When Teens Deny Depression: Understanding Stigma, Fear, and the Influence of Social Media

Ensuring an accurate mental health diagnosis for your digital-savvy teen

By Meredith Gansner, MD, author of Teen Depression Gone Viral

Liam, age 12, is irritable and feels “down.” He is sleeping all day, eating more than usual, and having periodic suicidal thoughts. Liam’s parents, pediatrician, and teachers are all relatively sure he’s depressed. He’s completed two PHQ-9 questionnaires at two separate times, and his scores indicated that he was at high risk for moderately severe depression. However, every time his depression diagnosis is brought up, Liam adamantly denies being depressed and says the tests are “wrong.” Why is he doing this?

Stigma

You no doubt know about the persisting stigma against psychiatric illness; it can be a reason that kids like Liam don’t want to admit to having a depressive disorder. While undeserved, there’s a pervasive belief that depression is a personal “failure” or weakness. This perception may be particularly relevant based on a teen’s gender and/or racial and ethnic background. Results from multiple studies have found increased mental health stigma among certain racial and ethnic minority populations, and this bias is not unique to adults. A study of over 1,000 sixth graders found that some racial and ethnic minority groups were more likely to desire social separation from classmates with mental illness.

Over time, mental health stigma has been lessening, and social media may have played a part in orchestrating this shift. Many organizations have been working to change societal perception of psychiatric illness for decades, but the advent of social media has made it possible to mobilize their messages on a massive scale. I’ll admit that (some) progress has been made; globally, we still have a long way to go.

Fear

Teenagers may also reject a depression diagnosis because they’re scared and the very organ required to process this news—the brain—is the same one that’s working suboptimally due to depression. We shouldn’t expect people with active depressive symptoms to display good insight any more than we should expect someone with a sprained ankle to run at their maximum speed. None of our organs are at the top of their game when they’re sick.

Belief in a “Different” Diagnosis

Liam’s parents, unsure of what to do, decide to consult a therapist. At the initial visit, the therapist asks Liam to talk more about why he doesn’t think he’s depressed. Liam says he’s not depressed because he’s seen videos posted online by teenagers with depression, and they don’t look like what he’s experiencing. He’s frustrated that his parents don’t believe his “real diagnosis.” When Liam’s therapist asks him to explain, Liam tells her he saw an online video with screening questions for dissociative identity disorder (DID), and the video made him realize that he must have DID. DID would explain why he feels like he has different “parts” to him and sometimes forgets doing things. Liam says that he told his parents about his DID diagnosis and they told him that he didn’t have DID. Now Liam is angry at them and thinks their disagreement is further proof that they don’t understand him.

I imagine that many of you have heard the phrase “If it looks like a duck, swims like a duck, and quacks like a duck, it probably is a duck.” Essentially, if an animal appears to meet all the objective qualifications to be classified as a duck, don’t overthink it: That animal is probably a duck. The medical field has a related proverb, “When you hear hoofbeats, think of horses, not zebras,” which also cautions against the dangers of overthinking things; stick with the most likely explanation for a collection of symptoms, rather than a rare illness.

In pediatric psychiatry, our horses are ADHD and depressive and anxiety disorders. Our zebras are disorders like DID, schizophrenia, or bipolar disorder. Zebra disorders need to be considered for sure, but they are far less common. So why might a teenager think they have one of these rare zebra disorders?

Social Media Influence

Psychiatrists and other mental health professionals have long suspected that social media platforms were influencing patients’ perceptions of their psychiatric symptoms. However, 2020 appeared to confirm these suspicions when a wave of zebra self-diagnoses coincided with the pandemic-induced explosion in screen time. Social media self-diagnosis refers to the seemingly contagion- like process of individuals identifying with less common neurocognitive or psychiatric disorders like ASD, DID, or tic disorder after watching videos about these disorders on social media. The videos are frequently posted by other individuals who report having these rarer diagnoses, but sometimes the veracity of their diagnoses is questionable. For example, many of the social media videos depicting tic disorder don’t match what neurologists typically see in real-life cases of tic disorder. Social media platforms create ideal conditions for the lateral transfer of psychiatric diagnoses, tics, nonsuicidal self- injury, disordered eating . . . you name it, it can probably be contagious.

What a Zebra Diagnosis Offers a Teen with Depression

Others may disagree, but I do not believe that a single online video or internet forum can convince an individual in perfect mental health to attempt suicide, develop an eating disorder, or adopt a rare psychiatric condition. That viewpoint seems alarmist and a gross oversimplification of what is likely a more complex psychological process. We must give more credit to the resiliency of the human brain, and there are valid concerns that a widespread belief that mental illness is contagious will further marginalize those who suffer from it.

However, vulnerable minds—especially young minds that are depressed, anxious, or have experienced trauma—may have more difficulty resisting social contagion. Every young person I’ve seen with “new-onset DID” was suffering from psychiatric symptoms, but symptoms of anxiety, depression, or trauma—not DID. Fortunately, existing research appears to support my belief. For social contagion to take off, you need individuals who are highly susceptible to influence and the social contagion process, like adolescents in psychiatric distress. Your child might not have DID, but they definitely could have another psychiatric disorder.

So, what does a zebra diagnosis offer an adolescent with depression? Imagine you’re 15 years old. You’re tasked with coming to terms with a rapidly changing body, emotions that are difficult to control, figuring out who you are and what you care about, and establishing a place within a network of peers, literally all at the same time. That alone is pretty tough. Now imagine you also have a depressed brain telling you, “You’re not worth it,” “You don’t belong,” and “You’re not special.” Then you discover an online video where another teenager talks about how they felt alone and were never understood until they realized that they had “X” disorder. You feel misunderstood. You feel alone. You know something is wrong, but you don’t know what that something is, and “X” disorder is rare; having “X” disorder makes you unique and special. You now know who you are, a teen with “X” disorder, and there’s a group of people online who are “just like you.” You’re not alone anymore.

It’s also worth mentioning that in addition to being less common, the social-media-fueled self-diagnoses “taking off” are ones that are increasingly embraced as neurodivergent identities. A similar movement toward acceptance hasn’t happened as much with anxiety or depressive disorders, perhaps because society tends to view depression and anxiety as symptoms that should be managed and treated, rather than as types of neurodiversity. Therefore, even if unconscious, it may feel easier for teens to adopt ASD or a tic disorder as part of a “new neurodivergent identity,” rather than “simply having depression.” Not infrequently, I hear the phrase “but I can’t just have depression” from my young patients.

The Takeaway

Depressive disorders are not uncommon in teenagers and are characterized by a depressed mood, negative thoughts about oneself, and various physiological symptoms like poor sleep and appetite. Most physicians and mental health clinicians can diagnose adolescent depression based on clinical presentation alone, but other tools can be used to help arrive at the diagnosis (questionnaires, testing).

Sometimes it’s hard for parents to recognize when their teenager is depressed. Sometimes it’s hard for teenagers to recognize that they’re depressed. There are multiple reasons a teen might push back against their depression diagnosis. Regardless of the specific reason, it’s best to avoid direct confrontation and to work slowly—yet methodically—to nudge the adolescent toward accepting their diagnosis. There will be many more battles to fight along the road to recovery. Forcing your teen to accept a depression diagnosis before they are ready to do so will only make that long journey harder for both of you.

Managing Digital Dangers

It’s totally understandable if you want to get your teenager off social media so they stop watching videos about DID. But if that’s the only place they’re feeling like they “belong,” forcing an abrupt separation may prove challenging.

Consider making their continued engagement with these videos depen- dent on their also accessing other forms of peer support specifically for depression (either online or offline!).

It might not go over too well with your teen if you demand to sit next to them while they scroll through videos on social media, but you should at least be checking out where they’re getting their information about psychiatric diagnoses. That’s the most surefire way to avoid being caught off guard if new (potentially unexpected) symptoms emerge.

Along those lines, even if you only suspect that your child is watching videos about psychiatric self-diagnosis, try to alert the other in-person supports in your child’s life who are helping to manage their mental health symptoms (like their therapist, pediatrician, psychiatrist, school counselor). New “symptoms” of “multiple personalities” or “dissociation” are extremely worrisome to most mental health providers, but potentially less so if clinicians realize that there may have been a social media influence.

Screen Supports

Social media self-diagnoses notwithstanding, the internet remains a valuable tool to help teenagers with depression. Especially for teens still resisting their depression diagnoses. While there can sometimes be opportunities for in-person peer-support groups through regional medical centers or local chapters of mental health advocacy organizations, access to in-person groups is by no means guaranteed. Thus, online groups or peer-support net- works nested under larger, mental health organizations (read: not random internet forums) may be the only option for many teens to “see” what depression looks like in people just like them. The National Alliance on Mental Illness has a teen and young adult helpline (reportedly staffed by well-trained young people who “get it”) that is available via text and chat (and old-school phone call). Or, if your teen isn’t yet ready for an active conversation, the AACAP website features some videos about depression specifically for teens (videos created by people who are way cooler than us child psychiatrists).