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The Rise of Teen Depression

By Joe Sugarman
In the past decade, clinical depression and anxiety among adolescents ages 12 to 17 have gone up. As medical professionals seek to find the reasons, how can parents determine: When is it typical teen moods and when is it something more?

There were times when Abby Webster* felt like she had a bully in her brain. That’s what the Harford County middle schooler called it anyway. The bully would tell her that she wasn’t good enough, that she couldn’t do things she wanted to do. It made her so sad sometimes that she would come home from school and hide in her closet. And when she was 15 years old, it told her to cut herself.

She had been working on a project—fashioning a wallet out of duct tape—when she took the X-acto knife she was using and carved a neat little square on the back of her hand. When her mother questioned her about it, she said, “I just scratched myself.”

Her mother was aware that her daughter was suffering but didn’t know the depths of it. Abby got straight As in school. She had a lot of friends. “She was really good at hiding it,” her mother, Sarah, recalls. “I would chalk up her moodiness to just being a teen.”

About six months later, Sarah saw several red cuts on the back of her daughter’s hand again. “Why are you doing this?” she asked. “Why are you hurting yourself?” But Abby couldn’t explain her feelings. At that point, Sarah knew she had to get help. She found psychiatrist Leslie Miller at Johns Hopkins Bayview Medical Center. Miller, director of the Mood Disorders in Adolescents and Young Adults Program, knew the story well. “Everyone says teenagers are moody, but how much moody is normal and how much is a mood disorder?”

For parents raising teenagers, it’s a question they’re asking more often. The odds of adolescents suffering from clinical depression grew by 37 percent between 2005 and 2014, according to a study by Ramin Mojtabai, a professor at Johns Hopkins Bloomberg School of Public Health. The National Institute of Mental Health estimates that 3 million adolescents ages 12 to 17 have had at least one major depressive episode in the past year. Teen depression appears to be on the rise equally among urban, rural, and suburban populations. Research also shows that more dangerous behaviors, like self-harm, are increasing.

Has the emergence of social media created a wave of depressed teens? Are our kids, hovered over by helicopter parents, more fragile than previous generations? Or is the rise in the number of cases simply a result of teens being more comfortable about sharing their problems and seeking help?

What’s going on here?

“That’s the million dollar question,” Mojtabai says.

To understand the rise in depression among adolescents, it’s helpful to know that it’s a relatively new diagnosis. Until the 1980s, psychiatrists didn’t think teenage brains were developed enough for such an adult affliction. Doctors were quick to dismiss mood disorders as simply part of normal human development—an idea that still riles Karen Swartz, a psychiatrist who is the director of clinical programs at the Johns Hopkins Mood Disorders Center. “It’s not easy being a teenager, but it’s a terrible disservice to young people to dismiss their medical problems as just part of their development process,” Swartz says. She notes that historically doctors were reluctant to diagnose depression in adolescents because there weren’t effective or safe pharmaceutical treatments for it. (That changed with the approval of Prozac by the FDA in 1987 and similar drugs in later years.)

Teens and those around them are painfully slow in acknowledging warning signs, especially compared to symptoms of other diseases.

For her patients, Swartz sometimes compares depression to asthma—another medical condition where environmental factors can worsen the situation. With asthma, an increase in dust or pollen could bring on an attack. With depression, it might be a family tragedy or a stressful situation at school. But outside factors don’t always play a role in either condition.

“People who have depression—and especially psychiatrists with depression—are always caught up in the whys. Everybody wants a good story to explain it. But sometimes the story is as boring as, ‘ It runs in your family, you’re vulnerable to it, and when the combination of life stress and hormones react,you get it,’” Swartz says. “Sometimes you just have depression. Sometimes you just have asthma. That said, if you ignore the fact that you sneeze every time you pet the cat in your house, it’s hard to imagine how you’re going to get better.”

In 1998, three Baltimore-area high school students, including a star lacrosse player at one of the city’s top private schools, took their own lives around the same time. These were unrelated, but the suicides jolted the community, and several schools asked Swartz to speak with parents, teachers, and students about depression. She quickly realized how little people knew about it. The following year, she and several colleagues formed the Hopkins-based Adolescent Depression Awareness Program (ADAP) to help high school teachers and students recognize its symptoms. The team developed a three-hour curriculum for health teachers to share the facts about adolescent depression with their classes. The goal was to convey two primary themes: number one, depression is a treatable medical illness, and number two, if kids are concerned about themselves or a friend, talk to an adult. Since its inception, the program has reached more than 75,000 students nationwide. Still, Swartz says a lot more needs to be done, as teens and those around them are painfully slow in acknowledging warning signs, especially compared to symptoms of other diseases.

“If you have a person showing certain recognizable symptoms, you say, ‘I think that person’s having a stroke. I’ll call 911.’ We haven’t done that so well with depression. With depression, it’s still a mystery to so many people and they don’t know to take action,” Swartz says. The goal with educating people on the basics of the disease is so “they know it exists, that it’s a real medical problem. Then they might say, ‘Oh, my gosh, I might have that. And they say it’s treatable, so maybe I should do something or talk to somebody.’”

Swartz recognizes that it can be hard for parents to acknowledge that some behavior is more than typical teen behavior. But left unchecked, depression can have dire consequences. “It’s tricky that a really common illness among teens is potentially fatal, but it’s often not recognized, which sets up a dangerous issue,” she says. “Parents given the choice between ‘my child is sort of being an annoying teenager’ or ‘my child has a potentially life-threatening medical problem,’ are not going to pick the second. It’s terrifying.”

At the end of her sophomore year in high school, Rebecca Green started feeling sad but had no explanation. She lived in a loving, two-parent household and excelled academically at the Baltimore-area private school she attended. She enjoyed playing sports and studying foreign languages and had ideas of traveling abroad someday. To her friends she was known as being outgoing and cheerful, but increasingly, Green felt a lack of motivation, a feeling that she’d be better off dead. She began fantasizing about her own death. “Most girls picture their weddings,” she says. “For me, it was really important to plan my own funeral.” After telling her school counselor that she had taken a friend’s Lexapro, a drug used to treat depression and anxiety, the counselor contacted her parents, who sought help at Leslie Miller’s clinic.

Through sessions with Miller and therapist Arielle Goldman, Green learned to alter her thought patterns, to not escalate minor problems, like a disappointing grade, into suicidal thoughts.

“I learned to take things for what they are and how to reason in different ways,” she says. “Now if I get frustrated or feel defeated, it doesn’t translate into me wanting to give up. Now when I envision my own future, it’s in more tangible ways, and I want to be there for that future.”

In her office at Bayview Medical Center, Goldman sketches on a whiteboard what she calls the “cognitive triangle,” a core element of cognitive behavioral therapy. At each point, she writes a word: “Thoughts,” “Feelings,” “Behaviors.” Goldman uses the graphic to help clients visualize the areas they can work on to improve their condition. It may be hard for people to alter their feelings, she says, but people can change their thoughts and behaviors, affecting how they feel. Instead of brooding about a perceived slight at school, she recommends changing a behavior—go out for a bike ride or watch a movie with a friend.

Goldman says she spends about 90 minutes with each new client, trying to suss out a diagnosis. In the world of teenage mood disorders, sometimes getting the right diagnosis is where the challenge begins.

Take someone who’s having problems with concentration. That could be symptomatic of depression, anxiety, ADHD. “The context is really important,” she says. “You can’t look at a symptom in isolation. You have to look at it as a constellation of symptoms. Then look at the timeline of when these episodes started.”

two teens walking

Anxiety, she says, can be harder to spot. A 2015 report from the Child Mind Institute found that only about 20 percent of young people with a diagnosable anxiety disorder get treatment. Goldman is often called upon to treat a patient for depression, only to find out they’re suffering from anxiety as well. “Kids can be perfectionists or overachievers,” she says. “Depression is usually noticed more easily, but anxiety can fuel achievement and, thus, it’s this hidden affliction.”

Warning signs for so-called “general anxiety” often manifest as physical symptoms—frequent stomachaches, headaches, not wanting to get up in the morning. “Social anxiety,” on the other hand, is easier for parents and teachers to see, as kids will be afraid to speak with strangers and won’t raise their hands in class or eat in the cafeteria with others.

Over the years, Goldman and Miller say they haven’t necessarily noticed a spike in kids suffering from depression, but anecdotally they have witnessed new trends and triggers associated with mood disorders. Unfortunately, one of them is an increasing number of kids committing acts of self-harm—cutting, burning, striking themselves. And girls tend to do it more often than boys. Whether due to hormonal changes at puberty, societal pressures regarding appearance, or the fact that they’re more likely to share their feelings, girls have always recorded rates of depression about twice that of boys. Mojtabai’s research found that one in six had suffered a major bout of depression. Another recent analysis by the RAND Corporation pegged the number even higher—estimating that more than 36 percent of girls in America have been or are depressed by the time they reach 17.

Research on why teens—and girls in particular—harm themselves remains in its infancy. Psychiatrists say that kids who self-injure are, in essence, self-medicating emotions, much the way an adult might by using alcohol. They may want to calm themselves down. Or, conversely, they feel so numb to the world that they just want to feel something. Some research has shown that cutting can stimulate the pleasure zones of the brain. It could also be used as a form of self-punishment.

Goldman says it often comes down to teens wanting to experience something different. “Their [depressive] feelings are difficult to tolerate and they want to feel something else,” she says. “It’s not usually a suicidal gesture. It’s something that helps them feel better in the moment.”

She says convincing them to alter their behavior can be difficult since the gratification from self-harm is immediate, and potentially addicting, and other forms of distraction, like going for a hike or getting ice cream, are less intense and not as direct. 

Perhaps the most significant impact on their clients Goldman and Miller have witnessed in the last decade has been the arrival of social media. They point out that it’s hard enough being a teen and having to endure hormonal upheaval, peer pressure, and high academic expectations, without the added pressures of comparing their lives to others online.

The hyperconnectivity of today’s teenagers—nearly 80 percent of them have cellphones—means that school-day dramas play out in real time. Every embarrassing moment, every snippet of gossip, has the potential to be recorded,posted, and commented upon.

When struggling teens use social media to connect with others in order to find social support, it can have a positive impact. But more often, it’s used as asocial barometer, a measurement of achievements and failures. Teens can feel pressure to portray an idealized version of themselves on social media sites—a phenomenon that has given rise to its own malady, called “Facebook depression,” in which people feel down after visiting the site.

“Sometimes parents are afraid to speak up, but teenagers are usually happy the parent has noticed and is saying something. Sometimes people think they need to suffer silently and that’s absolutely not the case.”

Social media has also given rise to cyberbullying, which is particularly insidious because it occurs outside the schoolyard and in homes, previously a safe zone for victims. And while playground bullying has a finite time frame, damaging photographs, vicious comments, or websites can live on. Cyberbullies have even been known to take screenshots of the material, ensuring its life in perpetuity. Offensive postings sometimes follow kids to new schools as well. “Teenagers need to know that a good rule of thumb is that everything is public and permanent,” Miller says. “It’s hard because they act impulsively, but there needs to be some sort of increased awareness. Even if you think something on social media is temporary, it’s not.”

Cyberbullying has been implicated in numerous cases of teen suicide in recent years, including Texas teen Brandy Vela who shot herself in front of her parents last year. Even after her death, the cyberbullying continued, with hateful comments about being a “fat cow” and “you should have done this a long time ago” appearing in the comments section of a website established in her memory.

Alison Papadakis, an associate teaching professor in the Johns Hopkins Department of Psychological and Brain Sciences, researches the social environment and how kids deal with interpersonal stressors. She separates peer aggression into two categories: overt, or classic physical bullying, and relational aggression, what she refers to as the “mean girl ideal.” She says research shows that relational aggression—just the sort that kids inflict on each other via social media—can be more damaging to young psyches than a punch to the gut. “At their age, relational aggression has more meaning to their identity and place in the social structure,” she says. “My impression is that adolescents think, ‘Maybe there’s some truth in the rumors they spread about me.’ They take it to heart maybe more.”

The other problem is that social media is more pervasive. Kids can’t escape its addictive nature. A 2015 survey by Common Sense Media showed that girls spend more than 90 minutes a day engaged in social media, while boys, just 52 minutes. Ironically, those surveyed don’t find it all that fun. While 45 percent admitted to using social media every day, only 36 percent say they enjoy using it “a lot,” compared with 73 percent who like listening to music and 45 percent who enjoy watching TV “a lot.”

The first time a client showed Facebook to Swartz, she knew the “scrubbed up version” of life it portrayed could mean trouble for vulnerable people. “If you’re well and you see on Facebook that someone didn’t invite you to a party, you think, ‘My friends aren’t being nice and they should have invited me to that party.’ If you’re depressed, it’s, ‘No one likes me. This is proof that I don’t have any friends.’ The depression actually changes how you interpret the world.”

For Brian Gregorio, a transgender male, Facebook was just too much. The 16-year-old had been the target of school bullies since he was 8 or 9. Kids would tease him about his weight, throw textbooks at him, or punch him outside of class. When Facebook came out, he signed up for an account, only to find his “friends” posting the same insults—and worse—on his page. “Not only was I dealing with the stress from school, I was dealing with the threat of people cyberbullying me,” he says. “All it was doing was hurting me.”

Gregorio, who is in therapy for depression, has since changed schools and has been Facebook-free since last fall.

Although Swartz admits social media can be a trigger for some, she says it’s far too simplistic to blame the rise of social media on the recent rise in depression. “It’s like saying everyone who has been bullied will suffer depression. If you’re a depressive person, being bullied could be a tipping point.” She returns to her asthma analogy. “Look, I could visit someone with three cats and not have an asthma attack because I don’t have asthma. We’re all looking for the easy answer and it’s really a complex situation.”

Once teens leave home for college, they are thrust into an adult-like world that can be fraught with new challenges and result in added stressors. Many colleges around the country are addressing this situation by increasing their mental health services, and students have responded. Visits to counseling centers at universities and colleges increased by 30 percent between 2009 and 2014, according to a recent report from the Center for Collegiate Mental Health at Penn State University.

"[Counseling centers] are doing all they can to encourage people to come forward, and it makes it look like there’s been a huge explosion in the number of depressed kids,” says Matt Torres, director of the counseling center at Johns Hopkins University’s Homewood campus. The majority of the students who visit the center are experiencing depression or anxiety “with a little D or a little A,” he says. They’re feeling depressed or anxious about something,but it doesn’t necessarily rise to the level of a diagnosis.

Torres doesn’t think the current generation of students is less capable of dealing with stressors than previous generations were (an accusation made by some), but he does think that teens are living in an increasingly challenging social and political environment. This is the post-9/11 generation, one that has grown up in an era of terrorism, school shootings, and economic turmoil. College campuses have historically been places of political tensions, and that’s true today. “This is reminiscent of the ’60s in some ways,” Torres says. “Students and people are taking to the streets and protesting and demanding change and advocating for groups that aren’t getting what they deserve. And that causes stress, especially when the dialogue becomes defensive.”

teen sitting in office

So what are we to make of all this? Even as depression in teens is on the rise, it remains unclear whether it’s due to increased awareness and acceptance or environmental factors. All doctors interviewed for this story emphasized that convincing teenagers to talk to adults is paramount. And parents shouldn’t be afraid to raise the issue with school counselors, pediatricians, and their kids.

“If there’s something indicating concern, there usually is something going on,” Goldman says. “Sometimes parents are afraid to speak up, but teenagers are usually happy the parent has noticed and is saying something. Sometimes people think they need to suffer silently and that’s absolutely not the case.”

Abby Webster is now 20 years old and the “bully in her brain” shows itself far less frequently. She takes medication to treat her depression and continues therapy. Much to Sarah’s delight, Abby’s in college and living on her own.

Sarah’s only regret is that she didn’t immediately seek help for her daughter. “I would say to parents that if you think your kid is depressed, it’s probably worse than you suspect,” she says. “I thought I knew everything, but I did not, and I wish I would have gotten help sooner. It has made such a big impact in Abby’s day-to-day life. I feel like I have my daughter back.”

*Patient and parents names have been changed.

teens
Illustrations by Carmen Segovia

Is Your Teenager Depressed?

Karen Swartz, psychiatrist and director of clinical programs at the Johns Hopkins Mood Disorders Center, says to look for changes in three main areas:

Changes in Mood

  • Feeling sad or low
  • Irritability
  • Feeling nothing or a lack of enjoyment in formerly pleasurable activities

Changes in Physical Symptoms

  • An increase or decrease in appetite, leading to changes in weight
  • Sleeplessness or not being able to get out of bed in the morning
  • Not being able to focus or concentrate
  • Having little or no energy
  • Feelings of agitation or restlessness, sometimes relieved by self-medication via drugs, alcohol, or self-harm

Changes in Self-Attitude

  • A loss of confidence or self-esteem
  • Feelings of worthlessness

While most people have experienced at least one or more of these symptoms in their lives, to diagnose depression, psychiatrists look for a cluster of symptoms lasting for a sustained period of time (at least two weeks) that interferes with a person’s functioning socially, academically, or emotionally.

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