Depression in pre-teens and teenagers

Mona* looked like she wanted to be anywhere but here, in this office, talking to me about her period with her dad. She had no issue with her dad being part of the conversation, she was just tired of him not letting her express her thoughts and what she thought regarding the treatment options. He is a doctor, go figure…

I eventually had to ask dad to step out of the room for a moment of privacy between Mona and I. I had known Mona for the past two years; I knew she needed the space. At 12, Mona was very concise in her communication. She just wanted to get heard. She had started her menses at nine, earlier than most girls in her class. But she was also taller and heavier than most. 

The period started well, and through the first year, she had gotten accustomed to the regular 26-day cycle, with a menstrual period of five days. She had minimal pain and easily settled into this new phase of her life. However, in the past year, her periods had become a burden. The cycle was irregular, anything from 14 to 42 days, with bleeding lasting anything from two to nine days. 

Then came the pain. The once peaceful periods were now putting Mona out of class every so often due to pain. She would sleep throughout, nursing a hot water bottle and popping pain medication. She would avoid food as she had no appetite.  However, when I dug further, Mona gradually thought through her responses and brought out a lot more information. 

Mona was not just irritable and moody during her period; it seemed to be throughout the cycle. Her weight was all over the place because she would go through cycles of poor feeding and those of binge eating. She noted recurrent headaches, difficulty waking up in the morning to start the day; and she had quietly pulled out of most of her extra-curricular activities. 

I knew Mona loved swimming. She dropped out of the swimming club, citing that swimming left her too exhausted to do her school work; yet this was never an issue before. She had unconvincing excuses as to why she was no longer hanging out with her best friends as much as she used to. Further, she was a talented pianist; and she couldn’t explain why she was no longer interested in staging shows as she previously was. This had gone on for more than a year, it was a wonder the dad had taken this long to take action. 

Mona was rapidly checking off on the PHQ-9 (patient health questionnaire) for depression. So far, she was easily balancing off on moderate depression. This was truly concerning, especially with regard to her young age. This may very well have been the cause of her menstrual changes. 

Mona owned up to struggling with bullying in school at one point. The bullying was on social media, having started using Instagram at 10, though under strict supervision from her parents. She closed her account after a few months, citing that Instagram was lame. Her parents were happy to not have to deal with the social media threat; what they had no idea was that they had already missed the harmful moment. It appeared that though the cyberbullying had been disturbing, she seemed to have handled it well enough, hence it did not seem to be a reason for the current state. 

This was a very difficult conversation to have with her dad. He adamantly insisted that Mona was just going through a difficult puberty compounded by an early onset of menses, for a child who set a very high bar for herself, both academically and in the extra-curricular space. But going through the questionnaire with him made him a bit more receptive. He didn’t like the suggestion of his little girl starting to see a psychiatrist at such an early age, but it was crucial that she did so to avert unnecessary complications. 

Research shows that 70 per cent of adolescent girls who suffer from severe menstrual pain will have underlying depressive illness as a result of the discomfort. This is different from where depression causes menstrual disorders; including making them irregular and painful. 

Depression disorganises the body’s hormones, starting with a rise in the corticotropin-releasing hormone (CRH); a hormone produced in the hypothalamus, controlling the function of the pituitary gland. At the level of the pituitary gland, the high CRH causes an increase in the release of Adreno-cortico-tropic hormone; a hormone that triggers the adrenal glands to make cortisol. 

High cortisol levels cause significant chaos in the body, one of them being suppression of the hypothalamus and pituitary gland functions with regard to the ovary. There is interference with the ovarian production of oestrogen and progesterone; alongside ovulation. This causes periods to be irregular and painful. The high cortisol levels also disrupt glucose regulation through interfering with insulin production and sensitivity; translating into weight changes. 

Mona did get help. She saw a paediatric psychiatrist who evaluated her and diagnosed the depression; starting her on comprehensive care to get it under control. She was briefly put on antidepressants but with good progress with psychotherapy, she was able to get off the medication within a year. 

Not only did Mona get therapy for herself, but the whole family went for therapy too. The psychiatrist and the psychologist were able to identify various triggers in the family dynamics that were contributing to worsening the depression. Additionally, the awareness of depression helped them to identify a family history of depression that was otherwise overlooked. It helped to work through these as a family, not just for Mona, but also for her two younger siblings.

According to the World Health Organization (WHO), one in four adolescents will struggle with mental health disorders. Factors that contribute to poor mental health include having to face adversity in instances such as peer pressure, identity crisis, media influence and gender norms that can ‘exacerbate the disparity between an adolescent’s lived reality and their perceptions or aspirations for the future’. 

Therefore, factors such as the quality of their home life, relationships with peers, bullying, sexual violence, harsh parenting and severe and socioeconomic problems are regarded as critical risks that are a threat to mental well-being.

This makes some adolescents extremely vulnerable to depression, anxiety disorders, truancy and antisocial personality disorders, as outlined by WHO. These include adolescents living in humanitarian and fragile settings; adolescents with chronic illness, autism spectrum disorder, intellectual disorders, or other neurological condition; pregnant adolescents, adolescent parents, or those in early or forced marriages; orphans; and adolescents from minority ethnic or sexual backgrounds or other discriminated groups.

Today, Mona is a strapping 16-year-old excelling in swimming and in performing arts. She knows that she faces a daily struggle against the illness, but she is not letting it hold her back. She has learnt the necessary tools to help her navigate the world better, manage the stressors and most importantly, identify when she begins the slide down the deep dark hole; to ask for help in a timely manner to prevent complications such as suicidal thoughts and self-harm. And her periods, are right back on track!

Dr Bosire is a gynaecologist/obstetrician