News & Views

Harold S. Koplewicz, M.D. is the Arnold and Debbie Simon Professor of Child and Adolescent Psychiatry and Professor of Pediatrics and the founder and director of the NYU Child Study Center. The author of the book More than Moody: Recognizing and Treating Adolescent Depression, he is one of the country’s leading child psychiatrists. News & Views met with him recently to discuss teenage depression.

Larold S. Koplewicz, M.D. is the Arnold and Debbie Simon Professor of Child and Adolescent Psychiatry and Professor of Pediatrics and the founder and director of the NYU Child Study Center.

How can you tell if a teenager is depressed?
The first issue that has to be addressed is moodiness. Normal teens are moodier than children or adults because there are so many developmental tasks that have to be accomplished in the 10 years of adolescence—from the onset of puberty at age 11 or 12 to 22. For example, you are supposed to adjust to the physical changes of puberty, separate from your parents or caretakers, develop a social network, and create vocational goals. There are many stressors that can affect mood. In addition, normal teenagers have brain changes that are part of adolescence. So you have to use moodiness as your baseline.

The most prominent symptom of depression is irritability. When teenagers are depressed, they don’t recognize that they’re depressed, and their parents often think their kids are just difficult. Teens are also likely to medicate themselves with marijuana, alcohol, and drugs such as ecstasy. So they feel irritable and uncomfortable, which is different from feeling lethargic and sad—the telltale signs of depression in adults.

Parents have to know their child’s behavior so that they can tell when changes occur. Unusual behavior that lasts for more than two weeks should be evaluated by a child psychiatrist. The worst thing is to leave the kid alone and hope that it will pass.

How widespread is depression among teens and children?
Studies estimate that 2 million teenagers in the United States suffer from depression and that it is more prevalent among teens than adults or children. Depression affects some 8 percent of teens, 5 percent of adults, and less than 1 percent of children. This makes it a major health problem for teenagers.

Are many adolescents being diagnosed for depression?
For a variety of reasons, we tend to under-diagnose depression in adolescents. If you’re following the news, you would think that everybody in America is taking a pill for depression. But that isn’t the case. In 2002 some 2,000 teens committed suicide, accounting for a higher death toll in that age group than all other diseases combined. According to a recent annual survey by the Centers for Disease Control, about 3 million teenagers had thoughts of suicide and some 400,000 made actual suicide attempts requiring medical attention. That means that each day about 1,000 kids showed up in emergency rooms or doctor’s offices needing, say, sutures or having their stomachs pumped.

Are there medications that can effectively treat depression in teens?
The old antidepressants didn’t work very well in teens at all, and in adults they could cause some serious side effects, and you could overdose on those drugs. The newer generation of antidepressants, which includes Prozac, are more effective in teens, and you can’t overdose on them.

However, these drugs have given pediatricians and internists a false sense of security about their safety. For some teens, the newer antidepressants boost their energy but can also disinhibit them, increasing aggression and hostility, particularly when the dose is going up or going down.

These drugs are effective, but they really have to be monitored on a weekly basis.

There has been a lot of controversy about antidepressants triggering suicide among teenagers. What are your concerns about these prescription drugs?
I have one of the largest child psychiatry consultation practices in the United States, and I haven’t had one case of suicide. Over 4,000 teens participated in clinical trials of all the newer generation of antidepressants, and no one committed suicide. Some had thoughts of suicide, but when the dose was lowered or raised, the thoughts went away.

Clearly, people with depression are at significant risk for suicide. Antidepressants work slowly; they take about three weeks to affect your brain chemistry. With that information, the clinician and parents have to know that these drugs aren’t candy—they are medicines we have to closely monitor.

The Food and Drug Administration recently mandated that a black box warning label be placed on antidepressants, indicating that these drugs increase the risk of suicide in teenagers and children. Do you think this warning is necessary?
That warning isn’t based on science, but on the heart-wrenching testimony of parents. I worry that the black box has two outcomes. The first is that primary care physicians and child psychiatrists will now hesitate to prescribe antidepressants.

The second is that many parents will worry that these medicines are killing kids instead of saving lives. These are unfortunate results, and I worry that lives will be lost.