Depression or Demoralization?

An examination of our Youth Mental Health Crisis.

As a psychologist who has devoted a large part of my career to helping adolescents and young adults deal with mental health issues, I currently find myself in uncharted territory in our uncertain world.  Review of current statistics estimate roughly one out of five young adults have been diagnosed with depression.  According to the CDC Morbidity and Mortality weekly report, June 2023, adults ages 18 to 25 have the highest rates of diagnosed depression (http://dx.doi.org/10.15585/mmwr.mm7224a1).

SSRI uptake in our young people is at an all time high.  Often being dispensed after 15 minutes with a well-meaning nurse practitioner or physician’s assistant.  Generally, a caring professional who genuinely wants to help their young patient feel better while lacking the clinical experience to understand the complex determinants of mood and anxiety. These professionals are generally lacking the time or experience to differentiate between depression symptoms that are more biochemically driven versus those that are more situationally driven.

Let’s talk about how one gets a diagnosis of depression. For most medical professionals a medical  diagnosis equals some kind of underlying pathological process. In the case of depression, there is some assumed physiological brain related  process.   All that is required is the patient’s subjective report that certain symptoms are present and that their functioning in daily life is negatively impacted.  The circumstances under which these symptoms occur are often not considered when diagnoses are assigned.  This is especially true of less experienced non mental health practitioners who operate in practices that are protocol driven (e.g. family medicine practices). Checking the necessary symptom boxes on a clinical questionnaire is likely all it takes.  

Let’s look at the symptoms of depression.  For Major Depression the symptoms include: depressed mood, lack of experiencing pleasure, unintended changes in weight, changes in appetite, sleep disturbance (insomnia/hypersomnia), physical agitation, loss of energy, feeling worthless, trouble concentrating/indecisiveness, and thoughts of suicide.  For Dysthymic Disorder (a lower grade depression) symptoms include:  poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.  If you have enough of these symptoms within certain time frames and it affects your functioning,  you qualify for a depression diagnosis.  

There is no time in the typical fifteen minute medical office visit to explore the circumstances under which one develops these kinds of symptoms and the degree to which these symptoms may be an expected response to a series of circumstances.  

Does it matter that you are feeling hopeless because you cannot see anyway that you can afford to start a family or buy a home, or that you have figured out that there is no functional meritocracy and you have wasted hours/days/years of your young life focused on getting grades for the dream of college that you can no longer afford. 

Does it matter that you are feeling disillusioned and depressed because you are intelligent enough to see that vapid and obnoxious influencers receive obscene economic rewards through Tik Tok channels than you will ever see in an arduous course of study and engaging in meaningful work that contributes to an improvement in our society?  Sure, you never expected that pursuing a meaningful career would make you rich, but you were not prepared for the fact that it would put you in a spiral of debt that you could never possibly escape. What about the fact that you live in a world fraught with Nihilistic values?  Where we look at actual  human beings  as profit centers and not people.  

Does it matter why you are thinking about death? For example, it is very common when someone loses a loved one in the recent past or is exposed to a traumatic death in their community or via the news feed.  Please understand that when someone expresses a suicidal thought it should be taken seriously.  Any expressed plan or intention should be evaluated by a competent licensed therapist.  Any actual gesture or rehearsing of suicidal behavior should be evaluated immediately. Anyone can reach the National Suicide Prevention Lifeline: by dialing 988 from any phone if you need someone to help you decide whether or not immediate medical/psychiatric help is needed for yourself or a loved one.  

At the same time, even suicidal thoughts do not automatically necessitate medication.  Like all depressed symptoms, they happen in a context.  Yearning to escape a meaningless and hopeless existence can make one consider taking an early exit.  One way of looking at these thoughts is that your brain is trying to get your attention.  That it’s time for you to take the time to explore and find your way to a meaningful life.  

The answer to the challenges that our young people face are not found in a prescription pill bottle dispensed after a 15 minute interview with a medical provider.  As a psychologist I tell my patients that the best outcome is for them to learn and grow their way out of their anxious and depressed symptoms.  If we find that is not possible after serious and consistent attempts,  then medication can be helpful in addressing core symptoms that interfere with learning.  Like intense obsessive thoughts that preoccupy and mentally and emotionally exhaust, extreme attention problems that do not allow for learning, and severe mood swings that leave extensive damage to personal and professional lives in their wake.  

In my clinical experience, thoughtful use of SSRIs do a reasonably good job of lessening the severity and intense anxiety and mood symptoms. This can help someone get out of their own way and make progress in their lives as a temporary measure.  At the same time, we need to be aware that muting these signal emotions  comes at a motivational cost and is not a long term answer, as big pharma would have you believe.  It’s no accident that there are no protocols for weaning off psychiatric medications. Ask your provider if you don’t believe me.  We should not be using medication to be better able to put up with a demoralizing world on a long term basis.   

Let’s face it young people live in a demoralizing world.  To pretend otherwise is an insult to their reality testing.  The problem is not the depressed symptoms, per se.  Rather it is the circumstances that breed these symptoms.  We need to acknowledge their reality rather than pathologize their reactions.  Acknowledging the realities of the world in which young people find themselves allows them to begin to explore meaningful ways to navigate their world.  Rather than fear their negative emotions and look for a “safe space,” these emotions can drive personal changes and help our young people develop the strength and resolve they need to effectively exist in or even change the world in which they find themselves.