“In children,” says Sylvia Simpson, a psychiatrist at Johns Hopkins, “depression prevents personality development. All this energy goes into fighting depression; social development is retarded, which does not make life any less depressing later on. You find yourself in a world which expects you to be able to develop relationships, and you just don’t know how to do it.” Children with seasonal depression, for example, frequently spend years doing badly at school and having trouble; their complaint is not picked up because it appears to coincide with the school year. It’s hard to know when and how aggressively to treat these disorders. “I work on the basis of family history,” says Joshi. “It can be very confusing whether it’s attention deficit hyperactivity disorder (ADHD) or real depression, or whether a child with ADHD has developed depression also; whether it’s an abuse-related adjustment disorder or depressive illness.” Many children with ADHD show extreme disruptive behaviors, and sometimes the natural response to these is to discipline the child; but the child is not necessarily able to control his actions if they are tied to deep cognitive and neurobiological problems. Of course the conduct disorders tend to make these children unpopular even with their own parents, and that exacerbates the depression—it’s yet another of depression’s novel downward spirals.
“I have to warn the parents of these children when they come in,” Christie says, “ ‘Well, we’ll be getting rid of this angry stuff, but you may then have a very sad child for a while.’ Children never come by themselves. They are brought to therapy. You have to find out from them why they think they’re there with you, and what they think is wrong. It’s a very different situation from one in which people seek out psychological care on their own.” One of the important elements in therapeutic work with young children is the creation of an alternative world of fantasy, a magical version of the safe space of psychodynamic therapies. Asking children to name their wishes will often reveal the exact nature of their deficits in self-esteem. It is important, as an opening gambit, to get silent children to transit into speech. Many of them cannot explain their feelings except to say that they feel okay or they feel not okay. They must be given a new vocabulary; and they must be taught, on the cognitive model, the difference between thoughts and feelings, so that they can learn to use thoughts to control feelings. One therapist described asking a ten-year-old girl to keep a diary of thoughts and feelings for two weeks and then bring it in. “You could say your thought is ‘Mommy’s angry at Daddy.’ And your feeling could be ‘I’m frightened.’ ” But the distinction was beyond this child’s cognitive grasp because her depression had so disabled her cognitive functioning. When she brought the diary, she had written each day: “Thoughts: ‘I’m sad’; Feelings: ‘I’m sad.’ ” In her hierarchy, the world of thought and the world of feeling were simply inseparable. Later on, she was able to make a pie chart of her anxieties: this much of her anxiety was about school, this much about home, this much about people hating her, this much about being ugly, etc. Children who have worked with computers are often receptive to metaphors that work on the principle of technology; one therapist I met said he told such children that their minds have programs to process fear and sadness and that treatment would take the bugs out of those programs. Good child therapists inform and distract their patients at once; as Christie has observed, “There is nothing as unrelaxing to children as being told to relax.”
Depression is also an acute problem for children who suffer physical illness or disability. “Kids come in with cancer and they are constantly being poked and prodded and having needles stuck in them, and they become accusatory and accuse their parents of punishing them with these treatments, and then the parents become anxious; and then everyone becomes depressed all together,” Christie says. Illness breeds secrecy, and secrecy breeds depression. “I sat down with a mother and her very depressed son, and I said, ‘So, tell me why you’re here,’ and the mother said, right in front of this little boy, in a loud stage whisper, ‘He’s got leukemia but he doesn’t know it.’ It was extraordinary. Then I asked to have some time alone with the little boy and I asked him why he had come to see me. He said it was because he had leukemia, but not to tell his mother because he didn’t want her to know that he knew. So the depression was tied into huge issues around communication, and those were exacerbated and brought into play by the leukemia and the treatments that disease required.”
It has now been established that depressed children usually go on to become depressed adults. Four percent of adolescents who have experienced childhood depression commit suicide. A huge number make suicide attempts, and they have high rates of almost every severe social-adjustment problem. Depression occurs among a good number of children before puberty, but it peaks in adolescence, with at least 5 percent of teenagers suffering clinical depression. By that stage, it is almost always combined with substance abuse or anxiety disorders. Parents underestimate the depth of the depression of their teenagers. Of course adolescent depression is confusing because normal adolescence is so much like depression anyway; it is a period of extreme emotions and disproportionate suffering. Over 50 percent of high school students have “thought about killing themselves.” “At least twenty-five percent of teenagers in detention have depression,” says Kay Jamison, a leading authority on manic-depressive illness. “It could be treated and they might become less obstructive. By the time they’re adults, the depression level is high but the negative behavior has been ingrained into personality, and treating the depression isn’t enough.” Social interaction also plays a role; the onset of secondary sexual characteristics often leads to emotional confusion. Current research is directed at delaying the onset of depressive symptoms—the earlier your depression starts, the more likely it is to be resistant to treatment. One study says that those who experience depressive episodes in childhood or adolescence have seven times the rate of adult depression of the general population; another says that 70 percent of them will suffer recurrence. The need for early interventions and preventative therapies is absolutely clear. Parents should be on the lookout for early disengagement, disrupted appetites for food and sleep, and self-critical behavior; children who show these signs of depression should be taken in for professional assessment.
Teenagers in particular (and male teenagers most of all) fail to explain themselves clearly, and the industry of treatment pays too little attention to them. “I have teenagers who come in and sit in the corner and say, ‘There’s nothing wrong with me,’ ” one therapist explained. “I never contradict them. I say, ‘Well, that’s fantastic! How terrific that you’re not depressed like so many kids your age and like so many of the kids who come in to see me. Tell me what it’s like to feel totally okay. Tell me what it’s like right this minute to be in this room feeling totally okay.’ I try to give them opportunities to think and feel together with someone else.”
It is unclear to what extent sexual abuse causes depression through direct organic processes, and to what extent the depression is reflective of the kind of fractured home environment in which sexual abuse tends to occur. Sexually abused children tend to have life patterns of self-destructive behavior, and they encounter high levels of adversity. They usually grow up in constant fear: their world is unsteady, and that unbalances their personalities. One therapist describes a young woman who had been sexually abused and couldn’t believe that anyone could care for her and be reliable—“all she needed was for me to be consistent in my interactions with her” to break down the automatic mistrust with which she related to the world. Children deprived of early love and of encouragement toward cognitive development are often permanently disabled. One couple who adopted a child from a Russian orphanage said, “This was a kid who at five didn’t seem to have any cause-and-effect thinking, who didn’t know that plants were alive but furniture wasn’t.” They have been trying to compensate for that deficit ever since and now acknowledge that no full recovery will be possible.
For other children, though recovery seems impos
sible, accommodation is not. Christie describes treating a girl with horrible chronic headaches, “like banging hammers in my head,” who had given up everything in her life because of the headaches. She couldn’t go to school. She couldn’t play. She couldn’t interact with other people. When she met Christie for the first time, she announced, “You can’t make my headache go away.” Christie said, “No, you’re right. I can’t. But let’s think about ways to keep that headache all in one piece of your head and see if you can’t use another piece of your head even while the hammers are hammering in there.” Christie notes, “The first step is to believe what the child says even if it’s apparently untrue or implausible, to believe that even if the child is using metaphoric language that doesn’t make sense, it must make sense to them.” After extensive treatment, the girl in question said she could go to school despite her headaches, and then she began to have friends despite her headaches, and within another year, the headaches themselves were gone.
The elderly depressed are chronically undertreated, in large part because we as a society see old age as depressing. The assumption that it is logical for old people to be miserable prevents us from ministering to that misery, leaving many people to live out their final days in unnecessary extreme emotional pain. As early as 1910, Emil Kraepelin, father of modern psychopharmacology, referenced depression among the elderly as involutional melancholy. Since then, the breakdown of traditional caretaking structures and the removal from old people of any sense of importance have made things worse. Older people in nursing homes are more than twice as likely to be depressed as those who live in the world—in fact, it has been suggested that more than a third of those resident in facilities are significantly depressed. It is striking that the effects of placebo treatment on elderly patients are substantially higher than the norm. This would suggest that these people are experiencing some benefit from the circumstances around the taking of a placebo, beyond the conventional psychosomatic benefits of believing that one is receiving medication. The monitoring and close interviews that are a part of charting a study, the careful regulation and the focus for the mind, are having a meaningful effect. Old people feel better when more attention is paid to them. The elderly in our society must be horrifyingly lonely for this small response to give them such a lift.
While the social factors that lead to depression among the elderly are powerful, it would appear that important organic shifts also affect mood. Levels of all neurotransmitters are lower among old people. The level of serotonin in people in their eighties is half of what it would have been in the same people in their sixties. Of course the body is at this stage of life going through many metabolic shifts and much chemical rebalancing, and so diminishing neurotransmitter levels do not have the same immediate effect (so far as we know) as they would in a younger person whose serotonin levels were suddenly reduced by half. The extent to which brains change in plasticity and function with age is also reflected in the fact that antidepressant treatment takes a particularly long time to kick in for old people. The same SSRIs that in a midlife adult will begin to work within three weeks will in an elderly patient often take twelve weeks or longer to be effective. The rate of successful treatment, however, is not altered by age; the same proportion of people is treatment-responsive.
Electroconvulsive therapy is frequently indicated for the elderly for three reasons. The first is that, unlike medications, it acts rapidly; letting someone get more and more depressed for months before his meds begin to alleviate his despair is not constructive. Additionally, ECT does not have adverse interactions with other medications that elderly people may be taking—such interactions can in many cases limit the range of antidepressants that can be prescribed. Finally, depressed elderly people often have lapses in memory and may forget to take their medication or may forget that they have taken it and take too much. ECT is much easier to control in this regard. Short-term hospitalization is often the best way to care for older people who are experiencing severe depression.
Depression can be hard to spot in these populations. The libido issues that are important elements of depression among younger people do not play so significant a role among the elderly. They feel guilty less often than do younger depressives. Instead of getting sleepy, older depressed people tend to be insomniac, lying awake at night in the grip, often, of paranoia. They have wildly exaggerated catastrophic reactions to small events. They tend to somaticize a lot, and to complain of an enormous number of peculiar aches and pains and atmospheric discomforts: This chair isn’t comfortable anymore. The pressure in my shower is down. My right arm hurts when I pick up a teacup. The lights in my room are too bright. The lights in my room are too dim. And so on, ad infinitum. They develop irritable characteristics and become grumpy, often showing a distressing emotional bluntness with or an emotional indifference to those around them and occasionally manifesting “emotional incontinence.” These symptoms respond most frequently to the SSRIs. Their depression is often either a direct consequence of shifting organic systems (including lower blood supply to the brain) or a result of the pain and indignity of bodily decay. Elderly dementia and senility are often accompanied by depression, but the conditions, though they may occur together, are different. In dementia, the capacity for automatic mind functions goes down: basic memory, especially short-term, is compromised. In depressed patients, psychologically effortful processes are blocked: long-term complex memories become inaccessible, and processing of new information is impeded. But most elderly people are unaware of these distinctions, and they suppose the depression symptoms to be the quality of age and mild dementia, which is why they so often fail to take basic steps to ameliorate their situation.
One of my great-aunts fell in her apartment and broke her leg when she was in her late nineties. The leg was set, and she came home from the hospital with a team of nurses. She clearly found it hard to walk at first, and only with difficulty could she do the exercises set for her by her physiotherapist. A month later, her leg had healed remarkably well, but she was still afraid of walking and continued to struggle against locomotion. She had become accustomed to a commode, which could be brought to her bedside, and she refused to go the fifteen feet to get to the toilet. Her lifelong vanity was suddenly gone, and she refused to go to the hairdresser, whom she had visited twice every week for nearly a century. In fact, she refused to go out at all and kept postponing a visit to a podiatrist despite an ingrown nail that must have been painful. Weeks went by like this in her claustrophobic apartment. Meanwhile, her sleep was irregular and disturbed. She refused to talk to my cousins when they called her. She had always been meticulous about her personal affairs and somewhat secretive about details; now she asked me to open and pay her bills as they were too confusing for her. She couldn’t assemble simple information—she’d ask me to repeat eight times my plans for the weekend, and this cognitive retardation seemed almost like senility. She grew repetitive, and though she was not sad, she was altogether diminished. Her GP insisted that she was just experiencing some trauma-related stress, but I saw that she was getting ready to die and believed that this was an inappropriate response to a broken leg, no matter how old she was.
I finally persuaded my psychopharmacologist to come to her apartment and talk to her, and he immediately diagnosed severe old-age depression and put her on Celexa. Three weeks later, we had an appointment with her podiatrist. I pressed her to come out in part because I thought her foot wanted attention, but mostly because I thought it was necessary for her to venture into the world again. She looked at me with anguish when I made her come outside and seemed to find the entire thing utterly debilitating. She was confused and frankly terrified. Two weeks later, we had an appointment with the doctor who had set her leg. I arrived at her apartment to find her in an attractive dress with her hair combed and some lipstick on, wearing a little pearl brooch that she had often sported in happier days. She came downstairs without complaining. She clearly found our outing stressful, and she was fractious
in the doctor’s office, and a bit paranoid, but when the surgeon came in, she was charming and quite articulate with him. At the end of her visit, her nurse and I wheeled her back toward the door of the building. She was pleased to learn that her leg had healed nicely and thanked everyone profusely. I was exultant at every sign of reawakening in her, but nothing had really prepared me for her to say, as we were leaving, “Darling, shall we go out to lunch?” And we went to a restaurant we used to like, and with my help she even walked a short distance in the restaurant, and we told little stories and laughed, and she complained that her coffee was not hot enough and sent it back, and she was alive again. I cannot say that she then returned to regular lunching, but thereafter she consented to go out once every few weeks, and her basic coherence and sense of humor gradually returned to her.
Six months later, she developed what turned out to be internal bleeding of minor significance, and had a three-day hospitalization. I was concerned about her, but was pleased that her mood was resilient enough so that she could cope with the hospital entry without becoming panicked or confused. A week after she came home, I visited her and checked to make sure she had sufficient supply of all her medications. I noticed that the Celexa bottle was about as full as it had been when I checked it previously. “Have you been taking these?” I asked her. “Oh, no,” she said. “The doctor told me to stop taking them.” I assumed that she must have misunderstood, but her nurse had been present when these instructions had been given and confirmed them. I was frankly astonished and horrified. Celexa has no gastroenterological side effects, and that it had been implicated in her bleeding seemed highly unlikely. There was no good reason for terminating it, and there could be no good reason for terminating it so abruptly; even someone young and fit should go off antidepressant medication gradually and according to a clear program. Someone who is receiving substantial benefit from medication should not be taken off it at all, but the gerontologist who treated my aunt had whimsically decided that it would be good for her to go off any “unnecessary” medications. I called that doctor and screamed holy hell down the line, wrote an outraged letter to the president of the hospital, and told my aunt to return to her medication. She is living rather happily and less than a month from her hundredth birthday as this book goes to press. We are going to the hairdresser in two weeks so that she’ll look her best for the little party we’re planning to throw. I go to visit her every Thursday, and our afternoons together, which were once a leaden burden, are now full of fun; when I gave her some good family news a few weeks ago, she clapped her hands and then started to sing. We talk about all kinds of things, and I have recently benefited from her wisdom, which came creeping back to her along with the gift of joy.
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