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.
The best way of diagnosing major depressive disorder in children and adolescents is to come face to face with the troubled child. The essence of the diagnosis for MDD is hearing the youngster’s responses and getting a feel for his mood.
THE BRAIN CHEMISTRY
When I was growing up, everybody thought that acne was caused by eating chocolate: if we ate chocolate, we’d get pimples. Of course, lots of kids ate chocolate and didn’t get pimples. Some ate chocolate and got a few now and then. And then there were the poor kids who didn’t eat any chocolate but had terrible skin anyway. Today we know that chocolate isn’t the culprit; some people are just vulnerable to acne. Certain external factors may bring on acne and make it worse, to be sure, but the vulnerability has to be there first.
It’s a lot like that with MDD. There are internal and external events that may bring on a depressive episode, but the vulnerability—in this case a neurochemical vulnerability—has to be there first. Demoralizing or tragic events don’t make everyone depressed; some people are born invulnerable. Given sufficient stress, both physical and psychological, nearly everyone has some sort of physical reaction; asthma, high blood pressure, ulcers, colitis, migraines, and even cold sores can be brought on by stress. In some people it’s the brain that’s affected, and a depressive episode is the result. It’s important to remember, however, that it wasn’t the death in the family, the breakup with a boyfriend, or the five straight days of rain that caused the depression. The cause of MDD arises in the brain.
The chemistry of a child’s brain is what determines his vulnerability to MDD. A child inherits brain chemistry from his parents, so, not surprisingly, depression runs in families. Children whose parents have MDD have a greater than average chance of having MDD themselves; the relatives of youngsters with MDD are more than twice as likely to have the disorder than the relatives of normal kids. Abnormal responses have been reported in depressed adolescents during challenge testing of their endocrine system. These tests are not diagnostic, but they lend support to a biological basis for MDD.
The neurotransmitters that improve our mood or keep it stable are dopamine, norepinephrine, and serotonin. Any imbalance in these three neurotransmitters may account for an onset of MDD, but it is generally thought that underactivity of either serotonin or norepinephrine is largely responsible. In addition to those neurotransmitters the brain also produces endorphins, the chemicals that give people satisfaction or a sense of joy. Both internal and external stressors can have a strong effect on all of the brain’s chemical components. In an effort to “fix” what is causing their child pain, parents often spend too much time and effort trying to puzzle out what might have caused a child’s depressive episode and not enough time and effort seeking treatment. To treat the disease, it’s not necessary to know what causes depression. Saying, “Oh, his parents are getting a divorce. That’s why he’s depressed” is a typical response. MDD can’t just be explained away. It can’t be willed away either, although there are many people who would like to think so. “If she would just pull herself together” and “If she would just stop feeling sorry for herself” are typical reactions to depression in both children and adults. Years ago I met a woman who had MDD episodes after the birth of each of her children. For the first five kids she didn’t seek help, and no one encouraged her to do so. She figured she just needed to pull herself out of it; seeing a psychiatrist was a sign of weakness. After the birth of her sixth child she ended up in the hospital, psychotically depressed. Even then she was reluctant to talk about her symptoms. She felt guilty and ashamed. “Having babies is the most natural thing in the world,” she said. “What’s wrong with me?”
THE TREATMENT
The best treatment for MDD is a combination of pharmacotherapy (antidepressants), psychotherapy, and family intervention. The medications that are the most effective and most commonly prescribed for MDD are the SSRIs (selective serotonin reuptake inhibitors), especially Prozac but also Zoloft, Paxil, and Luvox. The side effects, which are mild and infrequent, are diarrhea, nausea, and sleeplessness. Parents and children are amazed at how fast the SSRIs work sometimes. The parents of a severely depressed 10-year-old girl for whom I had prescribed Prozac reported that her symptoms began to disappear in only three weeks.
Another group of antidepressants used in treating children and adolescents with MDD are TCAs (tricyclic antidepressants): Tofranil, Pamelor, Elavil, and Norpramin. These medicines take longer to work than the SSRIs; they require four to six weeks for a clinical response. The nuisance side effects of the TCAs are dry mouth, constipation, and drowsiness, but they may also have an effect on the cardiovascular system. Before the medication is started and before the dose is increased, a youngster should have his blood pressure and pulse measured and he should have an electrocardiogram. These medicines need to be monitored carefully, since an overdose can be lethal. There have been several reports of sudden death of children taking Norpramin, but there is
no proof that the Norpramin caused the deaths. When a child’s MDD is severe and other medications have not been effective, Norpramin may still be the answer. The nuisance side effects of Norpramin are minimal, and it does work.
Also occasionally prescribed for MDD are the atypical antidepressants, especially Wellbutrin and Trazadone. Wellbutrin has been used in patients who have not responded to either the SSRIs or the TCAs. Side effects of Wellbutrin are agitation, restlessness, and irritability, but they are infrequent, and they nearly always disappear over time or with a lower dose. Trazadone is usually given in addition to another antidepressant. The most common side effects—sedation, increased blood pressure, dizziness, and nausea—are mild and transient. A rare but serious side effect of Trazadone is priapism, a prolonged erection without sexual stimulation. For obvious reasons, Trazadone should not be prescribed for adolescent males.
A group of antidepressants that have been used in adolescents with MDD who have not responded to other antidepressants are the MAOIs (monamine oxidase inhibitors): Nardil, Parnate, and Marplan. Dietary restrictions are required with these medications. Foods that are rich in tyramine, such as aged cheese, beer, red wine, smoked fish, and aged meats, interact with MAOIs to produce a hypertensive reaction: severe headache, palpitations, neck stiffness, nausea, and sweating. Because of the difficulty of monitoring the diet of a child or adolescent, we usually stay away from the MAOIs.
Synthetic thyroid hormones have been used to increase the effectiveness of antidepressant medications, especially in adolescents with MDD who have responded partially or not at all to antidepressants. The hormones most frequently used are T3, Cytomel; and T4, Synthroid. The side effects are weight loss and nervousness, but they are unusual.
Parents whose children are taking medicine worry about a lot of things. When the child or teenager is being treated for MDD, we often hear parents voicing concern, even fear, that the child will become addicted to the drug. Some drugs that alleviate depression are addictive—cocaine and speed are two of the best known—but these drugs are different from the medicines we prescribe. When the effects of cocaine and speed wear off, there is a “crash” and a strong desire for more of the drug. The antidepressants aren’t like that. A child may well need to take this medication in order to rid himself of the MDD symptoms that are causing distress and dysfunction, but he will not become addicted.
An adolescent diagnosed with major depressive disorder may benefit from this medicine for a long time. Even with the medication, however, he may have an occasional relapse, usually brought on by stress. About 50 percent of all depressed children will have a second depressive episode within five years of the first.
The most significant problem associated with prescribing medication for MDD is that kids often take themselves off the medication, even though the beneficial effects of the medicine are nearly always quite obvious. I prescribed Tofranil for Wesley, a 17-year-old boy who was almost completely dysfunctional when he came to see me. He didn’t go to school or see friends. He barely left his bed. After a few weeks of the medication he was going to school every day and holding down a part-time job in his father’s store. He didn’t have any friends yet, and he still felt, in his own words, “lousy.” He decided that the medicine wasn’t doing him any good—he wasn’t happy, after all—so he stopped taking it. Shortly after that Wesley took to his bed again, until we got him back on the medication.
Lynn, a 14-year-old girl I treated for MDD, had a long-standing love-hate relationship with her medication. A bright girl with normal intelligence, she had a strong family history of MDD. Her older brother had attempted suicide a year earlier, and she herself had seriously considered taking her own life. Lynn responded well to Prozac, and cognitive behavioral therapy with a psychologist was progressing nicely. She was, she told me, “feeling pretty good.” The problem was that she didn’t like the idea of taking medication even if it did make her feel better. Her mother wasn’t happy about the medicine either and made no effort to disguise her feelings. Lynn was constantly asking to be taken off the medicine. “I’m feeling so much better now. I’m sure I’ll be fine,” she said. When I told her she needed more time with the medicine, she took herself off it anyway. Her depression got worse almost immediately; she stayed in bed all day, crying and overeating. Her thoughts of suicide returned. Even in her severely depressed state Lynn knew that she needed to start taking the medication again.
Parents will have to monitor a child’s medication, but the more involved a child is in the treatment process, the better the results will be. A youngster who understands that something is wrong with him and accepts the fact that this little pill is helping him to feel better is more likely to thrive than one who is kept in the dark about what’s going on or someone who is terribly resistant to the medication. Adolescents—Wesley and Lynn, for example—should be encouraged to take the initiative in their own treatment, especially since mothers and dads don’t typically have a great deal of power or influence over them anyway.
I find that making an adolescent take responsibility for treating his own illness may serve as a kind of wake-up call. “Okay. Why don’t you try yourself without medication for the next two weeks and we’ll see how it goes?” I said to one of my teenage patients recently. “But I want you to call me next week and report in about your symptoms. And that means you. I don’t want your mother to call me. And I don’t want to have to call you. This is your job now. You have to tell me what’s going on.” With the right kid, that strategy can work miracles.
Medication is an indispensable part of the treatment for MDD, but therapy, especially symptom-oriented therapy, also plays a vital part. Cognitive psychotherapy helps a child or adolescent to change the negative thinking that is symptomatic of MDD and work on improving his social skills so that he can make friends. Like children with social phobia, kids with MDD have to learn how to meet people and talk to them, and this requires preparation and rehearsal. Children with MDD have to learn how not to be depressed, and that takes practice and informed instruction. Professionals can be an immense help.
A specific treatment program for MDD, called interpersonal psychotherapy (IPT), has been helpful in the treatment of adults with milder forms of MDD, and recently it has been used for adolescents as well. The 16-week program, which focuses on helping the adolescent understand his illness and exploring how it affects his interpersonal relationships, can be extremely helpful in combination with the right medication.
Family intervention is often very beneficial as well. It helps the child, the parents, and the rest of the family to understand the nature of MDD as well as the treatment process. Parent counseling may provide insights about making changes in the child’s environment and resolving school and family problems that may have contributed to the depression in the first place.
Often regarded as a last resort, electroconvulsive therapy (ECT) has been effective in treating severely depressed adolescents who have been unresponsive to any other treatment. ECT induces a seizure in the patient while he is under anesthesia. A series of eight to twelve sessions is usually required. Although widely misunderstood and almost as widely maligned, ECT has been shown to be a safe procedure that can produce wonderful results with no long-term side effects.
Prompt treatment makes a big difference in the prognosis of this disorder. The earlier MDD is treated, the shorter and less severe any subsequent depressive episode is likely to be. Left untreated, MDD will get worse; the episodes will last longer and be much more serious.
PARENTING AND DEPRESSION
“I can’t remember a time when there wasn’t something wrong with Aaron,” recalled the mother of a teenager who was diagnosed with MDD nearly ten years earlier. “He has always been moody and irritable. When he was three years old, he’d get angry at us and stalk off and slam the door. He was hard on himself too. From the beginning my husband thought we should get some help, but I just couldn’t face the idea that such a little boy could need a psychiatrist. By th
e time he was five, he was talking about death all the time. That’s not something you expect in a small child. Everyone suspected that he was depressed. On his sixth birthday we took Aaron to see his first psychiatrist.”
Aaron’s mother is not alone in her reluctance to accept the fact that she has a clinically depressed child. Emotions run very high with this disorder, and it is the rare parent who doesn’t react with strong feelings to the behavior of a child with MDD. Anger and frustration are especially common, since these kids are usually sullen and difficult to manage. Generally speaking, children with MDD are not very pleasant to be around, and it’s not unusual to discover that their parents don’t like them all that much. “I feel terrible about this, but I actually dislike my own daughter,” said the father of a 10-year-old. I’ve heard that comment, or some variation thereof, dozens of times.
Teenagers with MDD can be particularly annoying to their parents because it seems that they often have enough energy to do certain things, such as go out with their friends, but not others, such as their homework. They’re pleasant enough when they’re in the outside world and save their sullenness and their lethargy for the folks at home. There are occasions too in which a child is unpleasant with one parent but not the other. As difficult as it is to manage sometimes, parents have to realize that the behavior of a child with MDD is not willful. He’s not being impossible on purpose.
Most parents of kids diagnosed with MDD feel more than a little guilty too. After all, it is a parent’s job to make his child happy. Being happy is a basic essential of life. If a kid is depressed, the thinking goes, it must mean that the mother and father are doing something wrong. None of this is true, of course, but even parents who know better sometimes consider themselves dismal failures. The feelings of parental guilt associated with this disorder are very strong, particularly when a child tries to commit suicide. One of the many reasons we recommend parent counseling is that it helps parents understand that no one—not the parents, not the child—is to blame for this disease. There’s no reason for a parent to feel guilt or shame.
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