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An Interview with Frank Mondimore

What are the signals of serious clinical depression in adolescents?
Everyone gets down now and again. When being down becomes an everyday affair: day after day, week after week, then something is seriously wrong. This is clinical depression. Loss of interest in school, friends, sports, anything and everything is another sign of serious depression. Low energy and loss of appetite are common. Other possible signs are dropping grades in school and alcohol or drug use. Thoughts of death and suicide are always serious danger signals.

Are there different types of clinical depression?
In discussing serious depression, psychiatrists talk about mood disorders. The most common and one of the most serious mood disorders is Major Depressive Disorder. Persons with this problem have frequently incapacitating symptoms of depression that often last up to a year without treatment. Low, depressed mood, loss of interest in and the ability to enjoy things, sleep and appetite disturbance, low energy, feelings of failure and worthlessness are common. Dysthymic Disorder is a less severe, but longer-lasting depressive illness. Persons with dysthymic disorder have many of the same symptoms as those with major depressive disorder but fewer of them and their symptoms are not quite as severe. They may suffer from chronically poor sleep and energy level problems; they often feel bad about themselves and hopeless about the future. Dysthymic individuals often suffer with their symptoms for many years at a time.

Where does Bipolar Disorder fit in?
Bipolar Disorder is another mood disorder, formerly called “manic-depression.” As these names might suggest, persons with this illness have depression but also suffer from an opposite sort of mood state called mania. Persons in a manic state have a super-high energy level and don’t need to sleep, their thinking is fast and scattered and they may talk so fast as to become incoherent. Sometimes their mood is very high, sometimes they are very irritable and angry. Bipolar disorder is a complex and very serious mood disorder that always requires expert assessment and treatment.

How common are these illnesses?
Serious depression is very common, some experts have estimated are that as many as 1 in 5 persons will have symptoms of major depression during their lifetime. Bipolar disorder is much less common, affecting about 1% of the general population.

What are the treatments?
Several decades of clinical research have shown that antidepressant medications are safe and effective treatments for serious depression in adults, adolescents and even children. Almost all persons with serious depression will benefit from antidepressant medication.

Is medication always necessary?
Adolescents with milder depressions can sometimes be treated with psychotherapy (talk therapy) but research shows that “just talking” to a trusted friend or adult isn’t enough. A special kind of psychotherapy called cognitive therapy helps identify and change depressed thinking patterns and has been shown to be as effective as medication for some patients. Severely depressed adolescents and adolescents with bipolar disorder, however, should always be evaluated for medication.

I read that the antidepressant Prozac (fluoxetine) has been approved for the treatment of depression in children. What do you think about this?
FDA approval of a drug for a particular use only means that the pharmaceutical company that makes the drug can now include that use in their labeling of the drug for doctors. Physicians can legally prescribe any medication for any purpose based on their knowledge of the research literature and experience and child psychiatrists have been using antidepressants in children for years (called 'off-label" use). FDA approval of this use means that there are now enough research data to meet the FDA's standards for proven safety and effectiveness.

How long will my child need to be in treatment for depression?
We know that major depressions last about a year without treatment, so staying in treatment for at least that long is clearly necessary. We also know that persons who have had a bout of major depression have a 90% likelihood of having another one at some point in their lives. There is evidence that serious depression that starts early in life is even more likely to recur, so it’s important to take the long view when making decisions about treatment.

What causes serious depression?
Genetics is a big piece of the picture, but life events, trauma and bad experiences probably make important contributions. Everyone seems to inherit a greater or lesser tendency to develop depression and this tendency interacts with life events to set off the illness in some. Some researchers believe that the genetic factors are probably more important in persons with early-onset depression.

Can drug or alcohol abuse cause depression?
Mood disorders and substance abuse problems seem to go hand in hand in many individuals and it’s not clear at all how the two types of problems are related to each other. Sometimes the one seems to have caused the other, but it’s often impossible to say which came first. It’s toughest “chicken or egg” question we have in psychiatry. One thing is certain, however: depression is much harder, some would say impossible to treat in a person who’s abusing drugs or alcohol.

Where can I get help for my child?
Family doctors and pediatricians are more and more aware of how common depression is in their patients and are very capable of diagnosing serious depression. Some will be comfortable treating milder depressions, but many will want an expert to take over the treatment of such a serious illness and will refer their patients to a psychiatrist for treatment of a mood disorder. Either professional will usually be able to help arrange for psychotherapy as well.

Francis Mark Mondimore, M.D., is a psychiatrist and member of the clinical faculty of the Johns Hopkins University School of Medicine. His books include Depression: The Mood Disease and Bipolar Disorder: A Guide for Patients and Families, both available from Johns Hopkins.