Exercise
Vigorous exercise (for 20 minutes three times weekly) is as effective as SSRIs in treating mild to moderate depression. Even in severe depression, exercise may accelerate recovery and certainly contributes to returning to restful sleep and a feeling of improved energy. Inviting their depressed teens to join them on a trip to the gym may seem like a fool’s errand to parents, but they should prioritize getting their children moving. Don’t offer choices or ask what activity they would like to do. Most invitations will be met with “no, thanks” (or probably something less polite). Instead, initiate simple activities and then cajole the children with “let’s go!” They should use loving persistence to get them out the door. Parents are the experts on their children and will know if there is an activity that they are more likely to enjoy. Make any activities group ones, easy to start and not too long. They could initiate family walks or bike rides in their neighborhood. If it helps, they can blame you, “these are doctor’s orders!” This approach of warm persistence should be applied across the board, helping their depressed teens participate in mealtimes and other activities. Prepare parents that this can feel unnatural, if they have been letting their healthy teenagers have more space and independence and less time in family activities.
Social connections
Behavioral activation includes keeping a depressed teen engaged in social activities. Friendships are a potent motivator in the lives of healthy adolescents. If depressed teens can stay connected to close friends, it is a powerful force for recovery. Find out if their friends know about their depression, whom do they trust to tell about it? Help them find comfortable language to speak about their depression with trusted friends. Parents can use their behavioral activation strategies to prompt their teenagers to participate in social activities. If texting, video chatting, or social media platforms are how they stay connected with close friends, support their use of these platforms. But be mindful that social media promotes social comparison over connection, and depression sets them up to feel less than others even without assistance. Parents should support real time with their friends in small groups, for short periods during the time of day when they have the most energy.
Safety
Suicide is the second leading cause of death for adolescents in the United States, and the rate of attempted and completed suicide in adolescents has been steadily climbing over the past decade according to the CDC. The rate is higher in older adolescents, though thankfully relatively uncommon (about 1 in 10,000 a year), and, although we know risk factors, no one has been able to predict reliably the risk for an individual teenager at a point in time. In a clinically referred sample, 85% of depressed adolescents will have suicidal ideation and 32% will make a suicide attempt. The risk is higher in those adolescents with more than one psychiatric diagnosis and with a history of impulsive behaviors, substance abuse, prior suicide attempts, and a family history of suicide. It is important that parents hear that asking about suicidal thoughts will not cause them. On the contrary, preserving open communication and a warm relationship is very protective. Adolescent suicide attempts are likely to be impulsive, so helping the family to consider ways to “put up obstacles” that would slow down any possible attempt is an effective way to improve safety. Ask your patients about suicidal thoughts, plans, and what keeps them safe. Find out if they worry about sharing these thoughts with their parents and why. Ask if there are ways their parents can check on them that “aren’t too annoying.” Determine if there are guns in the home, and if so, are they safely stored (locked, separate from ammunition)? More than 50% of completed adolescent suicides involve firearms, so this question is critical. What about access to medications that could be dangerous in overdose in your home or a relative’s home they may visit? Discussing these facts with your patients and their parents together will make it easier for them to continue the conversation outside of your office and can make an enormous difference in their recovery.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Reference
Kovacs M et al. J Am Acad Child Adolesc Psychiatry. 1993 Jan;32(1):8-20.