The kids aren’t all right
It creeps up on you unannounced. One day you are coping, the next you aren’t. It’s as though a veil has come between you and the rest of the world. Even getting out of bed feels like too much hassle. Everything feels pointless. Quite often, you want to die. If depression is this unbearable for an adult, imagine what it must be like for a teenager.
Amy was 13 and living at home with her parents when she first started feeling low. “There was no single trigger,” she says. “I was stressed with Year 9 SATs, but so was everyone. Everything started to feel meaningless. I’d never had a lot of friends, but I began to find spending time with them less and less easy. Before long, I started to self-harm.”
Initially, Amy’s parents put her behaviour down to normal adolescent monosyllabism – she was good at concealing her cuts – but after three months they were worried enough to take her to their GP, who told them teenage depression was common and referred her to a psychiatrist.
“I was prescribed antidepressants,” Amy says, “and within a week I was feeling a whole lot worse. I told the psychiatrist, who promptly doubled my dosage. I soon felt twice as bad again; a couple of weeks later, I was admitted to the young people’s ward of my local mental hospital and taken off my medication.”
In hospital, Amy was given cognitive behavioural therapy (CBT) and seemed to respond well. In fact, she says, “I was just desperate to get out of there. I was convinced my parents were ganging up with the psychiatrist to keep me in there, so I started to lie about how I was feeling.”
The lying paid off after three months, and she went home. No one other than her parents and two much older sisters had come to see her while she was in hospital (her headteacher had taken it upon himself to say that no one should visit, and Amy felt too ashamed to call her friends), so she felt even more distant. She started seeing a different therapist, but that didn’t help. “I hadn’t appreciated how hard coming out of hospital was going to be,” she says. “But I was so scared of being readmitted that I carried on lying about how I was feeling. The lying just made things worse, and I felt more and more hopeless. Not long after, I took my first overdose and ended up in A&E.”
Amy is now 17. She has been in and out of mental hospital and has made several suicide attempts. She kept up with her schoolwork well enough to pass her GCSEs, but college is a struggle. “I’d like to get a degree and teach early-years kids, but my mood is still up and down. I’d like to think I can recover, but some aspects of my illness feel as if they will be around for ever.”
There are many more teenagers such as Amy, and their numbers are growing every year. The quantities of antidepressants prescribed by the NHS have almost doubled in the last decade, and figures released under the Freedom of Information Act last year showed that more than 113,000 prescriptions for antidepressants were issued to under-16s in 2007 alone.
“We’re getting clear evidence that the onset of depression is happening earlier and earlier,” says Marjorie Wallace, chief executive of the mental health charity Sane. “In previous generations, people would be overwhelmed by depression in their 20s. Now the peak age for onset is 13-15: the numbers of teenagers calling us for help suggest the rates of depression in the under-14s have doubled in the last four years, and in the 15-24 age group it has increased by one-third.”
So what’s going on? Are there really more teenagers suffering mental health problems than there were a generation ago? Is it that we are getting better at diagnosing depression in teens? Or is it, as some argue, that doctors in the UK have followed those in the US and started to medicalise the normal ups and downs of adolescence? When, in 2006, it became legal in the UK to prescribe fluoxetine (Prozac) to children as young as eight, there was a flurry of concern about the numbers of young people on medication, especially in the wake of the huge increase in the use of Ritalin to treat attention-deficit hyperactivity disorder.
But while some doctors might hand out drugs as an easy option for teenagers, most are well aware of the dangers – including addiction and suicidal feelings – and prescription is recommended only as a last resort. Meanwhile, experts agree that increasing numbers of teens are experiencing depression, and younger, whether due to a breakdown in family life, increased academic and peer pressure, or the widening gaps between rich and poor, expectation and opportunity.
With one in 10 children in the UK suffering from a diagnosable mental health disorder, and at a time when cuts to mental health services threaten the provision of psychotherapy, you can see why doctors might turn to antidepressants to treat teenagers such as Amy. In her case, the drugs didn’t work, but leaving the symptoms to develop can be a greater risk. “It’s an extremely worrying trend,” Wallace says, “not just because teenagers are more vulnerable than adults, but the earlier the age a depression is experienced, the more likely it is to be long-lasting if untreated.”
If depression is notoriously difficult to pin down, in teenagers it can be almost impossible. No two people report precisely the same feelings or respond to treatment in the same way. Rather, it’s a collection of symptoms ranging from persistent sadness, a lack of interest in life, tiredness, disturbed appetites, an inability to concentrate and low levels of self-confidence to suicidal thoughts and acts. If you have four or more of these for longer than two weeks, you may be diagnosed. And that’s just the start of the process.
Psychiatrists have dismissed as unhelpful ideas of exogenous (caused by external events) and endogenous (no obvious external cause) depression, since it’s often impossible accurately to disentangle the two: depression is classified as mild, moderate and severe – depending on how many of the symptoms the patient has and how acute they are. Even that’s not precise, because symptoms are not uniform: some may be mild, others acute. In short, it’s a minefield, with diagnosis and treatment frequently a matter of judgment – especially with teenagers who are hit by hormonal changes and mood swings, and so may not always be the most reliable reporters of their own symptoms.
What’s not in doubt are the numbers: 1% of pre-pubertal children are currently treated for depression, a figure that rises to about 3% for teenagers. Put in percentage terms, that may not sound too bad, but once you start counting the tens of thousands of lives affected, the picture changes. And that’s before you take into account the dead: 3% of those 3% of teenagers with depression will go on to kill themselves.
“While an adult is likely to refer themselves to a doctor,” says David Cottrell, dean of medicine and professor of child and adolescent psychiatry at Leeds University, “teenagers almost never do until their symptoms are acute. To pick up the symptoms of depression early on, you generally have to rely on the intervention of a parent or teacher. Parents are often reluctant to believe their children have serious mental health issues: they would rather think they were going through standard teenage angst.”
It’s easy to see why. No parent wants to admit their child has serious mental health problems, not just because of what it might mean for their child, but what it might say about them as a parent. Nor can we rely on schools to pick up on problems, as teachers often spend most of their time dealing with disruptive kids, so those who cause no trouble in class often slip through the net.
Adam is a case in point. Now 18 and living in Kingston-upon-Hull, his symptoms started when he was 11. “I could feel the pressure building when I had to move school,” he says, “but things got really bad when a 14-year-old friend attempted suicide. I felt really guilty that I had been such a bad friend to this boy and I began to get panic attacks. I didn’t know I was depressed. I just knew I felt empty and couldn’t cope. But I felt too ashamed to tell anyone. One day I accidentally cut myself and I realised it felt good. I saw the blood and it proved I was alive inside after all.”
Adam became skilled at concealing the scars, and the cutting went unnoticed for months before he eventually talked to a couple of friends, who advised him to go to his GP. He was given six months CBT, and the self-harming became less frequent. Though he never actually stopped. “I didn’t want to give up my weekly sessions with a therapist,” he says, “but I wasn’t given a choice. My school grades began to slip, I stopped going out, and when my best friend April killed herself in a psychiatric unit, I was devastated. I decided I was never going to get close to anyone again, and for four months my only real contact with people was chatting to a couple of mates online. At no point did my parents intervene: they’ve had no part in my treatment, and I’m not sure they are even aware I had a problem.”
What ultimately helped Adam was getting involved in the youth mental health organisations, Mind Matters and YoungMinds, as an organiser and a worker, setting up Facebook groups and helplines, and talking to other people his age with similar experiences. Adam doesn’t for a minute believe he is cured, though. “I think I will always be susceptible to depression, though I do feel I now have the coping mechanisms to handle it.”
For those teenagers who do get referred there are clear National Institute for Health and Clinical Excellence (Nice) guidelines. Treatment ranges from counselling sessions, to more prolonged periods of CBT and other counselling and, finally, antidepressants.
“Parents and teenagers come to us expecting a solution,” Cottrell says. “But there is no cure-all. Treating depression is an inexact science. Antidepressants are only ever offered as a last resort. No one is ever casually put on fluoxetine [the only drug recommended by Nice for teenagers]. Of course, you need to be careful, because there is a known, if small, risk of teenagers developing suicidal thoughts when they start the medication, but you have to balance that against the fact that these patients are already severely ill and may be experiencing suicidal feelings anyway.”
Cottrell also suggests that the increase in the number of antidepressant prescriptions may actually be a sign of much better practice. “It used to be that teenagers were taken off antidepressants as soon as they showed any signs of getting better. We now know that long-term recovery is more likely if patients take their medication for six months. So I believe the increase in the number of prescriptions is in part because we are doing what we should, although more children are also getting prescribed antidepressants.”
At the root of the problem, Wallace says, is our shift from an age of anxiety to one of depression, from a time when people worried life was going to be hard to one where they know it’s going to be hard. “Families are fragmented and the inequality gap is widening,” she says. “Social networking sites provide a veneer of communication, but they make vulnerable young people feel more alone, as they are exposed to the lives of others who may seem more successful. This is reinforced by celebrity culture.”
Everywhere you look, the ante is being raised. Even the physical expressions of depression are getting more violent: youth agencies report anecdotal evidence that teenagers who once used a penknife on their wrist now cut or burn themselves secretly and badly. And the anxiety among mental health professionals is that there are still large numbers of cases going unreported. While the white middle classes may be reasonably adept at getting help for their children, some cultures regard mental illness as a social stigma too far. In cultures where arranged marriages are common, any hint of mental illness can make a child unmarriable, so depression is something to be ignored or explained away.
Take Nicky, an 18-year-old Asian girl from London. Her problems began when she was 14 and had anorexia, which her parents chose to ignore. “They liked to say I was on a diet,” she laughs. Anorexia became bulimia a year later. “It was out of control, a dirty secret. My parents didn’t want to know, but friends were harder to fool, so I took to hiding myself away. I felt terribly low. I wouldn’t talk to anyone and I let my appearance go.”
Not long after, Nicky started cutting herself four times a week. “I hoped it was a phase, but it got worse, and I began having trouble sleeping. I was having fights with my parents about my A-level choices, but still they had no idea what was going on with me.”
She missed school, forged her parents’ signature on absence slips and the cutting became burning. Things became so bad, she even tried to tell her parents, but they couldn’t cope and pretended everything was OK. In desperation, she opened up to a teacher, who put her in touch with a counsellor and she started to receive treatment.
“I’ve had all sorts of therapies and I’ve been on antidepressants,” Nicky says, “but I’ve never completely stopped self-harming, and I’ve been in and out of hospital after overdoses. It’s all got worse since I turned 18, as I’ve been passed on to adult services. It’s got so bad I’ve taken on a part-time job while I’m at college to save for private treatment.”
Like Adam, Nicky is closely involved with YoungMinds, and helping others with similar problems has made her feel better about herself. Yet her bleak assessment of her chances of making a long-term recovery are about right. The outcomes of the treatments are as variable as the treatments themselves.
“Ten per cent of those with milder depressions will recover spontaneously within three months,” Cottrell says. “Forty per cent will do so spontaneously within a year. Similarly, 40% of those who have been on antidepressants will be depressed after two years and 20-30% will have a recurrence within five. But predicting who is going to fall into which category is impossible. All we can say is that having an episode of depression makes it more likely you will have another one.”
Most experts think the situation will only get worse. Mental health is the Cinderella of the NHS, and with cuts in services inevitable, it’s likely that already overstretched mental health teams will be struggling still further to cope. It can be hard enough being a teenager at the best of times: depression brings on the very worst of times.
Some names have been changed