Sunday, September 29, 2002
BRIANNE STARTED DRINKING and experimenting with drugs. One Sunday she was caught shoplifting at a local store and her mother, Linda, drove her home in what Brianne describes as a “piercing silence.” With the clouds in her head so dark she believed she would never see light again, Brianne went straight for the bathroom and swallowed every Tylenol and Advil she could find—a total of 74 pills. She was only 14, and she wanted to die.
A few hours later Linda Camilleri found her daughter vomiting all over the floor. Brianne was rushed to the hospital, where she convinced a psychiatrist (and even herself) that it had been a one-time impulse. The psychiatrist urged her parents to keep the episode a secret to avoid any stigma. Brianne’s father, Alan, shudders when he remembers that advice. “Mental illness is a closet problem in this country, and it’s got to come out,” he says. With a schizophrenic brother and a cousin who committed suicide, Alan thinks he should have known better. Instead, Brianne’s cloud just got darker. After another aborted suicide attempt a few months later, she finally ended up at McLean Hospital in Belmont, Mass., one of the best mental-health facilities in the country. Now, after three years of therapy and antidepressant medication, Brianne, 19, thinks she’s on track. A sophomore at James Madison University in Virginia, she’s on the dean’s list, has a boyfriend and hopes to spend a semester in Australia—a plan that makes her mother nervous, but also proud.
Brianne is one of the lucky ones. Most of the nearly 3 million adolescents struggling with depression never get the help they need because of prejudice about mental illness, inadequate mental-health resources and widespread ignorance about how emotional problems can wreck young lives. The National Institutes of Mental Health (NIMH) estimates that 8 percent of adolescents and 2 percent of children (some as young as 4) have symptoms of depression. Scientists also say that early onset of depression in children and teenagers has become increasingly common; some even use the word “epidemic.” No one knows whether there are actually more depressed kids today or just greater awareness of the problem, but some researchers think that the stress of a high divorce rate, rising academic expectations and social pressure may be pushing more kids over the edge.
This is a huge change from a decade ago, when many doctors considered depression strictly an adult disease. Teenage irritability and rebelliousness was “just a phase” kids would outgrow. But scientists now believe that if this behavior is chronic, it may signal serious problems. New brain research is also beginning to explain why teenagers may be particularly vulnerable to mood disorders. Psychiatrists who treat adolescents say parents should seek help if they notice a troubling change in eating, sleeping, grades or social life that lasts more than a few weeks. And public awareness of the need for help does seem to be increasing. One case in point: HBO’s hit series “The Sopranos.” In a recent episode, college student Meadow Soprano saw a therapist who recommended antidepressants to help her work through her feelings after the murder of her former boyfriend.
Without treatment, depressed adolescents are at high risk for school failure, social isolation, promiscuity, “self-medication” with drugs or alcohol, and suicide—now the third leading cause of death among 10- to 24-year-olds. “The earlier the onset, the more people tend to fall away developmentally from their peers,” says Dr. David Brent, professor of child psychiatry at the University of Pittsburgh. “If you become depressed at 25, chances are you’ve already completed your education and you have more resources and coping skills. If it happens at 11, there’s still a lot you need to learn, and you may never learn it.” Early untreated depression also increases a youngster’s chance of developing more severe depression as an adult as well as bipolar disease and personality disorders.
For kids who do get help, like Brianne, the prognosis is increasingly hopeful. Both antidepressant medication and cognitive-behavior therapy (talk therapy that helps patients identify and deal with sources of stress) have enabled many teenagers to focus on school and resume their lives. And more effective treatment may be available in the next few years. The NIMH recently launched a major 12-city initiative called the Treatment for Adolescents With Depression Study to help determine which regimens—Prozac, talk therapy or some combination—work best on 12- to 18-year-olds. Brent is conducting another NIMH study looking at newer medications, including Effexor and Paxil, that may help kids whose depression is resistant to Prozac. He is trying to identify genetic markers that indicate which patients are likely to respond to particular drugs.
Doctors hope that the new research will ultimately result in specific guidelines for adolescents, since there’s not much evidence about the effects of the long-term use of these medications on developing brains. Most antidepressants are not approved by the FDA for children under 18, although doctors routinely prescribe these medications to their young patients. (This practice, called “off-label” use, is not uncommon for many illnesses.) Many of the drugs being tested—like Prozac and Paxil—are known as SSRIs, or selective serotonin reuptake inhibitors. They regulate how the brain uses the neurotransmitter serotonin, which has been connected to mood disorders.
Outside the lab, the hardest task may be pinpointing kids at risk. Depressed teens usually suffer for years before they are identified, and fewer than one in five who needs treatment gets it. “Parents often think their kid is just being a kid, that all teens are moody, oppositional and irritable all the time,” says Madelyne Gould, a professor of child psychiatry at Columbia University. In fact, she says, the typical teenager should be more like “Happy Days” than “Rebel Without a Cause.” Even adults who make a career of working with kids—teachers, coaches and pediatricians—can misread symptoms. On college campuses, experts say, cases of depression are too often misdiagnosed as mononucleosis or chronic-fatigue syndrome. That’s why many kids still suffer unnoticed, even though more schools are using screening tools that identify kids who should be referred for a professional evaluation. Often it’s only the overt troublemakers—disruptive or violent kids—who get any attention. “In most cases, if a child is doing adequately in school, is getting decent grades, but seems a little depressed, there’s a great likelihood that the child won’t come to the attention of the teacher, counselor administrator or school psychologist,” says Phil Lazarus, who runs the school-psychology training program at Florida International University and is chairman of the National Association of School Psychologists’ emergency-response team.
And finding the right help can be as difficult as identifying the kids who need help. There are currently only about 7,000 child and adolescent psychiatrists around the country, far fewer than most mental-health experts say is required. The shortage is most acute in low-income areas and there are severe consequences in communities with more than enough traumatic circumstances to trigger a major depression. At the age of 13, Jonathan Haynes of San Antonio was clearly on a dangerous path. His parents, both crack addicts, were homeless—a major risk factor for depression. Haynes did what he says was necessary to survive: sold crack himself, and broke into houses and cars. But his life began to improve in the most unlikely place: jail. In 1999, his parents, by then drug-free, encouraged him to get help. Still high from the marijuana he had smoked that day, Haynes turned himself in to police. At Southton, the county’s maximum-security facility for juveniles, he was diagnosed and prescribed antidepressants. Now 18, Haynes works as a cook and lives with his family on San Antonio’s East Side. “I got my priorities straight,” he says. “I gotta stay strong. I got strong parents. That helps. Ever since I got out of Southton, I’ve been off the streets.”
In his case, it seems clear that traumatic family events contributed to his illness. But more often the trigger for adolescent depression is not so obvious. Scientists are studying a combination of factors, both internal and external. The hormonal surges of puberty have long been shown to affect moods, but now new research says that changes in brain structure may also play a role. During adolescence, the brain’s gray matter is gradually “pruned,” and unused brain-cell connections are cleared out, creating superhighways that allow us as adults to focus and learn things more deeply, says Dr. Harold Koplewicz, author of “More Than Moody: Recognizing and Treating Adolescent Depression.” The link between this brain activity and depression isn’t clear, but Koplewicz says the pruning happens between the ages of 14 and 17, when rates of psychiatric disorders increase significantly.
Scientists also believe that there’s a genetic predisposition to depression. “The closer your connection to a depressed family member—a depressed father rather than a depressed uncle, for example—the greater an individual’s likelihood of suffering depression,” says John Mann, chief of the department of neuroscience at Columbia University. Negative experiences, such as growing up in an abusive home or witnessing violence, increases the probability of a depressive episode in kids who are at risk. Doctors around the country reported an influx of young patients after last year’s terrorist attacks, although it’s too soon to tell whether this will translate into significantly higher numbers of youngsters diagnosed with major depression. Lisa Meier, a clinical psychologist in Rockville, Md., a Washington, D.C., suburb, says the attacks made many kids’ worst fears seem all too real. “Prior to September 11, if a child said they were afraid a bomb would drop on their house, that was very clinically significant, because it was an atypical fear,” Meier says. “It’s not atypical anymore.”
Many depressed adolescents have a long history of trouble, which often includes misdiagnosis and a lot of trial-and-error therapy that can aggravate the social and emotional problems caused by the depression. Morgan Willenbring, 17, of St. Paul, Minn., has suffered from depression since he was 8, but school officials first thought he had attention-deficit disorder. “I think that’s because they see that a lot,” says his mother, Kate Meyers. “They tend to lump together what they see as acting-out behavior.” It took more than two years to figure out a good treatment regimen. Desipramine, one of the older antidepressants, didn’t work. Then Willenbring spent six years on Wellbutrin, which was effective but problematical because he needed to take it three times a day. “It’s very easy to forget, which was not helping,” he says. When he missed too many doses, he had trouble concentrating and got into fights at home. But a month ago he switched to a once-a-day drug called Celexa and says he’s doing better. He even managed to get through breaking up with his longtime girlfriend without missing a day of school.
The results of the NIMH study may help make life easier for youngsters like Willenbring. The lead researcher, Dr. John March, a professor of child psychiatry at Duke University, says there is already evidence from other studies supporting short-term behavioral therapy and drugs like Prozac and Paxil. But that regimen works only in about 60 percent of cases, and almost half of those patients relapse within a year of stopping treatment. “We’re hoping [the study] will tell us which treatment is best for each set of symptoms,” March says, “and whether the severity of symptoms biases you toward one treatment or another.”
Until the results of that study and others are in, parents and teenagers have to weigh the risk of medication against the very real dangers of ignoring the illness. A recent report from the Centers for Disease Control found that 19 percent of high-school students had suicidal thoughts and more than 2 million of them actually began planning to take their own lives. One of them was Gabrielle Cryan. In 1999, during her junior year at a New York City high school, “I obsessed about death,” she says. “I talked about it with everyone.” With her parents’ help, she found a therapist just before the start of her senior year who “put a name to what I’d been feeling,” says Cryan. “My therapist made me realize it, face it and get over it.” She also received a prescription for Prozac. Although she had some hesitations about Prozac, “it really did help me,” she says. So did the talk therapy. “The first part of the healing process—and I know this sounds corny—was becoming more self-aware,” she says. The therapy helped her see that “everything was not a black-and-white situation.” Before therapy, little things would throw her into a funk. “I couldn’t find my shoe and the whole week was ruined,” she says now with a laugh. “They taught me to get some perspective.” And while her depression now is “nonexistent,” she knows that she may have to face it again in the future. “We’re all a work in progress,” Cryan says. “But I’ve picked up a lot of tools. When I feel symptoms coming on, I can reach out and help myself now.” Stories like hers are the successes that lead others out of the darkness.