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Current Trends in Treating Adolescent Depression
By Judy Shepps Battle
"The first thing I noticed about Nancy was the sadness in her eyes and how distant she seemed. Even though she smiled when she spoke and wore the latest designer clothes, I could feel how close her tears were to the surface. Yet, when asked, all she would say was how irritable she was feeling and how often she gets stomachaches." -- A high school guidance counselor --
Fortunately for Nancy, her counselor was trained to recognize signs of adolescent depression, ask the right questions, and refer her to an outside professional for evaluation. She is now receiving individual therapy, participating in a weekly group for teens, and taking a mild antidepressant medicine. A family therapy session is held once a month to improve communications among all members.
Less than a decade ago her emotional pain might have been dismissed as driven by hormones or simply as a normal mood swing of a teenager as long as Nancy continued to behave in school, obey family rules, and did not attempt to physically harm herself.
Untreated, she may have expressed her fearful feelings through poetry writing or simply held them inside. Instead of getting "A"s she would have settled for "C"s as accurately reflecting her poor image of herself. Or, she may have self-medicated with food, alcohol, tobacco or other drugs, and/or acted out sexually.
If these measures failed to neutralize the pain she might have become a suicide statistic.
Today, we realize depression often begins in early childhood and that approximately 2 percent of preteens and 5 percent of adolescents suffer from this disorder. We are also learning that depression in youngsters presents differently than in adults and that some treatment modes may also differ.
Adolescents are not Little Adults
Depression has traditionally been seen as an adult disorder characterized by a loss of interest in life. In its extreme form, the sufferer experiences a slowdown of both time and the ability to think and often takes to bed as a refuge. Appetite, sexuality, and communication with others may be severely compromised. Even breathing may feel difficult as hopelessness fills each pore.
Depression in children and adolescents does not always manifest in this way. Instead of being sad and debilitated, a depressed youth may be agitated and irritable, have physical symptoms such as headaches and stomachaches, and even be able to move in and out of a depressed mood.
Adults with major depression usually turn their anger inward and have a flat emotional tone or affect. Their teen counterparts may snap at friends and family over the smallest things. "It is as though I wanted to push everyone away that was close to me," said one recovering youth. "The only way I could do it was to behave like a jerk."
Most depressed adults have a name for their disorder and know when "the depression" hits. Teens are not as well educated about feelings and somatize (express their emotions through their body) instead of talking. Thus "my head hurts" or "my stomach hurts" are ways of saying "I hurt." Unfortunately, these complaints are usually treated with medicine rather than therapy.
Finally, adults who are severely depressed are usually continuously depressed. Teens react more to their external environment and periodically leave their sadness behind. Thus, a depressed teen who is successful in getting tickets to see a famous music group may enjoy a spurt of excitement/happiness before and during the concert before returning home to emotional darkness.
Clinicians may have difficulty diagnosing teens because of these factors. The good news is that effective psychotherapeutic treatments are available for those properly identified as having major depression.
Psychotherapy may utilize a cognitive or interpersonal approach to exploring events and feelings that are painful to a teen. It also can help develop new coping skills.
Cognitive therapy recognizes that emotional health is related to thought patterns and beliefs about the world and that the thinking of a depressed teen may be pessimistic and dominated by negativity and anticipation of harmful outcomes.
"I don't go to dances because I am sure people will laugh at me for being clumsy," said fourteen-year-old Danny to his therapist. "Every other kid seems to know how to move but I have two left feet. I would rather stay home and watch TV."
A cognitive therapist will help Danny understand how his fear is creating a self-fulfilling prophecy and will teach positive ways of thinking about himself and others. These may include actions such as taking dance lessons and/or repeating affirmations that "I am graceful and loveable" several times a day before a mirror.
Interpersonal therapy focuses on the practicalities of developing healthy relationships at home and at school. It may teach coping mechanisms for loss and rejection, two major adolescent social issues, or how to get along with parents and siblings. It also helps the adolescent reduce and cope with stress.
For Danny, one focus might be on his fear of being rejected his friends. Session time may be spent role playing with his therapist in order to devise strategies for responding to criticism. As self-esteem improves and one portion of his depression lifts, he may risk attending another dance.
Cognitive and interpersonal therapy with adolescents can take place in individual sessions or in a group setting. Each has its advantage and many therapists prefer to allow the client to determine which format is more productive.
My experience is that most teens, however depressed, do not come to therapy voluntarily. Unlike their adult counterparts, they have not identified an area in which their depression is compromising their quality of life. When asked why they are in treatment, the likely answer is "she" (mother) or "he" (father) made me come.
At this point, group sessions are often less threatening and can teach social skills in a more relaxed, less stigmatizing environment. Rules of respectful sharing (not interrupting) are enforced but, unlike adult groups, food and drink may be served, kids may sit on the floor or move about, and are encouraged to contact the therapist and each other between sessions.
This "relaxation" of the classic rules of group therapy is primarily to make the experience "lighter" and to encourage a somber, depressed, teen to find enjoyment. The irritable youth has a chance to move about and discharge some of this energy while still listening to and being a part of the group.
Family sessions are often used to supplement group, as are individual sessions. A referral may be made to a medical doctor for evaluation regarding antidepressant medication if necessary.
Treating adolescents for depression has come a long way in the past decade. As we learn more about the physical, social, and emotional causes of this disorder, even more progress will be made in the future.
Copyright 2002 Judy Shepps Battle