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.