In the complicated world of the American teenager, Sarah Turner had it all.

Beauty, loving family and friends, good grades.

And yet, something was not right.

"I always would get really upset for no reason," said Sarah. "I would start crying for no reason. I had a really hard time falling asleep."

Sarah, 16, was diagnosed with clinical depression three years ago.

And so the teenager, like the 3 million other depressed adolescents across the country, unwittingly finds herself at the center of a passionate and sometimes politically charged discussion on the seriousness of teenage depression and whether, when and how medicine should be used to treat it.

Experts estimate that one in 20 teens will have a depressive episode, and most -- four in five -- will not receive treatment. Many will not be treated because their parents and teachers miss the symptoms -- anger chief among them.

For those who are treated, doctors have increasingly turned to anti-depressants. An estimated 2.5 million prescriptions were written for children and teens in 2002, up from about 50,000 in 1992.

Parents have reservations about the drugs, even under ideal circumstances. Many have become even more confused in light of three recent bits of conflicting news on the use of anti-depressants in teens:

• The Food and Drug Administration in June advised that Paxil not be prescribed for teens and younger children until further study.

• Wyeth, the manufacturer of Effexor, wrote a letter to thousands of doctors in August stating "increased reports of hostility" and suicide ideation in pediatric clinical trials. The company also said that benefits of the drug in children had not been established.

• Also in August, the results of a study were published in the Journal of the American Medical Association showing that sertraline, marketed as Zoloft, relieved symptoms of depression in children and teens.

Many parents interviewed did not want their children's names published because of the persistent stigma of mental health. Some spoke, with voices cracking, of innocence lost under the glaring lights of an emergency room after a suicide attempt. Or of their children riding in a deputy's car to be admitted to a mental health facility, and of the pain of having an illness for which some people offer little or no sympathy.

All spoke of the hard choices of treating an illness that pushed their children into an emotional and mental ditch.

"Yes, it was hard to make that decision," said Sarah's mother, Lisa Turner, of her choice to have Sarah treated with drugs. She worried that the drugs would steal Sarah's personality or teach her that it was OK to take a pill to change a bad feeling.

"I didn't want to make that mistake of treating someone who was just sad. I didn't want to gloss over normal emotions," Turner said.

But she also sensed that something was very wrong with her daughter. And she went through similar symptoms -- and struggles -- with her oldest daughter, Catherine.

"It was awful, just awful," she said. "I finally realized I would be depriving them if I didn't."

Misunderstood illness

Doctors and researchers have only recently begun to understand the seriousness of teenage depression. For years, they were unsure whether clinical depression -- a chemical imbalance in the brain that causes self-destructive thoughts, poor self-image, anger, sadness and lethargy and that can lead to suicide or homicide -- afflicted teens. Many physicians -- to say nothing of parents and teachers -- were quick to blame the hormonal roller coaster of adolescence.

A threefold increase in teen suicides from the 1950s until the late 1990s, coupled with more research and the first U.S. surgeon general's report on mental illness, revealed a malady more serious than hormonal changes.

"It's a major cause of teenage suicide, but to various degrees it interferes with a child's ability to learn, form relationships, and their sexual behavior," former U.S. Surgeon General David Satcher said in a recent interview.

Close to 3,000 teens each year take their own lives, and 90 percent had been diagnosed with a mental health condition, often depression. Doctors also link depression to violent behavior and crime, with some estimating that as many as two in three teens in the juvenile justice system had shown signs of depression.

"Getting sick in general is very bad in teens, but having a psychiatric disorder can really be devastating," said Dr. Harold Koplewicz, director of the Child Study Center at New York University. "The worst outcome is suicide, but the others are not very good."

"If a teen is depressed, they are missing out of essential socialization, learning about trust, learning about group behavior," said Larry Riso, a Georgia State University professor who is conducting a study on treating adolescent depression with behavioral therapy. "If you miss out on that, there's almost no getting that back."

Depression is hard to treat even in adults. In 1986, a class of anti-depressants called selective serotonin reuptake inhibitors, which include Prozac, Zoloft and Paxil, began to offer hope. As doctors saw improvement in adults, they began to prescribe the drugs for children and teens, usually in much smaller doses.

The drugs have long had their critics, even for adults. But the issue is even more charged for children and adolescents.

Tony and Mary Zizza of Douglasville learned that Mary's daughter, Heather Lawless, had been on Paxil when Heather lived with her father.

"I was horrified," said Tony Zizza, her stepfather.

	MONIRA AL-HAROUN / Special Heather Lawless, 16, now lives with her mother and stepfather -- who took her off Paxil. Mary and Tony Zizza belong to a group that opposes medicating children with mood-altering drugs.

After becoming caught in a custody dispute and going to live with her father, Heather, 16, was diagnosed with depression.

"I felt angry. I felt sad. I felt all the feelings except for happy," Heather said.

All she really wanted, she said, was to see her mother. Her father, Blackie Lawless, refused comment.

Last spring, she moved in with her mother and stepfather. She said her mood improved, and her mother and stepfather weaned her from Paxil.

"This is the part that bugs me," said Tony Zizza. "Kids can't go through anything sour anymore. We have grief counselors at schools. I'd love to see a kid go to a gym, sweat for an hour and see how they feel after an hour of exercise."

The Zizzas are members of a group that opposes the medication of children with mood-altering drugs. The group, Ablechild, has a Web site ( www.ablechild.org/) and advocates in seven states.

No easy choices

Doctors say there are two major forms of depression. Major depressive disorder, or clinical depression, is linked to a chemical imbalance in the brain. The other form of depression, which causes a chemical imbalance, is brought on by external forces, such as divorce, death or other forms of trauma.

Parents of teens who take anti-depressants are not elated that their children are on the drugs. Some blame themselves, seeing their children's illness as a personal failure. Most, like Turner, say they had no choice.

Turner knew that her daughters' difficulties could be biological because of a family history of depression. The family worked with a psychiatrist, who ruled out other causes over months and who helped the girls work through some behavioral issues, such as teaching them how to manage stress better. Their psychiatrist still carefully monitors their reactions.

Such careful handling of teenage depression, however, is more the exception than the norm, doctors and researchers report. And the lack of expert care is a bigger cause for concern than the prescribing of anti-depressants, many said.

"More mental health is falling to pediatricians, and it's very anxiety-provoking," said Dr. John Ring, chairman of the Committee on Drugs of the American Academy of Pediatrics. "The problem is not the drugs, it's who's prescribing them."

Ring's and others' concern is not only about a lack of psychiatric monitoring of the drugs. They also worry that teens are not getting an essential part of their treatment if they are not also undergoing behavioral therapy.

"Anti-depressants will not work by themselves," said Dr. Graham Emslie, a professor at the University of Texas Southwestern Medical Center in Dallas and the first researcher to study the effectiveness of anti-depressants in children.

Emslie, like many psychiatrists, is encouraged by a recent study showing that sertraline, or Zoloft, is effective in children and adolescents.

The results of that study, the first large-scale, multisite study on anti-depressants and children, were published in the Aug. 24 edition of the Journal of the AMA. Doctors and parents were encouraged that the study showed that 69 percent of respondents improved after taking sertraline, even though 59 percent of those who took a placebo also showed improvement.

That even a modest 10 percent difference was deemed encouraging reveals how eager parents are for some good news about the drugs, experts said, especially after the revelation that two other anti-depressants had been linked to increased suicidal thoughts in teens.

Two months earlier, the FDA had issued the advisory saying that Paxil should not be prescribed for children until further review.

And in August, Wyeth, which manufactures Effexor, sent letters to thousands of pediatricians telling them not to prescribe the drug for youngsters. Effexor is not in the same class as the SSRIs but has been prescribed for adolescent depression.

Still, experts said they believe the anti-depressants can be an important and effective tool if properly prescribed and closely monitored. Many said they worry more that the relatively low cost of the anti-depressants could lull parents into thinking their child's illness is cured when it is not.

A month's supply of Prozac, for example, costs about $140, while its generic counterpart is available on some prescription plans for $20. A psychotherapy session runs from about $120 to $225 an hour. Thus, a month's psychotherapy treatment would cost between $480 and $900.

Time also is an issue for families dealing with depression. While insurance companies are limiting the number of psychotherapy visits in a year -- some to as few as 10 -- busy parents and teens angry to be going to a therapist in the first place are just as content to skip the session in some cases.

A greater problem, mental health officials said, is a severe shortage of child psychiatrists and doctors who are trained in mental illnesses and their treatment. There are 6,400 child psychiatrists around the country, or an average of 128 per state.

An important option

In Sarah's and Catherine's cases, their anger became so sharp that it was hard to ignore.

Catherine's usual outlet, drawing, had no appeal. Sarah had trouble in school. Both lost interest in their friends.

Now the girls say they feel good. Catherine is a senior at Decatur High and is on the school newspaper staff. She has nurtured an interest in photography and is drawing again. Sarah was on the school's drill team last year. She is doing better in school and feels more connected to her friends.

While mental health professionals remain concerned about anti-depressant prescriptions coming from general practitioners and pediatricians, they stress that they believe the drugs are an important treatment option for children and teens. They do not want concern over the drugs to lead to children not being treated for depression; they want more providers, better insurance to cover the long hours of therapy and more research.

And they want parents to stay involved in their children's lives and closely watch children who have been diagnosed with depression and those showing prolonged anger.

"Parents should be as much engaged with the child as possible," said Dr. Thom Bornemann, director of Mental Health Programs at the Carter Center. "How are they relating to peers? How are they relating to other children in the home? Are they involved in appropriate peer activities?"