One promising alternative to drug treatment is cognitive behavioral therapy, which has been shown to be roughly as effective as drugs in treating teen depression. (Drugs and therapy together seem to be even more effective.) I asked James McCracken, the director of child and adolescent psychiatry at UCLA's Neuropsychiatric Institute, how many kids are willing to talk to a therapist. "More than you would expect," he said. "When it's very clear to the child that it's his or her therapy—and not [his or her] parents'—often that melts away a lot of the psychological barriers. The majority, when given the opportunity to meet with a generally skilled therapist, gain from it."
But it doesn't work for every kid. After I persuaded my daughter to begin therapy, she stuck with it for only a couple of months. She complained that her mother, with whom she lives, was not available to take her to her appointments, so I made it my job to pick her up and get her there. She went to therapy for another couple of months, and she dropped out again, despite my efforts. I was disappointed, but it wasn't a big surprise. Teenagers are working hard to become independent of the adults in their lives, and despite McCracken's confidence, I don't think it is possible to convince some teens to confide their most personal thoughts and feelings to any adult, even a skilled and understanding therapist.
Now, I'm beginning to hope that my daughter's darkest days are behind her. During the past few years, she's gradually become more stable, although she's continued to go through emotional ups and downs. At 17, she's still within an age range that carries a high risk of depression, especially for girls. (Beginning around puberty, women have about twice the risk of depression as men.) Yet she is consistently doing better, without therapy and with only intermittent medication. Why? For one thing, the disease may simply be waning, as it does from time to time.
There is another speculative but intriguing explanation: Perhaps as Alicia's brain matures, her susceptibility to depression declines. Until a few years ago, researchers believed that the brain finished developing at around age 12. The wiring was more or less complete, and the various parts of the brain had completed their growth. But the development of new brain scanners has led to a startling finding. It is now clear that the brain continues to grow and develop until about age 25. And the last area to develop is the so-called executive center of the brain, the site of mature decision making. It is possible that Alicia's improvement is due to the continuing development of her brain.
Researchers have believed for a long time that the brain produces too many neurons, or gray matter, early in life. These neurons are whittled away as the brain matures, leaving those that we have cultivated (through the study of Italian or jazz piano, for example) and dropping those we no longer need. But the story is not so simple. A few years ago, Jay Giedd of the National Institute of Mental Health (NIMH) showed that there is another burst of gray matter production just before puberty, and a second whittling during the teenage years, which ends in the early to mid-20s. In May 2004, researchers at NIMH and at UCLA released a fascinating "movie" showing the development of the human brain from the ages of 4 to 21. It shows that the neurons at the back of the brain are the first to undergo this pruning process. The frontal areas of the brain—the centers of decision making—are the last to mature.
In one series of studies, Deborah Yurgelun-Todd at Harvard University's McLean Hospital in Belmont, Massachusetts found that teenagers' brains process emotions differently than those of adults. When young teenagers are shown emotions on faces displayed on computer screens, their amygdalas become active. The amygdala is a brain center related to fear and other instinctual reactions. As the teens grow older, the same pictures trigger activity in the frontal lobes of their brains, areas responsible for reasoned decisions.
Researchers do not yet know whether mental illness is related to a disruption of the developmental process that leads to mature reasoning, but they have hints. In yet another study, NIMH researchers found an exaggerated loss of gray matter in the brains of teens with schizophrenia. And children with autism also show an altered pattern of brain development. Could some disruption in brain maturation explain my daughter's depression? It might explain why it came on so intensely—and why she seems to be getting better.
In the meantime, the controversy over the risks of treating teens with antidepressants continues. In June 2004, under the pressure of a lawsuit filed by New York Attorney General Eliot Spitzer, Paxil manufacturer GlaxoSmithKline released internal data which indicated that the drug was no better than a placebo for treating teen depression. Other research may ultimately provide better advice on the best treatment. At a medical meeting, child psychiatrist John March of Duke University announced preliminary results of a large study that showed that Prozac is effective in teens with depression. (In his study, drug and talk therapy combined were even more effective.) A report of the study appeared in The New York Times, but March will not discuss the early results or release any further details—not even to other psychiatrists—until the study is published.
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