More than Moody: Recognizing and Treating Adolescent Depressionby Harold S. Koplewicz
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The statistics are sobering. The first and only Surgeon General's report on mental health found that 3.5 million children and teenagers suffer from depression in the most recent survey on youth risk behavior from the Centers for Disease Control; in a given year, 3 million teenagers reported suicidal thoughts; over 2 million had made plans to carry them out; and sadly, approximately 400,000 made actual suicide attempts. These statistics notwithstanding, there is hope for the thousands of teenagers in turmoil.
For over twenty years, one of America's most distinguished child and adolescent psychiatrists, Harold S. Koplewicz, M.D., has been working to advance the understanding of mental health for children and their families. In this ground-breaking book, he uses his experience as a clinician and researcher to help parents distinguish between normal teenage angst and depression, a serious psychiatric illness with significant long-term consequences.
As any parent can attest, moodiness is almost a trademark of adolescence. Teenagers can be sensitive and irritable. After all, what teenager doesn't drive a parent crazy? For many years, it was widely believed that young people did not have the brain development to cause a chemical imbalance that is at the root of clinical depression. Sadly, with advancement of medical science we now know this is not the case. Adolescent depression is an under-recognized and under-treated problem that if left unchecked can have serious long-term consequences that last well into adulthood.
More Than Moody will help with the challenge of diagnosing depression versus recognizing when a young person is struggling to cope with the ups and downs of being a modern teenager. Dr. Koplewicz's combination of prescriptive advice and compelling stories shows parents the warning signs, risk factors, and key behaviors to look for in their teenage sons and daughters. Furthermore, he illustrates for parents, health-care professionals, and young adults the broad range of treatment options, including the use of SSRI anti-depressants in treating young people, as well as non-pharmaceutical approaches such as cognitive behavior therapy. More Than Moody is a comprehensive and valuable resource for parents and teens struggling with adolescent depression and bipolar disorder.
Author Biography: Harold S. Koplewicz, M.D., is the founder and director of the New York University Child Study Center. An award-winning child psychiatrist, he was named one of "America's Best Mental Health Experts" by Good Housekeeping magazine and repeatedly one of "America's Top Doctors" by Castle Connolly. Widely known as an advocate for children with psychiatric illness and as a respected academician, he is the editor-in-chief of the Journal of Child and Adolescent Psychopharmacology. He has appeared frequently on radio and television, on such programs as The Oprah Winfrey Show, Today, Good Morning America, CNN, and Dateline.
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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 anexplanation 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.
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.
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. (This is discussed in chapter 3.)
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.
—from More Than Moody: Recognizing and Treating Adolescent Depression by Harold S. Koplewicz, Copyright © October 2002, The Putnam Publishing Group, a member of Penguin Putnam, Inc., used by permission.
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As a mother of a teenager who is definiitely moody, I found this book to be remarkably easy to understand and helpful in clarifying the differences between normal teenage moodiness and depression. The stories about Dr. Koplewicz's patients are actually riveting and yet very realistic - some of the vignettes have dialogue that my daughter and I have all the time.This is a very reassuring book for parents of adolescents.