young adults are especially prone to mood lability because their emotional centers (limbic system) and impulse control (prefrontal cortex) are still developing. Thus, depressed youth are predisposed to suicide attempts.
Suicide is the second leading cause of death in adolescents behind unintentional injuries. The mixture of an intense emotional trigger with impulsive thoughts of escape or death increases the likelihood of an irrational action. Access to lethal means such as guns, sharp objects or pills/drugs are the last part of the equation for suicide completion. The most important thing we can do for youth in our lives, personally or professionally, is be aware of signs and symptoms of depression and be armed with the appropriate resources to support them. The American Academy of Pediatrics recommends depression screening at least once annually. One helpful adolescent mental health screening tool is the Patient Health Questionnaire (PHQ-9), which screens for symptoms and severity of depression beginning at age 11. This assessment in the clinic is used to initiate deeper conversations with youth about their experiences and assess their support and coping skills. Prior to ending a visit, we recommend educating both adolescents and families on restricting a young person's access to lethal means (e.g. safe-storage devices for weapons and locking up or monitoring prescription and non-prescription drugs).
Bringing up the topic of mood is often innately therapeutic. If teens discuss sensitive issues or meet criteria for major depression it is our duty to provide appropriate treatment services and support for depressed youth at the time of diagnosis.
Treating mental illness in teens
Three key components of depression treatment include psychotherapy, medication and appropriate follow-up. Psychotherapy ('talk therapy') is evidence-based and the primary treatment for depression. In these sessions, the goal of cognitive behavioral therapy and interpersonal psychotherapy is to provide alternative healthy coping skills. Research also shows that medication improves moderate to severe depression for some people. The most commonly prescribed medications in this age group are selective serotonin reuptake inhibitors (SSRIs) and are appropriate once acute psychosis and risk for bipolar disorder have been ruled out.
Primary care physicians can prescribe and monitor these medications if they feel comfortable with the medications. Consultation with board-certified specialists in Adolescent Medicine and the Pediatric Mental Health Institute are also available at Children's Hospital Colorado.
The role of clinical education in teen depression
Depression is a real and sometimes scary health problem so it's important to remember that mental health conditions are treatable. Patients and families also need to know that a mental health issue is not anyone's fault. Identifying untreated depression, actively treating mood conditions and preventing adolescent suicide are the most vital aspects of ensuring youth safety and success.
As providers, education in mental health is essential for best care of our adolescent patients in the same way that we provide care for physical illnesses and injuries. Striving to bring depression into regular healthcare visits improves the health of our teens — now and for their lifetimes.