Carla and Kelly are nonidentical twin sisters, age 15, coping with the recent divorce of their parents.
They are more tearful than usual. They spend more time in their rooms and seem more resentful when told by either parent what to do. But that is where the sisters' similarities end.
Carla's school grades have plummeted. She has all but stopped calling or joining friends on weekends. She is up most nights, and she is rarely smiling. All are stark behavioral changes, none of which have happened to Kelly.
Carla has developed depression. Kelly is sad, but OK.
Depression, when it occurs, is potentially lethal. Suicide is the third-leading cause of death in adolescents and is most often preceded by a major depressive episode.
Adolescents are particularly vulnerable to developing suicidal thinking in the context of depression, in part because adolescence is a time of identity formation during the human lifespan.
It is normal and typical for an adolescent to question his or her identity, to wonder what the meaning of his or her life is, to strive to define a useful role outside of the immediate family -- a way of fitting into the larger "whole" of the surrounding village, society, and universe.
It is particularly devastating then for an adolescent to be additionally bombarded with depressive symptoms, whether triggered by traumatic (or perceived traumatic) life events or not.
Warning signs of major depressive disorder in adolescents include:
Feelings of hopelessness and/or helplessness
Unexplained pangs of guilt
Blunting of facial expression
Isolating one's self from family and friends
Inability to derive pleasure from activities that are usually perceived as pleasurable
An increase in risk taking
New onset of drug or alcohol use
Deterioration in school work
Disruption of sleep and/or appetite
When any such warning signs arise, it is time to act quickly -- and compassionately -- to get help. Adolescents do not always welcome offers of help from parents, school counselors or even friends, and they may even see them as an intrusion.
It is important for all those involved with depressed adolescents to help them recognize the following:
That getting an evaluation is "only information." It does not mean they are sick, weak or crazy
That 10 to 20 percent of all teenagers experience major depressive symptoms and thoughts of death
That, left untreated, depression develops a biological "life of its own" in the brain -- one that is not controllable by willpower or personal strength
That part of the biological life of depression is suicidal thinking, which is always based on illogical assumptions (no matter how true they seem in the moment)
That depression is almost always curable or improved by treatment
That they must cooperate with the treatment process -- and that all privileges and freedoms need to be held contingent on cooperation with treatment
Parents need to be informed of all of these points and reassured that, in the vast majority of cases, they are not the cause of their child's depression.
Parents also need to be warned never to place themselves in the position of having to judge whether or not their own child is in danger of hurting him/herself. When in doubt, or when any signs are present, this judgment must be placed in the hands of a professional.
Parents should likewise always respond to a teenager's threat of suicide or self-harm by bringing the child immediately to a physician, mental health professional or emergency room in a secure way or to call 911.
If this is not done, some adolescents might learn to use the threat of suicide to manipulate their parents -- negotiating with children in the context of such threats rewards them in a sense for this behavior (somewhat like the problem of negotiating with a terrorist).
Parents should indicate to their children that suicide or self-harm would be viewed no differently (by the parent) than if they were to murder or harm their brother or sister; allowing harm to self is just as inappropriate, tragic and intolerable as allowing harm to a sibling.
Finally, parents should remain vigilant for any and all signs of drug or alcohol use, or subtle forms of self-injurious behavior (such as "cutting" or making deep scratches on their skin).
Any treatment plan for depression should include psychotherapy, with or without the addition of antidepressant medication.
Psychotherapy is an important tool that is misunderstood by many parents. Used effectively, it can help teens review and revise the negative thoughts and false assumptions that may underlie their depressive condition.
Through support, understanding and sometimes building an enduring therapeutic relationship, psychotherapy often helps a child build an identity that can offer both comfort and context to his or her situation.
Medications are also extremely important and helpful to a majority of adolescents to whom they are prescribed.
A recent pooled analysis of 27 trials of antidepressant medication treatment involving more than 5,000 children and adolescents revealed that the actual risk for worsening of suicidal thinking or behavior was 1 percent -- lower than many previously reported estimates.
None of the children in these trials actually committed suicide during the course of the respective studies, and a significant proportion were substantially improved by medication treatment, indicating that the use of antidepressant medications in children is safe and that the potential benefits generally outweigh the risks.
Of course, like any medication for any medical condition, antidepressant medications carry risks, including the highly publicized potential risk of an increase in suicidal thoughts (not actions), which can occur early in the course of antidepressant treatment with some medications.
Physicians are trained extensively to weigh these risks against the risk of not adequately treating the depression -- which, again, includes death.
The catastrophic outcome of death by suicide cannot be prevented in every case. The choice to live or die ultimately rests with the individual. This is a good thing in that it reflects a fundamental "freedom of will."
But major depression has insidious ways of disrupting the decision-making process by distorting the assumptions upon which complex life decisions are made.
Everyone involved needs to know (and believe) that overcoming depression is possible, even if it takes a while. The alternative -- not overcoming depression -- is never an acceptable option.
Dr. John Constantino is associate professor of psychiatry and pediatrics at Washington University School of Medicine, and Dr. Richard D. Todd is professor and director of the Division of Child Psychiatry at the Washington University School of Medicine Department of Psychiatry.