More Than Moody: Recognizing & Treating Adolescent Depression
DIAGNOSIS: DEPRESSION
More Than Moody: Recognizing & Treating Adolescent Depression
Dec. 17 — A national survey reveals that many teens experience feelings of
depression and sadness that often go untreated. Nine-out-of-10 adolescents say
they have experienced feelings of depression or sadness which last at least two
weeks. More than 80% of these depressed teens have never received treatment for
their symptoms. Dr. Harold Koplewicz, director of the New York University Child
Study Center, gives advice on how to treat teen depression in his latest book,
“More Than Moody: Recognizing and Treating Adolescent Depression.” Read an
excerpt below
What a pain Jasmine’s become. She’s sullen, she’s nasty to her parents and
siblings, and she’s generally very anxious. She’s doing poorly in school and
brings new meaning to the concept “lazy teenager.” Forget cleaning up her room;
Jasmine isn’t even bothering to brush her hair. She’s so irritable that when her
mother asked at dinner one night if she was going out later, she threw a roll at
her and stormed out, screaming, “I can’t talk to you! I can’t stand being in the
same room with you!” Jasmine’s parents wonder: Is she just being an unbearable
adolescent? Or is this something else?
The fact that Jasmine’s mom and dad are even asking the question is a good sign.
But the answer is a double-edged sword. On one hand, they want to see their
daughter as a normal teenager — even if it means putting up with all her
atrocious behavior. They feel a little guilty because they confide in each
other: “I can’t stand her.” Although they love her, they truly do not like their
child right now. But there’s comfort in the thought that they’re not the only
ones going through this — that millions and millions of other parents have
survived adolescence (including their own parents) and they will, too.
On the other hand, as with any other medical condition, there can also be relief
in finding out that what’s going on is not normal — as long as it’s followed
immediately by an assurance that something can be done about it. If Jasmine is
in fact depressed, her parents want to know what’s wrong, and they want to know
what can be done to help her — and they want to know it now. I have sat with
countless parents who are thrilled to hear that there is an explanation for
their children’s low moods and difficult behavior, and that there is a way to
treat it. That teenagers can suffer severe depression still seems
counterintuitive to many people — even physicians, who might be reluctant to
prematurely “brand” a young patient with a mental illness diagnosis. But we’ve
known for some time that, as was first reported in 1989 in the Journal of the
American Medical Association, depression seems to be occurring earlier in life
than ever before.
I’m not ready to declare that kids are more depressed than ever — we may just be
more aware of it — but the fact is that reported depression rates are actually
higher for adolescents than adults. This would no doubt be a big surprise to
Jasmine’s parents. But they would probably find it comforting to know that their
daughter isn’t the only one suffering — nor are they the only parents.
So what, exactly, is depression — what does this common word really mean? It is
actually a broad term that covers four distinct varieties of illness:
Major Depressive Disorder (MDD). This is a serious depression that in
adolescence lasts on average from seven to nine months. It has many similarities
to adult depression — sadness, pessimism, sleep and appetite disturbance,
decrease in concentration and sex drive — but in other ways it is distinct. For
instance, anxiety symptoms and irritability are more common in depressed
teenagers than adults. Adolescents frequently have the “atypical” form of MDD.
This is characterized by being overly sensitive to the environment and
responding to perceived negative interactions, with symptoms opposite of the
classic picture. Eating and sleeping too much, for instance, rather than not
enough.
Dysthymic Disorder. A milder but more chronic depression. Also called dysthymia,
it is a low-level depression that is felt most of the day, on most days, and
continues for years. In adolescents, the average duration is four years, meaning
that they spend virtually their entire adolescence depressed. A low mood for so
long a time during such a crucial period of development is likely to affect a
person’s mental state as an adult.
Double Depression. A combination of major depression and dysthymia — a
depression that is both serious and chronic.
Bipolar Disorder. Also known as manic-depression, this is characterized by
unusual shifts in mood and energy. Though there is debate about how prevalent it
is in young people, the condition frequently begins with a depressive episode
during adolescence. Research has also shown that anywhere from 20 to 40 percent
of adolescents with major depression develop bipolar disorder within five years.
Reactive Depression. The most common form of mood problem in children and
adolescents, but the least serious. This is a depressed state brought on by
difficulty adjusting to a disturbing experience — something as serious as the
loss of a parent or as relatively inconsequential as a rejection or a slight. It
usually lasts anywhere from a few hours to a couple of weeks and is not
considered a mental disorder.
Most of these terms and definitions apply generally, no matter a person’s age.
Clearly, though, there are differences between depression in adolescence and in
adulthood — sometimes subtle distinctions that parents need to understand in
order to know when it’s time to pick up the phone and make an appointment for an
evaluation. The good news is that there is a fairly straightforward list of
symptoms that can go a long way in distinguishing between normal teenage
moodiness and real depression. Some of these symptoms are similar to those that
characterize adult depression. Like adults, young people with depression are
likely to be lethargic, indecisive, and to lose interest in activities they
enjoy. They may be self-critical and feel unloved and pessimistic about the
future. But there are also some important differences — largely because adults
and adolescents are, physiologically and emotionally, very different animals.
Warning signs of depression in teens
IRRITABLE OR DEPRESSED MOOD
Parents need to get their teen help if they notice that their moods are lasting
more than two weeks
CHANGE IN SLEEPING HABITS
This includes either over or under sleeping.
CHANGE IN APPETITE
Same thing take note if your teen is eating more or less.
DIFFICULTY CONCENTRATING
Parents can usually notice if teens change their study habits or if there is
deterioration in academic performance.
Unfortunately, little can be said about diagnosis that is hard and fast. There
is no gold-standard medical test for depression or, for that matter, any other
mental illness. That’s the Holy Grail of psychiatry. Many parents have asked me
to do a brain scan on a child to determine what’s wrong. Today we can do any
number of scans and lab tests to diagnose cancer, heart disease, diabetes, and
other physical illnesses. We haven’t gotten there yet for mental illness.
Compared with, say, cardiology, psychiatry is an immature field, and a much more
complicated one. The brain is by far the most complex and mysterious of the
body’s organs, and the growing brain is even more so. The fact is that we barely
understand the mature brain, much less the developing one. So we have to
diagnose by talking to people. No matter how good a psychiatrist or psychologist
is at it, it’s still not a great way to make a medical diagnosis. But for now
it’s all we have.
With those caveats, there are some pretty reliable differences between adult and
adolescent depression. For instance, whereas depressed adults tend to be quietly
sad — you can feel their depression — teenagers are more likely to be angry,
irritable (or more irritable than usual), or to act out. It’s not that there is
a different quality to the irritability when a teenager is depressed, but that
it is more easily triggered, lasts longer, and comes with other symptoms. That
there is a closer relationship between irritability and depression in young
people than in adults is partly due to the fact that, to begin with, virtually
all teenagers are irritable. But it’s also because teenagers often have trouble
verbalizing their emotions, so instead of expressing how bad they feel, they
lash out. Parents and educators, in turn, might misinterpret this suddenly
aggressive behavior as a conduct problem. It’s no surprise that parents do very
poorly at identifying major depression in their children.
There are other differences. While sad adults are apt to have trouble sleeping
and lose their appetites, teenagers are likely to sleep and eat more. Depressed
young people are more likely to have an anxiety disorder — fear of separation
from parents or a reluctance to meet and socialize with peers — than adults with
depression. Also more common for teenagers are “somatic symptoms” — general
aches and pains, stomach aches, headaches. And while depressed adults tend to
lose their sex drive, teenagers will still likely have an interest. They may be
masturbating or responsive to someone else’s sexual interest. But they tend not
to pursue sex (or the idea of it) as they might have before they became
depressed.
Perhaps the biggest difference is the instability of adolescent depression.
While a 40-year-old is going to stay glum until the depression lifts, you can’t
count on a teenager to stay depressed 24/7. She has an ability to snap out of
it, even if it’s just for a few hours when she goes out with her friends, before
falling back into the depression. A friend with a teenager remarked to me, “I
never know who I’m going home to. She can be sweet and charming, but there are
days when she’s Cruella DeVil.” I remember my mother calling my sister “Dr.
Jekyll and Miss Hyde.” My father, coming home late, tired, and oblivious, called
her “Princess.”
Here is a glance at typical differences between adult and adolescent depression.
More Than Moody: Recognizing & Treating Adolescent Depression
I must repeat that — as you will see — the rub is that none of this is etched in
stone. Many teenagers experience depression in ways very similar to adults —
being more sullen than irritable, for instance, or having trouble eating and
sleeping. And, of course, whether it’s school or work, a person of any age going
through a depression will find it difficult, if not impossible, to concentrate.
So a marked drop in performance in school is one of the primary indicators that
a teenager is more than moody. But the fact that depression doesn’t always look
the same-and that it comes at a time of life that can be inscrutable anyway —
confuses parents: What do you mean he’s depressed? He’s kissing his girlfriend,
and as soon as she leaves he becomes surly with me. Isn’t that just being a
teenager? Parents often don’t recognize that this is a biological disorder with
consequences that can be much more serious than when it happens to an adult. One
sobering piece of evidence is that rates of completed suicides have increased
dramatically in adolescents over the past 40 years. We know that a large
percentage of suicide victims suffer from depression.
But even if it never comes to that extreme and irrevocable step, the teenager
can find herself falling behind in life in ways that can be hard to recover
from. An adult can manage to tread water at work and eventually regain her
footing without losing much ground. But a 15-year-old who falls into a
depression can lose an entire year or more of school, as well as become socially
impaired. In later chapters you will meet several young people whose depressions
have put them on such a detour that it will take years for them to recover — not
so much from the depression itself but from what they lost during their
struggles to overcome it. Recent research has demonstrated that depression that
comes on in adolescence is particularly insidious. It often follows the onset of
other mental disorders, such as an anxiety disorder or disruptive or antisocial
behavior, raising the possibility that the depression is a response to those
problems. Depression in teenagers is also closely associated with substance
abuse. In all, some two-thirds of young people with major depressive disorder (MDD)
have another mental disorder....
The good news is that the recovery rate from a single episode is quite high. The
bad news is that each episode increases the risk of having another one and that
the condition might continue into adulthood. So young people with severe
depressions can find themselves in a serious hole — especially if their illness
goes unrecognized and untreated. When their peers are graduating from college
and getting ready to become productive, independent adults, they are still
living at home, struggling to get on track. A generation ago, my generation,
this was sometimes known as “finding yourself.” I would venture to say that some
of these young people who were said to be finding themselves were actually
suffering from MDD. The message: it’s vital to recognize depression early and to
take aggressive steps to treat it.
What, exactly, is “mood”? It can be defined as a way of characterizing how
someone feels in the broadest sense, and how he or she expresses that feeling.
Mood, in either direction, can be affected by external events. In the case of
adolescents, this can be anything from acing a big test to getting dumped by a
boyfriend. Whether they are up or down, most people, of any age, return to their
“normal” moods — whatever that happens to be — after a short period. Not getting
to go on a date or to a movie might cause a teenager to be dispirited. Being
rejected by a boyfriend might cause her to become demoralized.
One way to distinguish between being dispirited and feeling demoralized is to
think of weather versus climate. Being dispirited is like the weather: it’s
raining today, and it may rain tomorrow, but the sun will be out the next day.
Being demoralized is like climate. It’s broader, more defining, more
all-encompassing. Florida has a tropical climate; you can count on it being hot
and humid a lot of the time. Semantics aside, the real issues are how bad a
young person feels and how easily he bounces back. An adolescent who is
demoralized may be able to snap out of it momentarily — if something good
occurs, he may be able to enjoy it — but it might not last. If it doesn’t — if
feeling bad becomes the new climate — then we’re talking about depression.
Dysthymia, meanwhile, a form of depression that may be less severe than major
depressive disorder, is chronic, and the treatment is the same. Clinical studies
on adults have shown that antidepressants are successful at treating both
dysthymia and depression.
Adolescence is demoralizing almost by definition. So how do parents decide if
their children may be depressed and need an evaluation? Here is a list of signs
that may be associated with depression in adolescents, compiled by the National
Institute of Mental Health:
Persistently sad or irritable mood
Loss of interest in activities once enjoyed
Significant change in sleeping patterns or appetite — sleeping or eating too
much or too little
Loss of energy
Feelings of worthlessness or inappropriate guilt
Difficulty concentrating
Recurrent thoughts of suicide
Frequent vague, unspecific physical complaints — headaches, muscle aches,
fatigue
Frequent absences from school, cutting classes, or a drop in academic
performance
Outbursts of shouting, complaining, unexplained irritability, or crying;
increased anger or hostility
Excessive boredom
Social isolation: lack of interest in friends and poor communication
Alcohol or drug abuse
Fear of death
Extreme sensitivity to rejection or failure
Reckless behavior
All of us experience some of the feelings and behaviors on this long list at one
time or another. I’ve been bored. I’ve had low energy. I’ve feared death. But it
takes more to make a diagnosis of major depressive disorder. There has to be a
significant change in mood overriding these feelings that lasts at least a few
weeks. “Significant” is the operative word, because with teenagers a mood can
last 30 seconds. Simply put, a significant change in mood for an adolescent
means going from fine to miserable and staying there for more than a couple of
weeks. Of course, what makes the diagnosis difficult in teenagers is that it’s
not uncommon for them to feel some of the things on the list and to have a
period of moodiness as well — and still not be clinically depressed. It’s the
duration of the symptoms that tell us if a teenager has crossed the line into
depression.
It can also be tough to distinguish between some associated conditions. For
instance, people who are socially anxious can look sad or withdrawn, especially
if they are in a public situation. Someone with separation anxiety might very
well look depressed when not in the company of her parents. These young people
may have an anxiety disorder alone, or they may have both anxiety and
depression. Consider also grief and bereavement. A reaction to a sudden and
powerful loss — whether it’s a personal tragedy or a more communal one, such as
the September 11 terrorist attacks, can make anyone depressed. Again, the key is
how long it lasts.
Meanwhile, physical illnesses always have to be ruled out before a diagnosis of
major depression can be made. A parasitic illness such as Lyme disease or a
virus such as the one that causes mononucleosis can lead to symptoms suggestive
of depression. Meanwhile, various diseases of the brain have strong associations
with depression. For example, there is evidence that lesions of the left frontal
lobe frequently cause major depressive disorder. Similarly, diseases such as
Parkinson’s also seem to be associated with depression. Virtually all this
research, however, is based on studies of adults. With adolescents, there is
emerging evidence that various forms of allergic disorders, chronic infections,
and immunological diseases may show specific associations with depression.
It’s critical for parents to understand how the teenage years are different from
any other period of life, and to make certain adjustments in their perceptions
of their children. For instance, many parents remark (either wistfully or with
bemusement) that their kids no longer want to be around them. This is not only
normal, it’s healthy. Separating is an important part of the journey to adult
independence.
If it’s possible to scientifically document that parents move from center stage
of a child’s life to somewhere off to the side, Dr. Reed Larson at the
University of Illinois has done it. The psychologist conducted several studies
with large samples of normal, middle-class teenagers in the Chicago area in an
effort to find out how they really spend their time. He gave them pagers, then
beeped them systematically and asked them to write down what they were doing at
that moment. Over time, he found, kids spend less and less time with their
families — from 35 percent of their time in fifth grade to 14 percent by the
time they are high school seniors. He found no difference between boys and
girls. But at the same time, Dr. Larson found that the time children spend alone
with their parents, one-on-one, doesn’t decline. It seems they are just more
selective with the time they spend with their families — and this suggests that,
in the end, parents are still their biggest influence.
Another reason for hope is that it appears adolescents eventually learn to value
their families again. Dr. Larson’s studies have found that ages 13 and 14 are
the peak period for teenagers to be down on their families and to feel bad when
they are with them. Things improve dramatically by the time they are 17 and 18 —
so at least they can go off to college on good terms. As Mark Twain said, “When
I was a boy of 14, my father was so ignorant I could hardly stand to have the
old man around. But when I got to be 21, I was astonished at how much he had
learned in seven years.”
Parents might be surprised to learn that they aren’t the only ones being pushed
away. Teenagers distance themselves even from their friends. Sometimes, they
just want to be alone. Some parents might see this newfound preference as a
possible symptom of depression. In fact, it’s perfectly normal for a teenager to
go up to his room and not be heard from for hours. (It’s important to note that
this kind of isolation by choice is different from social isolation, in which
the teenager doesn’t have the energy for or interest in a social life.) Dr.
Larson concluded from his studies in Chicago that not only is spending time
alone normal, it often has a therapeutic effect. After spending a brief period
of time alone, teenagers who were feeling down often rebounded. But as is often
the case, it’s a question of degree. Dr. Larson found that teenagers who spent a
lot of time alone (approximately six hours or more on a school day) were more
likely to have mood problems. The message of all this is that it’s important to
look at the big picture, to go beyond one small behavior. How’s his appetite and
sleeping pattern? Is she still playing tennis? Have his grades dropped? These
and others are the questions that have to be asked.
For all the increasing awareness of teenage depression in the last decade or so,
we are only now starting to give it as much attention as we have to adult
depression. Research on adults and depression is vast, and famous depressives
are part of the culture: such celebrities as Mike Wallace, William Styron, and
Barbara Bush have helped bring depression out of the closet. But only in the
last few years have clinicians and researchers turned their attention to young
people and become more skilled at understanding how depression feels to them and
how it looks to us. We have become more focused on asking specific questions of
both adolescents and their parents that target the symptoms of depression.
Previously, it was common to talk only to the teenagers themselves, and ask only
general and open-ended questions — “How do you feel?” “How’s school going?” That
would not provide the clues that would lead to a correct diagnosis. What’s
needed are pointed questions that will yield helpful information: How many hours
did you sleep last night? How about the night before? How long does it take you
to get to sleep? How’s your appetite? Have you noticed any changes in your
ability to concentrate and your capacity to do schoolwork? How often do you see
your friends? Do you call them? How often? What do you do on weekends? Even now,
questions like these are not always asked, increasing the possibility that the
teenager will fail to be properly diagnosed.
Similarly, parents should be asked specific questions about their observations.
On the following page are some that Doctors Adrian Angold and Elizabeth J.
Costello of Duke University compiled into a “Mood and Feelings Questionnaire.”
There is a similar one for the teenagers themselves. The questions refer to how
the teen has felt in the previous two weeks. Marking TRUE means the statement is
true about the child most of the time.
In developing this questionnaire, Doctors Angold and Costello did not intend for
it to be a litmus test for depression. There is no scoring system with a magic
number that identifies depression. However, it can be a useful checklist for
parents who have concerns about a change in their child’s mood and behavior. Of
course, knowing the answers to some of these questions about your teenager’s
internal thoughts and perceptions is difficult for any parent. But being able to
observe changes in his or her behavior, and being able to help your teenagers
through demoralizing experiences and perhaps depression, means talking to him or
her. That can be a daunting task, especially if there’s isn’t a solid foundation
of dialogue from the child’s earlier years. But it’s vital to do. Just as
parents struggle with how to talk with their kids about things like sex and
drugs, they must be ready to discuss how their sons and daughters are feeling
emotionally. That’s why waiting until a child is 14 to start talking to him or
her about important emotional matters is a very bad idea. When they are young,
we talk to them about brushing their teeth and hygiene; we take them to the
pediatrician on a regular basis. Mental health is no different. If there is a
significant change in a teenager’s mood, it’s incumbent on parents to take note
and take action. To ignore it is to be neglectful. It conveys to the child that
the parents are insensitive, unaware, or uncaring.
Excerpted from “More Than Moody: Recognizing and Treating Adolescent Depression”
by Harold S. Koplewicz. Copyright © 2002 by The Putnam Publishing Group, a
member of Penguin Putnam, Inc.
Helpful Resources
More Than Moody: Recognizing & Treating Adolescent Depression
The Depressed Child: A Parent's Guide for Rescuing Kids