adolescent depression essay

Parent’s Guide to Teen Depression

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What is teen depression?

Signs and symptoms of teen depression, coping with suicidal thoughts, why am i depressed, overcoming teen depression tip 1: talk to an adult you trust, tip 2: try not to isolate yourself—it makes depression worse, tip 3: adopt healthy habits, tip 4: manage stress and anxiety, how to help a depressed teen friend, dealing with teen depression.

No matter how despondent life seems right now, there are many things you can do to start feeling better today. Use these tools to help yourself or a friend.

The teenage years can be really tough and it’s perfectly normal to feel sad or irritable every now and then. But if these feelings don’t go away or become so intense that you feel overwhelmingly hopeless and helpless, you may be suffering from depression.

Teen depression is much more than feeling temporarily sad or down in the dumps. It’s a serious and debilitating mood disorder that can change the way you think, feel, and function in your daily life, causing problems at home, school, and in your social life. When you’re depressed, you may feel hopeless and isolated and it can seem like no one understands. But depression is far more common in teens than you may think. The increased academic pressures, social challenges, and hormonal changes of the teenage years mean that about one in five of us suffer with depression in our teens. You’re not alone and your depression is not a sign of weakness or a character flaw.

Even though it can feel like the black cloud of depression will never lift, there are plenty of things you can do to help yourself deal with symptoms, regain your balance and feel more positive, energetic, and hopeful again.

If you’re a parent or guardian worried about your child…

While it isn’t always easy to differentiate from normal teenage growing pains, teen depression is a serious health problem that goes beyond moodiness. As a parent, your love, guidance, and support can go a long way toward helping your teen overcome depression and get their life back on track. Read Parent’s Guide to Teen Depression .

It can be hard to put into words exactly how depression feels—and we don’t all experience it the same way. For some teens, depression is characterized by feelings of bleakness and despair. For others, it’s a persistent anger or agitation, or simply an overwhelming sense of “emptiness.” However depression affects you, though, there are some common symptoms that you may experience:

• You constantly feel irritable, sad, or angry.
• Nothing seems fun anymore—even the activities you used to love—and you just don’t see the point of forcing yourself to do them.
• You feel bad about yourself—worthless, guilty, or just “wrong” in some way.
• You sleep too much or not enough.
• You’ve turned to alcohol or drugs to try to change the way you feel .
• You have frequent, unexplained headaches or other physical pains or problems.
• Anything and everything makes you cry.
• You’re extremely sensitive to criticism.
• You’ve gained or lost weight without consciously trying to.
• You’re having trouble concentrating, thinking straight, or remembering things. Your grades may be plummeting because of it.
• You feel helpless and hopeless.
• You’re thinking about death or suicide. (If so, talk to someone right away!)

If your negative feelings caused by depression become so overwhelming that you can’t see any solution besides harming yourself or others, you need to get help right away . Asking for help when you’re in the midst of such strong emotions can be really difficult, but it’s vital you reach out to someone you trust—a friend, family member, or teacher, for example. If you don’t feel that you have anyone to talk to, or think that talking to a stranger might be easier, call a suicide helpline . You’ll be able to speak in confidence to someone who understands what you’re going through and can help you deal with your feelings.

Whatever your situation, it takes real courage to face death and step back from the brink. You can use that courage to help you keep going and overcome depression.

There is ALWAYS another solution, even if you can’t see it right now. Many people who have survived a suicide attempt say that they did it because they mistakenly felt there was no other solution to a problem they were experiencing. At the time, they couldn’t see another way out, but in truth, they didn’t really want to die. Remember that no matter how badly you feel, these emotions will pass.

Having thoughts of hurting yourself or others does not make you a bad person. Depression can make you think and feel things that are out of character. No one should judge you or condemn you for these feelings if you are brave enough to talk about them.

If your feelings are uncontrollable, tell yourself to wait 24 hours before you take any action. This can give you time to really think things through and give yourself some distance from the strong emotions that are plaguing you. During this 24-hour period, try to talk to someone—anyone—as long as they are not another suicidal or depressed person. Call a hotline or talk to a friend. What do you have to lose?

If you’re afraid you can’t control yourself, make sure you are never alone. Even if you can’t verbalize your feelings, just stay in public places, hang out with friends or family members, or go to a movie—anything to keep from being by yourself and in danger.

If you're thinking about suicide…

Please read Are You Feeling Suicidal? or call a helpline:

• In the U.S.: 988
• UK: 116 123
• Australia: 13 11 14
• To find a helpline in other countries, visit IASP or Suicide.org .

Remember, suicide is a “permanent solution to a temporary problem.” Please take that first step and reach out now.

Despite what you may have been told, depression is not simply caused by a chemical imbalance in the brain that can be cured with medication. Rather, depression is caused by a combination of biological, psychological, and social factors . Since the teenage years can be a time of great turmoil and uncertainty, you’re likely facing a host of pressures that could contribute to your depression symptoms. These can range from hormonal changes to problems at home or school or questions about who you are and where you fit in.

As a teen, you’re more likely to suffer from depression if you have a family history of depression or have experienced early childhood trauma, such as the loss of a parent or physical or emotional abuse .

Risk factors for teen depression

Risk factors that can trigger or exacerbate depression in teens include:

• Serious illness, chronic pain, or physical disability .
• Having other mental health conditions, such as anxiety, an eating disorder , learning disorder , or ADHD.
• Alcohol or drug abuse.
• Academic or family problems.
• Trauma from violence or abuse.
• Recent stressful life experiences, such as parental divorce or the death of a loved one.
• Coping with your sexual identity in an unsupportive environment.
• Loneliness and lack of social support.
• Spending too much time on social media .

If you’re being bullied…

The stress of bullying—whether it’s online, at school, or elsewhere—is very difficult to live with. It can make you feel helpless, hopeless, and ashamed: the perfect recipe for depression.

If you’re being bullied, know that it’s not your fault. No matter what a bully says or does, you should not be ashamed of who you are or what you feel. Bullying and cyberbullying is abuse and you don’t have to put up with it. You deserve to feel safe, but you’ll most likely need help. Find support from friends who don’t bully and turn to an adult you trust—whether it’s a parent, teacher, counselor, pastor, coach, or the parent of a friend.

Whatever the causes of your depression, the following tips can help you overcome your symptoms, change how you feel, and regain your sense of hope and enthusiasm.

Depression is not your fault, and you didn’t do anything to cause it. However, you do have some control over feeling better. The first step is to ask for help.

Speak to a Licensed Therapist

BetterHelp is an online therapy service that matches you to licensed, accredited therapists who can help with depression, anxiety, relationships, and more. Take the assessment and get matched with a therapist in as little as 48 hours.

Talking to someone about depression

It may seem like there’s no way your parents will be able to help, especially if they are always nagging you or getting angry about your behavior. The truth is, parents hate to see their kids hurting. They may feel frustrated because they don’t understand what is going on with you or know how to help.

• If your parents are abusive in any way, or if they have problems of their own that makes it difficult for them to take care of you, find another adult you trust (such as a relative, teacher, counselor, or coach). This person can either help you approach your parents, or direct you toward the support you need.
• If you truly don’t have anyone you can talk to, there are many hotlines, services, and support groups that can help.
• No matter what, talk to someone, especially if you are having any thoughts of harming yourself or others. Asking for help is the bravest thing you can do, and the first step on your way to feeling better.

The importance of accepting and sharing your feelings

It can be hard to open up about how you’re feeling—especially when you’re feeling depressed, ashamed, or worthless. It’s important to remember that many people struggle with feelings like these at one time or another—it doesn’t mean that you’re weak, fundamentally flawed, or no good. Accepting your feelings and opening up about them with someone you trust will help you feel less alone.

Even though it may not feel like it at the moment, people do love and care about you. If you can muster the courage to talk about your depression, it can—and will—be resolved. Some people think that talking about sad feelings will make them worse, but the opposite is almost always true. It is very helpful to share your worries with someone who will listen and care about what you say. They don’t need to be able to “fix” you; they just need to be good listeners.

Depression causes many of us to withdraw into our shells. You may not feel like seeing anybody or doing anything and some days just getting out of bed in the morning can be difficult. But isolating yourself only makes depression worse. So even if it’s the last thing you want to do, try to force yourself to stay social. As you get out into the world and connect with others, you’ll likely find yourself starting to feel better.

Spend time face-to-face with friends who make you feel good —especially those who are active, upbeat, and understanding. Avoid hanging out with those who abuse drugs or alcohol, get you into trouble, or make you feel judged or insecure.

Get involved in activities you enjoy (or used to). Getting involved in extracurricular activities seem like a daunting prospect when you’re depressed, but you’ll feel better if you do. Choose something you’ve enjoyed in the past, whether it be a sport, an art, dance or music class, or an after-school club. You might not feel motivated at first, but as you start to participate again, your mood and enthusiasm will begin to lift.

Volunteer. Doing things for others is a powerful antidepressant and happiness booster. Volunteering for a cause you believe in can help you feel reconnected to others and the world, and give you the satisfaction of knowing you’re making a difference.

Cut back on your social media use. While it may seem that losing yourself online will temporarily ease depression symptoms, it can actually make you feel even worse. Comparing yourself unfavorably with your peers on social media , for example, only promotes feelings of depression and isolation. Remember: people always exaggerate the positive aspects of their lives online, brushing over the doubts and disappointments that we all experience. And even if you’re just interacting with friends online, it’s no replacement for in-person contact. Eye-to-eye contact, a hug, or even a simple touch on the arm from a friend can make all the difference to how you’re feeling.

Making healthy lifestyle choices can do wonders for your mood. Things like eating right, getting regular exercise, and getting enough sleep have been shown to make a huge difference when it comes to depression.

Get moving! Ever heard of a “runner’s high”? You actually get a rush of endorphins from exercising, which makes you feel instantly happier. Physical activity can be as effective as medications or therapy for depression, so get involved in sports, ride your bike, or take a dance class. Any activity helps! If you’re not feeling up to much, start with a short daily walk, and build from there.

Be smart about what you eat. An unhealthy diet can make you feel sluggish and tired, which worsens depression symptoms. Junk food , refined carbs, and sugary snacks are the worst culprits! They may give you a quick boost, but they’ll leave you feeling worse in the long run. Make sure you’re feeding your mind with plenty of fruits, vegetables, and whole grains. Talk to your parents, doctor, or school nurse about how to ensure your diet is adequately nutritious.

Avoid alcohol and drugs. You may be tempted to drink or use drugs in an effort to escape from your feelings and get a “mood boost,” even if just for a short time. However, as well as causing depression in the first place, substance use will only make depression worse in the long run. Alcohol and drug use can also increase suicidal feelings. If you’re addicted to alcohol or drugs , seek help. You will need special treatment for your substance problem on top of whatever treatment you’re receiving for your depression.

Aim for eight hours of sleep each night.  Feeling depressed as a teenager typically disrupts your sleep. Whether you’re sleeping too little or too much, your mood will suffer. But you can get on a better sleep schedule  by adopting healthy sleep habits.

For many teens, stress and anxiety can go hand-in-hand with depression. Unrelenting stress, doubts, or fears can sap your emotional energy, affect your physical health, send your anxiety levels soaring, and trigger or exacerbate depression.

If you’re suffering from an anxiety disorder , it can manifest itself in a variety of ways. Perhaps you endure intense anxiety attacks that strike without warning, get panicky at the thought of speaking in class, experience uncontrollable, intrusive thoughts, or live in a constant state of worry. Since anxiety makes depression worse (and vice versa), it’s important to get help for both conditions.

Tips for managing stress

Managing the stress in your life starts with identifying the sources of that stress:

• If exams or classes seem overwhelming, for example, talk to a teacher or school counselor, or find ways of improving how you manage your time.
• If you have a health concern you feel you can’t talk to your parents about—such as a pregnancy scare or drug problem —seek medical attention at a clinic or see a doctor. A health professional can guide you towards appropriate treatment (and help you approach your parents if that’s necessary).
• If you’re struggling to fit in or dealing with relationship, friendship, or family difficulties, talk your problems over with your school counselor or a professional therapist. Exercise, meditation , muscle relaxation, and breathing exercises are other good ways to cope with stress.
• If your own negative thoughts and chronic worrying are contributing to your everyday stress levels, you can take steps to break the habit and regain control of your worrying mind.

If you’re a teenager with a friend who seems down or troubled, you may suspect depression. But how do you know it’s not just a passing phase or a bad mood? Look for common warning signs of teen depression:

• Your friend doesn’t want to do the things you guys used to love to do.
• Your friend starts using alcohol or drugs or hanging with a bad crowd.
• Your friend stops going to classes and after-school activities.
• Your friend talks about being bad, ugly, stupid, or worthless.
• Your friend starts talking about death or suicide.

Teens typically rely on their friends more than their parents or other adults, so you may find yourself in the position of being the first—or only—person that your depressed friend confides in. While this might seem like a huge responsibility, there are many things you can do to help :

Get your friend to talk to you. Starting a conversation about depression can be daunting, but you can say something simple: “You seem like you are really down, and not yourself. I really want to help you. Is there anything I can do?”

You don’t need to have the answers. Your friend just needs someone to listen and be supportive. By listening and responding in a non-judgmental and reassuring manner, you are helping in a major way.

Encourage your friend to get help. Urge your depressed friend to talk to a parent, teacher, or counselor. It might be scary for your friend to admit to an authority figure that they have a problem. Having you there might help, so offer to go along for support.

Stick with your friend through the hard times. Depression can make people do and say things that are hurtful or strange. But your friend is going through a very difficult time, so try not to take it personally. Once your friend gets help, they will go back to being the person you know and love. In the meantime, make sure you have other friends or family taking care of you. Your feelings are important and need to be respected, too.

Speak up if your friend is suicidal. If your friend is joking or talking about suicide, giving possessions away, or saying goodbye, tell a trusted adult immediately. Your only responsibility at this point is to get your friend help , and get it fast. Even if you promised not to tell, your friend needs your help. It’s better to have a friend who is temporarily angry at you than one who is no longer alive.

Depression support, suicide prevention help

Depression support.

Find  DBSA Chapters/Support Groups  or call the  NAMI Helpline  for support and referrals at 1-800-950-6264

Find  Depression support groups  in-person and online or call the  Mind Infoline  at 0300 123 3393

Call the  SANE Help Centre  at 1800 18 7263

Call  Mood Disorders Society of Canada  at 519-824-5565

Call the Vandrevala Foundation  Helpline (India)  at 1860 2662 345 or 1800 2333 330

Suicide prevention help

Call  988 Suicide and Crisis Lifeline  at 988

Call  Samaritans UK  at 116 123

Call  Lifeline Australia  at 13 11 14

Visit  IASP  or  Suicide.org  to find a helpline near you

More Information

• Depression: What You Need to Know - Depression in teenagers, including symptoms, remedies, and how to talk to your parents. (TeensHealth)
• Depression in Teens - Recognizing and treating adolescent depression. (Mental Health America)
• How to Talk to Your Parents About Getting Help - Speaking up for yourself is the first step to getting better. (Child Mind Institute)
• Petito, A., Pop, T. L., Namazova-Baranova, L., Mestrovic, J., Nigri, L., Vural, M., Sacco, M., Giardino, I., Ferrara, P., & Pettoello-Mantovani, M. (2020). The Burden of Depression in Adolescents and the Importance of Early Recognition. The Journal of Pediatrics, 218, 265-267.e1. Link
• Hallfors, D. D., Waller, M. W., Ford, C. A., Halpern, C. T., Brodish, P. H., & Iritani, B. (2004). Adolescent depression and suicide risk: Association with sex and drug behavior. American Journal of Preventive Medicine, 27(3), 224–231. Link
• Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989. Link
• Bhatia, S. K., & Bhatia, S. C. (2007). Childhood and Adolescent Depression. American Family Physician, 75(1), 73–80. Link
• NIMH » Major Depression. (n.d.). Retrieved July 26, 2021, from Link
• Depressive Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link

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• Patient Care & Health Information
• Diseases & Conditions
• Teen depression

Teen depression is a serious mental health problem that causes a persistent feeling of sadness and loss of interest in activities. It affects how your teenager thinks, feels and behaves, and it can cause emotional, functional and physical problems. Although depression can occur at any time in life, symptoms may be different between teens and adults.

Issues such as peer pressure, academic expectations and changing bodies can bring a lot of ups and downs for teens. But for some teens, the lows are more than just temporary feelings — they're a symptom of depression.

Teen depression isn't a weakness or something that can be overcome with willpower — it can have serious consequences and requires long-term treatment. For most teens, depression symptoms ease with treatment such as medication and psychological counseling.

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Teen depression signs and symptoms include a change from the teenager's previous attitude and behavior that can cause significant distress and problems at school or home, in social activities, or in other areas of life.

Depression symptoms can vary in severity, but changes in your teen's emotions and behavior may include the examples below.

Emotional changes

Be alert for emotional changes, such as:

• Feelings of sadness, which can include crying spells for no apparent reason
• Frustration or feelings of anger, even over small matters
• Feeling hopeless or empty
• Irritable or annoyed mood
• Loss of interest or pleasure in usual activities
• Loss of interest in, or conflict with, family and friends
• Low self-esteem
• Feelings of worthlessness or guilt
• Fixation on past failures or exaggerated self-blame or self-criticism
• Extreme sensitivity to rejection or failure, and the need for excessive reassurance
• Trouble thinking, concentrating, making decisions and remembering things
• Ongoing sense that life and the future are grim and bleak
• Frequent thoughts of death, dying or suicide

Behavioral changes

Watch for changes in behavior, such as:

• Tiredness and loss of energy
• Insomnia or sleeping too much
• Changes in appetite — decreased appetite and weight loss, or increased cravings for food and weight gain
• Use of alcohol or drugs
• Agitation or restlessness — for example, pacing, hand-wringing or an inability to sit still
• Slowed thinking, speaking or body movements
• Frequent complaints of unexplained body aches and headaches, which may include frequent visits to the school nurse
• Social isolation
• Poor school performance or frequent absences from school
• Less attention to personal hygiene or appearance
• Angry outbursts, disruptive or risky behavior, or other acting-out behaviors
• Self-harm — for example, cutting or burning
• Making a suicide plan or a suicide attempt

What's normal and what's not

It can be difficult to tell the difference between ups and downs that are just part of being a teenager and teen depression. Talk with your teen. Try to determine whether he or she seems capable of managing challenging feelings, or if life seems overwhelming.

When to see a doctor

If depression signs and symptoms continue, begin to interfere in your teen's life, or cause you to have concerns about suicide or your teen's safety, talk to a doctor or a mental health professional trained to work with adolescents. Your teen's family doctor or pediatrician is a good place to start. Or your teen's school may recommend someone.

Depression symptoms likely won't get better on their own — and they may get worse or lead to other problems if untreated. Depressed teenagers may be at risk of suicide, even if signs and symptoms don't appear to be severe.

If you're a teen and you think you may be depressed — or you have a friend who may be depressed — don't wait to get help. Talk to a health care provider such as your doctor or school nurse. Share your concerns with a parent, a close friend, a spiritual leader, a teacher or someone else you trust.

Suicide is often associated with depression. If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

Also consider these options if you're having suicidal thoughts:

• Call your mental health professional.
• In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . The Spanish language phone line is 1-888-628-9454 (toll-free). Services are free and confidential.
• Or contact a crisis service for teenagers in the U.S. called TXT 4 HELP : Text the word "safe" and your current location to 4HELP (44357) for immediate help, with the option for interactive texting.
• Seek help from your primary care doctor or other health care provider.
• Reach out to a close friend or loved one.
• Contact a minister, spiritual leader or someone else in your faith community.

If a loved one or friend is in danger of attempting suicide or has made an attempt:

• Make sure someone stays with that person.
• Call 911 or your local emergency number immediately.
• Or, if you can do so safely, take the person to the nearest hospital emergency room.

Never ignore comments or concerns about suicide. Always take action to get help.

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It's not known exactly what causes depression, but a variety of issues may be involved. These include:

• Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that carry signals to other parts of your brain and body. When these chemicals are abnormal or impaired, the function of nerve receptors and nerve systems changes, leading to depression.
• Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression.
• Inherited traits. Depression is more common in people whose blood relatives — such as a parent or grandparent — also have the condition.
• Early childhood trauma. Traumatic events during childhood, such as physical or emotional abuse, or loss of a parent, may cause changes in the brain that increase the risk of depression.
• Learned patterns of negative thinking. Teen depression may be linked to learning to feel helpless — rather than learning to feel capable of finding solutions for life's challenges.

Risk factors

Many factors increase the risk of developing or triggering teen depression, including:

• Having issues that negatively impact self-esteem, such as obesity, peer problems, long-term bullying or academic problems
• Having been the victim or witness of violence, such as physical or sexual abuse
• Having other mental health conditions, such as bipolar disorder, an anxiety disorder, a personality disorder, anorexia or bulimia
• Having a learning disability or attention-deficit/hyperactivity disorder (ADHD)
• Having ongoing pain or a chronic physical illness such as cancer, diabetes or asthma
• Having certain personality traits, such as low self-esteem or being overly dependent, self-critical or pessimistic
• Abusing alcohol, nicotine or other drugs
• Being gay, lesbian, bisexual or transgender in an unsupportive environment

Family history and issues with family or others may also increase your teenager's risk of depression, such as:

• Having a parent, grandparent or other blood relative with depression, bipolar disorder or alcohol use problems
• Having a family member who died by suicide
• Having a family with major communication and relationship problems
• Having experienced recent stressful life events, such as parental divorce, parental military service or the death of a loved one

Complications

Untreated depression can result in emotional, behavioral and health problems that affect every area of your teenager's life. Complications related to teen depression may include, for example:

• Alcohol and drug misuse
• Academic problems
• Family conflicts and relationship difficulties
• Suicide attempts or suicide

There's no sure way to prevent depression. However, these strategies may help. Encourage your teenager to:

• Take steps to control stress, increase resilience and boost self-esteem to help handle issues when they arise
• Practice self-care, for example by creating a healthy sleep routine and using electronics responsibly and in moderation
• Reach out for friendship and social support, especially in times of crisis
• Get treatment at the earliest sign of a problem to help prevent depression from worsening
• Maintain ongoing treatment, if recommended, even after symptoms let up, to help prevent a relapse of depression symptoms

Teen depression care at Mayo Clinic

• Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed May 4, 2021.
• Bipolar and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed May 4, 2021.
• Brown AY. Allscripts EPSi. Mayo Clinic. April 9, 2021.
• Teen depression. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/teen-depression/. Accessed March 30, 2022.
• Depression in children and teens. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/The-Depressed-Child-004.aspx. Accessed May 4, 2021.
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• Suicidality in children and adolescents being treated with antidepressant medications. U.S. Food and Drug Administration. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications. Accessed May 4, 2021.
• Depression medicines. U.S. Food and Drug Administration. https://www.fda.gov/consumers/free-publications-women/depression-medicines. Accessed May 4, 2021.
• Building your resilience. American Psychological Association. https://www.apa.org/topics/resilience. Accessed May 4, 2021.
• Psychiatric medications for children and adolescents: Part I ― How medications are used. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-I-How-Medications-Are-Used-021.aspx. Accessed May 4, 2021.
• Psychiatric medications for children and adolescents: Part II ― Types of medications. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-II-Types-Of-Medications-029.aspx. Accessed May 5, 2021.
• Weersing VR, et al. Evidence-base update of psychosocial treatments for child and adolescent depression. Journal of Clinical Child and Adolescent Psychology. 2017; doi:10.1080/15374416.2016.1220310.
• Zuckerbrot RA, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018; doi:10.1542/peds.2017-4081.
• Cheung AH, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018; doi:10.1542/peds.2017-4082.
• Resilience guide for parents and teachers. American Psychological Association. https://www.apa.org/topics/resilience/guide-parents-teachers. Accessed May 4, 2021.
• Rice F, et al. Adolescent and adult differences in major depression symptoms profiles. Journal of Affective Disorders. 2019; doi:10.1016/j.jad.2018.09.015.
• Haller H, et al. Complementary therapies for clinical depression: An overview of systemic reviews. BMJ Open. 2019; doi:10.1136/bmjopen-2018-028527.
• Ng JY, et al. Complementary and alternative medicine recommendations for depression: A systematic review and assessment of clinical practice guidelines. BMC Complementary Medicine and Therapeutics. 2020; doi:10.1186/s12906-020-03085-1.
• American College of Obstetricians and Gynecologists. Practice Bulletin No. 92: Use of psychiatric medications during pregnancy and lactation. Obstetrics & Gynecology. 2008; doi:10.1097/AOG.0b013e31816fd910. Reaffirmed 2019.
• Neavin DR, et al. Treatment of major depressive disorder in pediatric populations. Diseases. 2018; doi:10.3390/diseases6020048.
• Vande Voort JL (expert opinion). Mayo Clinic. June 29, 2021.
• Safe Place: TXT 4 HELP. https://www.nationalsafeplace.org/ txt-4-help. Accessed March 30, 2022.
• Antidepressants for children and teens

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Understanding Teen Depression Essay

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Introduction

Teen depression.

A considerable number of teenagers around the globe extensively suffer from depression. Depression can lead to several unpleasant behaviors, especially when left unattended. However, in as much as the teen are extremely vulnerable to depressions, most of them adopt several mechanisms that significantly assist them in containing their situation. Although, the methods employed vary from one individual to another; some may employ constructive measures, while others use unhelpful approaches.

Understanding teen depression

It is noted that teen depression is primarily caused by two common factors i.e. unanswered sorrow and emotional disconnection. Unanswered sorrows are caused by certain life experiences such as the loss of loved ones, desertion, and disturbing events. On the other hand, emotional disconnection is caused by the fear of being unable to correlate with other.

Many people misunderstand teen depression, which is due to their several interesting behaviors at this stage. Therefore, it is extremely necessary to understand teenagers, incase one intends to detect and assist the teenagers fight against depressions. Depression is an awful illness to the teens, since it causes extraordinary grief, fury or despair among these youngsters. Furthermore, it is also a lethal disease; many people have perished after suffering severe depression i.e. either by committing suicide or by natural death.

Sources indicate that, approximately 20% of the depressed teens never seek help, despite the knowledge that it’s curable (Smith, & Barston, 2010). However, it is noted that the majority who seek for treatment, approach persons such as teachers or parents who often assist them get the best treatment.

Symptoms of depression on teenagers

It is extremely difficult to detect a depressed teenager. This is because; most depression symptoms are similar to certain normal behaviors of teens. Some of depression symptoms can be summarized as rejection of parents and friends; restlessness; fatigue; lack of concentration and enthusiasms; significant change in sleeping and eating pattern (Smith, & Barston, 2010).

However, the most regular symptoms considered as follows: extraordinary sensitivity to criticism, rejection of friends and families, fuming moods and unexplained pains.

Impacts of depression on teenagers

Depression is characterized by several effects; however, most of them impact negatively to the teens. Untreated teens end up: using illegal drugs; having class work problems, eating disorders; portraying immature behaviors and having low self-worth (Gelman, 2000). Furthermore, some of them become violent, practice lots of reckless activities and, in some instances, they even threaten to commit suicide.

How to help depressed teenagers

Teenager seek help to persons they trust; therefore, for one to assist them he or she must display certain tolerable and friendly qualities. One needs to be understanding and offer extensive support to the depressed teens. Furthermore, one must listen with kindness, and later emphasize to them, on the importance of seeking treatment. It is also helpful, to notify the teenagers, how they can seek for treatment i.e. by advising them to consult doctors or any other specialist, and maybe explore other treatment options.

How teens cope up with depression

Teenagers employ different approaches in their attempt to cope up with depression. Some teens employ positive approaches, whereas others use unconstructive measures, which end up messing their promising lives. Constructive approaches significantly assist the teens in learning to manage their depressions; whereas, most unconstructive measures destroy a teenagers’ lives.

Constructive ways used by teens

Teens employ several constructive ways of handling depression during their adolescent stage. For instance, a considerable percentage of teens use extra-curriculum activities such as sports and games, to cope with depression. They spend many of their free hours in playing different sports, games and other co-curriculum activities. This extensively assist them cope with depression since most of their free time is spent on sports, instead of idling with a depressed mind.

Unconstructive ways used by teens

A number of teens employ several unconstructive approaches of coping with depressions during their adolescent stage. For instance, a significant number of teenagers use drugs as a way of escaping their mental problems. They smoke, sniff and drink unhealthy drugs such as marijuana, cocaine and alcohol respectively (Gelman, 2000).

Interestingly, most of these teens are often convinced that drug abuse do solve their problems. This is extremely unfortunate to them, since abuse of drugs does not, in any way, solve their problems; instead, it further complicates it, to the extent of being uncontrollable.

A considerable number of teenagers engage in reckless behaviors, as a way of expressing their humiliation and depression. They often feel relived after doing or participating in certain irresponsible behaviors such as shop lifting. However, the relief is momentarily thus they keep on repeating the immature behaviors.

Some teenagers also keep off their friends and families, when they are depressed (Ayer, 2001). Their primary intension is always not to abandon their friends, but to avoid discussions and conversations that might complicate their situation. However, this is not necessarily a dire approach, since it may work well to some teens.

Depression is a common illness among teens, and it is associated with several complications including disagreeable behaviors. It is, therefore, imperative to, unmistakably, understand teenagers, incase one intends to assist them. This is because of the misconceptions surrounding their teenage lives thus one may misinterpret some of them as unusual behaviors. Teens employ several approaches in coping up with depression; some of them being beneficial, while others unconstructive.

Ayer, E. (2001). Everything you need to know about depression . New York: The Rosen Publishing Group.

Gelman, A. (2000). Coping with depression with other mood disorders . New York: The Rosen Publishing Group.

Smith, M. & Barston, S. (2010). Teen depression . Helpguide. Web.

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Depression in Teens

Verywell / Jo Zixuan Zhou

As much as 8% of teens experience depression each year, according to one survey.   By the time young adults reach age 21, one study found that nearly 15% have had at least one episode of a mood disorder.   Depression can cause problems such as difficulties in school, difficulties with relationships, and decreased enjoyment of life. At its worst, depression can lead to suicide, one of the leading causes of death for teens in the United States.

Depression is an illness with many causes and many forms. It is a disorder of a person’s moods or emotions—not an attitude that someone can “control” or “snap out of.” But it is treatable with psychotherapy and/or medication, which is why it's especially important for parents and caregivers to educate themselves about the disorder.

Adults sometimes don’t recognize symptoms of depression in teens because the disorder can look quite different from that in adults. A teenager with depression might have some or all of these signs of the illness:

• Sad or depressed mood
• Feelings of worthlessness or hopelessness
• Loss of interest in things they used to enjoy
• Withdrawal from friends and family
• Inability to sleep or sleeping too much
• Loss of appetite or increased appetite
• Aches and pains that don’t go away, even with treatment
• Irritability
• Feeling tired despite getting enough sleep
• Inability to concentrate
• Thoughts of suicide, talk of suicide, or suicide attempts

Types of Teen Depression

The National Institute of Mental Health states that there are two common forms of depression found in teens: major depressive disorder and dysthymic disorder (now known as persistent depressive disorder).

• Major depressive disorder , also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.
• Dysthymic disorder , also called dysthymia, is characterized by long-term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

There are thought to be many causes of depression . There are most likely many factors behind who develops depression and who doesn’t, and these factors are no different for teens.

• Traumatic life event, such as the loss of a loved one or pet, divorce, or remarriage. Any event that causes distress or trauma, or even just a major change in lifestyle, can trigger depression in a vulnerable individual.
• Social situation/family circumstances. Unfortunately, there are teens who live in difficult circumstances. Domestic violence, substance abuse, poverty or other family issues can cause stress and contribute to depression in a teen.
• Genetics/biology. It has been found that depression runs in families and that there is a genetic basis for depression. Keep in mind, though, that teens who have depression in their family will not necessarily get the illness, and teens without a history of depression in their family can still get the disorder.
• Medical conditions. Occasionally, symptoms of depression can be a sign of another medical illness, such as hypothyroidism, or other disorders.
• Medications/illegal drugs. Some legal, prescription medications can have depression as a side effect. Certain illegal drugs (street drugs) can also cause depression.

Depression in teens is most often diagnosed by a primary care physician.

Researchers suggest that teen depression is often underdiagnosed and undertreated.  

If teen depression is suspected, a doctor will often start with a physical exam that may include blood tests. Your teen's pediatrician will want to rule out any other medical illnesses that may be causing or contributing to your teen's symptoms.

Your child will also be given a psychological evaluation. This often involves a depression questionnaire as well as a discussion about the severity and duration of their symptoms. 

The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) recommend the following in the management of teen depression:

• Educating teens and families about treatment options that are available
• Developing a treatment plan that includes specific treatment goals that address functioning at home and school
• Collaborating with other mental health resources in the community
• Creating a safety plan with steps that should be taken if the teen's symptoms become worse or if they experience suicidal thinking
• Considering active support and monitoring before beginning other treatments
• Consulting a mental health specialist if symptoms are moderate or severe
• Incorporating evidence-based treatments such as cognitive-behavioral therapy, interpersonal therapy, and antidepressants
• Continuing to monitor symptoms and functioning during antidepressant treatment; doctors and family member should watch for signs that symptoms are worsening and for suicidal thinking or behaviors

Talk to your teen about your concerns. There may be a specific cause for why they are acting a certain way. Opening up the lines of communication lets your teenager know you care and that you are available to talk about the situation and provide support.

Other things that may help your teen manage symptoms of depression include:

• Talking about concerns with family and friends
• Having a healthy support system 
• Using good stress management techniques
• Eating a healthy diet
• Getting regular exercise
• Finding new things to look forward to
• Joining a support group, either offline or online

Also, talk to your pediatrician or family physician if you have concerns about your teen regarding depression. Your provider may be able to discuss the situation with your teen, rule out a medical reason for the behavior, recommend a psychotherapist, or prescribe medication .

Lastly, never ignore the signs or symptoms of depression. Depression is treatable and there is help available for both you and your teen. If left untreated, depression can lead to thoughts of suicide or even the act itself.

If your teen talks about suicide or attempts suicide, get help immediately. The Centers for Disease Control and Prevention (CDC) cites suicide as the third leading cause of death for people between the ages of 10 and 24.

If a teen is in immediate danger of suicide, call 911. If you or a loved one is having thoughts of suicide, call the National Suicide Prevention Lifeline at 988 to get support from a trained counselor in your area.

For more mental health resources, see our National Helpline Database .

Kessler RC, Avenevoli S, Costello EJ, Georgiades K, Green JG, et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement . Arch Gen Psychiatry . 2012; 69(4): 372-80. doi:10.1001/archgenpsychiatry.2011.160

Copeland W, Shanahan L, Costello EJ, Angold A. Cumulative prevalence of psychiatric disorders by young adulthood: A prospective cohort analysis from the Great Smoky Mountains Study . J Am Acad Child Adolesc Psychiatry . 2011; 50(3): 252-261. doi:10.1016/j.jaac.2010.12.014

Cheung AH, Kozloff N, Sacks D. Pediatric depression: An evidence-based update on treatment interventions . D. Curr Psychiatry Rep. 2013; 15: 381. doi:10.1007/s11920-013-0381-4

Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Larague D, GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management . Pediatrics . 2018; 141(3). pii: e20174082. doi:10.1542/peds.2017-4082

By Barbara Poncelet Barbara Poncelet, CRNP, is a certified pediatric nurse practitioner specializing in teen health.

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Teen Depression

Do you ever wonder whether your irritable or unhappy adolescent might actually be experiencing teen depression ? Of course, most teens feel unhappy at times. And when you add hormone havoc to the many other changes happening in a teen's life, it's easy to see why their moods swing like a pendulum. Yet findings show that one out of every eight adolescents has teen depression. But depression can be treated as well as the serious problems that come with it. So if your teen's unhappiness lasts for more than two weeks and they display other symptoms of depression , it may be time to seek help from a health professional.

Why do adolescents get depression?

There are multiple reasons why a teenager might become depressed. For example, teens can develop feelings of worthlessness and inadequacy over their grades. School performance, social status with peers, sexual orientation , or family life can each have a major effect on how a teen feels. Sometimes, teen depression may result from environmental stress. But whatever the cause, when being with friends or family -- or doing things that the teen usually enjoys -- don't help to improve their sadness or sense of isolation, there's a good chance that they have teen depression.

What are the symptoms of teen depression?

Often, kids with teen depression will have a noticeable change in their thinking and behavior. The most common symptom of depression is sadness for no apparent reason most of the time. They may have no motivation and even become withdrawn, closing their bedroom door after school and staying in their room for hours.

Kids with teen depression may sleep excessively, have a change in eating habits, and may even exhibit criminal behaviors such as DUI or shoplifting. Here are more signs of depression in adolescents even though they may or may not show all signs:

• Complaints of pains, including headaches, stomachaches, low back pain , or fatigue
• Difficulty concentrating
• Difficulty making decisions
• Excessive or inappropriate guilt
• Irresponsible behavior -- for example, forgetting obligations, being late for classes, skipping school
• Loss of interest in food or compulsive overeating that results in rapid weight loss or gain
• Memory loss
• Preoccupation with death and dying
• Rebellious behavior
• Sadness, anxiety, or a feeling of hopelessness
• Staying awake at night and sleeping during the day
• Sudden drop in grades
• Use of alcohol or drugs and promiscuous sexual activity
• Withdrawal from friends
• Feeling helpless
• Unexplained crying
• Extreme sensitivity to rejection or failure

For in-depth information, see WebMD's Symptoms of Depression .

Can teen depression run in families?

Yes. Depression , which usually starts between the ages of 15 and 30, sometimes can run in families. In fact, teen depression may be more common among adolescents who have a family history of depression.

How is teen depression diagnosed?

There aren't any specific medical tests that can detect depression. Health care professionals determine if a teen has depression by conducting interviews and psychological tests with the teen and their family members, teachers, and peers.

The severity of the teen depression and the risk of suicide are determined based on the assessment of these interviews. Treatment recommendations are also made based on the data collected from the interviews.

The doctor will also look for signs of potentially co-existing psychiatric disorders such as anxiety or substance abuse or screen for complex forms of depression such as bipolar disorder (manic depressive illness) or psychosis . The doctor will also assess the teen for risks of suicide or homicide. Incidences of attempted suicide and self-mutilation is higher in females than males while completed suicide is higher in males. One of the most vulnerable groups for completed suicide is the 18-24 age group.

The United States Preventive Service Task Force now recommends screening for anxiety in children and adolescents ages 8 to 18 years and screening for major depressive disorder (MDD) in adolescents ages 12 to 18 years.

How is teen depression treated?

There are a variety of methods used to treat depression, including medications and psychotherapy . Family therapy may be helpful if family conflict is contributing to a teen's depression. The teen will also need support from family or teachers to help with any school or peer problems. Occasionally, hospitalization in a psychiatric unit may be required for teenagers with severe depression.

Your mental health care provider will determine the best course of treatment for your teen.

The FDA warns that antidepressant medications can, rarely, increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. Use of antidepressants in younger patients, therefore, requires especially close monitoring and follow-up by the treating doctor. If you have questions or concerns, discuss them with your health care provider.

Does depression medicine work for teen depression?

Yes. A large number of research trials have shown the effectiveness of depression medications in relieving the symptoms of teen depression. One key recent study, funded by the National Institute of Mental Health, reviewed three different approaches to treating adolescents with moderate to severe depression:

• One approach was using the antidepressant medication Prozac, which is approved by the FDA for use with pediatric patients ages 8-18.
• The second treatment was using cognitive behavioral therapy, or CBT, to help the teen recognize and change negative patterns of thinking that may increase symptoms of depression.
• The third approach was a combination of medication and CBT.

At the end of the 12-week study, researchers found that nearly three out of every four patients who received the combination treatment -- depression medication and psychotherapy -- significantly improved. More than 60% of the kids who took Prozac alone improved. But the study confirmed that combination treatment was nearly twice as effective in relieving depression as psychotherapy alone.

What are the warning signs for teen suicide?

Teen suicide is a serious problem. Adolescent suicide is the second leading cause of death, following accidents, among youth and young adults in the U.S. It is estimated that 500,000 teens attempt suicide every year with 5,000 succeeding. These are epidemic numbers.

Family difficulties, the loss of a loved one, or perceived failures at school or in relationships can all lead to negative feelings and depression. And teen depression often makes problems seem overwhelming and the associated pain unbearable. Suicide is an act of desperation and teen depression is often the root cause.

Warning signs of suicide with teen depression include:

• Expressing hopelessness for the future
• Giving up on one's self, talking as if no one else cares
• Preparing for death, giving away favorite possessions, writing goodbye letters, or making a will
• Starting to use or abuse drugs or alcohol to aid sleep or for relief from their mental anguish
• Defiant behavior
• Acting violently
• Threatening to kill one's self

If your teenager displays any of these behaviors, you should seek help from a mental health professional immediately. Or you can call a suicide hotline for help.

Depression carries a high risk of suicide. Anybody who expresses suicidal thoughts or intentions should be taken very, very seriously. Do not hesitate to call your local Suicide and Crisis hotline immediately. Call 988.

What can parents do to alleviate teen depression?

Parenting teens can be very challenging. There are, though, some effective parenting and communication techniques you can use to help lower the stress level for your teenager:

• When disciplining your teen, replace shame and punishment with positive reinforcement for good behavior. Shame and punishment can make an adolescent feel worthless and inadequate.
• Allow your teenager to make mistakes. Overprotecting or making decisions for teens can be perceived as a lack of faith in their abilities. This can make them feel less confident.
• Give your teen breathing room. Don't expect teens to do exactly as you say all of the time.
• Do not force your teen down a path you had wanted to follow. Avoid trying to relive your youth through your teen's activities and experiences.
• If you suspect that your teen is depressed, take the time to listen to their concerns. Even if you don't think the problem is of real concern, remember that it may feel very real to someone who is growing up.
• Keep the lines of communication open, even if your teen seems to want to withdraw.
• Try to avoid telling your teen what to do. Instead, listen closely and you may discover more about the issues causing the problems.
• If there is a close friend or family member your teen is close to and comfortable with, you might suggest your teen talk with this person about their concerns.

If you feel overwhelmed or unable to reach your teen, or if you continue to be concerned, seek help from a qualified health care professional.

Can't teen depression go away without medical treatment?

Teen depression tends to come and go in episodes. Once a teenager has one bout of depression, they are likely to get depressed again at some point. The consequence of letting teen depression go untreated can be extremely serious and even deadly.

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‘It’s Life or Death’: The Mental Health Crisis Among U.S. Teens

Depression, self-harm and suicide are rising among American adolescents. For one 13-year-old, the despair was almost too much to take.

By Matt Richtel

Photographs by Annie Flanagan

Matt Richtel spent more than a year interviewing adolescents and their families for this series on the mental health crisis.

One evening last April, an anxious and free-spirited 13-year-old girl in suburban Minneapolis sprang furious from a chair in the living room and ran from the house — out a sliding door, across the patio, through the backyard and into the woods.

Moments earlier, the girl’s mother, Linda, had stolen a look at her daughter’s smartphone. The teenager, incensed by the intrusion, had grabbed the phone and fled. (The adolescent is being identified by an initial, M, and the parents by first name only, to protect the family’s privacy.)

Linda was alarmed by photos she had seen on the phone. Some showed blood on M’s ankles from intentional self-harm. Others were close-ups of M’s romantic obsession, the anime character Genocide Jack — a brunette girl with a long red tongue who, in a video series, kills high school classmates with scissors.

In the preceding two years, Linda had watched M spiral downward: severe depression, self-harm, a suicide attempt. Now, she followed M into the woods, frantic. “Please tell me where u r,” she texted. “I’m not mad.”

American adolescence is undergoing a drastic change. Three decades ago, the gravest public health threats to teenagers in the United States came from binge drinking, drunken driving, teenage pregnancy and smoking. These have since fallen sharply, replaced by a new public health concern: soaring rates of mental health disorders.

In 2019, 13 percent of adolescents reported having a major depressive episode , a 60 percent increase from 2007 . Emergency room visits by children and adolescents in that period also rose sharply for anxiety, mood disorders and self-harm. And for people ages 10 to 24, suicide rates, stable from 2000 to 2007, leaped nearly 60 percent by 2018, according to the Centers for Disease Control and Prevention.

Emergency room visits for self-harm by children and adolescents rose sharply over the last decade, particularly among young women.

600 E.R. visits

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Emergency room visits for self-harm by children and adolescents rose sharply over the last decade, particularly for young women.

room visits

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Rates of smoking, drugs, alcohol and sex declined among high school students over the last decade, continuing trends that started over two decades ago.

One notable exception was a rise in excessive smartphone and computer use over the last decade.

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tablet, computer or

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3 hours a day, not

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Last sex was

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Get at least

8 hours of sleep

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Feelings of sadness and hopelessness rose, and suicidal thoughts increased.

How Matt Richtel spoke to adolescents and their parents for this series

In mid-April, I was speaking to the mother of a suicidal teenager whose struggles I’ve been closely following. I asked how her daughter was doing.

Not well, the mother said: “If we can’t find something drastic to help this kid, this kid will not be here long term.” She started to cry. “It’s out of our hands, it’s out of our control,” she said. “We’re trying everything.”

She added: “It’s like waiting for the end.”

Over nearly 18 months of reporting, I got to know many adolescents and their families and interviewed dozens of doctors, therapists and experts in the science of adolescence. I heard wrenching stories of pain and uncertainty. From the outset, my editors and I discussed how best to handle the identities of people in crisis.

The Times sets a high bar for granting sources anonymity; our stylebook calls it “a last resort” for situations where important information can’t be published any other way. Often, the sources might face a threat to their career or even their safety, whether from a vindictive boss or a hostile government.

In this case, the need for anonymity had a different imperative: to protect the privacy of young, vulnerable adolescents. They have harmed themselves and attempted suicide, and some have threatened to try again. In recounting their stories, we had to be mindful that our first duty was to their safety.

If The Times published the names of these adolescents, they could be easily identified years later. Would that harm their employment opportunities? Would a teen — a legal minor — later regret having exposed his or her identity during a period of pain and struggle? Would seeing the story published amplify ongoing crises?

As a result, some teenagers are identified by first initial only; some of their parents are identified by first name or initial. Over months, I got to know M, J and C, and in Kentucky, I came to know struggling adolescents I identified only by their ages, 12, 13 and 15. In some stories, we did not publish precisely where the families lived.

Everyone I interviewed gave their own consent, and parents were typically present for the interviews with their adolescents. On a few occasions, a parent offered to leave the room, or an adolescent asked for privacy and the parent agreed.

In these articles, I heard grief, confusion and a desperate search for answers. The voices of adolescents and their parents, while shielded by anonymity, deepen an understanding of this mental health crisis.

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Social media use and depression in adolescents: a scoping review

There have been increases in adolescent depression and suicidal behaviour over the last two decades that coincide with the advent of social media (SM) (platforms that allow communication via digital media), which is widely used among adolescents. This scoping review examined the bi-directional association between the use of SM, specifically social networking sites (SNS), and depression and suicidality among adolescents. The studies reviewed yielded four main themes in SM use through thematic analysis: quantity of SM use, quality of SM use, social aspects associated with SM use, and disclosure of mental health symptoms. Research in this field would benefit from use of longitudinal designs, objective and timely measures of SM use, research on the mechanisms of the association between SM use and depression and suicidality, and research in clinical populations to inform clinical practice.

Introduction

Over the past several decades, adolescent depression and suicidal behaviours have increased considerably. In the USA, depression diagnoses among youth increased from 8.7% in 2005 to 11.3% in 2014 ( Mojtabai, Olfson, & Han, 2016 ). Additionally, suicide is the second leading cause of death among youth between the ages of 10 and 34 ( Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2017 ), with a 47.5% increase since 2000 ( Miron, Yu, Wilf-Miron, & Kohane, 2019 ). One suggested cause for this rise in adolescent depression and suicide is the advent of social media (SM) ( McCrae, Gettings, & Purssell, 2017 ; Twenge, Joiner, Rogers, & Martin, 2018 ).

The term ‘social media’ describes types of media that involve digital platforms and interactive participation. SM includes forms such as email, text, blogs, message boards, connection sites (online dating), games and entertainment, apps, and social networking sites (SNS) ( Manning, 2014 ). Over the past decade, SNS platforms designed to help people communicate and share information online have become ubiquitous. Among youth, 97% of all adolescents between the ages of 13 and 17 use at least one of the following seven SNS platforms: YouTube (85% of adolescents), Instagram (72%), Snapchat (69%), Facebook (51%), Twitter (32%), Tumblr (9%) or Reddit (7%) ( Pew Research Center, 2018a ).

Concerns have arisen around the effects of SM on adolescents’ mental health, due to SM’s association with decreased face-to-face interpersonal interactions ( Baym, 2010 ; Kraut et al., 1998 ; Nie, Hillygus, & Erbring, 2002 ; Robinson, Kestnbaum, Neustadtl, & Alvarez, 2002 ), addiction-like behaviours ( Anderson, Steen, & Stavropoulos, 2017 ), online bullying ( Kowalski, Limber, & Agatston, 2012 ), social pressure through increased social comparisons ( Guernsey, 2014 ), and contagion effect through increased exposure to suicide stories on SM ( Bell, 2014 ).

Conversely, others have described potential benefits of SM use in adolescents such as feelings of greater connection to friends and interactions with more diverse groups of people who can provide support ( Pew Research Center, 2018b ). In fact, higher internet use has been associated with positive social well-being, higher use of communication tools, and increased face-to-face conversations and social contacts in college students ( Baym, Zhang, & Lin, 2004 ; Kraut et al., 2002 ; Wang & Wellman, 2010 ). These findings suggest that internet use, including SM, may provide opportunities for social connection and access to information ( Reid Chassiakos et al., 2016 ).

Recent systematic reviews examining the association between online technologies and depression have found a ‘general correlation’ between SM use and depression in adolescents, but with conflicting findings in some domains (e.g. the association between time spent on SM and mental health problems), overall limited quality of the evidence ( Keles, McCrae, & Grealish, 2019 ), and a relative absence of studies designed to show causal effects ( Best, Manktelow, & Taylor, 2014 ). The scope of search in these reviews is broader in topic, including online technologies other than SM ( Best et al., 2014 ) or focussed on a select number of studies in order to meet the requirements of a systematic review ( Keles et al., 2019 ). With this scoping review, we aim to expand the inclusion of studies with a range of designs, while narrowing the scope of the topic of SM to those studies that specifically included SNS use. Additionally, we aim to expand the understanding and potential research gaps on the bi-directional association between SM and depression and suicidal behaviours in adolescents, including studies that consider SM use as a predictor as well as an outcome. A better understanding of this relationship can inform interventions and screenings related to SM use in clinical settings.

This scoping review was initiated by a research team including 3 mental health professionals with clinical expertise in treating depression and suicidality in adolescents. We followed the framework suggested by Arksey and O’Malley (2005) for scoping reviews. The review included five steps: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing and reporting the results.

Research question

The review was guided by the question: What is known from the existing literature about the association between depression and suicidality and use of SNS among adolescents? Given that much of the literature used SM and SNS interchangeably, this review used the term ‘social media’ or ‘SM’ when it was difficult to discern if the authors were referring exclusively to SNS.

Data sources and search strategy

The team conceived the research question through a series of discussions, and the first author (CV) consulted an informationist to identify the appropriate search terms and databases. A search of the database PsychINFO limited to peer-reviewed articles was conducted on 5 June 2019 (see Table 1 for search strategy). No additional methods were identified through other sources. The search was broad to include articles measuring depression as an outcome variable, and as a co-variate or independent variable. There was no restriction on the type of study design included, and English and Spanish language articles were included in the search. Articles were organized using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia).

Search strategy.

Eligibility criteria

(1) The study examined SM (versus internet use in general) and made specific mention of SNS; (2) participants were between the ages of 10 and 18. If adults were included, the majority of the study population was between 10–18 years of age, or the mean participant age was 18 or younger; (3) the study examined the association between SM use and depression and/or suicidality; (4) the study included at least one measure of depression; and (5) if the focus of the study was on SM addiction or cyberbullying, it included mention and a measure of depressive symptoms. We did not include articles in which: (1) the study primarily focussed on media use other than SM, or that did not specifically mention inclusion of SNS (e.g. studies that focussed only on TV, video game, smartphone use, blogging, email); (2) included primarily adult population; (3) was not an original study, but a case report, review, commentary, erratum, or letter to the editor; (4) focussed on addiction and cyberbullying exclusively without a depression measure; and (5) the method used was content analysis of SM posts without specification of the population age range.

Title and abstract relevance screening

The search yielded 728 articles of which six duplicates were removed. One author (CV) screened the remainder of the articles by title and abstract and a second author (TL) reviewed every 25th article for agreement. All authors screened full-text articles and extracted data from those that met the inclusion criteria. The authors met over the course of the full-text review process to resolve conflicts and maintain consistency among the authors themselves and with the research question. Of the total number of studies included for full-text review, 505 articles were excluded. Out of the 223 full-text studies assessed for eligibility, 175 were excluded. A total of 42 articles were eligible for review (see Figure 1 : PRISMA flow chart for details). A form was developed to extract the characteristics of each study that included author and year of publication, objectives of the study, study method, country where the study was conducted, depression scale used, number of participants, participant age, and results (see Table 2 for details).

PRISMA flow chart of data selection process.

Data charting form including author and year of publication, objectives of the study, method used, country where the study was conducted, depression scale used, number of participants, participant age, results and main social media focus.

AIU = Addictive internet Use; BIU = Borderline Addictive Internet Use; BSMAS = Bergen Social Media Addiction Scale; BIU = Borderline addictive internet use; CBP = Cyberbullying Perpetration; CERM = Cuestionario de Experiencias Relacionadas con el móvil (Questionnaire of Experiences Related to the cellphone); DIB = Dysfunctional Internet Behaviour; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th edition, Text Revision); FOMO = Fear of Missing Out; HVSM = Highly Visual Social Media; SNI = Intensity of social network use; IA = Internet Addiction; IAB = Internet Addictive Behaviour; OSNA = Online social networking addiction; PSMU = Problematic Social Media Use; RADS-2 = Reynolds Adolescent Depression Scale - Version 2; SITBs = self-injurious thoughts and behaviours; SNS = social networking sites.

Data summary and synthesis

After reviewing the table, each study was labelled according to the main focus of research related to SM, based on the objectives, variables used, and results of the study. The topics were classified into nine different categories based on the main SM focus of the article; categories were discussed and reviewed by two authors (TL and CV) ( Table 2 ). All authors then discussed the categories and grouped them into four main themes of studies looking at SM and depression in adolescents.

A total of 42 studies published between 2011 and 2019 met the inclusion criteria. Of the studies included, 16 were conducted in European Countries, 14 in the USA, 5 in Asia, 3 in Canada, 2 in Australia, and 2 in Latin American Countries. The number of participants per study ranged from 23 in a qualitative study (94 in the smallest quantitative study) to 118,545 participants in the largest study ( Table 2 ).

The studies reviewed were grouped into four themes with nine categories according to the main focus of the research. The themes and categories were: (1) quantity of SNS use: effects of the frequency of SM use and problematic SM use (or evidence of addictive engagement with SM); (2) quality of SM use: characteristics of SNS use and social comparisons; (3) social aspects of SM use: cyberbullying, social support, and parental involvement; and (4) disclosure of mental health symptoms: online disclosure and prediction of symptoms and suicide contagion effect ( Figure 2 ).

Number of studies by theme (quantity, quality, social and disclosure) and time period (2011–2012, 2013–2014, 2015–2016 and 2017–2018).

Quantity of SM use

The majority of studies ( n = 24) examined quantity of SM use by measuring either frequency or time spent on SM ( n = 17), or problematic or addictive engagement with SM ( n = 7).

Frequency of use

The majority of studies found a positive correlation between time spent on SNS and higher levels of The majority of studies found a positive correlation between time spent on SNS and higher levels of depression ( Akkın Gürbüz, Demir, Gökalp Özcan, Kadak, & Poyraz, 2017 ; Marengo, Longobardi, Fabris & Settanni, 2018 ; Pantic et al., 2012 ; Twenge et al., 2018 ; Woods & Scott, 2016 ). Higher frequency of SM use (≥2 h a day) was also found to be positively associated with suicidal ideation ( Sampasa-Kanyinga & Lewis, 2015 ) and attempts ( Sampasa-Kanyinga & Hamilton, 2015 ), in addition to deficits in self-regulation ( Lee, Ho, & Lwin, 2017 ). Factors such as the number of SM accounts and the frequency of checking SM ( Barry, Sidoti, Briggs, Reiter, & Lindsey, 2017 ) were associated with a variety of symptoms, including depression.

A study ( Oberst, Wegmann, Stodt, Brand, & Chamarro, 2017 ) examining SM use as an outcome suggested that depression may affect SM use both directly, and indirectly, mediated by the Fear of Missing Out (or the apprehension of missing rewarding experiences that others might be enjoying) ( Przybylski, Murayama, DeHaan, & Gladwell, 2013 ). Adolescents with depression were also found to have more difficulty regulating their SM use ( Lee et al., 2017 ).

Longitudinal studies suggested a reciprocal relationship between quantity of SM use and depression. Frison and Eggermont (2017) found that frequency of Instagram browsing at baseline predicted depressed mood six months later and depressed mood at baseline predicted later frequency of photo posting. Additionally, heavy use (>4 h per day) of the internet to communicate (including social networking) and play games (gaming) predicted depressive symptoms a year later ( Romer, Bagdasarov, & More, 2013 ). Further, depressive symptoms predicted increased internet use and decreased participation in non-screen activities (e.g. sports). Finally, Salmela-Aro, Upadyaya, Hakkarainen, Lonka, and Alho (2017) found that school burnout increased the risk for later excessive internet use and depressive symptoms. Conversely, Houghton et al. (2018) found small, positive bi-directional associations between depressive symptoms and screen use 1 year later, but their final model did not support a longitudinal association.

Yet, not all studies found a positive association between frequency of use and depressed mood. While Blomfield-Neira and Barber (2014) reported a link between adolescents having a SM profile and depressed mood, they found no correlation between SM frequency of use and depressed mood. Rather, investment in SM (a measure of how important SM is to an adolescent) was linked to poorer adjustment, lower self-esteem and depressed mood. Moderate SM use (a stable trend in the time spent on SM during adolescence and into early adulthood that did not interfere with functioning) was associated with better emotional self-regulation ( Coyne, Padilla-Walker, Holmgren, & Stockdale, 2018 ) and healthier development, especially when used to acquire information ( Romer et al., 2013 ). Finally, Rodriguez Puentes and Parra (2014) found a positive association between SM and externalizing behaviours, but no significant association between SM use and depression.

Additionally, age moderated the effects of frequency of use on depression. For example, in one study, older adolescents with higher SM use had higher ‘offline’ social competence, while younger adolescents with higher SM use had more internalizing problems and diminished academics and activities ( Tsitsika, Janikian, et al., 2014 ).

Problematic SM use

Seven studies explored problematic use or engagement with SM or the internet in an addictive manner (a dysfunctional pattern of behaviour similar to that of impulse control disorders, which causes distress and/or functional impairment) ( Critselis et al., 2014 ).

An addiction-like pattern of internet use (including SM use) was associated with emotional maladjustment ( Critselis et al., 2014 ), internalizing and externalizing symptoms ( Tsitsika, Tzavela, et al., 2014 ), and depressive mood ( Van Rooij, Ferguson, Van de Mheen, & Schoenmakers, 2017 ). Further, depressive mood predicted problematic internet use (both SM and gaming, independently) ( Kırcaburun et al., 2018 ; Van Rooij et al., 2017 ).

Bányai et al. (2017) assessed the prevalence of problematic internet use conducting a latent profile analysis to describe classes of users and found that the class described as ‘at risk’ for problematic internet and SM use tended to be female, use the internet for longer periods, and have lower self-esteem and more depressive symptoms. Yet, while Banjanin, Banjanin, Dimitrijevic, and Pantic (2015) found a positive correlation between internet addiction and depression in high school students (particularly for females), no such correlation was found with engagement with SM (measured by number of pictures posted).

Several studies examined mediators of the association of problematic SM use and depression. Wang et al. (2018) found that rumination mediated the relationship between SM addiction and adolescent depression, with a stronger effect among adolescents with low self-esteem. Additionally, insomnia partially mediated the association between SM addiction and depressive symptoms ( Li et al., 2017 ). Woods and Scott (2016) found that nighttime-specific SM use (in addition to overall use and emotional investment in SM) was associated with poorer sleep quality, anxiety and depressive symptoms. Finally, problematic SM use mediated the association between depressive symptoms and cyberbullying perpetration ( Kırcaburun et al., 2018 ).

Quality of SNS use

In addition to the frequency of adolescents’ engagement with SM, another focus of research has been the ways in which adolescents engage with SM. Of the studies selected, four primarily examined engagement styles with SM and two specifically examined social comparisons with other users.

Characteristics of SM use

The ways in which adolescents use SM may also have an effect on depression. One study ( Frison & Eggermont, 2016 ) characterized SM use as public (e.g. updating one’s status on a profile) vs private (e.g. messaging), and active (e.g. interacting with others on SM) vs passive (e.g. browsing on SM) and found that public Facebook use was associated with adolescent depressed mood. Among girls, passive use of Facebook yielded negative outcomes such as depressed mood, while active use yielded positive outcomes such as perceived social support ( Frison & Eggermont, 2016 ). A longitudinal study of Flemish adolescents by the same group ( Frison & Eggermont, 2017 ) found passive SM use at baseline to predict depressive symptoms 7 months later, while depressive symptoms predicted active use of SM. Interestingly, there was no association between depressive symptoms and Facebook use (frequency of use, network size, self-presentation, and peer interaction) in a study conducted among healthy adolescents ( Morin-Major et al., 2016 ).

Romer et al. (2013) found that the types of internet activities utilized (e.g. SNS, blogs, etc.) were associated with the frequency of self-reported depression-like symptoms. Additionally, using the internet for information searching was associated with higher grades, more frequent participation in clubs, and lower reports of depressive symptoms, while using the internet more than 4 h per day to communicate or play games was associated with greater depression-like symptoms, suggesting that Internet use for acquiring information is associated with healthy development.

A qualitative study further explored positive and negative aspects of SM use among adolescents diagnosed with clinical depression ( Radovic, Gmelin, Stein, & Miller, 2017 ). Participants described positive SM use as including searching for positive content (e.g. entertainment, humour, content creation) or social connection, while they described negative SM use as sharing risky behaviours, cyberbullying, or making self-denigrating comparisons with others. Furthermore, this study found that adolescents’ use of SM shifted from negative to positive during the course of treatment.

Social comparisons

Two studies examined social comparisons made through SM and the association with depression. Nesi and Prinstein (2015) found that technology-based social comparison and feedback-seeking were associated with depressive symptoms, even when controlling for the effects of overall frequency of technology use, offline excessive reassurance-seeking, and prior depressive symptoms. This association was strongest among females and adolescents low in popularity (as measured by peer report). Niu et al. (2018) found that negative social comparisons mediated the association between Qzone use (a Chinese SM site) and depression, and that the association between Qzone use and negative social comparisons was stronger among individuals with low self-esteem. However, there was no direct effect of Qzone use on depression. An additional study that primarily focussed on studying frequency of use ( Marengo et al., 2018 ) found that increased use of highly visual SM (e.g. Instagram) predicted internalizing symptoms and body image concerns in a student sample. Moreover, in this study, the effect of highly visual SM on internalizing symptoms was mediated by body image concerns.

Social aspects of SM use

Several studies looked at the social aspects of engagement with SM, either by evaluating the effects of cybervictimization ( n = 4) on depression, parental involvement both through monitoring of SM use or direct engagement with the adolescent ( n = 3), and aspects of social support received by the adolescent within and outside of SNS ( n = 2).

Cyberbullying/cybervictimization

Four studies examined cyberbullying via SM and depressive symptoms. Duarte, Pittman, Thorsen, Cunningham, and Ranney (2018) found that symptoms of depression, post-traumatic stress disorder, and suicidal ideation were more prevalent among participants who reported any past-year cyberbullying (either victimization or perpetration). After adjusting for a range of demographic factors, only lesbian, gay, and bisexual status correlated with cyberbullying involvement or adverse mental health outcomes. Another study found that cyberbullying victimization fully mediated the association between SM use and psychological distress and suicide attempts ( Sampasa-Kanyinga & Hamilton, 2015 ). Furthermore, a 12-month longitudinal study found that cybervictimization predicted later depressive symptoms ( Cole et al., 2016 ). Depressive symptoms have also been shown to be a risk factor (rather than an outcome) for cybervictimization on Facebook ( Frison, Subrahmanyam, & Eggermont, 2016 ), showing evidence of the bi-directionality of this association.

Social support

While many studies examined potential negative effects of SM use, some studies examined the positive effects of SM use on youth outcomes, including social support. Frison and Eggermont (2015) found that adolescents seeking social support through Facebook had improved depressive symptoms if support was received, but worsened symptoms if support was not received. This pattern was not found in non-virtual social support contexts, suggesting differences in online and traditional social support contexts. A later study that primarily focussed on the characteristics of SM use ( Frison & Eggermont, 2016 ) found that perception of online support was particularly protective against depressive symptoms in girls with ‘active’ Facebook use (e.g. those who update their status or instant message on Facebook). Finally, Frison et al. (2016) showed that support from friends can be a protective factor of Facebook victimization.

Parental involvement/parental monitoring

Studies examining parent and family role in adolescent SM use and its outcomes were heterogeneous. One study ( Coyne, Padilla-Walker, Day, Harper, & Stockdale, 2014 ) explored adolescent use of SM with parents and found lower internalizing behaviours in participants who used SNS with their parents (mediated by feelings of parent/child connection). Another study ( Fardouly, Magson, Johnco, Oar, & Rapee, 2018 ) examined parent control over preadolescents’ time spent on SM and found no association between parental control and preadolescent depressive symptoms.

Family relationships offline were also associated with adolescent outcomes. Isarabhakdi and Pewnil (2016) examined adolescents’ engagement with offline relationships and found improved mental health outcomes with higher involvement in family activities and with peers, while internet use did not significantly improve mental well-being. This finding suggests that in-person support systems were more effective for the promotion of mental well-being. Interestingly, in Szwedo, Mikami, and Allen (2011) , negative interactions with mothers during early adolescence were associated with youth preferring online versus face-to-face communication, experiencing more negative interactions on webpages, and forming close friendships with someone they met online 7 years later. An additional study that primarily focussed on suicide contagion ( Tseng & Yang, 2015 ) found that family support was protective for both males and females, while friend support was protective only for females. However, ‘significant other’ support was a risk factor for suicidal plans among females.

Disclosure of mental health symptoms on SM

A few of the studies selected focussed on studying the disclosure of depressive symptoms on SM and explored the potential of disclosure of symptoms of distress on SM to predict depression and suicide, in addition to the phenomenon of suicide contagion.

Online disclosure and prediction of mental health symptoms

Although content analysis is a method theorized to have potential to predict and prevent non-suicidal and suicidal self-injurious behaviours, the data are mixed. Ophir, Asterhan, and Schwarz (2019) examined the predictive validity of explicit references to personal distress in adolescents’ Facebook postings, comparing these postings with external, self-report measures of psychological distress (e.g. depression) and found that most depressed adolescents did not publish explicit references to depression. Additionally, adolescents published less verbal content than adult users of SNS. Conversely, Akkın Gürbüz et al. (2017) found that while disclosures of depressed mood were frequent among both depressed and non-depressed adolescents, those who were depressed shared more negative feelings, anhedonia, and suicidal thoughts on SM than those who were not depressed.

Suicide contagion effect

One longitudinal study examined suicide contagion effects ( Dunlop, More, & Romer, 2011 ) finding that even though traditional SNS (e.g. Facebook or MySpace) were a significant source of exposure to suicide stories, this exposure was not associated with increases in suicidal ideation one year later. On the other hand, exposure to online discussion forums (including self-help forums) did predict increases in suicidal ideation over time. Notably, this study found that in a quarter of the sample, the exposure to suicide stories took place through SM. Another study ( Tseng & Yang, 2015 ) found that higher importance attributed to web communication (e.g. chatting or making friends online) was associated with increased risk of self-injurious thoughts and behaviours in boys.

The recent rise in the prevalence of depression and suicide among adolescents has coincided with an increase in screen-related activities, including SM use ( Twenge et al., 2018 ), sparking an interest in investigating the effects of SM use on adolescent mental health. This interest has given rise to a broad scope of research, ranging from observational to experimental and qualitative studies through interviews or analysis of SM content, and systematic studies. This scoping review aimed to understand the breadth of research in the area of depression and SM (with a focus on SNS) and to identify the existing research gaps.

We identified four main themes of research, including (1) the quantity of SM use; (2) the quality of SM use; (3) social aspects associated with SM use; and (4) SM as a tool for disclosure of mental health symptoms and potential for prediction and prevention of depression and suicide outcomes.

Most research on SM and depressive symptoms has focussed on the effects of frequency of SM use and problematic SM use. The majority of articles included in this review demonstrated a positive and bi-directional association between frequency of SM use and depression and in some instances even suicidality. Yet some questions remain to be determined, including to what degree adolescents’ personal vulnerabilities and characteristics of SM use moderate the association between SM use and depression or suicidality, and whether other environmental factors, such as family support and/or monitoring, or cultural differences influence this association. Although moderate SM use may be associated with better self-regulation, it is unclear if this is due to moderate users being better at self-regulation.

Findings from the studies examining problematic SM use were consistent with prior studies linking problematic internet use with a variety of psychosocial outcomes including depressive symptoms ( Reid Chassiakos et al., 2016 ). Though limited in number, studies reviewed here suggested that problematic or addictive SM use may be more common in females ( Banyai et al., 2017 ; Kırcaburun et al., 2018 ) and in those starting use at a younger age ( Tsitsika, Janikian, et al., 2014 ). These findings suggest a possible role of screening for addictive SM use, with a particular focus on risk stratification for younger and female adolescents.

With respect to the effects of patterns and types of SM use, studies reviewed here suggest possible differential effects between passive and active, and private versus public SM use. This suggests that screening only for time spent on SM may be insufficient. Moreover, though there are types of SM use that have adverse mental health effects for adolescents (e.g. addictive patterns, nighttime use), other types of SM use, such as for information searching or receiving social support, may have a positive effect ( Coyne et al., 2018 ; Frison & Eggermont, 2016 ; Romer et al., 2013 ). Furthermore, over time, depressed adolescents can successfully shift their use of SM from negative (e.g. cyberbullying) to positive (e.g. searching for humour), possibly through increasing awareness of the effect of SM use on their mood ( Radovic et al., 2017 ). Given the ubiquity of SM use, these results suggest that interventions targeting changes in adolescents’ use of SM may be fruitful in improving their mental health.

Consistent with prior research ( Feinstein et al., 2013 ), studies examining social comparisons found significant associations between social comparisons made via SM and depression. The tendency of individuals to share more positive depictions of themselves on SM ( Subrahmanyam & Greenfield, 2008 ), and the increased opportunities for comparisons ( Steers, Wickham, & Acitelli, 2014 ) may suggest a confluence of risks for depression and an important avenue for interventions. Moreover, the studies reviewed and previous findings ( Buunk & Gibbons, 2007 ) suggest that individuals with low self-esteem may be at higher risk for the negative effects of social comparisons on mental health.

As previously shown ( Cénat et al., 2014 ), most studies found cyberbullying (either perpetration or victimization) was either associated with mental health problems ( Cole et al., 2016 ; Duarte et al., 2018 ) or moderated the relationship between SM use and depression and suicidality ( Sampasa-Kanyinga & Hamilton, 2015 ). Additionally, cyberbullying may be a distinctive form of victimization that requires further investigation in order to understand its impact on adolescent mental health ( Dempsey, Sulkowski, Nichols, & Storch, 2009 ).

Studies examining social support highlight the association of both depressed mood and low in-person social support with social networking and online support-seeking ( Frison & Eggermont, 2015 ). Moreover, while social support online can be beneficial ( Frison & Eggermont, 2015 ), excessive reliance on online communication and support may be problematic ( Twenge et al., 2018 ). Of note, parental involvement both positively and negatively affected SM use and adolescent outcomes. These mixed findings suggest a need to include parental relationships in research (both via online and ‘offline’ communication), to better understand their role in adolescents’ SM use and depression.

Surprisingly, depressed adolescents were not more likely to publish explicit references to depression on SM platforms than their healthy peers ( Ophir et al., 2019 ) which suggests that screening for depression via SM may not be useful when used alone. However, some depressed adolescents posted more negative feelings, anhedonia and suicidal ideation ( Akkın Gürbüz et al., 2017 ), suggesting that SM may be used as a supplemental tool to track the course of depressive mood over time and start discussions about mental health.

Suicide contagion effect is a relatively understudied area, despite concerns raised that increased exposure to SM may amplify this effect ( Bell, 2014 ). Given that adolescents are particularly vulnerable to the group contagion effect of suicide ( Stack, 2003 ) and the potential for increased exposure to suicide stories online ( Dunlop et al., 2011 ), interventions to limit this exposure could decrease suicide contagion.

The studies reviewed identified several potential moderators of the association between SM use and adolescent depression, including age and gender. The differential effects of SM use on mental health depending on the age of the adolescent ( Tsitsika, Tzavela, et al., 2014 ) are not surprising given the developmental differences in social and mood regulation skills between younger and older adolescents. Likewise, potential mediators of the effects of SM on mental health such as social comparisons ( Niu et al., 2018 ), body image concerns ( Marengo et al., 2018 ), perceived support online ( Frison & Eggermont, 2015 ), and parent–child relationship ( Coyne et al., 2014 ) may also be important targets for future interventions.

The studies reviewed present several limitations. Most studies were cross-sectional and could not elucidate the directionality of the association between SM use and depression. Most of the studies included self-report rather than clinician-administered measures of depression, and retrospective reports, asking participants to report on past activities. Newer methods that measure actual (and not just reported) use (e.g. news feed activity, number of likes and comments) and more frequent and timely reports of SM use (e.g. diaries) could more accurately explain these associations. Another limitation is that many of the studies recruited participants in schools, limiting the generalizability to clinical samples. It is possible that those students not in school were spending more time on SM and/or experiencing more depressive symptoms. Most studies included general assessments of SM without specifying whether the use was limited to SNS or other forms of SM or internet use. While we tried to narrow our search to studies that explicitly included questions on SNS use, many also asked about other types of SM use. Separating the different types of SM use may be difficult when asking for adolescents’ self-reports, but more immediate measures of mood symptoms and SNS use could be more specific and informative. Finally, while some studies included contextual factors such as the educational and family environments, other contextual factors such as ethnicity and cultural context are areas of potential for investigation.

Conclusions

In summary, extensive research on the quantity and quality of SM use has shown an association between SM use and depression in adolescents. Given that most studies are cross-sectional, longitudinal research would help assess the direction of this association. At the same time, some aspects of SM use may have a beneficial effect on adolescent well-being, such as the ability to have diversity of friendships and easily accessed supports. Furthermore, the use of SM content to detect symptoms has potential in depression and suicide prevention. Finally, moderators of the association between SM and adolescent depression and suicidality (e.g. gender, age, parental involvement) are areas to explore that would allow more targeted interventions. Since SM will remain an important facet of adolescents’ lives, a better understanding of the mechanisms of its relationship with depression could be beneficial to increase exposure to mental health interventions and promote well-being.

Acknowledgements

The authors acknowledge the help of Jaime Blanck, MLIS, MPA for her help with the search and retrieval of full-text articles.

Disclosure statement

Dr. Vidal is supported by the Stravos Niarchos Foundation. Ms. Lhaksampa and Dr. Miller are supported by the Once Upon a Time Foundation. Drs. Miller and Dr. Platt are supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Platt is supported by the NIMH 1K23MH118431 and the Robert Wood Johnson Foundation.

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Loyola University > Center for Digital Ethics & Policy > Research & Initiatives > Essays > Archive > 2018 > The Role of Social Media in Adolescent/Teen Depression and Anxiety

The role of social media in adolescent/teen depression and anxiety, april 3, 2018.

The adolescent and teen years have always been a challenging time. Peer pressure, insecurity and hormones are just some of the issues facing those in these age groups. But does social media exacerbate these problems?

For example, researchers from the Alberta Teachers’ Association, the University of Alberta, Boston Children’s Hospital and Harvard Medical School released a  study  that found significant changes in students at every grade level as a result of digital technology. In the past three to five years, 90 percent of teachers at the University of Alberta saw increases in emotional challenges, 85 percent saw social challenges and 77 percent observed cognitive challenges. Also, 56 percent of teachers report an increase in the number of kids sharing stories about online harassment and/or cyberbullying. There are increases in other areas as well. The majority of teachers say there has been an increase in students diagnosed with the following conditions: anxiety disorders (85 percent), ADD and ADHD (75 percent), and such mood disorders as depression (73 percent).

Also, a recent  study  by researchers at the Royal Society for Public Health and Young Health Movement found that 91 percent of those between the ages of 16 and 24 said Instagram was the worst social media platform as it relates to mental health. Instagram was most likely to cause negative effects such as poor body image, fear of missing out and sleep deprivation. Snapchat came in second place, followed by Facebook, Twitter and YouTube. The researchers theorize that Instagram and Snapchat are image-focused platforms and users compare themselves to others.

A  review  of 36 social media studies, published in JAMA Pediatrics, found that 23 percent of kids are victims of cyberbullying. The review also found that cyberbullying results in low self-esteem, depression, self-harm and behavioral problems — in both the victims and the bullies. In addition, cyberbullying was more likely to produce suicidal thoughts than traditional bullying.

Another  study , conducted by researchers at Glasgow University found that kids (some of whom were pre-teens) were on social media until the wee morning hours, and some were on more than one device (for example, a phone and a tablet) so they could simultaneously view multiple sites. These individuals reported lower sleep quality rates in addition to higher levels of depression and anxiety.

In a  survey  by the National Campaign to Support Teen and Unplanned Pregnancy, almost 20 percent of teens admitted to participating in "sexting" or sending nude photos.

The pressure these adolescents and teens feel can be intensified by the time they get to college. Stanford University coined the phrase “ Duck syndrome ” to describe the erroneous attitude of incoming freshmen that they’re struggling while everyone else is gliding along smoothly — but in reality, the gliders are also “paddling furiously under the water just to keep up.” Adolescents and teens become accustomed to creating the impression that everything is perfect to match the equally perfect posts of their friends. But it becomes too difficult to maintain this façade, resulting in  suicide  among college students who appear to be well-adjusted, but are actually experiencing mental and emotional problems.

Another  report , published in the American Journal of Preventive Medicine, reveals that among young adults between the ages of 19 and 32, those with high social media usage (those logging on for more than 2 hours a day and checking their accounts 58 times a week) were more likely to deal with feelings of isolation than those with low social media use (they logged on for 30 minutes and checked their accounts 9 times a week). 

In light of these studies, who is responsible for the role of social media in adolescent/teen depression and anxiety?

Many tech leaders seem to understand the unhealthy, addictive nature of technology in general and social media in particular. As far back as 2010, New York Times reporter Nick Bilton  interviewed  the late Steve Jobs of Apple. Jobs told Bilton that he limited the amount of technology that his kids use. Bill Gates  shared  that he didn’t let his kids have mobile devices until they were 14 years old, and he sets a time for them to turn off the devices at night.  

Evan Williams, one of the founders of Twitter, Medium and Blogger, told Bilton that his kids read physical books instead of using iPads. Dick Costolo, former CEO of Twitter, told Bilton that his teenagers had to be in the living room when they used their tech devices.

But, perhaps the most shocking revelation came from Sean Parker, former president of Facebook, in an  interview  with Axios. Referring to Facebook, Parker said, “God only knows what it’s doing to our children’s brains.”

But there’s more. Parker also said, “ . . . How do we consume as much of your time and conscious attention as possible? . . . And that means that we need to sort of give you a little dopamine hit every once in a while, because someone liked or commented on a photo or a post or whatever . . . And that's going to get you to contribute more content, and that's going to get you ... more likes and comments . . . It's a social-validation feedback loop ... exactly the kind of thing that a hacker like myself would come up with, because you're exploiting a vulnerability in human psychology . . . The inventors, creators — it's me, it's Mark [Zuckerberg], it's Kevin Systrom on Instagram, it's all of these people — understood this consciously . . . And we did it anyway.”

So, if Parker confessed that social media was designed to be addictive, should social media companies be responsible for depression, anxiety, bullying and other issues among adolescents and teens?

Donna Shea, director of  The Peter Pan Center  for Social and Emotional Growth, and Nadine Briggs, director of  Simply Social Kids , are passionate about helping kids make and keep friends, and together have formed How to Make and Keep Friends, LLC. Shea and Briggs both lead community-based social groups at their centers in Massachusetts and have also formed the Social Success in School initiative. The two have also written several books for kids and teens, including, “Tips for Teens on Life and Social Success” .

Both Shea and Briggs believe that it is the job of parents to monitor their kid’s social media activity. “You wouldn’t allow your teen to put a lock on their bedroom door, but your teen is not only now interacting with peers at school or in your neighborhood, they are interacting with the entire world,” Shea said. “It is a parent’s job to be as involved in their teen’s online life as they are in their offline life.”

In fact, she is not in favor of giving adolescents and teens a phone as a gift. “Mobile devices belong to the parent and the teen is being  allowed  to use it,” Shea said. “A contract can be a useful tool before putting a device in the hands of your teen which would allow parents to have access to the phone.”

She believes that parents should monitor their adolescent/teen’s activity — and teens should know this is being done. “Parents do not need to be sneaky about that — tell your child to hand over the phone,” she said. Shea also recommends that parents use subscription services to view all of their teens’ activities. “Teens should be prepared to be monitored until they are of legal adult age,” she said.

However, Briggs admits that apps change so quickly that it’s almost impossible to keep up with them. “Other than doing your best to monitor your teen’s activity —  and it won’t be 100% effective - it’s important from the very beginning that you teach your child and teen to be good consumers of what is available to them,” Briggs said. “This is the new norm, and we think it’s the parent’s responsibility to be involved in their teen’s online life.”

She compares giving kids a phone or device to putting them behind the wheel of a car. “Both can be dangerous in their own way, but teens can learn the responsibilities that go along with these more adult activities.”

But, do parents bear sole responsibility? For example, everyone knows that tobacco is bad for your health, and people consume it willingly; however, they continue to sue and win lawsuits against tobacco companies. In 2014, one plaintiff was  awarded $23.6 billion  when her husband died of lung cancer as a result of smoking up to three packs of cigarettes a day. He started smoking at the age of 13 and died at the age of 36. The plaintiff (his widow) argued that the tobacco company willfully deceived consumers with addictive products.

How is this scenario different from what social media companies are doing? And speaking of willful deception, what about companies that make  secretive apps  that allow teens to hide their sexting?

If someone trips and falls on your property, you could be sued. If someone gets harmed at your nightclub, you could be held liable for not having “adequate security.” If one of your employees sexually harasses a colleague, you would be held responsible — even if you didn’t know about it. If you sell alcohol, you’re responsible for making sure it doesn’t get into the hands of a minor. In fact, according to the Dram Shop Law, if you let an adult have too many drinks and this individual is involved in an accident, you could be responsible.

However, if kids become addicted to a communication platform that was designed to be addictive, if they’re bullied online, if there are no safeguards to stop them from utilizing the types of secretive apps that encourage risky behavior, shouldn’t these companies be held responsible?

I think they should be, but this is not likely to happen until society holds them responsible. Since most adults are also addicted to social media — and some of them are internet bullies and engage in sexting, it seems unlikely that they would advocate for changes.

In the aforementioned study by the Royal Society for Public Health and Young Health Movement, researchers offered several ways to reduce some of the problems adolescents and teens face online. For example, one of the reasons kids feel so much pressure to look perfect is because of the doctored photos they see. The researchers recommend that social media companies include some sort of notification, such as a watermark, when photos have been digitally manipulated (68 percent of surveyed students support this action).

Another suggestion is to create a social media cap. Users would be logged out if they went over a pre-determined usage level (30 percent of surveyed students agree with this suggestion).

The majority of surveyed students (84 percent) approve of schools having classes on safe social media. 

Another suggestion by the researchers (which did not include student responses) was to use social media posts to identify kids and teens who might be at risk for mental health problems. However, problems have already been identified with  using Facebook to identity potential problem drinkers .

In addition, it was suggested that youth workers be trained in digital media. 

These are nice Band-Aid solutions. But they don’t address the addictive nature of social media and the incredible amount of peer pressure that it involves. Parents can provide guidance, but history has shown that their values rarely outweigh the pressure of peers.

Albert Einstein once said, “We can’t solve our problems with the same thinking we used to create them.” But in this situation, the social media giants can solve these problems with the exact same thinking they used to create them. Just as they figured out what it would take to make these platforms addictive, they can figure out what it would take to make the platforms less addictive. But don’t hold your breath because the person who creates the problem and profits from the problem has no incentive to solve the problem.

Terri Williams  writes for a variety of clients including USA Today , Yahoo , U.S. News & World Report , The Houston Chronicle , Investopedia , and Robert Half . She has a Bachelor of Arts in English from the University of Alabama at Birmingham. Follow her on Twitter @Territoryone .

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Mental health of adolescents

• Globally, one in seven 10-19-year-olds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group.
• Depression, anxiety and behavioural disorders are among the leading causes of illness and disability among adolescents.
• Suicide is the fourth leading cause of death among 15-29 year-olds.
• The consequences of failing to address adolescent mental health conditions extend to adulthood, impairing both physical and mental health and limiting opportunities to lead fulfilling lives as adults.

Introduction

One in six people are aged 10–19 years. Adolescence is a unique and formative time. Physical, emotional and social changes, including exposure to poverty, abuse, or violence, can make adolescents vulnerable to mental health problems. Protecting adolescents from adversity, promoting socio-emotional learning and psychological well-being, and ensuring access to mental health care are critical for their health and well-being during adolescence and adulthood.

Globally, it is estimated that 1 in 7 (14%) 10–19 year-olds experience mental health conditions (1) , yet these remain largely unrecognized and untreated.

Adolescents with mental health conditions are particularly vulnerable to social exclusion, discrimination, stigma (affecting readiness to seek help), educational difficulties, risk-taking behaviours, physical ill-health and human rights violations.

Mental health determinants

Adolescence is a crucial period for developing social and emotional habits important for mental well-being. These include adopting healthy sleep patterns; exercising regularly; developing coping, problem-solving, and interpersonal skills; and learning to manage emotions. Protective and supportive environments in the family, at school and in the wider community are important.

Multiple factors affect mental health. The more risk factors adolescents are exposed to, the greater the potential impact on their mental health. Factors that can contribute to stress during adolescence include exposure to adversity, pressure to conform with peers and exploration of identity. Media influence and gender norms can exacerbate the disparity between an adolescent’s lived reality and their perceptions or aspirations for the future. Other important determinants include the quality of their home life and relationships with peers. Violence (especially sexual violence and bullying), harsh parenting and severe and socioeconomic problems are recognized risks to mental health.

Some adolescents are at greater risk of mental health conditions due to their living conditions, stigma, discrimination or exclusion, or lack of access to quality support and services. These include adolescents living in humanitarian and fragile settings; adolescents with chronic illness, autism spectrum disorder, an intellectual disability or other neurological condition; pregnant adolescents, adolescent parents, or those in early or forced marriages; orphans; and adolescents from minority ethnic or sexual backgrounds or other discriminated groups.

Emotional disorders

Emotional disorders are common among adolescents. Anxiety disorders (which may involve panic or excessive worry) are the most prevalent in this age group and are more common among older than among younger adolescents. It is estimated that 3.6% of 10–14-year-olds and 4.6% of 15–19-year-olds experience an anxiety disorder. Depression is estimated to occur among 1.1% of adolescents aged 10–14 years, and 2.8% of 15–19-year-olds. Depression and anxiety share some of the same symptoms, including rapid and unexpected changes in mood.

Anxiety and depressive disorders can profoundly affect school attendance and schoolwork. Social withdrawal can exacerbate isolation and loneliness. Depression can lead to suicide.

Behavioural disorders

Behavioural disorders are more common among younger adolescents than older adolescents. Attention deficit hyperactivity disorder (ADHD), characterized by difficulty paying attention, excessive activity and acting without regard to consequences, occurs among 3.1% of 10–14-year-olds and 2.4% of 15–19-year-olds (1) . Conduct disorder (involving symptoms of destructive or challenging behaviour) occurs among 3.6% of 10–14-year-olds and 2.4% of 15–19-year-olds (1) . Behavioural disorders can affect adolescents’ education and conduct disorder may result in criminal behaviour.

Eating disorders

Eating disorders, such as anorexia nervosa and bulimia nervosa, commonly emerge during adolescence and young adulthood. Eating disorders involve abnormal eating behaviour and preoccupation with food, accompanied in most instances by concerns about body weight and shape. Anorexia nervosa can lead to premature death, often due to medical complications or suicide, and has higher mortality than any other mental disorder.

Conditions that include symptoms of psychosis most commonly emerge in late adolescence or early adulthood. Symptoms can include hallucinations or delusions. These experiences can impair an adolescent’s ability to participate in daily life and education and often lead to stigma or human rights violations.

Suicide and self-harm

Suicide is the fourth leading cause of death in older adolescents (15–19 years) (2) . Risk factors for suicide are multifaceted, and include harmful use of alcohol, abuse in childhood, stigma against help-seeking, barriers to accessing care and access to means of suicide. Digital media, like any other media, can play a significant role in either enhancing or weakening suicide prevention efforts.

Risk-taking behaviours

Many risk-taking behaviours for health, such as substance use or sexual risk-taking, start during adolescence. Risk-taking behaviours can be an unhelpful strategy to cope with emotional difficulties and can severely impact an adolescent’s mental and physical well-being.

Worldwide, the prevalence of heavy episodic drinking among adolescents aged 15­–19 years was 13.6% in 2016, with males most at risk (3) .

The use of tobacco and cannabis are additional concerns. Many adult smokers had their first cigarette prior to the age of 18 years. Cannabis is the most widely used drug among young people with about 4.7% of 15–16-years-olds using it at least once in 2018 (4) .

Perpetration of violence is a risk-taking behaviour that can increase the likelihood of low educational attainment, injury, involvement with crime or death. Interpersonal violence was ranked among the leading causes of death of older adolescent boys in 2019 (5) .

Promotion and prevention

Mental health promotion and prevention interventions aim to   strengthen an individual's capacity to regulate emotions, enhance alternatives to risk-taking behaviours, build resilience for managing difficult situations and adversity, and promote supportive social environments and social networks.

These programmes require a multi-level approach with varied delivery platforms –   for example, digital media, health or social care settings, schools or the community – and varied strategies to reach adolescents, particularly the most vulnerable.

Early detection and treatment

It is crucial to address the needs of adolescents with mental health conditions. Avoiding institutionalization and over-medicalization, prioritizing non-pharmacological approaches, and respecting the rights of children in line with the United Nations Convention on the Rights of the Child and other human rights instruments are key for adolescents’ mental health.

WHO response

WHO works on strategies, programmes and tools to assist governments in responding to the health needs of adolescents.

For example, the Helping Adolescents Thrive (HAT) Initiative is a joint WHO-UNICEF effort to strengthen policies and programmes for the mental health of adolescents. More specifically, the efforts made through the Initiative are to promote mental health and prevent mental health conditions. They are also intended to help prevent self-harm and other risk behaviours, such as harmful use of alcohol and drugs, that have a negative impact on the mental  ̶  and physical  ̶  health of young people.

WHO has also developed a module on Child and Adolescent Mental and Behavioural Disorders as part of the mhGAP Intervention Guide 2.0. This Guide  provides evidence-based clinical protocols for the assessment and management of a range of mental health conditions in non-specialized care settings.

Furthermore, WHO is developing and testing scalable psychological interventions to address emotional disorders of adolescents, and guidance on mental health services for adolescents.

WHO’s Regional Office for the Eastern Mediterranean has developed a mental health training package for educators for improved understanding of the importance of mental health in the school setting and to guide the implementation of strategies to promote, protect and restore mental health among their students. It includes training manuals and materials to help scale up the number of schools promoting mental health.

(1)  Institute of health Metrics and Evaluation. Global Health Data Exchange (GHDx)

(2) WHO Global Health Estimates 2000-2019

(3) Global status report on alcohol and health 2018

(4) World Drug Report 2020  

(5) 2019 Global Health Estimates (GHE), WHO, 2020

Comprehensive Mental Health Action Plan 2013-2030 

Guidelines on promotive and preventative mental health interventions for adolescents

Mental Health Gap Action Programme (mhGAP) Intervention Guide 2.0

LIVE LIFE: an implementation guide for suicide prevention in countries

Mental health in schools: a manual 

Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030

Improving the mental and brain health of children and adolescents

• Open access
• Published: 17 September 2024

Adolescent anxiety and depression: perspectives of network analysis and longitudinal network analysis

• Dongyu Liu 1 ,
• Meishuo Yu 2 ,
• Xinyu Zhang 1 ,
• Jingjing Cui 1 &
• Haibo Yang 1  

BMC Psychiatry volume  24 , Article number:  619 ( 2024 ) Cite this article

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Anxiety and depression often co-occur, exhibiting high comorbidity, with their trends evolving over time. However, the specific pathways through which comorbid symptoms of anxiety and depression evolve and interact remain unclear. To investigate these questions, this study employed Network Analysis (NA) and Longitudinal Network Analysis (LNA) to explore the central symptoms of anxiety and depression, as well as the temporal evolution of these central symptoms.

The study focused on 606 high school students who were not in their final year in Shandong of China, with assessments conducted from March to September 2022. The bootnet package in R was used for establishing NA and LNA models, as well as for conducting accuracy analysis and node stability analysis.

The results of the NA indicated that adolescent highly susceptible to anxiety and depression. And uncontrollable worry was a common central symptom, while irritability emerged as a central bridging symptom across all three NAs. The LNA results revealed that suicidal ideation and worthlessness were key central symptoms in the LNA. Furthermore, worthlessness played a pivotal role in the developmental pathway of “suicidal ideation → worthlessness → anxiety and uncontrollable worry.” A reduction in suicidal ideation was associated with decreased severity in other symptoms.

Conclusions

The findings suggest that adolescent anxiety and depression are in a state of vulnerability, and that irritability, worthlessness, and suicidal ideation are potential targets for interventions to address adolescent anxiety and depression.

Peer Review reports

Anxiety and depression are among the most common psychological disorders. According to the World Mental Health Report published by the World Health Organization, the global incidence of anxiety and depression increased by 25% following the COVID-19 pandemic [ 1 ]. Of particular concern is the worsening of anxiety and depression among adolescents, which has shown a significant increase [ 2 ], attracting considerable attention from researchers.

Numerous studies have demonstrated a high level of comorbidity between anxiety and depression [ 3 , 4 , 5 ], with a specific interconnection [ 6 ]. This comorbidity frequently manifests during adolescence [ 7 ]. Given the severity of anxiety and depression and their substantial impact on disability-adjusted life years among adolescents [ 8 ], it is imperative to further explore the relationship between symptoms of anxiety and depression and to identify these symptoms effectively in adolescents. Addressing the potential risks associated with comorbid anxiety and depression is of paramount importance.

The network approach to psychological constructs is based on network theory, which suggests that higher-level attributes such as disorders, traits, and abilities can emerge from lower-level processes where individual symptoms, attitudes, behaviors, beliefs, and skills interact with each other, forming dynamic systems that culminate in specific outcomes [ 9 , 10 , 11 , 12 ]. From this theoretical perspective, patterns of symptom-symptom interaction can be represented within a network structure, with symptoms depicted as nodes. Network analysis (NA) is a valuable tool for analyzing and visualizing the interconnected relationships among symptoms in psychological disorders by quantifying the relationships between nodes. This approach provides unique insights into the genesis, perpetuation, and progression of psychological conditions.

In studies involving the NA of anxiety and depression, the PHQ-9 and GAD-7 scales are widely used. Table  1 described the findings from related literature. Most studies used the PHQ-9 and GAD-7. Variations in results were noted due to differences in research subjects, focus of inquiry, and research backgrounds. However, the importance of symptoms such as uncontrollable worry, excessive worry, and motor function, as well as the high stability of the anxiety and depressive symptom network, has been widely validated. Additionally, studies conducted during the COVID-19 pandemic revealed unique characteristics, such as the increased significance of motor function symptoms due to the social context. Specific details are presented in Table  1 .

Previous studies (as shown in Table  1 ) primarily used traditional NA methods to establish anxiety-depression networks. However, an NA model typically assumes that symptoms operate on the same time scale and that interactions between symptoms are pairwise and symmetrical. This approach does not allow for the inference of predictive relationships between central symptoms and other symptoms over time within a single network. Furthermore, in clinical practice, many symptoms exhibit multidimensionality and asymmetry, with interactions among symptoms unfolding over weeks or even months [ 12 , 13 ]. Consequently, Borsboom and Cramer advocated for collecting longitudinal data to further elucidate the causal relationships between symptoms [ 14 ]. In the study of anxiety and depression, although some research has collected longitudinal data [ 15 , 16 ], these studies only established multiple NAs, which might make it difficult to intuitively observe the changing relationships between symptoms.

To further elucidate the causal relationships between symptoms and explore temporal trends in networks and the mutual predictive relationships between symptoms, Longitudinal Network Analysis (LNA) was developed. LNA is particularly useful for understanding mental health problems from a temporal perspective, providing insights with clinical relevance [ 24 , 25 , 26 ]. The key characteristic of LNA is that the relationships among individual items are modeled over time as directed regression coefficients, reflecting the shared variance between a predictor variable at time T and an outcome variable at time T + 1, controlling for all other predictors at time T [ 25 ]. This approach allows LNA to identify the behaviors, emotions, traits, or symptoms that are causally responsible for these auto-regressive and cross-lagged longitudinal relationships. In LNA, central symptoms are identified by their roles as “high-output centrality symptoms” (those that influence other symptoms) or “high-input centrality symptoms” (those influenced by other symptoms) [ 13 ]. By establishing regression relationships between symptoms at different time points, LNA effectively reveals predictive relationships among symptoms over time, allowing researchers to examine the stability of symptom networks and predict interactions across multiple time points.

Given the limitations of methods used in previous research, this study aims to employ both NA and LNA methods to investigate the relationships between anxiety and depression symptoms among high school students. By identifying central symptoms and examining their interplay, the current study might help identify effective intervention targets, providing theoretical guidance for preventing and addressing mental health issues related to anxiety and depression in adolescents.

Method and data description

Participants.

Data on anxiety and depression were collected from non-graduating students of a high school in Shandong, China, at three different time points: March (T1), June (T2), and September (T3) in 2022. During data collection, questionnaires were uniformly distributed through the school’s class WeChat groups and sent to the parents’ phones (students were prohibited from using phones). The class teachers distributed the online questionnaire links, explained the purpose of the survey, and obtained informed consent. A total of 1,968 adolescents participated in March, 2,563 in June, and 2,030 in September. Participants were also free to withdraw at any time. After data collection was completed, data cleaning was performed, and questionnaires that were not submitted within the data collection period (distribution day and the following two days) and those with excessively long or short completion times (2 min < completion time < 10 min) were deleted. Furthermore, the study retained only those participants who completed all three assessments. Ultimately, 606 participants were included in the study (average age = 16.30 ± 0.69, with 229 males). The corresponding results are presented in Table  2 .

The Generalized Anxiety Disorder-7 (GAD-7) is a self-rating scale for assessing anxiety and is a highly effective tool based on the American Diagnostic and Statistical Manual of Mental Disorders [ 27 ]. It has been widely used in anxiety-related research [ 16 , 18 , 21 ]. The scale consists of 7 items (e.g., “Feeling nervous, anxious, or on edge”), with respondents rating their experiences on a 4-point Likert scale ranging from 0 (“never”) to 3 (“almost every day”). This study used the Chinese version of the GAD-7, which has demonstrated high reliability and validity among adolescents [ 28 , 29 ]. The total score indicates the severity of anxiety symptoms. In this study, the internal consistency was consistently strong across all assessment waves (Cronbach’s α = 0.93, 0.92, and 0.93 at T1, T2, and T3).

The 9-item Patient Health Questionnaire for Depression (PHQ-9) is a highly effective self-rating scale based on the American Diagnostic and Statistical Manual of Mental Disorders [ 30 ]. It has been widely used in depression-related research [ 16 , 18 , 21 ]. The scale consists of 9 items (e.g., “I feel sad or empty”), with items 1 through 9 representing different symptoms. Respondents rate each item on a 4-point Likert scale ranging from 0 (“not at all”) to 3 (“nearly every day”). This study used the Chinese version of the PHQ-9, which has demonstrated high reliability and validity among adolescents [ 28 , 29 ]. The total score is used to gauge the severity of depressive symptoms. In this study, the internal consistency was consistently strong across all assessment waves (Cronbach’s α = 0.89, 0.91, and 0.90 at T1, T2, and T3, respectively).

Data analysis

Before conducting the NA and LNA analyses, this study employed Multi-group Confirmatory Factor Analysis (MGCFA) to assess the measurement invariance of the PHQ-9 and GAD-7 across different time points (T1, T2, and T3) [ 31 , 32 ]. This analysis involved progressively adding constraints to compare the fit of the configural invariance, metric invariance, scalar invariance, and strict invariance models. The primary fit indices used were χ², CFI, TLI, RMSEA, and SRMR. All data analyses were performed using the lavaan package in R version 4.2.2.

NA was conducted using the bootnet package in R 4.2.2, incorporating accuracy and stability analyses along with centrality difference tests. Expected Influence (EI), defined as the sum of all edges extending from a given node, was used to measure central symptoms because there were negative edges in the network [ 33 ]. The Networktools package was used to calculate bridge centrality in the network, allowing for the identification of central bridge nodes, which play a critical role in communication between communities [ 34 ]. Similarly, bridge central symptoms were assessed using Bridge Expected Influence.

The NetworkComparisonTest package was used to compare the results of NA across different time points. The Network Invariance Test was employed to assess whether there were significant differences between two network models, and the Global Strength Invariance Test was used to compare differences in global expected influence between them [ 35 , 36 ].

LNA was established by referring to the code of Odenthal and colleagues [ 24 ]. In the network model, symptoms are represented as nodes, and the direction of the effect is depicted by edge arrows. Positive predictions are shown with green arrows, while negative predictions are shown with red arrows, with the thickness of the arrows indicating the strength of the association. Given that the autoregressive path is typically the strongest path in the network, it was visually de-emphasized to focus on the cross-lag effects, which were most relevant to the study’s objectives [ 37 ]. In this study, the autoregressive pathway was deliberately set to zero to highlight cross-lag effects and enhance the clarity of the prediction path. The R code to reproduce the current results is openly available on the OSF ( https://osf.io/bwdmc/?view_only=74416a90817e42f09f91cd442f14b1de ).

Specific data analysis included the following steps: First, the autoregressive path was calculated, representing the regression coefficient of a node from one time point to the next, while controlling for all other nodes. Second, the longitudinal path was computed, predicting one node at one time point from another node at a subsequent time point, taking into account the autoregressive effect and all other nodes. Regression coefficients were calculated using the least absolute shrinkage and selection operator (LASSO) method, with a tuning parameter of 0.5 to minimize the likelihood of spurious edges [ 38 , 39 ]. Longitudinal network models from T1 to T2 and T2 to T3 were derived using the glmnet package [ 12 , 40 ]. The visualization of the two cross-lagged network models was achieved using the averagelayout function in the qgraph package [ 41 ].

In quantifying the centrality of nodes in cross-lag network analysis, two key centrality metrics are typically used: out-expected influence (out-EI) and in-expected influence (in-EI). Out-EI represents the sum of all outgoing edges from a node, indicating the degree to which a node predicts other nodes in the network. In-EI represents the sum of all incoming edges to a node, indicating the extent to which a node is predicted by other nodes in the network. Nodes with high out-EI can predict a substantial number of other nodes, suggesting that their activation may trigger additional nodes in the network. This metric is especially valued in clinical studies [ 42 ].

Stability and accuracy analyses were conducted using the bootnet package [ 39 ]. Edge accuracy was calculated from the 95% confidence interval (CI) of the bootstrap weight of the edge, with 1,000 bootstrapped samples. The stability of node centrality in the model was assessed using a subsetting bootstrap approach, where a certain proportion of samples is removed, and the network’s centrality is recalculated. If the centrality of the network constructed after excluding most samples correlates highly with the centrality of the original network, the model is considered stable. The Centrality Stability coefficient (CS) served as a reference index, with CS values below 0.25 considered unacceptable. The edge weight difference test and centrality difference test were employed to assess differences in edge weights and centrality metrics, respectively [ 39 ].

Multi-group Confirmatory Factor Analysis

First, this study conducted MGCFA on three measurements of PHQ-9 and GAD-7 to assess their measurement invariance across different time points. By gradually adding constraints, the fit of the Configural Invariance model, Metric Invariance model, Scalar Invariance model, and Strict Invariance model was compared, as detailed in Table  3 . The results showed that although the model fit indices slightly decreased with each added constraint, these decreases were minimal. Overall, the factor structure, factor loadings, item intercepts, and measurement error variances of the questionnaires remained consistent across different time points. This indicates that the questionnaires possess good measurement invariance.

Network Analysis

Network comparison

Figure  1 illustrated the NA results at three different time points. The number of non-zero edges in different NAs is relatively consistent (n T1  = 39, n T2  = 40, n T3  = 38). And edge weights of the three NAs are highly correlated ( r T1&T2 = 0.609, p  < 0.001, CI 95% = [0.526, 0.680], r T2&T3 = 0.634, p  < 0.001, CI 95% = [0.555, 0.702], r T1&T3 = 0.650, p  < 0.001, CI 95% = [0.573, 0.716]). Similarly, the EI of symptoms in the three network models is highly significantly correlated ( r T1&T2 = 0.690, p  = 0.003, CI 95% = [0.295, 0.883], r T2&T3 = 0.593, p  = 0.015, CI 95% = [0.138, 0.841], r T1&T3 = 0.546, p  = 0.028, CI 95% = [0.069, 0.820]).

Network Analysis of Different Time Point

Results from the network invariance test indicate non-significant differences between NA T1 and NA T2 ( Test statistic M  = 0.255, p  = 0.25), between NA T1 and NA T3 ( Test statistic M  = 0.187, p  = 0.82), and between NA T2 and NA T3 ( Test statistic M  =  0.304 , p  = 0.05). The global strength test results demonstrate that the overall EI of the three networks remains stable. Specifically, there are no significant differences in global strength between NA T1 and NA T2 ( Global strength NAT1 = 5.89, Global strength NAT2 = 5.91, Test statistic S  = 0.019, p  = 0.95), NA T1 and NA T3 ( Global strength NAT1 = 5.89, Global strength NAT3 = 5.77, Test statistic S  = 0.120, p  = 0.82), and NA T2 and NA T3 ( Global strength NAT2 = 5.91, Global strength NAT3 = 5.77, Test statistic S  = 0.140, p  = 0.79).

Symptom centrality

Due to the presence of negative correlations in NA in this study, the EI centrality indicator is primarily referenced, with the other two indicators used as supplementary references. The results of the centrality analysis are depicted in Fig.  2 , along with the outcomes of the EI centrality difference test (Appendix fig S1 ). The specific symptom centrality results are as follows: in NA T1 , A2 has the highest EI, followed by A5 and D6. In NA T2 , A2, D8, and D6 show the highest EI. In NA T3 , D6 has the highest EI, with A3, A2, and A6 following closely.

As depicted in Fig.  2 , the Bridge Expected Influence analysis reveals that the EI of bridges in A6 and D2 in NA T1 is significantly higher than in some other symptoms. In NA T2 , A6 and D2 exhibit higher bridge EI compared to other symptoms. Among NA T3 , A6 and D6 have the higher bridge EI.

Centrality Measures of NA and LNA

Edges weight

The five strongest edges in the three network models differ. In NA T1 , the five strongest edges are A1 and A2 ( β  = 0.333), D2 and D1 ( β  = 0.266), A5 and A6 ( β  = 0.255), D9 and D8 ( β  = 0.238), and D9 and D6 ( β  = 0.212). In NA T2 , the five strongest edges are D7 and D8 ( β  = 0.305), D9 and D6 ( β  = 0.280), A1 and A2 ( β  = 0.258), A2 and A3 ( β  = 0.245), and D3 and D4 ( β  = 0.233). For NA T3 , the five strongest edges are D3 and D4 ( β  = 0.339), A4 and A5 ( β  = 0.328), A2 and A3 ( β  = 0.290), D3 and D5 ( β  = 0.284), and D1 and D7 ( β  = 0.243). The results of the edge weight difference test are illustrated in Appendix fig S2.

Accuracy and stability

The bootstrap confidence interval results for the edge weights indicate that all three network models are moderately accurate. There is considerable overlap between the CI 95% of the edge weights, although some of the strongest edges do not overlap with the confidence intervals, as illustrated in Appendix fig S3. The bootstrap results for node stability indicate that the EI of nodes and the EI stability of bridge nodes for the three network models are acceptable, as displayed in Appendix fig S4.

Longitudinal Network Analysis

The two cross-lagging network models are illustrated in Fig.  3 . There are variations in the number of non-zero edges in different cross-lag network models ( n T1 − T2 = 132, n T2 − T3 = 117). A significant negative correlation was observed between the edges of the cross-lagging network model ( r = -0.155, p  = 0.016, CI 95% = [-0.276, -0.029]). The correlation for out-EI was not significant ( r = -0.380, p  = 0.146, CI 95% = [-0.737, 0.142]), and the overall correlation for in-EI was not significant ( r  = 0.493, p  = 0.052, CI 95% = [-0.003, 0.795]).

Longitudinal Network Analysis of Different Time Point

The results of the centrality analysis for LNA are displayed in Fig.  2 , specifically in the out-EI and in-EI. Combined with the results of the centrality difference test (Appendix fig S5 & Appendix fig S6), it is evident that nodes with high out-EI and in-EI in the LNA exhibit temporal specificity. Notably, the in-EI of D6, D4, and A6 is the strongest, and the out-EI of D9 is the strongest in LNA T1−T2 . In LNA T2−T3 , A2, A4, and D2 have the strongest in-EI, while D6 has the strongest out-EI. Additionally, this study identified that D9 emitted a positive effect in LNA T1−T2 , while a negative effect in LNA T2−T3 .

The five strongest edges in the analysis of the two LNAs are not identical, and the results of the edge weight difference test are presented in Appendix fig S7. In LNA T1−T2 , the strongest edge is from D9 → D6 ( β  = 0.376), the second strongest is from D9 → D2 (β = 0.300), the third strongest is from D9 → D8 ( β  = 0.282), the fourth strongest is from D9 → A3 ( β  = 0.197), and the fifth strongest is from D9 → A7 ( β  = 0.196). In LNA T2−T3 , the strongest edge is from D6 → A1 ( β  = 0.250), the second strongest is from D5 → D3 ( β  = 0.211), the third strongest is from D6 → D2 ( β  = 0.206), the fourth strongest is from D6 → D1 ( β  = 0.197), and the fifth strongest is from D1 → A3 ( β  = 0.176).

The results of the edge-weighted bootstrap confidence interval indicate that both LNA are moderately accurate. There is substantial overlap between the CI 95% of the edge weights, although some of the strongest edges do not overlap with the confidence interval, as depicted in Appendix fig S8. The bootstrap results for node stability demonstrate that the edge, out-EI, and in-EI stability are acceptable in both networks, as illustrated in Appendix fig S9.

This study has shed light on the symptoms and relationships of anxiety and depression in adolescents across multiple time points. The NA results revealed the stability of the network structure and the central symptoms of anxiety and depression in adolescents over time. LNA further identified potential therapeutic targets by analyzing the pathways of symptom development. All network models demonstrated acceptable accuracy and stability, providing valuable insights into the understanding and characterization of anxiety and depression in adolescents.

In all three symptom centrality results of NA, uncontrollable worry consistently exhibited high EI. This symptom has been consistently identified as significant in both clinical and non-clinical studies on anxiety and depression [ 18 , 19 , 20 ]. There may be several reasons for this symptom’s prominence. Borkovec and Lyonfields suggested that concerns and thoughts about potential adverse events or risks could contribute to its emergence. High school adolescents often face considerable uncertainty, especially regarding their educational future, which aligns with Borkovec and Lyonfields’ definition [ 43 ]. Additionally, NA results showed that the strong association between uncontrollable worry and anxiety symptoms (T1) might evolve into a strong association between uncontrollable worry and generalized vocabulary symptoms (T3), consistent with the results of Chinese adolescents and college students [ 18 , 19 ]. This suggests that uncontrollable worry could play a significant role in anxiety and depression among adolescents.

The NA results for symptom bridge centrality revealed that irritability from the GAD-7 emerged as the key symptom with the highest bridge EI among the three network analyses. This finding contrasts with the results of Marian and colleagues [ 22 ], who conducted a 21-day intensive tracking study of anxiety and depression in university students, identifying “sad mood” and “concentration difficulties” as significant bridge symptoms. The discrepancy could be due to the fact that our study assessed participants every three months, while Marian et al. [ 22 ]. examined anxiety and depression on a daily basis, underscoring the impact of different measurement methods on the network model of anxiety and depression symptoms. Furthermore, this difference might also be due to variations in the study populations, suggesting that future research could explore these differences in more depth.

Irritability is one of the most common presenting problems in child and adolescent psychiatric practice [ 44 , 45 ]. It refers to a heightened propensity for anger compared to peers [ 46 ]. Neuroscientific and behavioral studies have shown that irritability is associated with dysfunction in circuits involving the frontal-striatal-lens-amygdala [ 46 , 47 ]. Irritability is also recognized as a predominant symptom of depressive disorder in children and adolescents [ 48 ]. From a clinical perspective, bridge symptoms are considered transdiagnostic indicators of comorbid conditions and serve as crucial targets for specific interventions [ 15 ]. The results of the present study support this view. In summary, the importance of irritability as a symptom in anxiety and depression highlights the emotional characteristics of adolescents at this stage of development. This observation warrants ongoing attention from educators and school-based mental health professionals.

From a holistic network perspective, most central symptoms in the NA at the three time points do not align with the high-weighted edges. This study suggests that the central symptoms within the anxiety and depression network among adolescents might in a state of high activation and low connectivity, and they remain relatively stable over time [ 13 ]. According to Borsboom [ 10 ], high activation and low connectivity represent a condition that falls outside the traditional spectrum of both mental health and mental disorders. This indicates that adolescents might in a delicate state of mental health, making them highly vulnerable to anxiety and depression [ 49 ]. Individuals in this state exhibit symptoms that are strongly influenced by external events, but these symptoms tend to diminish once those events are removed [ 13 ]. When adolescents encounter external stressors, such as the uncontrollable worry symptoms observed in the T2 network of this study, they are likely in a state of high activation and high connectivity. At T2, the participants in this study were going through their final exam period, with exam-related stress may contribute to their state of psychological sub-health [ 50 ]. Kumar and colleagues also found that exam stress was associated with a higher prevalence of anxiety, which tended to decrease once the exams were over [ 51 ].

The symptom centrality results from the LNA revealed a shift in the central symptoms involved in the development of anxiety and depression, specifically from suicidal ideation to worthlessness, then to anxiety and uncontrollable worry. This finding aligns with the viewpoint of Borsboom and Cramer [ 14 ], which suggests that symptoms do not stem from a single underlying cause but actively reinforce (or inhibit) each other, ultimately contributing to the emergence of generalized psychopathological condition [ 10 ]. Sowislo and Orth posited that individuals with low self-esteem, characterized by feelings of worthlessness, are more likely to experience anxiety and depression [ 52 ]. Rhodes suggested that a positive sense of self-worth could reduce adolescents’ vulnerability to the adverse effects of stressors on their mental health [ 53 ]. The placement of worthlessness within this sequence aligns with the findings of Van den Bergh et al. [ 54 ], underscoring the pivotal role of worthlessness in the development of anxiety and depression.

The result was also consistent with the study by Tao and colleagues which focused on suicidal ideation as a grouping indicator [ 18 ], showing a strong association between suicidal ideation and guilt (PHQ6) and nervousness (GAD1). The current result may enhance the understanding of this issue, providing insights into the longitudinal development of symptoms. This indicated that suicidal ideation symptoms may predict the emergence of other symptoms, and the decrease in suicidal ideation also triggered the recovery of other symptoms. The results of the current study suggested that, suicidal ideation in anxiety and depression of adolescents should be considered a significant signal of severe anxiety and depression, and a central target for intervening in anxiety and depression [ 55 ]. In future studies, more variables could be added to investigate the impact of suicidal ideation on symptoms of anxiety and depression.

Given the central role of key symptoms in previously reported networks, our findings could guide the customization and evaluation of interventions aimed at reducing the risk of concurrent anxiety and depression in adolescents. It should be stressed that adolescents are in a sensitive state, with a heightened risk of experiencing anxiety and depression. Furthermore, suicidal ideation among adolescents could be recognized as a critical warning signal for these conditions. Symptoms like feelings of worthlessness, uncontrollable worry, and irritability may serve as focal points for interventions addressing anxiety and depression. Lastly, it is crucial and urgent to nurture and strengthen adolescents’ psychological resilience and emotional regulation skills.

Certain limitations in this study must be acknowledged. Firstly, the generalizability of current results must be considered. Fried and colleagues compared multiple depression scales and pointed out significant content differences among them, covering 52 different depression symptoms [ 56 , 57 ]. Similarly, there are analogous issues with anxiety measurement scales [ 58 ]. The PHQ-9 and GAD-7 used in this study include only 16 items in total, which may limit the comprehensiveness of the current findings [ 59 ]. Future research may attempt to cover a wider range of symptoms, or optimize the network structure using different operationalizations, as suggested by Adamkovič and colleagues [ 60 ]. Secondly, this study relied on self-report measures from participants, which can introduce biases or concealment. Additionally, data collection relied on an online platform, which may limit the accuracy of the study’s results. Future research could utilize more robust assessment methods. Thirdly, the study’s sample was relatively concentrated, potentially limiting its representativeness. Finally, the findings in this study are data-driven and not grounded in a specific theoretical framework. Future research could consider developing theories of anxiety and depression from a symptomatic perspective.

Drawing insights from both NA and LNA, it is clear that the anxiety and depression network in adolescents exhibits a certain degree of temporal stability, yet also shows signs of partial susceptibility. Within these networks, uncontrollable worry consistently appears as the central symptom, while irritability might play a central role in the comorbidity of anxiety and depression among adolescents. Furthermore, worthlessness and suicidal ideation might be identified as potential therapeutic targets for addressing anxiety and depression in adolescents.

Data availability

The R code to reproduce the current results is openly available on the OSF .https://osf.io/bwdmc/?view_only=74416a90817e42f09f91cd442f14b1de.

Abbreviations

Centrality Stability coefficient

Comparative Fit Index

Confidence Interval

Degrees of freedom

Generalized Anxiety Disorder-7

In-expected Influence

Out-expected Influence

Patient Health Questionnaire

Root Mean Square Error of Approximations

Standardized Root Mean Squared Residual

Tuker-Lewis Index

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This study received a grants from the National Natural Science Foundation of China (32271140) and the Tianjin Normal University Graduate Research Innovation Project (2024KYCX006Z).

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Dongyu Liu, Xinyu Zhang, Jingjing Cui & Haibo Yang

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L.D.Y. designed the study protocol. Y.M.S. conducted conducted data collection. L.D.Y., Z.X.Y. and C.J.J. conducted data management, cleaning. L.D.Y. wrote the first draft of the paper. Y.H.B. and Z.X.Y. substantially revised the manuscript.

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Liu, D., Yu, M., Zhang, X. et al. Adolescent anxiety and depression: perspectives of network analysis and longitudinal network analysis. BMC Psychiatry 24 , 619 (2024). https://doi.org/10.1186/s12888-024-05982-y

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