Because they are notoriously hormonal and occasionally withdrawn—sometimes with mercurial moods on their best days—teenagers experiencing depression are difficult to pinpoint, notes Karen Swartz, MD, associate professor of psychiatry at Johns Hopkins University in Baltimore, and founder of the Hopkins Adolescent Depression Awareness Program.

Yet it is important to do so, as major depression, also known as clinical depression,1 is an illness with debilitating symptoms and life-altering outcomes when left untreated.

Depression is not a sign of weakness nor something that can be overcome by willpower2—and studies indicate it is on the rise.3

Sign(al) language

Depression is identified by emotional and behavioral changes that disrupt a person’s relationships, school or work performance, and physical health.1 Depression alters the way people feel about themselves, explains Dr. Swartz. And in teenagers, or teens, the mood change is often irritability rather than sadness, “so ‘depression’ doesn’t resonate,” she says.

Talking with teens can help determine what feelings are a temporary result of academic pressure, social struggles, and developing bodies, and what may be something more.2 Depression is diagnosable when at least five of the following symptoms—representing a disruptive change in behavior—are present for at least two weeks1:

  • Irritability
  • Boredom or loss of interest in favorite activities
  • Failure to gain weight normally, or overeating and weight gain
  • Difficulty falling asleep
  • Inability to sit still, or extreme lethargy
  • Persistent tiredness or feeling lazy
  • Self-criticism and self-blame for things beyond one’s control
  • Decline in school performance due to decreased motivation and focus
  • Thinking, talking, or writing about death or suicide and giving away belongings 

Other warning signs may include feelings of hopelessness, constant isolation, suspected drug or alcohol use, and outbursts of anger as extreme as damaging property or physical aggression, reports Stephanie Hartselle, MD, assistant professor of psychiatry at Brown University in Providence, Rhode Island, and a member of the American Academy of Child and Adolescent Psychiatry.

“It is natural for [teens] to push boundaries, want more time alone, and prioritize peers over family,” she says. But the warning signs for depression should be taken seriously, she notes.

Causes for alarm

Experts believe multiple factors can contribute to teen depression,2 and the disease’s causes are unclear, note Drs. Hartselle and Swartz. Risk factors include a family history of depression and mood disorders, substance abuse in the family, and early or ongoing abuse or neglect.2 “We believe genetic and environmental factors predispose kids to develop depression,” says Dr. Hartselle. “And then stressors can be the spark that starts the fire.”

Such stressors include having low self-esteem due to obesity, academic struggles, bullying, or troubled peer relationships; witnessing or experiencing violence; having an eating disorder; having a chronic physical illness or disability; abusing drugs; and being LGBTQ in an unsupportive environment.2

Also, recent studies explore the relationship between screen time and mental health issues in teens. “Adolescents who spent more time on new media (including social media and electronic devices such as smartphones) were more likely to report mental health issues,” concluded a 2017 study published by the Association for Psychological Science (APS).3

“Teens who spend five or more hours a day on electronic devices … are 66 percent more likely to have at least one risk factor for suicide, such as depression, thinking about suicide, or having attempted suicide in the past,” says Jean M. Twenge, PhD, psychology professor at San Diego State University and lead author of the APS study.3

Dr. Swartz says social media use can be both a trigger and a marker for teens with depression. Some may be triggered toward depression by their experiences on social media, “whether that’s cyberbullying or spending a lot of time comparing themselves with others when they’re already having negative thoughts,” she says. Then once experiencing depression, young people may isolate themselves and spend more time on social media than in healthy, in-person interactions.

Though depression’s cause is sometimes unclear, “we can identify when it’s happening, and treatments work regardless of the cause,” says Dr. Swartz. So, identifying those who need care should be the focus.

Sound checks

Treatment options for depressed teens vary widely, and their applicability depends on the symptoms and their severity, explains Dr. Swartz. In most cases, the primary care physician can screen a young person for depression and start treatment, then refer the patient for consultation with a psychologist as needed after that.

“You never know when someone will feel like talking about what they’re experiencing,” Dr. Swartz adds. And some of the changes caused by depression—weight gain or loss,1 a change in personality,1 and self-harm, such as cuts or burns2—are more easily observed by someone who does not see the teen every day. So, the eyes and ears of health professionals can be crucial in accurately assessing depressed teens.

Various forms of psychotherapy can be helpful. For example, cognitive behavioral therapy (CBT) helps patients recognize and adjust negative thinking patterns. Interpersonal therapy (IPT) equips patients with problem-solving techniques to repair damaged relationships, which can be both a cause and result of their depression.1 Peer support groups or self-help groups may also benefit young patients, as well as antidepressant medications.1 About 60 percent of adolescents respond to initial treatment with medication.1

Also, teens need to abstain from engaging in behaviors that can worsen their symptoms or make treatment less effective, such as drinking alcohol or smoking pot, says Dr. Swartz.

Family therapy may “help everyone learn how to support their teen,” says Dr. Hartselle. And she notes that when a teen shows “serious signs of severe depression,” including talk of hurting themselves or others, going to the ER for emergency evaluation is every bit as critical as it would be for someone having chest pain.

Allies, make some noise

Education and an attentive eye can help parents, medical professionals, and even other teens recognize early symptoms. A recent study indicated an average gap of eight years between onset of symptoms and treatment for depression, notes Dr. Swartz. “You redefine yourself and lose a lot of confidence in that time,” she says.

A cohort study in New Zealand reported that long-term complications of depression included dropping out of school, early parenthood, and unemployment, notes Dr. Swartz.

Dr. Swartz has spent 19 years in high schools educating students. “Teens are open to the idea of depression as a treatable mental illness, but being depressed makes you feel like you don’t have a medical problem, you’re just a screw-up and a loser,” she says. “The symptoms are very personal and make it harder to see you need help.” Therefore, educating parents and teens is key to getting depressed individuals the care they need.

At its worst, depression can result in suicide, which is why Dr. Hartselle and other experts are encouraged that the stigma around depression seems to be lessening and resources to help are growing. “Those in health care, including medical assistants, [should] continue to educate themselves on teen depression,” says Dr. Hartselle, “so we can help change this epidemic as a team.”