The Depression Treatment Gap for Teens — And How to Close It
The most common symptom of depression in teens is not sadness but irritability. When clinicians miss nuanced signs like this, or teens resist sharing their mental-health challenges due to stigma and fear of embarrassment, a treatment crisis may ensue. Here, learn about the mood disorder treatment gap for teens, and how to vault it.
Teenagers are notoriously moody, irritable, and fond of isolating in bedrooms. Parents expect a degree of angst at the onslaught of adolescence — but for some teens, this angst exceeds healthy norms. These teens no longer enjoy their favorite activities, and are withdrawn and irritable to the extent that behave like different people. Teens who fit this description may be struggling with major depressive disorder, a serious — and common — condition. According to the 2021 National Survey on Drug Use and Health (NSDUH),1 20% of teens had a major depressive episode (MDE) in the preceding year, with 75% of these episodes causing “severe impairment.” During that year, 13% of adolescents had serious thoughts of suicide and 6% — 1.5 million teens — made a suicide plan.
Depression is a condition for which evidence-based, highly effective interventions exist, yet only 41% of teens with major depression receive treatment. It’s what experts call the “treatment gap,” and it’s a significant — and complicated — problem.
Depression in Teens: Why Early Treatment Is Critical
Untreated depression in teens can have dire consequences including suicide, which was the second leading cause of death in 2020 among youth ages 10 to 14, and the third leading cause of death among individuals ages 15 to 24, according to the CDC. Teens with untreated major depressive disorder are more than twice as likely as their peers to use illicit drugs — at a rate of 28% compared to 11%, according to the NSDUH. This was the case for the son of an ADDitude reader in Maryland who described her 19-year-old’s experience in this way: “My child feels lost and like he cannot ‘get happy.’ He is afraid to take next steps forward and, unfortunately, he has turned to some substances.”
The long-term ramifications of untreated depression can reverberate through a lifetime. “For almost everybody who will have depression, the first episode will occur sometime in late high school or early college, between the ages of 16 and 19,” said William Dodson, M.D., in an ADDitude webinar titled, “Managing Mood Disorders and Depression in ADHD Adults and Kids.” Dodson explained that depression is a “kindling illness,” as are all mood disorders. “The more episodes you have, the more you will have in the future and the more severe they will get with each repetition,” he said.
One factor that influences the number and severity of future episodes is the early treatment approach for depression. “If you immediately treat each depressive episode for a full year, you should expect three episodes in your whole life,” Dodson explained. “If, on the other hand, you do not treat each episode completely, you can expect 17 more depressive episodes with each episode getting progressively longer, deeper, and worse. Waiting for depression to go away on its own is the single biggest perpetuating factor.”
Barriers to Treating Depression in Teens
1. Depression Is Often Mistaken for “Normal” Teen Moodiness
Complicating the evaluation and diagnosis process is the fact that depression often presents differently in teens than it does in adults. “Whereas most people stop eating, teens will eat everything in sight,” Dodson said. “Where most people sleep more, an adolescent will sleep less. Where most people lose an interest in sex, adolescents will become hypersexual.” Further, the assumption that depressed people appear sad or tearful can be dangerously inaccurate; the most common symptom of depression in teens is not sadness but irritability.
Experts urge caregivers to err on the side of caution and to seek professional guidance if they feel any concern about suicidality, or depression in general. Joel Nigg, Ph.D., made a persuasive case for this approach at a recent APSARD talk titled “Multimodal Prediction of Mood Disorders and Suicide Risk in ADHD Teens.” “Which kind of errors do we want to make in our prediction? Do we want to over-identify or under-identify suicidality?” he asked. “Do you want to intervene by mistake in kids who didn’t need it, or miss kids who are at true risk?”
A psychologist, psychiatrist, or pediatrician should be able to differentiate typical teen moodiness from depression. To ensure they have the opportunity to do this, the AAP recently changed its screening guidelines to recommend that pediatricians screen all adolescents ages 12 and up for major depressive disorder, even in the absence of documented symptoms.
Still, many adolescents will tell their doctor they are “fine” when they are not, thus ending the evaluation before it begins. “When a teen uses the word ‘fine,’ that is a major tip-off to inquire further,” Dodson said. If your child’s pediatrician does not probe beyond this cursory shrug, consider enlisting the help of another resource such as a pastor, rabbi, or trusted relative. According to Dodson, the emphasis should be on doing something rather than figuring out who the ideal referral might be.
2. Resistance from Teens
Diagnosing depression in teens is only the first step on the road to treatment. One of the most significant obstacles on that path is resistance from teens themselves. In ADDitude’s 2022 Youth Mental Health Survey, a reader in Utah described the significant hurdle posed by her 16-year-old daughter’s aversion to treatment for depression, anxiety, and self-harm.
“She gave up on her last therapist and refuses to get a new one,” the reader said. “I have worked on helping her to want to go to therapy, but I cannot physically drag her there, which is what it would take at this point.”
The root causes of resistance are different for every teen, but the following factors are common.
Sense of hopelessness
One particularly insidious aspect of depression is that it causes a sense of hopelessness that can immobilize individuals, preventing them from taking steps toward self-improvement. “When people get depressed, they think differently. There’s a tremendous amount of futility,” Dodson explained. “People tend to look entirely at the negative and think only of the negative outcomes. They think, ‘Why bother? Nothing’s going to work.’”
This was the case for the 17-year-old daughter of an ADDitude reader in Tennessee, who said, “She is dead-set against medications, counseling, and anything that could be beneficial for her mental health. She seems to withdraw more instead of being open to help of any kind.”
Trust is an essential element in the treatment process. Impeding this trust is teens’ common worry that any incriminating information they share with a clinician — substance use, reckless choices, sexual activity — may be shared with their parents or other authority figures.
A study published in Administration and Policy in Mental Health2 found that confidentiality concerns were an “important factor” preventing teens from seeking treatment. “Many [teens] viewed expression of their distress and feelings of inadequacy as privileged information that, if exposed, could have dire consequences,” wrote the study’s authors. The study also found that teens required privacy to speak candidly about mental health concerns with doctors and, in cases where parents were not asked to leave the exam room, teens often chose not to disclose information about mental health issues.
Stigma surrounding mental illness
Negative public perceptions about mental illness have created a stigma that blocks some teens’ access to care. “Stigma impacts care seeking at personal, provider, and system levels,” wrote the authors of a study in Psychological Science in the Public Interest.3
The Administration and Policy in Mental Health study discovered that many teens resisted seeking treatment because they feared appearing “crazy” or “sick.” “Teens’ reluctance to consult medical providers about their concerns was also strongly related to issues about identity. Contrasted with adults, the threat of an illness identity is likely to be much more salient to adolescents,” the authors of the study wrote. “Because of this threat, they may be more likely to refuse a diagnostic label or treatment.”
The study also found that teens’ attempts to appear “normal” included minimizing symptoms, not just to others, but even to themselves. This finding is consistent with the data collected by the National Comorbidity Survey Replication, which found that, among people with a mental health disorder who did not seek treatment, almost half of them did so because they perceived their need for treatment to be low.4
Combatting stigma takes time and collective action, which is helped by mental health literacy and action campaigns like NAMI’s Pledge to Be Stigma-Free. Celebrities such as Demi Lovato, Lady Gaga, Ariana Grande, and even Prince Harry have shared their struggles with bipolar disorder, post-traumatic stress disorder, and depression, normalizing these conditions — and the disclosure of them — for their teen fans.
3. Structural Barriers
According to a recent ADDitude survey, 62% of caregivers reported that it was “difficult” or “very difficult” to access mental health care due to challenges such as scheduling conflicts, lack of accessibility, as well as prohibitive wait times and cost.
“Mental health care is extremely expensive,” explained Kate, an ADDitude reader and parent to a young adult with ADHD, anxiety, and depression in Kansas. “If you have acute emergency mental health care needs, you face dropping $3,000 to $5,000 to get in at the ER. The other alternative is a long waiting list. In the meantime, your child suffers. It’s a nightmare.”
Half of ADDitude survey respondents said they could not reliably access therapy in their geographic region, a major barrier to care. The therapist shortage, which predated the start of the pandemic, has been exacerbated by a well-documented surge in mental health issues, especially among teens. According to the U.S. Department of Health and Human Services, the U.S. will have at least 10,000 fewer mental health professionals than it needs within two years.
“There are not enough providers,” said one ADDitude reader. “We have to wait 3 to 4 months for an appointment. That is not OK when you have a child with suicidal ideation.”
Cost of therapy and lack of insurance coverage
Once a family finds a geographically accessible clinician with availability, they may find their insurance plan doesn’t cover visits and the out-of-network cost is prohibitively high. Lawmakers have sought to address this problem by passing the Mental Health Parity and Addiction Equity Act (MHPAEA), a law that requires most health insurance issuers to cover mental health and substance use disorders just as they would physical disorders. Unfortunately, loopholes and workarounds have allowed insurance providers to largely sidestep the MHPAEA: a therapy appointment, for example, is five times as likely to be out-of-network as a primary care appointment.
An ADDitude reader sums the dilemma up succinctly: “Finding a child psychiatrist is very hard. Finding one that takes my child’s health insurance is impossible. This is when I have to get creative about finding my child the help he needs.”
The Life-Changing Implications of Treatment
While the barriers to care for teens with depression are varied, significant, and deeply entrenched, they can be surmounted, and the return on investment is often dramatic.
“The things [our son is] doing now, like exercise and mindfulness are a result of individual and family therapy he received in the past, which he resented at the time, but which he now says saved his life,” said an ADDitude reader, parent of a young adult in New York. “He uses what he learned then. To us, this is miraculous.”
How To Help Teens Resistant to Treatment
In adolescence, children naturally work to emancipate from their parents’ influence and control, which makes it that much more difficult for parents to guide them toward treatment. “When adolescents suffer from depression, parents find themselves in the awful position of caring deeply with an urgent need to get control, while their adolescent seemingly works against them,” Dodson said. “Every suggestion is immediately shot down and devalued as unhelpful or doomed to make the situation worse.” When this happens, Dodson has the following advice for parents:
- Ask your teen to talk to friends who have been through depression and have come out the other side healthier. Depression is so common at this stage of life that few teens don’t know someone else who has been depressed.
- Most high school students know what to say and do with their friends, but they have lost access to that active, hopeful part of themselves. Try asking them: “If you saw one of your friends struggling the way you were — sad, hopeless, struggling with school and withdrawing from friends — what would you say and do for your friend?” This approach reminds teens that they have friends they care about and who care about them.
- Suicide is a permanent solution to a temporary problem. The depressed person, however, is only aware of their misery right now. It falls to friends and families to hold onto the positive memories of their past and the bright vision of their future. Friends and families must remind the depressed teen that their hopelessness is a symptom of an illness, and that they’re the same person they were six months ago, someone who is precious to their family and friends, with a bright future ahead.
- Ask the teen to list the people with whom they still have a warm and trusting relationship — that special teacher or coach, their pastor or rabbi, their school counselor, a wise grandparent. These people do not have to have special training or be able to solve the depression themselves. All they have to do is communicate to the depressed adolescent that they are loved and that they have a promising future once this depressive episode is behind them.
Suicide & Crisis Lifeline: Call or Text 988
Depression in Teens: Next Steps
- Self-Test: Depression in Adults
- Watch: The ADHD and Depression Connection
- Read: What to Expect When You Start Depression Medication
- Watch: New Insights Into and Treatments for Comorbid Depression
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View Article Sources
1“The NSDUH Report.” Rockville, Md. Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Dept. https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
2Wisdom, J., Clarke, G. & Green, C. What Teens Want: Barriers to Seeking Care for Depression. Adm Policy Ment Health 33, 133–145 (2006). https://doi.org/10.1007/s10488-006-0036-4
3Corrigan, Pw, Druss, BG, Perlick, DA. The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care. Psychological Science in The Public Interest. 2014, 15(2);37-70.
4Mojtabai R, Olfson M, Sampson NA, Jin R, Druss B, Wang PS, Wells KB, Pincus HA, Kessler RC. Barriers to mental health treatment: results from the National Comorbidity Survey Replication. Psychol Med. 2011 Aug;41(8):1751-61. doi: 10.1017/S0033291710002291. Epub 2010 Dec 7. PMID: 21134315; PMCID: PMC3128692.