How To Monitor and Stabilize Depression in Teens and Children

Each time I write a prescription, I have a certain amount of trepidation. Although I know that medications can help, I am also aware of their limitations. It is also important to be vigilant as to whether there are other key factors that are causing a teenager to be overwhelmed (i.e., trauma, substance abuse). However, when children and adolescents are having difficulty functioning because of how impaired they are, medication can be critical. If a teenager is so depressed that she is thinking of tying a phone cord around her neck or jumping out a window, or if she finds it impossible to find the energy to get out of bed, or can’t concentrate long enough to read one page and her grades are dropping, an antidepressant along with therapeutic support can be vital.

Medication may require trial and error. Each time a patient agrees to a “trial” it’s very heroic because often he has already experienced his difficulties as a sign of failure, and if he doesn’t “respond” to a medication he can take it as further confirmation that his life is hopeless. Sometimes, if there is truly a biologic component to the depression, the change can be impressive after four to six weeks. Yet ironically, a positive outcome can be unsettling to a teenager who has come to see himself as permanently disgruntled and irritable. In addition, the wait time involved for most medications to begin to work can seem interminable, particularly because when people are depressed they may have a hard time remembering when they didn’t feel that way. When they start to improve, their mood can brighten, life can feel more manageable and they are less exhausted.

Even when there is improvement, I always invite teenagers to share the understandable ambivalence they may feel about taking medication. Sometimes a child may resent that her parents suggested medication because it implies that she needs to be “fixed.” Or, a teenager may identify with being miserable and become unsettled that medication is changing her core sense of who she is. Other times, particularly in kids who have grown up with a sense that their parents abandoned them, improvement can lead to a fear of dependence on a pill or a clinician. And if a parent has mental illness, a teen may fear that taking medication may make her more like her parents.

The toughest decision is regarding a trial of an antidepressant for a patient who is suicidal. Whereas in a small percentage of patients the antidepressant can make them more agitated and increase suicidal ideation, the medication can also alleviate incessant thoughts and planning about suicide. This is high stakes, so it’s key to share the responsibility with the parents and the teenager. The child needs to tell her parents or doctor if the medication is making her feel worse, and there must be a plan of how to access the doctor quickly and to monitor if there are troubling signs of worsening agitation, depression, or sleep.

A patient whose life has improved with medication will often feel so well that he forgets how bad he used to feel, and stops taking it. I anticipate this and ask that patients be open with me about this. I am working with a patient to see if medication will be helpful but it is always ultimately the patient’s choice. If he decides to transition off of medication, it is important to monitor him and to discuss how we will identify if he is having trouble again. I always encourage the patient to understand about why things reached a crisis, what may need to improve about how he manages stress, family dynamics and his sense of hope and belief in his future.

When I make a recommendation for a trial of medication, I do so as if the child were my own child. Parents should expect the psychiatrist to care deeply about the family, to be transparent about what he knows and doesn’t know and to share how he is making the decision.

Once teenagers who have come to me for help have stabilized, and adequate medication and therapeutic support are in place, it is not uncommon to see them come sauntering into my office, back on track, catching me up with what is going on in their lives — concerts, friends, classes. To me, it is always a blessed miracle that the suicidal feelings, bleak sense of hopelessness and depression was a temporary detour, the crisis was averted and the family left intact.

Editor’s note: This is part three of a three-part series about kids and depression. Feel free to read part one and part two if you missed them.

What Is Psychiatric Treatment?

Although we occasionally read about psychiatrists who are accused of overprescribing medications, and antidepressant usage is hotly debated, in most cases a patient’s quality of life is a psychiatrist’s number one priority (as it is with all medical doctors), and restoring a patient to optimum health is our goal. Parents whom I see for the first time are often rightfully concerned about treatment; they want to know what I can offer their child and how they can convince their child to see me.

Teenagers are understandably reluctant to see a “shrink” or talk to a stranger about their problems. At a time when they are incredibly self-conscious and want to blend in, teenagers can worry that people will think “they are nuts.” How parents communicate with their child about why they are asking for outside help is critical; often a parent’s plan to seek the help of a therapist slips out in the heat of exasperation or anger, and it sounds like a punishment.

It is not uncommon for teenagers to get angry when asked if they are depressed, as if depression is a sign of weakness. But a child may be more receptive if a parent says, “I notice you are pissed off (or angry) a lot of the time and I am not sure how to make things easier. It might be helpful for us to talk with a doctor to figure out what is making things so difficult and try to make things easier for you.”

Usually when I ask teenagers why they have come to my office, they give very different responses from their parents. It’s critical within the first session to let the patient know that my focus is to alleviate stress in his life because “things are hot” — which may include failing grades, suspensions, fighting with parents, or a suicide attempt. The first interview with the child has three main purposes: I learn who the patient is, try to form some sort of relationship with him, and seek to obtain crucial information (like a detective looking for clues).

Although teenagers may initially be wary, I tell them that they are free to fire me after the first session if they don’t feel it is the right fit, partly to communicate in a fundamental way that they are in the driver’s seat about making choices about what is best for them. It is imperative that the therapist and patient are able to find a common ground and work together to figure out what’s making life so difficult and how to improve it.

A major issue to decipher is whether or not there is an existing family history of depression or bipolar disorder — if there is a biological component or mental illness. If there is trauma or a learning disorder, this may also make a teenager less motivated and susceptible to withdrawing from treatment. A careful assessment is critical, and my approach is always to inform families that I am a “consultant” to the family and they need to make an informed decision based on my findings.

I am never cavalier about suggesting or prescribing a medication; we psychiatrists are usually making diagnostic assessments on “moving targets,” as children and adolescents are constantly evolving, and the decision is not always absolutely clear. With a careful explanation of the risks and benefits, of the various options (including no medication), and of what to look for to tell if medications are helping and what kind of time frame might be needed to see improvement, patients and families will always have a chance to share their questions and concerns.

Untreated depression and mental illness is highly debilitating and very difficult to live with. Outside help is essential, and medication can be lifesaving — just as insulin is to a child with diabetes.

Editor’s note: This is part two of a three-part series about kids and depression. Stay tuned for part three tomorrow, or feel free to read part one if you missed it.

When I do interviews or public readings parents often ask me about warning signs in children for depression and even suicidality. They may be worried about a daughter who is withdrawing, or a son who sleeps for hours on end and is failing in school. These behavioral changes can be signs of a biology gone awry and parents should take their observations seriously.

When considering whether a child is suffering from mental illness, the question you should ask yourself is, “how is my child functioning?” If your child is at an impasse, that’s when you should worry. Warning signs vary, but generally when kids can’t go to school, are up all night, are irritable, isolate or have prolonged periods of crying (such as bursting into tears and locking themselves in a room for 2-3 hours), these are signs that something is wrong and that parents need to act. Changes in eating patterns are also red flags. And if children talk about suicide or hopelessness, always take them seriously. Slow down, listen to figure out what’s going on, and mobilize to get help when needed. If another child comes to you with concerns about a friend or family member, it is important to take them seriously. Remember, it takes a lot of courage for kids to approach adults with their concerns and override the sense that they are betraying their friends.

Often parents can chalk up their child’s high-risk behavior, such as hanging out very late at night, running away, or experimenting with drugs or alcohol, to typical teenage conduct. Although it can be challenging to figure out when moodiness and risk-taking is appropriate, it’s key to decipher when a teenager is on a self-destructive path. Talking to your children with an open mind and an understanding ear, and getting outside support, is the first step in helping a struggling child.

Editor’s note: This is part one of a three-part series about kids and depression. Stay tuned for part two tomorrow.