The many faces of depression

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The incidence of mental illness among children and young people has risen sharply in recent years and is up by 27 percent since 2019. This was the finding of a recent Versorgungsatlas (Healthcare Atlas) report by the Central Institute of the German Association of Statutory Health Insurance Physicians. The very pronounced 74 percent increase in eating disorders among girls is especially striking. Private lecturer Dr. Ellen Greimel heads the Working Group on Depression Among Children and Adolescents at the Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics of the Hospital of the LMU Munich. In the interview reproduced below, she explains what is behind this development.

More and more children are suffering from mental illness. How does depression spread?

Ellen Greimel: The frequency of mental illnesses has gone up significantly, especially with regard to depression during adolescence. This condition affected about 7 percent of young people even before the coronavirus pandemic, so it was already very widespread. The increase is most apparent among girls, in whom it is also reflected in anorexia and anxiety disorders. These data now confirm what many had feared in the context of the pandemic – and we see it in international studies, too. One very important point is that patients who present at the hospital are often more seriously ill than used to be the case.

Why are more children becoming depressive?

Especially adolescents – we are talking about children aged 12 or 13 and upward – faced massive burdens during the pandemic. Contact restrictions were desperately bad for them because they ran counter to the urge to become independent and the desire to try new things, nurture contact with their peers and commit to relationships. All this was accompanied by worries about falling behind at school, by broken relationships and conflicts in the home – above all for those living together in cramped spaces – and sometimes by financial hardships in the family.

During the pandemic, were you already afraid that more children would suffer from depression as a result?

Yes, I was – like most experts. Far too little attention was paid to the needs of children and adolescents, particularly in the early days of corona. Compared to children, the limitations on grown-ups were far less severe. They could continue to exercise their professions, even if many of them were working from home. Particularlyy the children and youngsters were faced with truly massive restrictions, precisely because the schools were closed. That took away the structure and routine that is incredibly important to them. School is not just a place of academic learning, but a place of encounter as well. And teachers often serve as an important point of contact when problems arise. As a result, many issues did not become apparent until later.

Research on the interplay between genetic and environmental factors

Why does this kind of situation trigger depression in some but not in others?

There are a variety of reasons. There is an individual predisposition toward depression, partly for genetic reasons. Many different genes are involved. In my working group, we study the interplay between genetic and environmental factors such as stressful life events. And we also have been able to prove that this interaction is highly relevant. If you have a genetic predisposition and this kind of stressor is then added to the equation, as in the case of the pandemic, that can lead to depression, above all when youngsters do not have good strategies to deal with it.

Your research tackles the issue of regulating emotions. What does that mean?

Regulating emotions is an important factor in dealing with negative events. People with depression have a hard time handling their feelings properly. That is part of the reason why depression is triggered and also why it continues.

Could you give us an example of dealing with negative emotions?

Let’s say a friend turns away from you. You experience feelings such as anger or sadness. If you are the kind of person that tends to brood on things, that could amplify these negative feelings. On the other hand, there are useful strategies such as taking your mind off things, getting support and talking to others about the matter.

Do persons affected learn these strategies in a course of therapy?

That is an important aspect in the context of cognitive behavioral therapy, for example. It’s about trying to influence negative thoughts, seeing a situation in a more positive light. Depression is shaped by negative thought patterns, so therapy seeks to change these patterns.

Why do some people not have this ability? When and where do children learn such strategies?

Parents play an important part. If a child sees its parents trying to deal well with negative emotions – striving to make the best of a situation, for example, and talking about it rather than withdrawing – these are patterns of actively dealing with challenges that children can learn from their parents.

The role of social media

Do you see dangers in the use of social media?

There are many parts of the puzzle that play a role in depression. If excessive media consumption pushes youngsters to neglect their hobbies and spend less time with friends, that generally has an impact on mental health. In the case of social media, there is also the fact that you are living in an illusory world where everyone only shows their best side. Especially young people who question themselves can end up doubting their own abilities even more if they cannot distinguish between illusion and reality. Cybermobbing is another factor that can contribute to mental illness. It is important for schools to educate children about this issue.

The Healthcare Atlas says there is a discrepancy in the distribution of mental illnesses between girls and boys. Why is that?

There are different explanations, depending in part on the particular disorder. Starting from puberty, more girls than boys are affected by depression, for example. Puberty begins earlier in girls, so they are confronted by the biological and social changes it entails earlier on. Early-onset puberty, for example, is a risk factor for depression. Girls also speak of more stressors in interpersonal relationships. Socialization likewise has a part to play. Girls tend to react to social stressors in particular by withdrawing, blaming themselves, fretting over things. Boys tend to externalize their reactions in forms such as being more irritable and aggressive. We see the same picture in the illnesses themselves: Broadly speaking, we can say that girls tend toward internalizing or inward-looking mental disorders, whereas boys tend toward disorders associated with externalizing behaviors.

How much more frequently are girls affected by depression?

From puberty onward, depression is two to three times more common in girls than in boys. That said, depression is often not recognized in boys, one reason being that it sometimes expresses itself in different ways in boys. Most people associate depression with sadness and withdrawal. But boys tend to be more irritable, and that can also be an expression of depression.

To some extent, withdrawing from one’s parents and being irritable is part and parcel of puberty. When does the tipping point come that can lead to depression?

For a diagnosis of depression, you have to have multiple symptoms for the greater part of the day and over a period of at least two weeks. Depression is a heavy burden for affected persons to bear, it hinders them in their daily lives. Their school performance deteriorates, for example, and they no longer maintain friendships.

Getting well again

Does depression respond well to treatment?

There are effective treatment methods that are very useful. Psychotherapy is the most important aspect for children and adolescents with depression. Sometimes, it can also make sense to use medication as well. Regrettably, it often takes a very long time before affected persons get professional help, for a number of reasons. Some know too little about the condition and how it expresses itself. Youngsters themselves and their families often still feel a sense of shame about depression, or they are uncertain about who to turn to. Developed together with the Beisheim Foundation, our information portal “ich bin alles” (I am everything) provides youngsters and their parents with information about depression and effective treatment options. Persons affected also find details of where to turn for help.

So, your advice would be to reach out for professional help at the first sign of the condition?

Exactly – even if you are not sure whether the behavior can still be classed as normal behavior in puberty, or whether it is already a sign of an illness. It is the job of the experts to draw this distinction. Your first port of call could also be your pediatrician.

Will the number of cases decline again once all those that came in the wake of the coronavirus pandemic have been treated?

The effects of the pandemic will be with us for a long time. For some, this is because their performance at school has suffered and they have been unable to catch up, or their families have slipped into financial difficulties. That said, we must not forget that there are also young people who have handled the crisis and the burdens it brought very well. These youngsters have found good coping strategies. In the future, it will be a job for the whole of society to give children and young people a voice and pay more attention to their needs.

About Ellen Greimel

Private lecturer Dr. Ellen Greimel heads the Working Group on Depression Among Children and Adolescents at the Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics of the Hospital of the LMU Munich

More information about and research into depression:

Under the guidance of Professor Schulte-Körne, Ellen Greimel’s workgroup has –together with the Beisheim Foundation – published an evidence-based information portal for children and young people with depression and their relatives:

For the website, see: ich-bin-alles.de

Research groups at the Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics of the Hospital of the LMU Munich