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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
Welcome back to the Nimble Youth Podcast. I'm your host, Matt Butterman. And today we're continuing our series on depression across the age span for young people. We've talked about depression in elementary school kids and in middle schoolers and today we're moving into high school where rates are higher, symptoms are more complex, and mistakes can feel much bigger. I'm joined again by Doctor.
Matt (host):Gretchen Hoyle, a pediatrician with over twenty five years of experience and someone who spends a lot of time caring for adolescents with anxiety and depression. Before we start, we remind you that this podcast is intended for informational purposes only and does not substitute for medical advice from a qualified mental health or medical provider. Please visit a healthcare professional with any questions about your child's mental health. Doctor. Hoyle, again for joining us for what is an increasingly common, but so often misunderstood behavioral health concern for young people and their parents today.
Dr. Gretchen Hoyle:Thanks, Matt. High school is such an important and potentially vulnerable developmental stage, so I'm really glad we're talking about this. Right? So, by late adolescence, it's about fifteen to twenty percent of teens that will meet criteria for depression at some point, and we've seen a significant increase over the past decade, even like with the sharper rise since the COVID-nineteen pandemic. Certainly in my clinic, I've seen a lot of increase, so you ever sort of sense that event.
Dr. Gretchen Hoyle:Rates of depression, anxiety, suicidal ideation, and ER visits for self harm have all been increasing, especially among teen girls. And this isn't just anecdotal. It's showing up clearly in pretty much all the national data.
Matt (host):Yeah, it certainly is. So, depression symptoms look different in boys and girls?
Dr. Gretchen Hoyle:Yeah, they often do. Girls are more likely to report higher rates of depression and anxiety. They have higher rates of suicidal thoughts and attempts. Boys on the other hand have higher rates of completed suicide, even though they report depression less often. Their symptoms may show up more as irritability, anger, withdrawal, risk taking behavior, rather than sort of classic sadness.
Matt (host):And, what about in LGBTQ plus teens?
Dr. Gretchen Hoyle:Right, so, this group experienced significantly higher rates of depression, anxiety, and suicidality. This is largely driven by minority stress, things like rejection, bullying, discrimination, lack of affirmation. One of the most powerful protective factors that we know of is that at least one affirming adult in a teen's life and family acceptance matters enormously for these kids.
Matt (host):Yeah, that's really important to remember. So you said that in your practice, all high schoolers get screened for both anxiety and depression and why is that?
Dr. Gretchen Hoyle:There's just so much overlap between anxiety and depression and they're just like highly comorbid conditions in adolescence. Anxiety often comes first in their symptoms, and it can kind of mask depression, so we routinely use both the PHQ-nine to screen for depression and the GAD-seven to screen for anxiety in people aged 12 and up, so pretty much all high schoolers for sure.
Matt (host):Yeah, and as we asked or we discussed in the last episode as well, the PHQ-nine includes a question about suicide ideation.
Dr. Gretchen Hoyle:Correct. So, question nine asks whether or not that person has had thoughts that they would be better off dead or hurting themselves in any way. And so, then the responses can be not at all, several days, more than half a day, nearly every day. And this is like looking at the most recent two week period. Any positive response to that question requires additional follow-up.
Dr. Gretchen Hoyle:It doesn't automatically mean that the teen is sort of actively suicidal, but it always means we need to ask more questions to ensure safety.
Matt (host):Sure. So you also use some other tools besides the, the PhD?
Dr. Gretchen Hoyle:Doctor. We do. And a lot of times I think of this as because we do use these tools are readily available, but they were originally designed for adult patients. And so there are some additional information that I like to get for folks who are in that pediatric age group. And so I will often add the SCARED questionnaire.
Dr. Gretchen Hoyle:That one's normed all the way up to age 17. And that helps me understand what sort of subtypes of anxiety they're having. And it has both a parent and patient response form. So, there's one for each person to do. And sometimes I will get additional information from parents, because they're seeing other things.
Dr. Gretchen Hoyle:And then also I will, for depression, will use either it's the mood and feelings questionnaire, and there's a short version that's 13 questions and a long version that's 33 questions. I do find the long version is really helpful, especially in high schoolers, because it captures things that we don't see as clearly in younger kids, like sleep changes and appetite changes and body image concerns, feelings of hopelessness and suicidal thinking. Just like with the scared questionnaire, parents fill out their version and their perspective really does matter as well.
Matt (host):Yeah. So, stands out to you in the long version of the, MFQ?
Dr. Gretchen Hoyle:Right. So, just to give like a frame of reference quickly, the short version. So the questions on the short version are also present on the long version, but the short version is, you know, whether they feel unhappy or miserable, not enjoying things, feeling really tired, feeling really restless, not feeling like they were there good anymore, crying a lot, finding it hard to concentrate, self hatred, feeling they were a bad person, feeling lonely, feeling that no one really loved them. Never like feeling that they could never be as good as other kids and that they were doing things wrong. So those are the baseline questions that are on the 13 item scale.
Dr. Gretchen Hoyle:The 33 item scale, it has additional things about like appetite changes, slowed movement and speech. And these will show up on, the PHQ-nine as well, but, they're phrased a little bit differently for, for this age group. It talks about social withdrawal, talks about negative self-concept. So how they feel about themselves, hopelessness, and then it's an in-depth look at their thoughts about death and suicide. So those questions help us under some understand the severity, not just the presence of these depression type symptoms.
Dr. Gretchen Hoyle:So, you know, I will typically do a fairly deep dive when patients present
Matt (host):with these kinds of concerns. And so, how do you use the numerical scores that those questionnaires yield?
Dr. Gretchen Hoyle:Right. So, so, it's a, for the long version, it's a 27 or greater on the self report and then 21 or greater for the parent one, but more important than the single score is what's happening over time. So if you have a really high score, you know, you're when meeting them, you're making a diagnosis and stuff, then certainly that's alarming. We want to get all of our options for getting a handle on that as, you know, particularly if there's thoughts of self harm or really negative self thoughts. But we also use these tools over time.
Dr. Gretchen Hoyle:So, will do this questionnaire, get a symptom score, make interventions, and then remeasure it and see if we're going in the right direction. So, this is the idea between measurement based treatments to target. So, we're tracking symptoms and to help us sort of figure out what our best treatment plan is.
Matt (host):Yeah. And so, let's talk about those treatment options then.
Dr. Gretchen Hoyle:Sure. So, treatment usually includes therapy, medication, or both. A lot of times treatment is driven by comorbid conditions. So for sure, folks with depression need to be screened for anxiety as well. A lot of kids, especially in high school, will have both depression and anxiety.
Dr. Gretchen Hoyle:Sometimes they have had sort of long standing anxiety that started when they were much younger, like we talked about in the previous episodes. And now what's happening is that they're, you know, sort of their brain has been sort of inundated over a long period of time with worrying. And over time that can really make it so that the brain feels sort of overwhelmed and it sort of starts sort of shutting down instead of being hypervigilant. It sort of reduces its activity to where people withdraw from things that used to be enjoyable for them. And so we do need to address anxiety and depression, you know, based on what place we are in on that continuum.
Dr. Gretchen Hoyle:And then ADHD is often a factor in the mix as well. And so whether a child has anxiety, depression, or both, a lot of times that can impair their executive functioning and some, and sometimes it's, you know, it's a bit of a chicken and an egg kind of thing, because if you're having, you're having trouble with executive functioning and you're having ADHD and that's been going on for a while, and you've been struggling with that, then there are some things that can precipitate or really can cause your depression to stay around longer. So if you're having trouble with ADHD, that can be contributing to anxiety and depression, and vice versa. And so, when we think about depression, I'll often think about sort of the four P's things that we want to consider when we're, when we're seeing a patient who has this condition. So, one of those things, the first thing is, is things that predispose to depression.
Dr. Gretchen Hoyle:That first P is often the things that we think about as those sort of biological things, sort of how that child is wired up and whether or not they're prone to depression based on family history. There are also going to be precipitating factors. So precipitating things are often contextual events, like things that happen within that child's life that often happen around the same time that the depression starts. And so those are, you know, events often that are around grief and loss or just like continuous stress. So bullying can do that.
Dr. Gretchen Hoyle:You know, a lot of difficulty, like in school, all of those types of precipitating factors can play a role. And so that's predisposing and they're precipitating, then there's the perpetuating factors. So these are things that make it hard to pull out of. So if a child is in a family structure or system where we're sort of having ongoing stress and ongoing chaos for one reason or another, then that really can perpetuate their symptoms and it makes it harder to sort of turn that around. Then there are the protective factors.
Dr. Gretchen Hoyle:So, that's the other direction. These are things that reduce the likelihood of the depression continuing to worsen. So, the protecting things, we want to really look at ways that we can strengthen and further sort of leverage those protecting factors. So, those can be things like a good social network or like extended family that can be helpful in interests that the child has. We really want to get them to engage in in person embodied experiences that are healthy for their brain that they enjoy, as that can really help change your brain chemically.
Dr. Gretchen Hoyle:And of course, of changes going on in the high schoolers brain chemically with, you know, continuance of puberty. And also, you know, we have to consider that sometimes high schoolers, there are other chemicals involved. So that would be things like substance use, and we need to take that into account when we look at depression. And so we need to screen for those conditions. We want to address those conditions.
Dr. Gretchen Hoyle:We want to support that person with a therapy. The most common version that we use is cognitive behavioral therapy or CBT. And that is basically, you know, helping your brain get involved with what's happening with your thoughts and feelings and behaviors, those things contribute to each other. And so training your brain to be able to like modify negative self talk and negative thoughts about yourself and negative thoughts about your, like what's happening for, you know, how, how you were doing. Those are all things that can be helpful in trying to work with.
Dr. Gretchen Hoyle:And so we're wanting to engage in, you know, helping the brain find better ways to think about what's happening, but we also want to improve what's happening in the environment if we need to. So supporting the family is a really important thing to be able to do in this setting. So, and a lot of times, by the time kids are in high school, you know, families have been there, there's just a lot of time for things to accumulate that can be troublesome. So, a lot of times this is when, you know, parents are, you know, having to take care of other family members, so their own parents, or they're dealing with illnesses for themselves, for physical things, or they have, you know, additional stress at work. I mean, all of those things are happening sort of simultaneously as, as the child, as the patient is becoming more and more independent.
Dr. Gretchen Hoyle:A lot of times there's just more of a ramp up for responsibilities, parents in that same age group. And so, helping make that an easier transition is, can be really helpful. And then also addressing any issues at school, those, you know, like high schoolers spend a lot of time at school. They're doing that most of the day, most of the, most of, most of the time during the day and most days of the year. We're right at that.
Dr. Gretchen Hoyle:And so, it's important to try to the patient and their family and their community and their environment and all the things that go into affecting their mental health. And so, keeping all of that in mind, and we want to do all of those things, but then we also find that there's very good evidence that medication is helpful in this scenario, especially when you pair it with the other interventions that we were talking about. And so, for most people, what we're going to be using are medicines that help up regulate the amount of serotonin that is available, or it actually specifically reduces the rate at which serotonin is cleared from the place of connection between nerve cells. And so in the brain, and so we're going to make serotonin more available in the brain. And that tends to give people a sense of well-being and calm and makes it so that things that's unexpected are a little bit more tolerable.
Dr. Gretchen Hoyle:And so for folks with anxiety and depression, like having some help chemically can be extremely beneficial. And so again, I'll say in a lot of these episodes that if I could wake up in a world where nobody needed medicine, I would love that because it would mean that people weren't having trouble with anxiety and depression or ADHD, but that's just not a world that we live in. So I think it's important, especially in these very critical years to use all the tools in our toolbox that are appropriate. And so, is part of making that assessment and then making a treatment plan to use all of the things that we have at our disposal.
Matt (host):Yeah, and going back to what you were talking about earlier, the interplay of the environment, the family, situation, plus all these sort of chemical changes that are going on in the body. Seems like this is a really good use for the collaborative care model where you're dealing with the holistic system, right? You're looking at everything that's affecting the child's behaviors.
Dr. Gretchen Hoyle:Absolutely. So, will provide, you know, support for the patient and for the parents. It's just a, it's a, well, you know, I've both been there as far as like raising children through that age group. It can be challenging for all sorts of reasons. And so, and a lot of times having a third party person involved is really helpful.
Dr. Gretchen Hoyle:I feel like a lot of times parents can be, you know, articulating, you know, very, very good advice, but it's just not that the patient can't really accept that. It's that idea that, you know, sometimes your teenagers, it feels like they're allergic to your voice and you need somebody else's voice right to come in and yeah. And, and explain like, you know, kind of choices we want to do, what kind of things we want to do to try to get them feeling better. And to articulate that, you know, this is not a weakness. It's not something that anyone did wrong.
Dr. Gretchen Hoyle:It's just a matter of like, just like with any other condition. So with asthma and diabetes, we use medicine to treat those conditions. And the brain is an organ just like the other organs in our body. And sometimes things aren't going right with that. And so, using medication to do that is helpful.
Dr. Gretchen Hoyle:Then also using all of these other interventions can be helpful. And so, that model I do feel like is extremely helpful. That third party person who can support both sides of this equation has just been extremely valuable to a lot of our families.
Matt (host):So, again, in closing, if there's one message you want parents to remember from this episode, what would that be?
Dr. Gretchen Hoyle:Right. So, that depression in high schoolers is, is pretty common. I mean, comparison to other age groups, it often runs in connection with anxiety and ADHD. It can be caused some serious troubles. And so it's, it's very treatable.
Dr. Gretchen Hoyle:And so we really encourage folks, you know, to, if you're having those concerns to connect with a healthcare professional who can do an assessment and come up with a treatment plan. There are lots of available strategies and, you know, optimistic and, you know, confident that the right strategy can be found for these patients. Asking questions about how they're feeling and whether or not they're feeling like potentially having suicidal ideation or thoughts of self harm. Asking questions does not put an idea into someone's head. So it is important that if parents are concerned about that possibility that they ask those questions or they get the patient to, or the child or the adolescent to either pediatrics provider or a mental health provider, someone who can do a full assessment to try to see what is happening with them from the end.
Matt (host):Yeah, think it's a really important message. In this case, really do want to sort of address the elephant in the room, right? Right.
Dr. Gretchen Hoyle:Yeah. Sure.
Matt (host):Yeah. Well, Doctor. Hoyle, thanks again for walking us through this period of development and the various and how depression manifests this particular age group. We'll continue our discussion on depression through the lifespan, bringing our focus specifically on college age students, which is a time when stress often brings latent problems with depression two to four. And thank you to our listeners today for joining us.
Matt (host):Whether you're listening on our audio podcast, which is found on all major podcast platforms or watching us on YouTube. I will remind you to please rate our content and offer comments or questions at our website for youth And, please also follow us on social media at NimbleYouthPodcast. Until next time, please take care of yourselves and the young people in your lives. Bye for now.