In the fall of 2021, the rates of adolescent anxiety and depression were so dire that major medical groups like the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics declared a national emergency of mental health. That same year, as outlined in a report released recently by the Centers for Disease Control and Prevention, 42% of US high schoolers contended with persistent hopelessness or sadness, and 22% had contemplated suicide. The pandemic had, by all accounts, a staggering impact on our collective mental health, and adolescents were not immune; in fact, experts say, they were and continue to be more vulnerable. “Adolescents, for all their famous bravado, feel the impact much more than adults,” says Kenneth P. Pages, MD, the former chief of psychiatry at Tampa General Hospital who is now in private practice focused on the treatment of depression with TMS (transcranial magnetic stimulation), a therapy which recently earned FDA clearance for use in adolescents.
So, what is TMS?
TMS (transcranial magnetic stimulation) is a noninvasive procedure that relies on magnetic fields, delivered via coils placed against the scalp, to stimulate the brain’s nerve cells. According to the Mayo Clinic, where TMS is offered, the coil delivers magnetic pulses (patients experience it as a repeated tapping or snapping) that stimulate nerve cells in the region of the brain connected to mood control. Though the dorsolateral prefrontal cortex is spoken about as the target for TMS, says Pages, it’s just one of multiple starting points for a larger circuit that benefits from its effects.
A real-world study of those effects showed a 62% remission in depression symptoms among those who completed a course of treatment. In 2008, the FDA cleared TMS to treat depression in adults 22 and older (it’s also approved for OCD, migraines, and smoking cessation), and last year, they lowered the age to 15; a course involves 36 twenty-minute sessions done consecutively five days a week. That it’s not a forever proposition, as prescription meds can be, nor does it come with many of the adverse side effects of SSRIs, is what appeals to many parents of adolescents suffering, says Pages. Because the FDA qualifies it as a first-line, add-on treatment means, Pages adds, that a person doesn’t have to try and fail another medication before qualifying, and TMS can be used in tandem with therapy or other medications. “A well-functioning brain is a chatterbox, the neurons are talking and talking, but in depression, they dry up,” says Pages. “It’s like de-arborization, and arborization is a growing back of the leaves, that’s how we talk about neuronal connections.”
Issues of accessibility and awareness
TMS is a promising new option for adolescents that is slowly earning more mainstream awareness. There are a number of other treatments that can also be effective, something that can get lost in the discourse, says Lisa Damour, PhD, a clinical psychologist and author of The Emotional Lives of Teenagers. “I will hear young people talking about depression and anxiety as if those are factory settings, their life’s lot, not something that can be managed effectively with intervention, and that’s not true,” she adds. Stephen P.H. Whiteside, PhD, a professor of psychology at the Mayo Clinic in Rochester and author of Anxiety Coach, says that while CBT (cognitive behavioral therapy) has been the traditional course for kids with anxiety for over twenty years, a study published this month shows the potential of PCET (parent-coached exposure therapy), a form of therapy that helps kids confront fears. “We did a randomized control trial and the families that got PCET got better faster and needed fewer appointments with kids showing more improvement than the ones that got traditional CBT,” says Whiteside. “So it was more effective and more efficient.” A good clinician, says Damour, will work systemically through all the options, including compelling new ones like TMS, to find what clicks with their adolescent patient. The issue that may be bigger than availability is accessibility. According to Mental Health America, 60% of young Americans with severe depression or anxiety receive no treatment. So while awareness around mental health has grown, getting the help you need remains a challenge. “There were not enough clinicians to care for teenagers before the pandemic and then with the surge in suffering among them, we got even further behind in being able to care for that population,” says Damour, adding that there are few who, like herself, specialize in teenagers. “People talk a lot about the rising rates of depression and anxiety in young people, but what we don’t talk about enough is that we don’t have the workforce to help.”
What mental health actually is—and what it’s not
While the pandemic had an outsize impact on adolescent mental health, experts say those rates were already rising, and that while social media has also played a significant role, pinpointing one reason may be fruitless. “There are probably as many causes of depression and anxiety in teenagers as there are teenagers,” says Damour. Her latest book is devoted to clearing up what mental health is and what it’s not: crucially important to remember is that it’s not about feeling good. “It’s critically important that parents and teenagers understand that distress is natural to being human, to be expected in adolescence, and not on its own grounds for concern,” says Damour. “We only worry when a person struggles to manage the feeling well.” Identifying and stepping in when an adolescent is really struggling is key. Whether symptoms are very distressing or getting in the way of them being able to function normally are the traditional questions to ask.
Whiteside sees adolescents as having three jobs: school (attending, making some effort, and completing the work required), family (interactions and any chores or occasional activities), and socializing and extracurricular activities with friends. If they’re consistently struggling to engage with those “jobs” and withdrawing those are red flags. But engaging with your teenagers when they are, by nature, becoming more private can feel like an uphill battle.” What I hear from teenagers is they’re most likely to open up when adults make themselves an agenda-less presence, when they think they’ll get empathy instead of advice,” says Damour. Whiteside also encourages parents to be more open about their personal feelings of stress or frustration: besides talking we can inform our kids by modeling behavior that demonstrates effective coping. Or, adds Damour, let them not talk: there are other effective strategies for managing feelings. “Some teenagers like to talk about feelings, others like to put on their sad playlist and listen until they feel better, others like to go for a run, others like to cuddle a dog or watch reruns,” says Damour. “So long as the coping mechanism brings relief and does no harm, psychologists are good with it.” Just as adults have, particularly on social media, slid towards using diagnostic language to describe everyday experiences (and create “diagnoses,” like high-functioning anxiety that aren’t recognized by clinicians along the way), so too have adolescents. Talking more openly about mental health and lessening stigma are positives, but adolescents self-diagnosing can, says Damour, leave them feeling more worried about themselves than they need to feel and less hopeful about their ability to manage.
Parental Guidance Suggested
What’s hugely important for adolescent mental health are the adults in that adolescent’s life. Christy, a Florida-based teen, started experiencing depression at age 10 and tried a number of medications and therapy. Her mother saw a drastic change in her behavior, brought her to their pediatrician (more and more of them have screening tools now for depression and anxiety), and eventually got her signed up for a treatment course of TMS. “By the third week, I started to not feel sad and hopeless all the time,” Christy reported. The psychological health of teenagers often hinges not only on how their family is functioning (and during the pandemic many were suffering tremendously) but also on how invested the caregivers in their life are in getting them the appropriate help when they need it. “The most reassuring of all findings may be that the single most powerful force for adolescent mental health is strong relationships with caring adults,” says Damour. “We need many more clinicians to care for teenagers, but we also need the adults around teenagers to recognize how critically important their good working relationships are to adolescent mental health too.”