Your Teenager’s Silent Scream-A Phase or a Clinical Symptom?

More Than Moody: Recognizing and Treating Adolescent Depression , by Harold Koplewicz, M.D. Putnam, 304 pages, $25.95.

In the 1970’s, two British child psychiatrists evaluated the entire 9-year-old population of the Isle of Wight. When they followed up with these children five years later, they found a significantgroupof teenagers with depression-in this case, all girls-whose parents thought of them as problem-free.

As Harold Koplewicz points out in More Than Moody , when it comes to adolescent depression, things have changed slowly. Until recently, it was commonly thought that children were developmentally incapable of depression-yet another manifestation of the tendency of psychiatrists (and other scientists) to “see what they think.” (In my practice, I saw a 3-year-old girl with classical panic attacks that were easily treated. Twelve years ago, a professional maintained her condition did not occur in her age group.) But if, in recent years, mental-health professionals have attained a better understanding of these conditions in adults, the realm of childhood and adolescent depression continues to be hard to navigate for those who suffer the consequences daily-namely, parents. Dr. Koplewicz takes on the daunting task of helping parents and other caregivers distinguish what Anna Freud saw as the normative stormy course of the teen years from clinical depression, bipolar and anxiety disorders.

One of the many strengths of this book is that Dr. Koplewicz has been at the forefront of the debates and participated in the research. The book explains extensively the current thinking about what “causes” depression and offers detailed case vignettes.

For example, the case of Jesse (published with the patient’s and parents’ permission) covers 30 years, during 15 of which Dr. Koplewicz had contact with the family. In grade school, Jesse-a bright and creative child-began showing symptoms that are potential harbingers of the later onset of depression, such as moodiness, social anxiety and hypersensitivity. Psychoanalytic therapy offered some relief. During adolescence, Jesse became quitesymptomatic:Hisgrades dropped, he became surly and sullen, he stayed in his room for hours on end and talked of suicide. He went back into therapy, but the treatment failed, despite the use of medication. (The antidepressant drugs of that time were not effective for adolescent depression, a fact that remained unknown for years because such drugs are not evaluated for use in children.) This case also predates new and promising “talking” treatments, such as cognitive-behavior therapy, which have proved to be effective in treating depression in adolescence.) When he saw Dr. Koplewicz, Jesse’s depression had rendered him incapable of maintaining his daily life. Dr. Koplewicz prescribed Prozac, and Jesse got better, although whether the improvement was due to the medicine remained unclear, since depressions are often cyclical. The story didn’t end there: Like many adolescents who are, at best, ambivalent about such treatments, Jesse took himself off the medication without telling anyone and crashed, then got better again when he resumed taking it. This testing repeated itself many times. At one point during a stressful term at college, Jesse became psychotic and suicidal. Treating adolescents requires skill, fortitude and caring, as well as a willingness to meet our patients where they are and when they need us. Dr. Koplewicz scores high on all of these, and Jesse has weathered his stormy adolescence, is aware of his need for continued treatment, and is doing well as a young adult.

In this specific case, Dr. Koplewicz makes another important point: There’s a strong genetic component in this group of illnesses, so family history is crucial in making an accurate diagnosis. Such data may allow the treating physician to intervene earlier and more aggressively. Because of the stigma still attached to these illnesses, such information is not forthcoming, and although Jesse’s father’s depression was known, it was not until much later that other family members who also suffered from depression came to light. This kind of omission is common: I once treated a 12-year-old girl who suffered from a manic psychosis; though we knew her aunt had the disorder, it wasn’t until a year after she came into treatment that I learned of the history of this illness on the other side of her family.

Dr. Koplewicz has written a much-needed book that grapples with thorny issues and serves as a guide to parents faced with adolescents who are seriously off-track. Both the complexity of the topic and the book’s intended audience may explain the proliferation of detail and reiteration in More Than Moody . It’s not meant for professionals intimately familiar with the material, but for parents struggling with pressing and complicated questions, and therapists who have been slow to recognize the dramatic changes in the field. How do childhood anxiety disorders or stress lead to depression? What happens in the minds-and brains-of adolescents? How does one locate the amorphous border that separates moody from more than moody? Dr. Koplewicz is qualified to answer such questions: He translates his knowledge methodically and accessibly from the position of someone who has been in the forefront of clinical and research developments in the field, offering many anecdotal examples and citing key research studies.

But why should parents read this book? Because the statistics are startling: 3 percent of young people suffer from a major depressive disorder, and 30 percent of bipolar disorders are now known to begin earlier in life than previously believed. Anxiety disorders are even more common, affecting about 7 percent of children and up to 17 percent of teenagers. In a sense, we have put the wagon in front of the horse: Much of the suffering and the societal cost associated with these mental illnesses is now preventable; the revolution in brain research has informed our understanding of these conditions immensely; the development of successful pharmacological and therapeutic treatments lead to an explosion of knowledge. But confusion persists because of the inherent difficulties in distinguishing between “normal” behavior in a pressure-cooker society and maladaptive behaviors that take on a life of their own. More Than Moody is a successful attempt to set the record straight by offering the general public a comprehensive and informative perspective. After an initial read, it will serve families well to keep it around so that they may refer to it as needed.

Herbert Schreier is chief of psychiatry at the Children’s Hospital in Oakland, Calif.

Your Teenager’s Silent Scream-A Phase or a Clinical Symptom?