Publisher Health

GLASGOW, Ky. — 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 pediatrician 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: 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 bearing the words “Purple Rain.” She was depressed, she told Dr. Dennison, and had been cutting her arm to relieve her emotional pain. Dr. Dennison suggested therapy, but the girl said she would not go.

After the exam, Dr. 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.”

Dr. 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 U.S. adolescents have shifted drastically: Teen 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 U.S. Surgeon General, in a rare public advisory, warned of a “devastating” mental health crisis among American teens.

But the medical system has failed to keep up, and the transformation has increasingly put emergency rooms and pediatricians 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. “Pediatricians need to take on a larger role in addressing mental health problems,” the 2019 A.A.P. report concluded. “Yet, the majority of pediatricians do not feel prepared to do so.”

Dr. Cori M. Green, a co-author of that report and a pediatrician at Weill Cornell Medicine, said medical training lagged behind. “We need to overhaul the whole system,” she said. “We need to see mental health through a prevention lens and stop seeing physical health as different than mental health.”

In Glasgow, Ky., as elsewhere, there are counselors in the schools and therapists in town, including four at Dr. Dennison’s clinic. But they are often booked months out. Psychiatrists are scarce, here and nationwide. Seventy percent of counties in the United States lack a psychiatrist specializing 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.

Dr. 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 A.D.H.D.,” she said, referring to attention deficit hyperactivity disorder. She estimated that, back then, 1 percent of her cases related to mental and behavioral health; now at least 50 percent do.

The causes of this crisis are not fully understood. Experts point to many possible factors. Lifestyle changes have led to declines in sleep, physical activity and other healthful activities among adolescents. This generation professes to feeling particularly lonely, a major factor in depression and suicide. Social media is often blamed for these changes, but there is a shortage of data establishing it firmly as a cause.

In Glasgow, a town of 14,000, the challenges are intensified by high rates of drug addiction and poverty and their effect on families.

But the stigma around mental health issues, at least, has eased. Around the country, sites for mental health care look ever more like Glasgow Pediatric Associates: a bright hallway decorated with colorful images of animals, seats filled with adolescent patients, one entering Dr. Dennison’s office every 15 minutes.

Scars and medication

Dr. Dennison’s first patient the next morning was a 12-year-old girl in a black sweatshirt and ripped jeans who had arrived with her aunt. (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 took her usual spot behind a computer on a stand that she wheeled from room to room. She wore an orange blouse and black pants with tiger-print stripes. “I like to dress up when I have the energy,” she said.

She began as a pediatrician in Glasgow in 1990, after completing medical school at the University of Louisville (her parents had preferred that she become a nurse) and a pediatric residency in Texas. Her practice today includes the children of patients whom she treated in Glasgow two decades ago.

The girl in her office had first come to Dr. Dennison as a newborn. The parents were heavy users of various drugs, and at 6 months the girl was taken in by her grandmother and step-grandfather. At 7 years old, she was having trouble focusing in school, and Dr. Dennison prescribed Adderall for A.D.H.D.

When the girl was 9, it emerged that her step-grandfather had raped her. (The man is in prison in Kentucky, serving a 10-year sentence after being convicted in 2019 for sexual abuse of the girl.) The girl was transferred to the custody of the aunt.

At the time, Dr. Dennison prescribed Zoloft for depression. The girl took it for a brief period but worried about side effects and asked to stop. When the girl was 11, Dr. Dennison gave her a prescription for Trazodone to help with sleep.

Late in 2021, the girl was expressing “wild outbursts at home” and repeatedly getting into trouble at school, the aunt recalled: “I was getting a call once a week from the school.” Dr. Dennison put her back on Zoloft.

At the start of the recent visit, Dr. Dennison asked: “You think the Zoloft is helping?”

“It’s hard to say,” the aunt replied. “We had another incident over Christmas break. She started cutting herself.” She turned to the girl: “Show her.” She turned back to the doctor: “They were bad, really bad.”

The girl pulled up her left sleeve to show Dr. Dennison eight scars, still red and tender, on her wrist. “I thought it would take the stress away,” the girl said. “But it made everything 100 times worse.”

Dr. Dennison examined the scars. “You’ve got to help yourself — right, Ding-Dong?” she said. “You’re such a cute girl. You have so much going for you. I wish we could make you see that.”

Dr. Dennison suggested switching the antidepressant to Prozac. One key aspect of her job that has changed is the availability of powerful prescription medications to address a range of mental health issues.

Over two days, Dr. Dennison had 66 appointments, 20 of them related to mental and behavioral 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 A.D.H.D.; 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 percent for teenagers compared with 15 percent for adults, according to Express Scripts, a major mail-order pharmacy.

Some health experts have expressed alarm that, nationwide, major psychiatric drugs are so widely prescribed to children and adolescents even though many of these medications have not been studied for their combined or long-term effects. They also worry that some antidepressants have been shown to increase the risk of suicide among children and adolescents. Prozac carries a “black box” warning of such risks.

Dr. Dennison conceded that prescribing so many drugs was not ideal. “I don’t want to do it,” she conceded. “I do a lot of medication, but there is no place for these people to go.”

She added, “You want to do something, I guess, you know? Like the girl with Zoloft” — the 14-year-old who had come to her office in January. “I said, ‘This isn’t going to fix you, maybe it’ll help you. If it takes a month to get into your system, see if it makes you feel better, makes your mood better, makes you happier. But you need to do other things to make you happier, too.’”

Changing times, changing practice

In May 2001, one of Glasgow’s biggest employers, R.R. Donnelley & Sons Company, 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 spelled the decline of paper, and the plant closed for good in 2020; most other managerial and skilled manufacturing jobs had long since fled Glasgow.

Dr. 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 percent 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. American flags hang outside other retailers and on light poles. Just a few blocks away, residents say, opiates and methamphetamine are easily acquired in the streets amid the single-story and ranch-style houses.

Dr. 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 counselor 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.”

Around this time, she noticed a change in the health issues confronting her patients.

She decided to shift the emphasis of her practice and spread word that she was available to help with issues like A.D.H.D., autism, depression and anxiety. That meant retraining herself, learning online through continuing-education courses. In 2018, she attended a conference focused on child and adolescent psychiatry in New York City.

“I picked up a lot,” she said. She recalled asking psychiatrists about drugs not approved for use in children, like stimulants for A.D.H.D. “One said, ‘Dexedrine is approved for use down to 4 years of age.’ He was right. It was stuff like that.”

She noted that her current cases were rarely as clear-cut as the old ones. “The easiest thing to treat is an abscess,” she said. “You pop it open, give antibiotics and they get better.” With mental health cases, “we’re not resolving,” she said. “It’s like the old song: You’re putting a ‘Band-Aid on a bullet wound.’”

Dr. 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.”

She noted the decline in local church attendance, and she regularly tells patients “to get their God-walk right or it doesn’t do a bit of good,” she said. “That’s free of charge.”

Courtney Benefield, a counselor for ninth and 10th graders at the high school, has a 6-year-old son who sees Dr. Dennison for his A.D.H.D. and anxiety. “She’s going to tell you exactly how it is,” Ms. Benefield said of the pediatrician. The family had discussed finding a psychiatrist for her son, Ms. Benefield added, “but there wasn’t one available.”

She said that her experience with her son helped her support the students she counseled at school: “They’re on all the same medicine my son is on. I tell them, ‘You’ve got a good home and parents who love you.’” But a mental health problem can strike anyone, she tells them: “It doesn’t discriminate.”

Looking for healthy outlets

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 teens were less physically active and spent less time just hanging out.

“If you come to Glasgow right now,” Ms. Boston said, “the options for what you can do are the movie theater, which is identical to when I was a child, or you have Ralphie’s, the bowling alley.” A lot of time now is spent online, she said. “TikTok is such dopamine fuel,” she said. “I worry it is their dopamine.”

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 Dr. Dennison’s office; on a weekday afternoon, a couple 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 that 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 that she sometimes cut herself with the blade from a pencil sharpener to counter her anxiety and sadness.

“It releases the pain,” she said. She described a recent incident: “I wanted to cut more and let myself bleed out, but I talked to my friends and they said they’d be mad at me.”

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 a.m. 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 teens with poor sleep habits were more likely to have mental health problems during the pandemic. And in general, adolescents have been getting less sleep, according to the Centers for Disease Control and Prevention: 25.4 percent of high school students got at least eight hours of sleep a night in 2017, down from 31.1 percent in 2007.

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.”

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

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

The girl who wasn’t there

At 11 a.m. on that Tuesday, Dr. Dennison had scheduled a telehealth visit with a 13-year-old girl “who may be the most depressed kid I have,” she said.

The girl first began seeing Dr. Dennison, along with a dietitian in the office, in 2020, for weight issues, but she grew increasingly anxious. In August of 2021, Dr. Dennison prescribed Prozac and referred her to a behavioral therapist who also works out of the pediatric offices. In November, the girl had refused to come to the phone for a telehealth visit.

At the appointment, the mother revealed that her daughter had not been to school in months — and that the nearest inpatient psychiatric hospital, Rivendell Behavioral Health Hospital, 35 miles away in Bowling Green, did not have an opening.

“The mother was begging me for inpatient services,” Dr. Dennison recalled. “She could not get her daughter out of her bedroom. She could not get her to go to school.”

Dr. Dennison called the hospital herself and, by her account, was told that the mother had reported that her daughter was not suicidal. Dr. Dennison replied, “We’re about to lose her if we don’t do something.”

As the 11 a.m. appointment approached, Dr. Dennison stood in the hallway, waiting for the girl to check in online. The hour came and went. “They didn’t show up,” Dr. Dennison said with a sigh. Her office tried calling the mother but got no answer.

“I’m going to have to follow up with that one,” Dr. Dennison said. “Whatever we’re doing isn’t working.”