This is the third piece in a four-part series about teen mental health. In the first article, we discussed the increase in teen mental health complaints during 2020; the second piece covered the rising incidence of teen suicide attempts prior to the pandemic. This article investigates the problematic link between antidepressants and suicidal ideation; the final piece with cover the financial incentives for medical facilities to max out their available space and staff without buffers for times of crisis.

As covered in the first two parts of this series, children and adolescents have been diagnosed with emotional, mental and psychological disorders at a high rate for more than a decade, a problem that has only worsened globally since March 2020, when COVID-19 shut down the country. Challenges to appropriate treatment include the problematic nature of many psychoactive medications and the lack of medical professionals with the training to prescribe and monitor the use of these drugs in a pediatric population.

The United States does not publish pediatric antidepressant prescription data on an annual basis; however, existing data gives hints about the widespread usage of these drugs. National Health and Nutrition Examination Survey (NHANES) data from 2005-2010 indicate that 3.1 percent of American teens were taking at least one antidepressant; 3.9 percent were taking medication for attention deficit-hyperactivity disorder (ADHD); and 1 percent were taking at least one antipsychotic drug.

From the 1998 period to 2005-2010, antidepressant use in teens grew six-fold, and ADHD drug use grew more than 1,900 percent. Researchers involved in the study noted that these figures may be an undercount. Although medication use was independently verified for survey participants who responded positively, no checking was done to validate negative responses.

Treating teen depression with medication is different than prescribing drugs for well understood teen ailments like swimmer’s ear or athlete’s foot. Suicidal ideation (forming suicidal ideas from conception to implementation) is a known side effect of antidepressant medications, which carry the highest level of warning from the FDA: a boxed warning, often called a “black box warning.” The label for fluoxetine, also sold under the trade name Prozac, warns patients of an “Increased risk of suicidal thinking and behavior in children, adolescents, and young adults taking antidepressants” and instructs physicians and caregivers to “Monitor for worsening and emergence of suicidal thoughts and behaviors.”

The fluoxetine label shares the “class warning” that is present on all antidepressant drugs: “Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18-24) with Major Depressive Disorder (MDD) and other psychiatric disorders.”

Many prescriptions written, despite shortage of mental health professionals

While children and teens taking antidepressants – whether they’re approved for pediatric use, or prescribed “off-label” – there just aren’t enough professional specialists to do the job. Data reported in 2021 show that 70 percent of U.S. counties have zero child or adolescent psychiatrists. Much of the prescribing of psychoactive substances is done by family physicians rather than specialists, and patients often receive no specialized follow-up care. NHANES data from 2005-2010 show that roughly half of teen patients receive inadequate ongoing monitoring, follow-up, or non-pharmaceutical psychiatric or psychological care. During 2005-2010, 6.3 percent of American teens ages 12-17 were taking at least one psychotropic medication, and only 53.3 percent of these teens had seen a mental health professional in the past year.

The dearth of adolescent psychiatric specialists is taking its toll on teens in western nations. Data from the U.S. are sparse, but figures from Western Europe indicate that antidepressant prescription to adolescents regularly deviates from clinical guidelines. For example, in the Netherlands, 60 percent of teens were prescribed an adult starting dose, rather than the lower recommended dose, and researchers described overall adherence to guidelines as “poor.”

In the U.K., as many as 75 percent of antidepressant prescriptions for children and teens were written without consulting a child or adolescent psychiatrist. In Germany, more than 25 percent of prescriptions to outpatients 12 to 18 years old deviated from the guidelines in the choice of drug type. Given the high rate of non-specialist prescribing and poor guideline adherence, some researchers are calling for increased training for pediatricians and family practitioners.

Pharmacy-based care to the rescue?

Recent decisions by pharmacies such as CVS, Walgreens, and Walmart Health to add mental health counselors to their stores might seem like a solution to the shortage, but a closer look reveals a mixed bag. The pilot program at CVS involves licensed clinical social workers trained in cognitive behavioral therapy and is limited to 13 locations in major cities such as Philadelphia, which are not part of the teen psychiatrist “deserts” that make up most American counties. Additionally, CVS does not have plan for its therapists to provide long-term care or care for disorders that require more than a few visits.

Walmart’s pilot began in Arkansas and Georgia, and will reach Florida and Illinois during 2021. However, the locations are-like those of CVS-in or near major metropolitan areas, like Atlanta, where other psychiatric resources exist. Care is provided by licensed clinical social workers from Beacon Care Services. These professionals do not treat major depressive disorder, but coordinate care with individuals’ primary care providers if a counseling session indicates depression.

Walgreens is taking a slightly different approach, attaching VillageMD medical clinics to hundreds of its retail locations. By the end of 2025, the companies plan to have between 500 and 700 full-service medical offices co-located at retail pharmacy locations. According to a press release from VillageMD, more than half of these clinics will be in areas designated by the U.S. Dept. of Health and Human Services as “Health Professional Shortage Areas” or “Medically Underserved Areas.” However, VillageMD’s website indicates that only primary care, physical therapy, aesthetics, neurology, podiatry, and general surgery professionals are available at its clinics. The Press had not received a response to our request for information about future child psychiatrist plans by press time.

There is much debate in the medical literature about the appropriateness of prescribing psychoactive substances to teenagers with developing brains and rapidly changing body chemistry. Two recent peer-reviewed papers discuss the risks of psychoactive medications (https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00717/full and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5044489/). Two other papers raise the possibility of under treatment as an unintended consequence of black box warnings (https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00294/full and https://jamanetwork.com/journals/jamapediatrics/fullarticle/1465762).

One thing is clear: Taking psychoactive medications is different than taking a course of antibiotics for an uncomplicated bacterial infection. In other words, the pills do not obviate the need for ongoing medical observation, but rather, heighten its importance.

Ongoing involvement with a mental health professional specializing in teens is key to managing the risks of depression, whether pharmacological treatment is used or not. The National Institute of Mental Health (NIMH) advises, “In addition to medications, other treatments for children and adolescents should be considered, either to be tried first, with medication added later if necessary, or to be provided along with medication. Psychotherapy, family therapy, educational courses, and behavior management techniques can help everyone involved cope with disorders that affect a child’s mental health” (https://www.nimh.nih.gov/health/topics/mental-health-medications).