Dear Pediatrician: How Can I Tell If My Teen Has Depression?

Teens are experiencing record high levels of depression and sadness, according to the Centers for Disease Control and Prevention’s (CDC) most recent Youth Risk Behavior Survey. The survey revealed that feelings of sadness or hopelessness kept 42% of high school students from fully participating in their regular activities for at least two weeks during the previous year (a significant increase from 31% in 2017, and just 28% in 2011). Alarmingly, the survey also found 22% of high school students in 2021 seriously considered attempting suicide^[1]Youth Risk Behavior Survey Data Summary and Trends Report. Centers for Disease Control and Prevention, 2023. Accessed 3/27/2023. .

This report adds weight to the already existing National State of Emergency in Children’s Mental Health initiated in 2021.

We don’t know the primary cause of increasing mental health issues. Experts speculate factors like increased screen time, social media apps, family instability, social isolation during the COVID-19 pandemic, early identification of mental health problems in kids, sleep deprivation, excessive academic demands, parental mental illness and lack of independence as the impetus for the high number of children struggling with mental health issues. However, there is little evidence that any of these modalities are solely responsible.

Regardless of the primary cause, the reality is that more teens need urgent and chronic help for this complex condition. Depressed teens are more likely to have thoughts of death including suicide, and suicide is one of the leading causes of death in teenagers. This sobering fact should motivate anyone who cares for or lives with a teenager to take notice.

Depression is a serious mental health condition characterized by sustained, significant feelings of sadness and lack of interest in pleasurable activities. These symptoms result in disruption in a teen’s emotional, physical and social life. Depression has numerous subtypes that are diagnosed by trained mental health practitioners.

Depression is diagnosed by the presence of a variety of symptoms lasting at least two weeks. Symptoms of depression in teenagers may include:

• Feelings of sadness or persistent irritability
• Feeling hopeless or empty
• Being easily frustrated
• Unintentional weight gain/loss or change in appetite
• Changes in sleep habits
• An excessive sense of worthlessness
• Low self-esteem
• Sensitivity to rejection or failure
• Fatigue or tiredness
• Impaired ability to think, concentrate or make decisions
• Frequent complaints of headaches or stomach aches
• Poor school performance or increased school absenteeism
• Less concern for personal hygiene
• Self-harm behaviors
• Use of alcohol or drugs

Of note, depressive symptoms of at least two weeks warrant a call or visit to your child’s health care provider, therapist or school counselor. Kids don’t need to have months of symptoms prior to initiating therapeutic care.

All teenagers are at risk for mental health disorders. However, depression research has identified conditions that increase the risk of depression in teens. These depression risk factors include:

• Excessive stress
• Grieving the loss of a parent or loved one
• Break-up of a romantic relationship
• School issues, like attention or learning disorders
• Having a chronic illness, like diabetes
• Being a victim of abuse, neglect or trauma
• Having a negative body image
• Having parents with depression

In my practice, I focus additional attention to teenage populations known to have higher rates of depression, such as:

• Post-pubertal females
• Kids that identify as part of the LGBTQIA+ community
• Children of racial or ethnic minority

Despite possible predisposition, family history or personal attributes, all children 12 years and older should be given a validated depression screening tool at every well-child visit. These screening tools are not used to diagnose depression, rather they help pediatricians and parents identify kids at risk of mood disorders.

Teens have normal fluctuations in mood and behavior. The difference between a diagnosable mental health condition and normal mood changes is based on intensity, duration and location (meaning who those feelings are directed toward).

Teen depression is characterized by severe and unrelenting feelings of sadness for at least two weeks. This experience is significantly different from “teen angst,” which may be a fleeting down mood or increased irritability for a few days.

In addition, teens with normal mood changes are able to express themselves differently with different people. For example, it would be normal for a teen to be rude to a sibling and snarky with a parent, while laughing and connecting with a friend on the phone. A teen with depression, however, will have a persistently down mood with family, teachers and friends alike.

Treatment of teen depression begins with professional psychotherapy. Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) are two types of psychotherapy with some of the most supportive evidence. Although these therapies are primarily for the teen themselves, many therapists will include the family throughout the process.

For children who are not showing expected improvement with therapy alone, there are safe and effective medications for depression. These medications are prescribed by general practitioners and psychiatric clinicians. Evidence suggests teen depression is best treated through a combined regimen of therapy and medication.

Building in mental health protective factors is one way to promote mental wellness. Consider these action steps to protect teens, while opening the door to positive mental health conversations.

• Save 988 as a contact in your teen’s phone. A text to 988 connects anyone in crisis to the Suicide and Crisis Lifeline. This free, mental health connection point is monitored 24 hours a day, seven days a week. All teens should have this number saved in their phone as a personal mental health resource, or to be able to quickly share with a friend. For Spanish-speaking teens, the toll-free phone line is 1-888-628-9454. All services are free and confidential.
• Movement is medicine. Regular exercise is associated with mental wellness. Pediatricians encourage daily movement for all children as a mental health booster. For kids with depression, daily exercise on most days of the week can be an effective part of a therapeutic regimen due to the multitude of benefits that body movement offers.
• Support connections with adults who live outside of the home. Coaches, educators, extracurricular volunteers, art and music instructors, parents of friends, relatives…any adult in a teen’s life can provide the critical role of mental health advocate and supporter. Research suggests trusted adults outside the home are protective of youth mental health, especially in cases of family instability. Enrolling your teen in various school-based clubs, religious or community activities, are ways to find this protective social connectedness.
• Be screen conscious. As kids age and become independent with screen usage, a firm restriction of screen hours is nearly impossible to manage. However, creating boundaries that help teens be mindful of screen usage remains important. Keep phones off of dining room tables and out of bedrooms. Watch one screen at a time rather than the TV, smartphone and tablet all at once. Encourage screen breaks—a collaborative, scheduled, sustained fast from all screens for three days or more. This will help all kids recognize the value and joy that screens bring us, which demonstrates resilience and practices off-screen based communication methods that are valued by adults.
• Encourage peer-based initiatives. Peer-to-peer influence is exceptionally powerful during the teen years. Using this connection toward mental wellness is a unique way to combat high depression rates. Programs like Mental Health First Aid have been shown to increase mental health literacy, lower mental health stigma and empower peers to take care of one another during acute crises.
• Don’t be afraid to ask. Open lines of communication with loved caregivers is a protective lifeline to mental health access. Don’t be afraid to talk openly with your teen about their feelings, including thoughts of sadness or suicide. Talking about depression and suicide does not increase a person’s risk of death by suicide.
• Vote in local elections. Building community-based protective measures, such as suicide prevention initiatives in schools and expansion of mental health access points, requires local prioritization of funding. If mental wellness initiatives are a priority, vote for local candidates who will defend the use of public finances toward these efforts.
• Take action if someone is concerned. If a teacher, counselor or health professional suggests therapeutic or medical intervention may be needed for your teen, please believe them. It’s going to take a network of people to watch out for our teens as we work through this crisis. Having a child with mental illness can be very difficult and exceptionally painful for families, but dismissing or ignoring a clear message that your child may need help can lead to unmeasurable consequences.

The mental health crisis in our youth is real. Teens with depression can thrive with swift identification and proper treatment. Reach out to your child’s doctor if you ever have concerns—we can help.

“Dear Pediatrician” is for informational purposes only and should not substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your child’s pediatrician or other qualified health providers with any questions about a medical condition. By submitting your letter, you’re agreeing to let Forbes Health use it in part or in whole, and we may edit the letter for length and clarity.