I have had several episodes of violence since my first depression, and I have wondered whether these episodes, for which there was no precedent in my life, were connected to depression, were part of its aftermath, or were somehow to be associated with the antidepressants I have taken. As a child, I seldom hit anyone except my brother, and the last time I did that was when I was about twelve. And then one day when I was in my thirties, I became so irrationally angry that I began plotting murders in my mind; I eventually off-loaded that anger by smashing the glass on a series of pictures of myself that hung in a girlfriend’s house, leaving the broken glass on the floor and the hammer in its midst. A year later, I had a serious falling-out with a man whom I had loved very much and by whom I felt profoundly and cruelly betrayed. I was already in a somewhat depressed state, and I became enraged. I attacked him with a ferocity unlike any I had experienced before, threw him against a wall, and socked him repeatedly, breaking both his jaw and his nose. He was later hospitalized for loss of blood. I will never forget the feeling of his face crumpling under my blows. I know that right after I hit him I had his neck in my hands for a moment and that it took a powerful summoning of my superego to save me from strangling him. When people expressed horror at my attack on him, I told them almost what the batterer told me: I felt as though I were disappearing, and somewhere deep in the most primitive part of my brain, I felt that violence was the only way I could keep my self and mind in the world. I was chagrined by what I had done; yet though one part of me regrets the suffering of my friend, another part of me does not rue what happened, because I sincerely believe that I would have gone irretrievably crazy if I had not done it—a view that this friend, to whom I am still close, has since come to accept. His emotional and my physical violence achieved a curious balance. Some of the feeling of paralytic fear and helplessness that afflicted me around that time was alleviated by the act of savagery. I do not accept the behavior of wife batterers and I certainly do not endorse what they do. Engaging in violent acts is not a good way to treat depression. It is, however, effective. To deny the inbred curative power of violence would be a terrible mistake. I came home that night covered with blood—mine and his—and with a feeling of both horror and exhilaration. I felt tremendous release.
I have never hit a woman, but about eight months after the jaw-breaking episode, I yelled at one of my closest friends and humiliated her terribly and publicly because she wanted to reschedule a dinner plan. I have learned that depression can easily erupt as rage. Since I’ve got out of the deepest trough of depression, those impulses are under control. I am capable of great anger, but it is usually tied to specific events, and my response to those events is usually in proportion to them. It is not usually physical. It is usually more considered and less totally impulsive. My attacks have been symptomatic. That does not relieve me of responsibility for violence, but it does help to make sense of it. I do not condone such behavior.
No woman I have met has described these feelings in quite this way; many depressed men I have met have had similar impulses toward destructiveness. Many have been able to avoid acting on them; many others have acted on them and felt release from irrational terror as a result of doing so. I do not think that depression in women is different from what it is in men, but I do think that women are different from men, and that their ways of handling depression are frequently different as well. Feminists who wish to avoid pathologizing the feminine and men who believe that they can deny their emotional state are looking for trouble. It is interesting that Jewish men, who are as a population particularly disinclined to violence, have a much higher rate of depression than non-Jewish men—in fact, studies show them having about the same rate of depression as Jewish women. Gender, then, plays an elaborate part not only in who gets depressed, but also in how that depression manifests itself and, consequently, how it may be contained.
Depressed mothers are usually not great mothers, though high-functioning depressives can sometimes mask their illness and fulfill their parenting roles. While some depressed mothers are easily upset by their children and behave erratically as a consequence, many depressed mothers simply fail to respond to their children: they are unaffectionate and withdrawn. They tend not to establish clear control or rules or boundaries. They have little love or nurturance to give. They feel helpless in the face of their children’s demands. Their behavior is unregulated; they become angry for no apparent reason and then, in paroxysms of guilt, express extravagant affection for equally indistinct reasons. They cannot help a child to regulate his own problems. Their responses to their children are not contingent on what the children are doing or on displays of neediness. Their children are weepy, angry, and aggressive. Such children are often themselves incapable of caring behaviors; sometimes, however, they are too prone to caring behaviors and feel responsible for all the suffering of the world. Little girls are particularly likely to overempathize and so make themselves miserable; because they experience no lift in the mood of their mothers, they lose the capacity for elasticity of mood themselves.
The earliest manifestations of childhood depression, which are found in infants as young as three months, occur primarily in the offspring of depressed mothers. Such children do not smile and tend to turn their head away from all people, including parents; they may be at greater ease when they are not looking at anyone than when they look at their depressed mother. The brain-wave patterns of such children are distinctive; if you successfully treat the depression in the mothers, the brain-wave patterns of the children may improve. In older children, however, adjustment difficulties may not lift so readily; school-age children of a depressed mother were shown to be severely maladjusted even a year after their mother’s symptoms had been alleviated. The children of parents who have been depressed are at a significant disadvantage. The more severe the depression of the mother, the more severe the depression of the child is likely to be, though some children seem to pick up on maternal depression more dramatically and empathetically than do others. In general, the children of a depressed mother not only reflect but also magnify their mother’s state. Even ten years after an initial assessment, such children suffer significant social impairment and are at a threefold risk for depression and a fivefold risk for panic disorders and alcohol dependence.
To improve the mental health of children, it is sometimes more important to treat the mother than to treat the children directly; to try to change negative familial patterns to incorporate flexibility, hardiness, cohesion, and problem-solving ability. Parents can team up well for the circumvention of depression in their children even if their relationship to each other is highly flawed, though a single, clear front can be challenging to sustain. Children of depressed mothers have more difficulties in the world than do children of schizophrenic mothers: depression has a singularly immediate effect on the basic mechanisms of parenting. Children of depressed mothers may suffer not only depression but also attention deficit disorder, separation anxiety, and conduct disorder. They do badly in social and academic situations, even if they are intelligent and have some attractive qualities of personality. They have unusually high levels of physical complaints—allergies, asthma, frequent colds, severe headaches, stomachaches—and complain of feeling unsafe. They are often paranoid.
The University of Michigan’s Arnold Sameroff is a developmental psychiatrist who believes everything in the world is a variable in every experiment; all events are overdetermined; nothing can be understood except by knowing all the mysteries of God’s creation. Sameroff would suggest that though people have certain complaints in common, they have individual experiences, with individual constellations of complaints and individual networks of causes. “You know, there are these single-gene hypotheses,” he says. “Either you have the gene or you don’t, and those are very attractive to our quick-fix society. But it’s never going to work.” Sameroff has been looking at the children of people with major depression. He has found that these children, even if they start on a cogniti
ve level with their peers, go downhill beginning around age two. By the age of four, they are distinctly “sadder, less interactive, withdrawn, and low-functioning.” For this he proposes five primary possible explanations, all of which, he believes, come into play in various mosaics: genetics; empathetic mirroring, kids repeating back what they experience; learned helplessness, ceasing to attempt to connect because of lack of parental approval for emotional outreach; role-playing, as the child sees the advantages an ill parent gets from being too ill to do unpleasant things and decides to take on the illness role; and withdrawal, as a consequence of seeing no pleasure in communication between unhappy parents. Then there are all the subexplanations: depressed parents are more likely to be substance abusers than are other parents. What kind of treatment or trauma does a child experience at the hands of substance abusers? That would lead us right into stress.
A recent study has listed two hundred factors that may contribute to high blood pressure. “At a biological level,” says Sameroff, “blood pressure is really pretty simple. If there are two hundred factors influencing it, think how many factors must influence a complex experience such as depression!” In Sameroff’s view, the coincidence of a number of risk factors is the basis for depression. “Those people who get a group of risk factors all glommed together are the ones who have what we call a disorder,” Sameroff says. “We found that in terms of depression, heredity was not nearly as strong a predictor as socioeconomic status. The interaction of heredity and socioeconomic status was the strongest predictor of all, but then what were the key components of low socioeconomic status that made small children get so depressed? Was it lack of parental education? Lack of money? Low social support? Number of kids in the family?” Sameroff made a list of ten such variables and then correlated them with degrees of depression. He found that any negative variable on its own was likely to contribute to low mood, but that any group of such variables was likely to produce significant clinical symptoms (as well as lowered IQ). Sameroff then did research that showed that the child of a seriously ill parent was likely to do better than the children of a moderately ill parent. “It turns out that if you’re really, really ill, someone picks up the load. If there are two parents, the one who isn’t ill knows he has to do the work. And the child has a way of understanding what’s going on in the family; he grasps the principle that one of his parents is mentally ill and he isn’t left with all the unanswered questions that afflict the children of the mildly mentally ill. So you see? It’s not predictable according to a simple linear system. Every depression has its own story.”
While poor parenting or depressed parenting may cause depression in children, good parenting may well help to allay or alleviate it. The old Freudian blame-your-mom principle has been discarded, but the world of children is still defined by their parents, and they can learn some degree of resilience or debility from their mother, father, and other caretakers. Indeed many treatment protocols now involve training parents in therapeutic interventions with their children. Those interventions must be based on listening. The young are a different population and cannot be treated as though they were just dwarfish adults. Firmness, love, consistency, and humility must come together in parental approaches to depressed children. A child who has watched a parent solve a problem gains enormous strength from that.
A distinct form of depression, called anaclitic depression, occurs in the second half of the first year for children who have been separated too much from their mother. In various combinations and degrees of severity, it mixes apprehension, sadness, weepiness, rejection of environment, withdrawal, retardation, stupor, lack of appetite, insomnia, and unhappy expressions. Anaclitic depression may develop into “failure to thrive” starting at four or five; children with this complaint don’t have much affect and don’t bond. By five or six, they may show extreme crankiness and irritability and poor sleeping and poor eating. They do not make friends and have inexplicably low self-esteem. Persistent bed-wetting points to anxiety. Some become withdrawn; others become steadily more cranky and destructive. Because children do not tend to consider their own future as adults do, and because they do not organize their memories lucidly, they are seldom preoccupied with the meaninglessness of life. Without the development of abstract feeling, children do not feel the hopelessness and despair characteristic of adult depression. But they can suffer persistent negativity.
Recent studies have been at such statistical odds as to be ludicrous: one of these definitively proved that depression affects about 1 percent of children; another demonstrated that about 60 percent of children experience major affective disorders. Attempts to assess children through self-reports are much more complicated than they are for adult populations. In the first place, questions must be put in such a way that they do not dictate apparently “desirable” answers; therapists must be brave enough to ask about suicide without proposing it as a feasible alternative. One therapist provided the formulation “Okay, if you hate all these things so much in your life, do you ever think about ways you could just make it so you’d never be around anymore?” Some kids will say, “What a stupid question!” and some will say “yes” and provide full details, and some will become quiet and thoughtful. The therapist needs to watch the child’s body language. And the therapist has to persuade the child that he is prepared to listen to anything. Children with really serious depression talk about suicide under such circumstances. One depressed woman I met, who was striving to keep up a good front for her children, described the despair she felt when her son said, at age five, “You know, life’s crummy and a lot of times I don’t want to live.” By age twelve, he had made a serious suicide attempt. “They’ll talk about wanting to join someone, maybe a relative, who has died,” says Paramjit T. Joshi, who heads the children’s mental health division at Johns Hopkins Hospital. “They say they want to sleep forever; some five-year-olds will actually say, ‘I want to die; I wish I was never born.’ Then the behaviors set in. We see many kids who have jumped out of second-story windows. Some of them take five Tylenol and think it’s enough to die. Others try to cut their wrists and arms, or to smother themselves, or to hang themselves. A lot of little children hang themselves with their belts in their closets. Some of them are already abused or neglected, but some of them are doing these things for no apparent reason. Thank goodness, they’re seldom competent enough to succeed in suicide!” In fact, they can be surprisingly competent; suicides in the ten-to-fourteen age group increased by 120 percent between the early eighties and the midnineties, and the children who succeed are mostly using aggressive means: guns and hangings account for almost 85 percent of the deaths. The rate has been rising, as children, like their parents, experience escalating stress.
Children can be and increasingly are treated with liquid Prozac or liquid nortriptyline, carefully dripped into a glass of juice. Such medication appears to help. There are not, however, any adequate studies of how these medications work in children nor of whether they are safe or effective; “We have made children into therapeutic orphans,” says Steven Hyman, director of the NIMH. Only a few of the antidepressants have been tested to show that they are safe for use with children, and almost none have been tested for efficacy in children. Anecdotal experience varies widely. One study showed, for example, that SSRIs work better with young children and with adults than they do with teenagers; another showed that MAOIs are the most effective for young children. One should not take the results of either study to be definitive, but they point to the distinct possibility that treating children may be different from treating adolescents, and that both may be different from treating adults.
Depressed children also require therapy. “You just have to show them that you are right there with them,” says Deborah Christie, a charismatic child psychologist who is a consultant at University College London and Middlesex Hospital. “And you have to get them to be there with you too. I use a metaphor of mountain climbing a lot. We’re thinking about climbing a mountain and we’re
sitting at base camp and just thinking about what kind of luggage we might need, and how many of us should go up together, and whether we should rope together. And we may decide to make the journey or we may decide we’re not ready to make it yet, but maybe we can walk around the mountain so we can see which will be the easiest or best way up. And you have to acknowledge that they’ll be doing some climbing, that you can’t pick them up and carry them up there, but that you can stick by them every inch of the way. That’s where you have to start: you have to stir up motivation in them. Kids who are really depressed don’t know what to say or where to begin, but they know that they want change. I’ve never seen a depressed child who didn’t want treatment if he could believe that there was a chance it would change things. One little girl was too depressed to speak to me, but she could write things down, so she’d write these words, randomly, on Post-its, and then she’d paste them on me, so that by the end of a session I was just a sea of the words she wanted to get through to me. And I took on her language and I started writing words on Post-its too, and putting them all over her, and that’s how we broke through her wall of silence.” There are many other techniques that have proven useful for helping children to recognize and improve their mood states.
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