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Is the Epidemic of Teenage Suicide Caused by Depression?

Or a group of clinicians not willing to refrain from making a diagnosis?

There has been an unquestionable and alarming increase in the suicide rate among young people. Suicides among non-Hispanic white females aged 10-14 years increased from 0.5 per 100,000 in 1999 to 1.7 in 2014. That is more than a three-fold increase.

The question is why.

On May 18, 2016, Paolo del Vecchio, Director of the Center for Mental Health Services at the national substance abuse organization, SAMHSA (Substance Abuse and Mental Health Services Administration), said it is because of rising rates of depression among the nation’s youth. “Recognizing and treating depression among youth is critically important to our nation’s health,” he wrote.

Indeed, according to SAMHSA data, the figures look alarming. Major depression among youths aged 12 to 17 began what looks like a relentless increase in 2010, at 8.0 per 100 among youths aged 12 to 17, and culminated in 11.4 per hundred in 2014, the last year for which statistics are available. (Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health, A-15, tab A.17B)

So more than one out of ten adolescents is clinically depressed, according to this survey. At a high-school basketball game, a tenth of the turnout will be depressed.

There are two questions: (1) Are all these kids really depressed? (2) And if they do not have a serious, melancholic depression that often does entail suicide, why are they committing suicide?

On (1), We have been told for decades that rates of depression are increasing alarmingly. Indeed, in every survey, the number of respondents considered “depressed” is higher than before. Yet seen historically, depression is a major psychiatric illness that was actually not that common. “Depression” before the advent of DSM-3 in 1980 usually meant what was then called “endogenous depression,” or melancholia, the patients deeply sad, unable to experience pleasure of any kind, and slowed in movement and thought. Effective antidepressants had been on the market since the late 1950s and these agents were in fact quite effective in terrible bouts of melancholia, the patients curled into a fetal ball or pacing anxiously and saying, “Those explosions in Greece, it’s all my fault.”

Now, there was a second depression, a quite different ailment called “reactive depression,” “neurasthenia,” “neurotic depression,” or simply nervous illness, in which people were not deeply sad or slowed or unable to respond to their children’s affection. But instead they were anxious, obsessive, tired, had tons of physical complaints, and felt permanently as though they had gotten up on the wrong side of bed.

This second depression was real for those who had it, but they were not necessarily suicidal (though impulsively they might indeed act). It was not this grave, melancholic depression, where you would be admitted to a hospital psychiatric ward and watched very carefully.

What happened in 1980 was that DSM-3 merged these two depressions into one and called the highly heterogeneous pot that came out of it “major depression.” The apples and oranges had been hopelessly mixed.

So, today, to be considered clinically depressed, what might you have? There is a list of nine symptoms and you’ll qualify for major depression if you have any three of them. Here are three of the nine:

---Insomnia or hypersomnia nearly every day. We can easily translate this into not getting enough sleep. Up late at night messaging your friends? Really hate to get out of bed in the morning? Bingo, with the eye of faith, you’ve got criterion one.

---Psychomotor agitation: In a psychiatric hospital, this would mean episodes of “excitement”: smashing windows and attacking other patients. In the classroom it means, with the eye of faith, fidgeting (maybe Johnny has attention deficit hyperactivity disorder, ADHD, as well, unable to sit still, thoughts racing. Johnny is already on Ritalin for his ADHD but no harm in giving him a couple of diagnoses).

---“Fatigue or loss of energy nearly every day.” Need I say more? What adolescent doesn’t have this symptom? “Hey, you guys, I’m so tired . . . “

So bingo! We’ve got our three diagnostic criteria for major depression. And it’s really a kind of lifestyle thing, not getting enough sleep, distracted by the constant pinging of one’s personal device. But if you go through a screening program, you’re going to come out bearing the diagnosis of “depression.”

Therefore, I don’t believe in this epidemic of depression. I don’t think the level of serious depression changes that much from generation to generation, simply because the real disease has a big genetic component, and the genes don’t change greatly from decade to decade.

The epidemic is being caused by the willingness of well-intentioned clinicians to confer the diagnosis of depression, as opposed to making no medical diagnosis. You cannot believe how psychiatrists, psychologists, nurses and clinical social workers are being bombarded by the “D” word. It’s become the explanation of all clinical phenomena, and bears as much relationship to what the patients actually have as the “hysteria” diagnosis of yore. (Hysteria was once even commoner among women than depression is today; now, hysteria no longer exists.)

On (2), why this epidemic of suicides if the kids do not actually have serious depression? I think it’s the epidemic spread of suggestibility within the youth culture. Even in matters of utmost gravity, adolescents are infinitely suggestible. After the publication in 1774 of Johann Wolfgang von Goethe’s novel The Sorrows of Young Werther (where tear-drenched Werther commits suicide in a forlorn love affair), there was an epidemic of suicides in Europe among suggestible young people. They suggested themselves into the belief that their sorrows were like Werther’s, and that his solution might be theirs.

Today, the chatter on personal devices is indeed about depression, sometimes about suicidal thoughts. Young girls in particular are batting this stuff about on Facebook, and acting on it, not because they’re clinically depressed but because they have conceived the idea, thanks to the endless mental-health counseling sessions, that they might be depressed.

When, therefore, Paolo del Vecchio at SAMHSA tells us “We must turn the tide on youth depression,” my response is, yes, absolutely! This is a tragic loss of precious life. But then he says the answer is “universal depression screening by primary care physicians,” and, then we should really, really step up the treatment. So at the basketball game a tenth of these kids are going to be an antidepressants, with all their side effects? No, this is not the direction we want to go.

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