Depression: Shadows on the soul

It rarely starts with a big bang. Instead, depression creeps into life very quietly, almost gently. Into the life of the person affected, but also into that of their family and friends. The 13-year-old has less and less fun at weekly handball training and doesn't hang out with his club mates as often - but maybe that's simply due to puberty, when other things often become more interesting, right?

The 15-year-old stays in her room more and more often at the weekend, and the otherwise very good pupil has done unusually badly in recent maths tests - but it's clear that she has to get over her best friend moving away first, isn't it?

Girls are generally more affected by depression than boys.

In the Swiss SMASH study from 2002, 35 per cent of the girls and almost 20 per cent of the boys surveyed stated that they were sad and depressed more often. This trend has continued in recent years. Of course, not all of these young people develop depression that requires treatment. But some do - and the course of this illness is becoming more severe, as various experts said in the course of this research. Why is that? How does depression develop in childhood and adolescence? What warning signs should parents look out for and when should they consult experts?

Parents should investigate conspicuous changes

The basic rule is: «If parents notice changes in their child, they should not simply dismiss it as a phase, but should investigate it,» says Stephan Kupferschmid, head physician for adolescent psychiatry at the Integrated Psychiatry Centre Winterthur - Zürcher Unterland. He recommends first looking and asking around to see if the changes affect several areas of life.

What do the teachers say, is the child different at school than usual? How are things with friends? If the child is behaving differently in all situations, parents should consider the onset of depression. This is not, as is unfortunately still often assumed by many, simply sadness, but a persistent state in which all feelings are only experienced in a reduced form. Depression is a serious mental illness, and those affected often speak of a black curtain covering their lives and a «feeling of numbness».

Depressive disorders are among the most common mental illnesses. The Swiss Society for Anxiety and Depression assumes that they affect - in varying degrees - up to 20 per cent of the population. There are no exact figures for children and adolescents, but experts estimate the proportion to be between 10 and 20 per cent.

Depression is the most common illness among adolescents. The risk of depression rises sharply with the onset of puberty, and a little earlier in girls - who are generally more affected than boys.

Influence of puberty

Puberty, which now begins two to three years earlier and lasts much longer than it did 100 years ago, marks the beginning of a phase of change on a biological, psychological and social level.

«With the onset of puberty, the frontal brain becomes a huge construction site,» explains Gregor Berger, Head of the Emergency Service for Child and Adolescent Psychiatry at the Psychiatric University Hospital Zurich. A large proportion of the nerve connections that are no longer needed are eliminated. Conversely, those that are needed are strengthened. Depending on which part of the brain is currently developing, you are more or less in balance.

Children with a depressed parent have a threefold higher risk of depression.

90 per cent of young people go through this phase without any major damage. «But there are also those 10 per cent who are vulnerable due to their genetic make-up or their life history,» says Berger. Then it only takes one or two stress factors, such as ADHD, a partial performance disorder or family problems, to be added to the mix and the whole system runs the risk of becoming unbalanced.

Depression has many faces

Even diagnosing depression in adults is not easy. With children and adolescents, there is also the fact that they are sometimes not yet able to properly express what they are experiencing and feeling in words. «An eight-year-old child can say: «I'm sad»,» says Kupferschmid, «but they won't say: "I've been sad for a month.» What's more, there is no such thing as textbook depression.

Depression has many faces. The illness not only manifests itself in different phases of life, but also varies greatly from person to person. Children often react to the emotional pain with physical symptoms. They get stomach aches, headaches, are tired. Or - and this reveals the problematic nature of the diagnosis - they take refuge in aggression.

With the onset of puberty, the number of adolescents with a depressive disorder also increases. In families where there is no known case of depression, the risk of the offspring developing depression is around 10 per cent. «We know that external influences play a role, but there is also a genetic component to depression,» says Kupferschmid. «For example, children with a depressive parent have a threefold higher risk of depression compared to the normal population.»

Clear warning signs of depression

According to Kupferschmid, it is always a clear warning sign when children start to withdraw and give up things they used to enjoy. Psychosocial factors such as the loss or physical illness of a parent can also have an impact on the child's mental state. Simply «puberty» or «it's just a difficult phase» are not enough reasons.

School is increasingly seen as a very important point for depression in children.

Stephan Kupferschmid, psychiatrist

With a trusting conversation and fundamentally empathetic contact between parents and child, the reasons for the depressive mood can usually be identified. Sometimes the child confides in a gently enquiring adult, such as a family friend or a teacher.

Find out the cause

Parents who suspect that their son or daughter is becoming depressed should ask themselves: Are there understandable reasons that could explain why the child is depressed? Bullying or prolonged excessive demands at school, for example? «School is increasingly seen as a very important factor for depression in children,» says Kupferschmid. «Early selection based on performance profiles creates a lot of pressure, which many children now also put on themselves.»

Once a potential cause has been identified, in many cases it is possible to work on eliminating it - even with professional help. Just as often, however, this is not possible because some situations are the way they are. «If the cause cannot be tackled directly, for example because it is a seriously ill sibling, it can help the affected children to learn coping strategies together with experts,» says Kupferschmid.

These strategies make it easier to deal with a stressful situation. The children and young people are given a kind of mental toolkit that they can ideally use not only acutely, but also later in life in similar situations. «If parents and children pull together, you can achieve a lot with psychotherapy for children and young people, and it is very effective.»

Promoting children's resilience

Promoting resilience also plays a major role: difficult situations are easier to endure if there are small islands in everyday life that are unaffected by the difficulties, where the child feels competent and enjoys themselves. So sticking to the weekly football training session while the parents are perhaps separating. Simply being able to talk, to tell someone what it's like deep down inside, to get advice - children and young people can do this at the 147.ch counselling service, which the Pro Juventute Foundation has been running since 1999.

And they are using it more and more: in counselling by telephone, text message, e-mail or chat, serious personal problems accounted for more than a third of all consultations last year, at 35.6 per cent - compared to 10.9 per cent in 2009. The main issues here are suicidal thoughts, depressive moods, crises or anxiety.

Difficult situations are easier to endure if there are small islands in everyday life that are untouched by difficulties.

Depression as a counselling topic has doubled

Depressive mood as a counselling topic has doubled in the past four years. Renate Poncet also experiences almost daily that the causes can be very diverse. «It's usually a very complex situation in which several factors or stresses come together,» says the specialist psychologist and counsellor at 147.ch.

«There are arguments with friends or in the family, bullying, excessive demands at school, low self-esteem because you no longer feel up to the increased performance requirements.» This often accumulates. If, for example, your girlfriend breaks up with you in addition to your parents' separation dispute and the challenges at school or in your apprenticeship are generally overwhelming, some young people find themselves in a situation that feels hopeless.

Suicidal thoughts

Poncet estimates that at least twice a day, a young person comes forward who is dealing with the issue of suicide. If it is acute, the counsellors act immediately and initiate a crisis intervention. However, children and young people seek contact much earlier. This is because the vast majority of them do not actually want to die. They just don't know how to continue living in the current, very stressful situation. «We then ask them what has happened, signalling that we are happy to listen and take the time to do so,» says Poncet.

The counsellors pay attention to the strengths and resources of the young people, ask them what is important to them, what they want to tackle and who they might want to bring on board. «At best, we manage to reassess the situation.»

The fact that children and adolescents suffer from depression and other mental illnesses is nothing new. According to Michael Kaess, the prevalence, i.e. the frequency of such illnesses, has not changed significantly over the past five or six decades. «What has increased dramatically, however, is the utilisation of medical help in such cases,» says the Medical Director of the University Clinic for Child and Adolescent Psychiatry and Psychotherapy at the University Psychiatric Services Bern.

On the one hand, this is good because it shows the destigmatisation of mental illness: More sufferers are seeking help. On the other hand, however, says Michael Kaess, it also shows that the intensity of cases is increasing and the crises associated with depression are becoming more severe. This is leading to more inpatient stays: «Overall, the number of cases here in Bern has tripled over the past ten years.»

He also sees the demands of modern society, which are reflected in schools among other things, as well as the disappearance of the extended family and thus binding, supportive structures, as reasons for this.

The earlier depression is recognised, the better

If depression is recognised at a young age, doctors and psychologists can often provide better and more sustainable help. As with many other illnesses, the earlier the better. «It's important that depression doesn't lead to important developmental steps being missed in adolescence, as a lot happens in a young person's life: increasing autonomy, career, building a social network,» says Kaess. If gaps develop here due to prolonged depression, the risk of further depression increases.

What is still puberty? What is depression? It is often difficult for parents to draw the line.

Kaess also emphasises that the greatest difficulty lies in recognising depression as such in adolescents. Classic depression is characterised by three symptoms: Sadness, lack of drive and loss of interest and pleasure. «How much do children show their parents when they are depressed and sad?» asks Kaess. «In my experience, they tend to hide it.»

It is more common for parents to notice when their offspring suddenly loses interest in a hobby that was previously a favourite. «However, many children change their hobbies just like that. Especially during puberty and with new friends, other things become more exciting,» says Kaess. «So I don't immediately have to think about depression if my daughter decides to stop ballet at the age of 13.» However, if dance lessons are not replaced by another hobby or increasing social contact with peers, parents should take a closer look.

The difference between "no desire" and depression

The situation is similar with listlessness. The fact that adolescents can't get out of bed in the morning is not just a symptom of depression, but also one of puberty. The difference to the normal tiredness and «no energy» mood of a teenager lies in a very strong morning low with severe exhaustion.

What is still puberty? What is depression? It is often difficult for parents, and worried parents, to make the distinction. Important: A single problem or symptom alone is not pathological. In a mental illness such as depression, several symptoms occur in combination. The severity of these symptoms, their duration and the impairment they cause to the child or young person in their everyday life are also decisive.

A stable relationship with parents is considered protective. Sufficient physical exercise and sleep are also beneficial.

However, Kaess says that one should not necessarily commit oneself to all these definitions and explanations, because many depressions do not look typical at all. That's what makes it so difficult to recognise. In addition, the emotional world of young people is often difficult to observe. Male adolescents in particular tend to display aggressive and irritable behaviour. Parents should also be suspicious of drug use or self-harm and think of depression - of course not if their son comes home drunk from a party. But definitely if this happens more often.

There are a number of factors that can reduce the risk of children and adolescents developing depression: An open, optimistic personality and a stable parent-child relationship, for example, are considered protective. Sufficient sleep and physical exercise are also protective. The internet and social media should only be used in moderation. It plays an enormous role that the child feels comfortable and respected at school, among their classmates and friends - bullying is considered one of the main risk factors for depression.

Behavioural therapy helps many people

Psychotherapy is the first choice for helping children and adolescents with depression. «We now have a wide range of different methods to choose from, not everything works for everyone,» says Kaess. Behavioural therapy was the first to prove its effectiveness and has established itself.

Sometimes you have to try out several methods to find the one that helps the young person. «As a rule, there should at least be an improvement after around ten psychotherapy sessions. If this is not the case, you have to keep looking,» says Kaess. This always depends on the severity of the depression.

While psychotherapy is limited to mild depression, antidepressants can also be prescribed for severe illnesses. Statistically speaking, the risk of further depressive episodes in life is increased if you suffered from it once as a child or adolescent. However, it can be completely different for each individual, says Kaess: «The chance of being able to lead a good life after successful treatment is relatively high.»