Expanded Access Needed in Rural Areas and for Low-Income Families

In the post-pandemic 21^st century, most parents of teenagers know the state of mental health among adolescents in the U.S. is at a crossroads. Some experts say our teens are in crisis or call our current situation a bona-fide emergency. Crisis, emergency, or longstanding problem now getting public recognition for the first time, the Surgeon General of the United States released what’s known as a Surgeon General’s Advisory to bring attention to the problem.

The SGA was published in January 2021. You can read it here, and read our article about it here:

Surgeon General’s Advisory: Youth Mental Health in 2021

This article is about a specific topic in teen mental health: depression treatment. The very short version is that in some areas of the country, our teens need more access to evidence-based options for outpatient treatment for adolescent depression. And nationwide, both parents and teens need more education about the effectiveness of treatment for depression available in teen depression treatment centers. In particular, families in rural areas and families considered low-income need information on medication for depression and the potential approaches to psychotherapy that can help their teens learn to manage the symptoms of depression and live a full and vibrant life.

We’ll dive into the details on depression, prevalence of depression, and treatment for depression in a moment.

First, let’s get back to that Surgeon General’s Advisory (SGA). It’s important to understand that SGAs are not common. It takes a high threshold – like a crisis or emergency – for a Surgeon General to take the time and effort to publish a report meant to be disseminated nationally possible and read by as many citizens as possible.

That’s why we’ll start out with information on the big picture of teen mental health in the U.S., then narrow our focus to depression once we all understand where we are – and where we need to go.

Teen Mental Health in the U.S.

Here’s the data that prompted the publication of the SGA.

Youth Mental Health: Basic Facts

• In 2019, 20% of children between age 3 and 17 reported an emotional, behavioral, developmental, or mental health disorder.
• In 2016, only 50% of the children with a treatable mental health disorder received the treatment they needed.
• The percentage of high school students with persistent feelings of sadness or hopelessness increased by 40% between 2009 and 2019

That information is self-explanatory. In general, mental health problems among youth and adolescents are on the rise. As these problems increase, children and teens aren’t getting the support they need. Now let’s look at another set of data, directly related to the topic of this article.

Youth and Adolescent Suicide Trends 2007-2019

• 2007-2018:
  • Suicide rates increased by 57%
• 2009-2019:
  • Percentage of youth seriously considering suicide increased by 36%
  • Percentage of high school students with a plan to commit suicide increased by 44% between 2009 and 2019

We share these two sets of statistics – the general numbers and the suicide numbers – for two reasons:

1. Teens with clinical mental health disorders are at risk of significant disruption in their present lives. If untreated, mental health disorders that develop during adolescence can lead to impaired function and disruption throughout adulthood
2. Untreated depression increases risk of suicide. The earlier depression appears, the greater the risk. The longer it goes untreated, the greater the risk.

To put it directly, we share these statistics because the stakes are high.

Teen Depression: Decade-Long Upward Trend

Let’s take a look at rates of prevalence of major depressive episodes (MDE) among adolescents over roughly the same period of time as the statistics above. This data comes from a peer-reviewed journal article called “Prevalence of Depression Among Adolescents in the U.S. From 2009 to 2019.”

Trends in MDE Among U.S. Teens: 2009-2019

• MDE prevalence:
  • 2009: 8.1%
  • 2019: 15.8%
• Girls:
  • 2009: 11.4%
  • 2019: 23.4%
• Boys:
  • 2009: 5%
  • 2019: 8.6%

New data shows those numbers increased in 2020:

• MDE: 17%
  • Girls: 25.2%
  • Boys: 9.2%
• MDE With Major Impairment:
  • 2020: 12%

Now let’s get to the core of this article, which is treatment for depression.

In 2020:

• 41.6% of teens with at least one MDE received treatment
• 46.9% of teens with MDE with major impairment received treatment

That’s what we call the treatment gap. This data shows that while millions of teens each year get the treatment they need to manage the symptoms of depression, millions more do not get the treatment they need.

The longer we see this treatment gap persist, the more we know we need to spread awareness about and advocate for treatment for teen depression – because treatment works.

Evidence-Based Outpatient Treatment for Adolescent Depression

Teens receive outpatient treatment for depression at two levels of care, where typical and virtual treatment are considered the same level of care:

Typical/Traditional Adolescent Outpatient Treatment

Teens participate in individual office-based psychotherapy once or twice a week with a counselor or a therapist. Sessions last around an hour.

Virtual Adolescent Outpatient Treatment

Teens participate in psychotherapy via videoconference or telephone once or twice a week. Sessions last around an hour.

Intensive Adolescent Outpatient Treatment (IOP)

Teens participate in individual office-based psychotherapy, group psychotherapy, group counseling, group educational workshops, and complementary therapies three to five days a week for 2-4 hours per day

Outpatient treatment for teen depression most often occurs in teen depression treatment centers or outpatient treatment centers for teens. This level of care is most often recommended for teens with mild or moderate symptoms, while teens with severe depression need the enhanced support and care available in residential treatment.

Adolescent Outpatient Depression Treatment: What Works?

Evidence-based outpatient treatment approaches proven to work for the adolescent population include psychotherapy, medication, and combined treatment. Combined treatment means a teen takes medication for depression and participates in psychotherapy at the same time.

Let’s explore the details – and look at some data – about psychotherapy, medication, and combined treatment.

Psychotherapy

The American Academy of Child and Adolescent Psychiatry (AACAP) indicates that for depression in children and adolescents:

• Psychotherapy should be the first-option treatment for teens with mild to moderate depressive symptoms. Effective psychotherapy for teen depression includes:
  • Cognitive behavioral therapy (CBT)
  • Interpersonal psychotherapy
• The data:
  • Of teens who receive treatment for depression, around 80% participate in psychotherapy
  • 12-25 sessions over 2-4 months results in significant reduction of symptoms
    • On average, teens who receive psychotherapy for depression go to 8 sessions per year
    • About 1/3^rd of teens who receive psychotherapy for depression go to 1-2 sessions per year
  • Why the Gap?
    • In rural and low-income areas, access to outpatient treatment is limited
    • Families in urban areas and families with higher income may be more engaged in/actively seeking treatment than families in rural areas or low-income families

Pharmacotherapy (Medication)

The AACAP indicates that for depression in children and adolescents:

• Antidepressant medication is appropriate for teens with severe depression, psychotherapy-resistant depression, psychotic depression, or bipolar depression. Medications include:
  • Selective serotonin reuptake inhibitors (SSRIs)
• The data:
  • Of teens who receive treatment for depression, about 20% take medication.
    • SSRIs lead to significant reduction of symptoms in teens
    • In a large-scale trial, 41% of teens experienced reduction in symptoms while taking an SSRI, compared to 20% on a placebo
  • In 1999, 60% of teens with depression took medication, compared to the 20% who take it now
• Why the decrease in pharmacotherapy?
  • Black box labels warning of side-effects of SSRIs in teens, introduced in 2004, explain this reduction.
  • Side effects may include:
    • Problems having fun doing anything
    • Decreased participation in sport or hobbies
    • Increased suicidal ideation

Combined Psychotherapy and Pharmacotherapy (Medication)

The AACAP indicates that for depression in children and adolescents:

• Combined treatment is the optimal approach. Combined treatment can:
  • Mitigate/reduce depressive symptoms
  • Increasing self-esteem
  • Improve coping skills
  • Increase adaptive symptom management strategies
  • Improve family and peer relationships
• The data:
  • The Treatment for Adolescents with Depression Study (TADS) compared treatment in teens receiving CBT alone, an SSRI medication alone, or a combination of the two.
  • After 12 weeks:
    • 73% of teens who received combination therapy showed improvement
    • 62% of teens who received SSRIs alone showed improvement
    • 48% of teens who received CBT alone showed improvement
  • After 18 weeks:
    • 85% of teens who received combination therapy showed improvement
    • 69% of teens who received SSRIs alone showed improvement
    • 65% of teens who received CBT alone showed improvement
  • After 36 weeks:
    • 86% of teens who received combination therapy showed improvement
    • 81% of teens who received SSRIs alone showed improvement
    • 81% of teens who received CBT alone showed improvement
  • Important information from the TADS study:
    • 15% of teens on SSRIs alone reported suicidal ideation
    • 8% of teens in combination therapy reported suicidal ideation
    • 6% of teens who received CBT alone reported suicidal ideation

Let’s remember that suicidal ideation is a symptom of depression. We say that to remind parents that SSRIs don’t create suicidal ideation out of whole cloth, but rather, exacerbate the presence and frequency of suicidal ideation in some cases. We’ll end this section on treatment with the words Dr. John March of Duke University, who was the lead researcher on the TADS Study. He addresses how and why the combination approach works, and how can mitigate some of the problematic side-effects of SSRIs:

“In the combination approach, the two treatments complemented each other. [SSRIs] can help dissipate the physical symptoms of major depression relatively quickly, and CBT can help patients develop new skills to contend with difficult, negative emotions. TADS provides compelling evidence for families and clinicians that the most effective way to treat depression in teens is with a two-pronged approach. It reassures us that antidepressant medication combined with psychotherapy is an effective and safe way to help teens recover from this disabling illness.”

This should give anyone involved in the life of a teen with depression hope. The evidence clearly shows that treatment for depression works. For mild to moderate depression, a combination of outpatient treatment and medication leads to real improvement in over seventy percent of cases.

Depression Treatment: Early Detection and Early Treatment

It’s well-documented that the earlier a person with a mental health disorder receives an accurate diagnosis and appropriate, evidence-based treatment, the better chances they have of learning to manage their disorder, reduce symptoms, and mitigate the most serious consequences associated with their symptoms.

This is critical for depression –  mild or moderate included – because evidence shows that untreated depression can:

• Impair relationships during adolescence
• Impair school performance
• Degrade quality of life
• Prevent participation in social activities
• Prevent participation in sports, extracurricular activities, and school clubs
• Impair relationships during adulthood
• Impair the ability to find employment/stay employed during adulthood
• Increases suicide risk

Those are all things any parent wants their teenager to avoid. And they can, with early diagnosis and appropriate treatment. The treatment gaps we mention above are a serious concern. They exist not only in rural areas and for lower-income families, but for all people across all demographics. Although depression is a complex condition and the details of treatment plans vary by individual, the overall approach to treatment is straightforward: therapy, medication, and the healthy lifestyle habits that support wellbeing for anyone, such as healthy food, regular exercise, and robust stress management techniques.

Gaps In Outpatient Treatment for Adolescent Depression: What We Can Do

For families in rural areas, where therapists may be scarce, and for low-income families, who may not have the means to participate in consistent outpatient treatment, there are three things we can do to close the gaps in outpatient treatment options.

These three steps apply to everyone, but can increase treatment coverage in rural areas and for lower-income families in particular:

1. Reduce stigma through education and awareness. Everyone needs to know that depression is a medical condition that responds well to evidence-based treatment.
2. Screen for depression in the primary care setting. Early detection by a family doctor can get a teen in treatment sooner, and increase their chance of treatment success.
3. Expand virtual and telehealth options. Combined with screening for depression in the primary care setting, this can change the game for rural and low-income families. Psychiatrists can assess a teen and prescribe medication over the phone or via videoconference. A teen can then enter ongoing combination therapy with a therapist or counselor without barriers to treatment such as transportation, local treatment availability, travel time.

When we dedicate time and resources to implement these steps, the available evidence indicates we can help teens improve their quality of life dramatically. Treatment can help a teen move from a place where their depressive symptoms dominate their daily life to a place where they’re in control of their daily life, and can thrive at home, school, and with friends: that goal is one hundred percent achievable, given our current knowledge and technical capabilities. We can start with these three steps, and change millions of lives for the better.