Helping adolescents to overcome depression

Adolescent depression is a minefield for pediatricians that many–I dare to say, too many–try to avoid. The article in this issue, “Screening adolescents for depression” by Marissa Corona and doctors Carolyn McCarty and Laura Richardson, is an excellent review of adolescent depression that prepares pediatricians to deal with this common disorder. However, many pediatricians choose to avoid rather than navigate this minefield.

This choice is not one that should be lightly taken. Most pediatricians are aware of the prevalence and know that adolescent depression has a genetic basis with about half following a pattern of recurrence. Depressed teenagers are more prone to substance use including alcohol, which is associated with risk-taking behaviors. Depressed adolescents do poorly in school and have more family discord. Depressed adolescents may attempt suicide and, sadly, some complete this tragic act.

Many pediatricians have faced adolescent depression in their own children and certainly in their family’s circle of friends.

So, knowing these risks, a pediatrician’s decision to routinely screen for depression–a treatable disorder far more common than many other conditions we screen for–means navigating this minefield.

Although the diagnosis is readily definable symptomatically, conducting a meaningful interview with a depressed adolescent is not easy. He or she may be reluctant to share information. Really listening to the sadness and hopelessness of a depressed adolescent without excessive interruption is both a task and a burden. Rushing to give “answers” is tempting; however, premature suggestions limit the empathy and stop the listening.

The information gathered is also a burden. The pediatrician will have to weigh the issues of confidentiality. Should he or she keep some information private from the parents? That’s not a simple decision and one that is always open to second-guessing. If the pediatrician keeps the confidence, will that make him or her more trustworthy and supportive of the relationship with the adolescent, or are the risks of dangerous behavior so high that the confidence must be broken to protect the teenager from harm over the short term?

Lastly, interviewing a depressed adolescent does not fit into the workflow of the usual pediatric practice. Furthermore, in the office visit, the pediatrician faces a tough decision. How serious is this depression? Is it an emergency, urgent, or is it mild to moderate? Some might say, better not to know.

Yet, I must argue that screening, recognizing, evaluating, and treating the milder forms of adolescent depression can be one of the most relevant and fulfilling aspects of pediatrics. Recognizing and referring the more seriously depressed adolescents can be life saving. Often these are patients you have seen grow up in your practice. You care about them and want them to navigate adolescence successfully. You know that depression can be treated through support, verbal therapies, and medication, and you know that the combination of treatments has the highest chance of success.

A depressed adolescent gives you the privilege of entering his or her world as well as working with the family and experiencing vital life issues through a meaningful relationship. It is intense and requires judgment, creativity, and bearing risk. Navigating the minefield of adolescent depression can remind you why you became a pediatrician.

DR JELLINEK is professor of psychiatry and of pediatrics, Harvard Medical School, and Chief Clinical Officer, Partners HealthCare System, Boston, Massachusetts. He also is a member of the Contemporary Pediatrics editorial advisory board.

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