Chapter 11

3 Steps Forward, 1 Step Back

Depression in adolescence.
Loss of efficacy, meaning, prescription education.
BuSpar, Zoloft.
Voyage of new discovery.
(Suzanne); (bathtub analogy)

She fell to her knees, looked up, and prayed. There was little else Suzanne felt she could do. Things were hopeless. Her world was destroyed; and the worst part about it was that she didn't understand why. She just knew how incompetent she was and how hopeless she was in all things, and she felt entirely helpless. She might as well lie down and die.

Then from above, she was hearing the voice of her mother.
"No, no! Let's try one more time. Let's seek help!"

It was so perplexing. Suzanne had gone through it before. Each time she would take this Zoloft in higher dose it would help. She would be fine for a week and then the slide would begin; a rapid slide over days, back to the severe depression.

During my multi--session comprehensive evaluation of Suzanne, I was able to look in greater detail at the person behind the complaint. Suzanne was a young adolescent and life had been so easy until two months ago when she started to develop the symptoms of her first major depressive episode. There were no obvious environmental triggers. The illness seemed based on this being time for her biological clock to enter into overwhelming despair. It seemed that she was following in the footsteps of her maternal grandmother, who had committed suicide in her late twenties.

Andrew was waiting for me in my office in typical education mode.

I think, Doctor, that Suzanne's case will educate me a great deal about depression.
You're right: Her story is instructive, Andrew, so please listen carefully. Suzanne is a sixteen year old female who has dropped out of school these past seven weeks after suffering, and I mean suffering, her first major depressive melancholic episode.

I'm listening.
Her family practitioner--her FP--started her on sertraline (Zoloft), 50 mg daily. Three weeks later, she returned: "Doctor, I'm better." She went back to school for a week, but then she returned to her FP, with a familiar SSRI complaint, "Doctor, it worked, but it's no longer working."

So her FP pushed up the dose to 100 mg again, "It worked for a little while, but in a week it's no longer working." Again, he pushed up the Zoloft to 150 mg, then 200 mg. Same story. "Doctor, I'm better." But a little after that, "It worked, but it's no longer working."

At that point, Suzanne consulted with me.
She had again dropped out of school, despite taking the 200 mg of Zoloft a day.

Doctor, I cannot go on. In fact, I don't want to. There's not much point in coming here, because I know you can't do anything anyway. My mother persuaded me to come, but she's wasting your time and my time, so let me go. My family will get over it.

It was clear that Suzanne had had enough. Although there were times when she felt a little bit better, it was so much lower than her expectations that she saw absolutely no point to life. In fact, her description of depression was not a typical one, and the existential meaningless she exhibited was an all too common phenomenon. I realized that both aspects required treatment--the meaninglessness and the biological element which was likely largely responsible for the impediments--and rather quickly, because our risk of losing Suzanne in the long term was high, and our short--term risk was enormous.

I don't sleep so well, Doctor. I wake up two or three times in the night, then I go back to sleep, only to wake up early in the morning. I know I'm supposed to feel worse early, and my sadness does; but as an extra, my anxiety seems to build up during the day; and then well, it sounds like a little detail, Doctor, but it's uncomfortable: I'm constipated. I don't want to complain more, Doctor, but my concentration could be better; but that's minor: it's this draining feeling of sadness that really hits me. Doctor, don't waste your time. It's hopeless. I feel downright helpless. I'm a nothing.

Her self--esteem required working with, and so did her potential toward suicidality.
I've been wasted, Doctor. There's no point in going on. I don't experience any pleasure.

It seemed to me that a major facet was her anhedonic presentation--this inability to experience pleasure--no matter what she did.

Yeah, I watch the ball game sometimes, but it doesn't really interest me. I've been encouraged to support our local teams and I try hard, but I can't experience any pleasure when they win; and yet, at times, I feel sad, like weeping, but it always relates to when I'm inactive. Certainly, when I'm at school, I'm actually a bit better because I'm doing something, but I cannot get up to go there. It's when I've got time to think about myself that I'm pretty lousy.

And again I heard the awful plea: the cry to save her beloved mind.
Doctor, I cannot go on. I don't want to. Just let me go, my time is up.

It was clear that Suzanne had reached her nadir, and although there were times when she felt a little bit better, these periods were so much lower than her expectations that she saw absolutely no point to life.

She had also hit the typical age of adolescence where everything is in black and white--no tones, no shades, everything either wonderful or terrible, awesome or boring. In her case, this was augmented by her depression.

Doctor, there's no point in you trying to make me better, because there's no relevance to life anyway. Every last bit of life is worthless! I don't know why you're bothering. Everything in life is pointless and stupid.

She was the prototype iconoclast, possibly the product of our modern era, where even the most fascinating of phenomena becomes something ordinary and uninteresting for our new youth. I recognized this as a special kind of problem.

(The chapter continues...)

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