Depression Diagnosis in Teens: Is Decreasing Stigma Putting Normal Teens at Risk?

National campaigns to reduce mental health stigma and raise awareness have been in full swing for years. Awareness is needed. Equal treatment for mental health illnesses is paramount. Mental illnesses are real, devastating, and may be poorly understood.

But what happens when we mix in normal, healthy individuals with the truly ill? What happens when we treat people who don’t actually suffer from the illness in question? Who is at risk for unnecessary treatment? What harm can come of it?

NIH reports that 11% of kids will suffer from depression between the ages of 11 and 18. Illness rates are available on the NIH website and www.nih.gov.

From Web MD:

What Are the Symptoms of Depression?

For major depression, you may experience five or more of the following symptoms for at least a two-week period:

Persistent sadness, pessimism

Feelings of guilt, worthlessness, helplessness, or hopelessness

Loss of interest or pleasure in usual activities, including sex

Difficulty concentrating and complaints of poor memory

Worsening of co-existing chronic disease, such as rheumatoid arthritis or diabetes

Insomnia or oversleeping

Weight gain or loss

Fatigue, lack of energy

Anxiety, agitation, irritability

Thoughts of suicide or death

Slow speech; slow movements

Headache, stomachache, and digestive problems

Now consider the average teen:

Normal teens may be moody, sad, pessimistic, disinterested, or irritable. Normal teens often oversleep, complain of poor memory, may grapple with their worthiness, and have changes in weight. How many of these criteria might a healthy teen meet? The diagnosis only requires checking off five from the list.

These questions leave me wondering if psychiatry needs to re-write the criteria for depression in children and adolescents. Shouldn’t the criteria be limited to only the extremes, those outside the range of “normal” for the developmental stage of adolescence? Do these criteria limit, or capture too broad a group?

Kids who are diagnosed with depression will not follow the same long-term course as adults with the same diagnosis. Kids may outgrow mental health problems, or their problems may morph into a different diagnosis in adulthood. For example, childhood bipolar disorder raises the risks for adult depression and anxiety disorders, but less often results in adult bipolar disorder. (In the new criteria released in 2013, childhood bipolar disorder was renamed to decrease misperceptions about the adulthood risks).

Suicide: The Case for Treatment

Depression is one of many psychiatric disorders that can increase suicide risk. Many have argued for treatment of teen depression to prevent suicide. Suicide is terrible, and we all want to prevent it if possible. But the jury is still out on whether treatment for teen depression actually reduces suicide risk, and some studies raise concerns about depression treatments actually increasing suicidality in teens and young adults (those were the studies which sparked the black box warning for antidepressants).

So, if preventing suicide is not a clear reason to treat iffy teens, why risk it? Consider the following:

If we use limited mental health services on the wrong folks, what’s left for the truly ill?

Unnecessary treatments can be expensive and harmful. Antidepressants carry a black box warning in teens: they can make things worse.

Former child patients who feel they were inappropriately treated become some of the strongest voices in the anti-mental health organizations. Anti-mental health advocacy threatens to deprive patients in need of the psychiatry and psychotherapy services necessary to control their illnesses.

Expanded efforts to raise awareness and offer treatment may inadvertently raise the rate of false positives. We need to capture the truly depressed kids, but somehow avoid treating kids who don’t have the illness.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Parents: First-Line Healthcare Advocates

I awoke this morning to find my middle-schooler pasty-pale, feverish, and gaunt. I called the doctor’s office, and will head over to have him seen in a couple of hours.

Today, I am reminded of what it feels like to be a healthcare consumer, rather than my usual role as a physician—being the patient, or parent of the patient in this case, is not very fun. In fact, being the healthcare consumer is scary. I feel vulnerable. I don’t want my child to be sick, and I don’t want to rely on an expert (our doctor is wonderful, by the way!) to assess the situation and provide us with a plan. But today I have to trust and rely.

He probably has an acute illness, something short-term. I can already anticipate how the visit will go. Either he will need a week of antibiotics, or we will be asked to watch and wait. Most of my patients are not so lucky. In mental health, I rarely see a teen for a one-time, sick visit resulting a weeklong treatment or supportive care. The vulnerability parents must feel walking into my office is difficult to comprehend.

Increasingly, I read reports of a growing deficit of Americans’ trust in our healthcare system. Waning trust is attributed to many factors: the growing bureaucracy in medical care, a lack of a long-term personal relationship with our doctors, physician conflicts of interest, privacy concerns, seven minute visits… many among us fear we can no longer trust the professionals who deliver our care. But none of my anxiety about the visit today is due to any of these concerns. Even though I trust the doctor and know she will listen and give us the time we need today, my fear is more basic: “What if she doesn’t understand what’s wrong with him? What if our concerns cannot be addressed?”

Those reports I read come from professional medical journals and monographs, written by leaders in the field, all trying to address the quality of healthcare through changes in policy and education. But none of those reports contain anything that helps me today. Today’s clinic visit is not about policy.

As a parent, maintaining trust in my doctor means taking a few simple steps to make myself part of the healthcare team. It usually starts with a theory of the illness that I develop before I walk into the clinic. I might pull out a medical book, talk to a friend, or search the internet for information. Armed with information, I can ask intelligent questions.

And I will make a list. (As a doctor, I always appreciate when patients come in with a list. Lists are the best way to prevent the hand-on-the-door rememberings of important details we needed to address earlier, or the dreaded telephone message afterward noting, “I forgot to tell the doctor…”)

Finally, I will take a few notes when the doctor gives her opinions and instructions. These can guide me after we leave the office, in case I have trouble recalling directions.

We have a long-term relationship with our doctor, an invaluable commodity in healthcare. She knows our histories and she listens. But if I were in the unfortunate position of seeing a new doctor today, I would have a few more steps to take at this visit: I would need to decide whether this person could meet our needs as a family, be ready with a plan if the clinician might not work out, and advocate for the proper system of care to address my child’s specific medical care requirements. My questions might extend, not just to today’s needs, but to the greater spectrum of medical care needs my child has now and will have in the future.

In healthcare situations, the parent’s role is much like his/her role as advocate and overseer with a caring teacher who might not understand a child’s learning issues, or an aggressive gymnastics coach whose style is troublesome. We step in and take action when our experts fail us. We clear up misunderstandings and facilitate communication; we empower our kids to speak up for themselves; we pull them out of situations that can’t be repaired. We are their advocates in every way.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Tips for Parent’s to Instill Healthy Skills in Kids at Any Stage

“…our children don’t belong to us. They are both a loan and a gift from God, and the gift has strings attached. Our job is to raise our children to leave us. The children’s job is to find their own path in life. If they stay carefully protected in the nest of the family, children will become weak and fearful or feel too comfortable to want to leave.”-- The Blessing of a Skinned Knee by psychologist Wendy Mogel.

If you haven’t read The Blessing of a Skinned Knee, it’s a great read for a parent at any stage. Written by a psychologist, it highlights how much of the “sickness” she was treating in her teen patients was not individual sickness, but rather a culture or family sickness. Families often have misguided expectations and goals. They want the best for their children, yet somehow steer their parental lessons in the wrong direction. In my psychiatric work with teens and young adults, it’s the same.

Too many families are focused on “success” defined as academic or other types of achievement, while too few are teaching the necessary skills for survival after kids leave home. In a similarly themed book, The Price of Privilege by Madeline Levine, PhD, the author writes: “Indulged, coddled, pressured and micromanaged on the outside, my young patients appeared to be inadvertently deprived of the opportunity to develop an inside. They lack the secure, reliable, welcoming internal structure that we call the ‘self.'”

So how can parents avoid the pitfalls of misguided lessons, while fostering the development of a well-developed, healthy sense of ‘self’ with a toolbox full of necessary skills?

1. Start with a simple family tradition of teaching kids to be grateful. Gratitude is a powerful tool for happiness, as well as for the development of a healthy sense of self. Most religious traditions encourage the use of gratitudes as a spiritual practice.

2. Think of your role with your children in terms of your larger mission. When you are no longer available to advise your children, what lessons would you like them to be left with? Are you routinely moving them toward those goals today?

3. Remember that your child’s most difficult qualities are also the seeds of her best qualities. If he’s a daydreamer, he may be creating elaborate stories while he drifts off from his math homework. If she is a defiant teen, perhaps she has the seeds of a leader.

4. Children shouldn’t be admonished for their desires. But that doesn’t mean they should be indulged either. Their desires are automatic and not the result of disrespect, but even when normal, wish fulfillment doesn’t get to run the show.

5. Foster positive impulses, like generosity. Most children are naturally kind and generous. Give them opportunities to practice and expand on those inclinations. For younger children, donating old toys is a simple way to begin. For teens, volunteering for a community cause is a marvelous way to give.

6. Make rules, kids learn from their roles in the family. Whether they help clean up after dinner, or perform a list of chores- reward good behavior so they have an opportunity to feel good about themselves that’s not tied to achievement or success.

7. Teach manners. A firm handshake and a polite greeting can go a long way in the world. And kids need to remember to keep in mind the needs of others rather than only consider their own desires.

8. Spend time together as a family. Whether during nightly family dinners, a weekly outing, or a movie night, even teens need to stay connected with their nuclear families and to learn to schedule regular down time.

9. Let your kids take risks. For smaller children, perhaps that means letting them fall off their bicycles. For teens, it may mean letting them go out unsupervised. Stretch the limits of your own comfort here, parents!

10. Allow your kids to experience discomfort. Let them fail. Let them struggle to solve relationship problems without your involvement. As an adult, you probably have lots of experience solving problems, but your kids need opportunities to learn.

11. Spend less time worrying about your child, and more time believing in him.

12. From The Blessing of a Skinned Knee: “If your child has a talent to be a baker, don’t ask him to be a doctor… Your child is not your masterpiece.” 

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.

Armchair Personality Disorder Diagnosis Unhelpful

What is a personality disorder?

It seems I am asked this question at an increasing rate. People come in to discuss problems with family members whom they deem difficult, and they ask me if I think the difficult individual has a personality disorder. Since when did this term become common usage?

A personality disorder is a problem with emotions, coping skills, relationships, and behavior. Personality disorders take many forms. Individuals with personality disorders may have trouble keeping jobs, friends, or stable lives because of their tendency toward unhealthy coping. Like the range of personality itself, there is a continuum from healthy to unhealthy disposition. So, when do the moods, coping skills, relationship problems, and behaviors rise to level of “disordered?”

Some might say disordered is in the eye of the beholder. In the midst of a failing marriage, most people say their partner is cruel and selfish, cannot get along with others, or lacks the ability to communicate. Likewise, during a tumultuous period of development, parents ask if a teen or young adult exhibits signs of a disorder. Family members say, “This behavior is abnormal – out of control. There must be a name for this madness!”

A truly disordered individual has difficulty across most contexts (at work, at home, in both social and intimate relationships) and has the problems throughout adult life.

But in my experience, most of the people who ask me the question: “Does my loved on have a personality disorder?” are not, in fact, dealing with a person who has a true disorder. Most loved-ones can only accurately gauge their firsthand experience with a difficult person. We all have trouble with behavior and coping from time to time. Experts have shown that the most extreme failures of interpersonal communication happen in the closest relationships—we express ourselves poorly with the people we love most. When we are attached to someone, getting upset impacts our behavior and coping most severely.

Rather than search for diagnostic labels, family members get closer to a resolution when they search for methods – methods to resolve conflict, methods to communicate or cope with a difficult period in a relationship. Essentially, improvement comes when people work to address their own reactions to stressful encounters instead of naming the loved-one’s problem.

Personality disorders are serious mental health problems, requiring intensive, long-term psychotherapy. If working on one’s own reactions to difficult encounters is unproductive and if the unhealthy disposition crosses into most contexts, certainly seeking compassionate long-term care for a loved one is in order. But labeling with a mental disorder as a kind of blame for tough relationships is not helpful.

Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.