The trend towards younger depression seems to be becoming apparent. Last week, a group of adolescent depression data rushed to the hot search.
According to data from Hangzhou Seventh People's Hospital (Mental Health Center affiliated to Zhejiang University School of Medicine), the number of visits to the depression department increased from 3,148 in 2018 to 10,613 in 2021, a three-year increase.
That's just one hospital-specific figure, and a more ambitious statistic was released last week. The "Report on the Development of China's National Mental Health (2021~2022)" was released on February 23. The report shows that 14.8% of the adolescent group has a different degree of risk of depression, which is higher than that of the adult group, and needs effective intervention and timely adjustment.
How low can depression be? Dr. Liang Yuezhu of Beijing Anding Hospital has seen the youngest patient is 6 years old, and the youngest patient treated by adolescent psychologist Xu Kaiwen is 10 years old.
They present symptoms that are more diverse, changeable, and difficult to understand. Some people will deliberately exaggerate the symptoms and seem more unwilling to improve their condition quickly, and some patients will frankly tell Kaiwen Xu in psychological counseling, "I don't want to get better." Tan Zhonglin, chief doctor of Hangzhou Seventh People's Hospital, said that some children had offered to see a doctor a year before their visit, but they were considered "hypocritical" and "pretentious" by their parents until self-harm appeared.
It is not uncommon for patients to stop taking the drug on their own. Dr. Chen Jun of the Shanghai Mental Health Center said that in the eyes of some families, it seems that only by stopping the drug can they prove that they are not a patient and can they remove the hat of a depressed person.
Overall awareness of depression has increased, but in each small unit, stigma still besieged many families. Liang Yuezhu once met a child wearing a school uniform when he was out of the clinic, "I asked him why he was wearing this dress backwards?" His mother said that he was afraid that someone around would see which school he was from, and that he was afraid of revealing his identity. ”
We interviewed psychiatrists, psychological counselors, and psychological crisis intervention experts in Beijing, Shanghai and Hangzhou, trying to see from specific cases and data the problems that depression is facing in the process of moving towards a younger age.
Tan Zhonglin, chief physician of Hangzhou Seventh People's Hospital, diagnosed depressive disorders in adolescents in the Department of Depression. Photo courtesy of interviewee
Depression clinics "younger age"
On February 22, Director Tan Zhonglin, director of the Seventh People's Hospital of Hangzhou, often started with a depression self-rating scale.
"Just as no two leaves are exactly the same, no two depressed people are exactly the same." One day in late February, Tan Zhonglin saw 22 patients, and he made a simple count, 8 between the ages of 12 and 17, and 3 between the ages of 18 and 25. Adolescent visits are close to half of outpatient visits. This trend, he recalls, began about five or six years ago.
Most of the time, adolescents are accompanied by their parents, and doctors can understand the symptoms and daily situation from two perspectives, and some subtle answers will appear. For example, a 13-year-old boy who did not leave his tablet or do his winter vacation homework was brought to the clinic by his mother.
Tan Zhonglin remembers that when his mother made statements, the boy was always laughing. Tan Zhonglin asked: "The scale results show normal, do you think it is in line with your own situation?" The boy looked at his mother and asked, "She has always been next to me to ask me to choose the good ones, and when I choose the bad ones, I ask how it is possible and how it is so serious." How can the scale results be bad? ”
Tan Zhonglin, chief physician of Hangzhou Seventh People's Hospital, made ward rounds in the depressive disorder ward. Photo courtesy of interviewee
Other times the disagreement is over "time." For example, when a 15-year-old girl asked her how long her emotions had been and whether she had seen a doctor, her response was, "I proposed to see a doctor a year ago, but I was rejected." ”
In the narratives of parents, the word "recently" appears frequently. "Recently" there is the act of cutting herself, "recently" crying for no reason in school, "recently" is a little wrong, in fact in the girl's self-perception, the symptoms appear much longer.
It is not uncommon for self-evaluation to exaggerate symptoms. When parents feel that the child is deliberately answering in a serious direction, Tan Zhonglin often asks, "What is the purpose of his deliberate exaggeration?" This represents an idea of his, a tendency to do so. Are some needs not being met? ”
Beijing Anding Hospital is the second hospital in the country to set up a child psychiatric department, there are more than a dozen doctors in the child psychiatry department, and there is a shortage of manpower, and many people who cannot be hung up with pediatrics will even hang up to the adult department.
Liang Yuezhu, chief physician of the Department of Child Psychiatry, saw the youngest patient who attempted suicide at the age of 6. This shocked Dr. Leung. She remembers that when she went to the doctor, the 6-year-old didn't even understand many things, but she felt that "it's not interesting to live, don't cause trouble to mom and dad." Because children often chant such words at home, parents are a little overwhelmed and bring them to the hospital.
The process is the same as for most children. Symptoms also show many commonalities, such as low mood, decreased interest, decreased energy, and even a tendency to self-harm. Director Liang Yuezhu cautiously prescribed antidepressant drugs for 6-year-olds. The 6-year-old's diagnosis turned out to be a "depressive state" and eventually relieved with medication. When it comes to recovery again, when it comes to negative thoughts in the past, the child is a little embarrassed to recognize the previous situation.
The "2022 National Depression Blue Book" shows that 30% of the total number of people under the age of 18 are depressed; 50% of people with depression are school students. Image source: Institute for Depression
Adolescent depression in the Internet age
At the Shanghai Mental Health Center, more than one-third of patients in psychiatric clinics are adolescents.
Dr. Chen Jun specializes in treatment-resistant depression and is the youngest in his clinic being a junior high school student. Dr. Chen Jun said that in recent years, adolescent symptoms have taken on new characteristics, such as online violence and Internet-related bad forms of venting, such as non-suicidal self-injury. "Many children come to (outpatient), and the first complaint is not that I am depressed, or that I am very anxious and nervous, but that he may have made a very impulsive and excessive move."
He has treated teenagers who have been abused online, as well as teenagers who have abused others online. Chen Jun said that teenagers who abuse others online often do not have many friends in reality, tend to play games online, abuse others on the Internet, say a variety of ugly language, sometimes they are not too addicted, and they have to gather a group of people to scold together.
How do people who abuse others online realize to come to psychiatry? Chen Jun introduced that many people often affect normal learning and are required by the school to see a doctor. Others have excessive attitudes and behaviors at home and are brought in by their parents to see a doctor. The root cause of online violence often points to emotional states. "He's in a bad mood, to make himself feel a little better and feel above everyone else."
In Liang Yuezhu's consultation room, patients who are addicted to playing with computers and mobile phones, do not go to school or explain, the children themselves are depressed, tired of life, do nothing boring, and bring continuous pain to the people around them. Liang Yuezhu said that there have been many similar situations in the past three years. "Addiction to mobile phones is the result, when in fact the cause is a change in mental state." She introduced that many parents come to the doctor because their children are addicted to mobile phones, and in fact, this is a way for children to relieve their inner pain, because they are bored, they use mobile phones to escape, spending a lot of time.
What psychiatrists need to do is to discover the psychological mechanism behind addiction to mobile phones. Combined with symptomatic treatment, psychological counseling, reality attraction and other methods to help children come out.
Kaiwen Xu, who has been engaged in adolescent mental health for a long time, served as the chief supervisor of the Mental Health Education and Counseling Center of Peking University. He believes that a clear feature of depression in the Internet age is that the mobile phone war has exacerbated the conflict of parent-child relationships. Because of emotional problems, seek solace from mobile phones, and parent-child conflicts caused by mobile phones will in turn aggravate depression.
In addition, Xu Kaiwen observed in the consultation that today's teenagers are the natives of the Internet, familiar with the Internet, and it is easy to learn some mental abnormalities on the Internet. "So his symptoms will also have the color of performance or imitation, making the symptoms more varied and difficult to understand."
The Pediatric Psychiatric Clinic of the Shanghai Mental Health Center invited students from the Art Institute to draw cartoons on the walls, hoping to relieve the tension of the children attending the clinic. Photo courtesy of interviewee
Families trapped in stigma
Depression is not easy to identify. Tan Zhonglin said that depression is sometimes just a thread that comes out, and the bottom may be connected to an intricate tree root. Compared with children exaggerating their own symptoms, parents tend to weaken the situation, thinking that it is hypocrisy, "looking for trouble", and replacing their children's perception with their own feelings. "Any time a teenager feels pain and asks to see a doctor, the parents are probably going to be supportive, because you can't refuse on the grounds that you look okay, how many minutes a day do you see him?"
In the consultation room, Dr. Liang Yuezhu of Anding Hospital often heard his parents say, "I didn't find anything wrong with him." "Unconscious parents often fail to recognize their child's help in the early stage, resulting in untimely medical visits.
There are also many people who equate depression with not being strong and weak; Some parents will attribute their child's depression to their improper education and mistakes. "Just like high blood pressure, we are not saying that the parents deliberately want his next generation to have high blood pressure, and we cannot say that his high blood pressure is all caused by himself."
Exaggerating depression, stigmatizing depression, and weakening depression delay the opportunity. Depression is the result of the interaction of many factors, Tan Zhonglin believes that the correct view is to realize that depression is a disease, is a disease to receive systematic treatment, the ups and downs and fluctuations in the process of treatment, can not underestimate the difficulty of treatment.
The difficulty of identification is even more pronounced in remote areas. According to the 2019 Lancet Psychiatry, the number of child psychiatrists in China is less than 500, and the distribution is uneven, and most of the high-quality child psychiatrists are concentrated in third-class hospitals in first- and second-tier cities. Some remote cities and counties do not even have a regular child psychiatrist.
Suo Peng is an expert in psychological crisis intervention, and she has done training on campus psychological crisis intervention for universities in Beijing and townships in Sichuan. For example, she said, a student in the first year of high school in Yunnan Province who took a two-year break from school because of gastrointestinal discomfort and needed to go back to high school at the age of 18, but he was increasingly reluctant to go to school. It wasn't until suicidal thoughts emerged that schools and parents discovered that it might be associated with mental health issues.
Suo Peng did psychological crisis intervention training in schools, popularized practical skills of psychological first aid, and participated in the training, including class teachers, psychological teachers, dormitory staff, school doctors, safety principals, etc. Photo courtesy of interviewee
From gastrointestinal discomfort to psychiatry, there has been a long chain in between. First the gastroenterology department of the hospital, then the cardiology, neurology, and finally came to the psychiatric department, from accepting the concept of depression, to insisting on taking medicine, seeking psychological counseling, every link in the middle of the help path, in remote areas may encounter difficulties. "Finding out that he was depressed was going to see a doctor, there was a conceptual barrier; When he enters the psychiatric department, he may encounter barriers in professional diagnosis and treatment; Psychological counseling is hundreds of dollars an hour, and faces an economic barrier. ”
After accurately identifying depression, stigma still besieged many families. Liang Yuezhu once met a child wearing a school uniform when he was out of the clinic, "I asked him why he was wearing this dress backwards?" His mother said that he was afraid that someone around would see which school he was from, and that he was afraid of revealing his identity. ”
Another common manifestation of stigma is the unauthorized discontinuation of the drug. Dr. Chen Jun said that some parents think, "You look very good and you work, why do you still take medicine?" In their opinion, only by stopping the drug can they prove that they are not a patient, and can they remove the hat of a depressed person.
Dr. Liang Yuezhu of Anding Hospital has a personal experience. She recalls one patient who was treated "exceptionally well," but parents attributed the early symptoms to adolescent rebellion rather than depressive disorder after they improved. If the drug is stopped without the doctor's knowledge, the recurrence after stopping the drug is particularly serious, and there is a situation of injury and destruction of people, and it has no choice but to be hospitalized. After this experience, the parents of the children have improved their understanding, the children have learned self-management, insisted on taking their medications on time, and finally slowly recovered, all the way to the doctorate.
The "2022 National Depression Blue Book" shows that 77% and 69% of student patients are prone to depression in interpersonal and family relationships. Image source: Institute for Depression
Pharmacological interventions and psychotherapy
In addition to medication, physical therapy, and psychotherapy, depression treatment is usually carried out. The "2022 Blue Book of Adolescent Depressive Function Recovery" shows that 91.97% of adolescent patients have tried drug treatment; Followed by psychotherapy, accounting for 77.95%.
Depression is a biological disease that cannot be avoided by medication.
Several doctors have mentioned that depression in adolescents often presents with somatic symptoms. For example, abdominal pain and headaches, Dr. Chen Jun of the Shanghai Mental Health Center said, some teenagers will show refusal to go to school, yelling and even aggressive behavior, they are more inclined to relieve their inner discomfort through these harmful behaviors. In addition to emotional and physical discomfort, cognitive function can be affected. For example, inability to concentrate and memory loss.
Tan Zhonglin has met many people who don't know and asked, depression is low mood, will there be drugs to make you feel better? "The brain is closely related to emotions, and treating mood with drugs is like treating high blood pressure with drugs."
Studies have shown that patients with depressive disorders have a clinical recovery rate of 67% after complete sequential treatment with antidepressants, but more than 90% of patients still have residual symptoms. For example, there are still sleep disorders, but you can go to work and study.
"Maybe many people have this misconception that seeing a psychiatrist is telling you to take medicine. Actually, no, I think the more accurate positioning is that the psychiatrist helps you do the overall evaluation and treatment plan. Dr. Chen Jun said that although it is common to prescribe drugs, behind it is a complete set of rigorous physical examinations including blood tests, and psychological counseling is equally important for some patients with clear external triggers.
"When you understand what kind of disease a person has in life, I am afraid that you must first understand what kind of disease it is." Tan Zhonglin felt that the adolescent illness should be understood in the context of his family, his environment, and his experience. Drug treatment is symptomatic, psychological counseling is often more focused on the cause, such as academic pressure, teacher-student relationship, parent-child relationship, to explore the source of the emotions behind the causes, and provide a channel for emotional relief.
For example, the youngest age of the patients Xu Kaiwen receives is 10 years old. The main problem of the 10-year-old is that he is aggressive at school and shows suicidal tendencies.
Why is a 10-year-old child very aggressive and often beats people? After the consultation, Xu Kaiwen found that his behavior was the result of learning from his parents. When his parents beat him, he used the same way to communicate with others. The result of this psychological intervention is to make the child's parents realize, "If the parents do not want him to have such dangerous behaviors, the parents themselves need to adjust and improve, control themselves, and cannot use this way of beating and scolding the child to educate the child." "After reaching a consensus, the parent-child relationship began to improve significantly.
Xu said that teenagers suffering from depression sometimes do not want to come to counseling themselves, but often involuntary cases. At this time, whether the counselor can win the trust of the teenager is the key to healing. For example, some adolescents have menacing symptoms that show signs of seriousness and danger, but once a relationship of trust is established with a counselor, "improvement can be a very rapid process." "Conversely, it is difficult to make progress.
China's National Mental Health Development Report (2021~2022) was released on February 23. The report shows that 14.8% of the adolescent group has a different degree of risk of depression, which is higher than that of the adult group, and needs effective intervention and timely adjustment. Photo/IC photo
Kaiwen Xu also summarized the psychological differences between adolescent depression and adults. Teens' symptoms are often used to cope with their current predicament, and they seem less willing than adults to get better quickly. "They even want to keep themselves suffering from some kind of psychological problem, because then he has a good reason not to go to school, which means that he benefits from the illness." Some patients will frankly tell Kevin Xu during the questioning, "I don't want to get better."
Dr. Chen Jun feels the same way, in those relationships where the parents' marriage is rife, the depressed teenager tends to think that being sick will ease the relationship between the parents, "he will feel that being a patient, the parents will not be separated, but it will strengthen his role as a patient." ”
In Tan Zhonglin's observation, many patients' parents will rush to talk, accuse each other, and even slap the table in the consultation room. A 14-year-old girl later said to him, "My parents' relationship seems to be better after I got sick." ”
Xu said that while teenagers receive counseling, parents often also receive counseling. "In fact, many of the parents we contact recognize that their education style is problematic, so they will also actively seek the help of psychological counseling to adjust their behavior."
Hold the suicide line
According to epidemiological surveys, 10% to 15% of people with depression in China may eventually die by suicide. Professor Zhu Zhuohong of the Institute of Psychology of the Chinese Academy of Sciences wrote in February that middle school students accounted for about 51% of adolescent suicides, mainly due to "depression". Suicide prevention has become an important topic in the diagnosis and treatment of depression.
Tan Zhonglin followed up on one of the cases the longest, from his sophomore year of high school to his graduation from university. When he developed symptoms in his second year of high school, the boy could not concentrate in class, reacted slowly, had difficulty communicating with classmates, had obvious insomnia during his stay in school, was dissatisfied with the school, and felt that the classmates around him were too low, "because this school was not good for him to enter in the middle school entrance examination", and he began to refuse to go to school in the later stage.
His parents talked much more than he did at the time of the appointment, and he seemed to have given up and lost hope. He is 100 dissatisfied with himself and is also critical and demanding with those around him. He believes that his parents' level is too low, and he feels that his depression is entirely his parents' fault, "because they want him to study hard, only if he learns well, can he have a future, can he earn more money, and have a good life." In his eyes, his parents belong to this category of vulgar people. ”
The boy was hospitalized and attended group therapy in the ward during his stay, learning about the families of the other eight patients. Tan Zhonglin asked him, "If you were to change with them, who would you like to change to?" He thought about it very seriously, "I still won't change." ”
But that doesn't mean it's gone once and for all after a course of hospitalization. Tan Zhonglin explained that the prognosis of adolescent depression is easy to become chronic or recurrent, similar to that of adults; 60%--90% will be in remission within 1 year; Between 50% and 70% will have another depressive episode within 5 years.
At the height of the subsequent turmoil, the boy considered giving up his life, when he was already in college, and after standing on the roof of a building to leave a message to the counselor, the crisis was successfully resolved.
Almost six years later, the boy is still taking medication, and the psychological counseling has continued from once a week at the beginning to once every two months now. He was able to accept his current job and go to graduate school while working.
Chen Jun once treated a high school junior who was in poor physical condition and had serious negative emotions, "He doesn't have to run to the classroom, he just needs to be close to the school, it's very uncomfortable." While Chen Jun was trying to understand the patient's depression and hoped that he could relax, on the other side, his parents kept pressuring on the side, "What good way does the doctor have to make him get better quickly, he will go to the exam the day after tomorrow." Parents' goals sometimes seem to be contrary to "cure", "In fact, as doctors, we often want to directly say that your children are no longer alive, they are all thinking about suicide, and you are still thinking about tomorrow's exam." ”
When a teenager is already at risk of suicide, how to talk to his child? How to evaluate? In reality, what Suo Peng found was that almost no one dared to talk about it. "It's a very specialized skill, like CPR." Suo Peng said that when ordinary people hear the idea of suicide in children, they often dare not ask directly, but repeatedly advise from their own perspective, "There are still many beautiful places in life, you are still so young, you have to cherish life, you don't want this." Or share your own experience, "How about I used to be your age, and then I came over, you have to run more." ”
These words are not wrong, but they often prove ineffective. The content of her training is to first admit the facts, experience and accept his emotions, and take the initiative to ask, "I feel that you are very low, I am very worried about you, are you thinking about suicide?" When did you start thinking about this? For example, after a child was guided like this on the rooftop for more than an hour, he took the initiative to tell the teacher, "I'm hungry, you take me to eat."
Suo Peng also once dealt with a suicide crisis in Sichuan, a high school student with very good grades, he committed suicide at school during evening self-study, because the rescue was timely and he successfully escaped. Later, parents and psychology teachers took the child to the psychiatric hospital, and two months later he was discharged. Afterwards, people in all links were reflecting, "Why did we still not prevent him from committing suicide?" ”
In actual cases, some schools are difficult to quickly identify adolescents' psychological problems, and they also lose effective communication with parents, and parents will miss the opportunity for treatment if they do not have the concept of depression. In actual diagnosis and treatment, psychiatrists and psychological counselors often perform their own duties, one party does not understand the process and effect of the other, and more often can only ask about the situation through follow-up. Such a combination may present a bad combination.
Thankfully, in recent years, the state has issued several documents to prevent adolescent depression. In 2019, the "Healthy China Action - Mental Health Action Plan for Children and Adolescents (2019-2022)" jointly issued by 12 ministries and commissions clearly required that by the end of 2022, "a social environment conducive to the mental health of children and adolescents should be basically built, and a mental health service model linked by schools, communities, families, media, medical and health institutions and other links should be formed." In 2020, the General Office of the National Health Commission issued the "Work Plan for Exploring Characteristic Services for the Prevention and Treatment of Depression", which requires that "mental health education be made a compulsory course for all students in middle schools and colleges and universities, and professionals are hired to teach every semester, guiding students to scientifically understand depression and seek professional help in a timely manner".
Some good shifts are emerging. In recent years, Suo Peng has received two or three training needs for campus psychological crisis intervention every week. A crisis team is usually set up among the training targets, which includes parent representatives, dormitory managers, school doctors, class teachers, psychological teachers, safety principals, etc., "As long as we can find that students have problems and can protect them in time, we will train them again." For example, she would write a script word for word, simulating a suicide conversation scene, and let the crisis team practice how to guard the scene and stabilize the mood.
Some local health commissions have taken the initiative to invite and carry out psychological crisis intervention training including police, communities, psychological counseling institutions, psychiatrists, class teachers, and psychological teachers, and the social chain of standardized diagnosis and treatment of adolescent depression and suicide prevention has gradually become clear.
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