The first time my brother tried to kill himself he was 6 years old.
My brother Dean is uniquely empathetic, thoughtful far beyond his age. He listens intently, stares into you with his big, brown doe eyes. He loves animals, especially foxes. He spends hours on end out in the woods behind our house and comes back with bruises and scrapes, frogs in his pockets, animal bones, pieces of robin eggshells, occasionally the neighbor’s outdoor cat. He was frustrated a lot. He didn’t like to ask for things. He rarely spoke. When he got angry he turned it on himself, slamming his hands, his toys, the walls into his head. He didn’t throw tantrums or scream, in fact when he was a baby, Dean rarely cried. One day he opened the second story window of our house and tried to climb out of it because he couldn’t think of a reason he should be alive.
Depression is one of those unimaginable pains that we pray the cosmos has deemed too-intense-for-children. We tend to underestimate children as a whole. We expect them to be non-sentient, like pets. To experience turbulent rushes of love, excitement, joy, sadness, anger, in a whirlwind of firsts, to be discovering what we’ve already found out long ago. We feel a hierarchy associated with age, that the old have known and will continue to know and the young are just beginning to learn. Maria Kovacs, professor of psychiatry at the University of Pittsburgh School of Medicine, said that in the 1950s and ’60s, children were believed to not have sufficient ego to be able to experience depression. Some would call this school of thought bad medicine, ageism, or hubris; but really this is fear. It’s all dumb, blind hope that there’s some kind of moral balance, some “fairness” to it all, that young people don’t deserve to feel unworthy because we’re afraid that we’re failing to protect children from harm. All the preventative measures, “What to Expect When You’re Expecting” books, and child-proof locks on toilet seats can’t protect a child from a chemical imbalance. And that terrifies us. Because what if it happened to you and your child? What if you saw it happening and couldn’t stop it because you can’t just crawl into their heads and patch up their wounds and make them better, all on your own?
I am often grappled with guilt. I know my parents are too. Slowly, in the process of dealing with it all, I started to figure out that what is happening to Dean is not unique to Dean. Humans find comfort in knowing that their pain is being experienced by someone else. That they aren’t alone. I am unburdened, and at times given hope, by the idea that there are many children like Dean because I want that aforementioned cosmic assurance that eventually, things will be alright. But I am equally unnerved and mournful that there are many children like Dean, because why are our children hurting? Why is a child experiencing suicidal ideation, wanting to end a life that’s only just begun?
I don’t pretend to have an answer to this question. After compiling research, scouring articles far above my medical lexicon, interviewing pediatricians and my mother—which was definitely harder than figuring out how to read National Health Survey Datasheets—I have brought forth not an answer to a question but an opportunity to share my pain, to offer something like hope. Let this be an accurate, insightful portrait of childhood depression. Let this be a love letter for you, Dean. I hope you’re reading this.
The earliest written accounts of depression sprang out of the fertile crescent as soon as we humans did. In the second millennium B.C.E. in Mesopotamia, man first recorded “spiritual illness” rather than a physical one. It was to be dealt with by priests instead of doctors. Greek, Romans, Babylonians, Chinese, and Egyptian societies thought depression was caused by demons, or the presence of evil and treated it with exorcisms, fasts, and restraints. In this era, to be depressed was to be possessed by a dark spirit.
Having experienced depression, I can’t say that possession is an entirely false interpretation. It in fact seems surprisingly apt of a metaphor were it not to be taken literally. Depression does feel like possession. Especially in children. Childhood depression often attaches itself to childhood mania. Impulsivity, lack of control, erratic mood swings, all of these symptoms can feel like you’re being possessed. One moment Dean’s happy, if not happy at least calm, and the next he’s filled with an internal itch, a discomfort, like everything in the world is a little off-kilter.
My brother Dean is sitting in the backyard and making a hammer out of a piece of wood, whittling it down until its darkest, hardest pieces are revealed. He’s a little out of breath over the phone. Dean knows when he’s starting to be possessed. He says he feels it in his chest, when he’s about to do something he knows he isn’t supposed to do.
“You can’t really pay attention to all the signs that are going around in your head and in your body. There’s too many, and you’re so caught up in everything that’s happening,” Dean says.
He talks about the feeling that you’ve lost yourself. Most of the time when he does finally gain control of his body again, he feels guilty. Dean’s return to therapy this last year followed an incident at school. He stuck a pair of scissors in a light socket in science class. At first, he said it was because a classmate told him to, but later he said maybe he really wanted to hurt himself.
“I just look at what happened, and I know I could have done the right thing. Be normal.”
The very first time my mother knew that Dean was going to need help was when she got a call from his 1st grade English teacher. Ms. Bennet Weiss had taught me and all of my brothers. She loved Dean. She was trying to convince him it was okay to ask for what he wanted. He was really withdrawn, to the point that he wouldn’t raise his hand to go to the bathroom. She was careful and patient and finally one day Dean had asked for a book, just a book to take to the playground. When he finally got it, another kid on the playground took it away from him. When he did, Dean decked him.
“And you know Ms. BW, she wisely realized it wasn’t because Dean was a violent kid, or a bad kid, or didn’t have enough self-control, but that Dean had worked so hard for the thing that he needed, to get it taken away was just too much,” my mom says. She laughs a little.
In the very beginning we didn’t understand how bad it was because Dean has always been very good at being silent through the low swings of depression. The punch was an upswing, and a loud one, that brought us to first introduce Dean to a therapist in 2016. He was on Zoloft for about a year, at the age of six.
It wasn’t until the Greek physician Hippocrates that depression was given a name, “Melancholia.” In the 400s BC, Greeks and Romans were split on their understanding of Melancholia. Hippocrates believed that the treatment plans for Melancholia should revolve around the idea of chemical imbalance between yellow bile, black bile, phlegm, and blood. He prioritized bloodletting, baths, and exercise.
Modern Medicine has brought just that, medicine, into the realm of mental health. My brother was on Zoloft for a little over a year at the age of six, experienced a chemical rebalance, and was put back on Zoloft at 12 for a two-year plan. For a lot of parents the idea of a medicated child is terrifying.
Zoloft is actually a brand name for sertraline hydrochloride, a Selective Serotonin Reuptake Inhibitor Antidepressant (SSRI). SSRIs treat depression by increasing serotonin in the brain, one of the chemical messengers that carry signals between brain nerves. In a depressed brain, serotonin is reabsorbed into neurons, a process known as reuptake, and SSRIs inhibit that reuptake, improving the transmission of messages between neurons.
And that sounds great. Pill make brain work good, right? But there’s risks involved with SSRIs. Aside from your usual laundry list of side-effects—nausea, vomiting, headache, drowsiness, dizziness, insomnia—SSRIs have been shown to increase suicidal ideation in some people. Brains work differently, different brains process different chemicals differently, and guess what? Sertraline hydrochloride isn’t a wonder drug. A meta-analysis of randomized, controlled trials of SSRI versus placebo in children from 5-18 suggests SSRIs “tend” to have benefits that outweigh their risks, but how can you place the weight of potential suicide on the conscience of a parent or loved one?
When it comes to the doctors who are prescribing these medications there can certainly be a lot of weight to the question. Dr. Laura Voigt is a practicing pediatrician in Pittsburgh Pennsylvania, and she’s also been my family’s go-to since I was a baby. She’s been a practicing pediatrician for 20 years, from a general academic pediatric Fellowship with the Children’s Hospital of Pittsburgh, in outreach clinics in Mount Oliver, and then Bass-Wolfson Pediatrics in 2004. She’s been there ever since, and so has my family. To be at a single practice for that long, it’s impossible to not develop relationships with patients, but Voigt builds real, lasting trust. Pediatricians like Voigt can directly prescribe medications, but that takes a certain expert level of expertise.
“I’m good. I’m good at prescribing meds, but I’m not a psychiatrist. I’ve got some basic skills…but when it comes to that higher level of care, like prescribing antipsychotics, which I don’t do, or moving between multiple different medications that aren’t working quite right, I feel like it’s out of my realm of care,” says Voigt.
My mother talks about the first dose of Zoloft Dean took. She saw a difference, and a positive one, in the way Dean opened up and began asking for things. That was still the issue when he was that age, his complete closed-offness. She felt a huge difference coming out of therapy and having Dean on Zoloft. Part of that could have been that we had better tools in our toolbox, ways of talking, but the medication was doing something there.
“But I was still worried, and probably this has something to do with the way I process the world, but I felt like I didn’t see his depression again until we were at an extreme level.”
Dean’s slip back might have had to do with the “Zoloft withdrawal,” documented by places like the CDC and the NHS. SSRIs aren’t addictive, but stopping antidepressants abruptly, missing doses, or weaning off too early—like Dean’s doctors believe happened—can cause withdrawal like symptoms. It can cause nausea, dizziness, lethargy, and flu-like symptoms, as well as dropping the patient back into depressive emotions and episodes.
Now that Dean’s back on Zoloft, he says he’s feeling a change.
“It’s very clear for me, because I used to have like an emotional breakdown almost every day. It was hard to get through most days. I ended up staying on my phone, sucked in and talking to people. I know that’s not healthy.” Dean says now, he feels like he doesn’t need to escape from the real world. SSRIs can turn into long term medications, and Dean’s current plan is being treated as “semi-permanent,” under the observation of his extreme levels of chemical imbalance.
Roman philosopher and statesman, Cicero, argued that Melancholia was a direct effect of rage, fear, and grief. Cicero believed Melancholia to be the result of horrors or atrocities experienced, the environment one grew and lived in, and one’s inability to resolve dispute without violence. To Cicero, Melancholia was an ailment purely of mind and perception, not of body.
Dr. Voigt describes depression as a uniquely multifactorial condition. Mental health doesn’t happen in a vacuum. Chemical imbalances like Dean’s don’t come from nothing, and that’s not say there’s a blame to be placed or a permanent, definitive causation, but that there are preventative measures. Measures Voigt says most Americans aren’t doing.
“Mental health is related to how much sleep kids get, and kids are getting less and less sleep because of handheld devices at night. Then there’s what we feed our bodies, which has everything to do with how our brains work because our gut microbiome and our health from a nutritional standpoint spreads out to everything else.”
There’s a classic misconception, a fallacy of mental health understanding, that depression can simply be cured by physical activity and a balanced diet. Voigt argues that there is some science there, but it’s preventative, not curative, and it has to happen in addition to therapy and medication in order to resolve a true critical mental health issue.
“It’s like, how do we make serotonin? How do we need substrates in our belly to make the neurotransmitters that make us happy?” says Voigt.
Just like physical health, there’s no one solution, one cure to making our bodies safe and healthy. Physical health has so many connections between experts, but as of now there’s no real syncopation in the mental health world. Voigt imagines a future where mental health is treated more cohesively, where sleep experts and nutritionists and educators build a foundation for good mental health from the early developmental stages.
Towards the beginning of the 1800s, many wild and unconventional strategies were attempted to treat depression: water immersion—which involved keeping people underwater as long as possible without drowning them—and a spinning stool for “dizziness therapy,” were attempted. Benjamin Franklin was the first to introduce electroshock therapy, a whole new meaning to his key and kite mythos. Depression was first distinguished from Schizophrenia in 1895 by the German psychiatrist Emil Kraepelin. During the same time, psychoanalysis based on the psychodynamic theory became increasingly popular as a treatment for depression. This sparked the first time depression would be widely acknowledged as a tangible and separate illness. In 1917 Sigmund Freud explained depression as a response to loss, and first recommended the “talking cure,” what would eventually become modern therapy.
One popular flaw of children’s therapy is the insertion of blame, especially when it’s directed at parents. At the close of the 19th century, Freud theorized that like the mythical Greek king of Thebes, a child unconsciously wants to kill off his father so that he can have sex with his mother. Freud believed that bringing awareness of the anger towards a parent to a patient’s mind, it would free that patient of this symptoms. But as often is the case historically, Freud’s theory has been proven wrong and largely misogynistic.
Many children who suffer from depression have cohabitating issues, like trauma, PTSD, or parental abuse at the heart of their mental health crisis. Validating feelings and perceptions is a helpful and at times necessary step in therapy and can help redirect self-blame to rightful anger. However, research done at University of California, Berkley shows that it further harms and even severs familial relationships, as well as creating more depressive symptoms in the child long-term. Well-meaning parents who take their children in crisis to therapy, only to be told that they are the root of the problem are significantly less likely to pursue mental health treatment in their child. Therapy that centers on parental blame can even increase the chance of continuing the cycle of abuse to the patient’s own children.
When Dean first attended therapy at the age of six, his former therapist centered a lot of blame on my parents. Whether or not their actions or parental strategies did lead to Dean’s depression was irrelevant in his treatment. Therapists should work together with parents and children to build better relationships and means of communication. They should teach parents how to better connect with their kids, not what they’re doing wrong. At the end of the day, disenfranchising the parents of a mentally distressed child is dangerous to that child.
Dean has a particularly hard time at our family dinners. My father grew up in a classic, Southern family that valued and honored family dinners. He tried to teach us all table manners. Most of us have picked it up, but Dean struggles a lot with the Ps and Qs.
“I eat too fast, and I don’t know why I eat too fast but then everyone gets mad at me and its scary,” Dean says as quickly as possible. He hates talking about it even, I can hear the unease in his voice. “I don’t like being around Dad for such a long time because he’s always talking about how terrible everything is. After a terrible day hearing about other terrible things, it’s not the best.”
Dean’s current therapist helps him come up with strategies to talk to our dad about the things that upset and distress him, instead of accusing our father of causing Dean distress. Together they’ve gotten Dean to the point where he can sit and eat a meal and feel safe, and my father doesn’t feel like he’s ruined his son.
Over the last couple of years, the idea of having a therapist has almost become a meme. Dr. Voigt sees the increase of awareness about mental health issues in young people as both a positive and negative. Awareness is great because it connects people who feel alone, who feel like how they’re experiencing the world is wrong or bad, to people who think and feel like them. It helps children see that they’re not the only ones dealing with depression, again that cosmic hope. But there’s also draws to it. Her young patients often rely on each other, to vent, to give support, to pull them out of crisis points.
“But that’s an inadequate level of care for their friend who’s distressed or even suicidal, and then the child who’s listening to their friend who’s suicidal or distressed gets very upset themselves. They feel overwhelmed, especially if their friend isn’t getting the help they need.”
Dean says several of his sixth-grade peers express suicidal ideation, and many express issues with depression and especially anxiety. He tells me about a friend, AJ, who had a panic attack in class.
“Yeah, they lost themselves for a while,” Dean says and then falls very quiet. He’s talked about AJ a couple of time before. They seem like a sweet kid, very soft-spoken, the stories Dean tells sound like he’s always protecting them. I ask him if he feels responsible for his friend’s mental health, like he needs to help them.
“I don’t feel like I have to, but I’m always going to try. But I know that sometimes it isn’t going to help. It’s hurtful because I care about them and seeing them have a very bad time…it’s hard to not care about.”
Dean saying that made me think a lot about this animation, voiced over by Dr. Brené Brown. In the short, titled “Empathy” a bear walks up to a fox who is experiencing depression. Depression is illustrated as a dark hole the fox cannot escape, and the bear represents empathy. He sits in the hole with the fox, and listens. He tries to understand the fox’s feelings. A deer up above offers suggestions, offers a sandwich, offers “at least you don’t…” statements. These things do not make the fox feel better, or safer. They make the deer feel like he is a good person for trying to help, but they don’t change the experience the fox is dealing with. The bear does not offer suggestions, he just offers companionship. Empathy is sitting with someone in the dark. But we can’t expect twelve-year-olds to be able to handle sitting with each other in the dark.
Dean’s been making incredible progress in the last six month cycle. His behaviors have reregulated, his decision-making is measured and he’s being nicer to himself. He shares more, instead of bottling up. When I called him to interview him, I could hear him smiling in the way he talked. But I’ve always known Dean to be strong, emotionally mature. Talking to him I hear the skills he’s built in therapy, the self-reflection he’s learned to look back with. He sounds older than I do sometimes. Dean says he still feels bad about himself, and sometimes he still wishes he wasn’t around.
“But now I think of how upset you and mom would be, and how it’s just in my head that no one likes me. Because I know people love me. And if it’s like a bad thing I do that makes me want to hurt myself, I remember that nothing I’ve ever done is worthy of that punishment,” Dean says.
I wish I could promise that every child recovers like Dean. I wish I could know that Dean’s recovery now will be permanent in the future, that one day his brain will transmit serotonin on its own and Dean will be happy and safe and free. There’s no guarantees in mental health, just like physical health. Pro-athletes at their peaks get career-ruining injuries, fit people can still develop chronic illnesses, any of us at any time could be struck by a meteor or spontaneously combust or develop cancer or be hit by a bus. At the end of the day, life and health are fleeting, unpredictable animals we attempt to herd and train but never fully tame.
My mother and I talk for over an hour on the phone. Her voice is quiet, rough. I feel like maybe if we were face-to-face, she’d be crying. Dean’s such an incredible kid that it seems unbelievable. When you talk to him, you forget that he’s a sixth grader. Sometimes you let the adult topics slip into conversation, and you’re shocked to hear him return fire from the hip, raw, insightful, and often funny.
“It’s horrible, but when he’s at his lowest, when he’s manic and impulsive and really wild, it’s the only time he really feels like a normal kid,” she says. We’re both silent for a while. Neither of us know what to say. Incredible children deserve to be incredible, but they also deserve to be children.