Teen Depression in the Pandemic

This week’s guest columnist is Dr. Stephanie Barrow, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

A 16 year-old girl saw me in clinic after she’d told mom she was feeling down. Prior to the Pandemic, she’d been a spirited teenager, involved in student council, the Welcoming Committee, and intramural sports. After school closed last spring, she went from being busy every day to having nothing to do for months. She started isolating in her room, sleeping more, eating less, and becoming irritable with family.

Since the beginning of COVID, we’ve seen an uptick of patients with depression. Some  are having symptoms for the first time in their lives. Scariest of all, in the past month we’ve had an epidemic of adolescent overdoses. Every day at least one teen’s come to the Emergency Department having taken whole bottles of their medication, or someone else’s. One girl took fistfuls of several of her grandmother’s medications, any one of which could have been lethal.

My 16 year-old patient had a more common presentation of depression. Her world was turned upside down, like everyone’s this past year. Stuck at home with only social media and family, she felt trapped in four walls, and trapped in her own mind. She went from wanting to be with everyone and involved in everything, to closing herself in her room and even minimizing social media interactions with friends.

When we see kids like this in clinic or the ER, one first thing we do is check for metabolic causes for depression, like thyroid disease or drug use. We also ask questions to assess the symptoms and severity. His he feeling like a failure?  Has he lost interest in favorite activities? Trouble concentrating or sleeping? Appetite changes?  Moving more slowly? Even more worrisome: has he had suicidal thoughts or worse, attempted suicide in the past and not told anyone?

We set my patient up with a counselor and started an anti-depressant. She slowly improved with video counseling and the medicine, and mom saw a positive change. She began to feel like she had her daughter back.

Once my 16 year-old patient was doing better, mom brought in her 13 year-old brother. He was always an introvert, keeping to himself and never having many friends. However, recently he began sleeping poorly and barely eating. In clinic, he stated that he felt like nothing he could do was good enough. During my interview, he was slow to answer questions, mumbled, and wouldn’t make eye contact.

We knew his sister had depression, and counseling and medication had worked for her, so we tried that with him. Just one month later when he returned for a check-up, I could tell he was a new boy the moment he walked in. He looked all around and asked a million questions, and when he sat down he didn’t slump like a sack of potatoes; he sat straight up, looked me in the eye, and smiled! His sister was excited too, because earlier that week he spontaneously hugged her, which he hadn’t done for over a year.

Both my patients are so far having happy endings to their depression. Unfortunately, not all kids have that. As we mentioned above, we’ve seen a spate of suicide attempts by overdose recently. While some of those teens have had life-long depression and even admissions to psychiatric facilities, we’re seeing more and more with no previous histories.

It’s sometimes difficult to know what’s on a child’s mind. Knowing was less of an issue when they were going to school five days per week, interacting with teachers and schoolmates, and busy with school work and extracurriculars. And early in the Pandemic children could coast along with electronic interactions. As things linger though, they’re getting just as fed up with it as adults are. Many are also dealing with illness and death in loved ones and friends.

If you’re suspecting a child’s depressed, seek help immediately. Your kid’s doctor, your priest or pastor, the school, or counseling centers have resources to help. At home, restrict access to medications, lock away guns or keep them out of the house, monitor your kid’s on-line activities, and just talk to them about depression. Depression, and the Pandemic, aren’t quite going away just yet.

Stressed Teens, Stressed Parents

The parents brought their teenager into the Emergency Department because she was acting bizarrely.  The normally cheerful, outgoing girl was suddenly sullen, irritable, and lashed out at the slightest provocation.  She also seemed paranoid, suspicious of everyone around. Usually ready to hug, she now acted afraid of any contact.  During my physical exam her eyes darted back and forth, and she flinched when I reached out with my stethoscope.

The onset of mental illness can seem sudden.  In medical school they called it “the psychotic break,” where previously well teens become paranoid or delusional, often when faced with new stress, like moving away to college. This break was thought to herald life-long illness like schizophrenia or bipolar disorder.  However, it turns out that most teenage psychological troubles have a slower, more subtle beginning; and if treated early, can have a happier ending.

Seemingly dramatic changes in behavior are often preceded by symptoms that are missed or denied by teens or parents.  These include weight loss and drop in appetite, plummeting grades, chronic abdominal pain or headaches, irritability and combativeness.  These can easily be dismissed as normal teen “phases,” which they often are. Unless they’re not.

Other signs that your teen is coping badly are…having to cope.  Profound stress can push your teen to depression or other maladjusted behaviors.  Are parents divorcing or having other troubles, like infidelity?  If you as a parent think you’re stressed by the situation, it’s as bad or worse for your kids.  Love and security that they counted on their whole lives has now blown up.  Many divorcees state that they wouldn’t have divorced if they’d known what it would do to their kids.  Other profound stressors include moving; a parent’s job loss or other economic hardship; and death of a loved one, like a friend or close grandparent.  If your kid’s facing these issues, be ready to get help.

The more distressing symptoms of mental illness, like our girl above, are clearer signs that it’s time to get help now.  These include alcohol and drug use, sexualization or being sexually abused, eating disorders, or paranoia and hallucinations.

It’s no fun dealing with angry parents who make their teen’s mental illness a battleground.  Often they bring their kids to the Emergency Department demanding that they be drug-tested, to “win” the fight over suspected abuse.  In the most recent instance, after I told a mom that we could not legally force a drug test on a teen, she stormed out of the ER, yelling that it was her right to know.  Fortunately, the teen stayed behind, and we had a good talk about her drug use, her depression, and how she could get help.

Having proof that your teen is using drugs won’t make him or her snap-to.  Looking back, I could have handled the situation better by asking the mom, “how will a positive test help you and your child?” and explore the issue from there, rather than shut her down with the law.  If the girl’s behavior already made mom worried that she’s abusing drugs or alcohol, that behavior is often evidence enough that she needs help, better than a drug test.

Like we discussed above, symptoms of depression or other mental illness can be subtle, or not-so-subtle- weight loss, plummeting grades, chronic headaches and abdominal pain, drug use and promiscuity.  Now that you’re properly scared, where to get that help?

If you belong to a major denomination church, clergy and staff often have training and offer competent counseling.  Your child’s doctor should have a list of mental health services, and some even do counseling and anti-depressant prescribing themselves.  School counselors also should know their cohorts in the community.  You’ll want a counselor that partners with a psychiatrist or other provider who prescribes.  Anti-depressant or mood-stabilizing medication often helps get teens through a bad patch, and keep them steady as they learn new, healthier habits with thinking and interactions.

If you find yourself getting angry at your teen’s behavior, when they’re combative, sullen, or just plain lazy, take a step back.  Maybe they’re not acting this way to piss you off, maybe they’re crying for help the only way they know.  Laziness may just be laziness, or that inability to get off the couch could be depression.  Don’t take it as a personal affront, take it as a call to action.  

A Tale of Two Teenagers

Hard to believe, Amy loves the Army.  She’s in boot camp, enjoying lots of exercise, full days, new jargon to learn, and she even likes the lectures on Army protocol. It’s stressful to be sure; it’s supposed to be tough.  Some girls are fainting, some are washing out because they can’t hack it, some stay up too late and lose sleep. Amy has her eyes on the prize- graduating and moving up.  When she gets anxious, she swallows it and moves on. Uncharacteristic for her, she’s eating well and going to bed early.  Her parents are proud, not only for her accomplishment but for how far Amy has come.  Her life wasn’t always this way.

From an early age, Amy was having a rough go.  She had trouble paying attention in first grade, though she was highly intelligent.  She angered some teachers with her pointed, seemingly rude commentaries, though other teachers “got” her. She was tried on ADHD medications, which helped for a time, but then began causing side effects where Amy acted confused and panicky.  By high school, it was clear Amy was depressed.  She was sullen, didn’t get along with most of her classmates, and scraped out poor grades. Despite grasping the material, she just didn’t care enough to get papers in on time or study for tests.

Amy had no obvious reason for depression.  She had two loving, educated parents and two happy siblings.  At the first sign of trouble with attention or mood, she got the best doctors and therapists.  As Amy got older and was able to verbalize what was going on inside, it seemed her depression was “chemical:”  she was just born that way, with no external reasons like bullying or her looks.

Anti-depressant medication helped, as did continued counseling.  Her parents cheered her on through thick and thin, and as she got older Amy’s life began looking up.  College was much better than high school as far as academics and having friends. She had positive dreams for her future.  Joining the Army wasn’t her parents first choice; heck, even with a bachelor’s degree she enlisted rather than take on the responsibility of being an officer. But now they were singing a different tune.

Sharon has it much worse than Amy.  I saw Sharon in the Emergency Department last month.  She came by ambulance after being beaten by a gang of boys.  They ran up behind her, knocked her down, and kicked her repeatedly in the head and chest. There had apparently been some bad blood between Sharon’s friends and other factions in the neighborhood.

From our computer record I saw that Sharon had had a tough life already, though only 15 years-old. She had been seen by us twice for sexual assaults, another time for being beaten up, and once to be admitted to a psychiatric hospital for suicidal thoughts. She came from a rough house in a rough neighborhood.  Her mom obviously had mental illness of her own, from the pressured speech of hyperactivity or drug use, to her peculiar tattoos.  Mom yelled a lot, at Sharon and us, though this seemed to be not from anger but how she usually spoke.

Certainly Sharon’s depression has not gotten the attention that Amy’s did.  Though she had been in hospital for depression, Sharon isn’t on anti-depressants and isn’t in counseling.  Chaos rules her home life: her father’s gone, and she bounces between mom’s and the homes of several other families. Her school and neighborhood aren’t safe.

Despite all this, I have some hope for Sharon.  Kids can be resilient, and Sharon still had an occasional smile and some spunk, despite what just happened.  Mom also did seem to care about her, as did an aunt with her who seemed more emotionally stable.  They agreed that counseling was a good idea, and to see her doctor about a psychiatric referral.

Some kids like Amy are born with depression.  Some like Sharon, besides having inborn depression, also have life stresses that contribute.  Both kids need attention- counseling and maybe medicine to get them through bad patches. If your kid seems depressed, telling them to buck up and act happier isn’t enough.  You should ask about suicidal thoughts, why he is depressed, and see his doctor.  Depression is rough, so better that your kid gets the attention that Amy got, rather than Sharon’s. 

Unreasonable Teens, Unreasonable Parents (Hamiltons included)

Every so often a parent brings their teenager to the Emergency Department for a drug test.  The parent is suspicious that their teen is using drugs, even if the teenager denies it.  There is obvious tension in the air between the two.  We politely tell the parents that we can not legally or ethically make teens take drug tests (or pregnancy tests either).  If the teen doesn’t want the test, we can’t make them do it.  What would the parent have us do- hold their adult-sized kid down and catheterize him or her for their urine sample? 

Communication break-downs between parents and teens lead to a lot of miserable ED visits.  Problems with honestly discussing drug use, and trusting each other, lead to the trouble above.  Even worse, mistrust and anger between kids and parents can lead to depression, violence between parents and kids, and teen suicide.  Teen years are tough enough, and it is even tougher when the teen can’t rely on his folks for sympathy.

We all know teenage years are difficult.  New hormones lead to mood swings, love sickness, feelings of awkwardness as the body grows and changes and breaks out in sweat and zits.  Inside that big, lumbering body is a brain swinging from wisdom to toddler tantrum, and back.  Stresses of school, the meaning of life, sleep deprivation, fitting in, all take a toll.  Little problems to an experienced adult are new, huge problems to a teenager.

Parents respond to their stressed teenager in two ways.  Parents at their best are understanding, forgiving, and patient.  The other response is anger; anger at the teen’s whining, misbehavior, and snappishness.  We condemn our teens for bad grades, slowness to do chores or find a job, and inappropriate clothes.  Parents often show both understanding and anger in the same day, or the same hour.  I sure do with my three teenagers.

The trick is to be more of the first, less of the second.  If you are angry, walk away and cool off before you say hurtful things.  Pick your battles- having it out with them over drugs and alcohol is much more important than dogging them about their clothes, or manners, or speech. 

Most importantly, rewards are more important than punishment.  Finding something (anything!) to compliment your teen about will get you much farther with them than grounding them for a month for denting the car.  I’m not saying don’t discipline your teen- only that the punishment should be fair and the compliments kind.  Everyone likes to have nice things said to them like “Good job cleaning the kitchen,” or ”your hair looks great.”  Everyone feels wronged when having privileges taken away for mistakes, especially when the mistake was an accident and not intentional. 

So parents, next time you get really angry at your teen, back off.  Don’t let anger and a loose tongue wound your relationship with your kid.  Cool off, be calm, and remember that your love for your child is more important than your own righteousness. 

Got that, Scott?