It's Nobody's Fault (30 page)

Depression is the most common brain disorder in America; each year some 8 to 14 million Americans are recognized as suffering from clinical depression. One survey found that 19 percent of all adolescents had experienced an episode of MDD.

“It’s been raining all weekend. I’m so depressed.”

“That movie was
so
depressing.”

“I had such a depressing day at work today.”

“I can’t believe the Yankees lost again. I’m incredibly depressed!”

We’ve all heard comments like those. Most of us have made them ourselves.
Depression
is an overused word these days, describing our reaction to everything from a train crash to a failed soufflé. Of course, true clinical depression—MDD—is a lot more serious than a bad day at the office. It’s a serious mood disorder with very specific symptoms, and it requires prompt, active treatment.

MDD may come and go, with occasional flare-ups; kids with MDD have their “ups and downs.” For example, Charlie, described earlier in this chapter, had his first depressive episode back in the first grade. His mother says she knew there was something wrong, but she had no idea what it was. Then Charlie got better and stayed that way until fifth grade, when he went through a month-long period of being agitated and all but impossible to live with. That too passed, and he was fine until that frightening incident in tenth-grade English class, the one that led his parents to my office. MDD doesn’t spring up overnight, although it may seem that way sometimes. Like a volcano, it simply lies dormant until some sort of crisis triggers the first episode.

Other children and adolescents suffer from
dysthymia
, a milder, more chronic form of depression, which should be distinguished from MDD. If MDD is like a full-blown infection, dysthymia is like a chronic virus—with a low-grade fever, some aches and pains, perhaps a mild headache. Kids with dysthymia get the “downs,” but they rarely experience any “ups.” One child who fits this description perfectly is Dominick, 16 years old. To hear his mother tell it, Dominick is a child who never seemed to get any joy out of life. He was the best student in his class and the star of the football team, but none of it seemed to make him happy. Getting an A on a test was incredibly important to him—he was completely focused and driven in his efforts—but when he got the A, there was no pleasure attached to the accomplishment. Dominick wasn’t morose, but he had no zest for life. “He never cries, but I don’t think I’ve ever seen him smile either,” his mother said. Recent studies show that dysthymia may well be a stepping-stone to MDD. Dominick is a likely candidate for clinical depression.

Major depressive disorder in children and adolescents is characterized by at least two weeks of a nearly constant depressed mood severe enough to cause distress and dysfunction. (We look for the so-called
depressed triad:
feelings of hopelessness, helplessness, and worthlessness.) The two-week minimum requirement for symptoms rules out the many unpleasant events and situations that can and do cause people to be unhappy and even temporarily depressed, such as a divorce, a medical emergency, a family financial crisis, or any of a dozen other problems. (An important exception is bereavement. The period of mourning considered normal for a death in the family is two months.) If the depressed mood is not a result of MDD, it will wax and wane; it won’t be predominant for two weeks. In addition to the two weeks of depression, a child or adolescent with MDD will have at least four of the following symptoms: inability to concentrate, irritability and anger, marked fatigue, feelings of worthlessness, sleep problems, appetite disturbance, social withdrawal, restlessness, and decrease in libido. One final symptom of MDD that may be present is
anhedonia:
the inability to experience pleasure. Most youngsters have had their symptoms much longer than two weeks by the time they receive professional help.

MDD manifests itself differently in children and adolescents. Very young children may not necessarily look or act sad, although some will have downcast eyes or a blank expression. In fact, many children with MDD will seem more oppositional than depressed. They’ll be irritable and cranky;
everything
bothers these kids. Behavior disturbances such as hyperactivity, temper tantrums, and absence of normal play are not unusual. A small number of children, perhaps as many as a third, will have thoughts of suicide. They also often complain about various aches and pains,—headaches, stomachaches, even back troubles. Typically a depressed youngster will see his pediatrician or some other physician before finally making his way to a child and adolescent psychiatrist’s office.

In teenagers the symptoms of MDD tend to be a little different, more like those of depressed adults. Depressed mood, diminished ability to concentrate, sleep, and appetite disturbance, sensitivity to rejection, a feeling of being weighed down, and thoughts of suicide are common symptoms. Depressed adults often undereat and undersleep; teenagers are more likely to overeat and oversleep. A lot of depressed adolescents sleep in the middle of the day, coming home from school and taking a nap. Then they wake up at seven or eight o’clock in the evening, grumpy and irritable. After having something to eat—probably not with their parents and the rest of the family—they’re wide awake until three o’clock in the morning and have trouble waking up the next day for school. Sleep disturbance is a vicious circle.

Depressed teenagers often have an additional symptom:
mood reactivity.
These youngsters are able to cheer up when they are in a positive interaction or environment. Chad, a 16-year-old boy I treated for MDD, was chronically irritable. He didn’t eat much, showed no interest in television, and couldn’t concentrate on his schoolwork. That was when he was home alone or with his family. When his friends came over, his mood would brighten; sometimes he seemed almost happy. His father was baffled and angry. “He must be doing this on purpose,” he said. “How can he be so pleasant when his friends come and so miserable the rest of the time?”

Depressed teenagers may also be very sensitive to rejection and may have a tendency to be histrionic, with extreme reactions to real or imagined slights. One 16-year-old girl with MDD whose boyfriend broke a date with her went up on the roof of her house and threatened tojump
off. She stayed up there for hours, feeling completely despondent. She told her mother and father that life wasn’t worth living if her boyfriend didn’t love her. The fact that he had canceled their date because he had to study for a test made no difference.

The irritability associated with MDD can lead to very erratic, even violent behavior. A 14-year-old boy named Gerard was brought in to see me after pulling a knife on his father. Gerard had been having problems at school—skipping classes on a regular basis and behaving badly when he did attend. On the days he didn’t go to school, he would just lie in bed all day, mostly sleeping but occasionally watching television. He hardly ate at all. He had no social life, no friends. One evening his father lost patience with Gerard and told him he had to go to school or else, and Gerard became enraged. That’s when he reached for the knife, after pounding on and then overturning the kitchen table. When I interviewed him, Gerard wasn’t forthcoming about his symptoms at first except to say he was tired all the time. All he would tell me about the episode with the knife was: “My father made me mad.”

It is highly unlikely that anyone watching Gerard turn over that table and grab that kitchen knife would describe him as depressed. The word
depressed
summons up images of a weepy, withdrawn child. By the same token, when a child or an adolescent does look unhappy or withdrawn or demonstrates any of the other symptoms associated with clinical depression, there are many possible explanations besides MDD. Before making a diagnosis of major depressive disorder, a child and adolescent psychiatrist must take a detailed history by interviewing the child, the parents, and the teachers. Then he must systematically consider and rule out all the other possibilities, bearing in mind that co-occurent conditions are very common with MDD.

It’s not uncommon for kids with MDD also to have an anxiety disorder, especially separation anxiety disorder (discussed in
Chapter 9
) and social phobia (
Chapter 10
). Studies have shown that nearly half of the children diagnosed with MDD will have an anxiety disorder as well. Leonard, a 16-year-old boy I treated for MDD, was originally diagnosed with social phobia. When I first met him, Leonard told me that he had
been feeling unhappy for five years. The other kids think he’s weird, and he’s afraid to talk to people at school, he told me. He would like to have friends, but he doesn’t know how. Leonard’s mom and dad have their own theories. Dad says that the problem is that Leonard has always had low self-esteem. Mom says it all started because Leonard is the smallest kid in his class, and that makes him feel inadequate. One thing I learned during that first visit was that lately Leonard has been having a lot of trouble sleeping. He’s been suffering from both
initial insomnia
(trouble falling asleep) and
middle insomnia
(waking up in the middle of the night). Both sleep disturbances are common symptoms of MDD.

Major depressive disorder may sometimes look a lot like attention deficit hyperactivity disorder too (see
Chapter 7
). Not too long ago I saw a little eight-year-old boy who was sent to me by a neurologist because of his disruptive behavior at home. He behaved himself at school well enough, but after school he would bang on the walls of his bedroom until he made holes in them. Almost anything would
set
him off. He was agitated and cranky all the time, and he had many physical complaints. Nothing gave him pleasure. When his parents didn’t give him his way, he went ballistic. My eventual diagnosis was MDD.

Yet another relative of MDD is CD: conduct disorder (
Chapter 18
). Jamie, a 16-year-old boy, came in because he was irritable, fresh, and always getting into trouble both at home and out in the world. He was terrific at sports and a very good artist, but his academic achievement left a lot to be desired. He frequently cut classes and had lots of fights after school. A psychologist had given Jamie’s parents the diagnosis of CD, and there was no question that Jamie had it. It turned out that he also had MDD. (Depressed kids are often regarded as oppositional because of their irritability.) It took me a few weeks to find out that Jamie was also feeling, in his words, empty. “I felt like nothing. I felt like: Why move? Why get out of my chair?” he told me. It’s important to remember that teenagers Jamie’s age, and particularly those considerably younger than Jamie, don’t necessarily speak the language of MDD. They don’t say they’re depressed or blue or gloomy or morose or any of the many words an adult might choose.
Empty
was the closest Jamie could get.

Another disorder that must be ruled out is schizophrenia (see
Chapter 16
). This can be a tricky business sometimes, because children and teenagers with MDD may have delusions and other psychotic symptoms. The key here is that the delusions and hallucinations are all mood
congruent—consistent with the mood of the youngster—and, in their own way, logical. For instance, kids with MDD will be depressed because they think they’re dying, or they may hear voices that criticize them. When I met Franklin, I was all but certain that he had schizophrenia. He had just dropped out of college, and he had all sorts of symptoms: obsessions, compulsions, anxieties, the works. He thought his
eyes
were burning, so he had to look down at the floor all the time. He also constantly inspected his hair and his clothes. He told me he felt sad all the time, and he couldn’t sleep. After a lifetime of accomplishments—he had good grades in high school, and he was a varsity basketball player—Franklin had zero confidence in his abilities. “I feel as if I’ve lost myself,” he told me. “When I lie in bed, I have to keep checking to see if my heart is still beating. I’m sure I have a tumor in my chest.” Franklin’s delusions sounded like schizophrenia, but further investigation pointed toward MDD.

Chronic fatigue syndrome is another disguise in which major depressive disorder may appear. That’s what everyone thought was wrong with 14-year-old Nellie, who came to see me after she had been sick for over a year. Nellie had always done well in school, but friends didn’t come easily, even back in elementary school. The other kids teased her a little back then because she was so shy and awkward. By the seventh grade she had no friends to speak of, but no one really knew why. At the beginning of the ninth grade Nellie had mononucleosis, which basically put her out of commission for a couple of months. She was better by Christmas, but in February she had a relapse. She was tired all the time. In March her pediatrician diagnosed chronic fatigue syndrome and sent her to school with a note saying she should take a nap every afternoon.

Fatigue was just the beginning of Nellie’s symptoms. Before that school year was over, her list of complaints was quite long. She couldn’t concentrate; she cried all the time; and for the first time ever, she didn’t make the honor roll. Her appetite was terrible, and although she went to sleep every night at nine and got up at six, she woke up several times during the night. The, reason I didn’t have the opportunity to see her—and diagnose her MDD—for nearly a year is that her parents and everyone else around her thought that all her new symptoms were simply an offshoot of her chronic fatigue syndrome. They thought Nellie was just tired from her illness and overwhelmed by the workload of a regular teenager.

In the process of making this very elusive diagnosis of major depressive disorder, the child and adolescent psychiatrist must eliminate one last disorder, the one most closely related to major depressive disorder: bipolar disorder. As will be explained in
Chapter 15
, bipolar disorder combines depression and mania, a sustained “high.” With major depressive disorder (occasionally referred to as unipolar disorder) there is depression but no mania.