Neither Music nor Facebook Cause Depression in Teens

Although a recent study published in the Archives of Pediatrics and Adolescent Medicine did not find that listening to music causes depression in teenagers, news headlines and tweets on Twitter may have left the impression it does. Despite caveats provided by the authors, most readers are likely to believe it  because they don't understand the difference between correlation (the degree to which things tend to occur together) and causation.

Researchers at the University of Pittsburgh School of Medicine contacted 106 adolescents up to 60 times via cellphone over 5 weeks to ask about their media use at the time of the call. Forty-six teens had already been diagnosed with Major Depressive Disorder. Of the five media activities (television or movies, music, video games, Internet, and print media, such as magazines, newspapers, and books), only listening to music and reading were correlated with depression. In other words, the depressed teens were significantly more likely to be listening to music and less likely to be reading print media than the non-depressed teens. The researchers properly conclude that the association does not prove causality:

Major depressive disorder is positively associated with popular music exposure and negatively associated with reading print media such as books. Further research elucidating the directionality and strength of these relationships may help advance understanding of the relationships between media use and MDD.

These results are not surprising. One of the symptoms of depression is withdrawal. In previous generations, depressed teens would shut themselves in their room and listen to music on their stereos. Now, Ipods and MP3 players make it possible for them to isolate themselves while in the presence of others. The finding that depressed teens spend less time reading is likely due to poor concentration--another symptom of depression.

Sometimes researchers demonstrate their own problems in interpreting correlational results. The supposed discovery of "Facebook depression" is one such example. A clinical report published in Pediatrics linked teen depression and time spent on Facebook. In it, the authors created the term "Facebook depression" which they defined as "depression that develops when preteens and teens spend a great deal of time on social media sites, such as Facebook, and then begin to exhibit classic symptoms of depression." They go on to state that "adolescents who suffer from Facebook depression are at risk for social isolation and sometimes turn to risky Internet sites and blogs for 'help' that may promote substance abuse, unsafe sexual practices, or aggressive or self-destructive behaviors."

Dr. Grohol points out in his critical analysis (Pediatrics Gets It Wrong About 'Facebook Depression') that the authors incorrectly relied on correlational results and second-hand media reports to come up with the term. He concludes:

If this is the level of “research” done to come to these conclusions about “Facebook depression,” the entire report is suspect and should be questioned. This is not an objective clinical report; this is a piece of propaganda spouting a particular agenda and bias. The problem now is that news outlets everywhere are picking up on “Facebook depression” and suggesting not only that it exists, but that researchers have found the online world somehow “triggers” depression in teens.

Overdrawn conclusions from single studies misdirects public attention away from known risk factors of depression such as child abuse, bullying, family history and learning disabilities.It leads parents to believe that limiting their teenager's time listening to music or using Facebook will prevent emotional problems including depression. If only it were that simple.

Primack, B., Silk, J., DeLozier, C., Shadel, W., Dillman Carpentier, F., Dahl, R., & Switzer, G. (2011). Using Ecological Momentary Assessment to Determine Media Use by Individuals With and Without Major Depressive Disorder Archives of Pediatrics and Adolescent Medicine, 165 (4), 360-365 DOI: 10.1001/archpediatrics.2011.27

O'Keeffe, G., Clarke-Pearson, K., & , . (2011). The Impact of Social Media on Children, Adolescents, and Families PEDIATRICS, 127 (4), 800-804 DOI: 10.1542/peds.2011-0054

Mental Health Parity and Health Insurance Reform

According to the American Psychological Association, nearly 90% of Americans have never heard of the Mental Health Parity law which requires equal benefits for medical, mental health and substance abuse treatment for most group health insurance plans. Forty-five percent did not even know if their health insurance covered mental health services.

The final regulations for the 2008 Paul Wellstone & Pete Domenici Mental Health Parity & Addiction Equity Act took effect January 1, 2011. Previously, many people seeking mental health treatment were shocked to find that their benefits for mental health and substance abuse were less than for medical. Most policies required higher co-pays or co-insurance, limits on the number of services per year, fewer days in the hospital, more intrusive authorization, and an additional deductible to satisfy. Plans that allowed subscribers to go out-of-network for medical services often restricted access for mental health providers to in-network providers.

The law now requires group health insurance plans and self-insured employers to provide equal benefits for physical health, mental health and substance abuse treatment. This translates into one deductible for all services, the same co-pay as for primary care doctors, and similar limits on number of visits, days of coverage, and annual and lifetime dollar amounts. Out-of-network services must be available if covered for medical benefits. However, the law did not cover plans for companies with less than 50 employees or most plans for individuals.

The healthcare reform bill passed in 2010 (aka the Patient Protection & Affordable Care Act) provides additional protections for persons needing mental health or substance abuse treatment. It extended parity to group plans with fewer than 50 employees and to individual plans which will be available through state exchanges by 2014.  Other provisions that took effect for all policies issued or renewed after September 23, 2010 include no more lifetime dollar limits for most health insurance benefits. (Annual limits will be prohibited starting in 2014.) Children under age 19 with preexisting conditions can no longer be excluded from health insurance coverage. The same protection will be extended to adults in 2014. Adult dependent children can now be covered under their parents' plans up to age 26.

Taken together, the two laws have significantly improved access to mental health services for the majority of children and adolescents:

• Pre-existing conditions - Teenagers first diagnosed and treated for depression as a child can not be excluded for coverage for subsequent episodes of depression when their parents change health insurance plans. Nor can the treatment of mental illness in childhood disqualify anyone for health insurance coverage as an adult.

• Lifetime caps on benefits - Children treated for severe mental illness in a residential facility will be less likely to max out their benefits before treatment is completed. This should lead to fewer parents having to give their child up to foster care after exhausting their private health insurance benefits and financial resources so that Medicaid (and taxpayers) will pick-up the bill.

• Coverage for dependent children up to age 26 - Parents will be able to afford life-saving treatment for their young adult child struggling with serious mental health conditions such as mood disorders, eating disorders, addiction, or schizophrenia. Research has established that early intervention and treatment is essential to prevent lifelong disability, suicide, or death from related causes.

To bring it home to dollars and cents, here's a story about how mental health parity has helped a teenager and his family afford treatment (Kaiser Health News):

For the Bryan family of San Antonio, the new laws are already making a difference. Their 17-year-old son, Kevin, has had bipolar disorder since he was a child. But as he went through adolescence, Kevin became increasingly paranoid and out of touch with reality, says his mother, Chris. About three years ago clinicians determined he suffered from schizoaffective disorder, a diagnosis that led to a change in his medication and a doubling of his outpatient therapy visits to twice a week. 

Unfortunately, the health plan covered only 52 outpatient therapy sessions annually, so by August or September of each year, the Bryans were paying $60 out-of-pocket each time Kevin had an appointment, or roughly $3,000 a year. "I kept making the point to the insurer that it was cheaper to cover his visits than to have him wind up in the hospital," says Chris Bryan, but nothing changed. 

Under the new parity provisions, and the annual cap on visits was lifted. Now, when Kevin visits his therapist, his parents are responsible only for a $15 co-payment. He is responding well to treatment and considering going to college next year. 

Now that parity has or will be extended to nearly all Americans with health insurance, there will be more success stories like Kevin's. For more information from the American Psychological Association see:

Resources on the Mental Health Parity Law

ADHD Awareness All Year Long

Let me start by saying I know ADHD Awareness Month was in September, but I believe it's important to be aware of ADHD all year long. So, in solidarity with ADHDers who procrastinate, here's a round-up of articles and resources I like.

One of the pages on the ADHD Awareness Week - September 13-17, 2010 site is Myths About ADHD. The article, originally from Attitude Magazine, describes seven common myths. My two favorites (italics are mine):

Myth #5: ADHD is the result of bad parenting. When a child with ADHD blurts things out or gets out of his seat in class, it’s not because he hasn’t been taught that these behaviors are wrong. It’s because he cannot control his impulses. The problem is rooted in brain chemistry, not discipline. In fact, overly strict parenting— which may involve punishing a child for things he can’t control— can actually make ADHD symptoms worse. Professional interventions, such as drug therapy, psychotherapy, and behavior modification therapy, are usually required.

Myth #6: Children who take ADHD medication are more likely to abuse drugs when they become teenagers.

Actually, it’s just the opposite. Having untreated ADHD increases the risk that an individual will abuse drugs or alcohol. Appropriate treatment reduces this risk. The medications used to treat ADHD have been proven safe and effective over more than 50 years of use. These drugs don’t cure ADHD, but they are highly effective at easing symptoms of the disorder. The drugs do not turn kids into addicts or zombies.

Both sites have links to a downloadable poster you can use to educate the misinformed.

Pediatrician Claudia Gold, M.D. expresses her concern about the common belief that medication without psychotherapy is sufficient to treat ADHD - With Psychiatric Drugs as an Option, Motivation may be Lost. I often see the results of this belief in my practice. Many of the children and teens with ADHD I see come to me after being on medication for several years as their only treatment. Their parents generally have little understanding of how ADHD affects their child beyond problems paying attention in school. Some have taken their child off medication because it hasn't "worked." Others are frustrated that their child still has academic and behavior problems despite being on medication. Unfortunately, both groups may blame their child for "not trying hard enough."

Let me be clear. I don't blame parents for their uneducated beliefs and misguided attempts to help their children. It's not surprising that parents are influenced by our contradictory cultural beliefs that drugs are the answer to everything or that all these children need is better discipline. Last year for ADHD Awareness Month, I wrote about the child's point of view in The Question ADHD Kids Dread Most and how their parents' frustrations can lead to parent-child conflict and more problems.

Teachers are another group who can use more education. Joan Teach at ADHD and School Success writes about the child with ADD (Attention Deficit Disorder without Hyperactivity) in the classroom--what it was like for her as a student, and what teachers can do to help in I’m In Your Classroom. Don’t Forget Me! She notes:

This child doesn’t make waves, appears somewhat spacey, not intellectually prone, seldom speaks up when called upon, and may not participate or turn in homework. You may be observing the youngster with the inattentive form of ADHD that is more difficult to diagnose.

Her description of herself as a child provides insight into the experience of the struggling, undiagnosed child. As a teacher today, she give specific tips teachers can use to help these children with memory, organization, and writing assignments.

Let's not get caught up in the either-or debate on medication vs. psychological treatment, or placing the blame on children, parents, or schools. It takes medical, psychological, and educational interventions along with parent education to make the difference for many children with ADD or ADHD. Here are some great resources for understanding the effects of ADHD on children and adults and what all of us can do to help:

• CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder)
• National Resource Center on AD/HD 
• LD OnLine (Learning Disabilities and ADHD)