An Epidemic of Anguish: Major Depressive Disorder, Self-Harm, and Suicide
Madison Holleran was everything most young girls want to grow up to be: beautiful, academically successful, athletic. She was raised in New Jersey, one of five siblings in a close-knit family, and headed off to college at the University of Pennsylvania, where she ran track. Like many college students, she posted pictures on her Instagram page: track meets, friends, parties. “Madison, you look like you’re so happy at this party,” her mother told her. “Mom,” Madison replied. “It’s just a picture.”
Madison’s Instagram account didn’t capture what was really going on: she was depressed. She was, she confided to her friend Emma, scared to grow up, terrified that she didn’t know exactly what would happen next. She had yet to get a driver’s license. After a tough first semester at Penn, she started seeing a therapist near her home in New Jersey. One day in January of her freshman year, her father called and asked if she had found a therapist in Philadelphia so she could continue her treatment when she was at school. “No, but don’t worry, Daddy, I’ll find one,” she said. A few hours later, she jumped off the roof of a nine-story parking garage to her death. She was 19 years old.
So far, what we’ve discussed is variations in symptoms among the normal population: worrisome signs but not evidence of clinical-level depression. Those feelings are still very important, as they affect larger numbers of teens and are risk factors for more serious issues, yet most of the time they don’t rise to the level of a debilitating mental illness. So it’s fair to ask: Has the rise in feelings of loneliness, depression, and anxiety also been accompanied by changes in diagnosable depression and its most extreme outcome, suicide?
The National Survey on Drug Use and Health (NSDUH), conducted by the US Department of Health and Human Services, has screened US teens for clinical-level depression since 2004. The project sends trained interviewers to assess a nationally representative sample of more than 17,000 teens (ages 12 to 17) across the country every year. Participants hear questions through headphones and enter their answers directly into a laptop computer, ensuring privacy and confidentiality. The questions rely on the criteria for major depressive disorder documented in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, the gold standard for diagnosing mental health issues. The criteria include experiencing depressed mood, insomnia, fatigue, or markedly diminished pleasure in life every day for at least two weeks. The study is specifically designed to prove a benchmark for rates of mental illness among Americans, regardless of whether they’ve ever sought treatment. A study like this is about as reliable and valid as you can get.
The screening test shows a shocking rise in depression in a short period of time: 56% more teens experienced a major depressive episode in 2015 than in 2010 (see Figure 4.10), and 60% more experienced severe impairment.
Figure 4.10. Percentage of 12- to 17-year-olds experiencing a major depressive episode or a major depressive episode with severe impairment in the last 12 months, overall and by sex. National Survey on Drug Use and Health, US Department of Health and Human Services, 2004–2015.
More young people are experiencing not just symptoms of depression, and not just feelings of anxiety, but clinically diagnosable major depression. With more than one in nine teens and one in eleven young adults suffering from major depression, this is not a small issue. Even more than the data on rising loneliness and depressive symptoms, these gold-standard data suggest that something is seriously wrong in the lives of American teens.
Just as with depressive symptoms and loneliness, the increase in major depressive episodes is far steeper among girls, the gender more likely to overuse social media. By 2015, one in five teen girls had experienced a major depressive episode in the last year (see Figure 4.10).
Depressed teens are more likely to self-injure, such as through cutting. Fadi Haddad, a psychiatrist at Bellevue Hospital in New York City, told Time magazine, “Every single week we have a girl who comes to the ER after some social-media rumor or incident has upset her.” Those ER visits are almost always caused by girls cutting themselves. Between 2011 and 2016, 6% more college students said they intentionally injured themselves (in the ACHA survey; see Appendix F). Some teens discuss their cutting on social media; one study found that the hashtag “#selfharmmm” zoomed from 1.7 million mentions on Instagram in 2014 to 2.4 million in 2015. The extra m’s are apparently to express pleasure, a cruel irony rooted in the feelings of release some cutters say they experience. Many parents have no idea what their children are doing on social media, and many feel helpless, Haddad says. One mother found that her self-harming daughter had seventeen Facebook accounts, which the mother promptly shut down. “But what good does that do?” asked Haddad. “There will be an eighteenth.”
Major depression, especially if it’s severe, is also the primary risk factor for suicide. A high school classmate once confided to Utah State student Whitney Howard that she didn’t understand how anyone could commit suicide. How could things possibly be that bad? “Little did she know that I was suicidal myself,” Whitney says. “. . . I tried overdosing on pain pills.” Depression, she says, is “an emptiness, an absence of feeling. [It] numbs you and strips you of happiness, hope and enjoyment. Think of the Dementors from ‘Harry Potter.’ ” Between 2009 and 2015, the number of high school girls who seriously considered suicide in the past year increased 34%, and the number who attempted suicide increased 43%. The number of college students who seriously considered suicide jumped 60% between 2011 and 2016 (see Appendix F).
Suicide, a carefully tracked behavior unaffected by the possible irregularities of self-report surveys, is the most extreme and sadly objective outcome of depression. If suicide rates have risen, it would be strong evidence that depression has reached problematic levels. Unfortunately, it has. After declining during the 1990s and stabilizing in the 2000s, the suicide rate for teens has risen again. Forty-six percent more 15- to 19-year-olds committed suicide in 2015 than in 2007, and two and a half times more 12- to 14-year-olds killed themselves (see Appendix F). These are heartbreaking numbers.
The rise in suicide is more pronounced for girls. Although the rate increased for both sexes, three times as many 12- to 14-year-old girls killed themselves in 2015 than in 2007, compared to twice as many boys (see Figure 4.11). Although the suicide rate is still higher for boys (likely because they use more lethal methods), girls are beginning to catch up.
Figure 4.11. Suicide rate per 100,000 people, 12- to 14-year-olds, by sex. Fatal Injury Reports, Centers for Disease Control and Prevention, 1999–2015.
For an outcome such as suicide—the end of a young and precious life—this is an extremely worrisome rise. It’s also surprising, because more Americans now take antidepressants (one out of ten in the last year, more than double the rate of the mid-1990s). Antidepressants are especially effective against severe depression, the type most strongly linked to suicide. Yet they haven’t been enough to stem the growth of suicide among teens that started right around the same time smartphones became common. We can’t say for sure that smartphones are to blame, but the timing is very suspicious. With twice as many young teens killing themselves, something clearly needs to be done.
Why the Rise in Mental Health Issues?
Although the rise in anxiety, depression, and suicide has occurred at the same time as the rise of smartphones, it makes sense to consider other causes as well. An article in The Atlantic blamed teen mental health issues almost exclusively on academic pressure. “Students are challenged to take a demanding course of study, to get a high GPA . . . . School is more challenging,” said one high school counselor. But one good indicator of academic pressure is the amount of time students spend on homework, and as we saw in chapter 1, time spent doing homework is less or about the same as in previous decades, with little change between 2012 and 2016, the years when depression skyrocketed. Plus, as we saw in chapter 3, students who spend more time on homework
are actually less likely to be depressed. Thus, it seems highly unlikely that too much time spent studying is the cause of the rise in anxiety and depression.
Other causes also seem unlikely given the available evidence. We can apply a two-part test to possible causes: (1) it must be correlated with mental health issues or unhappiness (see chapter 3) and (2) it must have changed at the same time and in the correct direction. Time spent doing homework fails both tests; it’s not linked to depression, and it didn’t change much over that time period. TV watching is linked to depression, but teens watch less TV now than they used to, so it fails test number two. Time spent on exercise and sports is linked to less depression, but it didn’t change much since 2012, so they fail test number two, too.
Only three activities definitively pass both tests. First, new-media screen time (such as electronic devices and social media) is linked to mental health issues and/or unhappiness, and it rose at the same time. Second and third, in-person social interaction and print media are linked to less unhappiness and less depression, and both have declined at the same time as mental health has deteriorated. A plausible theory includes three possible causes: (1) more screen time has led directly to more unhappiness and depression, (2) more screen time has led to less in-person social interaction, which then led to unhappiness and depression, and (3) more screen time has led to less print media use, leading to unhappiness and depression. In the end, all of the mechanisms come back to new-media screen time in one way or another. By all accounts, it is the worm at the core of the apple.
Of course, even with this evidence, these data can’t definitively show that the shift toward screen time has caused more mental health issues. However, other studies can: experiments that randomly assign people to experience more or less screen time and those that track behavior over time have both found that more screen time causes more anxiety, depression, loneliness, and less emotional connection. It seems clear that at least some of the sudden and large increase in depression has been caused by teens spending more time with screens.
Another possibility is that iGen’ers are unprepared for adolescence and early adulthood due to their lack of independence. With iGen’ers less likely to work, manage their own money, and drive in high school, perhaps they are not developing the resilience that may come from doing things on your own. One study asked college students if their parents “supervised my every move,” “stepped in to solve life problems for me,” and didn’t “let me figure things out independently.” Students whose parents displayed those characteristics (often known as “helicopter parents”) had lower psychological well-being and were more likely to have been prescribed medication for anxiety and depression. Thus, reduced independence passes both tests: it is correlated with mental health issues, and it changed at the same time.
The 2015 song “Stressed Out” by Twenty One Pilots captures this possible link between growing up slowly and mental health issues. In the music video, the band members ride oversized Big Wheels down a suburban Columbus, Ohio, street and drink Capri Suns with straws. Lead singer Tyler Joseph says he wishes they could “turn back time to the good ol’ days when our momma sang us to sleep.” Adulthood is also a sudden, unexpected reality: their parents, they say are “laughing in our face/Saying ‘Wake up, you need to make money.’ ” He thought his fears would go away when he got older, he says, but now he’s insecure and cares what other people think. The song was number two on the Billboard top 100 for 2015, and the video has more than 800 million views on YouTube. As Asbury University student Alyssa Driscoll wrote, the song “has exactly what we’re thinking written in it. . . . [It] really GETS US.”
In the video, Tyler wears black makeup on his neck and hands, which he says is a metaphor for stress. It represents “kind of a feeling of suffocation,” he said in an interview. It makes sense: trying to find your way as an adolescent can be difficult when your childhood was a protected cocoon and you were always told not to care what anyone else thinks. Suddenly it matters what other people think, suddenly you have to be an adult, and that’s stressful. Between student loans and tree houses, he sings, we’d all choose the tree house.
Stealing Sleep
Just before you go to bed, you check on your teen. It looks as though her light is off, but you’re not sure. Then you see it: the faint blue light of her phone as she looks at it in bed.
Many iGen’ers are so addicted to social media that they find it difficult to put down their phones and go to sleep when they should. “I stay up all night looking at my phone,” admits a 13-year-old from New Jersey in American Girls. She regularly hides under her covers at night, texting, so her mother doesn’t know she’s awake. She wakes up tired much of the time, but, she says, “I just drink a Red Bull.” Thirteen-year-old Athena told me the same thing: “Some of my friends don’t go to sleep until, like, two in the morning. “I assume just for summer?” I asked. “No, school, too,” she said. “And we have to get up at six forty-five.”
Smartphone use may have decreased teens’ sleep time: more teens now sleep less than seven hours most nights (see Figure 4.12). Sleep experts say that teens should get about nine hours of sleep a night, so a teen who is getting less than seven hours a night is significantly sleep deprived. Fifty-seven percent more teens were sleep deprived in 2015 than in 1991. In just the three years between 2012 and 2015, 22% more teens failed to get seven hours of sleep.
Figure 4.12. Percentage of teens who get less than seven hours of sleep on most nights, 8th, 10th, and 12th graders (Monitoring the Future) and 9th to 12th graders (Youth Risk Behavior Surveillance System), 1991–2015.
As always, it’s difficult to say for sure what the cause is in a trend over time. Still, the timing of the increase is suspicious, once again occurring just as most teens began to have smartphones, around 2011 or 2012. The increase is also larger for girls than for boys (see Appendix F), and girls are more active on social media.
If teens who spent more time online also slept less, that would be further evidence that new media and smartphones might be behind the lack of sleep. That is indeed the case: teens who spent three or more hours a day on electronic devices were 28% more likely to get less than seven hours of sleep, and teens who visited social media sites every day were 19% more likely not to get adequate sleep (see Figure 4.13). The number of teens who don’t sleep enough goes up after two or more hours a day of electronic device use and skyrockets from there (see Appendix F). An extensive meta-analysis of studies on electronic device use among children found similar results: children who used a media device before bed were more likely to sleep less than they should, more likely to sleep poorly, and more than twice as likely to be sleepy during the day.
Figure 4.13. Relative risk of getting less than seven hours of sleep on most nights based on screen (black bars) and nonscreen (gray bars) activities. Monitoring the Future and Youth Risk Behavior Surveillance System, 2009–2015.
Electronic devices and social media seem to be unique in their effect on sleep compared to older forms of media. Teens who read books and magazines more often are actually less likely to be sleep deprived—either reading puts them to sleep, or they can put the book down at bedtime. TV time is barely related to sleep time. Apparently, teens who watch a lot of TV can turn it off and go to sleep, while those on their phones do not. The allure of the smartphone, its blue light glowing in the dark, is often too much to resist.
Other activities that take up a lot of time, such as homework and working for pay, also increase the risk of missing out on sleep. But since teens spent about the same amount of time working and on homework in 2015 as they did in 2012, those activities are unlikely to be the cause of the increase in sleep deprivation since 2012. Other activities that take time, such as exercising and spending time with friends in person, actually correlate with getting more sleep. New-media use is both the most strongly related to sleep deprivation and the only activity that increased significantly between 2012 and 2015. Thus, smartphones appear to be the p
rimary cause of the recent increase in sleep deprivation, which means this new technology has adversely affected physical health as well as mental health.
Lack of sleep can have serious consequences. Sleep deprivation is linked to myriad issues, including compromised thinking and reasoning, susceptibility to illness, increased weight gain, and high blood pressure. Sleep deprivation also has a significant effect on mood: people who don’t sleep enough are prone to depression and anxiety.
Sound familiar? Lack of sleep might be another reason why iGen’ers are more likely to be depressed. Teens who don’t sleep enough are more than twice as likely to report higher levels of depressive symptoms (31% do, versus only 12% for those who sleep more). Teens who sleep less than seven hours a night are also 68% more likely to have at least one risk factor for suicide (see Figure 4.14). Sleep deprivation is the ultimate buzzkill to mood, and over time it can snowball into serious mental health issues.
Figure 4.14. Relative risk of having a high level of depressive symptoms or having at least one suicide risk factor based on sleeping less than seven hours on most nights, 8th and 10th graders (Monitoring the Future) and 9th to 12th graders (Youth Risk Surveillance System), 2009–2015.
These risks look almost identical across gender, race, and socioeconomic status, so those factors are not the cause. Intriguing new research shows that the blue light emitted by electronic devices tells our brains it’s still daytime, which makes the brain take longer to fall asleep. It probably doesn’t help that social media exchanges, especially for teen girls, are filled with drama, not the best thing when you’re trying to relax before bed. So smartphones could be causing lack of sleep, which leads to depression, or the phones could be causing depression, which leads to lack of sleep. It’s all rooted in the allure of the phone: when the phone calls its siren song, teens crash into the rocks instead of crashing into their beds.
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