How Much Support Does My Child Need?
When your teenager receives a diagnosis for a mood disorder like depression – known by mental health disorder as major depressive disorder – the first thing you want to know is what you should do.
Do you listen to the people who say mental health disorders are all made up and people with depression simply need to get over it and think positive thoughts?
No.
You don’t do that.
Please don’t listen to people who say that.
Positive thinking is an important element of recovery, but it’s not a treatment.
Good vibes only is a bumper sticker slogan that’s not a valid approach to a clinical depressive disorder. In treatment, all emotions are important – not just the good ones. Taking a dismissive attitude toward a disorder like depression will not help your teenager. In the long run, it could make it worse. And it will also add to the misconceptions and misunderstandings around mental health issues that pervade our culture – even in 2021.
But we digress.
We assume your teen received a diagnosis from a mental health professional, otherwise you wouldn’t be reading an article like this. If they haven’t received a diagnosis from a licensed professional and you suspect your teen has clinical depression and needs treatment, then your first step is to arrange a full biopsychosocial assessment from a licensed clinician. They can give your teen an accurate diagnosis. They can also recommend treatment and make a recommendation for a level of care that matches your teen’s level of need.
When and if they diagnose your child with a major depressive disorder, they’ll determine whether the disorder is mild, moderate, or severe. They make that decision based on criteria published in the Diagnostic and Statistical Manual of Mental Disorders (DSM–V). That’s the go-to, gold-standard reference psychiatrists, therapists, and other mental health professionals use to ensure consistent and accurate diagnoses for mood, behavioral, and alcohol/substance use disorders.
Your teen’s level of need will determine what level of care is appropriate.
What Are the Levels of Care?
We’ll start this section by offering a quick and simple answer to the question in the title of this article. Psychiatric hospitalization is the most intensive and immersive level of care available. In most cases, psychiatric hospitalization is appropriate for teens in immediate crisis. These are teens with depressive symptoms so severe they pose an imminent danger to themselves or someone else.
While this article cannot diagnose your teenager, we can say with a fair amount of confidence that most teens with depression start their treatment journey at a less immersive and intensive level of care. Your teen may be in crisis and need psychiatric hospitalization. If that’s the case, listen to their therapist or psychiatrist and follow their advice: do not wait. However, if your teen is not in crisis, it’s unlikely they’ll being treatment in a psychiatric hospital.
Again, that’s possible, but unlikely.
Once a clinician has a solid grasp of the severity of your teen’s depressive disorder, they make a level of care referral based on the following criteria:
- Acuity. Acuity means how severe or serious the symptoms are at the time of assessment. The highest level of acuity for a disorder like depression, for example, is suicidality or suicidal ideation.
- Disruption. Disruption describes the effect depressive symptoms have on daily thoughts, emotions, thoughts, and behavior. Symptoms that prevent your teen from engaging in typical activities related to family, school, and social at all are considered severe. Symptoms that are less disruptive are considered mild or moderate.
- History. If your teen has previously attempted treatment at a non-immersive/intensive level of care without success, a clinician will likely recommend a higher, more immersive level of care.
Those are the criteria. Now let’s talk about the levels of care themselves.
Treatment for Depression: Common Levels of Care
- Outpatient. Outpatient treatment is an entry level of care for teens with mild or sometimes moderate symptoms. If your teen has symptoms that do not significantly disrupt their daily life, they’ll most likely start treatment with office visits to a therapist or psychiatrist once or twice a week.
- Intensive Outpatient (IOP). Intensive outpatient is the second level of care. If your teen has disruptive symptoms but can still function at school, they may receive a referral to an IOP program. These programs typically involve treatment three hours a day, three to five days per week.
- Partial Hospitalization (PHP). Partial hospitalization is the third level of care. If your has disruptive symptoms that prevent them from going to school and participating in extracurricular activities and some aspects of family life, they may receive a referral for a PHP program. These programs typically involve a full day of treatment, five days a week.
- Residential Treatment (RTC). Residential treatment is the fourth level of care. If your teen has symptoms so severe and disruptive they prevent them from going to school and participating in family or social activities, they may receive a referral for an RTC program. Teens in RTC programs live on-site at the treatment center. They receive 24/7 support and monitoring so they can focus on recovery without distraction.
You’ll notice that psychiatric hospitalization is not on that list. That’s because it’s the most immersive level of care. It’s not a common entry level of treatment for a teen with a depressive disorder. However, a teen diagnosed with severe depression who is in active crisis may need to start at that level of care.
We’ll explain what psychiatric hospitalization is now.
Psychiatric Hospitalization: How is it Different than the Lower Levels of Care?
Psychiatric hospitalization is different than the levels of care we describe above. It resembles residential treatment – with some important distinguishing characteristics – but it’s a far more intensive level of treatment than outpatient, intensive outpatient, and partial hospitalization treatment.
The difference between IOP, PHP, and RTC are relatively easy to understand. During residential treatment, your teen lives 24/7 at the treatment center. At the other levels of care, they don’t. They participate in treatment for a specified number of hours per day, then go home. In addition, if your teen is in an IOP or PHP program, treatment most often happens Monday-Friday. Whereas in an RTC, your teen receives treatment on the weekends, as well.
If your teen receives a referral for psychiatric hospitalization, then you need to understand the primary ways that level of care differs from residential treatment. Both levels of care are for teens with severe, disruptive symptoms. However, psychiatric hospitalization is for teens in acute crisis. Therefore, the approach to treatment is designed to meet that need.
Here are the five main differences between psychiatric hospitalization and residential treatment:
1. Treatment Objectives
The primary objectives of treatment in a psychiatric hospital are the safety and stability of your teen. In a psychiatric hospital, clinicians and staff closely monitor your teen’s physical and emotional condition until the crisis passes. When your teen stabilizes and a psychiatrist determines they’re ready to step down to a lower level of care, they will discharge them from the hospital.
Residential programs focus on therapy and treatment, rather than stabilizing a teen in crisis. Safety comes first at all levels of care, of course, but teens at the lower levels of care need less intense supervision because their symptoms indicate they’re safe and stable. If your teen receives a referral for psychiatric hospitalization, it’s most likely to prevent serious harm, such as a suicide attempt.
2. Treatment Environment
Most psychiatric hospitals look like regular hospitals. The environment is clinical and institutional. In most psychiatric hospitals, all the doors – to bedrooms, common areas, and eating areas – are locked at all times. Hospital staff control who goes where, when, and why. Most areas are off limits when not in use for their specified purpose.
Most residential RTCs for teens do not look like regular hospitals. In fact, many teen RTCs are located in renovated residential homes designed to feel welcoming and relaxing – like a family home. In addition, a psychiatric hospital typically has a much higher census, meaning the number of people receiving treatment at a time. A psychiatric hospital may have dozens of patients at a time, whereas a teen residential treatment center may have as few as six to ten teens on-site. In addition, there’s more freedom of movement in an RTC: doors between common areas and eating areas are not always locked, for instance. Treatment is immersive, but compared to a psychiatric hospital, far less restrictive. Since teens are not in crisis, the environment is designed to put them at ease and allow them to focus on therapy and recovery.
3. Admission Type
Admission rules will vary from state to state, but in some cases, admission to a psychiatric hospital may be involuntary. In most states, a psychiatrist can refer a teen for mandatory hospitalization for their safety and the safety of their friends and family. Admission to a teen residential treatment center, on the other hand, is more often voluntary than mandatory.
4. Rules of Contact
Rules about contact between staff and teens will also vary from state to state. Most states allow staff in a psychiatric hospital to use direct physical contact when a teen is in crisis: this means the facility is hands-on. This type of contact occurs when a teen in crisis is a threat to themselves, the other patients, or hospital staff. Residential treatment centers, in contrast, are more likely to have hands-off policies. That means that during a crisis, rules prohibit staff from making direct physical contact with a teen. Instead, licensed and trained staff use non-physical de-escalation techniques.
5. Time in Treatment
Psychiatric hospitalization for crisis related to a depressive disorder typically lasts ten days or less. If your teen is in crisis, clinical staff determine how long they stay in the hospital. They assess your teen’s safety and stability, and when the crisis passes, and they’re ready to begin treatment at a lower level of care, a psychiatrist will discharge them from the hospital. In most cases, a teen in a psychiatric hospital steps down to residential or partial hospitalization treatment.
Residential treatment most often lasts for 6 – 8 weeks. However, if your teen needs more time, they may stay in residential treatment for three months or more. Your teen’s length of stay depends on their progress, family input, and available resources. RTC staff will discharge your teen to a less immersive level of care when they learn to manage their symptoms, tolerate difficult emotions, and learn the coping skills necessary to live at home. When your teen is discharged from an RTC program, they most often step down to a PHP or IOP program. However, time in RTC may prepare your teen to return home and continue treatment in an outpatient setting.
Does My Teen Need Psychiatric Hospitalization?
The sections above describe psychiatric hospitalization and what distinguishes it from the next least immersive level of care, residential treatment. And as we mention above, clinicians determine admission to a psychiatric hospital based on your teen’s level of acuity, their symptom severity, and their treatment history.
Let’s talk about symptom severity for a moment, before we close this article.
We’ve written the phrase in crisis several times. To clarify what we mean by that, in crisis means your teen is – right now – a danger to themselves or others. For a teen with depression, this often means they’re actively suicidal or engaging in suicidal ideation.
Note: Do not ignore talk of suicide: it’s a red flag. If you think your teen is in immediate danger, call 911 or take them to the emergency room.
A teen with depression may also act out in angry, aggressive, or violent ways, which may make them a danger to you, their siblings, or their friends. That’s why a teen with depression with violent symptoms – which is more common than most people realize – may need hospitalization to protect others, as well as themselves.
Let’s talk about what we mean by a disruption that’s below crisis level. If your teen has depressive symptoms that prevent them from participating in the following activities at all, they will likely receive a referral for residential treatment. With that said, significant disruption in the following areas often precedes a crisis – and you should understand they need some form of immersive support as soon as possible.
Home Life.
Depressive symptoms that prevent your teen’s ability to do things like eat family meals, participate in family events, or meet minimum expectations with regards to chores or personal hygiene are serious. If your teen’s symptoms meet these criteria, a clinician will likely consider them severe and disruptive.
Relationships.
Depressive symptoms that prevent your teen’s ability to sustain peaceful and positive relationships with you, their friends, or their teachers are considered severe and disruptive. Relationships that involve daily conflict, anger, and misunderstanding are not peaceful and positive.
School and Extracurriculars.
Depressive symptoms that prevent your teen’s ability to go to school and/or participate in school clubs, sports, or any other hobby, interest, or passion are considered severe and disruptive.
Here’s a quick example: a teen who doesn’t complete the to-do list you give them – such as minor yardwork or cleaning their room – because they don’t want to is most likely being a recalcitrant teenager. They do not meet the criteria for severe and disruptive depressive symptoms. On the other hand, a teen who cannot complete the to-do list you give them because they feel so sad, angry, and hopeless that they can’t get out of bed does meet the criteria for severe and disruptive depressive symptoms.
The former teen might need to experience a typical consequence, like losing phone privileges for a short period, whereas the latter teen most likely needs immersive mental health support for a depressive disorder.
But again: we can’t diagnose your child. Only a mental health professional can do that. For a complete list of the symptoms of depression in teens, please read this article:
When Should a Parent Seek Professional Help for a Teen with Depression?
To help you decide if your teen is simply moody or has clinical depression, please read this article:
Is My Teen Depressed or Just Moody?
If you think your teen has clinical depression, we recommend arranging a full assessment with a mental health professional. And we recommend doing it as soon as possible, because treatment works. Evidence shows that the sooner a teen with a depressive disorder receives appropriate, evidence-based treatment, the more likely they are to make a full recovery.
Finding Help: Resources
If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.
In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.