Paediatricians hold the front lines of a mental health crisis in US

One crisp Monday morning in January, Dr Melissa Dennison sat in a small, windowless exam room with a 14-year-old girl and her mother. Omicron was ripping through Kentucky, and the girl was among three dozen young patients — two of them positive for the coronavirus — that the paediatrician would see that day.

But this girl was part of a different epidemic, one that has gripped the community and nation since long before COVID-19: She and her mother had come to discuss the girl’s declining mental health.

The girl was depressed, she told Dennison, and had been cutting her arm to relieve her emotional pain. Dennison suggested therapy, but the girl said she would not go.

After the exam, Dennison stood in the hallway and described the case. “You need to get off the phone and the computer,” she had told the girl. “When it’s pretty outside like this, put on a bunch of clothes and go for a walk.”

Dennison prescribed the antidepressant Zoloft, although she wasn’t sure the girl was clinically depressed.

“I’d rather they see a psychiatrist,” she said. “But if I’ve got this child and they’re cutting and saying they’re going to kill themselves, I’ll say, ‘Well, I’ll see them today.’ If I call a child psychiatrist, they say, ‘I’ll see them in a month.’”

Over the last three decades, the major health risks facing US adolescents have shifted drastically: Teenage pregnancy and alcohol, cigarette and drug use have fallen while anxiety, depression, suicide and self-harm have soared. In 2019, the American Academy of Pediatrics issued a report noting that “mental health disorders have surpassed physical conditions” as the most common issues causing “impairment and limitation” among adolescents. In December, the US surgeon general, in a rare public advisory, warned of a “devastating” mental health crisis among American teenagers.

But the medical system has failed to keep up, and the transformation has increasingly put emergency rooms and paediatricians at the forefront of mental health care. Community doctors now routinely deal with complex psychiatric issues, making tough diagnoses after brief visits and prescribing powerful psychiatric medications for lack of better alternatives. “Paediatricians need to take on a larger role in addressing mental health problems,” the 2019 AAP report concluded. “Yet, the majority of paediatricians do not feel prepared to do so.”

In Glasgow, as elsewhere, there are counsellors in the schools and therapists in town, including four at Dennison’s clinic. But they are often booked months out. Seventy percent of counties in the United States lack a psychiatrist specialising in children or adolescents — and the psychiatrists who can be found are concentrated in wealthier areas, with many accepting only private payments.

“There’s a need and nowhere else to go,” Dr David Lohr, a child and adolescent psychiatrist at the University of Louisville, said of the growing role of primary-care doctors in mental health.

Dennison, 62, has adapted. Two decades ago, she routinely prescribed antibiotics and saw patients with “strep throat, earaches and wheezing,” she said. “And no one heard of ADHD,” she said, referring to attention deficit hyperactivity disorder. She estimated that, back then, 1% of her cases related to mental and behavioural health; now at least 50% do.

Dennison began as a paediatrician in Glasgow in 1990, after completing medical school at the University of Louisville and a paediatric residency in Texas. Her practice today includes the children of patients whom she treated in Glasgow two decades ago.

Over two days, Dennison had 66 appointments, 20 of them related to mental and behavioural health. She dealt with patients taking a range of drugs, many of which she had prescribed and some of which were combined. The drugs included Abilify for mood disorders; Zoloft, Trazodone and Clonidine for sleep issues; Ritalin, Adderall, Qelbree and Vyvanse for ADHD; and Remeron for major depressive disorder.

The growing use of psychiatric medications in youth is one metric of the adolescent mental health crisis. From 2015 to 2019, prescriptions for antidepressants rose 38% for teenagers compared with 15% for adults, according to Express Scripts, a major mail-order pharmacy.

In May 2001, one of Glasgow’s biggest employers, RR Donnelley & Sons Co, announced a major expansion. The company, a printer of magazines, bibles and other materials, would add manufacturing space and another 100 employees to its staff of 1,100.

But the rise of the internet spelt the decline of paper, and the plant closed for good in 2020; most other managerial and skilled manufacturing jobs had long since fled Glasgow.

Dennison and her husband, a radiologist, raised three children in the town and watched the local economy evaporate. Today, Glasgow has a poverty rate of 27% and a median household income of $28,000, according to 24/7 Wall Street, a data company that in 2020 ranked Glasgow the poorest town in Kentucky.

A handful of the businesses are shuttered in the aging downtown square, with the county seat, a red-brick Colonial-style building, in the middle. Just a few blocks away, residents say, opiates and methamphetamine are easily acquired in the streets amid the single-story and ranch-style houses.

Dennison’s life changed, too. She grew up in nearby Scottsville, on a tobacco farm, where she developed strong beliefs about self-reliance and determination. Then, in 2017, she got divorced and grappled with bouts of anxiety. She took the antidepressant Wellbutrin, saw a counsellor and “prayed a lot,” she said.

“I used to be a self-righteous little jerk,” she said. “I used to pooh-pooh all that anxiety stuff and think you can get through this. And then I went through the divorce.”

Dennison provides advice in addition to medication. She readily shares with families her opinions about the need for their children to put down their devices, exercise and spend time outdoors.

“They have too much screen time, they’re not sleeping, on phones all the time,” she said. Parents lack the will to make their children disconnect. Poverty, obesity and puberty, which is arriving earlier for many children, are factors, too, she said: “It’s hard to have the body of a 15-year-old and the mind of a 12-year-old.”

Other adults who work with adolescents in Glasgow have theories about why this generation is burdened with mental health issues. Mallie Boston, who grew up in town and is now the executive director of the Boys & Girls Club of Glasgow-Barren County, said that today’s teenagers were less physically active and spent less time just hanging out.

At the Boys & Girls Club, she tries to encourage young people to be more physically engaged and expressive. “I try to get them to play dodgeball,” she said. “If I can get them to be aggressive, maybe I can get to the root cause of what’s happened to them.”

The club is in a building a couple of miles from Dennison’s office; on a weekday afternoon, a couple of hundred children and adolescents come to play basketball and volleyball or to hang out. Many are from families that are struggling economically; a few said they didn’t see a doctor at all.

“My mom refuses to take me to one,” one 15-year-old girl said. “She says there’s nothing wrong with me.” She and more than a dozen other adolescents from the club agreed to share their thoughts about mental health on the condition that their names not be published, to protect their privacy.

Some described struggling with anxiety, depression, suicidal thoughts or self-harm. The girl said she sometimes cut herself with the blade from a pencil sharpener to counter her anxiety and sadness.

Like many in the group, she said she stayed up late on her phone and slept only a few hours each night. Another girl, 12, was often up until 1 or 2 am looking at TikTok and Snapchat. “I’m overwhelmed a lot, by school,” she said. A third girl, 13, described the previous night: “I took a melatonin at 3 o’clock and fell asleep at 3:15.”

Recent research found that teenagers with poor sleep habits were more likely to have mental health problems during the pandemic.

Katrina Ayres, the mental health coordinator for the local school district, pointed to another change: Students were deeply focused on themselves, selfie-obsessed, which led them to “think everybody is looking at me,” she said. “We’re raising a generation that is very ‘me’ focused.”

Ayres joined the school district in 2020 with support from a federal grant and other funds. Under a new programme, the schools have surveyed students, and those who are found to be at risk receive counselling, regular check-ins from a teacher or referrals for treatment. As part of a separate programme, some of the students distributed food to needy families at Thanksgiving and Christmas.

“They need to see they’re part of a bigger picture,” Ayres said.

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