Adolescent Depression: Insidious and Prevalent 

Depression is prevalent in up to 8 percent of adolescents and may steadily rise because of COVID's persistent fallout—continued sequestering at home, loneliness, and substance abuse. The relapse rate is alarmingly high: About 45 percent of adolescents with a history of major depression develop another episode in early adulthood.

Adolescent Depression

Source: Frank John Ninivaggi MD, author

Depression is a prolonged mood of sadness, irritability, and loss of interest or pleasure in everyday life. Other symptoms include appetite and weight changes, sleep difficulties, agitation or apathetic slowness, fatigue, a sense of worthlessness, inappropriate guilt, problems concentrating, and recurrent thoughts of death. Anxiety as feelings of powerlessness, helplessness, and deep emotional insecurity accompany depression. Pronounced social isolation and a history of bullying may lead to self-harm.

Chronological age, developmental status, and context nuance the above. Depression is experienced and expressed as the same disorder from adolescence to later life. In adolescents, irritability, anger, and violent behaviors accompany depression. These are "depressive equivalents." All need careful assessments.

A significant loss of a relationship (e.g., parental divorce) or an unanticipated life event such as family housing, educational status, or physical trauma may precede depressive problems. Often, no discernible trigger is apparent. Subjective self-image becomes impaired because of accidents, illnesses, and other complex losses.

Normal Adolescent Development

Normal adolescent development provides a baseline to measure excursions that might become problematic. Adolescence is a period of biomental change between childhood and adulthood. Brain development is active. Immature neurocircuitry is maturing and open to toxic and traumatic insults, particularly from illicit drugs.

Psychologically and socially, adolescents' peer relationships deepen, autonomy in decision-making grows, intellectual pursuits and social belonging are sought. Mastery over these takes place in the family, school, on interpersonal and social levels. Identity is being formed.

Areas of vulnerability to problems are increased risk-taking, expanded sexual interests and behavior, and moving outside the security of family bonds. Successful adaptation to normal adolescence with no psychiatric disorders occurs in up to 75 percent, but impairing psychiatric disorders emerge in about 20 percent of the adolescent population.

For example, normal sadness is common, brief, and not impairing. Normal grief is an appropriate response to a significant loss and more transient than normal bereavement or mourning a loved one, which can be months in duration. The predominant feelings in grief are emptiness and loss occurring in waves or pangs.

In clinical depression, self-esteem has been so impaired that worthlessness and self-loathing take place. Thus, depression is an attack on self-esteem. Recent studies show self-esteem to be a leading cause of self-harm in adolescence. Para-suicidal behaviors, such as cutting and scratching, are frequent presentations. Inappropriate guilt or feelings of worthlessness do not characterize normal grief and bereavement.

Sadness occurs over days, grief over weeks, and bereavement over many months. In informal conversations, colloquial expressions are common sad conditions. Clinical depression is a psychiatric disorder occurring over several years and needing formal therapy, often medication.

Risk-taking Behaviors

High-risk behaviors increase the odds of severe adverse consequences, including drug and alcohol abuse, unsafe sexual practices, self-injurious behaviors, and reckless driving.

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Substance use among teens is a leading cause of impairment, leading to multiple problems, including depression.

Alcohol, marijuana, and tobacco are substances most commonly used by adolescents.

• By 12th grade, about two-thirds of students have tried alcohol.
• Almost half of 9th through 12th-grade students report ever having used marijuana.
• About 4 in 10 9th through 12th-grade students report having tried cigarettes.
• Among 12th graders, close to 2 in 10 report using prescription medicine without a prescription.
• Although it is illegal for people under 21 to drink alcohol, the findings show that teens from 12 to 20 use about one-tenth of all alcohol consumed in the United States.

The average age when youths first try alcohol is 11 years for boys and 13 years for girls. The national average age at which Americans regularly begin drinking is 15.9. Alcohol dependence and other drug abuse are associated with depression, anxiety, oppositional defiant behaviors, antisocial personality disorder, and an increased rate of suicide.

According to the American Cancer Society, over one in five students has smoked cigarettes. In addition, cigarette smokers are more likely to get into fights, carry weapons, attempt suicide, suffer depression, and engage in high-risk behaviors.

About 6 percent of 12th graders report daily use of marijuana. About 13 percent of high school seniors use cocaine, and 1 percent of 12th graders admit using phencyclidine (PCP). Statistics show that about 5 percent of 12th graders have used illicit opioids.

The consequences of substance abuse cause physical and psychological problems. Depression leads to all mental disorders. Depression may not show directly but expresses itself as withdrawal, irritability, anger, and violence.

Red Flags Signaling Psychological Distress

The risk-taking behaviors described lead to violence, bullying, gang affiliation, association with weapons, and involvement with the law. The impact on school attendance and learning is the fallout influencing current and future life trajectories.

All strata of society are affected by the vulnerabilities that adolescents fall prey to. Genetic predispositions, emotional and physical neglect and abuse, chronic medical problems, and intercurrent trauma may have lasting sequelae. Loneliness is central to depression.

Depression intensifies loneliness. Younger generations are lonelier than older generations. Nearly eight in 10 GenZers (79%) and seven in 10 millennials (71%) self-identify as lonely, vs. half of the boomers (50%).

After stability from 2000 to 2007, the suicide rate among adolescents and young adults aged 10–24 in the United States increased. The rise was 57.4%, from 6.8 per 100,000 in 2007 to 10.7 in 2018. The Centers for Disease Control and Prevention (CDC) Data & Statistics Fatal Injury Report for 2019, retrieved February 9, 2021, show that 15 to 24-year-old's had a 13.95% suicide rate.

Warning Signs

Early warning signs that are mild to subtle that can alert parents, caregivers, teachers, and those who care for children and adolescents include:

• Social withdrawal
• Excessive feelings of isolation and being alone
• Excessive feelings of rejection
• Being a victim of violence
• Feelings of being picked on and persecuted
• Expressions of violence in writings and drawings
• Uncontrollable anger
• Patterns of impulsive and chronic hitting, intimidating, and bullying behaviors
• History of disciplinary problems
• History of violent and aggressive behaviors
• Intolerance for differences and prejudicial attitudes
• Drug and alcohol use
• Affiliation with gangs
• Inappropriate access to, possession of, and use of firearms
• Serious threats of violence

Imminent warning signs that are severe and portend impending danger:

• Serious physical fighting with peers or family members
• Severe destruction of property
• Intense bouts of rage for minor reasons
• Detailed threats of lethal violence
• Possession of/or use of firearms and other weapons
• Self-injurious behaviors or threats of suicide with a plan and access to a means

Recognition is Prevention

Primary prevention is awareness of risk factors leading to adolescent depressions. Changes in mood, social withdrawal, anger, illicit substance use, and preoccupation with violence suggest impending emotional problems. Signs are objectively detectable signals, while symptoms are an adolescent's statements of distress. Social isolation and self-harm demonstrate that someone suffers from low self-esteem, a significant indicator associated with depression. Detecting warnings of psychological disruptors is the first step toward effective interventions and treatments.