Tuesday, February 9, 2016

Teen depression: Not just a phase they will outgrow

Rima Himelstein, M.D., a Crozer-Keystone Health System pediatrician, talks about the complexities and many faces of teen depression through experiences with her patients, and how to recognize the signs of depression in teens.

Teen depression: Not just a phase they will outgrow


This is the first in an ongoing series that will examine mental illness in teens. Blog contributor Rima Himelstein, M.D., a Crozer-Keystone Health System pediatrician and adolescent medicine specialist, opens the series with how to recognize signs of depression in teens. In the following weeks, we'll go more indepth into how depression can accompany other mental illness, treatment options available for teens, and the risks for not treating depression such as suicide.

Teen depression is a problem with many faces. I learned this from my patients.

 At 19, one of my patients hadn’t been sleeping well for months. She dropped out of college, stayed home and cried. She refused to say if she was suicidal. She agreed to go to a crisis center and was hospitalized. A few months later she stopped taking her prescribed medication and attempted suicide.

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Isn’t adolescent depression just normal teenage moodiness? Once upon a time, everyone thought so. Being moody and irritable was a “rite of passage” and it was felt that “this too shall pass.” Advances in medicine have shown that some teens do experience real depression. But it may be difficult to recognize and even the most attentive parents and the most astute physicians may miss it.

Crossing the line: When a bad day lasts longer than two weeks then it’s not normal teen moodiness. Adolescent depression is as much of a medical illness as are diabetes and asthma; it is caused by a chemical imbalance in the brain that leads to changes in a person’s thoughts, feelings and behavior.

Depression is common. One in five teens experience depression. It can recur: over half of depressed adolescents have a recurrence within seven years. During adolescence, girls are more likely to have depression than boys. Depression may be common but it makes a teen feel like he or she is all alone

One of my 17-year-old patients did not speak English. Even so, she was doing well while living with her mother. When her mother died suddenly, her world fell apart. She had to live in an orphanage and share a room with babies and young children. She started to wish she was with her deceased mother and needed to be hospitalized.

Who gets depression? It can happen to anyone but some people are at greater risk: those with a family history of depression and those with significant life stressors...

Another patient was 19 and already an accomplished musician. Over the prior year her parents had divorced and both an aunt and a close friend had passed away. It was one major stress after another, and she could not spring back to her old self. She stopped enjoying her friends and her music; she was not looking forward to anything.

Watch for the many faces of depression. Teens may not tell you they feel sad because they may not be able to recognize their own depression or describe what they’re feeling. Or like one teen poet, they may wear “The Mask”  to hide their pain:

Look for what’s under the mask:

  • Sad, irritable or blue feelings
  • Suicidal thoughts

  • Decline in school performance

  • Physical complaints

  • Poor self-esteem

  • Social withdrawal   

  • Alcohol or drug abuse

It’s often complicated. A teen may have another diagnosis with depression like an anxiety disorder or an eating disorder.

At 15, my patient’s grades were going downhill. He had a low self-esteem and had been feeling sad for many months. Although he was normal weight, he believed that he was “fat”. He started extreme dieting and exercising. He lost 25 pounds, making him underweight, but he believed he was still fat … and he was still sad.

Sometimes the depression is actually part of bipolar disorder :

One of my 15-year-old patients was out of control. His family complained that he was always screaming and yelling at them. One day, outside of the school, he climbed up a tree with a knife and threatened to kill someone.

In bipolar disorder, the mood can swing from over-excitement (“mania”) to extreme sadness. Mania includes:

  • Too much energy

  • Distractibility

  • Not sleeping

  • Talkative with racing thoughts 

  • Risky sexual behaviors

There’s hope: depression can be treated. The two main treatments for teenagers are medication and psychotherapy—and they are most effective when used together: 

  • Medication: Medication is used to correct the chemical imbalance in the brain. Although fluoxetine (Prozac) is the only antidepressant approved by the FDA for treatment of adolescents, research studies have demonstrated that other medicines are also effective. They may take several weeks to work and are continued for at least six months. 

  • Psychotherapy: Two types of therapy have been shown to help: cognitive behavioral therapy (CBT) addresses negative patterns of thinking and behaving, and interpersonal therapy (IPT) focuses on developing healthier relationships.

Clinical depression is definitely not a “phase” a teen will outgrow. The risks of not treating depression include worsening symptoms as well as:   

  • Bullying (both for the individual being bullied and the one doing the bullying) 

  • Suicide 

My advice: If you see signs of depression in your teen, seek help: start by talking with his or her primary care provider and get the mental health help your child needs.

In another blog next week, I will talk about teen suicide.

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About this blog
Anna Nguyen Healthy Kids blog Editor
Sarah Levin Allen, Ph.D., CBIS Assistant Professor of Psychology at Philadelphia College of Osteopathic Medicine
Stephen Aronoff, M.D., M.B.A. Chair of the Department of Pediatrics at Temple University Hospital
Peter Bidey, D.O. Medical Director of Family Medicine at Philadelphia College of Osteopathic Medicine
Christopher C. Chang, MD, PhD, MBA, FAAAAI, FACAAI Associate Professor of Medicine in division of Rheumatology, Allergy and Clinical Immunology at UC Davis
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist of The Anxiety Behaviors Clinic at Children's Hospital of Philadelphia
Gary A. Emmett, M.D., F.A.A.P Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Magee DeFelice, M.D. Chief of Allergy and Immunology at Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Chief of Pediatric Emergency Services at Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Adolescent Medicine Specialist at Crozer-Keystone Health System
Jessica Kendorski, PhD, NCSP, BCBA-D Associate Professor in School Psychology/Applied Behavior Analysis at Philadelphia College of Osteopathic Medicine
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, R.D. Registered Dietitian at Children's Hospital of Philadelphia
Emiliano Tatar, M.D. Pediatrician at Einstein Healthcare Network Roxborough Plaza
Jeanette Trella, Pharm.D Managing Director at The Poison Control Center at CHOP
W. Douglas Tynan, Ph.D., ABPP Director of Integrated Health Care for American Psychological Association
Flaura Koplin Winston, M.D., Ph.D. Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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