A rising mental health crisis
Pediatricians hold the front line as depression soars among teens
GLASGOW, Ky. — One crisp Monday morning in January, Dr. Melissa Dennison sat in a small, windowless exam room with a 14-year-old girl and her mother. Omicron was ripping through Kentucky, and the girl was among three dozen young patients — two of them positive for the coronavirus — that the pediatrician would see that day.
But this girl was part of a different epidemic, one that has gripped the community and nation since long before COVID-19: She and her mother had come to discuss the girl’s declining mental health.
The girl was depressed, she told Dennison, and had been cutting her arm to relieve her emotional pain. Dennison suggested therapy, but the girl said she would not go.
After the exam, Dennison stood in the hallway and described the case. “You need to get off the phone and the computer,” she had told the girl. “When it’s pretty outside like this, put on a bunch of clothes and go for a walk.”
Dennison prescribed the antidepressant Zoloft, although she wasn’t sure the girl was clinically depressed.
“I’d rather they see a psychiatrist,” she said. “But if I’ve got this child and they’re cutting and saying they’re going to kill themselves, I’ll say, ‘Well, I’ll see them today.’ If I call a child psychiatrist, they say, ‘I’ll see them in a month.’ ”
Over the last three decades, the major health risks facing U.S. adolescents have shifted drastically: Teenage pregnancy and alcohol, cigarette and drug use have fallen while anxiety, depression, suicide and selfharm have soared. In 2019, the American Academy of Pediatrics issued a report noting that “mental health disorders have surpassed physical conditions” as the most common issues causing “impairment and limitation” among adolescents.
But the medical system has failed to keep up, and the transformation has increasingly put emergency rooms and pediatricians at the forefront of mental health care.
Community doctors now routinely deal with complex psychiatric issues, making tough diagnoses after brief visits and prescribing powerful psychiatric medications for lack of better alternatives. “Pediatricians need to take on a larger role in addressing mental health problems,” the 2019 AAP report concluded. “Yet, the majority of pediatricians do not feel prepared to do so.”
In Glasgow, as elsewhere, there are counselors in the schools and therapists in town. But they are often booked months out. Seventy percent of counties in the United States lack a psychiatrist specializing in children or adolescents — and the psychiatrists who can be found are concentrated in wealthier areas, with many accepting only private payments.
“There’s a need and nowhere else to go,” Dr. David Lohr, a child and adolescent psychiatrist at the University of Louisville, said of the growing role of primary-care doctors in mental health.
Dennison, 62, has adapted. Two decades ago, she routinely prescribed antibiotics and saw patients with “strep throat, earaches and wheezing,” she said. She estimated that, back then, 1% of her cases related to mental and behavioral health; now at least 50% do.
Over two days, Dennison had 66 appointments, 20 of them related to mental and behavioral health. She dealt with patients taking a range of drugs, many of which she had prescribed and some of which were combined.
The growing use of psychiatric medications in youth is one metric of the adolescent mental health crisis.
From 2015 to 2019, prescriptions for antidepressants rose 38% for teenagers compared with 15% for adults, according to Express Scripts, a major mail-order pharmacy.
Dennison provides advice in addition to medication. She readily shares with families her opinions about the need for their children to put down their devices, exercise and spend time outdoors.
“They have too much screen time, they’re not sleeping, on phones all the time,” she said. Parents lack the will to make their children disconnect. Poverty, obesity and puberty, which is arriving earlier for many children, are factors, too, she said: “It’s hard to have the body of a 15-year-old and the mind of a 12-year-old.”
Other adults who work with adolescents in Glasgow have theories about why this generation is burdened with mental health issues. Mallie Boston, who grew up in town and is now the executive director of the Boys & Girls Club of Glasgow-Barren County, said that today’s teenagers were less physically active and spent less time just hanging out.
At the Boys & Girls Club, she tries to encourage young people to be more physically engaged and expressive. “I try to get them to play dodgeball,” she said. “If I can get them to be aggressive, maybe I can get to the root cause of what’s happened to them.”
On a weekday afternoon, a couple of hundred children and adolescents come to the club to play basketball and volleyball or to hang out. Many are from families that are struggling economically; a few said they didn’t see a doctor at all.
“My mom refuses to take me to one,” one 15-year-old girl said. “She says there’s nothing wrong with me.” She and more than a dozen other adolescents from the club agreed to share their thoughts about mental health on the condition that their names not be published, to protect their privacy.
Some described struggling with anxiety, depression, suicidal thoughts or self-harm. The girl said she sometimes cut herself with the blade from a pencil sharpener to counter her anxiety and sadness.
Like many in the group, she said she stayed up late on her phone and slept only a few hours each night. Another girl, 12, was often up until 1 or 2 a.m. looking at TikTok and Snapchat. “I’m overwhelmed a lot, by school,” she said. A third girl, 13, described the previous night: “I took a melatonin at 3 o’clock and fell asleep at 3:15.”
Recent research found that teenagers with poor sleep habits were more likely to have mental health problems during the pandemic.
Katrina Ayres, the mental health coordinator for the local school district, pointed to another change: Students were deeply focused on themselves, selfie-obsessed, which led them to “think everybody is looking at me,” she said. “We’re raising a generation that is very ‘me’ focused.”
Under a new program, the schools have surveyed students, and those who are found to be at risk receive counseling, regular check-ins from a teacher or referrals for treatment. As part of a separate program, some of the students distributed food to needy families at Thanksgiving and Christmas.
“They need to see they’re part of a bigger picture,” Ayres said.