The doctor sat in a small exam room with a mother and a girl in January. The girl was one of three dozen young patients that the doctor would see that day that were positive for the coronaviruses.
This girl was part of a different epidemic that has gripped the community and nation since long before Covid: She and her mother had come to discuss the girl's declining mental health.
The girl had dark hair and wore jeans and a T-shirt with the words "Purple Rain" written on it. The girl said she wouldn't go for therapy.
She told the girl to get off the phone and computer.
The girl was prescribed Zoloft by Dr. Dennison, but she wasn't sure if she was depressed.
I would rather they see a Psychiatrist, she said.
The major health risks facing adolescents in the U.S. have changed dramatically over the last three decades. Mental health disorders have overtaken physical conditions as the most common issues causing limitations among adolescents according to a report by the American Academy of Pediatrics. In December, the U.S. Surgeon General warned of a mental health crisis among American teens.
The medical system has failed to keep up, and the transformation has put emergency rooms and pediatricians at the forefront of mental health care. Community doctors now deal with complex psychiatric issues, making tough diagnoses after brief visits and prescribe powerful psychiatric medications for lack of better alternatives.
She said medical training lags behind and that the whole system needs to be changed.
In Glasgow, Ky., there are counselors in the schools and therapists in town. They are usually booked months out. There are few Psychiatrists here and nationwide. Most of the United States lacks a psychiatrists specializing in children or adolescents, and the psychiatrists who can be found are concentrated in wealthier areas.
There is a need and nowhere else to go, according to Dr. David Lohr, a child and adolescent psychiatrist at the University of Louisville.
Dr. Dennison has adapted. Two decades ago, she prescribed antibiotics to patients with strep throat, earaches and wheezing. At least 50 percent of her cases are related to mental and behavioral health.
The causes of the crisis are not fully understood. Many possible factors are pointed out by experts. Declines in sleep, physical activity and other healthful activities have been caused by lifestyle changes. A major factor in depression and suicide is feeling particularly lonely. Social media is often blamed for the changes, but there is a lack of data to back it up.
The challenges in Glasgow are intensified by the high rates of drug addiction and poverty.
Percentage of children living in poverty.
300
Per 100,000 people.
Percentage of children living in poverty.
300
Per 100,000 people.
Percentage of children living in poverty.
300
Per 100,000 people.
The stigma around mental health issues has lessened. A bright hallway decorated with colorful images of animals, seats filled with adolescent patients, one entering Dr. Dennison's office every 15 minutes, are just some of the examples of sites for mental health care around the country.
A girl in a black sweatshirt and ripped jeans was the first patient of Dr. Dennison the next morning. The aunt and girl allowed a reporter into the exam room, but asked that their names not be used, to protect their privacy.
Dr. Dennison moved from room to room on a stand behind her computer. She wore an orange blouse and black pants with tiger-print stripes.
After completing medical school at the University of Louisville, she went to work as a doctor in Glasgow. The children of patients she treated in Glasgow two decades ago are included in her practice today.
The girl in her office was a newborn. At 6 months the girl was taken in by her grandmother and step-grandfather because the parents were heavy users of drugs. She was 7 years old when she was prescribed Adderall.
The girl's step-grandfather had raped her when she was 9. The man is serving a 10-year sentence in Kentucky for sexually abusing a girl. The aunt was in charge of the girl.
Zoloft was prescribed by Dr. Dennison at the time. The girl took it for a short time but was concerned about the side effects. The girl was given a prescription for Trazodone when she was 11.
The girl was getting into trouble at school and her aunt was getting a call once a week from the school.
At the beginning of the recent visit, Dr. Dennison asked if the Zoloft was helping.
The aunt said it was hard to say. She turned to the girl and said: "They were bad, really bad."
The girl showed Dr. Dennison the scars on her wrist, which were still red and tender.
Dr. Dennison looked at the scars. You have so much going for you. I wish we could show you that.
Dr. Dennison suggested Prozac. The availability of powerful prescription medications to address a range of mental health issues has changed one aspect of her job.
Over the course of two days, Dr. Dennison had 66 appointments. Many of the patients she dealt with took 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 A.D.H.D., and Remeron for major depressive disorder.
The use of psychiatric medications in young people is one indicator of the mental health crisis. The number of prescriptions for antidepressants for teenagers increased by 38 percent from 2015 to 2019.
Many of the major psychiatric drugs have not been studied for their combined or long-term effects, and some health experts are alarmed that they are so widely prescribed to children and adolescents. Some antidepressants have been shown to increase the risk of suicide among children and adolescents. Prozac has a black box warning of the risks.
She conceded that it was not ideal to prescribe so many drugs.
She said, "You want to do something, you know?" I told the 14-year-old that this wasn't going to fix her. If it takes a month to get into your system, you should be happy. You need to do more to make yourself happy.
R.R. Donnelley & Sons Company, one of Glasgow's biggest employers, announced a major expansion in 2001. The company, a printer of magazines, bibles and other materials, would add manufacturing space and 100 employees.
The plant closed in 2020 because of the decline of paper, and most other managerial and skilled manufacturing jobs left Glasgow.
Dr. Dennison and her husband were the parents of three children who lived in the town. Glasgow has a poverty rate of 27 percent and a median household income of $28,000 according to a data company.
The county seat is in the middle of the aging downtown square and a few of the businesses are closed. There are American flags on light poles. The streets are a few blocks away from the single-story and ranch-style houses.
Dr. Dennison's life changed as well. She grew up on a tobacco farm and developed strong beliefs about self-reliance. She got divorced and had bouts of anxiety. She took the drug and saw a counselor.
She said that she used to be a self-righteous little jerk. I went through the divorce.
She noticed a change in her patients' health issues around this time.
She decided to spread the word that she was available to help with issues such as A.D.H.D., depression and anxiety. She had to learn online through continuing-education courses. She attended a conference on child and adolescent Psychiatry in New York City.
Understand the signs. Depression and anxiety are different issues, but they share some indicators. Look for changes in the behavior of a youth. A teen in distress may express worry or profound sadness.
Approach with sensitivity. If you want to start a discussion with a teen who might be struggling, be clear and direct. Don't shy from hard questions, but also approach the issue with compassion and not blame.
The correct diagnosis should be obtained. Ask for recommendations to find the right doctor for your child. Ask the specialist if she uses the measurement tools to make medical assessments and if she has treated specific conditions in children.
Carefully consider the effects of your medication. If you want to know if a medication is working and how hard it is to wean off of it, you need to know the doctors experience treating children with specific drugs.
Don't forget the basics. Young people with developing brains need eight to 10 hours of sleep to promote mental and physical health. Lack of sleep can affect development. Physical activity is important.
She said she picked up a lot. She asked psychiatrists about drugs that were not approved for use in children. It was like that.
She said that the easiest way to treat an abscess was to pop it open.
Dr. Dennison gives advice and medication. She shares with families her opinions about the need for their children to exercise and spend time outdoors.
She said that they have too much screen time and are not sleeping. Parents don't want their children to be disconnected. She said that poverty, Obesity and puberty, which is arriving earlier for many children, are factors.
She told patients to get their God-walk right or it wouldn't do them any good.
She is going to tell you that her son sees Dr. Dennison for his A.D.H.D. and anxiety. There wasn't a psychiatrist that the family could find.
She said that her experience with her son helped her support the students she counseled at school. She tells them that a mental health problem can strike anyone and that they have a good home and parents who love them.
Some adults who work with adolescents in Glasgow have theories about why this generation has mental health issues. Mallie Boston, who grew up in town and is now the executive director of the Boys and Girls Club of Glasgow-Barren County, said that today's teens are less physically active and spend less time hanging out.
If you come to Glasgow right now, you can either go to the movie theater or watch a movie with your friends.
She tries to get them to play dodgeball.
On a weekday afternoon, a couple hundred children and adolescents come to play basketball and volleyball at the club, which is located in a building a couple of miles from Dr. Dennison's office. Many of them are from families that are struggling and a few didn't see a doctor at all.
One 15-year-old girl said that her mom wouldn't take her to one.
Some said they were struggling with anxiety, depression, suicidal thoughts or self- harm. The girl said that she used to cut herself with the pencil sharpener blade to counter her feelings.
She said that it releases the pain. She said that she wanted to cut more and let herself bleed out, but she talked to her friends and they said they would be mad at her.
She said she stayed up late on her phone and slept only a few hours each night. The girl was up until 2 a.m. looking at her phone. The third girl said that she took melatonin at 3 pm and fell asleep at 3:15.
Teens with poor sleep habits are more likely to have mental health problems. According to the Centers for Disease Control and Prevention, the percentage of high school students getting at least eight hours of sleep a night has fallen.
Ayres said that students were focused on themselves and thought everyone was looking at them.
Ms. Ayres joined the school district in 2020 with the help of a federal grant. Students who are found to be at risk receive counseling, regular check-ins from a teacher or referrals for treatment under a new program. Some students distributed food to needy families at Thanksgiving and Christmas.
They need to see that they are part of a bigger picture.
At 11 a.m. on Tuesday, Dennison was going to have a telehealth visit with a 13-year-old girl who may be the most depressed kid she has.
The girl began seeing Dr. Dennison for weight issues in 2020, but she grew more anxious. Dr. Dennison prescribed Prozac to her in August of 2021. The girl refused to come to the phone in November.
At the appointment, the mother revealed that her daughter had not been to school in months and that the nearest hospital that could care for her was 35 miles away in Bowling Green.
The mother was begging for help. She couldn't get her to go to school.
Dr. Dennison called the hospital and was told that the mother had reported that her daughter was not suicidal. If we don't do something, we're going to lose her.
Dr. Dennison stood in the hallway waiting for the girl to check in online. The hour came and went, and they didn't show up. The office tried to call the mother, but couldn't.
Dr. Dennison said he would have to follow up with that one.
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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