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Milwaukee Journal Sentinel
MILWAUKEE - For almost three years, Hope felt totally worthless.
She lost interest in activities she loved, such as playing basketball and meeting people.
She constantly criticized herself.
She cried for no apparent reason.
At just 12 years old, Hope (not her real name) was already feeling as if the world was closing in on her.
"It didn't make sense because I had no reason to feel weird," she said. "I would tell people how I felt and it was the same old thing -
you're just having growing pains,' oryou have a lot on your plate.' It just wasn't going anywhere."
That changed when her mother walked in on her and found her crying. The two decided she should see a therapist outside her school.
A few sessions and therapists later, Hope finally had a diagnosis: depression.
"I was like, `thank you,' because I'd known for a while that I was depressed and no one would say it," said Hope, now 15, of Brookfield, Wis. "I felt like somebody cared."
Increasingly, children and adolescents are being diagnosed with mental illnesses such as depression and bipolar disorder. The illnesses aren't unusual in children, though diagnosing them can be difficult.
Children can't always express what's happening to them, meaning that doctors must rely on parents and teachers for clues to determine a child's mental health. Furthermore, children are still developing and act according to their developmental stage, often complicating diagnosis based on behavior. Finally, the criteria for diagnosing adults aren't necessarily applicable to children.
"It's a very difficult analysis to make, but it is there," said Anthony Meyer, medical director of Aurora Psychiatric Hospital in Wauwatosa, Wis., and a clinical professor of psychiatry at the Medical College of Wisconsin. "Sometimes we have to rely on second-tier information to give further insight - talking to family and teachers, determining if there is a family history of mental illness, or even substance abuse."
"We try to accumulate a genetic background that will try to help us tip our hats one way or the other," he said.
Mental illness in children isn't as well-documented as in adults, but the first surgeon general report on the topic in 1999 estimated that 20 percent of the nation's children have mental disorders with at least mild functional impairment.
The report defines mental disorders as health conditions marked by alterations in thinking, mood or behavior that cause distress or impair a person's ability to function. Mood disorders such as major depression, bipolar disorder and schizophrenia affect 6 percent of children with a mental illness.
In addition, 5 percent to 9 percent of children ages 9 to 17 have disorders that cause serious emotional disturbance, the report found.
However, fewer than one in five children who have a mental illness receive the treatment needed, according to the National Institute of Mental Health.
"The way children act is a form of communication," Meyer said.
Many times parents may tell their children to "just snap out of it," but he cautioned that a child who is depressed is not merely moody, but feeling significant levels of biological distress.
In addition, it's not easy for feelings of hopelessness to subside without intervention - whether it's through psychotherapy, medication or a combination, he said.
"Of course everyone goes through disappointments, but there is usually a sense of resilience and in a couple of weeks, things get back to normal," he said. "But if these feelings persist, then you need to contact a physician."
Mental disorders aren't picky.
They occur in all ages, races and income levels. But they usually surface at the prime of life, often during adolescence and young adulthood.
Some mental illnesses may be confused with other conditions in children.
"ADHD is common and it's not necessarily a wrong diagnosis, but about 18 percent of kids with ADHD also have bipolar disorder," said Martha Hellander, executive director of the Child & Adolescent Bipolar Foundation, based in Wilmette, Ill.
Hellander said that though children with both conditions have high rates of irritability, hyperactivity and distraction, there are key differences.
Children with bipolar disorder tend to exhibit much more of the following behaviors than kids with attention-deficit hyperactivity disorder: elated moods, grandiosity, flight of ideas, racing thoughts, hypersexuality, decreased need for sleep, daredevil beliefs and expressions of suicidal thoughts.
Thus, "it's very important to treat the mood disorder first and see what's left over," she said.
Beth, 19, began having symptoms of bipolar disorder about a year ago.
"I would go through lows and highs and feel really depressed, then flip to a very motivated, active state," she said. "I had racing thoughts - my mind would go a mile a minute. At times I thought I could do anything and be the best at it."
Beth, who grew up in Milwaukee and now lives in Canada, attempted suicide by cutting her wrist more than a couple of times, though she described herself as "self-injurious, a cutter" and said that the events were not always related to her disorder.
"My lows were so low," she said. "I didn't realize that I would get high again."
Beth sought help and is on medication. It will be about a month before she's up to the full dose and the drug takes effect.
"In a perfect world I'd have no mood swings and total stability," she said. "But I know I'll probably still have mood swings, but that they'll be less severe."
Depressive disorders are mental illnesses that, left untreated, can lead to serious complications. Symptoms affect both the mind and body.
"We now have a basic understanding of the brain systems that underlie emotions and anxiety in normal people that should help in our understanding of what goes wrong in people that are depressed," said Ned Kalin, director of the HealthEmotions Research Institute at the University of Wisconsin-Madison.
For example, the brain's prefrontal cortex has been shown to play an important role in depression and modulating emotions, with the right prefrontal cortex associated with negative emotions and the left with positive emotions.
And increasing research is confirming that genetics and life events work together to produce depression.
A study this summer published in the journal Science found that people with two shortened versions of the serotonin transporter 5-HTT gene, which plays a key role in depression, were twice as likely to develop depression after stressful events than those in the general population. But those with two long versions were only half as likely to develop depression.
People can inherit long or short versions of the gene from their parents, resulting in three possible combinations: two short, two long or a short and long.
Brain imaging studies from Kalin's lab have found that people with increased activity in the anterior cingulate cortex are more likely to respond to anti-depressant medication. The cortex, located in the front part of the brain, is involved in decision-making, conflict resolution and attention or focus, Kalin said.
"But we don't know if it will generally apply," he said. "We know very little from imaging perspective in children. This area is very understudied."
While scientists aren't sure if some brain research on adults applies to children, they're also unsure of the effects of standard treatments.
Medicating children for depressive disorders is tricky, said Russell Scheffer, medical director of child and adolescent psychiatry at Children's Hospital of Wisconsin and chief of the child and adolescent psychiatry department at the Medical College of Wisconsin.
Many drugs are prescribed "off label," meaning that the treatments aren't approved by the U.S. Food and Drug Administration but are allowed because the drugs already have undergone safety testing for another use, he said.
But that doesn't mean that it will render the same results in children and adolescents as adults, Scheffer said.
For example, Depakote (divalproex sodium) is often given to children to treat manic episodes associated with bipolar disorder and is fairly safe and effective, but Lamictal (lamotrigine) can cause a life-threatening rash in children under 16, he said.
To date, Scheffer said there have been two placebo-controlled studies involving lithium, a mood stabilizer, for children with bipolar disease and a few more studies evaluating anti-depressants such as Prozac (fluoxetine), Paxil (paroxetine) and Zoloft (sertraline) in adolescents.
Ramiro Guevara, director of the anti-stigma program at the National Alliance for the Mentally Ill, said it's important to pick up on the signs of mental illness early and to help remove the shame associated with a diagnosis.
"Mental illness is not a death sentence, it is treatable," he said. "The earlier the intervention, the better the outcome, the better the life for someone with a mental illness can be."
Guevara, 32, had symptoms of bipolar disease as early as age 7. Though he had a strong family history of the illness, he was labeled as developmentally disabled. He wasn't diagnosed until age 26.
He believes that better recognition of the disorder in children could have helped him gain control of his life sooner. Still, he said that no matter when a person is diagnosed, it's never too late to lead a healthy, productive life.
"I've been able to get to a point in my life that I couldn't have imagined," he said. "I've been there. I've been down in the streets. I've been homeless.
"Nobody's gone down too far and can't be helped."
For more information on mental illness in children, visit:
National Alliance for the Mentally Ill: www.nami.org
Childhood and Adolescent Bipolar Foundation: www.bpkids.org
National Institute of Mental Health: www.nimh.nih.gov
CLASSIFYING TYPES OF DEPRESSION
There are three primary types of depression:
Feelings of hopelessness, loss of interest in activities, decreased energy, an inability to concentrate, changes in appetite and irritability
A less severe form of depression
Chronic symptoms don't significantly hinder a person's activities
Person feels down and unable to function normally
Person will experience major depressive moment at some point
Also called manic-depressive illness
Mood changes cycle between severe highs (mania) and lows (depression)
Mood swings are gradual, though research at Washington University suggests that the cycles in children are quicker and more pronounced
Mania, if left untreated, may worsen to a psychotic state
Source: National Institute of Mental Health
(c) 2003, Milwaukee Journal Sentinel. Distributed by Knight Ridder/Tribune News Service.